tag:theconversation.com,2011:/uk/topics/hospitals-859/articlesHospitals – The Conversation2024-01-29T14:53:48Ztag:theconversation.com,2011:article/2215112024-01-29T14:53:48Z2024-01-29T14:53:48ZFrom mud and vinegar to 3D printing skin, the way we treat wounds still challenges humanity<p>Whether it’s the sting of a paper cut or the trauma of battle injury, wounds are woven into the tapestry of human experience. And since ancient times, we’ve fought the enemy that lurks within them – infection. </p>
<p>The constant threat of injury on the battlefield led to the search for new ways to combat wound infection. But early surgical procedures lacked the sterile instruments available today, meaning that for many years, surgery came with the added risk of post-operative <a href="https://cha.com/wp-content/uploads/2017/11/AJIC-2012-Infection-Control-Through-the-Ages.pdf">wound infection</a>, resulting in high numbers of deaths. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601883/">Ancient practices</a>, such as using oils, mud, turpentine, or honey to treat wounds, were common around 2000BC. The Greek physician Hippocrates (460-377BC) <a href="https://www.dermatologytimes.com/view/acetic-acid-and-wound-healing">used vinegar</a> to clean wounds, followed by bandaging to keep dirt at bay.</p>
<p>While the first hospitals were <a href="https://scientificsurgery.bjs.co.uk/article/the-surgery-of-theodoric-ca-a-d-1267-translated-from-the-latin-by-eldridge-campbell-m-d-and-james-colton-m-a-volume-i-books-i-and-ii-8-38-x-5-12-in-pp-223-xi-with-coloured-front/">established</a> in Europe in the middle ages, they were dangerous and brutal places. Wound infection rates were high because of unsanitary conditions and the use of cautery, which involved pushing a burning iron into a patient’s wound until it reached the bone.</p>
<figure class="align-center ">
<img alt="A drawing of a pot containing a fire with several medical instruments poking out of it." src="https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571587/original/file-20240126-19-5nmbkg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A receptacle for burning coal to heat cautery instruments.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/gcg933n2/images?id=jghkdnp4">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>By the 1860s, the pioneering surgeon Joseph Lister had revolutionised wound infection treatment by introducing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895849/">carbolic-acid-soaked bandages</a>. And Robert Wood Johnson, who founded Johnson & Johnson, <a href="https://wounds-uk.com/journal-articles/sterilised-gauze-and-baby-powder-robert-wood-johnson-i-and-frederick-barnett-kilmer/">produced</a> the first sterile gauze bandages by 1890. The combination of antiseptic and sterile bandage marked a turning point in the evolution of wound treatment and infection control.</p>
<p>The discovery of penicillin by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520913/">Alexander Fleming</a> in 1928 was also a pivotal moment in the treatment of wound infections. By the 1940s, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369031/">penicillin</a> was being used to treat second world war soldiers who had wound infections that would have been deemed fatal in previous years. For less serious wounds, Lister’s approach of using a dressing and an antiseptic was still used.</p>
<p>Substances like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756674/">silver</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/12914356/">iodine</a> have also been recognised for their antimicrobial properties since the 1800s. Iodine, though effective, caused pain and skin discolouration until safer and less painful formulations were developed in 1949. <a href="https://bnf.nice.org.uk/wound-management/antimicrobial-dressings/">These formulations</a> endure in modern wound dressings.</p>
<p>For everyday cuts and scrapes, a simple cleaning with water and application of antiseptic cream is usually enough. This helps to prevent the inadvertent introduction of bacteria into the wound, minimising the risk of additional pain and swelling. </p>
<p>But while most wounds nowadays heal without issue, some become become infected. Research published in 2021 showed that <a href="https://wounds-uk.com/wp-content/uploads/sites/2/2023/02/68803cd147c4d81a02b9cc56823f19a1.pdf">3.8 million</a> people were having their wounds managed by the NHS between 2017 and 2018, up 71% from between 2012 and 2013. They included surgical wounds, leg ulcers and burns. This shows how hard it can be to care for wounds that are difficult to heal and particularly susceptible to infections.</p>
<h2>Modern-day challenges</h2>
<p>One of the biggest challenges in the modern-day treatment of wound infection is <a href="https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance">antibiotic resistance</a>. This happens when bacteria develop the ability to defeat the drugs designed to kill them. Resistant infections can be difficult, and sometimes impossible, to treat. </p>
<p>Many bacteria have also become resistant to the antimicrobial ingredients used in wound dressings. This is the case for <a href="https://www.sciencedirect.com/science/article/pii/S0195670104005201">silver-based</a> wound dressings, which are often used to treat chronic wound infections. This type of wound characteristically <a href="https://www.nature.com/articles/s41572-022-00377-3">fails to heal</a>, and can remain an open, infected wound for many months – or even years. As well as the devastating effect on people’s quality of life, this also places a huge financial burden on the NHS.</p>
<p>The constant fight against wound infections drives extensive research for new, safe and effective treatments. While progress is being made, a crucial hurdle lies in the <a href="https://academic.oup.com/jacamr/article/3/1/dlab027/6186407">limitations</a> of laboratory testing methods. These tests, while necessary for regulatory approval, often fail to capture the nuanced realities of wounds in the human body. </p>
<p>No two people are the same and no two wounds are the same either. This can lead to situations where treatments shine in the lab but ultimately prove ineffective in real patients.</p>
<h2>Creating wound models</h2>
<p>In response to this, scientists are tackling the limitations of lab tests by creating more realistic synthetic wound models. Some are even <a href="https://pubmed.ncbi.nlm.nih.gov/30172300/">3D printing</a> human skin (using leftovers from surgical procedures), or animal skin, complete with artificial body fluids, such as pus. The aim is to create a model environment that mimics real wounds more accurately. </p>
<p>Recently, my own <a href="https://pubmed.ncbi.nlm.nih.gov/36678466/">research group</a> has made strides in developing lab models that act like real chronic wounds when treated with antimicrobial dressings. While not perfect, our models are a step in the right direction, contributing to the development of formulations with promising potential for treating wound infections in the future.</p>
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Read more:
<a href="https://theconversation.com/we-built-a-human-skin-printer-from-lego-and-we-want-every-lab-to-use-our-blueprint-203170">We built a human-skin printer from Lego and we want every lab to use our blueprint</a>
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<p>As we navigate the complexities of wound care, the quest for new, effective and safe treatments continues, driven by the efforts of scientists worldwide. We are working towards a future where the management of difficult-to-heal wounds and infections improves, enhancing both individual wellbeing and the efficiency of health systems.</p><img src="https://counter.theconversation.com/content/221511/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Maddocks does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Keeping wounds clean and infection free has challenged people for thousands of years.Sarah Maddocks, Lecturer in Microbiology, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2198972024-01-29T13:36:54Z2024-01-29T13:36:54ZNonprofit hospitals have an obligation to help their communities, but the people who live nearby may see little benefit<figure><img src="https://images.theconversation.com/files/571244/original/file-20240124-27-pprmzs.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4708%2C3016&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scholars interviewed people living near the University of Colorado Hospital to assess whether it's a good neighbor.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/university-of-colorado-hospital-news-photo/586104222?adppopup=true">John Greim/LightRocket via Getty Images</a></span></figcaption></figure><p>Does living near a hospital make you more likely to get the health care you need?</p>
<p>Even though the <a href="https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3">federal government requires nonprofit hospitals</a> to regularly assess the health needs of their surrounding communities and publicly post a plan to address those concerns, many people living nearby struggle to get basic health care.</p>
<p>We are a <a href="https://www.ohio.edu/experts/expert/daniel-skinner">political scientist</a> and an <a href="https://scholar.google.com/citations?user=vAgVzVAAAAAJ&hl=en&oi=ao">urban sociologist</a> who study how hospitals interact with and shape the communities in which they are located. As we explain in our book, “<a href="https://press.uchicago.edu/ucp/books/book/chicago/C/bo206056945.html">The City and the Hospital</a>,” most top-ranked hospitals in the U.S. <a href="https://lowninstitute.org/us-news-best-hospitals-still-falling-short-on-equity/">aren’t doing enough in this regard</a>.</p>
<h2>A paradox for local communities</h2>
<p>Despite living in the shadow of world-class medical facilities, people residing in these communities often have poor health.</p>
<p>We call this the paradox of medically overserved communities.</p>
<p>Many nonprofit hospitals amass <a href="https://www.definitivehc.com/resources/healthcare-insights/top-non-profit-hospitals-net-patient-revenue">revenues in the millions and even billions</a>. This <a href="https://www.kff.org/health-costs/issue-brief/most-nonprofit-hospitals-and-health-systems-analyzed-had-adequate-or-strong-days-of-cash-on-hand-in-2022-though-about-one-in-ten-did-not/">economic power</a>, coupled with their stated missions to take care of their local community, positions most of them well to benefit the neighborhoods surrounding their campuses.</p>
<p>Urban hospitals tend to be centrally located; residents of <a href="https://www.brookings.edu/articles/three-charts-showing-you-poverty-in-u-s-cities-and-metro-areas">these city centers tend to be low income</a>, and many of them are disproportionately Black and Latino. Using census data, we found that the neighborhoods around our case sites were, overall, less white, had lower household incomes, lower property values and greater vacancy rates than the rest of their cities. They also had worse health. </p>
<h2>Worse off in terms of health</h2>
<p>To better understand how hospitals serve local populations, we and our colleague, medical sociologist <a href="https://scholar.google.com/citations?user=gZG5HAQAAAAJ&hl=en">Berkeley Franz</a>, conducted over 200 interviews.</p>
<p>We spoke with local residents, hospital administrators, business owners and health care advocates. Our conversations focused on three American hospitals: the Cleveland Clinic in Ohio, Hartford Hospital in Connecticut and the University of Colorado Hospital in Aurora. Like these three, about <a href="https://www.aha.org/statistics/fast-facts-us-hospitals">half of U.S. hospitals are nonprofits</a>.</p>
<p>In all three cities, these neighborhoods had lower rates of health insurance compared with citywide and national averages. And so, when looking at a map, these neighborhoods might appear to have greater access to health care than, for example, those living in rural communities. This is not the case. </p>
<p>We found that Americans residing in a <a href="https://www.census.gov/geographies/reference-maps/2020/geo/2020pl-maps/2020-census-tract.html">census tract</a> next to those three hospitals were actually more likely to be in poorer health than their fellow city dwellers.</p>
<p>We examined 12 key health conditions, including heart disease, high blood pressure, diabetes, high cholesterol and mental illness. Local residents were faring worse than city averages 64% of the time and worse than national averages 80% of the time. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A multiracial group of people fill out their paperwork in the doctor's waiting room." src="https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571300/original/file-20240124-21-3mm8f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Sometimes low-income people living near prominent hospitals fear getting care at them because of billing concerns.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/diverse-people-fill-out-forms-in-doctors-waiting-royalty-free-image/1745157924?phrase=nonprofit+hospitals&adppopup=true">SDI Productions/E+ via Getty Images</a></span>
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<h2>Vague mandate</h2>
<p>Nonprofit hospitals get <a href="https://www.gao.gov/assets/gao-23-106777.pdf">tax exemptions</a> because the Internal Revenue Service recognizes that the promotion of health is a <a href="https://www.gao.gov/products/gao-23-106777">charitable mission that serves the public good</a>. Because for-profit hospitals pay all applicable taxes, they are <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542">not subject to these IRS requirements</a>.</p>
<p>Nonprofit hospitals <a href="https://www.kff.org/health-costs/issue-brief/the-estimated-value-of-tax-exemption-for-nonprofit-hospitals-was-about-28-billion-in-2020/">save billions every year</a> in federal, state and local taxes. But they are required to spend some of their money to provide what the government calls “<a href="https://nchh.org/tools-and-data/financing-and-funding/healthcare-financing/hospital-community-benefits/">community benefit</a>.”</p>
<p>How much should these hospitals spend?</p>
<p>Until now, the authorities have not specified an amount or percentage of a hospital’s revenues or profits. The <a href="https://www.irs.gov/charities-non-profits/charitable-hospitals-general-requirements-for-tax-exemption-under-section-501c3">IRS test for community benefit</a> is vague. It requires that hospitals make “investments” that are “broad enough to benefit the community” and must “serve a public rather than a private interest.”</p>
<p>Although <a href="https://www.kff.org/health-costs/issue-brief/hospital-charity-care-how-it-works-and-why-it-matters/">providing charity care</a> isn’t the only contribution hospitals make to their communities, it’s an important one. And in 2020, when the question was last looked at closely, nonprofit hospitals’ charity care totaled US$16 billion – during a year <a href="https://www.kff.org/health-costs/issue-brief/the-estimated-value-of-tax-exemption-for-nonprofit-hospitals-was-about-28-billion-in-2020/">when they got $28.1 billion in tax breaks</a>.</p>
<p>Some hospitals do little to nothing to meet this goal. The U.S. Government Accountability Office, a government watchdog, found 30 nonprofit hospitals that got tax breaks in 2016 <a href="https://www.gao.gov/products/gao-23-106777">despite reporting no spending on community benefits</a> at all.</p>
<p>And although hospitals are required to report their community benefit activities to the IRS every three years, the government agency “was unable to provide evidence that it did so because it did not have a well-documented process to ensure those activities were being reviewed,” the GAO said in 2023.</p>
<h2>Community benefit</h2>
<p>People living near hospitals complained, as you might expect, about blaring sirens, helicopters and traffic. We also heard confusion over hospitals’ responsibilities toward their local community. </p>
<p>Local residents often told us they expected more from hospitals than other neighborhood institutions. As Mansfield Frazier, a Cleveland community advocate, put it, the Cleveland Clinic is “not in the business of making widgets. They’re in the business of promoting health.”</p>
<p>On the other hand, hospital administrators at the three hospitals we studied insist that they spend generously to improve their local communities. One Cleveland Clinic administrator, for example, lamented, “There are some people who think it is our job to repair potholes on their streets.” </p>
<p>In terms of “how well hospitals invest in community health,” a health-focused think tank, <a href="https://lownhospitalsindex.org">the Lown Institute</a>,
graded our three hospitals as <a href="https://lownhospitalsindex.org/rankings/compare/?hospitals=070025,060024,360180">average</a>: Hartford Hospital earned a B grade, and the University of Colorado Hospital and the vaunted Cleveland Clinic both earned a C.</p>
<p>The American Hospital Association has responded to these assessments by <a href="https://www.aha.org/news/blog/2023-04-11-lown-institute-once-again-cherry-picks-data-fit-their-preconceived-notions-about-hospitals">criticizing Lown’s methods and data</a>. Most notably, it accuses Lown of “cherry-picking,” insisting that delivering “life-saving treatments” and educating newly graduated physicians should be considered part of “community benefit.” Such activities are generally not considered part of hospitals’ broader nonprofit obligations because they are paid for the medical care they deliver and the <a href="https://crsreports.congress.gov/product/pdf/IF/IF10960">physicians they train</a>.</p>
<h2>‘Appetite for land’</h2>
<p>Residents of the three neighborhoods where we conducted our research often noted their local hospital’s prominence. But they also said they felt unwelcome there, using words like “behemoth,” “intimidating” and “imposing” when describing them.</p>
<p>They also told us they were upset when the hospitals purchased neighborhood homes and other buildings and razed them for new facilities. In Hartford, residents pointed to an example of how the hospital bought a family-run funeral home that had catered to the local Latino community and then turned it into a parking lot. </p>
<p>The local community expressed similar concerns about the Cleveland Clinic’s “<a href="https://www.cleveland.com/business/2012/01/historic_churches_near_clevela.html">appetite for land</a>,” which threatened the future of the neighborhood’s historic churches.</p>
<p>We also heard concerns over unfair billing practices that echoed what The New York Times has found – that overcharging patients entitled to free care is <a href="https://www.nytimes.com/2022/10/04/business/providence-hospital-poor-patients.html">perhaps more common than previously believed</a>.</p>
<p>In all three communities, people told us they avoided their local, prominent hospitals because of fears of the financial burden a visit would yield. Many local residents said they saw less celebrated hospitals that were farther from home as safer options in terms of what they expected to pay.</p>
<h2>An unfulfilled promise</h2>
<p>When Congress passed the <a href="https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/">Affordable Care Act in 2010, it reasserted</a> the idea that nonprofit hospitals should provide substantial benefits to communities in exchange for their tax exemptions. That hasn’t happened.</p>
<p>Scholars widely agree there’s <a href="https://doi.org/10.1101/2022.08.17.22278878">no evidence</a> that nonprofit hospitals have generally <a href="https://www.ncbi.nlm.nih.gov/books/NBK241401/">done more to benefit their local communities</a> with the ACA than they did without it.</p>
<p>Yet a lack of oversight has meant that hospitals have rarely faced penalties for noncompliance.</p><img src="https://counter.theconversation.com/content/219897/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Standards are vague, and the IRS, which is tasked with enforcement, hasn’t provided much oversight.Jonathan Wynn, Department Chair and Professor of Sociology, UMass AmherstDaniel Skinner, Associate Professor of Health Policy, Ohio UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2209802024-01-15T20:46:57Z2024-01-15T20:46:57ZRSV, flu and COVID: demystifying the triple epidemic of respiratory viruses<figure><img src="https://images.theconversation.com/files/568892/original/file-20240110-27-k3w5hm.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C995%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The influenza virus, which causes seasonal flu, is back at its usual rate after a hiatus due to health measures.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Since 2022, a triple epidemic of respiratory viruses — RSV, influenza and SARS-CoV-2 — has been disrupting our daily lives. In addition, the media constantly reminds us of how this is straining emergency departments.</p>
<p>How does the present respiratory virus season differ from seasons during the pre-COVID era?</p>
<p>As a specialist in virus-host interaction, I would like to shed some light on the new dynamics of the respiratory virus season.</p>
<h2>The infamous SARS-CoV-2</h2>
<p>SARS-CoV-2, the instigator of the COVID-19 pandemic, is still with us. Despite limited access to screening tests, analysis of the number of hospital admissions shows that the virus is still going strong.</p>
<p>Québec’s Institut National de Santé Publique counted more than 33,000 hospitalizations in Québec in 2023 affecting all age categories, <a href="https://www.inspq.qc.ca/en/node/29197">including 648 children under the age of nine</a>.</p>
<p>The virus is not seasonal. It has a strikingly efficient capacity to spread through aerosols, especially as we take refuge indoors to escape the cold. The virus currently circulating is actually a mixture of different viruses, known as variants, each of which has the potential to partially evade the immunity an individual has acquired through a previous infection or vaccination.</p>
<h2>Resurgence of seasonal flu</h2>
<p>After a hiatus due to health measures, the influenza virus, which causes seasonal flu, has returned with the same force. It is once again circulating <a href="https://www.cdc.gov/flu/about/viruses/types.htm">in different variants belonging to Types (strains) A and B</a>, although scientists believe that one Type B strain, the <a href="http://doi.org/10.2807/1560-7917.ES.2022.27.39.2200753">Yamagata lineage, has disappeared</a>.</p>
<p>A variant of H1N1 Type A, different from the viruses that caused the 1918 and 2009 pandemics, is now dominant in North America where it is causing an increase in hospital admissions, <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2023-2024/week-49-december-3-december-9-2023.html">especially among the elderly and young children</a>.</p>
<p>However, we must remain vigilant, as the strain may change within the same season. What could this mean? The target population could change, <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2018-2019/annual-report.html">as it did in the 2018-2019 season</a>.</p>
<h2>And what about RSV?</h2>
<p>The respiratory syncytial virus (RSV) also appears to be <a href="https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada/2023-2024/week-50-ending-december-16-2023.html">resuming its pre-pandemic transmission levels</a>.</p>
<p>RSV causes bronchiolitis and pneumonia. <a href="https://cps.ca/en/documents/position/bronchiolitis">Bronchiolitis is characterized by the obstruction of the small airways, which can progress to wheezing or respiratory distress</a>.</p>
<p>Virtually all children are infected with RSV before the age of 2, and RSV infection is one of the main causes of hospitalization in young children.</p>
<p>Before the COVID-19 pandemic, there was an average of 2,523 hospitalizations per year in Canada, <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810133">half of them in children under six months of age and more than a quarter requiring admission to intensive care</a>.</p>
<p>But RSV also severely affects the elderly and adults who are immunocompromised or have existing chronic conditions. RSV shows high levels of severe illness, hospital admissions and in hospital deaths in adults, <a href="https://doi.org/10.1093/infdis/jiad559">figures which are comparable to those for influenza</a>.</p>
<p>Admittedly, although these three viruses are attracting attention, other less publicized respiratory viruses are also circulating, <a href="https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada/2023-2024/week-50-ending-december-16-2023.html">demonstrating a diverse viral environment</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman in hospital" src="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The continued presence of SARS-CoV-2 means our hospitals can’t catch their breath.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>SARS-CoV-2 has turned everything upside down</h2>
<p>The presence of SARS-CoV-2 marks the principal difference from the pre-pandemic era, since it is augmenting the burden on an already weakened health-care system. The challenge is amplified by the extremely high transmission capacity of SARS-CoV-2 compared with influenza and RSV, which makes seasonal management much more complex.</p>
<p>Until the SARS-CoV-2 pandemic, the respiratory virus season had a fairly predictable beginning and end that was determined by virus surveillance over the years. Our systems were already struggling to absorb this seasonal increase in patients. But today, the picture has become even more complex with the continuing presence of SARS-CoV-2. And our hospitals, with no time to catch their breath, are struggling to keep up.</p>
<h2>Beyond infection</h2>
<p>The second major difference that should not be overlooked is SARS-CoV-2’s ability to cause widespread health problems well beyond the respiratory system. In addition, it causes long-term consequences after infection, such as post-COVID syndrome (also known as long COVID), which affects millions of people.</p>
<p>The extent of the consequences of infection and reinfection on human health remains uncertain, as does the effectiveness of vaccines in limiting these effects. The SARS-CoV-2 pandemic – with its exceptional transmission levels – has produced a large number of patients available for research. Coupled with unprecedented funding, this has made it possible to undertake research that has never been possible before on a post-viral syndrome.</p>
<p>Of course, the number of people infected with RSV or influenza globally each year does not even come close to the number infected with SARS-CoV-2, even at this stage of the pandemic. However, there is considerable evidence that, in addition to the acute symptoms and mortality associated with influenza and RSV, <a href="https://doi.org/10.1038/s41591-022-01810-6">post-viral conditions also exist</a>, as they do with SARS-CoV-2.</p>
<h2>The importance of vaccines</h2>
<p>The final distinction from the pre-pandemic period is the arrival of RSV vaccines. In Canada, the Arexvy vaccine has been approved for people over 60, and the Abrysvo vaccine was also approved for pregnant women, providing immunity to children from birth. However, these two vaccines have not yet been officially recommended. We are still waiting for a vaccine to be made available for children. The trio of vaccines against COVID-19, influenza and RSV will certainly help to reduce the severe symptoms associated with respiratory virus infections in the coming seasons.</p>
<p>However, our primary objective must be to reduce the incidence of respiratory virus infections. Despite vaccination, we can expect the mortality and morbidity associated with these infections to increase as the population ages.</p>
<p>All three viruses share a common trait — they spread through the air. Their transmission could be reduced by implementing passive strategies aimed at reducing the concentration of aerosols in indoor air.</p><img src="https://counter.theconversation.com/content/220980/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nathalie Grandvaux received research funding from the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council of Canada (NSERC), the Fonds de recherche du Québec - Santé (FRQS), the Canada Foundation for Innovation (CFI), the Fondation du centre hospitalier de l'Université de Montréal, and the Ministère de l'économie et de l'innovation du Québec.</span></em></p>The current triple epidemic of respiratory viruses is affecting all age groups, prompting comparisons with the pre-COVID-19 era.Nathalie Grandvaux, Professeure en biochimie des interactions hôte-virus, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2192032023-12-05T19:25:50Z2023-12-05T19:25:50ZWhat is the hospital funding agreement politicians are talking about today?<p>National Cabinet meets today to discuss three big issues in Commonwealth-state financial relations: <a href="https://www.afr.com/politics/an-end-to-the-gst-guarantee-would-be-disastrous-20231129-p5enol">GST allocation</a>, National Disability Insurance Scheme (NDIS) funding, and a Commonwealth government proposal to kick-start negotiations on a new National Health Reform Agreement, to take effect in July 2025. </p>
<p>So what is the reform agreement? What are the chances it could result in better access to hospital care when Australians need it? And what does the GST have to do with it?</p>
<hr>
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<em>
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Read more:
<a href="https://theconversation.com/a-tussle-between-the-federal-and-state-governments-over-disability-supports-is-looming-what-should-happen-next-217839">A tussle between the federal and state governments over disability supports is looming. What should happen next?</a>
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<h2>What is the reform agreement?</h2>
<p>State and territory governments are responsible for running public hospitals, but <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2021-22/data">about 40%</a> of public hospital funding comes from the Commonwealth government.</p>
<p>The National Health Reform Agreement is front and centre of any discussion about health funding. Negotiated every five years or so, it was originally designed to:</p>
<ul>
<li>increase the Commonwealth’s share of public hospital funding</li>
<li>introduce more transparency about how states spend this extra Commonwealth funding</li>
<li>drive efficiency in public hospital care.</li>
</ul>
<p>Its performance on all three objectives has been mixed. </p>
<p>Efficiency initially improved, but there has been back sliding and, even in the pre-COVID years, the average cost of a public hospital admission <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/health/public-hospitals">increased faster than inflation</a>. </p>
<p>Transparency has been a double-edged sword, causing a heightened focus on the agreement and its formula, but de-emphasising the broader GST context.</p>
<p>The previous Commonwealth Liberal government reduced the planned increase in the Commonwealth share of public hospital funding in its first budget, and its share has <a href="https://johnmenadue.com/new-data-shows-the-commonwealth-government-is-not-pulling-its-weight-on-hospital-funding/">now declined to 41%</a>. </p>
<p>Tight state budgets and increasing costs per patient mean hospitals’ capacity has not expanded in line with population growth, resulting in poorer access and longer waiting times.</p>
<h2>Working out the Commonwealth’s fair share</h2>
<p>Under the <a href="https://www.health.gov.au/our-work/2020-25-national-health-reform-agreement-nhra">National Health Reform Agreement</a>, total Commonwealth funding to the states collectively will increase in line with total public hospital “activity” growth across all states. </p>
<p>“Activity” includes hospital admissions and outpatient activity (seeing a specialist in an outpatient clinic, for example) and is measured in “activity units” with a “national efficient price”. The price for each unit is currently <a href="https://www.ihacpa.gov.au/">set</a> at <a href="https://www.ihacpa.gov.au/resources/national-efficient-price-determination-2023-24">$6,032</a>.</p>
<p>The current formula is that the Commonwealth funds 45% of the costs of increases in hospital admissions, emergency department visits or outpatient attendances but only paid at the “national efficient price”. Total Commonwealth funding growth is capped at 6.5% each year.</p>
<figure class="align-center ">
<img alt="Hospital bed in corridor" src="https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563504/original/file-20231204-21-tk0pd5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Commonwealth hospital funding has declined.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/darkhaired-woman-middleaged-man-walk-along-2273073889">Shutterstock</a></span>
</figcaption>
</figure>
<h2>But it’s often misunderstood</h2>
<p>Many commentators and government officials assume the same model applies for funding to each state. It doesn’t. Funding to each state is determined by a separate process (which we’ll get to in a moment). </p>
<p>This false assumption about the way the National Health Reform Agreement works for each state leads to complaints the agreement constrains good policy initiatives, rewards “volume not value” and encourages unnecessary hospitalisations. </p>
<p>Worse, it allows states to blame the agreement for their own mismanagement of their hospitals. </p>
<p>And it encourages fruitless discussions between Commonwealth and state officials about “reform projects” that typically go nowhere but can be used by politicians to hoodwink the public that big issues in the health sector are being addressed.</p>
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<em>
<strong>
Read more:
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<h2>How funding to the states is really allocated</h2>
<p>Funding from the Commonwealth to the states must be considered at two levels: the National Health Reform Agreement and the GST.</p>
<p>If you look at the <a href="https://www.publichospitalfunding.gov.au/">national health funding body’s</a> website, you can see tables purporting to show how Commonwealth funding is allocated to <a href="https://www.publichospitalfunding.gov.au/public-hospital-funding-reports">health services across Australia</a>, down to the last dollar. This reflects the transparency objective of the National Health Reform Agreement.</p>
<p>These numbers are real. The dollars reported actually end up in state bank accounts. </p>
<p>However, the big picture is somewhat different, and this is where the GST comes in.</p>
<p>Money collected through the GST is allocated among the states based on need. The aim is to ensure each state has the capacity “to provide services and the associated infrastructure at the same standard”. </p>
<p>An independent body, the <a href="https://www.cgc.gov.au/about-us">Commonwealth Grants Commission</a>, assesses need, including the need for public hospital spending by states. It also assesses how states can raise money through taxes to meet their needs.</p>
