key: cord- -nw a qco authors: béland, daniel; lecours, andré; paquet, mireille; tombe, trevor title: a critical juncture in fiscal federalism? canada's response to covid- date: - - journal: nan doi: . /s sha: doc_id: cord_uid: nw a qco the covid- crisis could trigger a critical juncture for several institutional arrangements in canada, potentially leading to notable changes in fiscal federalism. this research note combines insights from historical institutionalism with recent economic and fiscal projections to explore avenues for reform in response to the covid- crisis. given the magnitude of the crisis, provincial governments may be unable to absorb the fiscal costs on their own. but vast differences in fiscal and economic circumstances across provinces make federal arrangements difficult to design. we argue that intergovernmental power dynamics and the principle of provincial autonomy are particularly important considerations in thinking about fiscal federalism post–covid- . the covid- crisis could trigger a critical juncture for several institutional arrangements in canada, potentially leading to notable changes in fiscal federalism. this research note combines insights from historical institutionalism with recent economic and fiscal projections to explore avenues for reform in response to the covid- crisis. given the magnitude of the crisis, provincial governments may be unable to absorb the fiscal costs on their own. but vast differences in fiscal and economic circumstances across provinces make federal arrangements difficult to design. we argue that intergovernmental power dynamics and the principle of provincial autonomy are particularly important considerations in thinking about fiscal federalism post-covid- . much has been written about the inertia and stickiness of public policies, which can become increasingly entrenched over time through self-reinforcing feedback mechanisms leading to path dependence (pierson, ) . there is strong evidence that institutional continuity is a central aspect of policy development, both during and between crises (campbell, ). yet recent literature on policy change inspired by historical institutionalism also stresses the existence of selfundermining mechanisms that can lead to the gradual erosion of existing policies (jacobs and weaver, ) . this emphasis on self-undermining mechanisms has added to previous insights about exogenous shocks as a trigger for institutional and policy change (pierson, ) . central to historical institutionalism is the idea of institutions as regimes (mahoney and thelen, ) : the dynamic "relationships between actors [which], through formal and informal rules, organize the distribution of resources and power" (paquet, : ) . the canadian federation represents such a regime where, in addition to the formal division of responsibilities, power and resources are distributed dynamically through interactions between federal and provincial governments. in this context, policy feedback is as much about the costs of deviating from existing policy solutions as it is about the behaviour of institutional actors, which reflects both their core principles and their actual capacities. in canada, nowhere is this more visible than in fiscal federalism. as keith banting ( ) and alain noël ( )-among others-have amply discussed, the fiscal arrangements that distribute resources within the federation illustrate some measure of agreement over core principles that shape the behaviour of governments. while they can transform or drift over time, abrupt changes in institutional regimes typically follow large-scale crises such as economic depressions, energy shocks, global pandemics and world wars (campbell, : ) . institutionalist scholars understand such crises as "critical junctures" during which political actors have much more capacity than usual to fight policy inertia and bring about transformative change. as james mahoney ( : ) argues, "critical junctures are moments of relative structural indeterminism when willful actors shape outcomes in a more voluntaristic fashion than normal circumstances permit." the development of many important features of canada's current arrangements, for example, emerged out of the great depression and world war ii. and out of these critical junctures emerged a new consensus over the principles in which redistribution should be embedded (jenson, ) , subject to the time-specific interests and capacities of the federal and provincial governments. the covid- crisis may be another critical juncture that opens the door to new approaches to canadian fiscal federalism. as historical institutionalism has taught us, these alternatives are much more than technical debates; they both emerge from and shape collective understandings of federalism and power relations among governments. federal transfers to provincial governments are central to fiscal federalism in canada. there are three major transfers: the canada health transfer (cht), a per capita transfer meant to support provincial healthcare systems; the canada social transfer (cst), also a per capita transfer intended to support post-secondary education, social assistance and child services; and equalization, an unconditional transfer to provinces with fiscal capacity below a national standard, whose principle is enshrined in the constitution act (béland et al., ) . the cht represents approximately per cent of the major transfers; equalization about per cent; and cst approximately per cent. transfers embody core political principles such as substantive equality among both citizens and governments, provincial autonomy, and economic and fiscal sustainability. prior to covid- , fiscal arrangements were increasingly challenged by provinces. these disputes represent important legacies that could shape how fiscal federalism responds to covid- . some of these pressures had strong political expressions. the government of alberta made it clear that it felt unfairly treated in the federation. resistance by the federal government and some other provinces to certain pipeline projects, in the context of alberta's weak economic performance, provoked such discontent that the provincial government established the fair deal panel to consult albertans about their place in the federation. a key theme here was that the province contributes more to the country than it receives. this assessment triggered forceful criticism of equalization, with alberta premier jason kenney promising to hold a referendum on equalization if he found progress on pipeline expansion to be unsatisfactory. because no change to equalization would make alberta a recipient, the province also pressured ottawa to reform its fiscal stabilization program so alberta could be compensated for swift downturns in its economy (tombe, ) . the current crisis, which is hurting the whole country, could dampen alberta's grievances. beyond these public rows involving alberta, fiscal federalism in canada was also experiencing, prior to the covid- crisis, significant structural challenges that were of concern to many provinces. population aging and out-migration have placed some provinces, particularly newfoundland and labrador, in a precarious fiscal situation. federal healthcare financing has been blind to the specific situations of provinces, a situation lamented by quebec and british columbia, among others. the cst is similarly unresponsive to specific provincial needs. from an intergovernmental perspective, bilateral agreements around federal transfers for infrastructure and housing have been difficult to negotiate, especially with the quebec government. the canadian response to covid- and reforms to fiscal transfer arrangements will be shaped by existing policy legacies as much as by current power relations in the federation. respecting provincial autonomy will likely remain a key political and policy consideration, although the federal government's dominant fiscal capacity, a considerable source of federal power, could be deployed at a time when the provinces badly need it. but in the short term, the speed of the covid- crisis necessitates working within existing arrangements. two programs stand out. first, to address provincial spending pressures, the federal government can use its existing disaster assistance program with only minor modification. the federal disaster financial assistance arrangements (dfaa) aims to "assist provinces with the costs of dealing with a disaster where those costs would otherwise place a significant burden on the provincial economy and would exceed what they might reasonably be expected to fully bear on their own" (government of canada, ). covid- is clearly such an event. yet the dfaa explicitly excludes "pandemic health emergencies," though the restriction is regulatory in nature. cabinet could therefore change the dfaa guidelines and insulate provinces from many of the direct covid- costs under the current formula. for perspective, a canadian package equivalent to the united states' $ billion (us) coronavirus relief fund-which will aid state and local governments-would be $ per person to provinces at a cost of roughly $ billion (can). second, to address provincial revenue pressures, the federal government may expand the fiscal stabilization program. given the scale of the economic contraction, provincial own-source revenues could feasibly decline by per cent-or around $ billion-although much uncertainty remains. the current fiscal stabilization program will cover only a small portion of these losses, as total payments are limited to $ per capita for a total of just over $ billion nationally. existing legislation, however, provides the minister of finance discretion to provide interest-free loans for a period of five years-buying time for a more comprehensive solution. going forward, the covid- shock may strengthen the case some provinces have made-most recently alberta, as previously discussed-for a dramatically expanded and potentially uncapped program. both short-term measures respect provincial autonomy, but as the expediency of the moment wanes, deeper changes may be on the table. there is no shortage of fiscal pressure, including the dire financial situation of various municipalities (mason, ) , but pre-existing challenges in healthcare financing may lead it to the top of the national agenda. the cht could be enlarged and adjusted to increase funding more quickly to provinces with more challenging demographic pressures-a long-standing provincial demand by some, notably quebec, although one opposed by others, such as alberta. regardless, an immediate boost of $ billion would grow cht to onequarter of provincial health spending (a level not seen since the late s). if implemented as an "age-adjustment" to the current transfer, it could provide a larger benefit to provinces with comparatively older populations (especially the atlantic provinces). this could not only strengthen health systems, in general, but better prepare for future health crises because, as we have seen with covid- , elderly populations are more vulnerable. the federal government may also consider returning to funding assistance in other areas, notably education-particularly post-secondary-hit hard by the covid- crisis. as federal fiscal capacity and sustainability vastly exceed those of the provinces, even more dramatic re-evaluations of fiscal arrangements are possible. for example, following the great depression, the rowell-sirois commission recommended that the federal government take on provincial debt (rcdpr, ) . there may be renewed pressure to consider this option, at least in part. newfoundland and labrador, which faces both covid- and low oil prices, now relies on bank of canada purchases of provincial debt. though important to ensure market liquidity, this debt remains on provincial balance sheets and may strain fiscal sustainability. the federal government could step in. in the extreme, shifting the total provincial net financial liabilities of roughly $ billion to the federal government would roughly double canada's net debt to gross domestic product (gdp) position from its current per cent to nearly per cent: a large increase, but just marginally above its level-and significantly below that of the united states. and given today's low rates, the higher federal interest costs are equivalent to barely over one percentage point of the goods and services tax (gst). this is not to say such a move is wise, only that federal fiscal capacity is difficult to overstate. regardless of how fiscal federalism responds or what the specific design details are, the covid- crisis potentially represents a critical juncture with lasting implications for fiscal federalism in canada. the welfare state and canadian federalism fiscal federalism and equalization policy in canada: political and economic dimensions government of canada. . guidelines for the disaster financial assistance arrangements. public safety canada when policies undo themselves: self-undermining feedback as a source of policy change fated to live in interesting times: canada's changing citizenship regimes the legacies of liberalism: path dependence and political regimes in central america explaining institutional change: ambiguity, agency, and power the next covid- crisis? canada's cash-strapped cities fédéralisme d'ouverture et pouvoir de dépenser au canada province building and the federalization of immigration in canada increasing returns, path dependence, and the study of politics an (overdue) review of canada's fiscal stabilization program a critical juncture in fiscal federalism? canada's response to covid- key: cord- -ppiqpj i authors: bjarnason, thorarin a.; rees, robert; kainz, judy; le, lawrence h.; stewart, errol e.; preston, brent; elbakri, idris; fife, ingvar a. j.; lee, ting‐yim; gagnon, i martin benoît; arsenault, clément; therrien, pierre; kendall, edward; tonkopi, elena; cottreau, michelle; aldrich, john e. title: comp report: a survey of radiation safety regulations for medical imaging x‐ray equipment in canada date: - - journal: j appl clin med phys doi: . /acm . sha: doc_id: cord_uid: ppiqpj i x‐ray regulations and room design methodology vary widely across canada. the canadian organization of medical physicists (comp) conducted a survey in / to provide a useful snapshot of existing variations in rules and methodologies for human patient medical imaging facilities. some jurisdictions no longer have radiation safety regulatory requirements and comp is concerned that lack of regulatory oversight might erode safe practices. harmonized standards will facilitate oversight that will ensure continued attention is given to public safety and to control workplace exposure. comp encourages all canadian jurisdictions to adopt the dose limits and constraints outlined in health canada safety code with the codicil that the design standards be updated to those outlined in ncrp and bir . oversight might erode safe practices. harmonized standards will facilitate oversight that will ensure continued attention is given to public safety and to control workplace exposure. comp encourages all canadian jurisdictions to adopt the dose limits and constraints outlined in health canada safety code with the codicil that the design standards be updated to those outlined in ncrp and bir . canada has adopted the guidelines of the international commission on radiological protection (icrp) on occupational dose limits for radiation. starting with the publication of icrp in , estimates were given of the radiation sensitivities of various organs and tissues (w t ), and the whole-body dose was considered as the sum of doses to all organs and tissues each weighted for their radiation sensitivities. publication icrp ( ) improved upon icrp with better data on radiation sensitivities. equivalent dose (h r ) was defined as the absorbed dose multiplied by a radiation weighting factor (w r ) related to relative biological effect of a given type of primary radiation. for xray photons of concern here, w r = . effective dose (e) was defined as the sum of the equivalent dose to each organ or tissue weighted by the relevant radiation sensitivity. icrp ( ), using new data, further refined the tissue sensitivities. the tissue weighting factors from the different icrp reports are compared in table and it is noteworthy that these weighting factors change over time as the understanding of the effects of radiation on human biology improves. at the time of publication for icrp , the occupational limit for eyes was under review, and icrp was subsequently published recommending a lower limit for the eyes. the recommended stochastic dose limits from icrp , , and are shown in table the dose limits in table • no information on modalities such as computed tomography (ct), mammography, and digital imaging. • attenuation data were not applicable to three phase or constant potential generators. • typical mas workloads were no longer valid due to the use of newer high speed rare-earth film/screens. • the use factors and occupancy factors appeared to be unrealistically high. • shielding was specified using half-value-layers (hvls) of pb or concrete required to attenuate scattered and primary radiation to designed levels, and the requirement to "add-one-hvl" was considered overly-conservative. • the requirement to cover screws or nails with pb tabs was questioned. as shown in table , many jurisdictions use the annual dose limits from sc a; that is, msv for x-ray workers, msv for the public, and msv for the remainder of a pregnancy following declaration. a few provinces have adopted the more recent msv for radiation workers from sc , and some jurisdictions have no limits due to the lack of regulations. for jurisdictions without regulations, institutions or authorities usually set their own limits as best practice, but there is a risk they might not. no two provinces or territories have the same standards for the shielding of x-ray facilities, as shown in more specifically define the practice of engineering as "the principles of mathematics, chemistry, physics or any related applied subject" and prince edward island has similar wording, note whereas quebec considers the field of practice to include works using "processes of applied chemistry or physics." note in practice, most jurisdictions do not formally require an engineer's oversight for a shielding design, with the exception of quebec and ontario. as part of any engineering design work, field reviews are required, which include visual inspections and scatter surveys in table . consequently, with regards to table , an engineer is not obligated to use only specific design documents permitted by regulations or accreditation agencies, but are expected to use any and all methodologies that would be considered good practice and obvious to peers performing similar design work. as shown in table , for all provinces with regulations, except ontario, ncrp is identified as the main source of information for the design of x-ray shielding. in ontario, assuming a radiographic detector has a certain pb equivalency as suggested by ncrp has to be approved by the x-ray inspection service. many provinces there is a wide range of annual dose constraints used for the design of shielding, as shown in table . for x-ray workers, where there are regulations, the range is to msv, and the range for the general public is to msv. it is also interesting to note that the constraints and dose limits (table ) are often different. an appropriate and conservative approach, and one recommended by the authors of this paper who perform shielding design, is to set a shielding design goal of msv for all cases, allowing future use of adjacent spaces to change without the need to change shielding, for example, if an office fully occupied by a radiation worker becomes office space for a nonradiation worker (general public). the average and median annual occupational dose for radiographic technologists in canada are shown in fig. . the average value for is approximately . msv/yr and the median value is zero. technologists working in fgi procedures, who typically experience higher occupational exposures, were not separated from technologists exclusively working in general radiography. the canadian average is slightly higher than the uk radiographer average value of . msv/yr. it appears that the bir recommendations to use a dose constraint of % of the dose limit (or . msv) would also be applicable to canadian practice, since this constraint level is already achieved, especially considering the measured values reported here include staff who are exposed to workplace radiation without protection from structural shielding, including technologists who work in fgi procedures. a breakdown of radiographer occupation exposure by different dose ranges is shown in fig. distinction between diagnostic x-ray personnel and nuclear medicine personnel in terms of permissible exposure, but the latter of course are monitored under the csnc regulations. in practice, it is the experience of these authors that x-ray radiation workers rarely exceed an occupational exposure of msv/yr, whereas a nuclear medicine radiation worker has a much higher probability of doing so. in the interests of public safety and to control workplace exposure, it would be useful for different jurisdictions in canada to adopt a harmonized approach, by implementing uniform dose limits and con- international commission on radiological protection. icrp publication : recommendations of the international commission on radiological protection international commission on radiological protection. icrp publication : recommendations of the international commission on radiological protection international commission on radiological protection. icrp publication : the recommendations of the international commission on radiological protection icrp publication : icrp statement on tissue reactions/early and late effects of radiation in normal tissues and organs -threshold doses for tissue reactions in a radiation protection context structural shielding design for medical x-ray imaging facilities radiation shielding for diagnostic radiology structural shielding design and evaluation for medical use of x-rays and gamma-rays up to mev medical x-ray and gamma-ray protection for energies up to mev-structural shielding design and evaluation history of the shielding of diagnostic x-ray facilities shielding evaluation of a typical radiography department: a comparison between ncrp reports no. and derivation of factors for estimating the scatter of diagnostic x-rays from walls and ceiling slabs radiation shielding for diagnostic x-rays: report of a joint bir/ipem working party safety code a: x-ray equipment in medical diagnosis part a: recommended safety procedures for installation and use. canada: minister of health canada safety code : radiation protection in radiology -large facilities. canada: minister of health canada canadian organization of medical physicists. position statement: safety code safety code : radiation protection and quality standards in mammography: ministry of health canada health canada. safety code : radiation protection in dentistry: ministry of health canada report on occupational radiation exposures in canada: minister of health, canada response to the repeal of pei's public health act radiation safety regulations [updated an act to amend, repeal and enact various acts in the interest of strengthening quality and accountability for patients canadian organization of medical physicists. comp comment on the harp act renewal process report and recommendations on modernizing ontario's radiation protection legislation use of personal monitors to estimate effective dose equivalent and effective dose to workers for external exposure to low-let radiation radiation dose management for fluoroscopically-guided interventional medical procedures icrp publication : occupational radiological protection in interventional procedures the authors thank monika kumala, narine martel, graeme wardlaw, richard smith, and gary hughes. key: cord- -tz jajeb authors: deaton, b. james; deaton, brady j. title: food security and canada's agricultural system challenged by covid‐ date: - - journal: nan doi: . /cjag. sha: doc_id: cord_uid: tz jajeb the effect of covid‐ on canadian food security is examined from two different perspectives. covid‐ creates a unique “income shock” that is expected to increase the prevalence of household food insecurity. this food insecurity can be measured by utilizing the canadian community health survey (cchs). more fundamentally, covid‐ heightens household concern about the capacity of the canadian food system to ensure food availability. despite surges in demand and supply chain disruptions, we currently do not observe broad, rapid appreciation in food prices. this suggests that there is an adequate supply of food for the near term. there is less certainty over intermediate and longer time periods because so many factors are in flux, particularly the rate of increases in sicknesses and deaths across the country and globally. data on these health factors and elements of the food supply chain are needed to predict beyond a short time frame. in this regard, we discuss three ongoing considerations—ease of capital flows, international exchange, and maintaining transportation—that will help ensure food availability in the longer run. this paper examines the effect of the covid- pandemic on canadian food security. the loss of income to canadian households and challenges to the food supply chain are our primary focus, as those are the only factors that we can readily speak to with any degree of confidence. the loss of income associated with covid- is expected to increase measures of food insecurity as derived from the household food security survey module (hfssm) of the canadian community health survey (cchs), conducted by statistics canada. importantly, by this measure, the income shock associated with covid- will likely increase the prevalence of households identified as food insecure. beyond the effects captured in the food security module, households across canada are now concerned about the capacity of the food system to ensure food availability, both now and in the future, at relatively stable food prices. the private and public sectors working in tandem must address this more fundamental issue of food security, and it is our conviction, based on the ready response of supportive public policy at all levels of government, that this will occur. consequently, our assessment is that food availability will be relatively stable over the coming months. longer-term challenges to food security in reality and in the realm of public perception depend on a number of factors that cannot be fully anticipated. that said, we identify and briefly discuss three critical factors to monitor and analyze: international exchange, farm financial stability, and transportation. covid- is recognized as a health threat that poses a challenge to food security, from both an actual and a perceptual basis. section describes the expected effect of covid- on household income and subsequent levels of food insecurity. in this context, the measure employed to determine food insecurity will be clarified, so that the substantive meaning is understood regarding the basis of our expectation that the prevalence and intensity of food insecurity may increase. section examines the threat that covid- poses to more fundamental aspects of food security: society-wide expectations that food availability and food prices will be adequate to meet national needs and remain relatively stable. covid- has had immediate consequences on household income and future expectations thereof, as public and private workplaces and businesses closed principally to enforce "social distancing." workers also left jobs for health concerns for themselves and their families. in one week in mid-march, as the events described above unfolded, there were over , applications for unemployment insurance, compared to , applications that same week in the previous year (breen, ) . the canadian economy is expected to contract in the second quarter; some estimate by more than % (deloitte, ) . the u.s. economy is expected to contract by % (goldman sachs, ) . this last measure is comparable to contractions associated with the great depression (inman, ) . the u.s. contraction (and strength of its eventual rebound) is a critical consideration for canada, as canadian provinces do more north-south trade than east-west trade (deloitte, ) . the economic effects of covid- , like many income shocks, will have a depressing effect on the global economy for some time. covid- has some important characteristics that make its deleterious effects on employment and income generation unique and different from previous income shocks like the financial crisis of . first, covid- impairs the health and vitality of the work force, both directly, through illness, and indirectly, as some workers stay home to avoid carrying the virus back to their families and friends. another unique aspect of covid- is that the policies of social distancing significantly limit the range of public agency, university, organizational, and entrepreneurial responses that might accompany other recoveries and serve to stabilize household income-thereby reducing food insecurity. even before the pandemic, approximately . % of canadian households experienced some level of food insecurity according to results from the cchs (tarasuk & mitchell, ) . the first nations regional health survey (rhs), employing a similar survey approach to the cchs, found that . % of first nations adults living in first nations communities reported their households as food insecure (first nations information governance centre, ). income is a key factor influencing both whether a household identifies as food insecure and self-reports on the intensity of food insecurity. to better understand the relationship between household income and food insecurity, and build an appreciation of the potential effect that covid- social distancing refers to the practice of leaving space (often m) between people so as to limit the spread of covid- . in addition, the number of people (not already living together) that can gather in one place at the same time is restricted, and those exposed to covid- are expected to isolate themselves for a period of time (typically weeks). social distancing is more than a best practice; at the time of our writing, governments across canada have implemented a host of specific rules regarding social distancing. f i g u r e food insecurity by household income. source of figure: tarasuk ( ) will have on food insecurity, we briefly describe the most common method of determining food insecurity as measured and reported in canada. a similar food security module is used in the united states and administered by usda. the household food security survey module (hfssm) of the cchs (canadian community health survey) conducted by statistics canada (statistics canada, ) is a standardized survey that poses up to questions designed to probe the degree of food insecurity in the respondent's household. for example, an initial question asks respondents to assess whether they worried if food would run out before they had money to buy more. later questions in the survey identify more severe situations. for example, one question asks the respondent if they believe they lost weight due to a lack of money to buy food. answering affirmative to the initial question only, for example, identifies a "marginal" degree of food insecurity, while answering affirmative to questions along the lines of the latter example indicates more "severe" food insecurity. depending on the number of affirmative responses to the survey questions, households can be categorized as marginally food insecure, moderately food insecure, and severely food insecure. using this classification scheme and cchs results from and , . % of canadian households were classified as "food insecure" (tarasuk & mitchell, ) . of these, % were defined as marginally food insecure, . % were moderately food insecure, and % were considered to be severely food insecure. these categories imply considerable differences in what it means to be food insecure. statistics canada ( ) provides definitions of each of these categories as follows: • marginally food insecure: at times during the previous year, these households had indications of worry about running out of food and/or limited food selection due to a lack of money for food. • moderately food insecure: at times during the previous year, these households had indications of compromise in quality and/or quantity of food consumed. • severely food insecure: at times during the previous year, these households had indications of reduced food intake and disrupted eating patterns. with respect to these measures of food insecurity, a couple of points merit consideration. first, food insecurity is associated with a lower income. that said, food insecurity is complex, and, unsurprisingly, there are observations of relatively high-income households that are food insecure and low-income households that are food secure. nonetheless, figure reinforces an important association between household income and food insecurity. as incomes increase, the prevalence of food insecurity declines. in the context of first nations, deaton, scholz, and lipka ( ) find that individuals in the low-income category-$ - , are approximately times as likely to be food insecure as individuals with an income of $ , or more. covid- ′ s negative influence on employment levels, subsequent incomes, and future economic growth is expected to increase the prevalence of food security by this measure. a loss of household income is expected to influence the quantity of food consumed as well as the type of goods purchased. generally, food is considered income inelastic so the percentage change in consumption levels are expected to be less than the percentage change in income. additionally, the loss of income will lead households to increase their consumption of f i g u r e food insecurity by main source of income, . data are from canadian community health survey, statistics canada. figure retrieved from proof attributed to https://proof.utoronto.ca/wpcontent/uploads/ / /public-policy-factsheet.pdf, attributed to tarasuk, michell, and dachner ( ) so-called "income inferior goods." in the future, the change in consumption associated with income and price volatility caused by covid- can be more rigorously analyzed using income and price elasticities. as discussed above, the income shock triggered by covid- is expected to increase the prevalence of household food insecurity. but an important additional consideration is how the distribution of food insecurity changes across the three categories: marginal, moderate, and severe. the severely food insecure category (presently % of canadian households) is the most concerning. given that covid- is expected to lead to both losses as well as shifts in employment, the likely effect will be to skew the distribution of food insecurity towards the relatively more harmful experiences of "moderate" and "severe." a recent study by tarasuk, fafard st-germain, and mitchell ( ) finds that every $ , increase in income (before tax) reduces the odds of marginal food insecurity by %, the odds of moderate food insecurity by %, and the odds of severe food insecurity by %. this indicates that moderate and severe food insecurity may be more sensitive to changes in income. figure demonstrates how the experience of food insecurity varies by sources of income (i.e., employment income versus unemployment, social assistance, workers compensation, etc.). importantly, from the perspective of this discussion, a lack of employment income is associated with a higher prevalence of moderately and severely food insecure households. the health considerations associated with covid- add additional complications that may influence both the prevalence and intensity of household food insecurity. additionally, covid- might have debilitating health effects that persist after economic recovery. by contrast, the income shock associated with the financial crisis of was not accompanied by sickness or death. from a financial standpoint, the debilitating health effects or deaths associated with covid- further endanger the capacity of the household to recover. ameliorative policy measures are being undertaken in rapid fashion by the government and non-governmental groups throughout canada. these measures include government efforts to provide support for families-for example, mortgage support and increased child care benefit payments; assistance to people facing unemployment-for example, direct payments of $ , a month to eligible workers, improved access to employment insurance; and financial backing to business to support continued employment-for example, the canadian emergency wage subsidy covers % of salaries for qualifying businesses (government of canada, ). the government has expanded support to non-governmental groups addressing the challenge of food insecurity. many of these groups have been at the fore of addressing food insecurity for some time. food banks, for example, are presently challenged to maintain and expand their capacity to address food insecurity. food banks are particularly important to the most food insecure households. indeed, households that use food banks have been found to be relatively lower income and relatively more likely to be moderately or severely food insecure (tarasuk, fafard st-germain, & loopostra, ) . any comparisons with past events must recognize the additional challenges that covid- ′ s health effects place on the response, and this is an important distinction from past income shocks. food banks and home delivery to the elderly, for example, rely heavily on volunteers, many of whom fear the potential health effects of covid- . social distancing and health concerns complicate all efforts to respond to the pandemic. this is particularly concerning because many support services, like food banks, administer services to those who experience food insecurity most severely. recent surges in demand (and hoarding behavior) reflect household responses to public health requests for people to stock up on food, in order to comply with social distancing, and reflect public fear that covid- could limit food availability. such demand surges might, at times, lead to temporary shortages on grocery store shelves. observations of these shortages by consumers may also reinforce the notion that food availability was under immediate threat. however, these surges will likely be tempered by the fact that shelves will be restocked, and shoppers will not empty them at the same rate, having already stored up on the high demand items. if this be the case, then food shortages and/or a rapid upswing in food prices are unlikely in the short term. the relative stability of food prices in the later weeks of march is a signal that expectations regarding the demand and supply of food are relatively stable. over a longer-term period (i.e., months- year) in which we could even experience a second wave of the virus, being able to prevent food shortages and a rapid upswing in prices are key to determining whether the necessary and sufficient supply of food (in terms of nutrition and quantity, respectively) are available and affordable at the point of consumer purchase. with this in mind, we identify and examine three factors that impact food shortages and price increases, specifically impacted by covid- , which could undermine the food supply chain. these are: (a) challenges to international exchange; (b) farm financial stability; and (c) transportation. though % of what is purchased in grocery stores is "produced" in canada (statistics canada, ) , continued exchange among countries remains paramount to ensuring diversity in both production and consumption. key to this exchange is the health stability of the labor force, which includes temporary foreign labor. the importance of temporary foreign labor to ontario's fruit and vegetable production was underscored after trudeau announced the closing of the borders to foreigners (with the exception of u.s. citizens) on march , . this action alarmed key sectors because this foreign labor was viewed as essential to vegetable production. so, very quickly, the restrictions were relaxed and temporary foreign labor was given an exception (hughes, ). yet, as we write, there are reports of uncertainty about the availability of cross-border laborers, presumably because of logistic challenges and their own covid- related health conditions (grant, ) . with respect to the food industry, the importance of borders will differ depending on the particular industry. some industries like animal production are less dependent on foreign inputs than others like sugar and confection processing. should the border "thicken" in the longer-run, this effect will differ across industries and alter relative prices. accordingly, the consumption basket for food will adapt, depending on cross-price elasticities among choices available, and while consumers will adapt, some nutritional consequences could occur as well. though our focus is on examining food security from a canadian standpoint, we would parenthetically note that, from a global perspective, the rise of protectionist policies could ultimately entail deleterious export/import constraints-such as those now taking place in kazakhstan and viet nam, and threatened by russia. protectionist policies may be particularly harmful, from a global perspective, to the world's most severely food insecure populations (glauber, laborde, martin, & vos, ) . given the economic ties between the united states and canada, the spread of protectionist policies is concerning and worthy of careful assessment and scrutiny. achieving a balance of trade and domestic production in food systems is an ongoing challenge determined by economic efficiency, consumer choices, and social and political preferences. conditions that generate increased fear or uncertainty about food availability spark new debates about how best to achieve societal goals and meet food needs. this pandemic will continue to fuel such debate in canada about the appropriate balance of domestic production and international trade. some commentators have already raised concern about our current reliance on trade. fraser ( ) argues that the dialogue regarding regional selfsufficiency "could spark a reinvestment in canadian farms, food processors, and our rural economies that have been declining for decades" (fraser, ) . the relationship among the components of the rural economy of canada deserves continuing attention, especially to determine the components relationship to a "robust balance of domestic production and global trade" (fraser, ) . whether that robust system will lead to more or less regional self-sufficiency can be more fully evaluated after this crisis. at the moment, two issues are worth noting. over the course of the past month, the food supply chain has adjusted relatively well to an extraordinarily challenging situation. it is not clear to us, at least as of the writing of this article, that a more regionally selfsufficient system would have adjusted more quickly to the challenge. many of the challenges associated with social distancing would apply to a more "regionally self-sufficient" system as well. second, "self-sufficient" regional agricultural systems, even in the best of times, are threatened by challenges like weather. in the extreme, regional self-sufficiency in production can become regional dependency in consumption in situations of drought or plague, severely restricting the quantity and quality of available goods. some farm families will suffer along with others from sickness and loss of productivity from covid- illness. more to the point of this section is concern about the capacity of capital to flow smoothly to farmers and to supportive businesses along the supply chain. this was addressed by efforts of the bank of canada to dampen interest rates and the federal government's increased enhancement base to farm credit canada, which provides more flexible extension of credit to farmers. many farmers have multiple loans and policies that enable deferments of interest payments, and flex was provided to allow farmers to manage loans and financial burdens to ensure stability in production. similar steps to strengthen small business concerns will offer further protection. these policies will likely require extension if the crisis persists for a longer period of time (i.e., beyond months). covid- has the potential to influence the smooth function of transportation at nearly every step along the food supply chain. illnesses related to covid- could limit the availability of skilled personnel in the transportation sector all along the food supply chain. this complex supply chain includes inputs to the field, to storage, to processors and manufacturers, and to distributors and retailers. remote and food insecure areas like nunavut are particularly susceptible to transportation challenges. in these areas, the majority of food in grocery stores is flown into the communities. indeed, naylor, deaton, and ker (forthcoming) note that none of the communities in nunavut are connected by road and rely heavily on food flown in by air, at an average distance of , km. given the high rates of food insecurity in these areas, maintaining air transportation is critical. the authors provide evidence that the primary program of addressing food security in these remote areas-that is, the nutrition north program-successfully lowers prices to households, but depends on air transportation. the effect of covid- on food security is examined from two different perspectives. from the perspective of food insecurity as measured by the canadian community health survey, covid- is a unique "income shock" that is expected to increase the prevalence of household food insecurity. moreover, because this income shock is associated with unique detrimental health effects, covid- has the potential to increase the proportion of households identified as "moderately" and "severely"' food insecure. unfortunately, covid- has threatened canadian food security in more fundamental ways than the cchs is designed to assess. specifically, canadians worry that covid- might limit the capacity of our food supply chain to ensure adequate food availability. despite short-term surges in demand and the challenges of ensuring worker safety, we expect that food availability will be stable over the course of the next months. nonetheless, temporary shortfalls in food supply and increased prices for certain foods might still occur. this cannot be determined due to the unprecedented nature of this global tragedy. what we do know is that the magnitude of the covid- tragedy demands that it be studied in great detail in terms of key variables that impact food security, the comparative weight of variables impacting food security, and how amenable they are to policy interventions. finally, we look with great expectation to the regional, and country, specific data and global meta data analysis that will certainly follow in the aftermath of covid- to provide a more confident basis for responding to comparable tragedies in the future. we thank bethany lipka, elsie richmond, and alex scholz for helpful comments and edits. we also appreciate insights from discussions with pat westhoff. that said, any opinions expressed and all errors should be attributed to the authors. coronavirus: , canadians have filed for ei this week. global news an empirical assessment of food security on first nations in canada predicting the post-pandemic recovery. deloitte economic-insights the covid- pandemic and canada's food system. ipolitics covid- : trade restrictions are worst possible response to safeguard food security. ifpri blog: issue post us daily: a sudden stop for the us economy crops in peril as temporary foreign workers yet to arrive ottawa to exempt temporary foreign workers from some covid- travel rules. the globe and mail a hundred years on, will there be another great depression?the guardian assessing the effect of food retail subsidies on the price of food in remote indigenous communities: a case study of nutrition north canada section : food in canada canadian community health survey-annual component (cchs)- determining food security status household food insecurity in canada geographic and socio-demographic predictors of household food insecurity in canada the relationship between food banks and food security: insights from canada. voluntas household food insecurity in canada implications of a basic income guarantee for household food insecurity key: cord- -y a yan authors: schiff, rebecca; buccieri, kristy; schiff, jeannette waegemakers; kauppi, carol; riva, mylene title: covid- and pandemic planning in the context of rural and remote homelessness date: - - journal: can j public health doi: . /s - - - sha: doc_id: cord_uid: y a yan addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the canadian federal response to the covid- crisis. rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic. similarly, there has been little to no research on rural communities’ pandemic preparedness in the context of homelessness. there are large numbers of homeless individuals in rural and remote canada, including indigenous peoples who are over-represented in homeless populations. rural communities, including rural and remote indigenous communities, are often isolated and more limited than urban areas in their capacity to respond to pandemics. they are particularly vulnerable due to fewer healthcare and social service resources—the lack of which has been particularly evident during the covid- pandemic. in this commentary, we suggest that policy-makers need to take seriously the situation of rural homelessness in canada, its implications for individual and community health, and consequences in the context of pandemics. policy- and decision-makers can address these concerns through increased homelessness funding and support for rural and remote communities, policy change to recognize the unique challenges associated with rural pandemic planning and homelessness, and more research that can be translated into policy, programs, and supports for rural homelessness and pandemic planning response. la prise en compte de la vulnérabilité et des besoins spécifiques des populations itinérantes lors des pandémies a été un élément majeur de la réponse fédérale canadienne à la crise de la covid- . toutefois, pendant la pandémie, les communautés rurales et éloignées n'ont reçu que peu ou pas de financement pour les soutenir dans leur offre de soins et de services aux personnes en situation d'itinérance. de même, il n'y a que très peu de recherche dans le contexte de l'itinérance sur la préparation des communautés rurales en cas de pandémie. or, il existe un nombre important de personnes en situation d'itinérance dans les mileux ruraux et éloignés, parmi lesquelles on observe une surreprésentation de personnes d'ascendance autochtone. les communautés rurales, incluant les communautés autochtones rurales et éloignées, sont souvent isolées et plus limitées que les milieux urbains dans leur capacité à répondre aux pandémies. elles sont particulièrement vulnérables en raison du manque de ressources en matière de soins de santé et de services sociaux; ceci est particulièrement évident dans le contexte actuel de pandémie de la covid- . dans ce commentaire, nous appelons les décideurs politiques à prendre au sérieux la situation de l'itinérance en milieu rural au canada, ses implications sur la santé individuelle et communautaire, et ses conséquences dans le contexte des pandémies. les responsables politiques et les décideurs peuvent répondre à ces préoccupations en augmentant le financement pour contrer l'itinérance et mieux soutenir les milieux ruraux et éloignés en modifiant les politiques afin de addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the canadian federal response to the covid- crisis (office of the prime minister ). rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic (kelford, personal communication). some funding was made available under the competitive rural and remote stream of canada's national housing strategy-reaching home-for rural homelessness response to covid- . the amounts available under the rural and remote stream, however, have been disproportionately less (if comparing population size) than what is made available to urban communities-"designated communities" in the reaching home terminology (kelford, personal communication). this is despite emerging evidence that rural and remote communities experience homelessness rates that are equivalent to or potentially higher than those experienced in urban areas. rural and remote communities must apply for and compete for funding against other rural communities, whereas urban "designated" communities are guaranteed a certain amount of funding under the strategy. some rural and remote communities, particularly larger centres, have more resources than others, which makes it more difficult for smaller communities to complete funding applications and successfully compete for funding. these issues are further complicated during pandemics, when scant resources are stretched even further and result in more limited capacity to complete funding applications. there has also been little to no research on rural communities' pandemic preparedness in the context of homelessness. pandemic preparedness and homelessness (buccieri and schiff ) was the first book to bring together the work of canadian researchers exploring the vulnerability of homeless populations in the event of a pandemic, and was utilized by the public health agency of canada (phac) in their pandemic preparedness guide for the health sector (phac ). there is little other literature examining pandemic preparedness in the homeless sector. the chapters in buccieri and schiff ( ) had a primary focus on urban populations in four canadian cities-analyzing the impact of the h n outbreak within the context of urban homelessness, with little attention to rural contexts. similarly, the phac guide contains no mention of rural communities and their unique needs during pandemic crises. there is clearly a large gap in current supports for, and understandings of, pandemic responses in the context of homelessness in rural settings. estimates suggest a rise in homelessness in canada and that , or more individuals use homeless shelters annually (gaetz et al. ) . the extent of homelessness in canada is a major social and public health concern, particularly in the context of pandemics. homelessness presents key challenges for emergency and pandemic planning due to complex health, situational, and structural vulnerabilities. this has been particularly evident during the covid- crisis (government of canada a). housing is a key social determinant of health, and it is widely documented that homeless people (including hidden homeless/housing-insecure individuals) suffer from much poorer health status and health outcomes than the general population (frankish et al. (frankish et al. , hwang et al. ). these medical-and health-related issues combine with social exclusion to create particularly significant vulnerability to infectious disease transmission and recovery (buccieri et al. ) . the homelessness response system has historically been focused on emergency response. this service system is characterized by overcrowded sleeping conditions, poor air quality, and a range of other public health issues that are alarming in the light of high transmission rates and the need for social distancing during pandemic situations. even in urban communities, homeless shelters are often not open for clients during daytime hours, meaning that if you are homeless and ill then there are limited options for rest and recovery. in rural settings, these shelters have even more limited services and availability. homeless people typically suffer from poor health, nutritional vulnerability, compromised immune systems, and barriers to accessing health services (frankish et al. ) . their health is further compromised when food sources are very restricted, supplies limited, and opportunities to store supplies non-existent (buccieri and schiff ) . it is essential to ask what kind of impacts a pandemic is having on homeless individuals and others living in precarious housing situations across the country. during the current covid- pandemic, it is clear that the infrastructure to address homelessness and the associated public health and healthcare services have not been prepared to adequately respond to the risks faced by the homeless population. this is particularly concerning for rural canada. until recently, there was little acknowledgement that homelessness existed in rural areas in canada (waegemakers schiff et al. ) . understanding of rural homelessness is minimal compared with that focussed on urban populations, and assessment of needs within the non-urban population is often overlooked. rural homelessness was unacknowledged in this country until reports from diverse rural areas of canada began to emerge in the last decade which shed light on the unique context of the issue (kauppi et al. (kauppi et al. , waegemakers schiff et al. ) . rural and remote homelessness is indeed a significant issue in canada (kauppi et al. ; taylor ) . there are large numbers of homeless individuals in rural and remote canada, and undercounts of those who are without permanent housing are alarming. however, the majority of homelessness funding in canada continues to be directed towards large urban centres (government of canada b). rural communities are often isolated and thus more limited than urban areas in their capacity to respond to pandemics. they are particularly vulnerable due to fewer healthcare and social service resources, scarcity of soup kitchens and food banks-the lack of which has been particularly evident during the covid- pandemic and which has significantly impacted their ability to respond to the needs of homeless people (kelford, personal communication) . it is imperative that pandemic responses be specifically designed for rural communities, rather than simply being extensions or adaptations of existing urban strategies. for rural communities to be better prepared for the ongoing covid- crisis, and future pandemics, it is critical to understand their capacities for pandemic planning. we must consider the unique strengths of rural communities, such as the potential to mobilize existing networks and local knowledge that already exists among residents. we must also consider the unique challenges that accompany pandemic response in rural settings, such as accessing remote dwellings, limited or nonexistent public transportation, the increased potential for fuel poverty, and less access to technology such as high-speed internet connections. we must also consider situational vulnerabilities (e.g., housing insecurity, food insecurity, poverty) that might be exacerbated in the context of pandemics and which might force some individuals and families into even more precarious housing situations and homelessness. because mobility between regions can be limited because of confinement protocol, it is also important to understand the impact of the pandemic on the ability of rural service providers and homeless individuals to access resources that are usually provided by their urban counterparts. policy-makers need to take seriously the situation of rural homelessness in canada, its implications for individual and community health, and consequences in the context of pandemics. policy-and decision-makers can address the pandemic preparedness needs of rural and remote communities through increased homelessness funding and support which is more equitable and in line with that available to urban communities. we also suggest a need for policy change to formalize recognition of the magnitude of rural homelessness and the unique needs and capacities of rural communities in the context of pandemics, and to include rural and remote homeless persons as a vulnerable population in the context of pandemics. there is also a need for more applied research on rural and remote homelessness that is readily translated into policy, programs, and supports-to ensure that rural health and social service providers are better prepared for future waves of the covid- pandemic and future pandemics. conflict of interest the authors declare that they have no conflict of interest. pandemic preparedness and homelessness: lessons from h n in canada