<p>A <a href="https://www.cgc.gov.au/about-gst-distribution">state’s GST allocation</a> is based on the gap between its spending needs and its assessed revenue raising capacity. </p>
<p>Importantly, most Commonwealth grants, including the National Health Reform Agreement, are taken into account by the Grants Commission in a similar way to how it assesses the state’s ability to raise payroll tax or stamp duty. </p>
<p>The result is that a state’s funding under the National Health Reform Agreement is effectively reallocated back to the state, with a lag, not in line with the agreement’s formula, but rather in line with the GST formula (this is essentially based on the state’s population, weighted for factors such as age, the proportion living in remote locations, and the proportion of First Nations Australians).</p>
<p>The National Health Reform Agreement formula, although impressively precise, is somewhat of a fiction, providing a funding flow which is effectively overridden a few years later. </p>
<p>The reality therefore is that the principal impact of the National Health Reform Agreement is to determine the total <em>national</em> contribution the Commonwealth makes to public hospitals. </p>
<p>However, because states often assume the National Health Reform Agreement formula is real, it has a life of its own which can shape the health and hospital system for good or ill.</p>
<h2>What to watch for out of National Cabinet</h2>
<p>The entrails of today’s National Cabinet decision need to be examined carefully. The words may obscure what is really happening, but there are two factors to look for. </p>
<p>Most importantly, will the 6.5% cap be increased? If so, by how much? This determines the total amount of money the Commonwealth might be required to pay states. </p>
<p>And what will states commit to in exchange for any increase in the Commonwealth’s potential spending? A commitment to <a href="https://www.afr.com/policy/health-and-education/six-reforms-to-repair-the-ndis-20230425-p5d33n">work together (and share spending) on NDIS reform</a> may be on the cards here.</p>
<p>Funding commitments for specific “reform projects” send signals about what governments collectively think are important issues in the public hospital system such as joint commitments to improve efficiency or to expand access to digital services, such as telehealth.</p>
<p>For patients, an increase in the Commonwealth share and in the cap, provided it is coupled with tighter accountability for access (such as commitments to reducing waiting times for planned procedures), could lead to a much improved public hospital system. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-does-australias-health-system-stack-up-internationally-not-bad-if-youre-willing-to-wait-for-it-218031">How does Australia's health system stack up internationally? Not bad, if you're willing to wait for it</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/219203/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>National Cabinet is meeting today to discuss hospital funding, and the interconnected issues of NDIS reform and GST allocation. But how are hospitals actually funded? And what’s GST got to do with it?Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2170502023-11-12T14:02:41Z2023-11-12T14:02:41ZRegina hospital allegations point to an epidemic of bullying and discrimination in health care<figure><img src="https://images.theconversation.com/files/558148/original/file-20231107-15-3o7m1j.jpg?ixlib=rb-1.1.0&rect=0%2C34%2C1920%2C1043&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Complaints of racial discrimination at the Regina General Hospital highlight how bullying and harassment are damaging workplaces across Canada. </span> <span class="attribution"><a class="source" href="https://momsandkidssask.saskhealthauthority.ca/hospitals-facilities/hospitals-health-centres/regina-general-hospital">(Moms & Kids Health Saskatchewan)</a></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/regina-hospital-allegations-point-to-an-epidemic-of-bullying-and-discrimination-in-health-care" width="100%" height="400"></iframe>
<p>Foreign-trained physicians at Regina General Hospital have <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">alleged that discriminatory practices</a> by the hospital’s “racist, and discriminatory leadership” have led to them being targeted and sidelined. </p>
<p>Ten physicians trained in Africa and Asia filed a complaint with the Saskatchewan Human Rights Commission alleging they have faced bullying, harassment and racial discrimination. They claim that since a new director for the division of internal medicine was hired, <a href="https://www.cbc.ca/news/canada/saskatchewan/human-rights-complaint-internal-medicine-regina-general-hospital-1.7021106">white physicians have been given more favoured shifts</a>.</p>
<p>When the physicians brought their concerns to hospital administrators, they said their complaints were dismissed. <a href="https://www.ctvnews.ca/health/the-most-toxic-place-foreign-trained-doctors-file-human-rights-complaint-alleging-discrimination-1.6627237">A Saskatchewan Health Authority (SHA) spokesperson said</a> the health authority was committed to having a representative workforce and would not comment on legal matters. Saskatchewan’s health minister <a href="https://regina.ctvnews.ca/sask-health-minister-says-alleged-racism-at-regina-hospital-under-third-party-review-1.6633523">said the SHA has launched a third-party investigation into the circumstances</a>.</p>
<h2>Physicians in distress</h2>
<p>Workplace violence in the form of bullying, harassment, sexual abuse and discrimination is not new to health care. The industry operates within a framework of entrenched hierarchical structures that create fertile ground for senior professionals to exhibit negative behavior towards their less experienced and trained counterparts. In fact, <a href="https://www.cma.ca/physician-wellness-hub/content/bullying-workplace">a 2018 survey by Resident Doctors of Canada</a> noted that more than three-quarters of medical residents said they had experienced workplace bullying, harassment and intimidation.</p>
<p>While bullying can manifest in any workplace, a more significant and enduring issue emerges when a toxic work environment not only tolerates but also enables such behavior. <a href="https://doi.org/10.36834%2Fcmej.57019">A systematic review</a> of 52 studies into workplace bullying in medicine found that it was prevalent and led to a range of negative outcomes that impact patient care and physician burnout.</p>
<p>In addition to causing distress to those directly impacted, widespread abuse in hospitals has far-reaching negative consequences. The rupture of trust and a breakdown in support invariably leads to a greater <a href="https://doi.org/10.1186/s12960-019-0433-x">likelihood of medical errors and misjudgments</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A stressed Black doctor in scrubs sits with her head resting on her hands." src="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/558151/original/file-20231107-19-7023v6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Workplace bullying in hospitals can have far-reaching negative impacts on health-care workers and patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Racialized physicians in particular are more likely to encounter racism at work, and when this happens, they usually feel abandoned by their employers. This is re-enforced when complaints go unaddressed or if they are unfairly dismissed through policies designed by the organization. </p>
<p>In British Columbia, <a href="https://engage.gov.bc.ca/app/uploads/sites/613/2021/02/In-Plain-Sight-Data-Report_Dec2020.pdf1_.pdf">a 2020 report</a> described widespread systemic racism against Indigenous Peoples in the provincial health-care system. Almost 60 per cent of Indigenous people described witnessing racism and discrimination.</p>
<p>Hospital reputations are also adversely affected, which undermines patient confidence and draws unfavourable scrutiny. Bullying at work also has an <a href="https://www.routledge.com/Bullying-and-Harassment-in-the-Workplace-Theory-Research-and-Practice/Einarsen-Hoel-Zapf-Cooper/p/book/9781138615991">impact on the organization as a whole</a>. The negative impact on a person’s self-worth can significantly affect their performance at work. Frequent employee turnovers, diminished staff retention and a <a href="https://doi.org/10.1007/978-981-13-0935-9_8">general decline in employee morale</a> can result in significant financial consequences. An environment that is unsafe and antagonistic compromises the standard of care provided to patients and jeopardizes the fundamental <a href="https://www.britannica.com/topic/Hippocratic-oath">principles of professional ethics</a>.</p>
<p>Like other health issues, workplace bullying has severe consequences and can lead to <a href="http://dx.doi.org/10.28933/ijprr-2020-01-1205">long-term psychological stress</a>. Bullying is also linked to <a href="https://academic.oup.com/eurheartj/article/40/14/1124/5180493?login=false">cardiovascular illness</a>, musculoskeletal disorders, <a href="https://doi.org/10.1111/j.1467-9450.2011.00932.x">sleep problems</a>, and <a href="https://doi.org/10.5964/ejop.v15i4.1733">generalized pain</a>. For those who are already struggling with mental health issues and suicidal thoughts, workplace bullying can increase the <a href="https://www.suicideinfo.ca/local_resource/workplace-suicide-prevention/">risk of suicide</a>.</p>
<h2>Independent oversight needed</h2>
<p>It’s time to understand workplace violence as a <a href="https://theconversation.com/workplace-bullying-should-be-treated-as-a-public-health-issue-190330">public health issue</a>. Substantial change may finally be achieved by allocating the proper financial and legal resources required for assessing, substantiating and intervening in to workplace bullying under the framework of the <a href="https://lois-laws.justice.gc.ca/eng/acts/P-29.5/">Public Health Act</a>. There is <a href="https://doi.org/10.22454/FamMed.2020.384384">no independent oversight of complaints in Canada</a>, and it’s time to acknowledge that internal <a href="https://hrdailyadvisor.blr.com/2020/07/07/the-dangers-of-mishandling-harassment-complaints/">human resource departments are ill equipped</a> to deal with this issue.</p>
<p>A bold step forward would be the appointment of a national commissioner for workplace violence with the authority to probe allegations and impose heavy penalties. Such a dedicated entity would send a clear message: workplace harassment and discrimination will not be tolerated.</p>
<p>Workplace bullying could be significantly reduced by a public health mandate that includes a <a href="https://www.cdc.gov/eis/field-epi-manual/chapters/Interventions.html">universal prevention focus</a>, intensive intervention and ongoing public health surveillance. </p>
<p>Through a national public health mandate, the commissioner could prevent and address workplace bullying, harassment and sexual abuse through mandatory, sector-specific training for workers and employers. </p>
<p>They could also oversee a confidential and standardized reporting system for complaints. This would remove the risk of retaliation by employers or supervisors and circumvent internal investigations that can be riddled with conflicts of interest.</p>
<p>A public health framework also allows experts to improve strategies to prevent bullying. Legal mechanisms with financial and criminal penalties would create an accountability framework for organizations that promotes safe and respectful workplaces. These strategies, along with a regulatory authority that can intervene, will improve workplaces across Canada.</p><img src="https://counter.theconversation.com/content/217050/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Walker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Internal reviews are insufficient to investigate discrimination by hospital administrators and external frameworks are needed to protect employees who face bullying and harassment.Jason Walker, Program Director & Associate Professor, Industrial-Organizational and Applied Psychology, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2156792023-10-17T01:38:03Z2023-10-17T01:38:03ZDecades of underfunding, blockade have weakened Gaza’s health system − the siege has pushed it into abject crisis<figure><img src="https://images.theconversation.com/files/554124/original/file-20231016-15-4u7mpn.jpg?ixlib=rb-1.1.0&rect=0%2C98%2C4121%2C2644&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A health service on its knees.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/personnel-carry-a-man-to-a-hospital-in-khan-yunis-injured-news-photo/1726774222?adppopup=true">Abed Zagout/Anadolu via Getty Images</a></span></figcaption></figure><p>For the wounded, injured and sick in Gaza, there is seemingly no escape. On Oct. 17, 2023, news broke that at least 500 patients, staff and people seeking shelter from Israeli bombs had been <a href="https://apnews.com/article/israel-palestinians-gaza-hamas-war-biden-rafah-e062825a375d9eb62e95509cab95b80c">killed in an explosion at a hospital</a>, according to health authorities in the Hamas-run enclave.</p>
<p>It amounts to a devastating loss of life during a campaign of bombing that has not spared the frail or sick. Just days earlier, the World Health Organization said <a href="https://twitter.com/WHO/status/1713277138437038573">in a stark assessment</a> that an <a href="https://www.theguardian.com/world/2023/oct/16/it-will-be-worse-than-hamas-order-to-evacuate-strikes-fear-into-north-israel">order to evacuate</a> from hospital beds and head south amounts to a “death sentence.”</p>
<p>By that time, four hospitals <a href="https://www.pbs.org/newshour/world/food-water-and-medicine-run-low-in-gaza-amid-deadly-israeli-airstrikes-delayed-aid#:%7E:text=Four%20hospitals%20in%20northern%20Gaza,patients%20and%20newborns%20on%20ventilators.">had already ceased functioning</a> in Gaza’s north because of damage from Israeli bombs. </p>
<p>Beyond the sheer immediate devastation of the current conflict – in which <a href="https://www.wsj.com/livecoverage/israel-hamas-war-gaza-palestinians">thousands of Israelis and Palestinians</a> <a href="https://ochaopt.org/content/hostilities-gaza-strip-and-israel-flash-update-9">have been killed</a> – there will be significant and undoubtedly long-lasting implications for the Gaza Strip’s health system.</p>
<p>As a <a href="https://ccie.ucf.edu/person/yara-asi/">Palestinian expert in global health</a> who has worked with medical professionals from Gaza, I know that even before this latest escalation of violence, health services in Gaza were in a poor shape. Insufficiently and poorly resourced for decades, doctors and hospitals also had to contend with the <a href="https://doi.org/10.1136/bmj.g6644">devastating effects of a 16-year blockade</a> imposed by Israel, in part with <a href="https://www.csmonitor.com/World/Middle-East/2010/0402/Israel-Gaza-tensions-Why-Egypt-helps-maintain-the-blockade">coordination with Egypt</a>.</p>
<h2>A system completely overwhelmed</h2>
<p>The immediate concern in Gaza is for those seeking assistance due to the bombing campaign that Israel ordered after an attack on its people by Hamas fighters. An <a href="https://www.washingtonpost.com/national-security/2023/10/15/israel-gaza-urban-warfare-bloodbath/">expected ground offensive</a> will only further risk more civilian casualties. </p>
<p>Hospitals in Gaza are <a href="https://www.lemonde.fr/en/international/article/2023/10/16/overwhelmed-gaza-hospitals-try-to-treat-thousands-under-bombings_6178146_4.html">completely overwhelmed</a>. They are seeing around 1,000 new patients per day, in a health system with only <a href="https://www.aljazeera.com/news/2023/10/12/war-crime-gaza-medics-say-israel-targeting-ambulances-health-facilities">2,500 hospital beds</a> for a population of over 2 million people. It has forced hospitals to tend to patients <a href="https://www.who.int/news/item/14-10-2023-evacuation-orders-by-israel-to-hospitals-in-northern-gaza-are-a-death-sentence-for-the-sick-and-injured">in corridors and nearby streets</a>. People maimed in the bombing are being treated for horrific injuries without basics such as <a href="https://apnews.com/article/israel-palestinians-gaza-hamas-war-781b3c63af4ae6e51c313a68f314e66d">gauze dressings, antiseptic, IV bags and painkillers</a>. Those experiencing traumatic injuries are unable to receive sufficient care, increasing rates of infection and amputation.</p>
<figure class="align-center ">
<img alt="Paramedics roll over a man on a a gurney." src="https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554125/original/file-20231016-25-6vsoc6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A citizen receives first aid at a hospital in Khan Yunis, Gaza, on Oct. 16, 2023.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/citizen-receives-first-aid-at-a-hospital-in-khan-yunis-news-photo/1726774220?adppopup=true">Abed Zagout/Anadolu via Getty Images</a></span>
</figcaption>
</figure>
<p>And things may soon get worse. According to the United Nations’ Office for the Coordination of Humanitarian Affairs, Gaza’s hospitals have been forced to work <a href="https://ochaopt.org/content/hostilities-gaza-strip-and-israel-flash-update-9#:%7E:text=KEY%20POINTS,Ministry%20of%20Health%20in%20Gaza.">without electricity</a>, using fuel to run generators to ensure life-saving equipment remains functioning. The U.N. estimates this fuel will run out any day due to a complete siege placed on Gaza by Israel. </p>
<p>Such conditions have led to concerns that alongside the massive number of bombing victims, Gaza health services will soon have to <a href="https://abc7chicago.com/news-israel-war-palestine-hamas/13921958/">contend with the outbreak of disease</a>. Patients with immediate health needs, like dialysis or chemotherapy, are among those being ordered to leave and head for greater safety in Gaza’s south, although evacuation routes <a href="https://www.reuters.com/world/middle-east/palestinians-fleeing-fighting-south-find-no-escape-danger-2023-10-15/">have also been bombed</a>.</p>
<h2>A century of underfunding</h2>
<p>The current devastation to Gaza’s health system is obvious. But Gaza’s health care system was already under stress before the latest bombardment. In fact, policies that stretch back decades have left it unable to meet even the basic health needs of Gaza’s residents, let alone respond to the ongoing humanitarian catastrophe.</p>
<p><iframe id="Ky3de" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Ky3de/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In <a href="https://www.un.org/unispal/history/">just over a century</a>, the health system in Gaza has been administered by six authorities: the <a href="https://www.jewishvirtuallibrary.org/ottoman-rule-1517-1917">Ottomans until the end of World War I</a>, the <a href="https://time.com/3445003/mandatory-palestine/">British during the mandate period</a> from 1917 to 1947, <a href="https://embassies.gov.il/MFA/AboutIsrael/Maps/Pages/1949-1967%20Armistice%20Lines.aspx">Egypt from 1949 to 1967</a>, Israel under <a href="https://www.aljazeera.com/features/2018/6/4/the-naksa-how-israel-occupied-the-whole-of-palestine-in-1967">occupation starting in 1967</a>, and then a Ministry of Health led first by the Palestinian Authority from 1995-2006 and since then by Hamas.</p>
<p>What each have had in common is that, from my perspective as a global health expert, they invested little in Palestinian health. For periods of the 20th century, the health priorities of successive governing bodies appeared focused more on reducing the spread of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847484/">communicable disease</a> to protect foreigners interacting with the native Palestinian population. </p>
<p>There was seemingly far less attention paid to building health infrastructure, adequately training health personnel, promoting preventive care and other long-term initiatives that make up a sustainable health system.</p>
<p>Under Israeli occupation from 1967, several Palestinian hospitals were <a href="https://www.un.org/unispal/document/auto-insert-201580/">turned into detention centers or military offices</a>, while others were closed, and new ones were prohibited from opening. Palestinian physicians working in the occupied territories earned one-third the salary of their Israeli counterparts.</p>
<p>As a result of this neglect, health indicators throughout what are now called the occupied territories – the West Bank and Gaza Strip – have been poor. </p>
<p>Maternal and infant mortality – typical indicators of health system functioning – tends to be high. For example, <a href="https://www.un.org/unispal/document/auto-insert-201580/">in the mid-1980s</a>, infant mortality was over 30 per 1,000 live births for Palestinians, compared with just under 10 per 1,000 among the Jewish population of Israel. And infant mortality has <a href="https://www.unrwa.org/newsroom/press-releases/infant-mortality-gaza-no-longer-decline-%E2%80%9Calarming-trend%E2%80%9D-according-new">remained stubbornly high in Gaza</a>.</p>
<p>Meanwhile, a lack of a reliable drinkable water infrastructure and overall unsanitary conditions resulted in the spread of parasitic and other infectious diseases, like rotavirus, cholera and salmonella – which <a href="https://www.haaretz.com/middle-east-news/palestinians/2018-10-16/ty-article-magazine/.premium/polluted-water-a-leading-cause-of-gazan-child-mortality-says-rand-corp-study/0000017f-e847-dc7e-adff-f8ef68c50000">remain leading causes of death</a> in Gaza’s children.</p>
<h2>Dying before they can leave</h2>
<p>Most residents of Gaza <a href="https://www.prb.org/resources/the-west-bank-and-gaza-a-population-profile/">fled there in 1948</a> after being displaced from their homes in what became the state of Israel. They were classified as refugees, many receiving limited services from the <a href="https://www.unrwa.org/sites/default/files/about_unrwa.pdf">United Nations Relief and Works Agency for Palestine Refugees in the Near East</a> that was established in 1949.</p>
<p>Since then, chronic underfunding of public hospitals has meant that Palestinians in Gaza have remained reliant on outside money and nongovernmental organizations for essential health services. This started a trend of <a href="https://reliefweb.int/report/world/dependency-and-humanitarian-relief-critical-analysis">humanitarian dependence</a> that continues to this day, with many of Gaza’s health facilities funded by the United Nations, humanitarian agencies like <a href="https://www.msf.org/hospitals-are-overwhelmed-catastrophic-situation-gaza">Doctors Without Borders</a> and religious organizations.</p>
<p>During the passage of the <a href="https://history.state.gov/milestones/1993-2000/oslo">Oslo Accords</a> in the mid-1990s, the Palestinian Authority was established to administer services in the occupied territories. The accords called for health responsibilities to be transferred to the newly formed Palestinian Ministry of Health as preparation for a sovereign Palestinian state, which the accords called for within a five-year period.</p>
<p>The Palestinian Authority received a <a href="https://arabcenterdc.org/resource/international-aid-to-the-palestinians-between-politicization-and-development/">significant influx of humanitarian aid</a> as it took on civil responsibilities, including health. As a result, health indicators for Palestinians, including <a href="https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=PS">life expectancy</a> and <a href="https://data.worldbank.org/indicator/SH.IMM.MEAS?locations=PS">immunization rates</a>, started to improve in the late 1990s. </p>
<p>But as it became increasingly clear that the overarching goal of the Oslo Accords for Palestinians – statehood – <a href="https://theconversation.com/30-years-after-arafat-rabin-handshake-clear-flaws-in-oslo-accords-doomed-peace-talks-to-failure-211362">would not materialize</a>, disillusion with the Palestinian Authority led to victory for Hamas in 2006 elections held in Gaza. Since then, Hamas has been considered the de facto governing body in Gaza, while the Palestinian Authority operates in the West Bank.</p>
<p>The rise of Hamas, which <a href="https://www.dni.gov/nctc/groups/hamas.html">the U.S., Israel and others</a> designate as a terrorist group, saw Gaza become isolated from the international community. It also coincided with Israel imposing a full land, sea and air blockade of Gaza. </p>
<p>There is no doubt that the blockade has rapidly accelerated the <a href="https://www.map.org.uk/downloads/map-al-mezan-access-to-health-online.pdf">deterioration of the health system</a> in Gaza and <a href="https://www.worldbank.org/en/news/press-release/2023/09/18/palestinian-healthcare-critically-impacted-by-weak-economy-and-barriers">directly impacted the mortality</a> rate.</p>
<p>Gazans who need advanced care, whether for cancer or other chronic illnesses, traumatic injuries and other life-threatening ailments, often can only <a href="https://pubmed.ncbi.nlm.nih.gov/2215363/">access needed services</a> in Israeli hospitals and require a permit to cross the border from Gaza. Some die before the <a href="https://www.unicef.org/mena/documents/gaza-strip-humanitarian-impact-15-years-blockade-june-2022">permit process is complete</a>.</p>
<h2>Gaza health services after the siege</h2>
<p>This vulnerable health system is now facing unprecedented challenges, staffed by health professionals who have <a href="https://reliefweb.int/report/occupied-palestinian-territory/prcs-statement-al-quds-hospital-evacuation-order-enar">committed to stay with their patients</a> even under hospital evacuation orders and at risk of death.</p>
<p>It is uncertain what the health system of Gaza will look like in the future. </p>
<p>In years past, <a href="https://arabcenterdc.org/resource/rebuilding-gaza-yet-again/">international aid would help repair</a> and rebuild some, but not all, of the infrastructure damaged in airstrikes, especially schools and hospitals. </p>
<p>But Israeli Prime Minister Benjamin Netanyahu has promised a “<a href="https://www.nytimes.com/2023/10/08/world/middleeast/hamas-israel-netanyahu-gaza.html">long and difficult war</a>.” And with the level of destruction seen in just a few days, it remains unclear just what will be left in the aftermath.</p>
<p>Already <a href="https://insecurityinsight.org/wp-content/uploads/2023/10/2.-12-15-October-2023-Attacks-on-Health-Care-in-Israel-and-the-oPt.pdf">at least 28 doctors and other health workers</a> have been killed in Gaza, with ambulances and a number of hospitals rendered useless by the bombs.</p>
<p>Replacing this human capital and vital infrastructure could take years, if not generations – and that is without the limits of a punishing blockade and continued bombardment.</p>
<p><em>This article was updated on Oct. 17, 2023 to add news of an explosion at a Gazan hospital.</em></p><img src="https://counter.theconversation.com/content/215679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yara M. Asi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hospitals have been destroyed, and doctors and health care staff killed. Gaza’s health services may take years to recover, warns a Palestinian health specialist.Yara M. Asi, Assistant Professor of Global Health Management and Informatics, University of Central FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2120722023-08-29T12:25:50Z2023-08-29T12:25:50ZPrescriptions for fruits and vegetables can improve the health of people with diabetes and other ailments, new study finds<figure><img src="https://images.theconversation.com/files/544806/original/file-20230825-16121-jw13nf.jpg?ixlib=rb-1.1.0&rect=38%2C0%2C6430%2C5266&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">"Food is medicine" programs recognize the vital importance of fresh produce in a person's overall health. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/healthy-eating-exercising-weight-and-blood-pressure-royalty-free-image/1280587810?phrase=food+as+medicine&adppopup=true">fcafotodigital/E+ via Getty Images</a></span></figcaption></figure><p>The health of people with diabetes, hypertension and obesity improved when they could get free fruits and vegetables with a prescription from their doctors and other health professionals. </p>
<p>We found that these patients’ <a href="https://doi.org/10.1161/CIRCOUTCOMES.122.009520">blood sugar levels, blood pressure and weight improved</a> in our new study published in Circulation: Cardiovascular Quality and Outcomes.</p>
<p>The improvements we saw in clinical outcomes could have a meaningful impact on overall health. For example, systolic blood pressure, or blood pressure during heartbeats, decreased more than 8 millimeters of mercury, or mm Hg, while diastolic blood pressure, or blood pressure between heartbeats, decreased nearly 5 mm Hg. For context, this is about half the drop <a href="https://doi.org/10.1016/j.amjhyper.2005.01.011">gained through medications that lower blood pressure</a>.</p>
<p>Many U.S. health care providers have been experimenting with “<a href="https://doi.org/10.1136/bmj.m2482">food is medicine</a>” programs, which provide free, healthy food to patients – sometimes for a year or more. </p>
<p>This is the largest analysis to date of produce prescription programs, which are one variety of these efforts. They let patients with diet-related illnesses get apples, broccoli, berries, cucumbers and other kinds of fruits and vegetables for free. In Los Angeles, Boise, Houston, Minneapolis and other places where the programs we studied were located, participants selected the produce of their choice at grocery stores or farmers markets using electronic cards or vouchers. They typically received about US$65 per month for four to 10 months. </p>
<p>We pooled data from 22 U.S. produce prescription locations operated by <a href="https://www.wholesomewave.org/">Wholesome Wave</a>, a nonprofit that promotes access to affordable, healthy food. None of the pilots had previously been evaluated. All 4,000 participants either had, or were at risk for, poor cardiometabolic health and were recruited from clinics serving low-income neighborhoods.</p>
<p>Participants in these programs ate more fruits and vegetables. They were also one-third less likely to <a href="https://theconversation.com/what-is-food-insecurity-152746">experience food insecurity</a> – not having enough food to meet basic needs and lead a healthy life. </p>
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<figcaption><span class="caption">Wholesome Wave’s Fruit & Vegetable Prescription Program explained.</span></figcaption>
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<h2>Why it matters</h2>
<p>More than 300,000 Americans <a href="https://doi.org/10.1001/jama.2017.0947">die annually of cardiovascular disease and diabetes</a> cases tied to what they eat.</p>
<p>The people in the estimated <a href="https://www.ers.usda.gov/webdocs/publications/104656/err-309_summary.pdf?v=9300.6">13.5 million U.S. households</a> experiencing food insecurity are more likely than others to have <a href="https://doi.org/10.1007%2Fs13668-021-00364-2">cardiometabolic health problems</a>, such as diabetes or heart disease. They also have <a href="https://doi.org/10.1161/JAHA.119.014629">shorter life expectancy</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426124/">higher medical costs</a>. </p>
<p>Most Americans, regardless of their income, <a href="https://doi.org/10.1001/jama.2016.7491">don’t follow a healthy diet</a>. However, research shows that <a href="https://doi.org/10.1001%2Fjama.2019.13771">lower-income Americans tend to eat food</a> that’s slightly worse for their health than those who can afford to spend more.</p>
<p>The <a href="https://health.gov/our-work/nutrition-physical-activity/white-house-conference-hunger-nutrition-and-health">2022 White House Conference on Hunger, Nutrition and Health</a> brought together experts who outlined a national strategy to eradicate food insecurity and reduce diet-related illnesses. It <a href="https://www.whitehouse.gov/wp-content/uploads/2022/09/White-House-National-Strategy-on-Hunger-Nutrition-and-Health-FINAL.pdf">ended with a strategy calling for</a>, among other things, more produce prescription programs.</p>
<p>The last White House conference on hunger and nutrition, which occurred over 50 years earlier, <a href="https://doi.org/10.1093%2Fcdn%2Fnzaa082">led to significant and lasting changes in U.S. food policies</a>. The National School Lunch Program expanded and the <a href="https://www.fns.usda.gov/wic/about-wic-how-wic-helps">Special Supplemental Nutrition Program for Women, Infants and Children</a>, known as WIC, was created. </p>
<p>Within a year of the latest conference, two government agencies – the <a href="https://www.hhs.gov/about/news/2023/04/26/hhs-announces-25-million-produce-prescription-programs-indian-country.html">Indian Health Service</a> and the <a href="https://www.va.gov/houston-health-care/news-releases/va-and-the-rockefeller-foundation-join-forces-to-increase-healthy-food-access-improve-health-outcomes-for-veterans/">Veterans Health Administration</a> – announced produce prescription pilots. Eight state Medicaid programs have <a href="https://www.axios.com/2023/03/16/medicaid-for-food-next-states">received or applied for federal waivers</a> that would allow Medicaid to pay for produce prescriptions <a href="https://www.statnews.com/2023/06/27/food-as-medicine-cms-guidelines-produce-prescription/">for up to six months</a> for some people. However, these programs remain unavailable to most Americans who might benefit.</p>
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<figcaption><span class="caption">Dariush Mozaffarian of Tufts University discusses ‘food is medicine’ initiatives.</span></figcaption>
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<h2>What’s next</h2>
<p>We are evaluating “food is medicine” pilots funded by the <a href="https://www.mass.gov/info-details/massachusetts-delivery-system-reform-incentive-payment-program#flexible-services-">Flexible Services Program</a> in Massachusetts’ Medicaid program. We are also running a large, randomized controlled trial, in which one group of patients with cancer will get free home-delivered meals and another will receive standard care.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/212072/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kurt Hager volunteers as a steering committee member for the National Produce Prescription Collaborative.</span></em></p><p class="fine-print"><em><span>Fang Fang Zhang receives funding from the Rockefeller Foundation and East Bay Community Foundation for this work. </span></em></p>When people taking part in 22 pilot programs across the US got free fruits and vegetables, their health improved.Kurt Hager, Instructor of Epidemiology, UMass Chan Medical SchoolFang Fang Zhang, Professor of Epidemiology, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2107552023-08-07T16:09:40Z2023-08-07T16:09:40ZExercising during a hospital stay linked with faster recovery – new research<figure><img src="https://images.theconversation.com/files/541207/original/file-20230804-29-q1q0wv.jpg?ixlib=rb-1.1.0&rect=48%2C0%2C5400%2C3597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As little as 25 minutes of walking a day had benefits.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurses-well-good-taken-care-elderly-1627720162">Photo_imagery/ Shutterstock</a></span></figcaption></figure><p>When a person is admitted to hospital for any reason – whether due to illness or to undergo surgery – it’s expected they will spend the duration of their stay resting in bed while they recover. While rest is important, too much sitting or bed rest can actually make matters worse, with <a href="https://journals.lww.com/ccmjournal/fulltext/2009/10001/Consequences_of_bed_rest.19.aspx?casa_token=rSkaD_UMbOAAAAAA:6gylXSOMr6ioHtEpUpaa3g3bdrYbt0yHHV8mcWXLRRtCGq_KEzrz9Uw-Dw7ZeLuE9nel-R9N9v0c0n-VjlQx-CV5tWjy5gl8eA">research showing</a> it can slow recovery and lead to more health problems.</p>
<p>Our <a href="https://bjsm.bmj.com/content/early/2023/05/22/bjsports-2022-106409">latest study</a> shows that physical activity may help to counteract the effects of bed rest. We found that even just 25 minutes a day of walking while in hospital can significantly speed up recovery for older adults – and it may also prevent new hospital stays in the future.</p>
<p>To conduct our study, we analysed data from 19 clinical trials that looked at the effect of staying active in the hospital on a participant’s physical function, their risk of subsequent health problems (such as falls), and also risk of hospital readmission. </p>
<p>In total, we looked at data from 3,000 older adults aged 55 to 78, who were admitted to a hospital intensive care unit or general medicine ward for seven to 42 days because of an acute illness (such as respiratory failure) or for surgery. We also looked at different types and amounts of physical activity, from simple bedside stretching exercises to walking programmes, as well as daily strength and aerobic exercises. </p>
<p>Our analysis revealed that older adults who did light physical activity (such as walking) while staying in hospital had better physical function by the end of their hospital stay, and a 10% lower risk of being readmitted to hospital within 30 days of discharge, compared with those who did not. The more activity a person did – and the more intense that activity was – the better their physical function and the lower their risk of being readmitted.</p>
<p>Overall, we found the optimal amount of activity was around 40 minutes per day of walking at moderate intensity – that is, walking at a speed that makes you slightly out of breath. </p>
<p>Importantly, older adults who remained active in the hospital were also 10% less likely to experience falls, disability or death after discharge, compared with those who remained inactive. This suggests physical activity may protect against the harmful effect of too much bed rest during hospital stays. </p>
<figure class="align-center ">
<img alt="A young female nurse helps an older patient perform an exercises using a resistance band." src="https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541208/original/file-20230804-23-p7nvgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Strength exercises during a hospital stay were also shown to be beneficial.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-physical-therapist-caregiver-assisting-mature-2303029337">PanuShot/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Other studies have also shown the benefits of physical activity during a hospital stay. For instance, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223185">research shows</a> that early mobility therapy for critically ill and unconscious patients staying in intensive care units have faster recovery, better physical function, and more ventilator-free days.</p>
<p>Our study adds to this evidence by identifying optimal exercise types, as well as the amount of activity needed to see benefits.</p>
<h2>The importance of movement</h2>
<p>The idea that we should rest in bed while in hospital – and that activity could hamper recuperation – has long been a misconception. In fact, we have known since the 1940s about the <a href="https://pubmed.ncbi.nlm.nih.gov/18860463/">negative effects of bed rest</a>. </p>
<p>Since then, a lot of bed rest research has been conducted – mainly to understand what <a href="https://link.springer.com/article/10.1007/s00421-007-0474-z">effect space exploration</a> may have on the body, since astronauts spend long periods in a weightless environment. Surprisingly, within hours of bed rest, we start to lose <a href="https://pubmed.ncbi.nlm.nih.gov/15900645/">muscle and bone mass</a>. This leads to <a href="https://journals.lww.com/ccmjournal/fulltext/2009/10001/Consequences_of_bed_rest.19.aspx?casa_token=rSkaD_UMbOAAAAAA:6gylXSOMr6ioHtEpUpaa3g3bdrYbt0yHHV8mcWXLRRtCGq_KEzrz9Uw-Dw7ZeLuE9nel-R9N9v0c0n-VjlQx-CV5tWjy5gl8eA">deconditioning</a>, loss of strength, and ultimately a reduced ability to do daily tasks independently.</p>
<p><a href="https://www.nursingtimes.net/clinical-archive/gastroenterology/effects-of-bedrest-3-gastrointestinal-endocrine-and-nervous-systems-21-01-2019">Prolonged bed rest</a> also decreases blood flow and lung capacity and increases the risk of deep vein thrombosis. It can also lead to pressure sores and constipation and incontinence.</p>
<p>But physical activity helps to prevent deconditioning and <a href="https://pubmed.ncbi.nlm.nih.gov/10822903">preserve the muscle strength</a> needed for mobility and daily tasks. It also keeps the <a href="https://www.sciencedirect.com/science/article/pii/S0002914911027597?casa_token=7ZHp3vx8aR0AAAAA:M_wf6wL7PaIL9e7EjOeLMPZf1XERBIk29f2vnw5LI2SzTTyvZqQqLnAt1PDMmxd8EDeblowiDTeH">cardiovascular system</a> working as it should, and helps prevent <a href="https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0038-1673636?casa_token=ZkSINK5itBQAAAAA:TEQ6Jx4BUTCTWw05F_kmYgCaDdhcArY30fmcqMN8jQ4vLPwWz8C3JZk4CQuRd8WlMzJ9j6OPMcr3dXqS">deep vein thrombosis</a> and <a href="https://www.ingentaconnect.com/content/ben/cpd/2018/00000024/00000018/art00002">gastrointestinal problems</a>. </p>
<p>And the benefits of movement aren’t only physical. Exercise is shown to relieve <a href="https://bjsm.bmj.com/content/early/2023/07/11/bjsports-2022-106195">boredom and improve mood</a>. It also connects patients with staff and caregivers, <a href="https://onlinelibrary.wiley.com/doi/10.1111/jocn.15994">improving mental health</a>.</p>
<p>Importantly, being active while in the hospital will help patients remain active in their daily lives, which is one of the most effective ways to <a href="https://www.who.int/publications/i/item/9789240015128">stay healthy</a> once back at home. This may explain why our study found that those who were active during a hospital stay had lower readmission rates.</p>
<p>So, next time you need to go to the hospital, pack your walking shoes. There’s no “one size fits all” solution, but every movement counts. The key is to make sure you’re doing activities suited to your abilities. If you’re recovering from surgery or have a heart condition, be sure to start slowly with exercise and then increase it gradually.</p>
<p>Even small things – such as getting out of bed and moving to a nearby chair to rest, or going for a short stroll to the toilet or cafeteria – are a good start. If you aren’t sure where to begin, be sure to talk to your GP, nurse or even a physiotherapist who can recommend a tailored routine.</p><img src="https://counter.theconversation.com/content/210755/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Borja del Pozo Cruz receives funding from the Government of Andalusia (Spain), Research Talent Recruitment Program (EMERGIA 2020/00158)</span></em></p><p class="fine-print"><em><span>Sebastien Chastin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients who exercised during a hospital stay had a 10% lower risk of being readmitted to hospital within 30 days of discharge.Sebastien Chastin, Professor Health Behaviour Dynamics of People, Places and Systems, Glasgow Caledonian UniversityBorja del Pozo Cruz, Investigador principal en Ciencias de la Salud, Universidad de CádizLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2080902023-06-27T14:52:52Z2023-06-27T14:52:52ZHow the NHS’s original vision to design healthier hospitals fell into disrepair<figure><img src="https://images.theconversation.com/files/534381/original/file-20230627-21-xd13tl.jpg?ixlib=rb-1.1.0&rect=5%2C2%2C1764%2C1114&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When St Helier Hospital in Carshalton opened, it was viewed as the last word in modernist design.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Student_Nurse-_Life_at_St_Helier_Hospital,_Carshalton,_Surrey,_1943_D13888.jpg">Imperial War Museum Archives via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><blockquote>
<p>Outpatients at St James’ Hospital feel better even before they see the doctor – thanks to a new note in hospital design. ‘Comfort while you wait’ is the new policy, and that means an informal atmosphere, extra comfy chairs, concealed lighting, heated cork floors, and an ultra-modern design throughout. No shades of depressing institutions here.</p>
</blockquote>
<p>You might think this description comes from the glossy marketing material for one of today’s cutting-edge private hospitals. In fact, it’s from a <a href="https://www.youtube.com/watch?v=qygR9TwXHbU">1954 Pathé News clip</a> celebrating one of the earliest buildings designed for Britain’s fledgling National Health Service (NHS) – launched six years earlier on July 5, 1948.</p>
<p>What St James’ Hospital in Balham, south London, lacked in size, it made up for in ambition. The new central complex embodied the stated ideals of the NHS, to provide an equitable service for all citizens, free of charge and of the highest standard. The new buildings contained consulting rooms, staff offices and waiting rooms, and a children’s room that was lauded by the Pathé commentator:</p>
<blockquote>
<p>In the children’s room, the longer the youngsters have to wait, the better they like it. They can play as loudly as they like, for in their own room their chatter and high spirits can’t worry other patients … It’s no wonder that in this hospital, some of the children and their parents come a little early for their appointments on purpose!</p>
</blockquote>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/qygR9TwXHbU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A tour of the newly opened St James’ Hospital in Balham (1954)</span></figcaption>
</figure>
<p>As we take stock of the NHS on the occasion of its 75th anniversary, most attention is focused on staff pay demands, lengthy waiting lists for treatment, and the intolerable pressures on staff during and beyond the pandemic. But the design and upkeep of NHS hospital buildings, and the impact these can have on the patients and staff who inhabit them, is another <a href="https://www.itv.com/news/2023-02-21/patient-safety-at-risk-from-crumbling-nhs-hospitals-in-urgent-need-of-repair">pressing</a>, if less widely publicised, issue.</p>
<hr>
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<img alt="" src="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
<hr>
<p>I believe we can find answers to at least some of today’s health service problems by looking at the history of these buildings, and the shifting design priorities they reflect.</p>
<p>The story of St James’ Hospital is a case in point. Less than 40 years on from the proud launch of its new central complex, the entire hospital stood empty and ruinous – a symbol, perhaps, of the failed ambitions of the early NHS. The buildings were demolished in 1992, and the site was redeveloped for housing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Overgrown and disused hospital building with graffiti" src="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St James’ Hospital outpatients department in 1991, prior to its demolition.</span>
<span class="attribution"><span class="source">Harriet Richardson Blakeman</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Parts of this hospital are sinking</h2>
<p>Another south London hospital was in the news recently. “Patient safety at risk in crumbling hospital Boris Johnson promised to replace,” read a <a href="https://www.theguardian.com/society/2023/may/13/patient-safety-at-risk-in-crumbling-hospital-boris-johnson-promised-to-replace">headline in the Observer</a>, describing conditions in St Helier Hospital, Carshalton.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Crumbling hospital building" src="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=685&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=685&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=685&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=861&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=861&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=861&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St Helier Hospital, Carshalton.</span>
<span class="attribution"><span class="source">Harriet Richardson Blakeman</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><a href="https://en.wikipedia.org/wiki/St_Helier_Hospital">St Helier was built</a> just before the outbreak of the second world war, constructed on reinforced concrete foundations with a steel-frame and brick infill, faced in white-painted cement render. At the time, it was regarded as the last word in up-to-date modernist design, with “accommodation of the highest class in any part of the world”.</p>
<p>Now, parts of this hospital are sinking. The basement floods, wards are sometimes forced to close, and the hospital has become “dilapidated and unpleasant”, <a href="https://www.theguardian.com/society/2023/may/13/where-are-the-tories-promised-40-new-hospitals-we-cannot-afford-to-wait-any-more">according to Ruth Charlton</a>, chief medical officer of Epsom & St Helier University Hospitals NHS Trust. In a recent commentary, she wrote:</p>
<blockquote>
<p>Our ageing estate looked awful even when I joined, and over the years it’s decayed further before my eyes. Healthcare standards are getting higher while our hospitals are sliding into even more disrepair … Only last week we had to close one of our wards because the lift wasn’t working.</p>
</blockquote>
<p>Nor is this an isolated case. In April, a <a href="https://twitter.com/doctor_oxford/status/1643894825182285827?s=20">tweet</a> by palliative care doctor and author Rachel Clarke showed “an actual interior corridor of a major NHS hospital”. The photograph looks like the bowels of a particularly unsavoury multi-storey carpark, yet the reflection in the mirror clearly shows it is an internal space. The paint is peeling, the damp so bad that a streak of green algae is running down the corner of the room.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1643894825182285827"}"></div></p>
<p>Along with such images of decay and dereliction, we have also seen images of egregious overcrowding over the past few years, as COVID-19 put extreme demands on NHS facilities that were already creaking badly. <a href="https://www.theguardian.com/society/2022/jul/14/hospital-patients-being-treated-in-corridors-and-waiting-areas-says-rcn">Accounts</a> of patients being treated in corridors and even in <a href="https://www.thetimes.co.uk/article/patients-treated-in-car-parks-as-a-e-crumbles-under-pressure-lnxqgd6nf">hospital car parks</a> continued last winter, even when the COVID threat had receded somewhat.</p>
<p>In January 2023, Alice Kenny, a junior sister at Queen’s Hospital in Romford, east London, who had been redesignated as a “corridor nurse”, <a href="https://www.bbc.co.uk/news/uk-england-london-64226656">told the BBC</a>:</p>
<blockquote>
<p>We don’t train to give care in corridors. It is really not nice and if we were in [our patients’] shoes, we’d be really upset as well. We’re supposed to look after patients like we do our own family, and we’re not able to do that.</p>
</blockquote>
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<figcaption><span class="caption">Interviews with staff forced to look after patients in corridors at Queen’s Hospital, Romford.</span></figcaption>
</figure>
<h2>The ideas and ideals of early NHS designs</h2>
<p>As the architectural history of the NHS is such a huge subject, I have mainly focused on Scotland where I live and can access the official records – some of which have only become available to researchers in recent years. This has provided fresh insights into the ideas and ideals behind the design of the first purpose-built hospitals built by the NHS.</p>
<p>The problems back then were not dissimilar to those faced today: old worn-out buildings, staff shortages, rising costs and economic austerity. Take Old Monkland Home in Coatbridge, to the east of Glasgow – one of the 3,000-or-so hospitals that were transferred to state ownership when the NHS came into being in July 1948. A review of this <a href="https://www.workhouses.org.uk/OldMonkland/">former poorhouse</a>’s facilities, published in a <a href="https://archive.org/details/b32179121_0005">national hospital survey</a> before the end of the second world war, was damning:</p>
<blockquote>
<p>Old Monkland Home occupies a depressing site in Coatbridge. The hospital part now contains 69 beds, and there is also an asylum for milder types of lunatic … The impression is one of general neglect. The dining-room is very gloomy, the hospital is very little better than the main house, and the asylum block is totally unsuitable for patients of any kind. We are of the opinion that this institution is quite unsuitable for the care of the sick, and should be abandoned.</p>
</blockquote>
<p>The NHS had inherited a patchwork of hospitals, predominantly over half-a-century old, that had been built to meet the medical needs of the time: sanatoria for tuberculosis, isolation hospitals for once-common infectious diseases such as measles and diphtheria, and cottage hospitals run by country GPs who carried out routine surgery, delivered local babies, set bones and treated wounds from accidents.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>There were also large urban workhouse infirmaries full of chronically ill elderly patients, huge mental hospitals, teaching hospitals, and convalescent homes. Funding to build and run them came from a wide range of sources, including public donations, church collections, the rates, government loans, and work-placed insurance schemes.</p>
<p>These buildings had been “built to last” 100 years or more (brick or stone buildings that were expensive to construct were only economically viable if they had a long lifespan). But they suffered from a lack of structural maintenance and redecoration during the war, and afterwards from the severe shortages of labour and materials.</p>
<p>The UK-wide survey of hospitals had been intended to inform post-war reconstruction and the development of a “<a href="https://wdc.contentdm.oclc.org/digital/collection/health/id/208/">national hospital service</a>”, which aimed to “ensure that every patient requiring hospital treatment could obtain it without delay in the hospital most suited to their needs”. In reality, it painted a picture of uneven distribution and poor facilities, with the worst of the buildings being the old workhouses:</p>
<blockquote>
<p>Wigtownshire Home, Stranraer, has not undergone any appreciable change since it was built about 1850. The building is worn out and dreary … This is a very poor place, and is quite unsuitable for housing the sick or aged, or indeed for any other purpose.</p>
</blockquote>
<p>In the immediate post-war years, new housing was the most urgent requirement throughout Britain, along with new schools after the <a href="https://www.nationalarchives.gov.uk/cabinetpapers/themes/butler-act.htm#:%7E:text=The%20Education%20Act%20%2D%20or%20'Butler,into%20primary%20and%20secondary%20schools.">Butler Act of 1944</a> raised the school-leaving age to 15 (with a post-war baby boom to follow). Yet there was also a widespread consensus among the public that the current level of healthcare provision was no longer acceptable. A new type of hospital facility was needed to reflect the scientific advances of medicine and the aspirations of post-war Britain.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Aerial view of hospital complex on front of postcard with text" src="https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532893/original/file-20230620-29-veiebv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A postcard extols the futuristic design of Vale of Leven, the NHS’s first new general hospital.</span>
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</figure>
<h2>A five-star ‘hospital of the future’</h2>
<p>These aspirations found physical form in the <a href="https://historic-hospitals.com/2016/04/10/vale-of-leven-hospital-the-first-new-nhs-hospital-in-britain/">first new general hospital</a> built in Britain for the NHS, which <a href="https://www.facebook.com/savethevale/videos/aother-old-video-of-the-vale-hospital-thank-you-for-these/209682076082610/">opened</a> in Scotland in 1955 at Vale of Leven to the north-west of Glasgow. One of its most striking features were the wards, which were dramatically different from the traditional “Nightingale-style” open wards that offered no privacy to patients.</p>
<p>At Vale of Leven, the beds were grouped in bays separated by glazed screens. Ceiling heights were lower to create a more homely feel. The day room was furnished like a domestic sitting room, with comfortably upholstered armchairs. Windows were set low enough in the walls for patients to be able to see the grounds while lying in bed – and they also provided natural ventilation, allowing fresh air and the sound of birdsong to enter each ward.</p>
<p>Facilities for staff were an important consideration, as <a href="https://archive.org/details/sim_architect-building-news_1955-09-29_208_13/page/n35/mode/2up?q=%22Vale+of+leven+Hospital%22">the Architect & Building News</a> explained:</p>
<blockquote>
<p>A nurse’s station is an L-shaped counter containing knee space, drawers, filing cabinets etc, with a dwarf glass screen to cut off draughts, record board and shaded reading light, and small cupboards behind in the storage wall. The station is raised on a low step so that, when sitting, the nurse has a view of her 13 beds and, in fact, is only 25 feet away from her farthest patient and is quickly conscious of any movement or disturbance. Signal lights from beds are placed so that they can be seen from either of two nurse’s stations in case one is temporarily unoccupied.</p>
</blockquote>
<p>The subject of hospital design was now a hot topic among architects, health professionals and administrators alike – with an emphasis on the collaborative planning processes and research-led design that had evolved in more progressive architecture schools before the war. Schools such as the Architectural Association in London and Liverpool had developed a belief in social theory and managerial efficiency. Architects sought specialist advice on every aspect of the hospital, from the wards to catering and even laundries. As the regional architect for the South Eastern Regional Hospital Board wrote in 1951 about his new building schemes:</p>
<blockquote>
<p>It would be futile for medical science to progress and leave in its wake a dull, unimaginative architecture.</p>
</blockquote>
<p>Another reason for the extra care being taken over these new buildings was that, in the period of full employment in the 1950s and ‘60s, it was often proving difficult to attract enough hospital staff. The shortage of nurses, traditionally a female role, was especially acute because the rate of pay was lower than for many office jobs in the private sector – jobs that also offered shorter hours and fewer pressures than nursing.</p>
<p>To entice new recruits and enhance retainment levels, local management boards pushed hard to get well-appointed nurses’ homes built and to provide generous staff social and recreational facilities – from tennis courts to swimming pools, coffee bars to halls for cinema shows and dances.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/RMlFYzcJS78?wmode=transparent&start=2" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An introduction to High Wycombe General Hospital: ‘Medical science, 1967-style’.</span></figcaption>
</figure>
<p>At this time, the opening of a new hospital was a newsworthy event, featured in the architectural and medical press, national and local newspapers, and in newsreels. The opening of the new High Wycombe General Hospital in the mid-1960s was met with another <a href="https://www.youtube.com/watch?v=RMlFYzcJS78">gushing tribute</a> from the Pathé News team:</p>
<blockquote>
<p>The spaciousness of the entrance and reception hall will give patients confidence that here they are meeting medical science 1967-style, equipped as it should be. Gone is the old atmosphere of healing on the cheap, gone too is the belief that staff of the hospitals should put up with third-rate food and bad quarters. The menus in the nurses’ dining room are varied and make eating a pleasure deserved by women whose devoted service goes far beyond the minimum they could get away with.</p>
</blockquote>
<p>I remember this hospital (more commonly known as Wycombe General) from not long after the film was released. It was where I had a tonsillectomy – then a routine operation – at the age of seven. I recall the hospital being shiny and modern, with toilets that were spotlessly clean and, unlike our loo at home, heated!</p>
<p>I remember the children’s ward being a bright sunny room with about eight beds, and a small dayroom where we had breakfast that was made rather cramped by an enormous toy cupboard, where a kind nurse hid my bowl of porridge which I could not eat. I had no trouble with the ice cream we were allowed to have in bed after our operations, though.</p>
<p>Our parents only visited for a short time during the day, but we didn’t seem to mind or feel anxious about it – perhaps in part because of the atmosphere in the hospital, where modern architecture conveyed, even to a young child, confidence in medical science. As the Pathé commentator concluded:</p>
<blockquote>
<p>There is a good reason for High Wycombe General being called a five-star luxury hospital. It’s part of the new approach to the art and science of getting sick people well.</p>
</blockquote>
<p>Fast-forward just over half a century, however, and Wycombe General is now <a href="https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-65913081">“approaching its end of life”</a> and in “dire need of replacement”, according to the NHS trust that runs it. While confirming to the BBC that the hospital is still “safe”, the hospital’s ongoing repairs and maintenance now cost the trust around £2 million a year.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="External view of general hospital building" src="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Wycombe General in May 2020: the hospital is ‘in dire need of replacement’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/high-wycombe-buckinghamshire-uk-05-18-1737902921">Ben Molyneux/Shutterstock</a></span>
</figcaption>
</figure>
<h2>The ambitious plan quickly comes off the rails</h2>
<p>Wycombe General was built following a period when funding for hospital building had increased by over 50%. In 1962, the UK government had published its <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-9515.1981.tb00662.x">Hospital Plan</a>, which promised that 90 new hospitals would be commenced in England and Wales by 1971. The plan was to provide a network of new district general hospitals evenly distributed around the country, so that everyone would be in easy reach of all the main hospital services, with just a few of the more unusual specialities based at a regional centre.</p>
<p>However, it did not take long for this ambitious plan to come off the rails. Not enough money had been pledged by the government to fund all the schemes that were proposed, the process of planning and design took a long time, costs escalated, and by 1964, comprehensive revisions had to be made. In successive years, the plans were scaled back.</p>
<p>By the mid-1960s, relatively little had been achieved and the policy of concentrating on district general hospitals was questioned. The <a href="https://hansard.parliament.uk/Commons/1969-05-23/debates/bc336ab2-a648-4657-82eb-8790c4de9597/Scotland(HospitalBuildingProgramme)">1966 revision</a> of the Hospital Plan refocused the building programme towards creating units for the elderly and mentally ill. Start dates for new hospitals were postponed and, to try to combat rising costs, stricter financial controls were introduced.</p>
<p>Despite this, there was still a belief in producing good quality buildings designed to meet the needs of modern medicine in attractive surroundings. As the Architects’ Journal put it when discussing the new staff restaurant and stores building at Kingston Hospital in Surrey:</p>
<blockquote>
<p>The matter of nurses’ meals is almost a household topic and, along with spectacles and false teeth, has been giving the health ministry a bad press.</p>
</blockquote>
<p>At Falkirk Royal Infirmary in Scotland’s central belt, meanwhile, an experimental surgical ward unit was designed around new ways of organising nursing on the lines of progressive patient care, while also making the nurses’ routines easier and reducing the amount of walking they would have to do. Hospital infection and resistance to antibiotics were already a concern in the 1960s, and engineers designed more sophisticated heating and ventilation systems to control the movement of airborne infections and prevent cross infection.</p>
<p>Unfortunately, such considerations cost more than the government was willing to spend, and no health minister of either political persuasion was able to convince the cabinet or the Treasury to provide the amount of money that the rebuilding programme was going to cost.</p>
<p>The 1970s was a period of devaluation of sterling, strikes and war in the Middle East that caused an oil crisis. There was a three-day week, petrol rationing and power cuts. This led to public spending cuts that only worsened the position for the hospital building programme. At the same time, there was widespread criticism of the amount of time it was taking to build each hospital, and concern that a number of recently completed hospitals had been found to have structural defects.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="View of hospital building with hills in the distance" src="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Inverclyde Royal Hospital: the brutalist building took 15 years to finish and ran way over budget.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scottish-hospital-brutalist-architecture-greenock-inverclyde-2270853881">Richard Johnson/Shutterstock</a></span>
</figcaption>
</figure>
<p>A case in point is the saga of Inverclyde Royal Hospital in Greenock, west Scotland – one of the new district general hospitals promised in the original Hospital Plan. After a provisional cost limit of just over £4 million was approved in 1964, a design team was appointed the following year. However, the UK government halted the project for nearly two years due to a shortage of funds – a time when lots of large national projects were being halted. At the same time, the design brief had to be revised to keep up-to-date with technical guidance.</p>
<p>Amid new tenders, spiralling budgets and a further cost reduction exercise, work finally started on site in 1970, but the official contract completion date of March 1976 was missed, and the fabric of the building was eventually completed in November 1977 – only for the ventilation systems to be found to be defective.</p>
<p>It was not until the very end of 1979 that Inverclyde Royal Hospital was finally completed, at a cost of over £13m – more than three times the original cost limit. There was no single reason for the vastly increased cost, but the era’s high inflation rates were a significant factor. Each delay led to the cost going up, cancelling out the cost reduction exercise. Time and again on new hospital schemes, such exercise led to the use of poorer-quality materials and inferior heating and ventilation systems, which would cause problems with the building later on.</p>
<p>But more fundamentally, the new hospitals being built were now anticipated to last only between 40 and 50 years at the most. The reasons why this changed from the Victorian era when hospitals were built to last for a century or more, are many and complex. The main reason was the increasingly rapid advances being made in medical science, which led to a widespread view that the buildings would become obsolete as medical needs evolved.</p>
<p>But 40 is no age to be consigned to the scrap heap. We do not expect our homes to expire after such a short timespan – but equally, we understand that we need to invest in maintenance to keep them in good condition.</p>
<p>As the NHS celebrates its 75th anniversary, many of its hospitals built in the 1960s, ‘70s and early ‘80s have reached the end of their anticipated lifespan. As a result, the UK is now having to tackle the problem of large numbers of hospitals that have reached the end of their predicted lives.</p>
<p>Part of Johnson’s 2019 general election manifesto promised that <a href="https://www.gov.uk/government/news/pm-confirms-37-billion-for-40-hospitals-in-biggest-hospital-building-programme-in-a-generation">40 new hospitals would be built by 2030</a>. There was talk of “levelling up our NHS” and a determination “to build back better”. However, this plan was later exposed as something of a numbers trick or “<a href="https://www.bmj.com/content/381/bmj.p1259#:%7E:text=In%202020%2C%20when%20he%20was,of%20his%202019%20election%20manifesto.">mirage</a>”, with many of the “new” hospitals turning out to be extensions or refurbishments. In February 2023, <a href="https://www.theguardian.com/society/2023/feb/04/only-10-of-boris-johnson-promised-40-new-hospitals-have-full-planning-permission">the Observer reported</a> that only ten of the projects had secured full planning permission, with one NHS trust leader warning that: “Some hospitals are literally falling down.”</p>
<h2>Downgrading ambitions from ‘ideal’ to ‘adequate’</h2>
<p>Search for King’s Lynn’s Queen Elizabeth Hospital online, and you are likely to find multiple <a href="https://www.edp24.co.uk/news/health/20676118.behind-scenes-britains-dilapidated-hospital/">news</a> <a href="https://uk.news.yahoo.com/first-phase-replacing-crumbling-queen-110000118.html">items</a> about its dilapidated condition, demands to hasten its replacement, and images of ceilings being <a href="https://twitter.com/RootlessCosmo/status/1643896998771269632?s=20">held up by acrow props</a>.</p>
<p>“Isn’t it lovely,” the Duchess of Kent had told the Lynn Advertiser when she first entered the new hospital in July 1980. According to the same newspaper, the public had been similarly impressed when given guided tours of the newly completed building:</p>