hospital discharge planning for canadians experiencing homelessness. housing, care and support homelessness and health in canada: research lessons and priorities the relationship between homelessness and health: an overview of research in canada guidance for providers of services for people experiencing homelessness (in the context of covid- ) mortality among residents of shelters, rooming houses, and hotels in canada: year follow-up study homelessness and hidden homelessness in rural and northern ontario homelessness enumeration in the cochrane district prime minister announces support for vulnerable canadians affected by covid- public health measures: canadian pandemic influenza preparedness: planning guidance for the health sector how is rural homelessness different from urban homelessness? available at rural homelessness in canada: directions for planning and research publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -lz chxab authors: goddard, ellen title: the impact of covid‐ on food retail and food service in canada: preliminary assessment date: - - journal: nan doi: . /cjag. sha: doc_id: cord_uid: lz chxab covid‐ has imposed a series of unique challenges on the food retail and food service sectors in canada. almost overnight, the roughly % of the food dollar that canadians have been spending on food away from home has shifted to retail. the impacts of the covid- outbreak on the food retailing sector in canada are significant and, to a great extent, unexpected. the impacts fall into two major categories, the first being the actual impacts of public health on individuals, on employees in retail and food service, and on individuals throughout the rest of the supply chain, and the second being the dramatic change in what and where people want to buy their food. although there is an immediacy to the impacts of covid- on the food retail and food service industries, there is a remarkably uncertain projection for the future in a world where the sars-cov- virus is manageable and we go back to "normal" life. the new "normal" is unlikely to be the same for the retail/food service level of food markets as life was in january . in canada, for example, over the period - , household expenditure share on food away from home increased from % to %. revenues generated by different industrial categories of retail trade and food service (figure ) illustrate the significant increase in revenues in food service and drinking places (deflated dollars), whereas food and beverage stores, convenience stores, and beer, wine, and liquor store revenues remain relatively flat across the period from to . both food retail and food service sectors are significant in terms of employment within canada. as seen from data in figure , the share of employees in food retail declined from a peak of . % of . million employees in to % of million employees in . the share of food service employees, on the other hand, increased from % of total employees in to . %, on average, over the period - . brown ( ) reported that, as of april , % of , canadian respondents had shopped for groceries online (with % regularly). these numbers were up from % of survey respondents from months earlier. in , statistics canada reported an increase in food service and drinking places that report e-commerce sales from . % of businesses in to . %. although canadians had awareness of the sars-cov- virus elsewhere in the world, the first report of a presumptive case of covid- in canada occurred on january , , in toronto. the virus began to get more serious attention from the public as states of public emergency were declared by individual provinces (march - ). with the shutdown of schools and eventually other nonessential services, heightened concerns were felt throughout the country. the recommendations/orders to stay home immediately changed the way individuals looked at food purchases. first of all, everyone (both children and adults) became housebound (with the exception of essential workers). second, people realized that they personally were vulnerable, to disease and to loss of employment, and that food habits needed to change-for example, eating three meals a day at home, changing the frequency of "shopping" trips, and being faced with the unavailability of certain places where they had traditionally shopped. at terrific speed, the following changes were felt in the food retail and food service system: . eating and drinking places were closed with the exception of takeout or delivery options. . there was a surge in the demand for online grocery shopping that caused the existing infrastructure to struggle (evidenced by websites that crashed or operated extremely slowly and by long turnarounds in delivery time options from between and days to days or more). the shutdown of sit-down restaurant dining switched food purchases to grocery stores. this significantly changed the volume and types of foods purchased at grocery stores without the stores having time to adjust their supply chains. in some notable cases, the shopping behavior resulted in shortages of products in grocery stores (e.g., toilet paper), which exacerbated people's concerns and may have increased stockpiling behavior. actions taken by food service, food retail, and government in response to the declaration of public emergency status and the changes in consumer behavior that ensued included the following: . distribution of food service excess foods to centers feeding vulnerable people and to food banks (with higher usage due to the sudden unemployment of major sectors of the population) (harvey, ). . grocery store chains and supermarkets hired more employees to deal with online orders and distribution, provided additional support to employees, and raised wages (wilson, ) . . grocery store chains changed their just-in-time inventory management strategies to be able to deal with uneven shortages throughout their largely national distribution networks, in some cases avoiding distribution centers completely (canadian grocer, ). . grocery store chains develop strategies to deal with older and more vulnerable shoppers, including specific shopping hours for the vulnerable group only and targeting the vulnerable group first for grocery delivery. . grocery store chains installed protective plastic shields to protect cashiers and adopted customer management strategies to maintain safe distances between customers; food service delivery systems adopted no-contact food drop off to reduce contact between customer and delivery person (shah, ) . . grocery store chains attempt to deal with the surplus of certain foods arising from reduced demand from food service through diversion to consumer-ready retail products. short-term problems arise due to "transportation shortages caused by an overwhelmed trucking industry, processing and packaging challenges, a sharp decline in bulk customers due to the mass closures of restaurants and bakeries, and inconsistent distribution to stores" (shaw, ) . . regulatory rules related to labeling and food packaging began to be adjusted to facilitate product processing for retail as opposed to bulk processing for food service (health canada, ) . further adjustments to regulatory policy are recommended by some analysts, including relaxation of some antitrust measures related to retailers collaborating on supply logistics (keogh, ) . . food retailers step up in response to request for aid from food banks and shelters (e.g., loblaw company ltd., a, b; metro inc., ; opinko, ). . the competition bureau signaled that it will generally refrain from exercising scrutiny in circumstances where there is a clear imperative for companies to be collaborating in the short term to respond to the pandemic (competition bureau, ). it is difficult to predict exactly what might happen in the food service and food retail sectors as canada recovers from the economic and public health effects of this covid- outbreak. once states of emergency are lifted, then food service will likely reopen, and the question of how long it might take for people to be comfortable eating in restaurants again remains open. income elasticities of demand for food-away-from-home purchases are considered to be more elastic than similar elasticities for food-at-home purchases. from table , the potential impact of the covid- outbreak on potential food expenditures in total and by segment can be illustrated. a base of the food expenditure levels is used to translate percentage expenditures into dollars. an assumption of a % impact on disposable income in and a % impact on disposable income in is used as the shock to the system. the above numbers assume that restaurants are allowed to open again in and that the income effects are distributed across the years rather than being captured in one or two quarters of . the results highlight the shift between food away from home and food at home (even in the absence of restaurant closures) arising from the oppositely signed income elasticities. food retailing and food service sectors are both important economically in canada. prior to the covid- crisis, the food retailing sector has been evolving to higher sales through supermarkets and convenience stores, and the food service sector has been growing considerably, taking food market share away from food retailing. actions taken under the states of emergency imposed to deal with the pandemic in canada have changed the reality of food purchasing and the confidence people have in the ability of the food retail system to maintain consistent food and grocery availability. some reactions by the public, such as increased online purchasing with grocery delivery, will likely be maintained after the pandemic restrictions are over. there are uncertainties about how the public will react after states of emergency are lifted in terms of restaurant visits and the types of foods that will be purchased through food retail. amazon leads online grocery shopping in canada: survey. canadian grocer grocers respond to food shortage fears amid covid- outbreak competition bureau statement on competitor collaborations during the covid- pandemic canadian food banks struggle to stay open, just as demand for their services skyrockets. globe and mail temporary suspension of certain labelling requirements for foodservice products due to covid- covid- : rules of game must be changed to ensure supply of food loblaw provides $ million donation to get food and health essentials to canada's most vulnerable president's choice children's charity funds $ million response to vulnerable kids missing school-based hunger programs due to covid- closures covid- -metro demonstrates together we can with a commitment to give $ million to help communities in need; encourages customers to come together and donate too save-on-foods launches $ -million campaign to feed kids during covid- pandemic. lethbridge herald grocery chains install checkout shields, raise wages in response to coronavirus pandemic. global news b.c. farms dumping milk because of problems getting it to the store walmart hires workers amid covid- how to cite this article: goddard e. the impact of covid- on food retail and food service in canada: preliminary assessment key: cord- -phepjf authors: hsieh, ying-hen; fisman, david n; wu, jianhong title: on epidemic modeling in real time: an application to the novel a (h n ) influenza outbreak in canada date: - - journal: bmc res notes doi: . / - - - sha: doc_id: cord_uid: phepjf background: management of emerging infectious diseases such as the influenza pandemic a (h n ) poses great challenges for real-time mathematical modeling of disease transmission due to limited information on disease natural history and epidemiology, stochastic variation in the course of epidemics, and changing case definitions and surveillance practices. findings: the richards model and its variants are used to fit the cumulative epidemic curve for laboratory-confirmed pandemic h n (ph n ) infections in canada, made available by the public health agency of canada (phac). the model is used to obtain estimates for turning points in the initial outbreak, the basic reproductive number (r( )), and for expected final outbreak size in the absence of interventions. confirmed case data were used to construct a best-fit -phase model with three turning points. r( )was estimated to be . ( % ci . - . ) for the first phase (april to may ) and . ( % ci . - . ) for the second phase (may to june ). hospitalization data were also used to fit a -phase model with r( )= . ( . - . ) and a single turning point of june . conclusions: application of the richards model to canadian ph n data shows that detection of turning points is affected by the quality of data available at the time of data usage. using a richards model, robust estimates of r( )were obtained approximately one month after the initial outbreak in the case of a (h n ) in canada. epidemics and outbreaks caused by emerging infectious diseases continue to challenge medical and public health authorities. outbreak and epidemic control requires swift action, but real-time identification and characterization of epidemics remains difficult [ ] . methods are needed to inform real-time decision making through rapid characterization of disease epidemiology, prediction of shortterm disease trends, and evaluation of the projected impacts of different intervention measures. real-time mathematical modeling and epidemiological analysis are important tools for such endeavors, but the limited public availability of information on outbreak epidemiology (particularly when the outbreak creates a crisis environment), and on the characteristics of any novel pathogen, present obstacles to the creation of reliable and credible models during a public health emergency. one needs to look no further than the sars outbreak, or ongoing concerns related to highly pathogenic avian influenza (h n ) or bioterrorism to be reminded of the need for and difficulty of real-time modeling. the emergence of a novel pandemic strain of influenza a (h n ) (ph n ) in spring highlighted these difficulties. early models of ph n transmission were subject to substantial uncertainties regarding all aspects of this outbreak, resulting in uncertainty in judging the pandemic potential of the virus and the implementation of reactive public health responses in individual countries (fraser et al. [ ] ). multiple introductions of a novel virus into the community early in the outbreak could further distort disease epidemiology by creating fluctuations in incidence that are misattributed to the behavior of a single chain of transmission. we sought to address three critical issues in real time disease modeling for newly emerged ph n : (i) to estimate the basic reproduction number; (ii) to identify the main turning points in the epidemic curve that distinguish different phases or waves of disease; and (iii) to predict the future course of events, including the final size of the outbreak in the absence of intervention. we make use of a simple mathematical model, namely the richards model, to illustrate the usefulness of near realtime modeling in extracting valuable information regarding the outbreak directly from publicly available epidemic curves. we also provide caveats regarding inherent limitations to modeling with incomplete epidemiological data. the accuracy of any modeling is highly dependent on the epidemiological characteristics of the outbreak considered, and most epidemic curves exhibit multiple turning points (peaks and valleys) during the early stage of an outbreak. while these may be due to stochastic ("random") variations in disease spread, and changes in either surveillance methods or case definitions, turning points may also represent time points where epidemics transition from exponential growth processes to processes that have declining rates of growth, and thus may identify effects of disease control programs, peaks of seasonal waves of infection, or natural slowing of growth due to infection of a critical fraction of susceptible individuals. for every epidemic, there is a suitable time point after which a given phase of an outbreak can be suitably modeled, and beyond which subsequent phases may be anticipated. detection of such "turning points" and identification of different phases or waves of an outbreak is of critical importance in designing and evaluating different intervention strategies. richards [ ] proposed the following model to study the growth of biological populations, where c(t) is the cumulative number of cases reported at time t (in weeks): here the prime "′" denotes the rate of change with respect to time. the model parameter k is the maximum case number (or final outbreak size) over a single phase of outbreak, r is the per capita growth rate of the infected population, and a is the exponent of deviation. the solution of the richards model can be explicitly given in terms of model parameters as using the richard model, we are able to directly fit empirical data from a cumulative epidemic curve to obtain estimates of epidemiological meaningful parameters, including the growth rate r. in such a model formulation, the basic reproduction number r is given by the formula r = exp(rt) where t is the disease generation time defined as the average time interval from infection of an individual to infection of his or her contacts. it has been shown mathematically [ ] that, given the growth rate r, the equation r = exp(rt) provides the upper bound of the basic reproduction number regardless of the distribution of the generation interval used, assuming there is little pre-existing immunity to the pathogen under consideration. additional technical details regarding the richards model can be found in [ ] [ ] [ ] . unlike the better-known deterministic compartmental models used to describe disease transmission dynamics, the richards model considers only the cumulative infected population size. this population size is assumed to have saturation in growth as the outbreak progresses, and this saturation can be caused by immunity, by implementation of control measures or other factors such as environmental or social changes (e.g., children departing from schools for summer holiday). the basic premise of the richards model is that the incidence curve of a single phase of a given epidemic consists of a single peak of high incidence, resulting in an s-shaped cumulative epidemic curve with a single turning point for the outbreak. the turning point or inflection point, defined as the time when the rate of case accumulation changes from increasing to decreasing (or vice versa) can be easily pinpointed as the point where the rate of change transitions from positive to negative; i.e., the moment at which the trajectory begins to decline. this time point has obvious epidemiologic importance, indicating either the beginning of a new epidemic phase or the peak of the current epidemic phase. for epidemics with two or more phases, a variation of the s-shaped richards model has been proposed [ ] . this multi-staged richards model distinguishes between two types of turning points: the initial s curve which signifies the first turning point that ends initial exponential growth; and a second type of turning point in the epidemic curve where the growth rate of the number of cumulative cases begins to increase again, signifying the beginning of the next epidemic phase. this variant of richards model provides a systematic method of determining whether an outbreak is single-or multi-phase in nature, and can be used to distinguish true turning points from peaks and valleys resulting from random variability in case counts. more details on application of the multi-staged richards model to sars can be found in [ , ] . readers are also referred to [ , ] for its applications to dengue. we fit both the single-and multi-phase richards models to canadian cumulative ph n cumulative case data, using publicly available disease onset dates obtained from the public health agency of canada (phac) website [ , ] . phac data represent a central repository for influenza case reports provided by each of canada's provinces and territories. onset dates represent best local estimates, and may be obtained differently in different jurisdictions. for example, the province of ontario, which comprises approximately / of the population of canada, and where most spring influenza activity was concentrated, replaces onset dates using a hierarchical schema, whereby missing onset dates may be replaced with dates of specimen collection (if known) or date of specimen receipt by the provincial laboratory system, if both dates of onset and specimen collection are missing. data were accessed at different time points during the course of the "spring wave (or herald wave)" of the epidemic in may-july of , whenever a new dataset is made available online by the phac. by sequentially considering successive s-shaped segments of the epidemic curve, we estimate the maximum case number (k) and locate turning points, thus generating estimates for cumulative case numbers during each phase of the outbreak. the phac cumulative case data is then fitted to the cumulative case function c(t) in the richards model with the initial time t = being the date when the first laboratory confirmed case was reported and the initial case number c = c( ) = , (the case number with onset of symptoms on that day). there were some differences between sequential epidemic curves in assigned case dates. for example, data posted by phac on may indicated an initial case date of april , but in the june data this had been changed to april , perhaps due to revision of the case date as a result of additional information. model parameter estimates based on the explicit solution given earlier can be obtained easily and efficiently using any standard software with a least-squares approximation tool, such as sas or matlab. daily incidence data by onset date were posted by phac until june , after which date only the daily number of laboratory-confirmed hospitalized cases in canada was posted. for the purpose of comparison, we also fit the hospitalization data to the richards model in order to evaluate temporal changes in the number of severe (hospitalized) cases, which are assumed to be approximately proportional to the total cases number. the case and hospitalization data used in this work are provided online as additional file . we fit the model to the daily datasets, acquired in real time, throughout the period under study. the leastsquared approximation of the model parameter estimation could converge for either the single-phased or the -phase richards models. for the sake of brevity, only four of these model fits are presented in table to demonstrate the difference in modeling results over time. the resulting parameter estimates with % confidence intervals (ci) (for turning point (t i ), growth rate (r), and maximum case number (k)), time period included in the model, and time period when the data set in question were accessed, is presented in table . note that all dates in the tables are given by month/day. we also note that the ci's for r reflect the uncertainty in t as well as in the estimates for r, and does not reflect the error due to the model itself, which is always difficult to measure. in order to compare the -phase and -phase models, we also calculate the akaike information criterion (aic) [ ] for the first, third, and fourth sets of data in table , where there is a model fit for the -phase model. the results, given in table , indicates that whenever there is a model fit for the -phase model, its aic value is always lower than that of the -phase model and hence compares favorably to the -phase model. parameter estimates fluctuate in early datasets, and the least-squared parameter estimations diverge within and between -phase and -phase models in a manner that seems likely to reflect artifact. in particular, for the earliest model fits, using data from april to may , the estimated reproductive number for the second phase is far larger than that obtained in the first phase, and that obtained using a single-phase model, and illustrating the pitfalls of model estimation using the limited data available early in an epidemic. estimates stabilize as the outbreak progresses, as can be seen with the final data sets (april to june and april to june ). for comparison, we plot the respective theoretical epidemic curves based on the richards model with the estimated parameters described in the table above in figure . as noted above, model can be used to estimate turning points (t i ) and basic reproductive numbers (r .), if the generation time t is know. we used t = . days ( % ci: . - . ), as obtained in [ ] by fitting an age stratified mathematical model to the first recognized influenza a (h n ) outbreak in la gloria, mexico. estimates are presented in table . we also conducted sensitivity analyses with r # calculated based on longer generation times (t = . ( . , . )) for seasonal influenza in [ ] (see last column in table ). excluding implausibly high estimates of r generated using initial outbreak data (april to may ), we obtain the estimates of r for the -phase model that range between . and . . inasmuch as richards model analyzes the general trends of an epidemic (e.g., turning point, reproductive number, etc.), it can be used to fit any epidemiological time series for a given disease process, as long as the rate of change in the recorded outcome is proportional to changes in the true number of cases. as such, for comparison, we fit our model using the time series for ph n hospitalizations in canada posted by phac on july [ ] (that last date these data were made available) ( table ) . this time series was easily fit to a one-phase model ( figure ) . further examples of using hospitalization or mortality data to fit the richards model can be found in [ ] . we used the richards model, which permits estimation of key epidemiological parameters based on cumulative case counts, to study the initial wave of influenza a (h n ) cases in canada. in most model fits, april - and may - were identified as early turning points for the outbreak, with a third and final turning point around june - in models based on longer time series. although this modeling approach was not able to detect turning points using some earlier data sets (e.g., those limited to the period from april to may ), in general the turning points identified were consistent across multiple models and time series. perhaps the most important divergence between models occurred with the detection of an april turning point in the case report time series, but not in the time series based on hospitalized cases. we believe this may be attributable to the small number of hospitalizations, relative to cases, that had occurred by that date, as well as the fact that hospitalization data only became available on april . the turning point can correspond to the point at which disease control activities take effect (such that the rate of change in epidemic growth begins to decline) or can represent the point at which an epidemic begins to wane naturally (for example, due to seasonal shifts or due to the epidemic having "exhausted" the supply of susceptibles such that the reproductive number of the epidemic declines below ). this quantity has direct policy relevance; for example, in the autumn ph n wave in canada, vaccination for ph n was initiated at or after the turning point of the autumn wave due to the time taken to produce vaccine; as the epidemic was in natural decline at that point, the impact of vaccination has subsequently been called into question. although the richards model is able to capture the temporal changes in epidemic dynamics over the course of an outbreak, it does not define their biological or epidemiological basis. as such, determining the nature of these turning points requires knowledge of "events on the ground" for correlation. we suspect that the last note that all dates in the tables are given by month/day. dates of posting are listed in parentheses. model duration indicates whether they fit a -phase or phase model. note that the maximum case number is rounded off to the nearest integer. r # is obtained using the generation interval of t = . ( . , . ) for seasonal influenza [ ] . table comparison of akaike information criterion (aic) values between -phase and -phase models for time periods with -phase model fit in table time table , last line) and a -phase model using hospitalization data (june ), this lag in turning points would actually be expected, due to the time from initial onset of symptoms until hospitalization, which was reported to have an interquartile range of - days in a recent study from canada [ ] . timelines for the -phase model for case data of / - / and the -phase model for hospitalization data are presented graphically in figure . in addition to identifying turning points, the richards model is useful for estimation of the basic reproductive number (r ) for an epidemic process, and our estimates derived using a richards model were consistent with estimates derived using other methods. for example, our r agrees almost perfectly with that of tuite et al., derived using a markov chain monte carlo simulation parameterized with individual-level data from ontario's public health surveillance system [ ] . our estimates of r is smaller than that derived by fraser et al. [ ] using mexican data, but such differences could relate in part to the different age distributions of these two countries [ ] , and may also reflect the fact that our estimate is obtained canadian data at a national level, while empirical mexican estimates were based on data from the town of la gloria with only residents. most epidemic curves in the early stage of a novel disease outbreak have multiple phases or waves due to simple stochastic ("random") variation, mechanisms of disease importing, initial transmission networks and individual/community behavior changes, improvements in the performance of surveillance systems, or changes in case definitions as the outbreak response evolves. however, changes in phase (signified by the presence of turning points identified using the richards model) may also pinpoint the timing of important changes in disease dynamics, such as effective control of the epidemic via vaccination or other control measures, depletion