<blockquote>
<p>Guides pointed out bright wards … most with outlooks over landscaped gardens. Mouths dropped as guides said patients would be able to choose the main course of their meals from a menu offering 17 options – and every three weeks, that menu would be changed.</p>
</blockquote>
<p>Yet, just 43 years later, the Queen Elizabeth has been described as “Britain’s most dilapidated hospital”. According to a report on the <a href="https://www.norfolklive.co.uk/news/norfolk-news/queen-elizabeth-hospital-kings-lynns-8062752">Norfolk Live website</a>:</p>
<blockquote>
<p>Patients lie in bed looking up at the [roof] supports … Regular checks take place every day to make sure the roof is not at more risk of collapse through holes in the concrete described as being ‘like an Aero chocolate bar’.</p>
</blockquote>
<p>The Aero bar analogy refers to the <a href="https://www.lboro.ac.uk/news-events/news/2023/march/reinforced-autoclaved-aerated--concrete-raac/">reinforced, autoclaved aerated concrete</a> (RAAC) used in the hospital roof’s construction, and in many other public buildings. In 2018, the roof of a primary school in Kent collapsed only a day after “signs of structural stress” had appeared in the staffroom ceiling. It transpired that the roof had been constructed of RAAC, which has an estimated shelf-life of just 30 years.</p>
<p>An initial investigation into the use of RAAC in schools has recently been <a href="https://www.theguardian.com/education/2023/jun/14/uk-public-buildings-feared-to-be-at-risk-of-collapse-as-concrete-crumbles">extended to look at public buildings more widely</a> – including hospitals. In May, a report on the Conservative government’s promise to build 40 new hospitals suggested that just five – <a href="https://www.theconstructionindex.co.uk/news/view/raac-crisis-prioritised-in-hospital-programme-reorganisation">those that had used RAAC in their construction</a> – were now being prioritised.</p>
<p>The Queen Elizabeth was one of the so-called “best buy” hospitals designed by the Department of Health & Social Security (DHSS) as a complete package. These were introduced in 1967 to remedy the problems of drawn-out design processes and escalating costs that had been derailing the NHS hospital building programme. It was a budget version of the district general hospital envisaged in the 1962 Hospital Plan, providing fewer beds per head of population in more confined spaces using simpler construction methods.</p>
<p>Standardisation and prefabrication were the principles of this design process, which was intended to provide an “adequate” rather than “ideal” hospital amid the country’s deep financial challenges of the 1970s. Hospital design was pared back to its essentials – a policy that has largely continued ever since.</p>
<p>The “nucleus” hospitals that followed from the mid-1970s were designed to limit new developments and major extensions to a nucleus of departments costing no more than £6 million (at 1975 prices). Every possible means of economising space and services was explored by the Hospital Building Division within the DHSS.</p>
<p>Crucially, a lower complement of beds per hospital was provided, based on the justification that earlier patient discharges would create a more intensive use of diagnostic and treatment facilities. In other words, Britain’s hospitals were now becoming high-turnover factory lines.</p>
<figure class="align-center ">
<img alt="External view of unusually designed visitor centre" src="https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pushing architectural boundaries: the Frank Gehry-designed Maggie’s Centre in Dundee.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Maggies_centre_Dundee.jpg">Ydam via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<h2>Good design can be life-enhancing</h2>
<p>As hospitals at the end of their lifespan struggle to deal with patient overcrowding amid crumbling facilities, have decades of cost-cutting exercises when it comes to hospital design and construction turned out to be a false economy? Can a price be put on the damaging effects of poor hospital design on staff morale or patient health?</p>
<p>While we can put a figure on the cost of buying in agency staff to cover staff shortages or even major building repairs, less quantifiable is the impact on health and wellbeing of the buildings themselves.</p>
<p>But we know that good design <a href="https://www.maggies.org/media/filer_public/78/3e/783ef1ba-cd5b-471c-b04f-1fe25095406d/evidence-based_programme_web_spreads.pdf">can be life-enhancing</a>. Within the NHS, Maggie’s centres are a network of cancer drop-in centres unified by a groundbreaking commitment to <a href="https://www.dezeen.com/tag/maggies-centres/">pushing architectural boundaries</a>, with their multi-award-winning buildings having been designed by some of the world’s leading architects such as Frank Gehry and Zaha Hadid.</p>
<p>These centres, located throughout the UK and also in Hong Kong, offer “unique physical environments” created on the basis of a wide body of evidence that shows how aspects of physical space affect us.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/QtCTqRge5Bk?wmode=transparent&start=17" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Explaining the ethos of Maggie’s Centre in Manchester.</span></figcaption>
</figure>
<p>The impact of design on inpatient wellbeing has been a growing focus of research for many years, highlighting the importance of obvious elements such as access to nature, attractive surroundings, artworks on walls, single rooms for patients. There is, for example, <a href="https://www.sciencedirect.com/science/article/abs/pii/S1618866716303089">evidence</a> for the therapeutic benefits of “healing gardens”, and gardening or outdoor exercise is sometimes prescribed by GPs.</p>
<p>More recently, consideration of therapeutic spaces has broadened to include hospital staff as well as patients, in order to tackle the high levels of sickness absence, <a href="https://bolt.nuffieldtrust.org.uk/media/summit-2023-solving-the-workforce-burnout-crisis">distress and burnout among healthcare professionals</a> – levels that are higher in this sector than any other. Yet most solutions so far offered have been <a href="https://pubmed.ncbi.nlm.nih.gov/29200422/">short-term interventions</a>, rather than a fundamental reassessment of <a href="https://eppi.ioe.ac.uk/CMS/Portals/0/IPPO%20NHS%20Staff%20Wellbeing%20report_LO160622-1849.pdf">how the workplace should be designed</a> with staff wellbeing placed on the same footing as patient wellbeing.</p>
<p>Designing a hospital in which it is a pleasure both to work and be a patient is surely a goal worth achieving, and one which it is possible to justify on economic grounds. Spending more now on hospital buildings can save having to rebuild, at higher costs, in 20 or 30 years’ time. If done in such a way as to attract new staff, it can reduce the amount spent on agency fees.</p>
<p>Good design does not have to mean a new hospital, even if that is what people believe they want. Promising to build new hospitals is good publicity for any government, but it can also lead to <a href="https://www.theguardian.com/society/2023/may/25/broken-pledge-over-40-new-hospitals-will-leave-nhs-crumbling-ministers-told">damning headlines</a> about wildly increased costs and failed promises further down the line.</p>
<p>Good design can also be achieved through <a href="https://www.cam.ac.uk/stories/a-retrofitting-revolution">retrofitting</a>, by altering and adapting existing buildings. It is a more sustainable route and ideally would be the first option considered in the face of the present climate emergency. It is a complex issue, and retrofitting may be impossible in some cases – and very probably more expensive than a new-build in almost every other case. However, it addresses the issues of the embodied carbon in existing buildings.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/W1oiC4PG4Zw?wmode=transparent&start=10" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Finalists discuss their approach to the big question: how would you design and plan new hospitals to radically improve patient experiences, clinical outcomes, staff wellbeing, and integration with wider health and social care?</span></figcaption>
</figure>
<p>Political pressures to win public votes favours the quick fix. We need a new way of thinking about building, adapting and retrofitting hospitals that can deliver comfortable environments in a sustainable way for the long term, and to understand that cost-cutting today often leads to greater expense in the future.</p>
<p>In 2021, the <a href="https://policyexchange.org.uk/wolfson-economics-prize-2021/">Wolfson Economics Prize</a> set as its challenge the planning and design of the hospital of the future, specifically with a view to “radically” improving patient experiences, clinical outcomes, staff wellbeing and integration with wider health and social care.</p>
<p>The designers of British hospitals in the 1950s and ‘60s – in the early years after the launch of the bold new NHS – might be surprised to find we are still asking the same questions they set out to solve all those years ago.</p>
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<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p class="fine-print"><em><span>Harriet Richardson Blakeman receives funding from AHRC for doctoral research. </span></em></p>Today’s reports of crumbling, dilapidated and dangerous hospital buildings are a far cry from the design ambitions extolled by early NHS architects and planners.Harriet Richardson Blakeman, PhD Candidate, Architectural History, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2064812023-06-16T12:39:10Z2023-06-16T12:39:10ZAbortion restrictions put hospital ethics committees in the spotlight – but what do they do?<figure><img src="https://images.theconversation.com/files/531517/original/file-20230613-24-qshws0.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C1991%2C1497&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ethics decisions are among the hardest hospital staff need to make.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mature-male-doctor-leading-medical-team-meeting-royalty-free-image/529400761?phrase=hospital&adppopup=true">Thomas Barwick/Stone via Getty Images</a></span></figcaption></figure><p>Many states have imposed <a href="https://crsreports.congress.gov/product/pdf/LSB/LSB10779">sweeping restrictions</a> that all but ban abortion since the June 2022 Supreme Court ruling that <a href="https://www.oyez.org/cases/2021/19-1392">overturned the 50-year-old constitutional right to the procedure</a>. These laws have created new obstacles for pregnant patients facing life-threatening complications like <a href="https://www.washingtonpost.com/health/interactive/2023/florida-abortion-law-deborah-dorbert/">severe fetal anomalies</a>, <a href="https://doi.org/10.1001/jamaoncol.2022.3785">cancer diagnoses</a> and <a href="https://www.propublica.org/article/tennessee-abortion-ban-doctors-ectopic-pregnancy">ectopic pregnancies</a> – when a fertilized egg <a href="https://theconversation.com/what-is-ectopic-pregnancy-a-reproductive-health-expert-explains-183800">implants outside the uterus</a>.</p>
<p>Some media reports about these challenging cases mention the involvement of <a href="https://slate.com/news-and-politics/2022/07/abortion-ban-hospital-ethics-committee-mother-life-death.html">hospital ethics committees</a>. </p>
<p>Stat, for example, a medical news website, reported that one OB-GYN had to <a href="https://www.statnews.com/2022/07/05/a-scary-time-fear-of-prosecution-forces-doctors-to-choose-between-protecting-themselves-or-their-patients/">wait for an ethics committee</a> to determine whether she could terminate her patient’s ectopic pregnancy under the narrow, vague exceptions to <a href="https://missouriindependent.com/2022/06/24/abortion-is-now-illegal-in-missouri-in-wake-of-u-s-supreme-court-ruling/">Missouri’s abortion ban</a>. In Texas, a patient told reporters that a hospital refused to abort her life-threatening pregnancy until a doctor on an <a href="https://www.npr.org/sections/health-shots/2022/07/26/1111280165/because-of-texas-abortion-law-her-wanted-pregnancy-became-a-medical-nightmare">ethics committee advocated</a> on her behalf. And a patient in Oklahoma told NPR that an <a href="https://www.npr.org/sections/health-shots/2023/05/01/1172973274/oklahoma-abortion-ban-exception-life-of-mother-molar-pregnancy">ethics committee declined to meet</a> with her husband after doctors refused to terminate her dangerous pregnancy. </p>
<p>Abortion debates have put the ethics of medical decision-making in the spotlight, but ethics committees’ roles are often misunderstood. As <a href="https://gufaculty360.georgetown.edu/s/contact/00336000014TwNiAAK/jacob-earl">trained bioethicists</a> <a href="https://med.uc.edu/landing-pages/profile/Index/Pubs/lanphieh">who have practiced</a> and <a href="https://doi.org/10.1080/15265161.2021.1887963">researched clinical ethics consulation</a>, we aim to clarify how ethics services work in U.S. hospitals.</p>
<h2>Basics of hospital ethics</h2>
<p>Ethics have been part of medical practice <a href="https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/ethics/ama-code-ethics-history.pdf">throughout history</a>, with principles like those in the Hippocratic oath guiding decision-making since the 5th century B.C.E.</p>
<p>Specialized <a href="https://journalofethics.ama-assn.org/article/hospital-ethics-committees-consultants-and-courts/2016-05">hospital ethics committees</a> originally formed in the 1960s to address decisions about the use of revolutionary therapies like <a href="https://my.clevelandclinic.org/health/treatments/15368-mechanical-ventilation">mechanical ventilators</a>, which could keep patients alive even if they would never regain consciousness or leave the hospital.</p>
<p>Today, accredited U.S. hospitals are required to <a href="https://doi.org/10.1016/j.jcjq.2022.09.004">provide ethics services</a>, and most <a href="https://code-medical-ethics.ama-assn.org/ethics-opinions/ethics-committees-health-care-institutions">use ethics committees</a> to help meet this requirement. Their functions include developing ethics-related policies and providing ethics education to staff. For example, ethics committees have contributed to hospital policies about what to do if a child’s parent <a href="https://doi.org/10.1080/15265161.2012.719263">opposes blood transfusions</a> for religious reasons and triage policies for <a href="https://doi.org/10.1086/JCE2020314303">allocating scarce resources</a> during the COVID-19 pandemic. </p>
<p>Another key service is clinical ethics consultation: advising staff, patients or families about how to navigate ethical issues related to a specific patient’s clinical care. Usually these requests are handled by <a href="https://doi.org/10.1080/15265161.2021.1893547">a subcommittee or an individual ethics consultant</a> – and, increasingly, hospitals are hiring staff with <a href="https://doi.org/10.1186/1472-6939-5-6">specialized training</a> in <a href="https://doi.org/10.1159/000509119">medical ethics</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women sit on a bench inside a waiting room talking with a third woman in a wheelchair." src="https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532301/original/file-20230615-18996-t5rpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Patients’ families can request a consultation with ethicists to help think through challenging decisions.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/caucasian-son-visiting-father-in-hospital-royalty-free-image/508484885?phrase=hospital+patient+family&adppopup=true">Luis Alvarez/DigitalVision via Getty Images</a></span>
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<p>Apart from ethicists, <a href="https://doi.org/10.1086/JCE2016274322">committee members</a> may also include physicians, nurses, social workers, chaplains, lawyers and administrators. Sometimes they include volunteers who represent the views and experiences of local communities. Member selection, funding and other organizational features vary by hospital. </p>
<h2>Recommendations, not rulings</h2>
<p><a href="https://doi.org/10.1086/JCE2018294291">Ethics consultations</a> about specific patients often address concerns about patients <a href="http://dx.doi.org/10.1136/jme.27.suppl_1.i24">who cannot make their own medical decisions</a>, such as if they are in a coma and it is unclear who should make decisions on their behalf. Requests for consultation also can occur when a medical team and a patient disagree about the goals of care: for example, whether applying a do-not-resuscitate order is in the best interests of a severely ill patient.</p>
<p>One essential aspect of <a href="https://code-medical-ethics.ama-assn.org/ethics-opinions/ethics-committees-health-care-institutions">ethics committees’ and consultants’ work</a> is that their input is advisory, not binding. They help identify the <a href="https://doi.org/10.1080/15265161.2012.750388">range of ethically acceptable options</a>, based on medical information from health care providers and on patients’ goals and values.</p>
<p>But even when ethics consultations result in a clear recommendation, neither patients nor health care providers are obligated to follow consultants’ advice. In other words, ethics consultants are not decision-makers, but they do contribute to a decision-making process. </p>
<h2>When medicine says yes, but the law says no</h2>
<p>Some media reports, however, have suggested that hospital ethics committees are <a href="https://slate.com/news-and-politics/2022/07/abortion-ban-hospital-ethics-committee-mother-life-death.html">acting as final arbiters</a>, determining <a href="https://www.statnews.com/2022/08/15/deciding-abortion-medically-necessary-isnt-ethics-question/">whether doctors can help end life-threatening pregnancies</a> in states with severe abortion restrictions.</p>
<p>Yet none of these states currently has laws suggesting that ethics committees must play a role in those decisions. The question of whether an abortion is medically necessary or legally acceptable is one that doctors or lawyers would make, not ethicists.</p>
<p>Other recent reporting on hospital ethicists’ experiences <a href="https://www.texasobserver.org/abortion-laws-pregnancy-loss-healthcare/">suggests a different reality</a>. New state laws threaten doctors with fines or imprisonment for providing abortions that are considered <a href="https://policysearch.ama-assn.org/policyfinder/detail/abortion?uri=%2FAMADoc%2Fdirectives.xml-D-5.999.xml">standard medical care</a> for patients facing serious risks to their health. Some of these doctors are seeking guidance from ethics experts about how to meet their ethical and professional obligations under these difficult circumstances.</p>
<p>Ethics consultants in states with restrictive abortion laws can help health care providers work through difficult questions. For example, how can providers communicate honestly and respectfully with patients about their health needs when they might risk prosecution for recommending abortion? How should providers navigate ambiguities in the law in order to protect their patients’ health and well-being? When might the severe health risks to a patient morally justify providing an abortion, even if there are unresolved concerns about legal liability?</p>
<p>Even if the law <a href="http://dx.doi.org/10.1136/medethics-2014-102311">prevents doctors from providing treatment their patients need</a>, talking with an ethics consultant can <a href="https://doi.org/10.1111/bioe.12064">help ease their moral distress</a> about being unable to do what’s best for their patient.</p>
<p>In fact, one study showed that only one-third of clinical ethics consultations wound up <a href="https://doi.org/10.1080/23294515.2015.1127295">changing a patient’s treatment plan</a>. However, consultations left three-quarters of clinicians feeling more confident about enacting a plan of care. Input from ethicists can help doctors confirm that their plan of care is appropriate or help them <a href="https://doi.org/10.1080/23294515.2015.1127295">clarify their own values</a>.</p>
<h2>Getting help</h2>
<p>Most hospitals allow anyone directly involved in a patient’s care to request <a href="https://doi.org/10.1080/15265161.2021.1893547">clinical ethics consultation services</a>, including patients and their families. </p>
<p><a href="https://doi.org/10.1080/15265161.2021.1893547">Yet available data</a> suggests that very few patients and families do. For example, <a href="https://doi.org//10.1086/JCE201122207">a review</a> of a hospital with a high volume of ethics consultation requests showed that only 4% came from patients or their families. However, the majority of patients and families who interact with ethics services say <a href="https://doi.org/10.1016/S0002-9343(96)80067-2">the process helped</a> them understand their situation, figure out difficult decisions or feel morally supported.</p>
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<a href="https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in blue scrubs and a white doctor's coat chats with a man and boy in a room with views out over a city." src="https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531521/original/file-20230613-15-awxc1v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ethics consultations can help patients and caregivers clarify their own values.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-talking-to-patient-in-hospital-royalty-free-image/1293517598?phrase=hospital&adppopup=true">The Good Brigade/DigitalVision via Getty Images</a></span>
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<p>Access to high-quality health care <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/">is deeply unequal</a> in the United States, and the same is true for ethics consultations. <a href="https://doi.org/10.1080/15265161.2021.1893547">Nearly all</a> teaching hospitals, religiously affiliated hospitals and hospitals with over 200 patient beds have ethics consultation services. But roughly 1 in 5 small hospitals, rural hospitals and nonteaching hospitals do not. </p>
<p>Many hospitals have other services, such as “<a href="https://www.aha.org/guidesreports/2012-10-25-call-action-safeguarding-integrity-healthcare-quality-and-safety-systems">ethics hotlines</a>” where people can report <a href="https://www.aha.org/advocacy/compliance">legal and compliance issues</a>, but these are not the same as ethics committees or ethics consultants. Patients seeking support in making care decisions should ask for the hospital’s clinical ethics consultation service to connect with the right resource. </p>
<p>Ethicists do not make decisions for others, but they can support clinicians and patients through dilemmas and distress.</p><img src="https://counter.theconversation.com/content/206481/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hospital ethics committees and consultants do not make decisions for others, but their input can help support doctors and patients navigate difficult dilemmas.Elizabeth Lanphier, Assistant Professor of Philosophy and Bioethicist, University of Cincinnati Jake Earl, Adjunct Lecturer of Philosophy, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2051312023-05-08T01:40:32Z2023-05-08T01:40:32ZA cancer centre is the latest victim of cyber attacks. Why health data hacks keep happening<figure><img src="https://images.theconversation.com/files/524796/original/file-20230508-197326-bn7rm5.jpg?ixlib=rb-1.1.0&rect=160%2C311%2C6548%2C4154&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-on-duty-working-computer-reception-2174397955">Shutterstock</a></span></figcaption></figure><p>It seems hardly a day goes by without another report of a cyber crime incident. With Medibank still fresh in our minds, the <a href="https://www.abc.net.au/news/2023-05-04/crown-princess-mary-cancer-centre-being-hacked/102305996">latest attack</a> is on a Sydney-based cancer treatment facility, Crown Princess Mary Cancer Centre in Westmead Hospital. </p>
<p>The cyber criminal group Medusa claims to have stolen thousands of files and is holding them to ransom.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Screenshot of Medusa Blog from Dark Web Site" src="https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=565&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=565&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=565&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=710&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=710&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524764/original/file-20230507-19-cjmogq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=710&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Screenshot of Medusa Blog from Dark Web Site.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>In what has become a common practice, the criminal gang seems to be using double extortion. In such scenarios, criminals typically demand a fee to “release” the data back to the organisation – often with a “sample” made available to verify their claims.</p>
<p>The gangs then double-down with threats to publicise the data via their websites if payment isn’t made – in this case, a deadline of seven days. </p>
<p>Medusa is offering a range of options to delay the public release of data by 24 hours (US$10,000), to download and/or delete the data from the gang for US$100,000.</p>
<p>It’s currently unclear what will happen on Friday morning if the ransom is not paid. However, the Medusa Blog offers free access to data stolen from previous victims who did not pay the ransom by the deadline.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Victims data published on Medusa Blog" src="https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=559&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=559&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=559&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=702&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=702&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524765/original/file-20230507-17-o29hhg.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=702&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Victims data published on Medusa Blog.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>According to <a href="https://www.cybersecurityconnect.com.au/critical-infrastructure/9016-nsw-cancer-treatment-centre-targeted-by-medusa-hackers">CyberCX</a>, Medusa is the “second-most active cyber extortion group in the Pacific”. Medusa has been <a href="https://www.bitdefender.com/blog/hotforsecurity/medusa-ransomware-gang-leaks-students-psychological-reports-and-abuse-allegations/">trying to compromise</a> organisations in Australia and New Zealand since the beginning of 2023.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-there-so-many-data-breaches-a-growing-industry-of-criminals-is-brokering-in-stolen-data-193015">Why are there so many data breaches? A growing industry of criminals is brokering in stolen data</a>
</strong>
</em>
</p>
<hr>
<h2>Why target health services?</h2>
<p>Any cyber attacks on the health sector are dangerous. While some cyber criminals have previously <a href="https://www.bitdefender.com/blog/hotforsecurity/ashamed-lockbit-ransomware-gang-apologises-to-hacked-school-offers-free-decryption-tool/">avoided schools</a> and <a href="https://www.bleepingcomputer.com/news/security/ransomware-gangs-to-stop-attacking-health-orgs-during-pandemic/">health-care organisations</a>, it seems these are now fair game.</p>
<p>Knowing the services and data held by these organisations are critical, it’s not surprising to see so many ransomware attacks are launched against critical health-care infrastructure. </p>
<p>Some notable incidents targeting the Australian health systems have included <a href="https://www.sbs.com.au/news/article/who-is-revil-the-russia-based-hacker-group-allegedly-behind-the-medibank-data-breach/b44xvb1ya">Medibank</a>, <a href="https://www.abc.net.au/news/2019-02-22/melbourne-heart-hack-cyber-criminals-my-health-record-risks/10834482">Melbourne Heart Group</a> and <a href="https://ia.acs.org.au/article/2021/victorian-hospitals-hit-by-cyber-attack.html">Eastern Health</a> which operates four hospitals in Melbourne’s east – an attack which resulted in elective surgeries needing to be postponed.</p>
<p>According to tech giant <a href="https://www.microsoft.com/en-us/security/business/microsoft-digital-defense-report-2022">Microsoft</a>, the health-care sector (and aligned industries) is one of the top targets for cyber criminals.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=567&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=567&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=567&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=713&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=713&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524805/original/file-20230508-8275-n9z3o1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=713&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ransomware incident and recovery engagements by industry.</span>
<span class="attribution"><span class="source">Microsoft Digital Defense Report 2022</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australian-hospitals-are-under-constant-cyber-attack-the-consequences-could-be-deadly-150164">Australian hospitals are under constant cyber attack. The consequences could be deadly</a>
</strong>
</em>
</p>
<hr>
<h2>What are the impacts?</h2>
<p>The health sector deals with our most private data – none of us want this data in criminal hands. Apart from the privacy issues, the inability to continue regular activities in any health-care facility poses life-threatening risks.</p>
<p>A <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2799961">recent study</a> showed from 2016-2021, US health-care providers experienced 374 ransomware attacks that exposed the private health information of nearly 42 million patients. </p>
<p>Nearly half of these ransomware attacks disrupted the health-care services, with impacts including electronic system downtime, cancellations of scheduled care, and ambulance diversions.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1393090933361623042"}"></div></p>
<h2>Why do they keep happening?</h2>
<p>Technical advances in the health industries have undoubtedly improved treatment and overall patient care. While this growth in technology is a positive for health care, it exposes health systems to cyber criminals. </p>
<p>With each passing year there is increased connectivity between clinical systems and medical devices. The health-care sector needs to be <a href="https://www.forbes.com/sites/saibala/2022/08/26/the-healthcare-industry-is-crumbling-due-to-staffing-shortages/?sh=6a0b545d7d6e">more staffed</a> and heavily reliant on <a href="https://www.sciencedirect.com/science/article/abs/pii/S1570870521001475">internet-connected systems</a> also known as digital health. This inter-connectivity makes health systems <a href="https://www.hackread.com/vulnerable-infusion-pumps-remotely-accessed-to-change-dosages/">more complex and harder to secure</a>.</p>
<p>With the exception of state-sponsored groups, cyber criminals are primarily motivated by financial gain. Health care is undoubtedly one of the most promising targets as, if compromised, the organisations are more likely to pay the ransom – ultimately, because lives are at stake. </p>
<p>Cyber criminals capitalise on this and, even after good governance and enhanced cybersecurity within the sector, these incidents are likely to continue. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-australia-a-sitting-duck-for-ransomware-attacks-yes-and-the-danger-has-been-growing-for-30-years-161818">Is Australia a sitting duck for ransomware attacks? Yes, and the danger has been growing for 30 years</a>
</strong>
</em>
</p>
<hr>
<h2>Living with cyber criminals around us</h2>
<p>So far, reports about the Cancer Centre at Westmead have not indicated that operations have been significantly impacted. This may imply no computing devices have actually been compromised and locked – this could be seen as a positive. </p>
<p>However, those who have examined the samples of data published on the Medusa Blog have <a href="https://www.databreaches.net/medusa-ransomware-group-starts-leaking-data-from-crown-princess-mary-cancer-centre-threatens-to-leak-more/">suggested it seems genuine</a>. </p>
<p>As Robert Mueller, former Director of the FBI, famously said:</p>
<blockquote>
<p>There are only two types of companies: those that have been hacked and those that will be hacked.</p>
</blockquote>
<p>Cyber crime has become a global industry with estimates predicting the impact at <a href="https://cybersecurityventures.com/cybercrime-to-cost-the-world-8-trillion-annually-in-2023/">more than US$8 trillion in 2023</a>. With such potentially lucrative benefits, we have to accept we will be sharing cyberspace with criminals for the foreseeable future.</p>
<p>There are, of course, actions that can improve our cybersecurity preparedness, regardless of the sector. While nothing will completely eliminate the risk, making ourselves a less attractive target helps to reduce the likelihood of being a victim. So it’s important to:
</p><ul>
<li><strong>protect your systems:</strong> apply patches to all devices (including mobile phones); educate users to segregate personal and business activities; use strong and unique passwords for all systems/services</li><p></p>
<p></p><li><strong>include all systems:</strong> don’t forget the internet of things and operational technology (all the devices and software we use that connect to the internet); check default settings (changing any default passwords); and plan the disposal of old systems</li><p></p>
<p></p><li><strong>protect your data:</strong> data collected from all sources need to be kept in appropriate locations; think about how long you will keep data; and ensure data is protected from creation to destruction.</li><p></p>
<p></p><li><strong>protect your people:</strong> educate all staff on basic cyber hygiene; vet new staff; and think about your off-boarding practices</li><p></p>
<p></p><li><strong>seek advice:</strong> when things go wrong bring in the experts and liaise with law enforcement or other government agencies as appropriate.</li>
</ul><p></p>