of disease-susceptible individuals (such that the effective reproductive number for the disease decreases to < ), or the peak of a "seasonal" wave of infection, as occurs with [ , , ] , some competing methods require more extensive and detailed data than are required to build a richards model, which requires only cumulative case data from an epidemic curve. as we also demonstrate here, the richards model produces fairly stable and credible estimates of reproductive numbers early in the outbreak, allowing these estimates to inform evolving disease table , derived using early case data accessed on may , closely approximate our final estimates (table , last row) . thus, while early estimation with the richards model failed to correctly detect turning points or accurately estimate the final outbreak size, it was nonetheless useful for rapid estimation of r within a month of first case occurrence in canada. as with any mathematical modeling technique, the approach presented here is subject to limitations, which include data quality associated with real-time modeling (as data are often subject to ongoing cleaning, correction, and reclassification of onset dates as further data become available), reporting delays, and problems related to missing data (which may be non-random). in our current study, the hierarchical approach used by canada's most populous province (ontario) for replacement of missing data could have had distorting effects on measured disease epidemiology: the replacement of missing onset dates with dates of specimen collection could have resulted in the artifactual appearance of early turning points identified by our model, due to limitations in weekend staffing early in the outbreak. if, as we believe to be the case, public health laboratories did not have sufficient emergency staffing to keep up with testing on weekends such that weekend specimen log-ins declined sharply, this would have created the appearance of epidemic "fade out" on weekends. other factors that might distort the apparent epidemiology of disease include changes in guidelines for laboratory testing of suspected cases, improved surveillance and public health alerts at later stages of the outbreak leading to increased case ascertainment or over-reporting of cases [ ] . however, the quality of the time series will tend to improve with the duration of the epidemic, both because stochastic variation is "smoothed out", and also because small variations become less important as the cumulative series becomes longer. we note that a further application of the richards model in the context of influenza would relate to comparison of the epidemiology of the influenza a h n epidemic to past canadian epidemics, though such an endeavor is beyond the scope of the present study. in summary, we believe that the richards model provides an important tool for rapid epidemic modeling in the face of a public health crisis. however, predictions based on the richards model (and all other mathematical models) should be interpreted with caution early in an epidemic, when one need to balance urgency with sound modeling. at their worst, hasty predictions are not only unhelpful, but can mislead public health officials, adversely influence public sentiments and responses, undermine the perceived credibility of future (more accurate) models, and become a hindrance to intervention and control efforts in general. additional file : electronic supplementary material. canada novel influenza a(h n ) daily laboratory-confirmed pandemic h n case and hospitalization data. epidemic science in real time pandemic potential of a strain of influenza a (h n ): early findings a flexible growth function for empirical use how generation intervals shape the relationship between growth rates and reproductive numbers sars epidemiology. emerging infectious diseases real-time forecast of multi-wave epidemic outbreaks. emerging infectious diseases richards model: a simple procedure for real-time prediction of outbreak severity intervention measures, turning point, and reproduction number for dengue turning points, reproduction number, and impact of climatological events on multi-wave dengue outbreaks public health agency of canada: cases of h n flu virus in canada public health agency of canada: cases of h n flu virus in canada a new look at the statistical model identification estimation of the serial interval of influenza pandemic influenza a (h n ) during winter influenza season in the southern hemisphere. influenza and other respiratory viruses critically ill patients with influenza a(h n ) infection in canada estimated epidemiologic parameters and morbidity associated with pandemic h n influenza age, influenza pandemics and disease dynamics comparative estimation of the reproduction number for pandemic influenza from daily case notification data the ideal reporting interval for an epidemic to objectively interpret the epidemiological time course initial human transmission dynamics of the pandemic (h n ) virus in north america. influenza and other respiratory viruses on epidemic modeling in real time: an application to the novel a (h n ) influenza outbreak in canada authors' contributions yhh conceived the study, carried out the analysis, and wrote the first draft. df interpreted the results and revised the manuscript. jw participated in the analysis, the interpretation of results, and the writing. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord- - qds e authors: richardson, katya l; driedger, michelle s; pizzi, nick j; wu, jianhong; moghadas, seyed m title: indigenous populations health protection: a canadian perspective date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: qds e the disproportionate effects of the h n pandemic on many canadian aboriginal communities have drawn attention to the vulnerability of these communities in terms of health outcomes in the face of emerging and reemerging infectious diseases. exploring the particular challenges facing these communities is essential to improving public health planning. in alignment with the objectives of the pandemic influenza outbreak research modelling (pan-inform) team, a canadian public health workshop was held at the centre for disease modelling (cdm) to: (i) evaluate post-pandemic research findings; (ii) identify existing gaps in knowledge that have yet to be addressed through ongoing research and collaborative activities; and (iii) build upon existing partnerships within the research community to forge new collaborative links with aboriginal health organizations. the workshop achieved its objectives in identifying main research findings and emerging information post pandemic, and highlighting key challenges that pose significant impediments to the health protection and promotion of canadian aboriginal populations. the health challenges faced by canadian indigenous populations are unique and complex, and can only be addressed through active engagement with affected communities. the academic research community will need to develop a new interdisciplinary framework, building upon concepts from ‘communities of practice’, to ensure that the research priorities are identified and targeted, and the outcomes are translated into the context of community health to improve policy and practice. the mandate of pan-inform is to develop knowledge translation methodologies with the aim of bridging the gaps between theory, policy, and practice [ ] . in a postpandemic workshop held in [ ] . pan-inform analyzed public health and clinical responses to the h n pandemic and found that canada's aboriginal (first nations, inuit, and métis) populations were disproportionately affected by the crisis. in fact, those living in first nations communities were . times more likely to be hospitalized after contracting the infection, with an intensive care unit admission rate times higher than non-aboriginal people [ ] . with a commitment to inform public health policies for the promotion of population health, pan-inform has prioritized initiatives to address the challenges of community health in protecting vulnerable populations from emerging infectious diseases. in order to identify the pertinent challenges, a public health workshop on "indigenous populations health protection" was held on may - , [ ] , at the cdm in york university. with the participation of key stakeholders from aboriginal health organizations, policy decision-makers, and representatives from the research community in canada, the workshop focused on public health responses, determinants of health, and the differential effects of intervention strategies in aboriginal populations. the presence of indigenous stakeholders was crucial in meeting the workshop objectives and providing a national forum to establish new partnerships, and foster research collaborations with aboriginal health organizations. modellers presented important research findings with relevance to indigenous health, and highlighted the importance of community-specific planning for vulnerable populations. from the standpoint of public health, the workshop uncovered some critical issues facing underserved communities in terms of access to healthcare services and program delivery. representatives from health departments shared their knowledge and experiences with addressing the disparities in healthcare access for many aboriginal communities across canada. through in-depth and collegial discussions, important inputs that must be encapsulated in modelling frameworks were identified, and the challenges that are involved in developing health policies were presented. aboriginal populations face different challenges during emerging infectious diseases. some of these challenges result from limited access to and the delivery of health services, particularly when some of canada's constitutionally identified aboriginal peoples have different levels of government responsible for the provision of healthcare. the federal government generally provides for first nations and inuit populations, whereas métis citizens generally fall under provincial health jurisdictions. what compounds this, however, is that first nations and métis citizens might live quite geographically close, but experience differential access to healthcare and noninsured health coverage. these differences can begin to be eliminated through collaborative multi-jurisdictional efforts designed to address the health needs of affected individuals, particularly those living in remote areas. aboriginal communities in the province of manitoba, especially in the northern region, were severely affected by the pandemic [ , ] . data for laboratory confirmed cases of h n infection and hospitalization collected during the first wave of the pandemic in the province of manitoba suggest significantly higher agespecific rates of incidence and hospital admission for first nations populations compared to non-first nations populations ( figure ). during outbreaks of the h n virus in manitoba, a tripartite table was established, which included representatives from the provincial and federal governments as well as representatives from first nations and métis self-governing organizations. the provincial minister of health liaised and dialogued regularly with the tripartite table to develop communication strategies for access to primary healthcare in northern manitoba. in addition, a table for 'equity and ethics' was established to collect feedback from communities and ensure that their respective citizens would receive equitable access to vaccine and other health resources. to facilitate responses, planning measures included the establishment of teams that were deployed to remote areas for the delivery of patient-care. patients with severe outcomes requiring hospitalization were transported to the southern part of the province for access to critical care. however, indigenous leaders stressed the importance of developing self-care systems. in response to this concern, manitoba health aided with the distribution of h n flu kits to communities where pharmacies and nursing stations were absent or not readily accessible. the provincial government also supported the use of traditional medicines and communicated the relevant information as to where such resources could be located. lessons learned from manitoba's experience during the h n pandemic included understanding that organizations and communities have developed their own plans for responding to emerging crises, and this underscores the necessity for effective communications at all levels of the healthcare system and community for the development of a coherent strategy [ ] . this was further highlighted by presenting the challenges that were encountered with the implementation of vaccination policies during the second wave, in particular with determining priority groups, eligibility criteria, and workforce requirements. pandemic prevention strategies included recommendations to adopt methods for the impact assessment of major decisions on health inequalities, to increase the engagement between services and communities, to strengthen the vital role of families and communities, to promote a more equitable distribution of the determinants of health, and to enhance prevention programs and encourage more outreach. several recommendations for enhancing pandemic preparedness at the provincial level were made, such as establishing recommended structures and elements for strategy development with an oversight body and a multi-stakeholder network. it was identified that there needs to be greater clarity in communicating policy guidelines, so that information is presented in a consistent and accurate manner to the public. to enhance the perspectives of northern communities, several impediments to adequate healthcare delivery during the h n pandemic in the territory of nunavut were discussed. cross-cultural barriers remain a key challenge in nunavut, as many of the healthcare professionals practicing in the territory are often considered outsiders. there is a general lack of orientation to the territory for outside staff, especially with regards to language training. the learning of nunavut's two languages is not mandatory and classes are limited to basic training. concerns regarding the potential to recruit and retain public health staff in nunavut remain unaddressed. nunavut still stores public health records in paper-based forms as opposed to electronic systems implemented in canada at large, which causes problems in maintaining accurate records and surveillance systems. although the need to generate and update these systems is known, vocalizing this concern has been limited. furthermore, regulations that have been put in place to protect public health are often rendered obsolete as few people are trained in policing these regulations. the lack of adherence to, or inadequate level of compliance with some regulations has resulted in an increased health burden in the inuit communities. the social determinants of health can be categorized as: distal (historic, political, social and economic contexts), intermediate (community infrastructure, resources, systems and capacities), and proximal (health behaviours, physical and social environment). colonization is a particularly important historical consideration, as are neocolonial policies because they perpetuate discrimination and social exclusion, even into the twenty-first century. these processes hinder the development of healthy identities and self-esteem, and are ultimately responsible for poor mental and physical health. chronic mental diseases affecting indigenous communities include schizophrenia, bipolar disorder and major depressive disorder, as well as post-traumatic stress disorder and addiction. most astounding is the suicide rate among first nations youth (aged [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , which is eight times the national average for females and five times the national average for males in canada [ , ] . other important social determinants of health include poverty, poor education, and overcrowded housing, which have a strong correlation to chronic and infectious diseases. the united nations' human development index has been applied to canada to understand the differences in quality of life and wellbeing between indigenous and non-indigenous populations [ ] . overall, canada has consistently ranked within the top five nations in the world but when the socioeconomic status of canadian aboriginal peoples is factored in, canada's ranking on the index drops significantly. many aboriginal peoples are essentially living in third world conditions within a first world country. geographic locale is a key factor in determining the level of access to healthcare, with the most underserved communities being those that are the most isolated and remote in the country. often these communities belong to indigenous groups living in the northern regions of the provinces and across the territories. approximately % of the inuit population lives in nunavut where resources pertaining to health practitioners and medical equipment are limited [ ] . geographic isolation complicates policy decisions, as the availability and lifespan of medicines need to be continually assessed to make accurate decisions about the shipment of medical supplies to remote communities. this was marked as one of the greatest challenges in serving these communities during the h n pandemic outbreaks. furthermore, the existence of multiple jurisdictions, each with differing policies concerning the health and wellbeing of first nations has led to a patchwork of polices. overlapping jurisdictions create conflicts in terms of identifying correct procedures to follow and assigning the responsibility for provision of care. currently, the provincial and federal governments share these responsibilities and there is little consistency in the modes for public health delivery between regions, especially between on-reserve and off-reserve indigenous populations. the outcome has been varying levels of healthcare delivery, number of personnel, and facilities available within each indigenous community. for relative infection (hospitalization) ratios, bar plots and % confidence intervals correspond to the age-standardized ratio of the proportion of infectious (hospitalized) cases in a given age group to the proportion of the population in the same age group [ ] . a relative ratio higher than indicates that the corresponding age group experienced a higher incidence of infection or hospitalization than the population as a whole. recognizing that limited access to healthcare acts as one of the perpetuating factors to increased rates of respiratory illness in aboriginal populations, a team of researchers has been conducting research to provide contrasting results if this limitation were removed [ , ] . the leading member of this research presented the findings specific to kahnawà:ke, an aboriginal reserve without any constraints in access to healthcare due to its close proximity to montreal, the largest urban centre in the province of quebec. data was collected on outpatient and emergency room visits between to for residents of both kahnawà:ke and montreal. analysis of such data, stratified by gender and age groups, indicates that the two regions had similar demographics, but the outpatient and emergency room visits were % higher for residents of kahnawà:ke compared to residents of montreal. when the access to healthcare factor was removed, questions arose about the reasons for the increased risk of vulnerability in residents of kahnawà:ke. although no conclusions have been drawn, data indicate that diabetes in first nations populations is % higher than the canadian national average; child obesity is % versus % in quebec; and smoking is % higher in quebec's first nations people compared to non-first nations. a constant annual pattern has been reported, linking the contributing factors, habitual smoking, and obesity to respiratory illnesses. although the link between social factors and health outcomes is strong, canada's approach to protecting vulnerable populations has focused on emergency services rather than prevention. a study conducted at york university's canadian homelessness research network analyzed how emergency response to homelessness impacts the vulnerability of homeless populations in the event of a pandemic, and how it presents impediments to effective pandemic planning [ ] . this study challenged key assumptions made about the resources available to homeless populations and raised important questions about system capacities in the homelessness sector. it also analyzed ethical considerations, noting that during emergency situations, there is a risk of compromising human rights for greater health and safety. it is common for difficult ethical questions about the prioritization and allocation of limited health resources to arise during these occasions, as well as concerns about the violation of individuals' autonomy through forced isolation or quarantine. the first wave of the h n pandemic exposed the vulnerability of aboriginal populations to poor outcomes, demonstrating the inefficacy of the polysaccharide vaccine that was in use at the time. this alerted health canada to fund a study that assessed the safety and immunogenicity of a new adjuvanted vaccine (arepanrix) in a sample of aboriginal adults [ ] . a leading member of the study team presented the results of this population-specific work. the study involved an open trial with participants, with first nations identity and métis, all from the winnipeg health region, which is the largest urban centre in the province of manitoba. the volunteers kept their daily symptom diaries for seven days following vaccination, including oral temperature measurements. there was a telephonebased safety interview on the seventh day, and an inperson review of adverse events on the twenty-first day. approximately % of the volunteers experienced adverse effects, although fever was not experienced and most general symptoms were abated by the end of the first week. the immune response assessment involved collecting blood samples at baseline, as well as to days post vaccination. sera were then tested for hemagglutination-inhibiting antibodies at the national microbiology laboratory in winnipeg. all of the patients had adequate antibody responses regardless of whether they were primed (previously exposed) or naïve (fully susceptible). results for the entire study, which examined , individuals across six projects, concluded that immunogenic responses to the vaccination in aboriginal adults exceeded those of non-aboriginal adults. workshop participants found the protocol completion rate impressive, with of the subjects present for the final blood draw, which was greater than the anticipated rate of participation by aboriginal people in the research. the safety profile of the adjuvanted vaccine was consistent with the projected rates. given the success of this study, it will be important in future work to determine if an equally satisfactory response follows the adjuvanted seasonal influenza vaccine. in the vaccine research domain, a study is currently being conducted for the development of a new vaccine candidate against heamophilus infuenzae type a (hia), which has emerged during the past decade in canadian aboriginal communities [ ] [ ] [ ] [ ] [ ] [ ] . the high prevalence of this infection, which manifests as meningitis, septicaemia, or bacteremic pneumonia, has prompted aboriginalspecific studies. invasive hia disease has become a major cause of severe outcomes in young children of several aboriginal populations in north america, with highest risk of contracting hia being reported in the navajo, white apache, alaskan natives, first nations, and inuit [ ] [ ] [ ] [ ] . in a study spanning the last decade, it was found that hia made up % of all serotyped isolates for heamophilus infuenzae [ ] . the emergence and high incidence of invasive hia disease in canadian aboriginal populations warrant further clinical and epidemiological studies, involving affected communities for the development of an effective hia vaccine candidate. helicobacter pylori (h. pylori), is yet another prevalent infection in canadian aboriginal populations [ ] . h. pylori is one of the most common pathogens affecting half of the world's population, particularly in developing countries. in canada, there are three identified groups, including aboriginal people, which are associated with higher risk of infection by h. pylori [ ] . the pathogen causes illnesses and conditions such as chronic gastritis and peptic ulcers, and increases the risk of gastric cancer [ ] [ ] [ ] . the current infection management strategies are based on antibiotic regimens. however, this treatment faces declining effectiveness, with rates dropping below % due to the emergence of drug-resistance. a team of canadian researchers has developed a new technology, which enables the formulation of a vaccine candidate against h. pylori. the leading member of the research team presented the results of this ongoing work that aims to analyze the characteristics of isolates from aboriginal populations. this analysis could identify the circulating strains in aboriginal populations, and determine the immune profiles of the affected populations. factors responsible for the increased vulnerability of these populations to h. pylori include crowded housing, poor sanitary conditions, and polluted water supplies, which underscore the importance of access to critical infrastructure in protecting and promoting community health. a major obstacle to developing appropriate health policies and responsive healthcare delivery is a lack of specific data. although data may be available for particular regions, there is a general lack of streamlining in data sets across multiple jurisdictions, as well as between hospital databases and public health surveillance systems in canada. as a result, public health professionals are often faced with a deficiency of information to make informed policy decisions. thus, incomplete data may be adapted or used out of the context in efforts to inform the development of programs and strategies. during the workshop, disease modellers discussed some key areas in which detailed population level data play a critical role in understanding the risk of infection and outcomes in different vulnerable groups. for example, the results of a study on comparative analysis of age distribution of infection and hospitalization during the h n outbreak, presented a marked difference in the risk of infection between first nations and non-first nations populations in manitoba [ ] . the study further discriminated between the first wave and second wave of the pandemic, and compared the incidence rates between on-reserve and off-reserve first nation communities, indicating that the risk for infection and hospitalization was significantly higher for the former. pre-school aged children in the first nation populations were at higher risk during the first wave, whereas school-age children were at higher risk of infection during the second wave. such comparative analysis was based on large databases created during the h n pandemic with stratification of health regions, age, gender, ethnicity, time for initial care, and the type and duration of health resources used for the management of infection. the need for detailed data is also important for the assessment of effectiveness and cost-effectiveness of intervention measures in the face of competing strategies. presented results of an ongoing research study highlighted the potential utility of an agent-based modelling approach to determine the most effective antiviral treatment and prophylaxis strategies for influenza infection control, and to evaluate the effect of limiting intervention duration [ ] . in summary, the preliminary findings suggested that a great deal of prophylaxis waste typically occurs at low treatment levels in early stages of the epidemic. the early administration of high treatment levels significantly reduces prophylaxis waste, but increasing prophylaxis coverage in some scenarios contributes to increased waste. limiting the duration of prophylaxis can reduce the waste for comparable outcomes. this work continues to investigate whether particular age groups contribute disproportionately to the waste of treatment resources, and during which stage of the epidemic the greatest amount of waste is created. the results of this study will be used to propose more specifically targeted interventions that can be tested in-silico using computer simulation experiments. workshop participants stressed the importance of developing relationships with aboriginal stakeholders to ensure that their voices are heard in policy-making, and their needs are addressed in strategy development and program delivery. yet, it can be difficult for researchers to honour all aspects of diversity in their work and use holistic and inclusive approaches, which equally weigh different systems of knowledge. to navigate these pertinent challenges, the use of a "communities of practice" (cop) model was presented. the cop model, defined as a group of people who have common concerns, a set of problems, and a passion about solving the problems [ , ] , consists of two core components: (i) the interrelationships formed around mutual trust, identity, and understanding; and (ii) the acknowledgement of differences in perception and understanding. there is a need to develop shared meanings through social engagements and interactions by working towards a common goal and communicating in an accessible jargon-free language [ ] . the concept of cop is best summarized by the term coined by mi'kmaw elder albert marshall, "two-eyed seeing," which refers to the ability to see with one eye from an indigenous perspective and with the other from a western perspective, learning to use both in tandem for the benefit of all. this creates a comprehensive approach to advancing aboriginal health objectives. within the context of cop, the director of the institute of aboriginal peoples' health (iaph) of the canadian institutes of health research (cihr) outlined the institute's two primary goals. first, the iahp aims to increase awareness, understanding, and appreciation of aboriginal beliefs, in addition to traditional knowledge among researchers, peer reviewers, and the canadian population by extension. second, the iaph places a high priority on recognizing, promoting, and incorporating the excellence and rigour of methodologies derived from indigenous norms. the objective is to have these methodologies incorporated into the way the iaph conducts its research, rather than remaining a mere side note. the iaph aims to increase the number of first nations, inuit, and métis researchers conducting aboriginal-related health research, as well as the number and quality of their research activities. the iaph also takes a grassroots approach in its support of community-based organizations that are eligible to receive and manage funds on behalf of the cihr, thereby increasing the communities' abilities to address their own health issues. the workshop highlighted three general areas of research that are neither discrete nor inclusive but can be labeled as instrumental, symbolic, or conceptual. instrumental research measures impact, symbolic research argues a position, and conceptual research evaluates whether the right questions are being formulated. each form of research has its own relevancy and can be more commonly associated with certain academic disciplines. for example, with respect to the topic of health risks among homeless populations, instrumental research may ask how shelters can be made more hygienic, while conceptual research would question whether it makes more sense to provide housing to homeless individuals rather than warehouse them in shelters. both types of research are important for public health and through interdisciplinary knowledge translation activities, the pertinent questions can be debated, re-framed and re-formulated so that they are meaningful and address public health concerns. the underlying process is complex and there will always be political challenges involved; however it is important that resources be marshaled to address these public health issues to produce maximum benefits to the communities at risk. with unique population characteristics that place some aboriginal communities at increased risk for adverse health consequences, it is imperative for public health authorities to identify vulnerable segments of the population, and in cooperation with local officials within the community, determine effective and feasible health responses. these responses must also take into account factors such as jurisdictional issues and the variability of aboriginal public health infrastructures. while effectiveness is a necessary criterion for the identification of optimal health responses, these factors must also be considered for assessing the feasibility of such responses in different community settings. taking into consideration these underappreciated aspects and realities of vulnerable populations, the workshop highlighted that modelling and simulations are invaluable tools that permit the rapid testing of hypotheses for the subsequent design and implementation of response strategies to address the needs of these populations. by permitting simultaneous observations of disease-related outcomes at multiple levels of communities and the healthcare system, models can inform the development of communitywide and specific contingency plans that incorporate the full spectrum of harms related to disease spread and benefits associated with response activities. the workshop was successful in bringing together key stakeholders, policy decision makers, and researchers from a wide array of disciplines, each with their own perspective but all with the common goal of improving the health status of canada's indigenous populations. during the preceding decade, canada has experienced the emergence of novel diseases that have caused tremendous public concern and economic consequences, including the sars epidemic and the influenza pandemic. the rapid containment of sars as the first major infectious disease threat of the st century was a public health success in the modern era [ ] , but also a warning that the global containment of emerging diseases may be much more difficult in this highly connected world, if not impossible. the influenza pandemic demonstrated this difficulty and incurred disproportionately large economic and political impacts, in addition to differential effects on many subpopulations including aboriginal peoples and underserved communities [ ] . while the focus here has been on first nations, inuit and métis people in canada, these experiences were similar to what happened for indigenous people living in the united states, australia and new zealand [ ] [ ] [ ] . the objectives of this networking event, and the spectrum of participants, attested to the fact that in the relatively short period of time since the inception of pan-inform, significant progress has been achieved through the hosting of bi-annual workshops of this scale. these networking activities have encouraged more intricate disciplinary dialogues, which challenge participants to re-evaluate their assumptions so that they are eventually resolved or dissolved. as a result of such interdisciplinary approaches, new and stronger links between theory, policy and practice have been forged. a strength of the workshop was the presentation of how appropriate use of data can lead to novel scientific findings that influence policy and practice. this is realized by involving the research community, affected populations, and policy makers in the interpretation and contextual use of data, which is becoming increasingly important as modellers aim to introduce ever more complex structures into the models such as social network patterns. public health challenges and research methods discussed during the workshop led to key recommendations outlined in table . presentations given during the workshop were evidence for the opening of a new chapter in canadian public health research and practice involving indigenous populations. ongoing studies for the development of vaccines for diseases to which aboriginal populations are prone, as well as projects that are population specific and function on community engagement are examples of movements towards addressing indigenous populations health protection. in moving forward, research should be integrated with planning, building capacity, and harmonizing response activities at all levels and across the healthcare system to help develop holistic policies that are context-specific and incorporate indigenous perspectives. pandemic influenza outbreak research modelling the first influenza pandemic of the st century: canada' s response, lessons learned, and challenges ahead public health agency of canada: statement on seasonal trivalent inactivated influenza vaccine (tiv) correlates of severe disease in patients with pandemic influenza (h n ) virus infection critically ill patients with influenza a(h n ) infection in canada statistical methods in medical research canada in the face of the h n pandemic suicide among aboriginal people in canada. ottawa: aboriginal healing foundation health canada: a statistical profile on the health of first nations in canada. ottawa: health canada state of the world' s indigenous peoples the nature of nursing practice in rural and remote canada increased influenza-related healthcare utilization among residents of an urban aboriginal community socioeconomic disparities and the burden of seasonal influenza: the effect of social and material deprivation on rates of influenza infection homeless youth's overwhelming health burden: a review of the literature. paediatr child health the responses of aboriginal canadians to adjuvanted pandemic (h n ) influenza vaccine invasive infections caused by haemophilus influenzae serotypes in twelve canadian impact centers invasive disease due to non-type b strains epidemiology of haemophilus influenzae serotype a invasive bacterial diseases in northern canada invasive haemophilus influenzae disease caused by non-type b strains in northwestern ontario invasive disease caused by haemophilus influenzae type a in northern ontario first nations communities helicobacter pylori infection in canadian and related arctic aboriginal populations canadian helicobacter study group participants: helicobacter pylori in first nations and recent immigrant populations in canada helicobacter pylori infection and the development of gastric cancer age distribution of infection and hospitalization among canadian first nations during the h n pandemic the impact of demographic variables on disease spread: influenza in remote communities situated learning: legitimate peripheral participation communities of practice communities of practice: learning, meaning and identity learning from sars: preparing for the next disease outbreak australian aboriginal and torres strait islander communities and the development of pandemic influenza containment strategies: community voices and community control the pandemic h n influenza and indigenous populations of the americas and the pacific differential effects of pandemic (h n ) on remote and indigenous groups indigenous populations health protection: a canadian perspective the workshop was supported by the canadian institutes of health research (dissemination event grant no. ), national collaborating centre for infectious diseases, mitacs and the centre for disease modelling. the funders had no role in writing this paper or making decision to publish it. the authors would like to thank all the participants for their significant contributions to the workshop. the authors declare that they have no competing interests.authors' contributions kr and sm wrote the first draft of this paper. md, np and jw contributed to the final version. all authors have read the paper and approved it. key: cord- - wbei h authors: langor, david w.; sweeney, jon title: ecological impacts of non-native invertebrates and fungi on terrestrial ecosystems date: - - journal: ecological impacts of non-native invertebrates and fungi on terrestrial ecosystems doi: . / - - - - _ sha: doc_id: cord_uid: wbei h nan since the arrival of europeans about years ago, an estimated , non-native species have been introduced to north america (including hawaii) (pimentel et al. ) . this averages two species every week; however, the rate of entry is generally thought to have been much higher in the last century as the amount of international trade rapidly increased. non-native or exotic species figure prominently in our lives. many of the species that we consume are not native. in urban environments we are inundated by exotic species, especially plants; however, a large proportion of exotic invertebrates are also anthropogenic (langor, unpublished data) . in forestry and agriculture many serious insect and fungal pests are non-native. rivers, lakes and ponds are increasingly becoming breeding grounds for a wide variety of aquatic invaders. marine environments, especially inland waters, have been colonized by a large number of exotic species. since charles elton's seminal book, the invasion ecology of animals and plants, published in , scientific interest in invasions has rapidly increased. however, in canada it is only over the last two decades that invasive alien species (ias) received significant public attention. this attention came about largely because of the incursion of a few highly visible species that had significant impacts on the economy, security and human health. species such as zebra mussel, asian longhorned beetle, sudden oak death, russian wheat aphid, sars, west nile virus caught the media and public attention. the enormous costs of ias in the usa, estimated at $ billion per year caught the attention of the federal administration and resulted in dedicated funding for ias research (pimentel et al. ) . soon after, ias also gained federal attention in canada, again largely because of the economic and health impacts of these species, and eventually resulted in an invasive alien species strategy for canada (environment canada ) . although economic, security and health impacts are deemed newsworthy, the ecological impacts of ias has generally received much less public and scientific attention, despite the fact that ias ranks second to habitat destruction as a cause of species loss. although the ecological impacts of marine, freshwater and plant invaders have received some attention, there is much less available information about the ecological impacts of hyper-diverse groups such as fungi and terrestrial invertebrates. to bring attention to this paucity of information and to encourage a review of the current state of knowledge, the canadian forest service, biological survey of canada and canadian food inspection agency convened a symposium, ecological impacts of non-native invertebrates and fungi on terrestrial ecosystems, held on november , during the joint annual meeting of the entomological society of canada and entomological society of quebec in montreal, quebec. this symposium brought together scientists from the usa and canada to review the state of knowledge in this field of work. most of these papers are contained herein. as well, we have added two papers that were not part of the original symposium. this set of papers represents a crosssection of work on ecological impacts of ias. most are review/synthesis papers, but we have balanced this with three case-studies. although there is a strong focus on canadian work, there is also significant focus on work in the northern usa and europe. david langor and colleagues provide an overview of the diversity of non-native arthropods feeding on woody plants in canada. almost every genus of woody plants hosts non-native species, and in many cases exotic species often exist at high population levels. some plant genera host many exotic species and the potential for significant impacts on native phytophagous insects and mites is high, although this has rarely been documented. langor argues strongly for better investment in taxonomy and improved information management/synthesis to allow ready identification of invasion by exotic species and to learn from the wealth of knowledge about ias that is largely buried in gray reports and restricted databases. marc kenis and colleagues review and synthesize the ecological impacts of invasive alien insects based on primary research publications, mainly from north america, concerning insect species. they show that most research focused on effects of ias on native biodiversity at population or community level. genetic effects and, to a lesser extent, effects on ecosystem services and processes were rarely explored. ecological impacts may occur through simple trophic interactions such as herbivory, predation or parasitism, but also through more complex mechanisms such as competition for resources, disease transmission, apparent competition, or pollination disruption, among others. dylan parry examines the potential for non-target effects among insect parasitoids introduced for biological control in north america. he highlights three techniques, quantitative food webs, life table analysis and experimental populations, to assess non-target effects in different systems. he also explores three methods to ascertain the strength of competitive interactions between native and introduced parasitoids, a potential non-target effect that has received little attention in the literature. switching our focus to another group of invertebrates, jan addison points out that although exotic earthworms are generally considered to be beneficial in agricultural soils, their effects can be less benign in forested ecosystems, where they can significantly alter the forest floor, affecting the distribution of carbon, nitrogen and other chemicals, roots, microbes and other elements of the soil fauna, and even understory vegetation. she summarizes the current distribution of exotic and native earthworm species in canadian forests and draws on the results of studies of invasion patterns and environmental impacts in northern forests in north america and europe to discuss potential outcomes for forests in canada. two papers examine the ecological impacts of non-native fungi. first, judy loo focuses on impacts in forested ecosystems, and reviews several treefungus systems in northern north america. impacts range from functional elimination of abundant tree species to loss of populations or all trees in the larger size classes. she shows that impacts are most significant when highly successful invading pathogens attack foundation species, setting in motion a long-lasting cascade of effects on the host and associated species. such impacts have generally not been well documented at the ecosystem level. amy rossman summarizes the impacts of some exotic fungi on agricultural ecosystems. although agricultural systems are unnatural, usually feature nonnative plant species and impacts by pests are largely economical, the persistence of non-native fungal species in these systems can result in spill-over to native ecosystems, resulting in ecological impacts. rossman also asserts that taxonomic challenges in this group inhibit early detection and identification of non-native species. in addition to review papers, three case studies of non-native insects are included in these proceedings, two from agricultural systems and one forest pest. lloyd dosdall and colleagues report on response of native parasitoid and hyperparasitoid assemblages to invasion by the cabbage seedpod weevil. owen olfert and colleagues describe the impacts of the wheat midge and a successful management program to minimize economic and environmental impacts. using the gypsy moth as a model, jacques régnière and colleagues demonstrate how use of historical data and modeling based on climatic suitability can be used to predict future distribution of this species, providing forest managers with an opportunity to apply early intervention to reduce economic and ecological impacts. to wrap up the proceedings, dan simberloff encourages us to take heart from the many success stories concerning management of ias. using many examples (often unpublished and not widely known) from around the world, he shows that it is possible to eradicate ias or at least to apply management to reduce them to low population levels. we need not be eternally pessimistic about managing ias but take inspiration from the many successes and push forward with optimism to add to these successes. this symposium would not have been possible without support from the canadian forest service and biological survey of canada (terrestrial arthropods). we also thank dr. hugh danks for his encouragement and practical suggestions that helped us through the planning stages. finally, we wish to thank all of the participants in this symposium for contributing to the success of the event and ensuing proceedings. we hope that this set of papers will help inspire others to pursue work on ecological impacts of non-native species. an invasive alien species strategy for canada. www.ec.gc.ca/eee-ias/default.asp?lang=en&n = db acf- environmental and economic costs of nonindigenous species in the united states ecological impacts of non-native invertebrates and fungi on terrestrial ecosystems key: cord- -lbtdex p authors: gilca, rodica; skowronski, danuta m.; douville-fradet, monique; amini, rachid; boulianne, nicole; rouleau, isabelle; martineau, christine; charest, hugues; de serres, gaston title: mid-season estimates of influenza vaccine effectiveness against influenza a(h n ) hospitalization in the elderly in quebec, canada, january date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: lbtdex p background: the / influenza season in canada was characterized by an early epidemic due to vaccine-mismatched influenza a(h n ) viruses, disproportionately affecting elderly individuals ≥ -years-old. we assessed vaccine effectiveness (ve) against a(h n ) hospitalization among elderly individuals during the peak weeks of the / epidemic in quebec, canada. methods: nasal specimens and clinical/epidemiological data were collected within days of illness onset from elderly patients admitted with respiratory symptoms to one of four participating hospitals between november , and january , . cases tested rt-pcr positive for influenza a(h n ) and controls tested negative for any influenza. ve was assessed by test-negative case-control design. results: there were participants including cases ( % vaccinated) and controls ( % vaccinated) included in primary ve analysis. median age was . years, two-thirds were admitted from the community and % had underlying comorbidity. crude ve against a(h n ) hospitalization was - % ( %ci: - % to %), decreasing to - % ( %ci: - to %) with adjustment for age and comorbidity, and to - % ( %ci: - to %) with additional adjustment for specimen collection interval, calendar time, type of residence and hospital. in sensitivity analyses, ve estimates were improved toward the null with restriction to participants admitted from the community (- %; %ci: - to %) or with specimen collection ≤ days since illness onset (- %; %ci: - to %) but further from the null with restriction to participants with comorbidity (- %; %ci: - to %). conclusion: the / mismatched influenza vaccine provided elderly patients with no cross-protection against hospitalization with the a(h n ) epidemic strain, reinforcing the need for adjunct protective measures among high-risk individuals and improved vaccine options. the / influenza season in quebec, as elsewhere in canada, was characterized by an early and intense influenza epidemic due almost exclusively to antigenically-drifted and vaccinemismatched a(h n ) viruses [ , ] . as expected with influenza seasons dominated by a (h n ) subtype activity, the elderly years-old were disproportionately affected by excess hospitalizations and deaths [ , ] . by mid-season in some jurisdictions, the number of longterm care facility (ltcf) outbreaks in / exceeded even the full-season tallies of recent prior seasons, including those also distinguished by dominant, vaccine-mismatched a(h n ) activity, such as / [ , , ] . in response to surveillance signals suggesting suboptimal vaccine performance, several midseason analyses assessed effectiveness of the / influenza vaccine against the a(h n ) epidemic strain. canada's sentinel physician surveillance network (spsn) measured vaccine effectiveness (ve) against medically-attended laboratory-confirmed outpatient a(h n ) illness of - % ( %ci:- - %) overall and % ( %ci:- - %) in non-elderly (< -year-old) adults, indicating little or no vaccine protection even among individuals capable of mounting an effective immune response [ ] . the canadian immunization research network (cirn) assessed ve against influenza a(h n )-related hospitalization, reporting estimates partially adjusted for age and comorbidity of % ( %ci:- - %) in non-elderly adults, substantially lower in elderly adults at - % ( %ci:- - %) [ ] . although canadian mid-season inpatient and outpatient ve findings for the / season have been consistent with null vaccine effects (statistically non-significant and spanning zero) in both age groups, the cirn finding of a lower and negative point estimate of ve against a(h n ) hospitalization in the elderly, more closely broaching statistical significance, warrants further clarification. here we assess ve against a(h n ) hospitalization in the elderly during the peak epidemic weeks of the / season in quebec, canada. this study was conducted under the surveillance mandate of the quebec ministry of health without requirement for institutional review board approval. as part of routine patient care, all patients admitted to hospitals participating in the project with respiratory symptoms are assessed for influenza by per-nasal specimen collection at local laboratory. all patients admitted hours at one of these sentinel hospitals with cough, sore throat, or fever/feverishness of unknown etiology were invited by a research nurse to participate in the study. authors themselves did not have direct contact with patients or access to patient identifying information and no additional samples were collected for the purposes of research. verbal consent was elicited from the patient and/or guardian to test the specimen for influenza and other respiratory viruses at the provincial public health laboratory and to record demographic and clinical information such as influenza vaccination, and date of illness onset on standardized questionnaires. patient charts were also reviewed at discharge to collect information on clinical progress. verbal consent was documented on the questionnaire. capacity to consent was determined by the nurse; the number of patients unable or refusing to give consent was recorded weekly on recruitment files and qualified as exclusions. the annual recruitment period for the quebec sentinel hospital surveillance system, implemented since , spans the peak of the influenza season defined as two consecutive weeks during which at least % of weekly samples from the quebec sentinel laboratory surveillance system test positive for influenza [ ] . for the / season, this threshold was surpassed beginning in week (november - , ) (fig ) . systematic respiratory virus surveillance was then conducted among the four acute-care regional hospitals ( community, academic/tertiary care) serving as sentinel sites and providing care to about % of the quebec population overall. only elderly participants with specimen collection within days of illness onset were eligible for inclusion in primary ve analysis. patients with respiratory symptom onset > hours after hospital admission were considered healthcare-associated and were excluded. elderly individuals in quebec are eligible for publicly-funded trivalent influenza vaccine (tiv). inactivated split or subunit tiv is primarily available for this age group but for the second consecutive season, elderly patients in ltcfs received an mf- adjuvanted subunit tiv. per recommendation of the world health organization, all / tiv retained the same three influenza vaccine antigens as were also used in / , including the a/texas/ / (h n )-like strain [ ] . nasal specimens were tested at the provincial public health laboratory using the luminex rvp fast version- assay which detects influenza a and b and other respiratory viruses. details are presented elsewhere [ ] . influenza a subtypes were confirmed by reverse transcription polymerase chain reaction (rt-pcr) to detect a(h ) and a(h )pdm subtypes where otherwise non-subtypeable by luminex [ , ] . comparison of proportions was by χ or fisher's exact test and for continuous variables was by wilcoxon and kruskal-wallis nonparametric tests. ve was estimated by test-negative case-control design [ ] . patients diagnosed with laboratory-confirmed influenza a(h n ) were considered cases and those testing negative for any influenza were controls. ve was defined as ( -odds ratio)x % for hospitalization with laboratory-confirmed influenza a(h n ) among vaccinated compared to non-vaccinated patients. participants who received the / tiv weeks before illness onset were considered vaccinated. those for whom vaccination timing was unknown or < weeks before onset were excluded but explored in sensitivity analyses as indicator variables. multivariable analyses by logistic regression adjusted for age, underlying comorbidity placing individuals at higher risk of influenza-related complications [ ] , interval between symptom onset and specimen collection ( days, - days), hospital site, epidemic week based on hospital admission date ( - , , and - ), and primary residence (community, ltcf or other institutional/group setting). sensitivity analyses explored ve by type of residence, comorbidity, specimen collection interval, and re-classification of patients with unknown vaccination status as vaccinated or as unvaccinated. during the recruitment period, nasal specimens were collected from elderly patients among whom were eligible for study participation. further inclusion and exclusion criteria as applied to the current data set for the primary ve analysis are shown in the median age of participants was . years and % were years-old (table ) . twothirds were community-dwelling and underlying comorbidity was reported in %. the / tiv was received by % of cases and % of controls, the latter comparable to coverage estimates for quebec elderly overall ( %) [ ] . median age of vaccinated elderly was slightly greater than unvaccinated participants ( . vs. . years; p = . ). a smaller proportion of community-dwelling elderly were vaccinated in / compared to those in ltcf ( % vs. %; p = . ), more comparable to those living in other kinds of institutional/group settings ( %; p = . ). those with underlying comorbidity were more often vaccinated compared to those without ( % vs. %; p = . ). there was also variation in vaccination coverage by hospital site, lowest in hospital a, located in a region that was affected earliest in the epidemic. virtually all who were vaccinated in / reported also receiving tiv at least once in the past ( % overall, % of those for whom this was known). fewer cases than controls had underlying comorbidity ( % vs. %;p = . ) and cases were hospitalized earlier in the epidemic. conversely, vaccinated participants were hospitalized later in the epidemic (table ) . a greater proportion of cases than controls were vaccinated among those admitted to icu ( % vs. %) or dying during their hospital stay ( % vs. %), but sample size was small and differences were not statistically significant (p> . ). specimen inclusion/exclusion criteria for primary vaccine effectiveness analysis. patients whom nurses were not able to approach because of early discharge or other operational considerations (i.e. workload demands during peak weeks of respiratory admissions); symptoms onset > h after hospital admission; exclusions are not mutually exclusive; respiratory syncytial viruses, entero/rhinoviruses, crude ve against elderly a(h n ) hospitalization was - % ( %ci: - to %). when adjusted for age and comorbidity, ve was - % ( %ci: - % to %) and with full adjustment for recognized confounders was - % ( %ci: - % to %)( table ). in sensitivity analyses, fully-adjusted ve point estimates were improved toward the null with restriction to interval from illness onset to specimen collection participants admitted to hospital from the community (- %; %ci: - to %) or with specimen