<p>And, finally, do not pay the ransom – it may be a difficult decision, but it only encourages the criminals behind the ransomware campaigns to keep going.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medibank-wont-pay-hackers-ransom-is-it-the-right-choice-194162">Medibank won't pay hackers ransom. Is it the right choice?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/205131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While some cyber criminals have previously avoided schools and health-care organisations, it seems these are now fair game.Mohiuddin Ahmed, Senior Lecturer of Computing and Security, Edith Cowan UniversityPaul Haskell-Dowland, Professor of Cyber Security Practice, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2032052023-04-06T12:07:20Z2023-04-06T12:07:20ZDeadly fungus Candida auris is spreading across US hospitals - a physician answers 5 questions about rising fungal infections<figure><img src="https://images.theconversation.com/files/519667/original/file-20230405-14-l85lwf.jpg?ixlib=rb-1.1.0&rect=215%2C32%2C6186%2C3847&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Candida auris is a fungal yeast that can infect humans.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/candida-yeast-and-hyphae-stages-illustration-royalty-free-illustration/1296293760?phrase=candida%20auris&adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p><em>In late March 2023, the U.S. Centers for Disease Control and Prevention highlighted the <a href="https://www.cdc.gov/media/releases/2023/p0320-cauris.html">threat posed by a rapidly spreading fungus</a> called Candida auris that is causing infections and deaths among hospital patients across the country. The unexpected rise of this recently discovered pathogen is part of a larger trend of increasing fungal infections in the U.S.</em></p>
<p><em><a href="https://directory.hsc.wvu.edu/Individual/Index/31722">Arif R. Sarwari</a> is a physician and professor of infectious diseases at West Virginia University. Amid rising concerns among doctors and public health officials, Sarwari helped explain what Candida auris is, how it is spreading and how worried people in the U.S. should be.</em></p>
<h2>1. What is Candida auris?</h2>
<p><em>Candida auris</em> is a recently identified, single-cell fungus that can infect humans and is moderately <a href="https://www.cdc.gov/fungal/candida-auris/index.html">resistant to existing antifungal drugs</a>. You might be familiar with superficial fungal infections – like athlete’s foot or vaginal yeast infections – which are quite common and don’t pose significant risks to most people. In contrast, <em>Candida auris</em> and other related fungi can <a href="https://doi.org/10.2174/1389450120666190924155631">cause infections within a person’s body</a> and are <a href="https://doi.org/10.3390%2Fjof7010031">much more dangerous</a>.</p>
<p><em>Candida auris</em> is a type of yeast that was first identified in 2009 and is one of a number of species in the candida family that can infect people. In the past, most invasive candida infections were <a href="https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html">caused by <em>Candida albicans</em></a>. Recently, though, infections with species of candida that are much more resistant to drugs than <em>Candida albicans</em> – <a href="https://www.cdc.gov/media/releases/2023/p0320-cauris.html">like <em>Candida auris</em></a> – have shot up, with a nearly <a href="https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html">fivefold increase since 2019</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A person holding an IV line with a patient's arm." src="https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519668/original/file-20230405-22-9491i2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Candida fungi can get into a person’s bloodstream through a contaminated IV line and cause a blood infection.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/checking-a-cannula-royalty-free-image/622263704?phrase=IV%20catheter&adppopup=true">Richard Bailey/Corbis Documentary via Getty Images</a></span>
</figcaption>
</figure>
<h2>2. How dangerous are candida infections?</h2>
<p>For the most part, healthy people do not have to worry about invasive candida infections. There are two groups of people who are <a href="https://doi.org/10.1056/NEJMra1315399">most at risk for dangerous candida infections</a>: first are patients in intensive care units who also have central intravenous catheters and are receiving broad spectrum antibiotics. Patients with weak immune systems, such as cancer patients on chemotherapy or patients with human immunodeficiency virus, are also at high risk of candida infection.</p>
<p>Nearly all people have candida fungi growing in their guts and on their skin as part of their microbiome. When a person is healthy, candida numbers are low, but the fungi can proliferate rapidly and overcome a person’s immune system when a patient is <a href="https://doi.org/10.1016/0195-6701(95)90036-5">sick and on antibiotics</a>. </p>
<p>If candida cells on a person’s skin contaminate an intravenous line, the fungus can get into a patient’s bloodstream and cause often deadly bloodstream infections. Candida species are the fourth most-common cause of <a href="https://doi.org/10.1086/421946">hospital associated bloodstream infections</a>. </p>
<p>There are three classes of antifungal drugs that can be used to <a href="https://doi.org/10.1016/j.idc.2021.03.005">fight invasive candida infections</a>. <em>Candida albicans</em> is susceptible to all three and easier to treat than <em>Candida auris</em>, which is moderately <a href="https://doi.org/10.3947/ic.2022.0008">resistant to all three classes of antifungals</a>.</p>
<h2>3. How common are invasive fungal infections?</h2>
<p>The CDC estimates that in the U.S., around <a href="https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html">25,000 patients get candida bloodstream infections</a> every year. </p>
<p>Candida bloodstream infections are best understood as a tale of two eras. In the past, they were almost always caused by drug-susceptible <em>Candida albicans</em> that arose endogenously from a patient’s own microbiome. There was no concern about infections spreading to other patients.</p>
<p>The recent emergence of drug-resistant and more transmissible <em>Candida auris</em> is <a href="https://www.cdc.gov/media/releases/2023/p0320-cauris.html">raising alarms</a> among health professionals. Because this species can contaminate surfaces and easily spread from patient to patient, the fungus is causing outbreaks both <a href="https://doi.org/10.1016/j.micpath.2018.09.014">within and between hospitals</a>. </p>
<p><iframe id="H18dQ" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/H18dQ/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>4. Why are fungal infections increasing?</h2>
<p>Fungal infections have been rising in the U.S. in recent years, especially infections caused by <em>Candida auris</em>. The pathogen only caused a few infections each year between 2013 and 2016, but starting in 2017, infections began to rise rapidly with <a href="https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html">2,377 confirmed cases recorded in 2022</a> according to the CDC. Deaths caused by all candida infections are rising, too, from 1,010 in 2018 <a href="https://www.cdc.gov/fungal/cdc-and-fungal/burden.html">to nearly 1,800 in 2021</a>.</p>
<p>The reasons for this increase are complicated, but I think there are two main drivers: more, sicker patients in hospitals and a stressed health system, both of which got worse during the COVID-19 pandemic.</p>
<p>Hospitals are seeing more very sick patients with weak immune systems, especially as the population ages. This means there are more susceptible patients at hospitals to begin with. </p>
<p>Additionally, any time the health system is stressed – like during a pandemic – drug-resistant <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">bacterial and fungal infections increase</a>. This is because very sick patients are usually in crowded wards and exposed to many antibiotics. In addition, loss of hospital staff and increased workload results in lower quality sanitation - causing more spread of resistant pathogens.</p>
<p>I view the rise of drug-resistant fungi like <em>Candida auris</em> through the same lens as <a href="https://theconversation.com/antibiotic-resistance-is-at-a-crisis-point-government-support-for-academia-and-big-pharma-to-find-new-drugs-could-help-defeat-superbugs-169443">worsening antibiotic resistance</a>. The more antibiotics people use, the greater the chances a resistant strain will become dominant.</p>
<h2>5. What can the medical community do about it?</h2>
<p>There are a few options for fighting the rise of drug-resistant <em>Candida auris</em>. </p>
<p>The most effective measures are <a href="https://www.ncbi.nlm.nih.gov/books/NBK563297/">good infection control practices</a>. These behaviors and protocols include practicing good hand hygiene before and after each patient contact, wearing isolation gowns and gloves that are carefully discarded in a patient’s room, and taking measures to detect <em>Candida auris</em> infections early and isolate patients to prevent the spread. Though relatively simple, these actions are key to preventing the spread of all antibiotic-resistant pathogens, not just fungi.</p>
<p>The second option is to develop better drugs to treat new, antifungal-resistant strains of candida. Many new antifungal drugs are <a href="https://doi.org/10.3390%2Fjof8111144">already under development</a>. However, prevention through sound infection control will always remain foundational, as further drug development is akin to an arms race.</p><img src="https://counter.theconversation.com/content/203205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arif R. Sarwari does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Candida auris is a relatively new addition to a family of fungi that can infect people. Most of these infections occur in sick, hospitalized patients and can be deadly.Arif R. Sarwari, Professor of Infectious Diseases, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004202023-02-27T21:26:52Z2023-02-27T21:26:52ZEmergency department crowding has gone beyond hallways onto ambulance ramps. Now there’s nowhere left to wait.<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/emergency-department-crowding-has-gone-beyond-hallways-onto-ambulance-ramps--now-there-s-nowhere-left-to-wait-" width="100%" height="400"></iframe>
<p>A hospital’s emergency department (ED) has long been considered the canary in the coal mine for the health-care system: when it’s congested, the whole hospital is congested. </p>
<p>Routine and prolonged ED congestion has since led to declarations that patients waiting in an ambulance outside the ED are the new <a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">canaries in the coal mine</a>. </p>
<p>But when ambulances waiting outside the ED become routine and prolonged, another new canary appears: patients at home waiting for an ambulance. They may represent the truest analogy for the canary in the coal mine because they are <a href="https://www.wsws.org/en/articles/2022/10/21/gebn-o21.html">literally dying</a> and are a clear indicator that the health-care system is congested at a dangerous level.</p>
<h2>Pinch points</h2>
<p>Delayed handovers of patients arriving by ambulance is a <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">decades-old problem</a> challenging health-care systems around the world. In the United Kingdom, the National Health Service has made eliminating handover delays one of its three priorty reforms for pre-hospital urgent care in its 10-year <a href="https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf">Long Term Plan</a>. </p>
<p>In <a href="https://www.paramedicchiefs.ca/wp-content/uploads/2022/07/PCCStatementonOffloadDelaysJuly2022Final.pdf">Canada</a>, where health care is provided by provinces, <a href="https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/identifying-approaches-for-optimal-management-of-ambulance-to-hospital-offload-processes.pdf?sfvrsn=9d809fdb_7">British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Québec, New Brunswick and Nova Scotia</a> have all experienced challenges handing over patients in a timely manner. </p>
<p>Australia has <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">likewise</a> seen long lineups of ambulances queueing at hospitals, and has committed to hiring thousands of paramedics in an effort to combat <a href="https://www.ama.com.au/articles/ama-ambulance-ramping-report-card">year-on-year increases</a> in patient handover times.</p>
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<strong>
Read more:
<a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">Ambulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs</a>
</strong>
</em>
</p>
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<p>Beyond ambulance handovers, delays and congestion also occur at other areas: the ED, wards and long-term care are some of the pinch points common in health-care systems around the world. </p>
<p>As an industrial engineer researching and working in health-care patient flow, this raises the question: where’s the next pinch point? </p>
<h2>Code zero</h2>
<p>We know hospital congestion is routinely caused by <a href="https://doi.org/10.1186/s12245-020-00312-x">access block</a>, which occurs when patients are blocked from flowing through the system by a lack of downstream capacity. This is often rooted in an inability to discharge patients from the hospital, which is often due to lack of space in long-term care.</p>
<p>Naturally, this stalls the flow of patients, causing them to wait in ward beds to be discharged from the hospital, in ED hallways waiting for ward beds, in ambulances waiting for ED beds, and eventually at home waiting for an ambulance. </p>
<p>This last group represents a new pinch point. Although ambulances not meeting targeted response times is not new, it is a relatively new phenomenon that there are <em>no</em> ambulances available to respond to calls in a timely manner — a situation known as “code zero.”</p>
<p>This new pinch point however, is substantially different from the others. The patients affected have not yet been seen by health-care providers, are not within meters of health-care services, and their urgencies are not known. These patients are at home, in unknown duress, waiting. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BDzhN14OFuA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Acute care director of the National Health Service in the U.K. discusses ambulance delays, and a family tells how delays led to tragedy.</span></figcaption>
</figure>
<p>Patients waiting with an ambulance on the “ramp” (known as “ramping”) or in a hallway between the ED and the ward are known to be at <a href="https://www.theguardian.com/society/2023/jan/25/record-exposure-to-severe-harm-from-england-ambulance-delays">higher risk</a> for adverse outcomes. Patients with hospital stays prolonged by delay are likewise at <a href="https://www.england.nhs.uk/urgent-emergency-care/reducing-length-of-stay/">higher risk</a> for hospital-borne infections and adverse outcomes. </p>
<p>Less is known about patients waiting at home for an ambulance, but given their precarious circumstance, it is logical to assume they are also at high risk.</p>
<h2>Patients at risk</h2>
<p>Many emergency services system evaluations in <a href="https://www.ama.com.au/articles/ama-ambulance-ramping-report-card">Australia</a>, <a href="https://www.niagararegion.ca/government/departments/health/ems-response-times.aspx">Canada</a> and the <a href="https://www.health.org.uk/publications/long-reads/why-have-ambulance-waiting-times-been-getting-worse">U.K.</a> have reported waiting times longer than performance targets. But the extent to which they are waiting is new. </p>
<p>It has become all too common to read about code zero situations, in which there are no ambulances available. Again there are reports from <a href="https://www.sbs.com.au/news/article/code-red-ambulance-and-triple-zero-systems-are-in-crisis-across-australia/nxf8kw7hc">Australia</a>, the <a href="https://www.mirror.co.uk/news/uk-news/nhs-crisis-brits-who-died-28897334">U.K.</a> and <a href="https://www.saltwire.com/atlantic-canada/news/paramedic-level-zeroes-more-than-doubled-in-2022-during-a-horrendous-year-for-ambulance-delays-100824629/">Canada</a>. People are dying while waiting. </p>
<p>In Australia, ambulance ramping and call delays were recently linked to <a href="https://www.wsws.org/en/articles/2022/10/21/gebn-o21.html">33 deaths over 18 months</a>. </p>
<p>In three examples from the U.K., a woman <a href="https://www.dailymail.co.uk/health/article-11594743/National-Hell-Service-Wife-dies-16-HOUR-ambulance-wait.html">died following a 16-hour wait for an ambulance</a>, a man <a href="https://www.youtube.com/watch?v=BDzhN14OFuA">died when no ambulance was available</a> to take him to the hospital, and an 87-year-old <a href="https://www.independent.co.uk/news/health/ambulance-delays-wait-nhs-glangwili-hospital-b2260228.html">died after waiting 17 hours</a> for an ambulance and then 13 hours in the ambulance at the hospital. </p>
<p>In all three U.K. cases, long handover delays and ambulance ramping were identified as the cause of ambulance unavailability.</p>
<h2>System failures spilling over</h2>
<p>In Canada, the frequency of zero ambulances available <a href="https://www.cbc.ca/news/canada/ottawa/paramedic-level-zero-incidents-2022-availability-numbers-1.6746551">doubled in Ottawa in 2022</a>, with offload delays identified as the number one cause. Code zeros are reported to be daily occurrences, with prolonged frequencies and durations <a href="https://www.thespec.com/news/hamilton-region/2022/10/17/hamilton-paramedics-ambulance-code-zero.html">in Hamilton, Ont</a>. A woman in <a href="https://globalnews.ca/news/8980799/urgences-sante-condolences-91-year-old-dies-waiting-hours-ambulance/">Montréal</a> died after waiting seven hours for an ambulance. </p>
<p>A “canary in the coal mine” is an early indicator of potential danger or failure. The response was insufficient when the ED’s canary died, and the failure spilled over to the ambulance service. Now, with prolonged offload delays routinely causing zero ambulances to be available, the ambulance ramping canary isn’t long for this world either. </p>
<p>This time when the failure spills over, the “canary” at risk is not a metaphorical bird, but is instead a patient waiting at home for an ambulance.</p><img src="https://counter.theconversation.com/content/200420/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Vanberkel receives funding from NSERC. </span></em></p>Ambulance response times have not always met targets, but the alarming new pinch point in our health-care system is that there are no ambulances at all available to respond to calls.Peter Vanberkel, Professor, Department of Industrial Engineering, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1962122022-12-12T03:20:47Z2022-12-12T03:20:47Z‘An arts engagement that’s changed their life’: the magic of arts and health<figure><img src="https://images.theconversation.com/files/499930/original/file-20221209-22427-uu5no9.jpg?ixlib=rb-1.1.0&rect=26%2C8%2C5964%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In 2007, a life-changing encounter at South Australia’s Flinders Medical Centre became the catalyst and symbol for a national arts and health movement. </p>
<p>A young woman, Becky Corlett, was being transported through the hospital where an artist-in-residence, Rebecca Cambrell, was painting a mural. Becky had suffered a stroke and cardiac failure. She had stopped eating and was non-responsive even to family. When Becky passed the mural, however, she made a noise of interest. </p>
<p>Cambrell instinctively drew Becky closer and gave her a paint brush. To everyone’s surprise, Becky started adding dabs of paint to the canvas, and then she smiled. The wonder of this moment only dawned on Cambrell when she turned around. </p>
<p>“Her parents were convinced that the moment she touched that paintbrush, something was triggered inside Becky that made her want to live”, remembers Cambrell.</p>
<p>Becky’s story is just one of many collected in our new report <a href="https://apo.org.au/node/321047">Telling the Story of Arts in Health in South Australia</a>.</p>
<h2>What is ‘arts and health’?</h2>
<p>Arts and health is broadly defined as using arts practice to deliver health outcomes, be they specifically targeted interventions or general wellbeing benefits. </p>
<p>Arts and health work comes in many forms. It can be <a href="https://statetheatrecompany.com.au/shows/euphoria/">play</a> about mental health issues in rural areas. It can be a <a href="https://www.visualisingmentalhealth.com/">university competition</a> to design solutions to community wellbeing challenges. It can be the <a href="https://celsus.net.au/a-hospital-within-a-park/">integration</a> of art throughout an entire hospital to create a calming environment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A giant, colourful sculpture in a hospital foyer." src="https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499931/original/file-20221209-13117-822mmp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Art can be integrated throughout a hospital.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>In an interview with us, design researcher Jane Andrew said the breadth of arts and health work means participant involvement can range “from passively viewing to making to being in the environment”. </p>
<p>The benefits are diverse. A <a href="https://www.who.int/europe/publications/i/item/9789289054553">2019 World Health Organisation study</a> looking at over 900 peer-reviewed publications found arts and health can do everything from encouraging health-promoting behaviours to supporting end-of-life care.</p>
<p>The diversity of the arts and health field is represented by the perspectives of our report’s 47 interviewees. We spoke to arts therapists, managers of hospital-based arts and health programs, government arts agency staff, CEOs of local health networks and former ministers. We asked them about their past experiences with arts and health, the present challenges and opportunities for the field, and how best to advance this work in the future. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-psychological-aspects-of-healing-are-important-for-hospital-design-178890">How psychological aspects of healing are important for hospital design</a>
</strong>
</em>
</p>
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<h2>Art and health in Australia</h2>
<p>Although benefits of the arts to health have been recognised <a href="https://academic.oup.com/book/9415/chapter/156246455">for millennia</a>, the formal field of arts and health work <a href="https://www.tandfonline.com/doi/abs/10.1080/17533010903421484">first emerged</a> across South Australia and the rest of the nation through the community arts movement of the 1970s and the rise of health promotion in the 1980s. </p>
<p>The establishment of the Flinders Medical Centre’s Arts in Health program in the late 1990s provided a major step for the field into health settings, and the program remains an <a href="https://anmj.org.au/the-art-of-healing-inside-flinders-medical-centres-pioneering-arts-in-health-program/">innovative leader today</a>. </p>
<p>The former director of the program, Sally Francis, recalled how, “on a regular basis” the program would have “three, four, five stories of someone who has been critically ill and had an arts engagement that’s changed their life.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An elderly man in a wheelchair paints." src="https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499932/original/file-20221209-25362-p3m533.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Engaging with art and health can be a life-changing experience.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>But Becky Corlett’s story had, as Francis describes it, a “huge and far-reaching effect” on arts and health in Australia. Days after Becky’s first painting experience, former South Australian Minister of Health and Assistant Arts Minister, John Hill, visited the hospital:</p>
<blockquote>
<p>I was just walking along, and I saw the painting going on and there was this little girl busily doing art. […] Her parents came up to me and had tears in their eyes. […] She was reconnected with life. </p>
</blockquote>
<p>Inspired by this encounter, Hill and Francis led a push to have arts and health formally recognised by the state and then federal government. The <a href="https://www.arts.qld.gov.au/images/documents/artsqld/Research/National-Arts-and-Health-Framework-May-2014.pdf">National Arts and Health Framework</a> was officially endorsed in 2014. </p>
<p>This historic statement declared the Australian federal, state and territory governments’ recognition of and support for the field. The framework aimed to raise awareness of arts and health, and to encourage government departments and agencies across the country to integrate arts and health work into their services. </p>
<p>However, it did not make any funding or legislative requests, meaning no permanent arts and health policy followed its endorsement.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/brain-research-shows-the-arts-promote-mental-health-136668">Brain research shows the arts promote mental health</a>
</strong>
</em>
</p>
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<h2>What next for arts and health?</h2>
<p>Next year marks ten years since the framework’s endorsement. </p>
<p>While there is continuing good work in this space across the country, our interviewees believe arts and health remains underutilised. Community artist Lisa Philip-Harbutt told us there is a lack of “connection between all the various things that people are doing” – different arts and health projects often aren’t speaking to each other.</p>
<p>To regain momentum for the field, interviewees recommend developing educational pathways for prospective arts and health workers, conducting a review and update of the National Arts and Health Framework to embed it in policy, and establishing research partnerships between universities and arts and health programs. </p>
<p>The hope is that the next generation of leaders will be inspired by witnessing arts and health’s life-changing power. </p>
<p>According to Deborah Mills, a key driver of the National Arts and Health Framework: </p>
<blockquote>
<p>If you want passionate advocates, they have to have a visceral understanding of what creative activity does. </p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/online-arts-programming-improves-quality-of-life-for-isolated-seniors-168559">Online arts programming improves quality of life for isolated seniors</a>
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<img src="https://counter.theconversation.com/content/196212/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tully Barnett receives funding from the Australian Research Council</span></em></p><p class="fine-print"><em><span>Joanne Arciuli currently receives funding from the Australian Research Council, The Channel 7 Children's Research Foundation, and the Ian Potter Foundation. </span></em></p><p class="fine-print"><em><span>Alexander Cothren does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>2023 will mark the ten year anniversary of Australia’s National Arts and Health Framework. Our new research points the way forward from here.Tully Barnett, Senior lecturer, Flinders UniversityAlexander Cothren, Research Associate, Flinders UniversityJoanne Arciuli, Dean (Research), College of Nursing and Health Sciences, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954002022-11-29T13:58:13Z2022-11-29T13:58:13ZPFI at 30: it’s hard to say anything positive about this deeply flawed financing model<p>It was Norman Lamont who first announced a new way of paying for public buildings and infrastructure in November 1992. In a <a href="https://api.parliament.uk/historic-hansard/commons/1992/nov/12/autumn-statement">speech to the House of Commons</a>, the then chancellor of the exchequer said he was looking to encourage more private financing for such projects. </p>
<p>Speaking only a few weeks after the government had been rocked by <a href="https://theconversation.com/why-black-wednesday-still-matters-it-was-the-start-of-markets-telling-politicians-what-to-do-190471">Black Wednesday</a>, he reassured the house he would “ensure that sensible investment decisions are taken whenever the opportunity arises”.</p>
<p>So began the era of private finance initiatives (PFIs), which saw more than 700 contracts signed off in the UK until the <a href="https://commonslibrary.parliament.uk/goodbye-pfi/">government stopped</a> doing them in 2018. They <a href="https://www.gov.uk/government/publications/private-finance-initiative-and-private-finance-2-projects-018-summary-data">produced projects</a> with assets worth approximately £60 billion, which are costing the taxpayer £170 billion – that’s a gap of £110 billion between what the assets are worth and what the taxpayer is paying for them. </p>
<p>So now that PFI has reached its 30th anniversary, how should it be remembered?</p>
<h2>What they are</h2>
<p>PFIs have paid for everything from roads to bridges to schools to hospitals, not to mention military training facilities, water and waste projects, sports facilities and prisons. Transport projects came first, such as the <a href="https://nation.cymru/news/a-u-turn-on-tolls-the-severn-bridge-pledge/">Severn River crossings</a> and the <a href="https://clok.uclan.ac.uk/22711/7/22711%20AAM.pdf">M6 Toll Road</a>. A refurbishment of some <a href="https://www.nao.org.uk/reports/innovation-in-pfi-financing-the-treasury-building-project/">HM Treasury buildings</a> was another early project, and was often cited by Conservative ministers as evidence of the Treasury’s belief in these schemes. </p>
<p>Generally PFIs – or public-private partnerships (PPPs), as they are sometimes known – involve a consortium of private companies financing, building, maintaining and operating assets for 25 to 30 years. Once operational, the public body effectively makes leasing payments to the lead contractor – subject to the assets being available and meeting key performance indicators. </p>
<p>The Treasury persistently claimed, at least initially, that this link between payments and performance would ensure the private sector bore most of the risks. By putting these experts in charge, it was argued that project management would improve. This was going to lead to more and better infrastructure, delivering value for money for taxpayers. </p>
<h2>Rhetoric vs reality</h2>
<p>PFI has certainly seen many infrastructure projects completed and facilities modernised which would not have been possible under traditional public procurement. But as far as the supposed benefits are concerned, the evidence suggests a disconnect between political rhetoric and reality. </p>
<p>Borrowing costs are one unavoidable problem, since contractors will most likely have a lower credit rating than the government. These costs get passed on to the taxpayer, which has constrained what authorities <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-0408.2010.00508.x?casa_token=67XC3f19J0IAAAAA%3A52iVpXX-HAZygSfwWE7LXdHdKHFkEMXnMYgBi3wNMpahaeMetcMgSgKCreHZN_anN355yLgs7w-slxtI">such as the NHS</a> can spend on essential services, forcing them to reduce budgets accordingly. It also created <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1467-923X.12990?casa_token=X17PTYGqWeUAAAAA%3AqMfhidbEmqwkcgTRc3sNCFDlZy4eiitOzQodVVPur-cM9hY4bFrd3N4Wt1naWqAFwE3xc9h0DiPl8hY4">pressure to reduce</a> project costs, leading to poorer infrastructure. </p>
<p>There’s evidence from PFIs in <a href="https://www.researchgate.net/profile/Jane-Broadbent/publication/238789662_Nature_Emergence_and_the_Role_of_Management_Accounting_in_Decision_Making_and_Post-Decision_Project_Evaluation/links/00b49528dcb0c11e93000000/Nature-Emergence-and-the-Role-of-Management-Accounting-in-Decision-Making-and-Post-Decision-Project-Evaluation.pdf">health</a> and <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/padm.12401?casa_token=tBI96iHYGo0AAAAA%3APAeIf5nkMMUdLgpKmnarEQQHgEJPesRcpEPccK86i0o0K-aOhrlQOd8Ju_2v5ux6f5gFSmDWCE29_2QH">roads</a> that performance-based payments don’t incentivise contractors. The financial incentives are often inadequate, since they form only a small portion of leasing payments, and it’s difficult to develop key performance indicators for long projects anyway. </p>
<p>There are also endless issues around asset risks. With schools, for example, <a href="https://www.sciencedirect.com/science/article/pii/S0890838914000031?casa_token=Uw2ZBlOFgD0AAAAA:WJG1mGN9MhTWZSToEfuhX66bzc3BG7TWjV9x6CXiBRPbFDlKs6aesAeg4vongNYgflyY3OFsfTU">empirical studies</a> highlight inherent complexities and subjectivity in how risks were allocated. According to this research, public authorities and their financial advisers could “manipulate” accounting numbers to make it look as though more risk was being transferred than was necessarily the case.</p>
<p>High returns earned by private investors also suggest departments were overpaying for transferring project risks. For example, equity returns in the M25 motorway project <a href="https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/894/89405.htm">were approximately 30%</a> – mkore than double the expected annual returns in PFIs.</p>
<p>Another issue is the difficulty in foreseeing and estimating all risks over a project’s lifetime. For example, the mid-1990s PFI contract for modernising the National Insurance Recording System (NIRS-2) experienced multiple delays and renegotiations during the pre-contract stage on account of uncertainties around future IT requirements. The Inland Revenue <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0408.00139?casa_token=ApoSFT6hNYsAAAAA:hiYpSdNpN8zS4PE8eG0HjmaqCCYARWjOvMlIzwgZ-ZvIKSngxf9ryNvAfX5E21PQizv0U-EkXStxik4">reportedly received</a> only limited compensation from the contractors for these delays, yet did not take further action to avoid prejudicing “the partnership relationship”. </p>
<p>Sometimes failures to estimate risks helped to push contractors into bankruptcy. The classic example is <a href="https://eprints.keele.ac.uk/4909/1/I%20Demirag%20-%20Sourcing%20public%20services.pdf">Carillion in 2018</a>, whose collapse was partly due to problems with <a href="https://www.theguardian.com/business/2020/jan/15/carillion-collapse-two-years-on-government-has-learned-nothing">PFI hospital contracts</a> in Birmingham and Liverpool. Similarly with the <a href="https://www.nao.org.uk/wp-content/uploads/2009/06/0809512es.pdf">London Underground</a> modernisation in the early 2000s, poorly foreseen costs caused contractor collapses. The incomplete project reverted to the government, costing taxpayers <a href="https://www.centreforpublicimpact.org/case-study/london-undergrounds-failed-ppp">billions of pounds</a>.</p>
<h2>Future concerns</h2>
<p>These difficulties help show why the UK government ultimately scrapped PFI. It had also found it more difficult to make austerity savings in the 2010s because of PFI payments, while unfinished projects such as the <a href="https://www.cityam.com/carillion-two-years-on-misery-as-major-hospitals-in-liverpool-and-birmingham-still-unfinished/">Birmingham and Liverpool</a> hospitals involved in the Carillion collapse produced waves of negative publicity. </p>
<p>Meanwhile, existing contracts remain a concern. Leaving aside leasing costs, <a href="https://www.nao.org.uk/report/managing-pfi-assets-and-services-as-contracts-end/">one critical issue</a> is contracts expiring at the end of their lifetimes. PFI holding companies aren’t required by law to to disclose much financial information, so there are unknowns around the state of <a href="https://committees.parliament.uk/publications/5144/documents/50775/default/">many assets</a>. Some could be passed on to the public in poor condition, and services could be disrupted as a result. </p>