collection days since illness onset (- %; %ci: - to %). conversely, the fullyadjusted ve point estimate varied further away from the null with restriction to participants with underlying comorbidity (- %; %ci: - to %). however, in all analyses confidence intervals spanned the null and were wider as expected with inclusion of more covariates and with subset restriction. this study corroborates earlier outpatient and inpatient findings from canada showing that the / influenza vaccine provided little or no protection against the dominant but vaccine-mismatched a(h n ) strain. here, we report no vaccine protection against the serious outcome of hospitalization with the / antigenically-distinct a(h n ) epidemic strain among elderly citizens of quebec, canada. our ve point estimates against elderly a(h n ) hospitalization for the / season, whether partially-adjusted for age and comorbidity alone (- %; %ci: - % to %) or for a fuller range of potential confounders (- %; %ci: - to %) are similar (within %) of the partially-adjusted ve estimate reported by the cirn hospital-based network (- %; % ci: - to %) [ ] . these ve estimates are substantially lower than cirn estimates for nonelderly adults for / ( %; %ci: - to %). they are also lower than cirn estimates for the elderly for prior seasons including their mid-season / ve against a(h n ) pdm -related hospitalization ( %; %ci: to %) [ ] or as reported by cirn in conference proceedings for the / season also against vaccine-mismatched a(h n ) hospitalization (crude ve = %; %ci: to %) [ ] . our / ve estimates are also lower than mid-season ve estimates against outpatient medical visits reported among younger adults by canada's spsn ( %; %ci: - % to %) [ ] , by the united states (us) ( %; %ci: - to %) [ ] or by the united kingdom overall (- %; %ci: − to %) [ ] . ve estimates specific to the elderly were not separately reported in any of these outpatient studies, but among participants years-old in the us, ve against outpatient a(h n ) illness was % ( %ci: - to %) [ ] . none of these ve estimates are statistically significant and confidence intervals broadly overlap so that it is not possible to conclude whether ve in hospitalized elderly patients is lower than outpatient ve estimates for elderly or non-elderly adults. taken together, however, these results challenge assertions [ , ] that vaccine provides better protection against severe complications than against infection per se, particularly during vaccinemismatched seasons. in fact, even in young adults in canada, point estimates of ve against influenza-confirmed hospitalizations reported by cirn have been consistently lower than estimates against ambulatory illness published by the spsn each season since [ , , , ] . consistent findings of negative ve point estimates in relation to hospitalization outcomes in the elderly during the / season require some explanation. confidence intervals around these negative point estimates are wide and cross the null, but broach statistical significance in some analyses. chance statistical variation, methodological bias, or a true biological phenomenon are among possible explanations. with vaccine coverage of %, our sample of just over participants, approximately equally cases and controls, would have been sufficient to detect a statistically-significant ve of at least % (in either direction of the null), with % power. sample size requirements increase dramatically as ve more closely approaches zero, as illustrated also by cirn's failure to achieve significance despite more than triple the sample size [ ] . in that regard negative ve estimates may reflect statistical variation around a true null effect although we cannot rule out that with additional sample size, ve estimates may have crossed toward statistically-significant negative ve. our study was predicated on the test-negative design, and, as for all observational studies, residual bias and confounding cannot be ruled out. with adjustment for recognized confounders ve estimates were generally reduced but showed greater variability, likely owing to greater sample size requirements to support multiple covariates. it is reassuring, however, that ve estimates were improved toward the null with restriction to more uniform and majority subgroups of participants including those with primary residence in the community, comprising two-thirds of our data set, or among participants with specimen collection days since illness onset, comprising three-quarters of participants. ve was reduced among patients with comorbidity, comprising > % of participants but including a wide variety of conditions, in whom bias related to propensity to vaccinate or to hospitalize likely varies a lot. factors confounding the association between vaccination and hospitalization risk are more complex than for outpatient medical visits, and this requires more in-depth evaluation generally in the interpretation of ve estimates for hospitalization outcomes, especially for seniors. although statistically most consistent with a null vaccine effect overall, it is also prudent to consider whether negative point estimates of ve in the elderly may reflect a true epidemiological finding. in subgroup analysis for the current / season, canada's spsn also reported ve estimates against medically-attended a(h n ) illness that were reduced and slightly negative in patients vaccinated in both / and / (- %; %ci: - % to %) but positive (i.e. protective) in participants who had received only the / vaccine ( %; %ci: - % to %) [ ] . spsn findings in repeat vaccine recipients for the / season were also associated with wide and overlapping confidence intervals, consistent also with null vaccine effects in both subgroups. a number of other recent studies in canada, the united states, and europe have also reported interference from prior receipt of seasonal influenza vaccine [ ] [ ] [ ] [ ] [ ] . while these other studies showed negative interference that sometimes reduces protection (i.e. a lower but still positive ve point estimate), a negative ve estimate would suggest that vaccine interference may sometimes also be associated with increased disease risk. for several decades, the elderly have been a highly and recurrently immunized group, and virtually all of the vaccinated elderly in our study had received tiv in the past. we were not able to stratify by current and/or prior vaccination history and neither has cirn explored these possible influences, which require further evaluation. the most noteworthy precedent of negative ve arose during the spring-summer of , and warrants mention here to highlight differences from the current context. prior receipt of / seasonal vaccine was associated with negative ve against the markedly mismatched pandemic a(h n ) virus, observed predominantly in non-elderly individuals. this observation was reported by canada's spsn and at least four other studies in canada [ ] , subsequently also from hong kong [ ] , the us [ ] and japan [ ] and thereafter also in a randomized ferret trial [ ] . the canadian studies showed statistically significant two-fold increased risk (ve of - %) for medically-attended outpatient a(h n )pdm illness but risk was not increased for hospitalization outcomes. this is different from the current season's finding of lesser magnitude, statistically non-significant and more variable vaccine effects (ve of - %) against a(h n ) hospitalization in the elderly, for which chance variation around the null and/or methodological considerations may be more likely explanations. additional studies are needed to definitively resolve the potential concern of vaccine-associated increased risk and/or to clarify the conditions of vaccine mismatch under which it may recur (e.g. antigenic distances [ ] , immunological cohort effects based on original antigenic prime vs. boost exposures). in fact, the underlying mechanisms and virus-host immunological interactions to explain variability in disease burden and ve by age and influenza subtype require better understanding generally. the reason why elderly people suffer disproportionately from a(h n ) subtype infections, as per the current season [ , ] remains a longstanding but unanswered question. immuno-senescence alone is unlikely to provide the complete explanation since the same exceptional vulnerability is not observed in the elderly in relation to influenza a(h n ) infection. our study has other limitations. a substantial proportion of elderly patients were excluded because they were unable to recall or report important information, such as vaccination status and date of symptom onset. however, their inclusion in indicator sensitivity analyses did not meaningfully alter ve estimates. vaccine status was self-reported and this may have resulted in exposure misclassification; however, this information was collected prior to influenza diagnosis, minimizing differential misclassification. studies in other settings, including hospitalized elderly, have reported consistency between self-reported and registry-based influenza vaccine status although that may not directly apply here [ , ] . we think accuracy of self-reported vaccine status in our study may even be better because information was collected from patients within a shorter period of time since vaccination campaign as compared to the studies cited above. in addition, vaccination coverage in influenza-negative patients enrolled in our study was consistent with that reported from other sources during previous years of the study [ , ] . our study was conducted during peak weeks of the influenza season; this may raise concerns about the particular impact of outcome misclassification (i.e. false negative cases) on our ve estimates. we have previously shown that other respiratory viruses remain an important cause of respiratory hospitalization even during peak weeks of the influenza epidemic [ ] . the assay we used for influenza diagnosis has been reported elsewhere to have sensitivity > % ( % for influenza a virus), with comparable proportions testing respiratory virus positive as per individual nucleic acid amplification testing across age groups [ ] . even with sensitivity for influenza detection as low as %, in the context of near-perfect specificity, outcome misclassification has been shown to have negligible impact on ve estimates [ ] . although test sensitivity may be lower in elderly adults, it is unlikely to drop below %. finally, in the test-negative study design, when patients with influenza are not censored and can also contribute as controls during another respiratory illness episode, the odds ratio directly estimates the relative risk and is not affected by the rare disease assumption [ ] . in conclusion, we report negative point estimates that are statistically non-significant for ve against a(h n ) hospitalization in the elderly for the / season. our findings are consistent with other outpatient and inpatient studies from canada, indicating little or, as here, no vaccine protection against the dominant but vaccine-mismatched a(h n ) epidemic strain. these findings reinforce the need for adjunct measures to protect high-risk individuals, including the elderly, from serious influenza outcomes during vaccine-mismatched seasons and for improved vaccine options over the long-term. public health agency of canada interim estimates of / vaccine effectiveness against influenza a(h n ) from canada's sentinel physician surveillance network influenza-associated hospitalizations in the united states mortality associated with influenza and respiratory syncytial virus in the united states low - influenza vaccine effectiveness associated with mutation in the egg-adapted h n vaccine strain not antigenic drift in circulating viruses interim estimates of / influenza vaccine effectiveness in preventing laboratory-confirmed influenza-related hospitalization from the serious outcomes surveillance network of the canadian immunization research network other respiratory viruses are important contributors to adult respiratory hospitalizations and mortality even during peak weeks of the influenza season recommended composition of influenza virus vaccines for use in the - northern hemisphere influenza season. geneva: world health organization evidence of viremia in cases of severe pandemic influenza a h n / real-time rt-pcr (rrt-pcr) protocol for influenza; revised the test-negative design: validity, accuracy and precision of vaccine efficacy estimates compared to the gold standard of randomised placebo-controlled clinical trials national advisory comittee on immunization. statement on seasonal influenza vaccine for enquête québécoise sur la vaccination contre la grippe saisonnière et le pneumocoque interim estimates of / influenza clinical severity and vaccine effectiveness in the prevention of laboratory-confirmed influenza-related hospitalisation effectiveness of / seasonal influenza vaccines in the prevention of influenza-related hospitalization in canadian adults: a public health agency of canada/canadian institutes of health research serious outcomes surveillance network study. option for the control of influenza early estimates of seasonal influenza vaccine effectiveness-united states low effectiveness of seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the united kingdom: / mid-season results influenza-the need to stay ahead of the virus cochrane rearranged: support for policies to vaccinate elderly people against influenza interim estimates of / vaccine effectiveness against influenza a(h n )pdm from canada sentinel surveillance network impact of repeated vaccination on vaccine effectiveness against influenza a(h n ) and b during seasons influenza vaccine effectiveness in the community and the household influenza vaccine effectiveness in the - season: protection against each circulating virus and the effect of prior vaccination on estimates / influenza vaccine effectiveness against hospitalised influenza a(h n )pdm , a(h n ) and b: estimates from a european network of hospitals association between the - seasonal influenza vaccine and pandemic h n illness during spring-summer : four observational studies from canada seasonal influenza vaccine and increased risk of pandemic a/h n -related illness: first detection of the association in british columbia protective efficacy of seasonal influenza vaccination against seasonal and pandemic influenza virus during the in hong kong clinical and epidemiologic characteristics of an outbreak of novel h n (swine origin) influenza a virus among united states military beneficiaries association between seasonal influenza vaccination in - and pandemic influenza a (h n ) infection among school students from kobe randomized controlled ferret study to assess the direct impact of - trivalent inactivated influenza vaccine on a (h n )pdm disease risk variable efficacy of repeated annual influenza vaccination validity of self-reported influenza and pneumococcal vaccination status among a cohort of hospitalized elderly inpatients evaluation of self-reported and registrybased influenza vaccination status in a wisconsin cohort comparison of the luminex xtag respiratory viral panel with in-house nucleic acid amplification tests for diagnosis of respiratory virus infections methodologic issues regarding the use of three observational study designs to assess influenza vaccine effectiveness we thank the quebec ministry of health (ministère de la santé et des services sociaux du québec) for providing financial support for this surveillance project. we are grateful to all participating hospitals and the molecular biology unit at quebec public health laboratory (laboratoire de santé publique du québec) for their dedication and strenuous effort during the peak of influenza season. key: cord- -yqcc iv authors: reitmanova, sylvia title: “disease-breeders” among us: deconstructing race and ethnicity as risk factors of immigrant ill health date: - - journal: j med humanit doi: . /s - - - sha: doc_id: cord_uid: yqcc iv race and ethnicity are well-established epidemiological categories that relate to the patients’ risk of exposure and their susceptibility/resistance to disease. however, this association creates the notion that factors other than a personal identity need not be held responsible for patients’ health problems. this work deconstructs the notion of race and ethnicity as risk factors for immigrant ill health, which is prevalent in current medical research and practice, by tracing its roots in canadian history. the understanding that medical knowledge is subject to diverse historical, social, cultural and political influences can change the way health professionals perceive their patients as a health threat. therefore, in this work i would like to deconstruct the notion of race and ethnicity as risk factors for ill health and, as well, elaborate on the relevance of these epidemiological categories to medicine and society. by the end of this article, readers should be able to understand to what degree someone's race and ethnicity can be associated with his or her ill health. they should also be able to trace the roots of the thought processes that led the physician examining my daughter to suspect a foreign origin of her condition prior to considering other options. race and ethnicity in epidemiology: a double-edged sword race and ethnicity are, indeed, long and well-established epidemiological categories defining patients' characteristics in company with other important categories such as age, sex, socio-economic status, marital status, lifestyle, etc. these factors are important in two regards: they relate to the patient's risk of exposure and his/her susceptibility/resistance to disease. the role of epidemiologists is therefore to search for the existing associations between these particular categories and specific diseases in order to determine the risk factors. some results of this epidemiological quest are well-known. for instance, old age is associated with a higher risk of cardiovascular disease, a sex worker's occupation with a higher risk of sexually transmitted disease, and a smoker's lifestyle with cancer. the purpose of epidemiological categories such as a patient's ethnicity and race can be understood in a similar way. for example, while canadian aboriginals are found to be at a higher risk of drug abuse-related health problems, immigrants are associated with a higher risk of developing tuberculosis than their non-aboriginal counterparts. although social scientists argue that race and ethnicity are social and not biological constructions , , and therefore irrelevant as epidemiological variables, the establishment of associations between one's race or ethnicity and specific health problems represents a useful medical concept. for example, if aboriginal people are found to be at a higher risk of contracting hiv than other groups in canada, then public health efforts can be directed towards aboriginal communities. linking one's race or ethnicity and a specific health problem can attract more resources with which to address a broader range of health-relevant problems in that particular community. furthermore, without recognizing race or ethnicity, scientists, researchers, decision makers and service providers cannot truly identify those who are the most disadvantaged and the most deserving of their help. however, despite the advantages of this approach, establishing an association between race or ethnicity and a specific health problem represents a double-edged sword because the association itself creates the notion that factors other than a person's racial or ethnic identity need not be held responsible for his or her health problems. as a result, it is often someone's personal agency that is blamed for his/her final health outcomes rather than the social environment in which these health outcomes are embedded. , the single association between a patient's race or ethnicity and health may not reveal other important factors shaping his or her risk of exposure or susceptibility to disease. for instance, it is well established that tuberculosis is a social disease affecting largely those at the bottom of the social ladder. in fact, some authors consider tuberculosis as a penalty for "ruthless exploitation" of the poor in capitalist economies. , for this reason, establishing that being an aboriginal or a third world person is per se a risk factor for developing tuberculosis ignores large socio-economic and political forces which frame the life chances and health of these people. linking personal health with one's race or ethnicity is a very old concept in western societies. in fact, the understanding of the health of immigrants has always been dominated by the sick-immigrant paradigm which assumed that it is sickness that leads people of diverse races and ethnicities to leave their homelands and seek a new life in another country. adhering to this ideological framework, immigrants were often suspected as reservoirs or vectors of many diseases and for that reason were assumed to pose a health threat to residents of their recipient countries. as hall writes: statistics in the united states show that the foreign-born 'furnished two and one-third times their normal proportion of [the] insane. they have been the cause of epidemics and of the spread of much infection…favus and trachoma were practically unknown in the united states before the immigration from southern and eastern europe…. probably the worst effect of immigration upon the public health is not the introduction or spread of acute diseases, but of large numbers of persons with poor physique who tend to lower the general vigor of the community. ' similar assumptions about immigrant ill health formed the basis for compulsory medical assessment of all immigrants entering canada. the purpose of this assessment was to select only the fit and the desirable. as a result, the canadian immigration regulations debarred from canada, among others, the following immigrants: . idiots, imbeciles, feeble-minded persons, epileptics, insane persons, and persons who have been insane at any time previously. . persons afflicted with tuberculosis or any contagious or infectious disease. . persons who are dumb, blind, or otherwise physically defective, unless security is given against such persons becoming a public charge in canada. . persons over years of age who are unable to read. . persons who are guilty of any crime involving moral turpitude; persons seeking entry to canada for any immoral purpose. . beggars, vagrants, and persons liable to become a public charge. . persons suffering from chronic alcoholism or the drug habit, and persons of physical inferiority whose defect is likely to prevent them making their way in canada. government reports documented the following health causes for deportation of immigrants from canada: tuberculosis, rheumatism, insanity, failing eyesight, physical and mental weakness, epilepsy, heart disease, varicose veins, leg ulcer, empyema, deafness, dumbness, twisted neck and head, old age, lost eye and thumb, pregnancy, immorality, vicious tendencies, alcoholism, chronic dysentery, diabetes, bright's disease, skin ulcer and abscess, malformations, frost bites, lead poison, and bad character. unfortunately, these records did not show how such assessments were made and to what degree they were objective and justified, taking into account that "immigrants [were] examined in groups often of , and over, and as many as , have arrived in a single day." besides being barred from entering the country, fear of immigrants also led to "campaigns against immigrant-run street markets and fruit stalls, which were condemned as germ-ridden threats to the public health. the fear of uncleanly foreigners has also been extended to imported foodstuffs." in canada, for instance, the august edition of the calgary herald appealed to canadians to boycott chinese laundry businesses as they were considered "nests of disease." for such reasons, immigrants were often subjected to surveillance, detention, or isolation. the notion of immigrants posing serious health problems and threats, however, varied significantly across race and class lines. reading woodsworth's description of characteristics and traits of various immigrant racial and ethnic groups, one can easily realize that the more closely immigrants resembled the white british living in canada and the closer their country of origin was in geographic proximity to britain, the more positive characteristics they were attributed. on the contrary, those with "brown skins," "bad characters" and "peculiar customs," such as levantines and orientals (defined at that time as chinese, japanese and hindus) appeared to be those whom canada least desired to embrace. these groups of immigrants, often seen as health and economic threats to canadians, were attributed the most negative features among all immigrants. as woodsworth noted: "whether it is in the best interests of canada to allow them to enter in large numbers is a most important question, not only for the people of british columbia, but for all canadians." similar sentiments appeared in a editorial in the vancouver sun: the attitude of the people on the coast, undoubtedly, is that we do not want east indians at all, but if we are to have them, or at least some of them, it shall be the men only, because we do not want a permanent colony of them, and one which would increase as a natural result of families being located here. this inconsistency in canadian selective attitudes and behaviours toward immigrants (on one hand, the white settlers from western europe were welcomed to this country and, on the other hand, asian immigrants were coerced to comply with various restrictions and taxes) can be explained only on the premises of racial discrimination. unfortunately, these sentiments were not exclusive to canada. for instance, the californian vallejo daily independent of published the following news piece under the title, "still they come": thirteen hundred and nine more chinamen arrived in san francisco yesterday to spread pestilence [bubonic plague] and take the bread from the mouths of our poor people. seriously, what is to be done with these creatures? the immigration is assuming frightful proportions with the prospect that, a few years hence, they [the chinamen] will swarm upon our coast like the locusts of egypt. another american newspaper, the modoc independent of , reported in a similar spirit that [t]here was no division in judgment in california as to the evil effects of chinese immigration…. it was the slave class that was shipped to this country-the lowest class of china's teeming millions. virtue was unknown to them. in a word, their habits, manners, customs, language, morality and religion constituted a system incompatible with civilization in this country. the two could not exist together, and it had been truly said that "we must conquer, be conquered or exclude them." this kind of negative reporting in newspapers coincided not only with certain attitudes toward "unscrupulous, lying, and treacherous chinamen," but also with serious actions taken against them. for instance, about , chinese immigrants were placed in quarantine, and all chinatown was burned down after only two cases of bubonic plague were discovered in hawaii in . fear of this plague led also to implementing quarantine laws in san francisco which did not apply to the houses of non-asians. incidents of violence against chinese immigrants were present in canada, as well. in , an alcohol-fuelled mob rioted in calgary's chinese district after an outbreak of smallpox was linked to a laundry business run by chinese people, although only four deaths from smallpox were reported. the calgary herald condemned the riot, but it also advised canadians to avoid sending their laundry to the chinese businesses so that they "may render the stay of chinamen in calgary useless and, in a short time, without violence, without any interference with personal liberty, … rid of what the majority regard as an obnoxious element." despite the fact that contemporary western societies, proud of their democracy, law and human rights charters, proclaim their concerns about world peace, justice and equality, many studies document that north americans believe that immigrants have been and continue to be a health threat. the passage of time between the last century and this one has not changed the notion of immigrants as "disease-breeders." in fact, tomes drew a parallel between the atmosphere of germ panic in north america that surrounded the immigration from southern and eastern europe at the beginning of the twentieth century and the one that surrounded the immigration from the third world at the end of the millennium: the association of immigration and infectious disease has intensified scrutiny of national border crossings, from ellis island inspection lines to detainment camps for haitian immigrants. as historians have noted, fears of racial impurities and suspicions of immigrant hygiene practices are common elements in both periods. recent research provides sound evidence that negative health discourses about immigrants are readily present in the western world even today, , , , whether they concern the ebola virus of black africans, the sars of the chinese, or the overreproduction of latinas, which all threaten in different ways the highly regarded and healthy bodies of white canadians, britons, or americans respectively. in addition, studies showed that more attention is paid to these assumed health risks rather than to the actual health issues of immigrants suffering from trauma, torture, malnutrition and physical violence endured in the past. moreover, immigrants' negative health images are as frequent as the images of immigrants posing threats to the safety, economic stability and cultural traditions of the native-born populations. , this negative representation of the "other" (a social construct implying immigrants' presumed or real physical, psychological and behavioural differences) can be traced to the enlightenment period, during which europe embraced the concepts of biological determinism and social darwinism. scientists of that era believed that people's minds, qualities and abilities (which were presumed to be as different as were their languages) were biologically determined. all these assumed differences had to be