<p>A <a href="https://committees.parliament.uk/work/921/managing-the-expiry-of-pfi-contracts">recent parliamentary review</a> pointed to uncertainties around funding to help better manage the expiry of contracts. The review also found an absence of clear guidelines for contract expiry in some of the oldest contracts (meaning the ones due to expire soonest), and limited trust between procuring authorities and their contractors. </p>
<p>The government’s Infrastructure and Projects Authority <a href="https://www.gov.uk/government/publications/preparing-for-pfi-contract-expiry">recently published guidance</a> for procuring authorities around contract expiries, but said nothing about making available technical, commercial, financial or legal expertise. Authorities will need to organise this in-house, raising the prospect of hiring expensive private consultants with taxpayers’ money. </p>
<p>Three decades after PFI launched as a “sensible” form of infrastructure investment, it’s <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/752173/PF2_web_.pdf">now seen</a> by the government’s Office for Budget Responsibility as a fiscal risk. This is both because PFIs have been allowed to remain off the government’s balance sheet and because the risks often revert to the government if a contract fails. </p>
<p>PFI may have seemed sensible on paper, but successive governments <a href="https://link.springer.com/chapter/10.1007/978-3-030-72128-2_11">appear to have</a> implemented it to make projects happen faster, often to score political points. To make the best of a bad situation, changing the rules around the financial reporting of PFI holding companies and making sufficient resources available to manage asset handovers to public authorities would be a step in the right direction</p><img src="https://counter.theconversation.com/content/195400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Yes it got many things built, but the legacy is fairly disastrous.Salman Ahmad, Lecturer in Accounting, Aston UniversityCiaran Connolly, Professsor of Accounting, Queen's University Belfastistemi demirag, Professor of Accounting, Tallinn University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952922022-11-27T13:09:07Z2022-11-27T13:09:07ZRSV FAQ: What is RSV? Who is at risk? When should I seek emergency care for my child?<figure><img src="https://images.theconversation.com/files/497240/original/file-20221124-14-7r3k7l.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5100%2C2868&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">RSV is the leading cause for hospital stays in infants in developed countries.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><h2>What is RSV?</h2>
<p>Respiratory syncytial virus (RSV) is <a href="https://doi.org/10.1093/cid/ciaa1719">one of many viruses that causes infection of the ear, nose, throat and lungs</a>. It <a href="https://doi.org/10.7150/ijbs.64762">infects people of all ages</a> and can be found worldwide.</p>
<h2>Who is at risk of RSV?</h2>
<p>RSV is an important cause of lung infections in children under two years of age, and is the leading reason for <a href="https://doi.org/10.1155/2017/4521302">hospital stays in children under one year of age (infants) in developed countries</a>. Premature infants, adults above 65 years of age and those with chronic heart and lung conditions are at <a href="https://doi.org/10.1056/nejmoa043951">higher risk for severe disease and hospitalization</a>.</p>
<h2>Why is RSV so prevalent this season?</h2>
<p>Infections due to RSV occur throughout the year, with higher numbers of infections in the late fall to early spring in North America. The start and end of RSV season changes slightly each year, <a href="http://dx.doi.org/10.15585/mmwr.mm6702a4">and infections peak in January and February</a>. Typically, RSV infections occur in two-year cycles — <a href="https://doi.org/10.1001/jamanetworkopen.2021.24650">a year of increased numbers and higher severity of illness alternating with a milder year</a>.</p>
<p>Most children will have had one RSV infection by two years of age, and some may have had more than one infection. Unfortunately, having been infected by RSV does not provide long lasting immunity, although re-infections are usually milder. Although antibodies (proteins made by the immune system in response to infection) are made against RSV, they only last six to 12 months and <a href="https://doi.org/10.1093/infdis/jiac192">require repeated exposure to keep high antibody levels</a>. </p>
<p>This likely explains why RSV infections have an alternating severe-mild cycle: in a bad year, patients develop high levels of antibodies that help protect against infection or a bad infection in the subsequent year.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rsv-experts-explain-why-rates-of-this-virus-are-surging-this-year-194403">RSV: experts explain why rates of this virus are surging this year</a>
</strong>
</em>
</p>
<hr>
<h2>How does RSV spread?</h2>
<p>RSV is spread through two ways:</p>
<ul>
<li><p>Contact with an object that has been sneezed on, coughed on, drooled on, touched or been in the mouth of a person who is sick with RSV. That person, who now has germs on their hands, becomes sick when he/she touches their nose or mouth.</p></li>
<li><p>Breathing in the virus when the infected person coughs or sneezes, within one metre of others, without covering their nose or mouth.</p></li>
</ul>
<h2>What are the symptoms of RSV?</h2>
<p>In general, approximately three to seven days after being infected, people will develop symptoms of a common cold including fever, runny or stuffy nose, sore throat, cough and decreased energy. Patients may complain of muscle aches and their appetite may decrease. Some may have difficulty breathing. The symptoms of infection due to RSV are identical to the symptoms of other respiratory viruses.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/KlHjKaGiWFY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CBC covers the surge in children needing treatment for respiratory viruses.</span></figcaption>
</figure>
<p>Some patients develop pneumonia (infection of the lungs). Infants may develop bronchiolitis — inflammation (swelling) of the very small tubes that deliver air (oxygen) to the lungs. Infants with bronchiolitis commonly have wheezing — a whistling sound when they breathe out. This whistling sound sometimes is only heard using a stethoscope, but sometimes can be heard even without one. </p>
<p>Bronchiolitis and pneumonia can lead to lower oxygen levels in the blood in some patients. It is important to remember that other respiratory viruses can also lead to pneumonia and bronchiolitis.</p>
<h2>How is RSV treated?</h2>
<p>Since RSV is a virus, use of antibiotics will not lead to shortening of the illness nor will it lead to shortening the period that sick people are infectious to others. There are no antivirals for treatment of RSV infections. Most patients can be managed at home:</p>
<ul>
<li><p>Antipyretics (medications to lower fever) if fever is present. Lowering the fever does not lead to shortening of the illness, but will also treat any muscle aches and the general feeling of being unwell.</p></li>
<li><p>Saline sprays or drops help with nasal congestion, and can be used often without the risk of overdose.</p></li>
<li><p>Commercially available nasal aspirators can be used to help infants and children breathe easier </p></li>
<li><p>Encourage fluids to reduce the risk of dehydration — offer small amounts, but offer often. Fluids for infants should be breastmilk or formula. Older children can be offered a variety of fluids including oral rehydration fluids like <a href="https://www.webmd.com/drugs/2/drug-11147/pedialyte-oral/details">Pedialyte</a>, chicken broth, popsicles, ice cream and jello. Extended periods of only water should be avoided, as should relying on soda. A few days without solid food is not harmful.</p></li>
</ul>
<h2>When should I seek emergency care for my child for RSV?</h2>
<p>Although most patients can be managed at home, there are several reasons to seek medical care. They include:</p>
<ul>
<li>Breathing too hard to sleep or feed properly even when fever is not present;</li>
<li>For infants, feeding has been significantly reduced below normal; </li>
<li>Being excessively sleepy or difficult to wake;</li>
<li>Not urinating in 12 hours.</li>
</ul>
<p>Patients with RSV infections will need to be hospitalized if they need:</p>
<ul>
<li>extra oxygen;</li>
<li>intravenous fluids if they are dehydrated.</li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a hospital sign directing people to EMERGENCY CHILDREN / URGENCE ENFANTS" src="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ontario has asked thousands of family health-care workers to work evenings and weekends to help ease the burden on overwhelmed children’s hospitals.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<h2>How do I protect myself and my family from RSV?</h2>
<p>Although there are no vaccines against RSV, a scientifically prepared antibody, palivizumab, <a href="https://doi.org/10.14745/ccdr.v48i78a08">is recommended to reduce the risk of complications of RSV infection in premature infants and children with chronic lung or heart disease who meet certain criteria</a>. Palivizumab is given as monthly injections during RSV season.</p>
<p>The same general measures that protect against COVID-19 and other respiratory viruses lead to reduced risk of getting infected with RSV:</p>
<ul>
<li>Wash your hands well and often;</li>
<li>Stay two meters from others when in public places — patients with RSV may be infected and capable of infecting others before they have symptoms;</li>
<li>Wear a mask when in enclosed public places.</li>
</ul>
<p>Be a good neighbour and reduce the risk that others will get sick:</p>
<ul>
<li>Stay home from school or work if you are sick;</li>
<li>Cough etiquette — cough into your elbow or a tissue. This reduces the chance that viruses are on your hands, which can then be passed onto others or objects that others may handle.</li>
</ul><img src="https://counter.theconversation.com/content/195292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Athena McConnell is affiliated with Sanofi as a member of an advisory board related to the development of nirsevimab, an alternate monoclonal antibody against RSV. </span></em></p>As visits to emergency departments surge — and in some cases overwhelm hospitals — here are answers to frequently asked questions about Respiratory syncytial virus (RSV).Athena McConnell, Associate Professor, Pediatric Infectious Diseases, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1947262022-11-20T15:22:34Z2022-11-20T15:22:34ZWith COVID, flu and RSV circulating, it’s time to follow the evidence: Return to mask mandates<figure><img src="https://images.theconversation.com/files/495816/original/file-20221117-13-u0jyep.JPG?ixlib=rb-1.1.0&rect=0%2C10%2C3190%2C2069&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ontario Premier Doug Ford and Health Minister Sylvia Jones in conversation at Queen's Park, the day after Ontario’s chief medical officer of health ‘strongly recommended’ mask wearing.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Chris Young</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/with-covid--flu-and-rsv-circulating--it-s-time-to-follow-the-evidence--return-to-mask-mandates" width="100%" height="400"></iframe>
<p>The number of children and babies with respiratory illnesses currently <a href="https://globalnews.ca/news/9273442/mcmaster-childrens-hospital-patient-crisis-grows/">exceeds the capacity of our health system</a> to care for them. More adult Canadians will die directly of COVID-19 this year <a href="https://public.tableau.com/app/profile/bill.comeau/viz/CanadaCovid19_16636261617930/Dashboard1">than died last year or in 2020</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph showing deaths from COVID in Canada" src="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=260&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=260&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=260&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=326&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=326&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=326&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">COVID deaths in 2022 outnumber those in 2020 or 2021.</span>
<span class="attribution"><span class="source">(Bill Comeau)</span></span>
</figcaption>
</figure>
<p>Eight per cent of vaccinated people with COVID infections that don’t require hospitalization <a href="https://doi.org/10.1038/s41591-022-01840-0">end up with long COVID</a>, with each subsequent infection <a href="https://doi.org/10.1038/s41591-022-02051-3">repeating the risk</a>. COVID increases the risk of <a href="https://doi.org/10.1038/s41591-022-01689-3">cardiovascular</a> <a href="https://doi.org/10.1016/S0140-6736(22)01214-4">and</a> <a href="https://www.ecdc.europa.eu/sites/default/files/documents/Prevalence-post-COVID-19-condition-symptoms.pdf">other health</a> <a href="https://doi.org/10.1038/s41591-022-01840-0">problems</a>, enough to cause a stark rise in <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">excess deaths</a> and to <a href="https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf">shorten life expectancy</a>.</p>
<p>In 2020, when adult intensive care units were at risk of being overwhelmed, we wore masks and accepted restrictions. With pediatric intensive care now at risk, will leaders follow the evidence and tell us to mask up? While federal officials and <a href="https://www.cbc.ca/news/canada/toronto/ontario-dr-kieran-moore-announcement-1.6650571">several provinces are now recommending masks in all indoor public settings</a> — although <a href="https://toronto.ctvnews.ca/ontario-s-top-doctor-goes-against-own-advice-while-maskless-at-toronto-party-1.6159050">Ontario’s Chief Medical Officer of Health Kieran Moore was seen without one at a party</a> — <a href="https://www.ctvnews.ca/canada/what-provinces-and-territories-are-saying-about-mask-mandates-as-covid-19-rsv-flu-cases-rise-1.6157262">there are no returns to mandates for the public yet</a>.</p>
<h2>Wear the best mask available</h2>
<p>We now know that <a href="https://doi.org/10.1073/pnas.2014564118">masks prevent the spread of respiratory diseases</a>; some better than others. </p>
<figure class="align-right ">
<img alt="A young woman wearing a white face masks with overhead ties" src="https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Vitacore CaN99 respirator with overhead elastic; N95s, CaN99 and FFP3 typically provide greater than 90 per cent filtration without formal fit testing.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The most effective masks, and the only ones recognized as respiratory protection by formal standards, are respirator masks: N95s, CaN99s, FFP3s and reusable elastomeric respirators. In workplaces, respirators are fit-tested to the individual, resulting in greater than 99 per cent protection. </p>
<p>Even without fit testing, respirator masks prevent <a href="https://doi.org/10.1093/annhyg/meq085">more than</a> <a href="https://doi.org/10.1371/journal.pone.0245688">90 per cent</a> <a href="https://doi.org/10.1097/MD.0000000000023709">of particles</a> smaller than one micron from reaching the wearer (submicron particles, the smallest among <a href="https://doi.org/10.1016%2FS2213-2600(20)30323-4">those thought</a> <a href="https://doi.org/10.1080/23744235.2022.2140822">to be</a> <a href="https://doi.org/10.1038/s41564-021-01047-y">relevant</a>).</p>
<p>Respirator masks are relatively expensive — typically a few dollars each — but thanks to Canadian manufacturers, they are <a href="https://www.clothmasks.org/">available</a> and there are no longer concerns about supply chains for front-line workers. They can be safely <a href="https://www.clothmasks.org/extended-use">reused, with good retention of their filtration</a>. New designs are comfortable and fit most faces. </p>
<figure class="align-left ">
<img alt="A young woman wearing a black face mask with ear loops" src="https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A KN95/KF94 mask with ear loops typically provides about 70 per cent filtration.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>N95s are secured with overhead attachments, providing a good seal at the edges. KN95s and KF94s have excellent filtration material, but their ear loops do not provide as secure a seal, and <a href="https://doi.org/10.1371/journal.pone.0258191">their filtration</a> is <a href="https://doi.org/10.1371/journal.pone.0245688">around 70 per cent</a>. A certified medical mask with a well-fitted cloth mask over it, preferably with overhead ties, provides <a href="https://doi.org/10.1038/s41591-022-01840-0">comparable</a> <a href="https://doi.org/10.1016/j.ajic.2021.10.041">filtration</a> at lower cost.</p>
<figure class="align-right ">
<img alt="A young woman wearing a cloth face mask over a surgical mask" src="https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A well-fitting cloth mask over a certified medical mask typically produces about 70 per cent filtration.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Certified Level 1 medical masks alone do not fit well, which affects their filtration ability because unfiltered air passes around the edges with every breath. In tests on humans, these have <a href="https://doi.org/10.1371/journal.pone.0264090">typically </a><a href="https://doi.org/10.1371/journal.pone.0245688">filtered </a><a href="https://doi.org/10.1001/jamainternmed.2020.8168">at around 50 per cent</a>, similar to <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">well-designed</a> <a href="https://doi.org/10.1371/journal.pone.0264090">two-layer cotton cloth masks, ideally with overhead ties</a>; both are around 50 per cent.</p>
<p>Poorly fitting <a href="https://doi.org/10.1016/j.ajic.2021.10.041">cloth masks</a> and non-certified procedure masks are likely worse than 50 per cent, but better than nothing. The World Health Organization advises: “<a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks">Make wearing a mask a normal part of being around other people</a>,” to which we would add: wear the best mask available.</p>
<figure class="align-left ">
<img alt="A young woman wearing a blue surgical face mask" src="https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Level 1 certified mask provides filtration around 50 per cent because of visible gaps and poor fit. To test fit, breathe out rapidly and feel for air leaks around the mask with your hands.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The filtration data above are mirrored by epidemiologic data showing that <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">protection correlates with mask type</a>. In studies of source control (prevention of contamination of the air by respiratory particles), the same hierarchy of efficiency is seen, with N95s at the top. N95s with exhalation valves are an exception and should not be used to prevent spread of respiratory diseases.</p>
<p><a href="https://doi.org/10.1136/bmj-2021-068302">Masks protect </a><a href="https://doi.org/10.1073/pnas.2014564118">against COVID-19</a> and other respiratory infections. They are also an <a href="https://doi.org/10.7326/M20-6625">ideal tool to counter COVID variants</a>, as well as <a href="https://theconversation.com/influenza-and-covid-19-whats-in-store-for-the-fall-winter-respiratory-virus-season-193076">RSV and influenza</a>. Working on basic physical principles — <a href="https://doi.org/10.7326/M20-6625">impaction, sedimentation and diffusion</a> — they protect regardless of the variant or strain. </p>
<p>Staying home when sick is helpful, but many people are infectious <a href="https://doi.org/10.1186/s12879-022-07440-0">before they have symptoms, or never have symptoms</a>. Wearing a mask to prevent infected particles from reaching the environment is basic pollution management: control is best at the source. </p>
<p>Wearing a mask to protect the individual, once controversial, is now settled by <a href="https://www.clothmasks.org/mask-hierarchy">filtration science</a> and <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">epidemiology</a>. The impact of mask mandates in countries where spontaneous mask wearing was low was repeatedly demonstrated, proving that masks protect us all.</p>
<h2>Why people aren’t wearing masks</h2>
<p>Why aren’t people wearing masks? Some remember the <a href="https://doi.org/10.1111/1467-9566.13525">inconsistency of the advice</a> early in the pandemic. Masks may be conflated with closures and capacity restrictions and the resulting hardships. Whatever the reason — <a href="https://www.theguardian.com/world/2021/oct/26/the-great-cover-up-why-the-uk-stopped-wearing-face-masks">stigma, peer pressure or concern about virtue signalling</a> — countries outside Asia do not have a mask-wearing culture. </p>
<figure class="align-center ">
<img alt="Infographic summarizing the literature on filtration properties of respirators and masks." src="https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Infographic summarizing the literature on filtration properties of respirators and masks.</span>
<span class="attribution"><span class="source">(Shiblul Hasan)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Under these circumstances, it will likely take more than strong recommendations to achieve the <a href="https://doi.org/10.1073/pnas.2014564118">high uptake of mask use that will be most effective</a> in reducing transmission of respiratory viruses. Masks protect individuals, imperfectly. Mask mandates (or high voluntary use of masks) protect populations.</p>
<p>Bringing back mask mandates with unequivocal signalling from governments about the effectiveness of both masks and mask mandates would be the best immediate response to our current crisis. <a href="https://doi.org/10.1038/s41398-022-01814-3">Confidence that mask-wearing is effective correlates geographically with willingness to wear a mask</a>: in time, we hope knowledge will change culture. Strong communication from political and public health leadership would increase community understanding that the minor inconvenience of wearing a mask in public indoor spaces is justified by the death and disability prevented. </p>
<p>In North America, the strategy of using masks according to personal judgment has predictably failed, the strategy of strongly recommending masks is unproven, and it’s too late to experiment. Mask mandates, however, are backed by strong evidence of effectiveness in <a href="https://www.nber.org/papers/w27891">both Canada</a> and the <a href="https://doi.org/10.1377/hlthaff.2020.00818">United States</a>. </p>
<p>Mask mandates are less damaging to a recovering economy than physical distancing and capacity limits, and less damaging to learning than a return to remote schooling.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two line graphs showing relationship between school openings, mask use and community COVID 19 cases and deaths" src="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=249&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=249&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=249&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=313&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=313&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=313&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The relationship between mode of school opening (remote, hybrid and in-person) and mask use at school with community cases and deaths, based on county-level data in the U.S.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1073/pnas.21034201">(Chernozhukov et al, PNAS 2021:118;e2103420118)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Schools and universities represent a particularly important opportunity. COVID spreads between children in schools <a href="https://doi.org/10.1073/pnas.2103420118">to infect the whole population; this is mitigated by mask wearing</a>. After Massachusetts lifted its mask mandate, school boards did so at different times, creating a natural experiment: <a href="https://doi.org/10.1056/NEJMoa2211029">transmission was higher among students and staff where mandates were lifted</a> compared with where they were still in place. </p>
<p>There is <a href="https://web.archive.org/web/20220826213955/https:/healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Do-face-masks-interfere-with-language-development.aspx">no convincing</a> <a href="https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html">evidence</a> to date that masks reduce social or language skills. Decreasing spread in schools would increase learning by reducing student and teacher sick days and preserving in-person instruction. Keeping children in schools <a href="https://www.washingtonpost.com/business/2022/11/15/work-absences-childcare/">keeps parents at work</a>.</p>
<p>Mask mandates will not produce a rapid fix of our current problems with respiratory viruses. Indicators will lag by weeks. Until we have a <a href="https://doi.org/10.1038/s41586-022-05398-2">whole-of-society approach</a> that recognizes that <a href="https://doi.org/10.1016/S0140-6736(21)00869-2">COVID is airborne</a>, mask mandates offer us the best immediate opportunity to preserve our health-care system, mitigate death and disability from respiratory viruses, support the economy and safely maintain social contacts in our private lives. </p>
<p><em>Rebecca Rudman, co-founder of the Windsor Essex Sewing Force and member of McMaster’s Cloth Mask Knowledge Exchange, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/194726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is editor-in-chief of clothmasks.org and a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group that includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. She is a member of McMaster's Centre of Excellence in Protective Equipment and Materials. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZeneca, Vifor Fresenius Medical Care, Relypsa, Bayer HealthCare and Boehringer Ingelheim. Catherine Clase receives funding from CIHR, and is a member of the Green Party, the American Society of Nephrology, the Canadian Society of Nephrology, the American Association of Textile Chemists and Colorists and ASTM International.</span></em></p><p class="fine-print"><em><span>Charles-Francois de Lannoy receives funding from the Natural Sciences and Engineering Research Council (NSERC) of Canada, the Global Water Futures (GWF) Research organization, Ontario Centres of Excellence (OCE), Federal Economic Development Agency for Southern Ontario (FedDev), Canadian Foundation for Innovation (CFI), the French Embassy, and McMaster University. He has received funding in partnership with Pall Water, Trojan Technologies, Hatch Ltd., and PW Fabrication. He has engaged in various research projects and testing/validation of facemasks for several private companies in Ontario. He is affiliated with the Cloth Mask Knowledge Exchange as an expert advisor.</span></em></p><p class="fine-print"><em><span>Ken G. Drouillard receives funding from Natural Sciences and Engineering Research Council (NSERC) of Canada, Environment and Climate Change Canada, Ontario Ministry of Environment, Conservation and Parks and Mitacs. He is affiliated with the WE-Spark Health Institute, Detroit River Canadian Cleanup Committee, International Association of Great Lakes Research, Editor of Bulletin of Environmental Contamination and Toxicology and science advisor for Windsor-Essex Sewing Force. </span></em></p>In 2020, with adult ICUs at risk of being overwhelmed, we wore masks and accepted restrictions. Now pediatric intensive care is at risk. Will leaders follow the evidence and tell us to mask up?Catherine Clase, Professor of Medicine, Epidemiologist, Physician, McMaster UniversityCharles-Francois de Lannoy, Associate Professor, Chemical Engineering, McMaster UniversityKen G. Drouillard, Professor, Great Lakes Institute for Environmental Research, School of the Environment, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1942532022-11-16T19:04:18Z2022-11-16T19:04:18ZOur health system is like a ‘worn pair of shorts’. This latest COVID wave will stretch it even thinner<figure><img src="https://images.theconversation.com/files/495526/original/file-20221116-23-7wz962.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C998%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-having-headache-tired-work-while-1715051302">Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">latest COVID wave</a> is with us, with its <a href="https://theconversation.com/from-centaurus-to-xbb-your-handy-guide-to-the-latest-covid-subvariants-and-why-some-are-more-worrying-than-others-192945">viral subvariants</a> <a href="https://www1.racgp.org.au/newsgp/clinical/new-variants-expected-to-supplant-ba-5-in-australi">BQ.1 and XBB</a>. Once again, our health system will be stretched.</p>
<p>That’s not just hospitals. A stretched health system affects the interaction between you and your GP, the availability of medicines, the policies of the aged care home your mother is in, the research that brought you vaccines, the mental health-care provider, Medicare and more.</p>
<p>The situation is very different to earlier COVID waves. Now, we have fewer public health measures in place. Health staff <a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">are also exhausted</a> from almost three years of the pandemic.</p>
<p>Here’s what needs to happen next for our health systems to cope with the latest COVID wave.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-can-we-expect-from-this-latest-covid-wave-and-how-long-is-it-likely-to-last-194444">What can we expect from this latest COVID wave? And how long is it likely to last?</a>
</strong>
</em>
</p>
<hr>
<h2>First, the good news</h2>
<p>The <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">current COVID wave</a> (Australia’s fourth) is being fuelled by ever-more “pushy” Omicron subvariants <a href="https://theconversation.com/from-centaurus-to-xbb-your-handy-guide-to-the-latest-covid-subvariants-and-why-some-are-more-worrying-than-others-192945">such as BQ.1 and XBB</a>, waning immunity from <a href="https://kirby.unsw.edu.au/news/least-two-thirds-australians-including-children-and-adolescents-have-had-covid-19-two-national">past infection</a> and vaccination, and fewer public health measures. Luckily it appears the new subvariants <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">don’t cause</a> more severe disease.</p>
<p>What we’ve learned from past waves, plus widespread availability of <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines?gclid=EAIaIQobChMImdXB6b6v-wIVVhwrCh3FQgcVEAAYASAAEgJZXfD_BwE&gclsrc=aw.ds">vaccines</a> and <a href="https://www.health.gov.au/health-alerts/covid-19/treatments/eligibility?gclid=EAIaIQobChMIp7Wr2r6v-wIVgINLBR2GGAbIEAAYASAAEgJTH_D_BwE&gclsrc=aw.ds">treatments</a>, should keep more people from getting severely ill and needing to go to hospital.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/previous-covid-infection-may-not-protect-you-from-the-new-subvariant-wave-are-you-due-for-a-booster-193292">Previous COVID infection may not protect you from the new subvariant wave. Are you due for a booster?</a>
</strong>
</em>
</p>
<hr>
<h2>But health workers are burnt out</h2>
<p>However, health professionals are <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2021.750529/full">burnt out</a>.</p>
<p>Globally, health-care systems are seeing more-complex cases compared with before the pandemic, for a number of reasons. This includes increased complexity of conditions due to our ageing population, delayed care over the pandemic and because COVID is complicating existing conditions and care processes.</p>
<p>Globally, health systems have also had to deal with surges in other viruses – such as influenza and, especially in children, <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">respiratory syncytial virus</a>.</p>
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<p>During this latest COVID wave, more health staff will likely become infected. This will result in workforce absences, which will be difficult to fill over the coming summer period. <a href="https://www.anmf.org.au/media-campaigns/news/australia-facing-nursing-shortage-as-more-than-two-years-of-covid-takes-its-toll">Nursing shortages</a> continue.</p>
<p>Health-care staff feel isolated, and <a href="https://www.sciencedirect.com/science/article/pii/S2772598722000319">lonely</a>. Some feel the care they provide <a href="https://insightplus.mja.com.au/2022/11/health-workforce-not-normal-not-safe-but-it-can-be-fixed/">is not safe</a>. <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-022-00764-7">Some</a> are <a href="https://www.apna.asn.au/about/media/one-in-four-primary-health-care-nurses-plans-to-quit">leaving</a> their professions.</p>
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Read more:
<a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">Health worker burnout and 'compassion fatigue' put patients at risk. How can we help them help us?</a>
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<h2>We know what works</h2>
<p>Health systems will revisit what we know has worked during past COVID waves.</p>
<p>As case numbers climb, hospitals may need to cancel elective surgeries. They may need to boost their intensive care unit (ICU) capacity, by redeploying staff and facilities. They can assess COVID patients outside to minimise the risk of viral transmission, as they’ve done before. </p>
<p>Telehealth services could be expanded, we could see more use of existing community fever and respiratory clinics.</p>
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Read more:
<a href="https://theconversation.com/omicron-is-overwhelming-australias-hospital-system-3-emergency-measures-aim-to-ease-the-burden-175233">Omicron is overwhelming Australia's hospital system. 3 emergency measures aim to ease the burden</a>
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<p>But these old measures may not be enough. The health system is bursting at the seams in multiple places simultaneously. It’s like we had an old pair of shorts, COVID came along, and is causing holes in multiple places where things were already worn. </p>
<p>That includes <a href="https://www.theguardian.com/australia-news/2022/aug/10/not-honest-new-health-minister-dismisses-coalition-election-claim-that-bulk-billing-had-hit-88">primary care</a> (patients’ first contact with the health system, such as general practice), <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">the ambulance system</a> and <a href="https://acem.org.au/News/August-2022/ACEM-statement-on-primary-care-and-emergency-depar">hospitals</a>.</p>
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Read more:
<a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">Ambulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs</a>
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<h2>Here’s what we need to do next</h2>