classified in some way. as a result of these classification efforts, carl linne first classified human races into four categories based on their physical differences. he also linked these different physical characteristics to different cultural, behavioural and moral traits. other scientists modified and advanced his classification; however, they always maintained the same organizing principle-namely, the hierarchy of races. it was the scientific and technological advancement and industrial prosperity of europe during that historic era which led scientists to a belief (which they empirically evidenced, for instance, by measuring people's skulls) that the white race was naturally and inherently superior to all other races. by maintaining this discourse of "the inferior other" in both scientific and public realms over several centuries, a non-white personal identity acquired a wide range of negative associations, connotations and meanings. said in his influential work on orientalism explained that "degenerated" and "uncivilized" non-white races were framed identically to the other undesirable elements in western societies such as criminals, the mentally ill, the poor, women, etc…. one may wonder why it is important that health professionals talk about this "othering" discourse today. as said noted, the construction of personal identity permeated by "othering" discourse is highly relevant to many political issues such as immigration, criminal law, foreign policies, and education, since those today deemed different and inferior experience profound inequalities in economic status, housing, health, education, criminal justice, and the labour market. the concept of "othering" serves as the boundarymaintaining mechanism that leads to the preservation of social distance and hierarchy between various groups in society. one of the efficient means of maintaining a socially stratified society with the white race on top of the social hierarchy is to feed continuous fear of and prejudice towards the "others." one way to feed this fear is to represent the "other" as a threat to health. for instance, by constructing immigrant personal identity as a tuberculosis threat, tuberculosis management and policies tend to focus on restricting immigration and surveying immigrants rather than on addressing the broad social, economic and political reasons which foster tuberculosis within the immigrant population. to avoid designing health policies and clinical practices operating on the premises of the "othering" discourse, we need to implement several changes in our medical, nursing or science school curricula. these curricula need to challenge the notion that disease is purely a biological entity residing in a depersonalized human body. future health professionals and service providers need to know that medical knowledge is subject to diverse historical, social, cultural and political influences. they need to reflect on how history, economy and politics-as well as their own personal biases and prejudices-can affect many health conditions, clinical practices, health policies and research, and even the structure of health organizations. , until our medical schools are ready to introduce such an educational approach, the query, "have you been abroad recently?" is likely to continue topping the list of diagnostic questions posed when addressing the health problems of our visibly different immigrant patients. mausner and others risk factors for elevated hiv incidence among aboriginal injection drug users in vancouver public health agency of canada, canadian tuberculosis standards. (public health agency of canada rethinking the color line the anatomy of racism: canadian dimensions infections and inequalities the white plague: tuberculosis, man, and society black labor: tuberculosis and the political economy of health and disease in south africa the health of immigrants and refugees in canada strangers within our gates canada-the new homeland (colonization and immigration; government of canada strangers within our gates the making of a germ panic, then and now in our opinion: more than years of canadian newspaper editorials power, medical knowledge, and the rhetorical invention of "typhoid mary strangers within our gates ibid our opinion: more than years of canadian newspaper editorials the anatomy of racism: canadian dimensions still they come congressmen berry and page on the chinese question the chinese as medical scapegoats in san francisco in our opinion: more than years of canadian newspaper editorials the making of a germ panic, then and now opinion discourse and canadian newspapers: the case of the chinese "boat people constructing a discursive crisis: risk, problematization and illegal chinese in canada when ebola came to canada: race and the making of the respectable body sars and new york's chinatown: the politics of risk and blame during an epidemic of fear when ebola came to canada: race and the making of the respectable body representations of sars in the british newspapers a glass half empty: latina reproduction and public discourse guest media lens alert: asylum and immigration. comparing the daily telegraph, the guardian and the independent opinion discourse and canadian newspapers: the case of the chinese "boat people constructing a discursive crisis: risk, problematization and illegal chinese in canada the anatomy of racism: canadian dimensions rethinking the color line: readings in race and ethnicity the anatomy of racism: canadian dimensions saving the empire: the politics of immigrant tuberculosis in canada eradicating essentialism from cultural competency education the health of immigrants and refugees in canada a glass half empty: latina reproduction and public discourse illness and medicine in canada risk factors for elevated hiv incidence among aboriginal injection drug users in vancouver the white plague: tuberculosis, man, and society. london: v. gollancz, . eichelberger, laura eradicating essentialism from cultural competency education government of canada. eastern canada. canada -the new homeland. colonization and immigration: government of canada opinion discourse and canadian newspapers: the case of the chinese "boat people power, medical knowledge, and the rhetorical invention of "typhoid mary constructing a discursive crisis: risk, problematization and illegal chinese in canada the anatomy of racism: canadian dimension. montreal: harvest house when ebola came to canada: race and the making of the respectable body congressmen berry and page on the chinese question black labor: tuberculosis and the political economy of health and disease in south africa public health agency of canada. canadian tuberculosis standards. public health agency of canada guest media lens alert: asylum and immigration. comparing the daily telegraph, the guardian and the independent saving the empire: the politics of immigrant tuberculosis in canada sellar, don. in our opinion: more than years of canadian newspaper editorials the making of a germ panic, then and now the chinese as medical scapegoats in san francisco, - representations of sars in the british newspapers strangers within our gates key: cord- -bejrttyk authors: rozmus, jacob; junker, anne; thibodeau, melanie laffin; grenier, danielle; turvey, stuart e.; yacoub, wadieh; embree, joanne; haddad, elie; langley, joanne m.; ramsingh, rose marie; singh, veeran-anne; long, richard; schultz, kirk r. title: severe combined immunodeficiency (scid) in canadian children: a national surveillance study date: - - journal: j clin immunol doi: . /s - - - sha: doc_id: cord_uid: bejrttyk purpose: severe combined immune deficiency (scid) is universally fatal unless treated with hematopoietic stem cell transplantation (hsct). following the identification of disseminated bacille calmette-guérin (bcg) infections in canadian first nations, métis and inuit (fnmi) children with unrecognized primary immune deficiencies, a national surveillance study was initiated in order to determine the incidence, diagnosis, treatment and outcome of children with scid in canada. methods: canadian pediatricians were asked to complete a monthly reporting form if they had seen a suspected scid case, from to , through the canadian paediatric surveillance program (cpsp). if the case met cpsp scid criteria, more detailed data, including demographics and clinical information about investigations, treatment and outcome was collected. results: a total of cases of scid were confirmed for an estimated incidence of scid in non-fnmi canadian children of . per , live births ( % ci to . / , ). the proportion of scid cases that were fnmi ( . %) was almost three times higher than was expected on the basis of proportion of the pediatric population estimated to be fnmi ( . %) resulting in an estimated incidence of . per , live births ( % ci . to . / , ) in fnmi canadian children. the mean age at diagnosis for all scid cases was . months (range – days). there were deaths ( %; % ci – %); seven died of confirmed or suspected infections before they could receive an hsct. conclusions: the frequency of scid cases in fnmi children is higher than in the general canadian pediatric population. the high mortality rate, due primarily to infection, suggests that early diagnosis by newborn screening followed by hsct could significantly benefit children with scid. severe combined immunodeficiency (scid) is a rare primary immune deficiency caused by genetic mutations resulting in severe deficiencies in both cellular and humoral immunity. scid patients are susceptible to serious infections and will typically die before year of age if immune function is not restored through allogeneic hematopoietic stem cell transplantation (hsct), enzyme replacement or gene therapy [ ] . scid is a pediatric emergency and early diagnosis is essential in order to initiate life-saving therapies and avoid severe infections and organ toxicity. in , public health authorities became aware of a number of cases of vaccine-associated disseminated bcg mycobacterial infection reported through the impact (immunization program monitoring active) surveillance network [ ] . eight of the nine cases identified were in first nations, métis and inuit (fnmi) children and seven of those children had an underlying genetic immune deficiency ( scid, interferon gamma receptor deficiency and uncharacterized) [ ] . disseminated bcg disease is a rare but devastating complication of bcg vaccination in severely immune compromised infants. this lead to a reevaluation of routine bcg vaccination practices in first nations and inuit communities. at the time, the frequency of scid in canada was unknown and health canada's first nations and inuit health branch (fnihb) initiated a national surveillance study in collaboration with the canadian pediatric society and pediatric academic centers across canada. acquiring this information was crucial to public health policy decision-making regarding the continued use of bcg vaccination in first nations communities and the need for scid newborn screening in canada. this study used the framework of the canadian paediatric surveillance program (cpsp), in which data are gathered from over , canadian paediatricians and paediatric subspecialists each month. the objectives of this study were to determine: ) the incidence and type of scid in the canadian fnmi and general populations; ) the incidence of disseminated bcg disease in scid patients; ) the average time delay to diagnosis; ) known risk factors and initial clinical presentations; ) whether patients received a hsct or gene therapy; and ) the causes of any deaths. potential cases were identified through the cpsp from april , to march , . a collaboration of the canadian paediatric society and the public health agency of canada, this program maintains monthly contact with more than , paediatricians and paediatric subspecialists in a two-tiered reporting system [ ] . the physician indicates that they have seen the disease in the last month or submits a "nil report". in follow-up, the cpsp sends a detailed data collection form for reporting physicians to complete. the detailed reporting form for a scid case is available online at the canadian paediatric society website [ ] . in almost all cases, the information provided in the reporting form was incomplete due to absence or lack of reporting. when the data were insufficient to make a definitive diagnosis the study investigator requested additional information, if available, from the cpsp who mediated requests to reporting physicians. however because of incomplete reporting of all the demographic and clinical variables, results do not equal the total number of reported cases in all analyses. ethical approval for this national study was obtained from the health canada research ethics board and research ethics board at iwk health centre in halifax, canada. this study was preformed in accordance with the declaration of helsinki and its later amendments. the cpsp case definition for scid was any child less than years of age with the clinical features of scid (including chronic diarrhea, recurrent pneumonia, failure to thrive, persistent thrush, and opportunistic infections) and at least one of the following: ) an absolute lymphocyte count of less than / mm or less than % cd + t cells, ) familial history of primary immunodeficiency. infants with hiv infection or cystic fibrosis were excluded. this case definition for scid was less specific than the diagnostic criteria for scid put forth in by pagid (pan-american group for immunodeficiency) and esid (european society for immunodeficiencies) and updated in , which requires additional criteria such as engraftment of trans-placental-acquired maternal t cells, a definitive genetic mutation or decreased proliferative responses to mitogens [ ] . this was done in order to capture as many cases as possible. two central study investigators (jr and aj) reviewed each cpsp case report to determine if it was a definitive or probable case of scid based on pagid/esid criteria. the average annual national reporting rate during the study period for the initial questionnaire was . %±sd . % and the average annual number of participants was ±sd . the completion rate for the detailed scid questionnaire was %. the cpsp received suspected scid case reports. of these were either duplicates or excluded according to the cpsp case definition. a total of cases met the cpsp case definition for scid during the study period ( to ). of the cases meeting the cpsp case definition for scid, ( %) fulfilled esid criteria for definitive or probable scid or x-linked scid. evidence of deficient ada catalytic activity and/or causative genetic mutations were identified in of the cases: adenosine deaminase (ada) deficiency (n= ), gamma chain deficiency (n= ) and rag deficiency (n= ). there were also cases each of zap and mhc class ii mutations. zap and mhc class ii deficiencies are not considered classical scid [ ] but in all four cases, the patients presented with clinical findings of typical scid. the remaining of cases were assigned per esid diagnostic criteria as probable scid (n= ), definitive x-linked scid (n= ), probable x-linked scid (n= ) and possible x-linked scid (n= ). of the remaining of that did not fulfill esid criteria but fulfilled the cpsp case definition, three were transplanted for presumed scid, two were waiting for transplant and two had passed away. we included all cases in our calculation of incidence. of the confirmed cpsp cases, seven were fnmi children, a disproportionate number ( . %; % ci . - . %) given that fnmi children represent . % of the total canadian pediatric population based on the statistics canada census of the - age group [ ] . this larger proportion is likely to introduce a bias in our incidence calculation and we therefore calculated the incidence in fnmi and non-fnmi canadian children separately. during the study period ( to ) , , live births were recorded in canada [ ] ; of patients were born in canada. if we predict that . % of those live births were fnmi children, the estimated incidence of scid in fnmi and non-fnmi canadian children is . per , live births ( % ci . to . / , ) and . per , live births ( % ci to . / , ) respectively. for the entire cohort, the mean age at diagnosis was days (mean . months; range - days) based on of cases reporting date of diagnosis or time of onset of clinical manifestations of scid. a commonly applied test for diagnosis of scid is the absolute lymphocyte count (alc) with an alc of < /mm as potentially pathogenic in early infancy [ ] . at risk populations can also be identified by evaluation of risk factors including a family history of scid and/or infant deaths and consanguinity. we evaluated whether the alc met this criteria in the canadian scid population. the mean alc at diagnosis was /mm (median: /mm ; range: - , /mm ), ( of confirmed cases). important clinical clues such as family history of scid, infant death and/or consanguinity were present in of cases ( %) reporting on family history. specifically in the fnmi cohort of patients, of had a positive family history and/or consanguinity ( %). among cases with no relevant family history and a reported alc, eight had an alc< /mm . screening with both the alc and risk factors properly identified of the confirmed cases ( %). the three most common presenting clinical manifestations were: interstitial pneumonia ( %), failure to thrive ( %), and a persistent bronchiolitic-like illness ( %) (table i ). in of the scid cases, one or more infections had been diagnosed at the time of reporting, including bacterial, viral and fungal pathogens (table ii) . no patients reported in this series were given bcg and the study did not capture any cases of disseminated bcg infection. of the patients with recorded information, patients received a hematopoietic stem cell transplantation (hsct), two received enzyme replacement therapy for ada scid and one was referred for gene therapy. of the patients who were transplanted, had no family history ( %). there was no statistical difference in average days to diagnosis between bmt patients with a family history and those without, versus days respectively. those without a family history were identified due to clinical features of scid. among the transplant patients, there was a fatal outcome in three ( %) due to gvhd (n= ) and respiratory failure (n= ). the donor sources for the transplant were matched unrelated (n= ), matched sibling (n= ), haploidentical related (n= ) and unknown (n= ). there was a mortality rate of % ( / cases) in the entire scid population. detailed information on each death is provided in table iii . the mean age at diagnosis based on / cases was days ( . months). four patients died before they could be referred for hsct and another three patients died while waiting for a hsct. infections were the confirmed cause of death in four cases (disseminated cmv (n= ), h n influenza a (n= )) and highly suspected in another cases (ards (n= ), respiratory failure (n= ) and encephalitis (n= )). this is the first national study in canada to estimate the incidence of scid. based on the study results, an observed incidence rate of . in , live births is reported in the canadian non-fnmi population, which is consistent with previous studies from the us and france [ , ] . the disproportionate higher estimated incidence of fnmi scid cases, . in , live births, suggests that there is a skewed distribution of scid in canada. this may be due to founder effects caused by ancestral mutations in certain aboriginal populations similar to the high frequency of t-b-scid among athabascan-speaking native americans [ ] . in our fnmi cohort, we did not find a higher incidence of positive family history and/or consanguinity compared to the larger group, although the numbers are small. in order to calculate the incidence among fnmi children we estimated the number of fnmi births based on the fnmi percentage of the canadian pediatric population using census data that reported the number of people stating aboriginal identity among different age groups, as there are no complete statistics on birthrates among fnmi peoples of canada. we could not comment on the incidence of disseminated bcg infection, as none of the patients reported in this study were administered bcg vaccine. this could be due to the fact that the use of bcg vaccine, even in first nations communities, has gradually been discontinued across canada in the last years and replaced with enhanced tuberculosis screening and control services. for example, the routine use of bcg was [ ] . hematopoietic stem cell transplantation (hsct) performed early before significant infections have developed has been shown to result in the optimal survival for a majority of scid infants. in one series of scid patients, those receiving a transplant before days ( . months of age), have a survival rate of % compared to % for those who received transplants when they were . months or older [ ] . the average days at diagnosis in the current report for the confirmed cases was days ( . months of age), despite positive risk factors and characteristic clinical signs in many instances. the average days at diagnosis for those patients that died was even shorter at days. seven patients died of infections before they could receive an hsct. thus, earlier diagnosis followed by hematopoietic stem cell transplantation could potentially decrease the mortality in our population. it is well established that neonatal diagnosis of scid leads to significantly improved survival outcomes [ ] . diagnosis at birth could prevent the almost certain life-threatening infections and end-organ damage, thus improving transplant outcome. in our report, survival after transplant was % ( / cases). however, key risk factors such as family history of scid and infant death and consanguinity were only present in half of the reported cases. this has been the impetus for establishing neonatal screening programs for scid. the first public health program to establish screening was in the state of wisconsin, usa in . currently, half of all births in the united states are being screened for scid as part of pilot or established state newborn screening programs. the standard approach for scid screening is testing for t-cell receptor excision circles (trecs), a dna biomarker of normal tcell development. they can be measured in dna isolated from the dried bloodspots already collected for newborn screening [ ] . trec screening will not detect primary immunodeficiencies in the differential diagnosis of scid such as zap and mhc class ii and certain cases of ada deficiency, but it does have the potential to detect other scid-related and t lymphopenic disorders not captured in this study [ ] . universal screening for scid has been predicted to be a cost effective means to improve quality and duration of life for children with scid [ ] , but currently there is only one provincial neonatal screening program for scid in canada in ontario. we believe that scid fulfills requirements for addition to newborn screening panels in canada. these criteria include: ) scid is fatal, often in the first year of life; ) newborns with scid usually appear healthy at birth; ) our estimated incidences support screening; ) diagnostic testing is well-established; ) curative treatment exists and earlier treatment leads to better outcomes; and ) lastly there is a cost-effective and accurate screening tool. there are several limitations to this national surveillance study. investigators had no control over how the original data were collected and we acknowledge that some scid cases may have been missed because of the exclusion criteria and general rate of participation in the cps surveillance program. we do not know the exact fraction of the canadian infant population that was captured by this surveillance study or the percentage of canadian pediatricians and pediatric subspecialists represented in this study but we are encouraged by the national reporting rate of % and high number of duplicate reports. the inclusion criteria we used was not as vigorous as those used by pagid or esid and in particular the use of an alc< /mm may have failed to capture patients with maternal t cell engraftment. this could also explain why our fraction of ada deficiency cases was higher then expected. in contrast to other forms of scid, maternal lymphoid engraftment is not observed with ada deficiency [ ] . another possibility is the existence of founder mutations for ada deficiency and zap scid in canadian old colony mennonite populations. unfortunately, this study did not capture any information about ethnicity beyond fnmi status. the use of a fixed alc can also be problematic as the normal lymphocyte range is very age dependent. we believe that the current diagnostic criteria set forth by the primary immune deficiency treatment consortium (pidtc) as part of their prospective scid study is the most rigorous description to date and should be employed in future studies [ ] . the reporting form often had missing data in certain categories. because of the many variables involved in the analysis, each with data missing for a number of cases, this can lead to biased results. information reporting tends to favor interesting and unusual results rather then normal ones. this study further highlights the need for canadian centers to register their primary immunodeficiency patients in registries such as the north american united states immunodeficiency network (usidnet) and participate in multi-center scid studies as part of the pidtc in order to acquire more comprehensive data. this national cohort study provides the first report on the incidence and outcome of scid patients in canada. it provides evidence that the incidence is comparable to other national studies, but there is a higher percentage in the first nations, metis and inuit pediatric population. it is clear based on recorded deaths, the majority due to infectious complications, that early identification of scid is critical to improved survival. we argue that the results of this study provide compelling evidence that the case for universal scid newborn screening in canada needs to be a high priority for public health decision markers in canada. severe combined immunodeficiency (scid): from molecular basis to clinical management serious adverse events associated with bacille calmette-guérin vaccine in canada a fresh look at an old vaccine: does bcg have a role in st century canada? the canadian paediatric surveillance program: celebrating years of successful paediatric surveillance pan-american group for immunodeficiency, and esid, european society for immunodeficiencies. diagnostic criteria for primary immunodeficiencies primary immunodeficiency diseases: an update on the classification form the international union of immunological societies expert committee for primary immunodeficiency table - -live births, by birth weight and sex, canada, provinces and territories, annual, cansim (database) aboriginal identity population by age groups, median age and sex, counts for both sexes, for canada, provinces and territories - % sample data (table) why newborn screening for severe combined immunodeficiency is essential: a case report development of population-based newborn screening for severe combined immunodeficiency severe combined immunodeficiency: a retrospective single-center study of clinical presentation and outcome in patients a founder mutation in artemis, an snm -like protein, causes scid in athabascan-speaking native americans bcg vaccine usage in canada -current and historical -tuberculosis prevention and control -phac hematopoietic stem-cell transplantation for the treatment of severe combined immunodeficiency neonatal diagnosis of severe combined immunodeficiency leads to significantly improved survival outcome: the case for newborn screening laboratory technology for population-based screening for severe combined immunodeficiency in neonates: the winner is t-cell receptor excision circles newborn screening for severe combined immunodeficiency and t-cell lymphopenia in california: results of the first years a markov model to analyze costeffectiveness of screening for severe combined immunodeficiency (scid) human severe combined immunodeficiency: genetic, phenotypic, and functional diversity in one hundred eight infants the natural history of children with severe combined immunodeficiency: baseline features of the first fifty patients of the primary immune deficiency treatment consortium prospective study acknowledgments we would like to thank ms. ruth milner for her statistical support and dr. louise pelletier, dr. maura ricketts, dr. marcus lem and dr. ezzat farzad for their help in setting up the study. funding for this project was obtained from the office of community medicine at fnihb, health canada. key: cord- -obeinwyq authors: horton, richard title: canada : what should global health expect? date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: obeinwyq nan for south africa in , it is the world cup. for canada, it is the g -on jan , , canada takes over the g presidency. as the predicaments facing the world's leading economies grow ever more complex, canada's global leadership has never been more keenly needed. over the next months, canada has an opportunity to make a decisive impact on global health. canada could learn a great deal from japan's example. japan occupied the g presidency in . the country's foreign policy team, together with national health leaders, prepared early. in , japan's foreign minister signalled his commitment to international health through human security. the government proceeded to create an academic collaboration to propose action on health systems. that proposal fed directly into the g meeting itself and led to a post-g process that identifi ed key policy areas for priority action: the health workforce, fi nancing, and information. an attempt was made at a collaborative handover with italy in , but internal italian political distractions-the personal life of silvio burlusconi-made something of a dead year in g history. it is now time for canada to restart the g engine. prime minister stephen harper has already signalled four priorities: the global economy, climate change, development, and democratic governance. but canada's health community has so far been silent publicly on what