<p>Here are three things <a href="https://www.nature.com/articles/s41586-022-05398-2">that would</a> <a href="https://www.who.int/publications/m/item/covid-19-strategic-preparedness-and-response-plan-2022--global-monitoring-and-evaluation-framework">help</a> an already stretched health system during this current wave and beyond.</p>
<p><strong>1. Reduce COVID transmission</strong></p>
<p>The <a href="https://www.who.int/publications/i/item/WHO-WHE-SPP-2022.1">World Health Organization</a> and Australian <a href="https://www.mja.com.au/journal/2021/215/4/we-are-not-doing-enough-prevent-spread-covid-19-and-other-respiratory-viruses">experts agree</a>, a clear priority is to reduce transmission of SARS-CoV-2, the virus that causes COVID.</p>
<p>We also need infection control <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1510059">trials that mimic the real world</a> and <a href="https://www.mja.com.au/journal/2021/215/4/we-are-not-doing-enough-prevent-spread-covid-19-and-other-respiratory-viruses">new approaches to infection control</a> not only in the health system but in education and in workplaces too. </p>
<p>As policies about wearing masks, testing or isolating after testing positive have been diluted, improvements such as <a href="https://www.mja.com.au/podcast/217/10/mja-podcasts-2022-episode-42-healthy-indoor-air-quality-why-its-important-prof-lidia">improving indoor air quality</a>, take on increased importance.</p>
<p><strong>2. Strengthen primary care</strong></p>
<p>World leaders <a href="https://apps.who.int/iris/bitstream/handle/10665/328123/WHO-HIS-SDS-2018.61-eng.pdf?sequence=1&isAllowed=y">have agreed</a> the bedrock of resilient and cost-effective health systems is a <a href="https://blogs.bmj.com/bmj/2020/10/26/a-safer-world-starts-with-strong-primary-healthcare/">strong primary health care</a> base.</p>
<p>So we need to bolster existing services, and to continue to address the aged care, disability and mental health care sectors to help with timely support of patients through the hospital system and out into other types of care. </p>
<p><strong>3. Gather and share information for decision making</strong></p>
<p>We should strive for better national data on health and the health system, building on existing valuable information held nationally and by state and territory health departments. </p>
<p>We could access and analyse data on individuals from across primary care and hospitals, public and private – <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4050016/">other countries do</a>. </p>
<p>This would allow us to better and more efficiently understand resource strengths and gaps across the health system (for instance improving wait-times for surgery). It would also help us to better understand needs (for instance, workforce needs) and to respond quicker, to ultimately improve people’s health.</p>
<h2>We all play a role</h2>
<p>COVID is <a href="https://www.mja.com.au/podcast/217/10/mja-podcasts-2022-episode-41-politics-pandemics-and-origins-omicron-prof-eddie">here to stay</a>. So we all play a role in reducing the impact on our health systems. Reduce the number of times you are infected. Get vaccinated. Wear a <a href="https://www.mhlw.go.jp/content/3CS.pdf">good quality mask</a> in crowded, closed, close-contact settings.</p>
<p><a href="https://www.health.gov.au/health-alerts/covid-19/testing">Test</a> often and stay home when unwell. Find out if you are eligible for <a href="https://www.health.gov.au/health-alerts/covid-19/treatments/eligibility">antiviral medications</a> and plan how you would get them if COVID positive.</p>
<p>Vote well. Politics are playing a <a href="https://www.nature.com/articles/s41586-022-05398-2">hefty hand</a> in our response to COVID locally and globally.</p>
<p>There will be more COVID waves. We need to focus on equity and social determinants of health, reducing the need for people to access the health system in the first place.</p>
<p>Health care is the pointy end of COVID. We need to aim to <a href="https://www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review">build stronger and fairer</a> systems for the years ahead. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/first-covid-hit-disadvantaged-communities-harder-now-long-covid-delivers-them-a-further-blow-183908">First, COVID hit disadvantaged communities harder. Now, long COVID delivers them a further blow</a>
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<p class="fine-print"><em><span>Alexandra Martiniuk receives funding from the National Health and Medical Research Council (NHMRC). </span></em></p>Here’s what needs to happen next for our health systems to cope with the latest COVID wave.Alexandra Martiniuk, Professor of Epidemiology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1916482022-09-30T06:50:26Z2022-09-30T06:50:26ZHurricane Ian flooded a hospital and forced evacuations from dozens of nursing homes – many coastal health facilities face rising risks from severe storms<figure><img src="https://images.theconversation.com/files/487410/original/file-20220929-24-4zfj3e.jpg?ixlib=rb-1.1.0&rect=0%2C489%2C4087%2C2690&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes patients had to be evacuated after Hurricane Ian cut access to safe water supplies. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/APTOPIXTropicalWeather/d283c8b0a2e7486abef97a86b00ee14d/photo">AP Photo/John Raoux</a></span></figcaption></figure><p>Hurricane Ian, one of the most powerful storms to hit the U.S., <a href="https://www.cbsnews.com/news/hurricane-ian-struck-florida-hospital-from-top-and-bottom/">tore part of the roof</a> off a hospital in Port Charlotte, Florida, and flooded the building’s lower level emergency room, sending staff scrambling to move patients as water poured in. At least <a href="https://www.msnbc.com/morning-joe/watch/fema-administrator-catastrophic-impact-to-lee-county-149497413543">nine hospitals</a> and dozens of nursing homes had to <a href="https://apnews.com/article/floods-hurricanes-health-hurricane-ian-storms-feafd6741badece7e416d9f1bfb2db73">transfer patients</a> after <a href="https://www.msnbc.com/morning-joe/watch/fema-administrator-catastrophic-impact-to-lee-county-149497413543">losing access to clean water</a> because of the storm.</p>
<p>Health care services are essential at any time, but when disasters strike, those services become even more crucial as injuries rise.</p>
<p>Yet in many coastal communities, the hospitals were built in locations that are at increasingly high risk of flooding during hurricanes.</p>
<p><a href="https://scholar.google.com/citations?user=35yZJBEAAAAJ&hl=en">I study ways to improve disaster communications</a>, including how health care organizations prepare for severe weather events. Here’s what research shows about the rising risks.</p>
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<h2>High percentage of coastal hospitals at risk</h2>
<p>Given the impact of climate change, many areas are susceptible to severe weather events and hazards. Health care facilities, including hospitals, clinics and long-term care facilities, are no exception.</p>
<p>A study released Sept. 29, 2022, as Ian was leaving Florida, found that even weak hurricanes can pose a <a href="https://agupubs.onlinelibrary.wiley.com/doi/10.1029/2022GH000651">severe risk to scores of hospitals</a> along the U.S. coasts. </p>
<p>In 25 metropolitan areas along the Atlantic and Gulf coasts, the authors found that at least half of the hospitals are at risk of flooding from a Category 2 storm, defined as wind speeds of 96 mph to 110 mph. In some cities, including Lake Charles, Louisiana; Naples, Florida, and Ocean City, New Jersey, 100% of the hospitals are considered at risk.</p>
<p>Those risks are rising with climate change. The study’s Harvard University authors estimated that the <a href="https://agupubs.onlinelibrary.wiley.com/doi/10.1029/2022GH000651">likelihood of coastal hospitals flooding would rise 22%</a> this century.</p>
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<p>What’s important about this finding is that communities can begin to identify hospitals at high risk and develop both backup plans and measures to help protect them and their patients.</p>
<p>The U.S. has a history of hospital disasters during severe weather. <a href="https://www.proquest.com/openview/65986d1c4c981fa1c2d3b2b5e37a64dd/1?pq-origsite=gscholar&cbl=36179">The aftermath of Hurricane Katrina in 2005</a> opened many people’s eyes to what disrupted health care systems look like. During that storm, <a href="https://www.urban.org/sites/default/files/publication/50896/411348-Hospitals-in-Hurricane-Katrina.PDF">many hospitals were without power</a> and the ability to communicate, and experienced damage to water and sewage services. Several could not replenish supplies of food, medicine, blood and linen, yet had to continue operations under horrific conditions.</p>
<p>The TV drama “<a href="https://tv.apple.com/us/show/five-days-at-memorial/umc.cmc.50agn5zbvuj7z70teq1p0pixn">Five Days at Memorial</a>” is built around that disaster and how the staff at New Orleans’ Memorial Medical Center struggled to keep patients alive while cut off by floodwater. It has triggered a lot of conversations around preparedness and risk in these critical facilities.</p>
<h2>Assisted-living communities overlooked</h2>
<p>My research explores how underserved and vulnerable populations prepare for and manage disasters. In particular, <a href="https://repositories.lib.utexas.edu/bitstream/handle/2152/83066/ROBERTSON-DISSERTATION-2020.pdf?sequence=1">I’ve done fieldwork analyzing how older adults living in retirement and assisted-living communities</a> perceive their own risks.</p>
<p>Ideally, these facilities should be able to provide the same services during disasters as before, without interruption. The reality is that when infrastructure is overwhelmed, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248769/">older adults may be trapped in dangerous conditions, unable to evacuate</a>. They also might not be mobile enough to be easily rescued, especially if the facility spans several floors.</p>
<p>Staff might not be available to administer medications. Electricity or power for life-sustaining medical treatments might not be available. Health care workers in these care facilities <a href="https://www.tandfonline.com/doi/full/10.3402/ehtj.v4i0.7167">are also not always able to execute disaster plans or protocols</a>, if such plans exist.</p>
<p>After Hurricane Irma knocked out power to Florida in 2017, <a href="https://www.local10.com/news/local/2022/09/22/charges-expected-to-be-dropped-against-nurses-in-hollywood-hills-rehab-case">a dozen patients died</a> in a nursing home that lost power for air conditioning. That led to a state law that now <a href="https://www.flgov.com/wp-content/uploads/2017/09/AHCA916.pdf">requires nursing homes to have backup generators</a>. But Ian showed that even that isn’t enough to keep residents safe.</p>
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<img alt="A muddy room with an overturned chair and a gurney. The mud line on the interior wall from floodwater is near the ceiling." src="https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487409/original/file-20220929-18-nwwafp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">During Hurricane Katrina, 35 patients died after St. Rita’s Nursing Home flooded in St. Bernard, Louisiana.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/NursingHomesDisasters/f0d3fc5219d14a4c9ebe46ac9f5e9ad5/photo">AP Photo/Anja Niedringhaus</a></span>
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<p>Other populations, such as people with <a href="http://kmu.ac.ir/Images/UserFiles/3058/file/%D8%B9%D9%84%D9%88%D9%85%20%D8%A7%D8%B7%D9%84%D8%A7%D8%B9%D8%A7%D8%AA%20%D8%B3%D9%84%D8%A7%D9%85%D8%AA/Health%20Care%20Emergency%20Management.pdf#page=394">physical, sensory or cognitive disabilities</a>, and those who are medically vulnerable, including homeless populations, also need to be considered in health care-related disaster planning. While those who are homeless may find shelters, including shelters created for disaster relief, <a href="https://www.sciencedirect.com/science/article/pii/S2212420919303413?casa_token=s-Crvy6E70UAAAAA:NIu9B7xZl_bJzbSiFsZOpgi81T1Ex6dhAA4rQ0Nnf3PpTXMSaPRxHDhYLqoFlfJruOblgv0_ZQw">it is not uncommon for people who are homeless to seek medical services</a> or find refuge in hospitals.</p>
<h2>Resilience and disaster plans</h2>
<p>After disasters, hospitals are essential for treating the <a href="https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2019.305520?casa_token=Vh-LU3pCfhgAAAAA:bRyBryi3n4Ew7OY8yz8_UPA4ApGClfkMYPZp1KM6NAj7zqWjd0TV_hHKzrD2DgxaYu2u9iLYQeM0">rise in injuries</a>, as well as mental health issues among disaster victims. <a href="https://apnews.com/article/hurricane-ian-impact-path-d4db93bcac5af1134e31a3b7f2f694f0">More than 700 rescues</a> were launched during Ian and its aftermath.</p>
<p>Therefore, it is important for hospitals, as well as nursing homes, to develop <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-4915-2">hospital disaster resilience plans</a>. These plans for hospitals cover topics like safety, staffing, surge capacity to handle a sudden increase in patients, handling emergency services amid flooding, and disaster plans, training and communications.</p>
<p>Looking long term, better building design, <a href="https://www.tampabay.com/hurricane/2022/09/28/tampa-general-fortifies-ian-with-aqua-fence-water-tight-doors/">flood barriers</a> and safer locations may be necessary. </p>
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<img alt="" src="https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=631&fit=crop&dpr=1 600w, https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=631&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=631&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=792&fit=crop&dpr=1 754w, https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=792&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/496180/original/file-20221118-18-3fj3ii.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=792&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">KING5-TV Senior Meteorologist Rich Marriott shared photos of a hospital’s temporary flood barrier.</span>
<span class="attribution"><a class="source" href="https://twitter.com/rtmarriott/status/1574784839471206400">Twitter</a></span>
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<p>The <a href="https://www.hfmmagazine.com/articles/2650-new-va-hospital-meets-patients-needs-in-a-highly-resilient-facility">Southeast Louisiana Veterans Health Care Center</a> in New Orleans is one model of how to design a health facility to withstand a disaster. The building was built to handle high winds, and the emergency department is on the second floor, at least 21 feet above base flood elevation.</p>
<p>Storms like Ian are a difficult reminder of the importance of protecting these facilities so emergency medical care is available in disasters, and why disaster planning at all health care sites is crucial.</p><img src="https://counter.theconversation.com/content/191648/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brett Robertson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Coastal hospitals are still at high risk, nearly two decades after Hurricane Katrina’s flood disaster at Memorial Medical Center shocked the world.Brett Robertson, Assistant Professor of Communication, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907452022-09-27T20:21:39Z2022-09-27T20:21:39ZHow health-care leaders can foster psychologically safer workplaces<figure><img src="https://images.theconversation.com/files/486635/original/file-20220926-26-578e68.JPG?ixlib=rb-1.1.0&rect=134%2C143%2C2694%2C1895&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, abuse from patients and a pandemic have contributed to overwhelming burnout and job dissatisfaction among workers.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>Every day it seems the Canadian health-care staffing crisis worsens, with <a href="https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html">emergency room closures</a>, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">not enough family doctors</a> and <a href="https://www.wellesleyinstitute.com/wp-content/uploads/2020/09/Waiting-for-Long-Term-Care-in-the-GTA.pdf">long wait times to get into long-term care</a>. </p>
<p>At the core are health-care workers who are physically and mentally burnt out from the unsafe work environments they’ve been asked to work in for years, which were made remarkably worse during COVID-19. </p>
<p>Health-care leaders have a key role to play in developing psychologically safer workplaces to support the well-being of our health-care workers. Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, <a href="https://doi.org/10.1186/s12913-020-05084-x">abuse from patients</a>, and <a href="https://doi.org/10.3389/fpubh.2021.750529">the pandemic</a> have contributed to the overwhelming burnout and job dissatisfaction evident among workers.</p>
<h2>Physically and emotionally unsafe</h2>
<p>Even before the COVID-19 pandemic, Canadian health-care workers were experiencing <a href="https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf">burnout and depression</a>. The pandemic has worsened already poor working environments, exposing them not only to a life-threatening virus, but <a href="http://doi.org/10.1001/jama.2021.2701">mounting physical and verbal abuse</a>, <a href="https://www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf">increasing rates of burnout and depression</a>.</p>
<p>It is not surprising, then, that health-care workers are leaving the profession in greater numbers, <a href="https://www.cbc.ca/news/canada/nurses-canada-overtime-pandemic-burnout-1.6545963">further exacerbating the working conditions for the remaining health-care workers</a>. </p>
<figure class="align-center ">
<img alt="A paramedic in a face shield wearing a neon yellow jacket walks past patients on gurneys in a hospital corridor" src="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers, nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting burnout.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers (PSWs), nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting higher levels of stress. <a href="https://clri-ltc.ca/files/2021/02/PSW_Perspectives_FinalReport_Feb25_Accessible.pdf">PSWs working in long-term care report</a> physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</p>
<p>We know that <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Workforce_Psychological_Safety_in_the_Workplace_ENG.pdf">psychological health and safety in the workplace</a> is directly tied to productivity, retention, absenteeism, workplace conflict and the overall operational success of the workplace. Canadian health-care leaders, managers and supervisors are exceptionally placed to help health-care organizations build work environments where staff feel supported and safe. </p>
<figure class="align-right ">
<img alt="An outdoor sign reading 'Hiring PSWs - many shifts - benefits'" src="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">PSWs working in long-term care report physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span>
</figcaption>
</figure>
<p>Our research team was recently funded by the <a href="https://mentalhealthcommission.ca">Mental Health Commission of Canada</a> to examine the facilitators and barriers that health-care organizations face in creating safe work environments. We surveyed and interviewed <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">hundreds of health-care workers from across disciplines, workplaces and provinces</a>. Here’s what they told us: </p>
<ul>
<li><p>There is much focus placed on health-care workers building resiliency, but without giving them the time and space to do so. Organizations can help by protecting time off for workers. </p></li>
<li><p>Health-care workers have told us that long-term organizational resources such as wellness champions, ethicists and effective health benefits for all health-care workers (for example, benefits that cover counselling services) would help support their well-being. </p></li>
<li><p>Appropriate and transparent operational policies and procedures related to clinical care and/or human resources that pervade an entire organization help to develop a fair and safe working climate. Managers can further support their workers by ensuring those policies and procedures are consistently applied and followed.</p></li>
<li><p>Organizations should seek out and support effective, compassionate and authentic leaders. Developing health-care leaders who are skilled and rise to the job in their stressful environments is critical and should be cultivated and rewarded. Managers have also been through the wringer over the past several years and need to be supported by their organizations. </p></li>
<li><p>Fewer than 50 per cent of health-care workers in our study reported working in an ethical climate. For example, many health-care workers do not have access to the necessary supports to work through ethical dilemmas. This is a great place for health-care organizations to focus; cultivating an ethical work environment can demonstrate to its employees that they want to protect them from moral distress. </p></li>
<li><p>Health-care workers have told us that transparency and effective communications are critical and increase trust in their leaders. </p></li>
</ul>
<p>The future of our health system is dependent on recruiting and retaining passionate, hardworking and highly skilled health-care workers. Every health-care worker, in ever workplace, across every province needs an organization that values and prioritizes their psychological health and safety. For the full report please visit: <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">MHCC – Exploring Two Psychosocial Factors for Health-Care Workers</a>.</p><img src="https://counter.theconversation.com/content/190745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The future of our health system depends on recruiting and retaining passionate and highly skilled health-care workers. It’s essential to build work environments where they feel supported and safe.Angela Coderre-Ball, Assistant Professor (Adjunct), Family Medicine, Queen's University, OntarioColleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioDenis Chênevert, Professor and director of healthcare management hub, HEC MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907952022-09-27T13:12:01Z2022-09-27T13:12:01ZNorthern Ghana is underdeveloped because of underinvestment during colonial rule, not geography<figure><img src="https://images.theconversation.com/files/485351/original/file-20220919-7117-csy9xg.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Northern Ghana was treated as a periphery outpost by colonial administrators.</span> <span class="attribution"><span class="source">Flickr</span></span></figcaption></figure><p>Ghana’s most important development problem is arguably the disparity between the north and south of the country. The north is acutely underdeveloped, trailing the south in practically all metrics of development.</p>
<p>Several inequality <a href="https://www.unicef.org/ghana/media/531/file/The%20Ghana%20Poverty%20and%20Inequality%20Report.pdf">reports</a> have consistently labelled the northern region as one of concern. Its rate of poverty level decline has remained very slow: from a poverty rate of 55.7% in 2006 to 50.4% in 2012. Southern Ghana enjoys a <a href="https://www.undp.org/ghana/publications/ghanas-multidimensional-poverty-index-report">lower poverty incidence</a> at 45%.</p>
<p>Explanations for the underdevelopment of the north often underscore its geography and climate. The north is dry, unsuited to growing cash crops, and lacking mineral resources. Another school of thought considers the impact of the colonial experience from 1897 till independence. The north was sidelined by the British colonial administration.</p>
<p>I have been looking into this to see which kind of explanation is most satisfactory. My <a href="https://www.tandfonline.com/doi/full/10.1080/00220388.2022.2113066">study</a> of the economic history of Ghana specifically examines the colonial roots of the north-south development divide. </p>
<p>I estimated the current development disparity between the two regions and examined the contribution of colonial public investments in education, health and infrastructure. The south received almost all the colonial public investments. </p>
<p>I found that the effects of past colonial investments persist now – even in the few northern locations where they were made. They still strongly determine current development outcomes in Ghana. </p>
<p>The findings suggest that colonial investments were equally productive in the north and the south. The current status of the north would be different had it received a fairer share of colonial investments. The findings also suggest how development could be achieved in future.</p>
<h2>Ghana’s north and south contrasted</h2>
<p>I found that an average location in the north is at least 51% less developed than one in the south. The level of development was based on satellite images of light density at night – a precise and objective measure.</p>
<p>More than 70% of the northern population live in disadvantaged rural areas. The region <a href="https://www.researchgate.net/publication/272325050_The_Contours_of_Poverty_in_Northern_Ghana_Policy_Implications_for_Combating_Food_Insecurity">scores lower</a> than the south in most development terms. For example, in the Greater Accra Region, 22.5% of the population is poor in several ways, according to the <a href="https://www.undp.org/sites/g/files/zskgke326/files/migration/gh/UNDP_GH_MPI_Report_2020.pdf">UNDP’s 2020 Inequality Report</a>. </p>
<p>The arid north is primarily savannah woodland with no significant potential for cash crop cultivation. The mineral-rich and wetter south, <a href="https://www.tandfonline.com/doi/full/10.1080/00220388.2022.2113066">covering about 56%</a> of the country, produces and exports cash crops. The population of the south (24.5 million) is four times that of the north.</p>
<p>Other arguments about the regional differences concern their history. It’s said that prior to colonial conquests, the north was more prosperous and developed, having built a fortune on trade and industry. That changed through colonial practices. The colonial state administered the north as a “periphery” and the south as a “core”. Colonial investments and expenditures in the north were kept at a bare minimum.</p>
<p>I explored the spatial distribution of colonial public investments in education, health and infrastructure. For example, northern Ghana had no class one road as at 1931 and no railway throughout the colonial period. Average distances to a colonial railroad were 324km and 59km for northern and southern areas respectively. The average distance to a class one road in 1931 was about 196km in the north and 32km in the south. </p>
<p>Colonial investments, railways in particular, stimulated local economic activities and development in the south. </p>
<p>In 1901 the north had no school or hospital. The south had 125 schools and eight places with at least one hospital. By 1931 the number of schools in the south had risen to 325 and places with hospitals to 24. But the number of schools in the north had only doubled to eight, and only six places had at least one hospital.</p>
<h2>Colonial effects persist</h2>
<p>I found that past colonial investments still strongly determine contemporary development in Ghana. Places closer to locations of past colonial investments are still relatively more developed today. </p>
<p>Even though the north received far fewer colonial investments, areas closer to the locations of colonial investments in the north are more developed today than other areas in the north. So colonial investments were equally productive in the north. </p>
<p>Current development outcomes in Ghana are also more heavily driven by colonial-era factors than by post-independence factors. </p>
<p>There are several reasons why the effects of past colonial investments persist.</p>
<p>First, once an investment had been made in a location, subsequent investments followed in the same location. It would be more cost-effective or more convenient to extend an existing railway line, for example, than to survey unexplored terrain for new railway lines. </p>
<p>Second, colonial investments brought associated benefits, prolonging their effects. If railway lines stimulated population growth in an area, more health facilities and schools would be provided. </p>
<p>Third, colonial investments like railway lines, schools and hospitals had a long physical duration. </p>
<p>Fourth, colonial investments had high returns because they were made in places that had not previously received such investments. </p>
<p>My study leads me to conclude that if more investments had been made in the north, the region could today be more like the south in terms of development.</p>
<h2>Diagnosis of the problem</h2>
<p>There have been numerous programmes to develop the north since Ghana gained political independence in 1957. Unfortunately, most either underperformed or failed. This is because the potential of the north has not been properly diagnosed. </p>
<p>The north’s historical fortune was oriented towards trade and industry. At the onset of colonial rule, the modernisation of its trade system depended on the extension of railway lines to the region. But the north still has no railways connecting it to the south. Roads to the south are also in a deplorable condition. </p>
<p>Development policies in the north have targeted food production instead of infrastructural developments. But food production can’t transform the north without better transport links. </p>
<p>The construction of the <a href="https://new-ndpc-static1.s3.amazonaws.com/CACHES/PUBLICATIONS/2016/05/03/1-MASTER+PLAN+GHANA+FINAL+REPORT+-+Fin4.pdf">Ghana Railway Masterplan</a>, designed in 2013 to connect the north and the south, has not started. The mooted <a href="https://projectsportal.afdb.org/dataportal/VProject/show/P-GH-DB0-018">Eastern Corridor Road</a> project has never seen concrete progress either. These two projects would arguably be the most important routes to transform the north.</p><img src="https://counter.theconversation.com/content/190795/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Iddrisu Mohammed Kambala does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana’s northern region would be more developed now had it received a fairer share of colonial investments.Iddrisu Mohammed Kambala, PhD Candidate, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1887122022-09-14T19:21:29Z2022-09-14T19:21:29ZHow improving COPD treatment in primary care could reduce demand on hospitals and emergency departments<figure><img src="https://images.theconversation.com/files/484673/original/file-20220914-19-lq6phg.jpg?ixlib=rb-1.1.0&rect=0%2C22%2C4715%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because of the difficulty in managing their care, patients with COPD have hospitalization rates 63 per cent higher than the general population, as well as 85 per cent more emergency department visits and 48 per cent more ambulatory care visits.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In Ontario, <a href="https://www.publichealthontario.ca/-/media/documents/c/2019/cdburden-report.pdf?sc_lang=en">nearly 900,000 people</a> live with chronic obstructive pulmonary disease (COPD). <a href="https://doi.org/10.1164/rccm.201211-2044OC">People with this condition account for 24 per cent of hospitalizations, 24 per cent of emergency department visits and 21 per cent of ambulatory care visits</a>. </p>
<p>Because of difficulty in managing care, patients with COPD have hospitalization rates that are <a href="https://doi.org/10.1164/rccm.201211-2044OC">63 per cent higher than the general population, as well as rates of emergency department and ambulatory care visits that are, respectively, 85 per cent and 48 per cent higher than the general population</a>, all of which contribute <a href="https://doi.org/10.1016/j.rmed.2007.10.010">significant financial costs</a> to Ontario’s health-care system. </p>
<p>Health-care sustainability has made headlines as emergency rooms around Ontario have closed due to <a href="https://www.cbc.ca/news/canada/toronto/ont-er-closures-1.6545119">staffing shortages, COVID-19 infections and burnout of frontline workers</a>. Ontario’s Health Minister Sylvia Jones has said that the province should <a href="https://toronto.citynews.ca/2022/08/11/ontario-health-minister-pushes-back-against-privatization/">embrace innovation</a> to help solve challenges within the health-care system. </p>
<p>Arguably, one of the most effective solutions would be to divert patients away from the emergency room and hospital in favour of more cost-effective primary care. Innovations in treatment of patients with COPD in primary care has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.</p>
<p>Fortunately, there is an existing program in primary care, called Best Care, that has been demonstrated to be <a href="https://doi.org/10.1186/s12962-022-00377-w">cost-effective</a>, <a href="https://doi.org/10.1186/s12913-022-07785-x">improve patient and provider experience</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce emergency department visits and hospitalizations</a>.</p>
<h2>The opportunity for Best Care</h2>
<p>Best Care is an innovative integrated disease management program (IDM) for managing high-risk, exacerbation-prone patients with COPD in a primary care setting. It was designed by a collaborative team of frontline health-care providers and administrators, supported by Ontario Health.</p>
<figure class="align-center ">
<img alt="A young woman behind a desk in a white coat with stethoscope watching an older woman use an inhaler" src="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People in the Best Care program become active partners in their care, taking back control over their lives.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The <a href="https://doi.org/10.1038/s41533-019-0119-9">Best Care IDM program</a> involves <a href="https://www.argi.on.ca/copd-patient">embedding a certified respiratory educator</a>, who is also a case manager, within the primary care practice where the patient normally receives care. In collaboration with the patient’s primary care provider, the certified respiratory educator delivers or supports access to all 14 of <a href="https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-chronic-obstructive-pulmonary-disease-quality-standard-en.pdf">Ontario Health’s COPD quality standards</a>, including diagnosis, assessment, care planning, patient education, medication management and specialized respiratory care.</p>
<p>People in the Best Care program become active partners in their care, taking back control over their lives. The efficacy of Best Care has been empirically <a href="https://doi.org/10.1038/s41533-019-0119-9">demonstrated to improve patients’ quality of life and to help avoid emergency department visits</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce hospitalizations</a>. </p>
<p>Over the past three years, 7,000 Ontarians affected by severe COPD have benefited from the program. Three Ontario health regions implementing Best Care have shown dramatic reductions in COPD-related emergency department visits and hospitalizations.</p>
<h2>Evaluating cost-effectiveness</h2>
<p>Recently, with a team of health economists from the University of Ottawa, we <a href="https://doi.org/10.1186/s12962-022-00377-w">evaluated the cost-effectiveness</a> of the Best Care integrated disease management program for high-risk, exacerbation-prone patients in a primary care setting. In this research we used data from our earlier clinical study and the best available evidence to evaluate if investment in the Best Care program was cost-effective from the perspective of the Ontario health system. </p>
<p>Our results show that Best Care is not just cost-effective, but is dominant in comparison to standard care in Ontario. Best Care integrated disease management program was cost-effective in 85.3 per cent of our simulations.</p>
<p>When evaluating programs in terms of health economics, a program is <a href="https://doi.org/10.1016%2Fj.jacc.2008.09.018">dominant</a> when it improves patient outcomes and costs less than the alternative standard of care: in other words, better care at a lower cost. </p>
<figure class="align-center ">
<img alt="A man breathing into a white tube through his mouth, with a blue nose clip on his nose." src="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One of the ways COPD patients are assessed is spirometry, a test of lung function.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>With a modest up-front investment in primary care, the Best Care program is expected to dramatically reduce demand for acute health services. In fact, our modelling anticipates a 1.5-fold return on investment in the first year of implementation. Continued health system savings are expected for at least 10 years by reducing the number of urgent care and emergency room visits and the frequency of hospitalization.</p>
<p>We also ran several different scenarios to test the assumptions we made within our economic analysis. The results consistently demonstrated that Best Care integrated disease management program was cost-effective and dominant in comparison to the usual standard of care. When we assume that a patient’s quality of life should only improve with access to a certified respiratory educator/ case-manager (i.e., the patient’s quality of life should remain the same or increase, but not decrease), the probability that Best Care IDM is cost-effective increases to over 96 per cent. </p>
<h2>Sustainable health-care investment</h2>
<p>The <a href="https://www.ontario.ca/document/healthy-ontario-building-sustainable-health-care-system/chapter-2-vision-health-care-ontario">Ontario health system</a> seeks to invest in sustainable, innovative solutions that will maximize health-care capacity. This includes reducing avoidable hospitalizations and emergency department visits; improving patient, caregiver and provider experience; and enhancing patient outcomes while containing costs. </p>
<p><a href="https://doi.org/10.1038/s41533-019-0119-9">Prior peer-reviewed publications</a> and health system data have confirmed that the Best Care integrated disease management program improves patient outcomes as well as patient, caregiver and provider experience. Our robust health economic analysis confirms that Best Care is economically attractive compared to the current provincial care standard. </p>
<p>Best Care in COPD is a <a href="https://www.hqontario.ca/Portals/0/documents/health-quality/quality-matters-print-en.pdf">sustainable health-care investment</a> and delivers on all of the goals of the <a href="https://doi.org/10.1370%2Fafm.1713">quadruple aim approach to health care</a>: optimizing patient experience, improving health at the population level, reducing costs and supporting the well-being of health-care providers.</p>
<p><em>Madonna Ferrone, Director of Operations, Asthma Research Group Windsor-Essex County Inc., co-authored this article.</em></p><img src="https://counter.theconversation.com/content/188712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew D. Scarffe (he/him) received funding from the Asthma Research Group Windsor-Essex County Inc. in the form of a doctoral student stipend. He also receives funding from Mitacs Inc. through the Mitacs e-Accelerate scholarship. Andrew is a two time recipient of the Queen Elizabeth II Graduate Scholarship for Science and Technology and is a one time recipient of the Ontario Graduate Scholarship. He also receives funding from the Telfer School of Management and the University of Ottawa in the form of a graduate student scholarship and excellence (admission) scholarship. Publication of this article was not contingent on approval and/or censorship from any of the funding sources listed above.</span></em></p><p class="fine-print"><em><span>Dr. Licskai has received salary support from Western University as Professor of Health System Innovation and is the Medical Director of the Best Care in Primary Care program related to this work. Outside of the submitted work Dr. Licskai reports personal fees and / or research grants from AstraZeneca, GlaxoSmithKline, Novartis, Teva, and Sanofi Genzyme.</span></em></p><p class="fine-print"><em><span>Doug Coyle, Kednapa Thavorn, and Kevin Peter Brand do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Innovation in primary care for COPD patients has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.Andrew Scarffe, PhD Candidate in Management (concentration in Health Systems), L’Université d’Ottawa/University of OttawaChristopher Licskai, Associate Professor of Medicine, Professor of Health System Innovation, Division of Respiratory Medicine, Western UniversityDoug Coyle, Professor, School of Epidemiology and Public Health, L’Université d’Ottawa/University of OttawaKednapa Thavorn, Senior scientist, L’Université d’Ottawa/University of OttawaKevin Peter Brand, Associate professor, Health Systems, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891992022-09-08T20:14:32Z2022-09-08T20:14:32ZWith family doctors heading for the exits, addressing the crisis in primary care is key to easing pressure on emergency rooms<figure><img src="https://images.theconversation.com/files/482397/original/file-20220901-14792-k5pnkl.JPG?ixlib=rb-1.1.0&rect=410%2C506%2C5418%2C3382&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span></figcaption></figure><p>The Ford government’s recently released plan to ease pressure on Ontario emergency rooms makes no mention of the <a href="https://ottawacitizen.com/opinion/abdulla-you-want-a-family-doctor-in-ontario-sorry-its-not-going-to-be-easy">mass exodus of physicians from family practice</a>. With that omission, the province’s <a href="https://files.ontario.ca/moh-plan-to-stay-open-en-2022-08-18.pdf">Plan to Stay Open</a> ignores the central role of family doctors in the health-care system, and sets itself up for failure.</p>
<p>A strong primary care system, identified as <a href="http://doi.org/10.1001/jama.1993.03500190088041">the cornerstone of health care</a>, keeps patients <a href="https://doi.org/10.1186/s12913-015-0705-7">away from emergency rooms</a> and plays a huge role in encouraging <a href="https://doi.org/10.9778/cmajo.20170007">self-management of illness and prevention of disease</a>.</p>
<h2>Critical role of primary care</h2>
<p>Focusing mainly on hospitals to fix the problem is akin to closing the barn door after the horses have fled. We must look upstream to primary care where about <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm">86 per cent of Canadians trust family doctors</a> to assist them in staying healthy. </p>
<p>In my ongoing research on integrated health-care systems — including <a href="https://health.gov.on.ca/en/pro/programs/connectedcare/oht/">Ontario Health Teams</a> and the capacity for family physicians to inform system change — I see a high degree of skepticism among family physicians about influencing system reform, since many have previously seen their input not heeded or not even sought. Time also limits their participation in health system research.</p>
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<img alt="A woman in a white coat is examining a little girl using a stethoscope, while another woman stands behind the girl." src="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Ontario’s plan ignores the central role of family doctors in the health-care system, and sets itself up for failure.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily. At the same time, family physicians are fed up. No wonder that some are <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away because they “can’t take it anymore</a>.” </p>
<h2>Increasing challenges in family medicine</h2>
<p>Family physicians are dealing with significant burnout, ever-increasing workloads, unrealistic patient demands and <a href="https://www.cfp.ca/content/57/9/983.long">lack of respect from other specialties</a>. In addition to having a passion for providing continuous, comprehensive care, family physicians also need to acquire business acumen to manage overhead costs, performance management skills to hire, fire and coach office staff, and administrative prowess to deal with the mounds of paperwork that is done after the patient leaves (and is mostly non-billable). </p>
<p>Despite the value that most of us place on having a family doctor that we trust with our cradle-to-grave health issues, they are among the <a href="https://nationalpost.com/opinion/why-five-million-canadians-have-no-hope-of-getting-a-family-doctor">lowest paid and the least respected physicians, yet they have the most knowledge about the inefficiencies</a> in a health-care system that is coming apart more each day. </p>
<p>To make matters worse, supply is decreasing. This year’s residency applications through the <a href="https://www.carms.ca/the-match/">Canadian Resident Matching Service</a> (CaRMS) indicates that <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">the number of medical school graduates choosing family medicine as their top choice for training spots is declining steadily</a>. </p>
<p>This should be worrying for all of us as patients. More exploration into why family medicine is no longer seen as a worthy profession is sorely needed as more and more patients will be unable to access the continuous, comprehensive care they require. </p>
<h2>More Canadians without a family doctor</h2>
<p>News headlines continue to highlight that <a href="https://www.thestar.com/opinion/editorials/2022/07/30/an-unhealthy-shortage-of-family-doctor.html">more patients across the country are without a family doctor</a> and fewer doctors want to enter, or stay, in family practice. </p>
<p>In addition to diminished supply of new family doctors, many are heading for the exits earlier than anticipated. Family physicians are choosing to retire early, and in some cases <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away from large and long-standing practices</a> leaving more and more patients without a family physician and having no other option but to visit the emergency department for their health concerns. </p>
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<img alt="A stethoscope on a desk in the foreground, with a doctor out of focus sitting at the desk with his hands to his face" src="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Family physicians are dealing with significant burnout and ever-increasing workloads.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Increasing the number of family physicians is important but retaining those that we already have should be viewed as absolutely critical. With the <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">average age of a family doctor in Canada at 49</a>, it’s not hard to predict that more retirements (planned or otherwise) will have a detrimental impact on the health of Canadians. </p>
<h2>Primary care challenges</h2>
<p>Primary care is not without its own challenges. For those that are lucky enough to have a family doctor, the time to see them varies, and <a href="https://healthydebate.ca/2015/11/topic/what-does-access-to-primary-care-really-mean/">access issues</a> are a common theme in patient complaints. Different physician offices use different appointment booking practices and scheduling rules, which can impact patient access ratings. </p>
<p>There are inequities between family physicians with solo practices in comparison to those who are attached to a family health team — health-care organizations that provide primary health care to communities and include various health professionals such as nurses, dietitians, social workers and others who share aspects of patient care with doctors. </p>
<p>Ontario has done better than most areas of Canada with the <a href="https://www.health.gov.on.ca/en/pro/programs/fht/">introduction of family health teams in 2005</a>, with team-based primary care reporting <a href="https://doi.org/10.1016/j.mayocp.2019.01.038">better outcomes for both patients and providers</a>. </p>
<p>But no new family health teams have been funded since 2012, which is a problem. Ontario Health Teams were introduced in 2019, and offer potential to influence what is currently a cadre of services (including primary care, hospitals, long-term care, home care, health support services) to function better as an integrated health system covering a geographic region. </p>
<p>Ontario Health Teams do not provide direct care, but are tasked with building a better system of care, working to break down silos between health-care providers and organizations to function better for patients. Primary care must be a major player in these. </p>
<p>Political will is required to invest in the entire health-care system and not ignore the fact that primary care represents a very large part of this system. We have a capacity crisis for certain — but cannot fix only one flat tire when all the tires are flat!</p><img src="https://counter.theconversation.com/content/189199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Grady does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A strong primary care system keeps patients away from emergency departments and helps patients self-manage illnesses. But Ontario’s plan to ease pressure on emergency rooms ignores family medicine.Colleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1872702022-07-21T20:23:16Z2022-07-21T20:23:16ZAmbulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs<p>Health-care systems across Australia are buckling in the wake of COVID waves and the flu season. Pictures of ambulances piling up outside hospitals have become commonplace in the media. Known as “ramping”, it’s the canary in the coalmine of a health system.</p>
<p>As a major symptom of a health system under stress, state governments across Australia are investing unprecedented amounts into ambulance services, emergency departments (EDs) and hospitals. South Australia has <a href="https://www.abc.net.au/news/2022-06-05/ambulance-funding-stop-ramping-more-paramedics-premier/101127486">committed to</a> an increased recruitment of 350 new paramedics. Likewise, New South Wales <a href="https://www.abc.net.au/news/2022-06-05/nsw-to-get-1858-paramedics-with-2-billion-dollar-budget-funding/101126918#:%7E:text=New%20South%20Wales%20is%20set,%2230%2Dyear%20deficit%22.">has committed</a> to 1,850 extra paramedics. </p>
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<a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">Bad for patients, bad for paramedics: ambulance ramping is a symptom of a health system in distress</a>
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<p>Victoria, meanwhile, has committed an additional <a href="https://www.premier.vic.gov.au/backing-paramedics-get-patients-care-they-need-sooner">A$162 million</a> for system-wide solutions to counter paramedic wait times, on top of the A$12 billion already committed to the wider health system. This could begin to alleviate the system pressures that lead to ambulance ramping. </p>
<p>But what happens when the paramedics return yet again to ED with another patient? Will they simply end up ramped again?</p>
<p>We also need to consider better care in the community – and paramedics could play a role in this too. </p>
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<h2>Smoother transfers and discharges</h2>
<p>The Victorian government initiative is based on a <a href="https://www.nhsconfed.org/articles/what-latest-data-tell-us-about-ambulance-handover-delays?fbclid=IwAR1uGgNx1m--nlGgKtvI9qQu4Q6Y7lNVaafs3Dh0WyOoJb7eCEGIbYAbKeo">similar model</a> used in Leeds, in the United Kingdom, which has resulted in decreased ramping times. The Leeds model has seen only 4.9% of paramedic attendances to ED having ramping delays over 30 minutes, compared to the UK average of 21%. </p>
<p>The model focuses on transferring the patient from the paramedic to the ED staff, discharging patients from hospital and coordinating the patient’s care in the community.</p>
<p>The aim is to improve patient flow in and out of the hospital. For patients requiring a hospital bed, they are admitted. For those not requiring admission, they are discharged home in a timely manner. Discharge coordinators will assist this process, coordinating the care patients need after an ED or hospital stay out in the community and in their homes.</p>
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Read more:
<a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">Emergency departments are clogged and patients are waiting for hours or giving up. What's going on?</a>
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<p>The discharge process is complex. Often a well-done discharge is the difference between a patient returning to the community healthily versus a re-presentation to the hospital due to actual or perceived worsening of their condition. </p>
<p>However, patients <a href="https://bmjopen.bmj.com/content/12/7/e062437">often feel rushed</a> when discharged from hospital and ill prepared to return home. Staff feel pressure to get patients discharged and out of beds to allow the next patient in.</p>
<p>The adoption of the Leeds model in Victoria aims to increase the flow in and out of the hospital. While this will get patients off ambulance stretchers, it may further exacerbate the feelings of being rushed.</p>
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<img alt="Person lays in hospital bed" src="https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475321/original/file-20220721-18-3szi3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A good discharge reduces the likelihood of a patient returning to hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-sick-male-patient-sleeps-on-1190997985">Shutterstock</a></span>
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<p>Discharge and transitional care services, which aim to guide patients from their time in hospital to living back at home, tend to be disconnected and misunderstood by the wider health service. We must overcome these disconnections if the proposed model is going to have success. </p>
<p>Otherwise, new initiatives may decrease ramping at the ED, but this may come at a cost to the most vulnerable of patients in our community, if they feel they’re discharged too soon, are unable to cope and end up going back to hospital. </p>
<h2>Paramedics can provide care in the community, too</h2>
<p>Poor access to primary care services, such as being able to see a GP and a lack of community services, are problems across the globe. This has <a href="https://www.phecit.ie/Custom/BSIDocumentSelector/Pages/DocumentViewer.aspx?id=oGsVrspmiT0dOhDFFXZvIz0q5GYO7igwzB6buxHEgeAwoe6hhx3Qzd%252fCRqybt66szE0PsYSC8wDndnJ4ZZBtixIuvZKX1%252f4wN58oIZl8uwPebsYwRo0IvX6hVCWn5T8FxWsBQJfWSaVSf%252bRJ%252b80BMTb0c8d%252b63Hj">led to the use</a> of paramedics in non-traditional roles in the UK, Canada, the United States, Finland and Ireland. Here, paramedics are used in emergency departments, in primary care practice and in outreach community services. Paramedics working in these non-traditional roles are collectively known as community paramedics.</p>
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<p>In Australia, paramedics are university educated and professionally registered, which maintains a high workforce standard. Paramedics can work independently within the community and are well situated to supplement or complement community services and primary care. Yet <a href="https://hwd.health.gov.au/resources/publications/factsheet-alld-paramedical-2019.pdf">80% of paramedics</a> in Australia work solely in ambulance services. </p>
<p>State governments should consider new models of care, such as the introduction of community paramedics to support primary care services and other sectors across the health care system. </p>
<p>With further training, paramedics in Australia could be used beyond ambulance services. This could include working alongside other health professionals in emergency departments, supporting GPs and in hospital discharge teams. <a href="https://www.ruralhealth.org.au/sites/default/files/publications/paramedic-fact-sheet.pdf">With a surplus of paramedic students</a> graduating, there is a ready-made workforce ready to assist the wider health care system. </p>
<p>Community paramedicine programs overseas have <a href="https://www.cmaj.ca/content/190/21/E638">resulted in</a> improved patient health outcomes and quality of life, and have <a href="https://www.phecit.ie/Custom/BSIDocumentSelector/Pages/DocumentViewer.aspx?id=oGsVrspmiT0dOhDFFXZvIz0q5GYO7igwzB6buxHEgeAwoe6hhx3QzVYOAEYRVFgraXLPVznIqVTUeBOa0wVaWUHjEXvMd63up72Fns8wtQOlSXGGsgTQ5civ5cnUzWXfV%252fJafBVHZKIcREMzaNINt4Mx0jjYaO1stN8kfAIXP5STxy7tT%252fzXRg%253d%253d">been found</a> to be economically beneficial. </p>
<p>A <a href="https://static1.squarespace.com/static/5d3620021438f10001b257ce/t/5e0b684d8818570cab622660/1577805905922/2019_OCPS_Report+2.pdf">Canadian report</a> found community paramedics saved the health-care system $29 million by keeping the 2,300 patients involved in the study healthy and avoiding hospital. Most importantly, patients had positive experiences of having their care delivered in their home. </p>
<p>However, not all patients wish to have their care delivered in their home or community. One report found <a href="https://ro.uow.edu.au/cgi/viewcontent.cgi?article=1383&context=ahsri">2.2% of patients refused to be treated</a> by community paramedics.</p>
<p>Investment solely in the acute sector of our health system fails to recognise the inter-connectedness of all parts of the system. We must also invest in community services and primary care. Without system-wide investment, our health services will continue to fail. </p>
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<a href="https://theconversation.com/when-is-it-ok-to-call-an-ambulance-91751">When is it OK to call an ambulance?</a>
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<p class="fine-print"><em><span>Brendan Shannon received funding from the Pre-hospital Emergency Care Council to provide evidence to support the introduction of Community Paramedicine across Ireland. </span></em></p><p class="fine-print"><em><span>Kelly-Ann Bowles received funding from the Pre-hospital Emergency Care Council to provide evidence to support the introduction of Community Paramedicine across Ireland.</span></em></p>Hospitals are struggling, with ambulances ramping outside emergency departments and patients facing long waits for care. But doing more of the same won’t fix the problem.Brendan Shannon, Senior Lecturer in Paramedicine, Registered Paramedic, Monash UniversityKelly-Ann Bowles, Director of Research/Associate Professor - Paramedicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1848132022-06-29T12:05:44Z2022-06-29T12:05:44ZA growing number of women give birth at Catholic hospitals, where they do not receive the same reproductive health options – including birth control – provided at other hospitals<figure><img src="https://images.theconversation.com/files/471255/original/file-20220627-24-2ifhs7.jpg?ixlib=rb-1.1.0&rect=0%2C64%2C6114%2C4006&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that short spacing between childbirth and another pregnancy comes with heightened health risks.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-sees-a-positive-pregnancy-test-result-and-royalty-free-image/1386831922?adppopup=true">Aleksandr Kirillov/EyeEm via Getty Images</a></span></figcaption></figure><p>Now that the <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">U.S. Supreme Court has eliminated</a> the constitutional right to an abortion, access to birth control has taken on new urgency. By moving the decision about abortion access to states, the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe v. Wade</a> means that it will be even more important for people to be able to prevent an unwanted or mistimed pregnancy. </p>
<p>Given the health risks of having a rapid repeat pregnancy, avoiding pregnancy is especially critical for those who have recently given birth. But not all health care providers offer birth control to their patients.</p>
<p>Over the past two decades, the number of <a href="https://www.communitycatalyst.org/news/press-releases/new-report-finds-rapid-growth-of-catholic-health-systems#">Catholic hospitals in the U.S. has risen dramatically</a>. But it might come as a surprise to many people to learn that Catholic hospitals are not allowed to provide health care that is considered by their religious leaders to be “intrinsically immoral.” </p>
<p>The Catholic religion holds that sex should only occur within marriage and that while it should be performed for the good of the spouses, each act must be open to procreation. Because of this, the U.S. Conference of Catholic Bishops has published <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a>, last updated in 2018, that prohibit Catholic hospitals from providing birth control, abortion and infertility treatments. There are no exceptions, even if the care is needed to protect a person’s life or health.</p>
<p>As a result, many people who want birth control before they leave the hospital after childbirth may not receive it. </p>
<p>One of the <a href="https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/intro.html">most effective methods of preventing pregnancy</a> is female sterilization, which is <a href="https://doi.org/10.1016/j.ajog.2021.12.261">used by 18% of women in the U.S.</a>. This permanent method of birth control usually consists of tubal ligation, a surgical procedure in which the fallopian tubes are cut or sealed. <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">Catholic hospitals are not permitted</a> to perform this procedure. </p>
<p>However, many people are not even aware that they are choosing a Catholic hospital when they decide where they will deliver. Others do not have an option or may not realize that where they give birth might affect the reproductive treatment options available to them.</p>
<p><a href="https://cph.osu.edu/people/mgallo">As a sexual and reproductive health epidemiologist</a>, I have carried out <a href="https://scholar.google.com/citations?user=xOQDyI8AAAAJ&hl=en">research on contraception and abortion</a> in countries throughout the world, including in the U.S., over the past 20 years. Much of my research involves studying disparities in people’s use of birth control.</p>
<h2>Avoiding a Catholic hospital can be difficult</h2>
<p>As a result of hospital mergers and acquisitions, between 2001 and 2016 the number of Catholic acute care hospitals grew by 22%. Overall, about 17% of acute care hospital beds in the U.S. <a href="http://static1.1.sqspcdn.com/static/f/816571/27061007/1465224862580/MW_Update-2016-MiscarrOfMedicine-report.pdf">belong to Catholic hospitals</a>. </p>
<p>Some people attend a Catholic hospital because they have limited choices. There are 46 Catholic hospitals in the U.S. that are the <a href="http://static1.1.sqspcdn.com/static/f/816571/27061007/1465224862580/MW_Update-2016-MiscarrOfMedicine-report.pdf">sole providers of short-term acute hospital care</a> in their geographic area, including in Santa Fe, New Mexico; Grand Junction, Colorado; and Bellingham, Washington. Others might be limited in where their health insurance will cover their care. </p>
<p>Some people are not even aware that they are attending a Catholic hospital. A 2018 national survey asked adult women of reproductive age where they go for their reproductive care; 16% named a Catholic hospital. However, over one-third of the women who named a Catholic hospital <a href="https://doi.org/10.1016/j.contraception.2018.05.017">did not know that their hospital was Catholic</a>. Furthermore, those who were wrong about their hospital’s Catholic status described themselves as being “sure” or “very sure” about their incorrect response. </p>
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<figcaption><span class="caption">‘As U.S. hospitals are struggling, more and more are merging with Catholic institutions.’</span></figcaption>
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<p>In some cases, people might be unaware of their hospital’s status because its name does not sound religious. Also, people might not know that a Catholic network purchased their secular hospital and that their hospital is now required to follow its <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a>. A 2017-2018 review of hospital websites found that <a href="https://doi.org/10.1001/jama.2019.0133">21% of Catholic hospitals did not explicitly disclose</a> their Catholic status on their website.</p>
<p>Even if people know that their hospital is Catholic, they might not know that attending a Catholic hospital could restrict the scope of care that they are able to receive. A large survey of women found that <a href="https://doi.org/10.1363/psrh.12118">most did not expect restrictions on care</a> at Catholic hospitals, especially for services viewed as less taboo than abortion. Respondents did not realize that Catholic hospitals are restricted in providing birth control, including female sterilization methods such as tubal ligation.</p>
<h2>The need for birth control after childbirth</h2>
<p>Using birth control after childbirth is critical, because people’s fertility returns quickly. Having at least 18 months of spacing between childbirth and a new pregnancy is important to protect the <a href="https://doi.org/10.1016/j.ajog.2006.05.055">pregnant person</a> and the <a href="https://doi.org/10.1016/j.ajog.2014.11.017">infant’s health</a>. </p>
<p>Short birth spacing increases the risks of adverse outcomes such as preeclampsia, preterm birth and health problems for the newborn infant. Because of the health risks, the U.S. Department of Health and Human Services recognized birth spacing as a high priority in the <a href="https://health.gov/healthypeople">2030 Healthy People Objectives</a>.</p>
<p>For people who do not want to have more pregnancies, immediately after delivery can be the most convenient time to have a tubal ligation. For this reason, about half of all tubal ligations <a href="https://doi.org/10.1097/aog.0b013e318262e354">are performed after delivery</a>. <a href="https://doi.org/10.1016/j.ajog.2022.05.021">About 6.2% of deliveries</a> in the U.S. are followed by a tubal ligation. <a href="https://doi.org/10.1097/aog.0b013e3181f73eaa">Failing to receive a desired </a> postpartum tubal ligation increases the risk of having a rapid repeat pregnancy. </p>
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<figcaption><span class="caption">A tubal ligation seals off the fallopian tubes, which carry eggs to a person’s womb, in order to prevent pregnancy.</span></figcaption>
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<h2>Birth control use following delivery at Catholic hospitals</h2>
<p>Our team decided to investigate whether women who recently delivered at a Catholic hospital were less likely to be using birth control during the postpartum period compared to women who delivered at a non-Catholic hospital. </p>
<p>Even if <a href="https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf">ethical and religious directives</a> state that Catholic hospitals are not allowed to provide birth control, it is plausible that some hospitals might fail to enforce the rules or providers might find ways to work around them. For example, providers at Catholic hospitals might place an intrauterine device, or IUD, in a patient who desires one by justifying its use for noncontraceptive purposes. Or providers might perform an elective cesarean delivery in order to surreptitiously perform a tubal ligation. </p>
<p>My colleagues and I used survey data from the <a href="https://www.cdc.gov/prams/index.htm">Pregnancy Risk Assessment Monitoring System</a> from five states – Alaska, Illinois, Maine, Oregon and Wisconsin – over the period of 2015 to 2018. The Centers for Disease Control and Prevention and state health departments annually conduct this survey of women who gave birth in the last two to six months. We linked this survey data to birth certificates to know whether women had delivered at a Catholic or non-Catholic hospital.</p>
<p>Our study found that at two to six months postpartum, women who had delivered at a Catholic hospital were about <a href="https://doi.org/10.1363/psrh.12186">half as likely to have had female sterilization</a> as women who delivered at another type of hospital. This difference remained statistically significant after we adjusted for women’s age, race or ethnicity, education, insurance status and parity. </p>
<h2>Pregnancy carries health risks</h2>
<p>Legal abortion is <a href="https://theconversation.com/study-shows-an-abortion-ban-may-lead-to-a-21-increase-in-pregnancy-related-deaths-167610">much safer than childbirth in the U.S.</a>. Because people are <a href="https://doi.org/10.1097/aog.0b013e31823fe923">14 times more likely to die from pregnancy</a> than from a legal abortion, it is important that they are able to avoid an unintended pregnancy. </p>
<p>These studies illustrate the need for people to have access to the birth control method of their choice – a choice that is all the more important now that people have lost their constitutional right to an abortion.</p>
<p><em>Editor’s note: This story has been updated to clarify the Catholic religion’s stance on the purpose of sex; it holds that sex should only occur within marriage and be performed for the good of the spouses, but that each act must be open to procreation.</em></p><img src="https://counter.theconversation.com/content/184813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Gallo receives funding from Relias Media for consultant work and grant funding from the National Institutes of Health and non-profit foundations for research.</span></em></p>Many people do not realize they are delivering at a Catholic hospital, and others may not have a choice. But where one receives care has a profound impact on the birth control options they’re offered.Maria Gallo, Professor of Epidemiology, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.