canada's priorities should be. canada has many natural advantages to shape its international policyworld-class universities with global ambitions, a history of international policy infl uence (eg, the lalonde report, which redrew the boundaries of health), frontrank scientists and intellectuals who have redefi ned what is possible in health, - and increasing overseas development assistance. the most prominent anomaly canada has to address is the failure of the international institutional and donor architecture to address in any comprehensive and co herent way the catastrophic failure in progress towards the millennium development goals (mdgs). integrating funding for maternal, newborn, and child health into the global fund for aids, tuberculosis and malaria and the us president's emergency plan for aids relief is urgently needed if mdg targets are to be met in . but beyond rebalancing existing programmes, canada's unique experience as a nation could lead it to make important contributions in fi ve further dimensions of global health. first, health systems. canada's health service benefi ts from relatively low health disparities, high levels of public solidarity, and a strong commitment to equity. universal coverage is now top of the global health agenda. , canada must deepen and broaden g commitments to health-systems strengthening. second, climate change. this issue is already a canadian priority. but the health aspects of global warming are largely invisible. the lancet-ucl commission on the health eff ects of climate change argued that global warming is the biggest threat to health in the st century. this view has been backed by doctors' leaders. , health advocates in canada need to press this point on their politicians as additional evidence for concerted action. third, peace through health. canada has been the leading nation bar none to develop the concept of peace dividends through policies on health. [ ] [ ] [ ] this idea has catalysed governments to embrace health as a vital force in foreign policy. as suff ering escalates in zones of confl ict such as afghanistan, embedding health in political thinking is critical to promote peace and reconstruction. fourth, indigenous health. some canadian writers, such as john ralston saul, argue that canada is more aboriginal than european. in a fair country, saul suggests that canada's inclusiveness and egalitarianism stem from these indigenous roots and that if canada is to free the full creative energy of future generations, it must embrace its indigenous past. with million indigenous people living in disrupted, exploited, and marginalised circumstances today, canada's voice-as a country with an important indigenous population-has the potential to command respect and infl uence. , the recent commission on social determinants of health emphasised the importance of inclusion and empowerment for indigenous peoples in governmental policy making. and fi nally, global evidence and ethics. as the birthplace of evidence-based medicine, canada's health community should have a strong voice about the way health metrics are used to shape global health policies. to be fair, canada's health community has called for increased canadian awareness, involvement, and funding in international health. [ ] [ ] [ ] these calls need to be channelled into a more coherent response. perhaps it is time for a change-a canadian health action network for global equity. the creation of such a coalition of canadian academic and institutional health interests could contribute signifi cantly to canada's g agenda. a change could also off er a mechanism for sustained follow-up and continuitybetween diff erent political parties and as the g chair rotates between nations. canada's evolution as a nation through the lens of health reveals a deepening commitment to global aff airs. in the th century canadian doctors and public health offi cials reached out beyond canada's borders to attract health workers to help build a national health system. the country's planners broadened the reach of canada's health system westwards. health leaders identifi ed the crucial importance of reliable information to shape the progress of canada's development. severe acute respiratory syndrome illustrated the powerful fact that no nation can be immune from the global forces of disease. and canada's political leadership now recognises that the institutions that govern the world today need to become more democratic and representative. a long-forgotten but exemplary canadian public health leader, charles hodgetts, once wrote about "health as a foundation of government". this is as true today in a global context as it was in canada a century ago. it is up to the canadian health community to seize the opportunity that now off ers. the lancet, london nw by, uk a version of this comment was presented at the university of british columbia, vancouver, bc, canada, on sept , . i owe thanks to many canadian colleagues who off ered views on the arguments presented here. global health and japan's foreign policy global action on health systems: a proposal for the toyako g summit human security approach for global health g and strengthening of health systems: follow-up to the toyako summit italian g summit: a critical juncture for global health g summit : what approach will italy take to health? the case for expanding access to highly active antiretroviral therapy to curb the growth of the hiv epidemic globalisation and health: the need for a global vision avoidable global cancer deaths and total deaths from smoking what will it take to stop maternal deaths? all for universal health coverage who maximising positive synergies collaborative group. an assessment of interactions between global health initiatives and country health systems lancet-ucl institute for global health commission: managing the health eff ects of climate change health and climate change politicians must heed health eff ects of climate change health and peace: time for a new discipline the mcmaster-lancet health and peace conferences peace through health: key concepts oslo ministerial declaration-global health: a pressing foreign policy issue of our time suff ering, and mental health in afghanistan: a school-based survey a fair country indigenous health : determinants and disease patterns indigenous health : the underlying causes of the health gap commission on social determinants of health. closing the gap in a generation the rich-poor gap in global health research: challenges for canada coordinating canada's research response to global health challenges critical public health ethics and canada's role in global health department of health for canada key: cord- -scbteel authors: richards, timothy j.; rickard, bradley title: covid‐ impact on fruit and vegetable markets date: - - journal: nan doi: . /cjag. sha: doc_id: cord_uid: scbteel canadian fruit and vegetable markets were significantly impacted by the spread of the novel coronavirus sars‐cov‐ (and covid‐ disease), beginning in march . due to the closure of restaurants, bars, and schools, produce growers and distributors were forced to shift supplies almost entirely from the foodservice to the retail channel. shippers reported labor and logistical constraints in making the change, but the fresh produce supply chain remained robust. in the long term, we expect lasting changes in consumers’ online food‐purchasing habits, heightened constraints on immigrant labor markets, and tighter concentration in fresh produce distribution and perhaps retailing. the spread of novel coronavirus, sars-cov- , and the covid- disease it causes has had unprecedented impacts on all food markets, including the market for fruits and vegetables. throughout the value chain, grower-shippers accustomed to just-in-time inventory management systems and retailers able to stock every product with minimal interruption faced shocks in both supply and demand. in this article, we review the nature of these changes due to the spread of covid- in canada and elsewhere and document some of the industry's response, from consumers and retailers through to produce suppliers. we divide our analysis into short-term, or immediate, impacts on the fruit and vegetable supply chain, and then consider longer term impacts that are likely to persist for the entire duration of the pandemic, and perhaps longer. our primary interest is on the implications to canadian markets; however, given the degree of integration between horticultural supply chains in mexico, the united states, and canada, we will provide a north american perspective and focus on the key overlapping issues across the three countries. the various issues affecting their day-to-day operations, taking time for "contingency planning" represented the most substantial change to their daily routines. finding workers, scheduling workers, and ensuring their safety are the most important operational concerns. these operational issues, however, are only the tip of the spear as the industry undergoes fundamental changes and dislocations in an otherwise well-operating value chain. in the short term, closing restaurants and schools-the near-complete loss of an entire distribution channel-has had the most dramatic impact. in , foodservice (both restaurant and institutional) sales in canada totaled $ . billion, while sales in the retail channel were $ . billion (usda, ) . it is reasonable to assume that total food consumption does not change, as the volumes lost to the foodservice channel are likely being picked up by retail. in response, suppliers are setting up packing lines and converting existing lines to move from foodservice to retail buyers. using us data as evidence, by march , , as quarantine measures began in only the most affected of the states in the united states, retail food sales were already up some . % in total, and . % in fresh produce (nickle, b) . we expected this shift to accelerate as the virus spreads, and it has. by march , volumes of fresh produce in the retail channel were up . % over the previous year (s. lutz, personal communication, march , ) . unit prices in the foodservice sector tend to be higher than retail (usda, a), but expenditure in each channel is roughly the same, so this means a roughly % shift in volume across supply chains that differ in fundamental ways. that is, the set of wholesale distributors for the foodservice sector is not always the same as the set that services retail accounts, and many retail accounts are served directly by grower-shippers. although foodservice distributors will clearly see an almost complete loss of demand, retail distributors need to be able to pack more frequently, have trucks in place more quickly, and anticipate moving greater volumes in the next few months. this will demand unprecedented flexibility in terms of shifting lines and suppliers as needs change. farm products destined for the retail and foodservice channels are largely fungible. that is, a head of lettuce contracted to a foodservice distributor is largely the same as one that would be sold to retail. however, that is where the similarity ends, as fresh produce in the retail channel is far more likely to be purchased on contract than it was years ago and more likely to be sold under contract than produce in the foodservice channel. contracting for fresh produce helps buyers ensure a consistent supply of high-quality produce from trusted suppliers, with lower transaction costs than purchasing from a spot, or terminal, market. however, these dedicated relationships break down when end-markets disappear. contracts in the retail fresh produce market are subject to a wide range of force majeure clauses that render them unenforceable in the event of an "act of god," which, we suspect, includes pandemic spread. from a business perspective, sellers servicing foodservice buyers will need to find alternative buyers in the retail channel and vice versa-retail buyers will need to quickly locate suppliers that have been selling to foodservice buyers. all of this search activity also needs to be completed before the current crop, which is highly perishable in most cases, becomes unsellable through any channel. in fact, perishability separates the fresh produce industry from most other agricultural sectors, particularly in terms of the most visible impact of covid- on the retail market. hoarding in both the united states and canada is rampant. however, consumers are only stockpiling nonperishable items as they, perhaps expecting to be completely excluded from food stores, are forward buying in the anticipation of not being able to purchase any of their basic needs. however, retailers have managed to keep relatively complete assortments of fresh fruits and vegetables at reasonable prices. suppliers of nonperishables will feel their armageddon in july or august when the current demand spike has run its course and consumers take months to work through their stockpiles of items. producers of perishable items are experiencing little of the same forward purchasing. there are reports of sporadic stockouts in some of the more storable produce items-table potatoes, onions, and sweet potatoes, for example-but most items in the fresh produce aisle appear to be readily available. some of the trends discussed above for the fresh produce sector are less prevalent for processed (frozen and canned) fruits and vegetables, which is a nontrivial market in canada. in fact, the value of processed fruit and vegetable production in canada is approximately $ billion (statscan, b). anecdotal evidence suggests that, like several nonperishable products, consumers have been stockpiling frozen fruits and vegetables, which has the potential to dampen current and future sales of fresh produce. furthermore, depending on consumers' experiences with processed fruits and vegetables, any short-term changes in the mix of fresh and processed fruits and vegetables have the capacity to alter shopping patterns in the future. this may prove to be an important time for the marketers of both fresh and processed fruit and vegetable firms to maintain, attract, and expand their consumer base (kapsak, ) . there are many reasons why fresh produce shelves remain relatively well stocked while nonperishables disappear quickly, reflecting differences in both supply and demand. first, decisions to grow most vegetables (and seasonal berries) are made from to months in advance of retail shipments, depending on the item in question. therefore, the onset of a crisis that occurred as rapidly as covid- does not necessarily interrupt the biological process of planting and harvesting. although the crops may be available in the field, harvesting crops that are currently in the field may face some difficulties as growers in the southern us (the main source of imports to canada) are reporting some problems obtaining h- a workers (the usual source of seasonal harvesting laborers). rising unemployment among domestic workers in the coming months may provide a ready supply of substitute workers, but attracting workers to the fields will require higher wages and production costs. as the pandemic began to move through the united states, suppliers reported little difficulty in moving their usual volume of fresh fruits and vegetables to retail stores. second, on the demand side, the fact that consumers are stocking up on nonperishable items means that they are likely substituting across-categories within the store at a rate that we have not seen before. retailers are, by now, very sophisticated in terms of their use of inventory and demand-management data in order to optimize prices and assortments in real time. the fact that shelves are empty for some categories (e.g., toilet paper and pasta) and not others (e.g., apples, tomatoes, and strawberries) is a testament to the knife's edge upon which retailers operate. even a small change in demand leads to category-reallocations within the store that result in perceptions of scarcity, even though retail supply chains remain relatively robust. there is evidence that category-substitution, even in normal times, is relatively strong. empirically, we know that consumers exhibit substitution patterns between different foods and food categories. okrent and alston ( ) examine the own-and crossprice elasticities of demand for six food-at-home categories (including fruits and vegetables), two beverage categories, and a food-away-from-home category. their results show that the fruit and vegetable category has important substitution patterns with the cereal and bakery category, meats, and nonalcoholic beverages (which includes fruit juices). so, in addition to any future switching patterns we see between individual fruits and vegetables and between fresh and processed fruits and vegetables, okrent and alston ( ) suggest that consumers will also substitute across food categories. with this shock-driven demand reallocation, budget constraints are likely to have substantially stronger effects, so past estimates may understate the true state of affairs. even items that were complements, such as meat and potatoes, may become substitutes as stockpiling in one leaves less money for the other. intuitively, if the budget share of toilet paper is typically %, the demand for toilet paper is almost meaningless to apple purchases, but when it becomes %, toilet paper purchases drive apple demand down through the budget constraint. although there are no reports of retailers price gouging hoarded-item categories, it is conceivable that higher retail prices for these items could, in turn, generate higher demand for fresh produce as the spread of the virus worsens. category substitution and the eventual run-down of household inventories of nonperishable items may have important implications for future purchases of fresh fruits and vegetables and dietary quality. if households substitute between nonperishable (or frozen) products that were stockpiled and stored during late-winter and the spring of , this could have nontrivial effects in fruit and vegetable markets and lead to a range of market responses in mid-to late . we know that consumers substitute readily between fresh and frozen fruits and vegetables (blumberg thompson, ) , so this effect is likely to be strong. first, the consumption of stockpiled items could begin to occur at the same time that harvest seasons begin for many canadian-produced fruits and vegetables, and this would place downward pressure on prices of fresh produce markets. this scenario would be particularly difficult for small-and medium-sized fruit and vegetable producers who rely more heavily on local and regional markets for their products. second, and perhaps more importantly, different food categories provide different micro and macronutrients to consumers, and the stockpiling and the potential large substitution patterns between food categories could have implications for dietary quality in canada. fruits and vegetables, in particular, are important sources of dietary fiber and many vitamins and minerals. any substitution patterns stemming from the eventual management of stockpiled items (mostly cereals) may inadvertently discourage consumers from eating the recommended amount of fruits and vegetables (canada food guide, ). of course, much of the produce sold in canada is imported. in fact, in , total retail sales of fresh fruits and vegetables produced domestically averaged about $ million (cdn) per month (statscan, a), while imports averaged approximately seven times that amount (statista, ) . consequently, most of the impact of changing consumption patterns will be felt by importers, including wholesalers, distributors, and retailers, and any impact on availability will be determined by conditions in the us fresh fruit and vegetable supply chain. among domestic stakeholders in the fresh value chain, importers, including distributors, wholesalers, and retailers will be the most directly impacted. in fact, retailers may experience changes that last well beyond the duration of the pandemic. borders remained open to commercial traffic well into the crisis. however, further restrictions on cross-border movement will dramatically affect trade-dependent firms, like those in the fruit and vegetable industries. losing access to us imports will clearly limit canadian retail sales this summer to items grown primarily in canada, reducing the variety of fresh items that canadian consumers have become accustomed to. reflecting consumers' fears of being in proximity to others, online food sales surged as the pandemic spread. prior to the spread of covid- , only . % of groceries were sold online in canada, a number that had grown to over . % by the third week of march (charlebois, ) . in fact, grocery chains were reporting surges in online orders of up to % (o'malley, ), and some were limiting physical access to stores. although much of this online ordering activity was surely for nonperishable and household items, the fact that many supermarkets charge fixed online delivery fees means that shoppers have an incentive to order their entire shopping list online and avoid the risk of shopping in physical stores. once consumers learn how to shop online and experience the benefits in terms of convenience and speed, many will remain online shoppers at least occasionally. for fresh produce retailers, many believe this experience could represent the tipping point that moves fresh food delivery beyond tech-savvy, regular online purchasers to the center of mass of the food-buying public. direct channels, such as farmers' markets and farm stands, have become an important source for fresh fruits and vegetables. although small in volume in canada (statscan, a), farmers' markets often represent the face of the industry as they attract the most engaged segment of the fresh produce market. although social distancing likely means the end of most face-to-face markets for fresh produce in the short term, it also provides an opportunity for community-supported agriculture organizations to seize a market opportunity by expanding local delivery services. shifting fruit and vegetable consumption from restaurants to home-based meals has potentially important implications for food waste. there are three mechanisms at work; leaving the net effect uncertain. first, gooch, felfel, and marenick ( ) estimate that some % of food waste in canada occurs in the home, while the foodservice sector is responsible for %-much different from the proportions of food volume consumed at home and away from home. therefore, shifting consumption from foodservice to households may, in fact, increase the amount of fresh produce that is wasted. second, overpurchasing is one of the key drivers of household food waste. if anxiety over the viability of the fresh produce supply chain leads to hoarding, or at least overbuying, then more fresh produce will be wasted as a result. on the other hand, perceptions of scarcity are likely to lead households to become more efficient, both in their use of food on hand and in planning food purchases. determining which effect dominates would be a fruitful question for future research. there are other effects that are more likely to persist or that reflect long-term developments in fresh produce supply chains. we identify three of the most significant in this context as an access to labor issues in the fresh produce growing industries of the united states and canada, consolidation, and the move to online food purchasing. canada obtains most of its fresh produce from the united states (statista, ) . reliance on imports, mainly from the united states, means that anything that interrupts production and distribution schedules in the united states may have dramatic effects on canadian availability. in that regard, a shortage of farm workers in produce-growing regions of the united states-not just for harvest, but for a wide range of production jobs-has, for many years, been perhaps the most important issue facing fresh produce growers, well before the spread of covid- (hertz & zahniser, ; richards, ; richards & patterson, ) . because this issue is structural, endemic to the us labor market, and defies an easy political solution, there has been a patchwork of policy remedies suggested and enacted over the past years. the us immigration and nationality act of established the h- guestworker visa program, which was later divided into the h- b program for seasonal workers in nonagricultural industries (and subject to strict limits) and the h- a program (not subject to limits on the number of workers). due to its bureaucratic and heavily regulated nature, workers hired under the h- a program represented only a small share of all agricultural workers each year, some , workers out of a total workforce of over . million. in the recent years, however, heightened enforcement of immigration laws in the united states, reduced out-migration from mexico, aging of the workforce in the united states, and the reluctance of domestic workers to do farm labor meant that the share of h- a workers rose from . % of the entire workforce in to some . % in (see figure , usda, b). as covid- spread in early , restrictions on cross-border movement between the united states and mexico meant that growers could no longer rely on a ready supply of h- a workers. although the spread of covid- began before the harvest season for most fruits and vegetables, growers could not conduct early-season planning for the coming harvest. somewhat perversely, perhaps, unemployment caused by the shock to the us economy more generally has provided an immediate pool of available workers. however, during the previous period of relatively high unemployment during the financial crisis of - , growers could not attract domestic workers, even by promising higher wages. as counterintuitive as it may seem, us workers' reluctance to do farm jobs may mean that crops go unharvested, despite a real demand for the final good and plenty of workers able to do the job. domestic production in canada faces many of the same issues. canada admits some , guestworkers annually, many of whom are employed in the fresh fruit and vegetable industry. although workers are still allowed into the country, difficulties in obtaining approval in mexico and traveling to canada may mean that far fewer than are needed will make the trip this growing season. moreover, canadians-even newly unemployed canadians-are not likely to take these jobs and risk losing unemployment support. if growers are forced to raise wages to attract domestic workers, the price of domestically grown produce may rise substantially. second, we expect the rate of consolidation to increase throughout the fresh produce supply chain. similar to the rest of the economy, much of the growth of small business in the produce sector during the - recovery and boom period was fueled by debt. although the consequences of debt-funded growth and declining cash flow are more obvious in the shale-oil industry, bankruptcies and consolidation will also rise in the fresh produce industry. in periods of financial instability, only large, stable firms with the ability to service interest payments and sustain business relationships through cash shortages survive. further, there is little reason to believe that per-capita consumption of fresh produce will change as we emerge from the pandemic, so the same amount of business will essentially be spread among fewer businesses. among empirical industrial-organization economists, the linkage between concentration and market power is far from settled. but, it is undeniable that the potential for margin expansion by large retailers on the consumer side, powerful packers and distributors on the wholesale-buying side, and exporters selling into the canadian market will be much greater in the absence of a strong, competitive fringe of small firms. another potential long-term trend that may emerge from the covid- pandemic is the way consumers purchase food and how they buy fruits and vegetables. the move to online grocery shopping has been particularly notable given the share of online purchases made by retirees and households that have not traditionally purchased groceries from home (charlebois, ) . this has important implications for produce as there is evidence that some consumers are more likely to make healthier purchases when groceries are ordered online, or at least less impulsive, as consumers tend to use automated shopping lists online (pozzi, ) . in predicting how this short-term response to covid- will affect longer term fruit and vegetable sales (both fresh and processed), the outlook will depend greatly on customers' satisfaction with their initial online shopping experiences in march and april . online grocery sales are expected to reach % of total grocery sales by (albrecht, ) ; some are now predicting that our experience with covid- will be a defining moment in north america's embrace of online grocery shopping. any further movement online will only accentuate the consolidation effect described above. after amazon's purchase of whole foods in , the movement online and increased concentration of retail grocery sales came to be viewed as essentially two manifestations of the same underlying dynamic. supermarket retailing is notoriously capital intensive, and endogenizing fixed costs is an important tool for strategic competition among grocery retailers (ellickson, ) . online grocery may appear to consumers to be "just an app," but to do it in a way that competes with amazon requires building distribution centers, establishing a delivery network, integrating with physical stores, and expanding geographic reach. small, independent, neighborhood stores may not be able to compete in a world in which consumers demand online grocery options. we believe that the greatest impact of the covid- pandemic in the short term will be felt through the realignment of fresh produce supply chains due to the closure of nearly all foodservice outlets. as consumers move to buying food almost completely through the retail channel, distribution infrastructure specific to retail will remain strained throughout the spread of the disease and will test supply-chain relationships for some time after. over the longer term, the potential impacts will be felt through input markets, most notably labor, and through structural changes in the industry, which may undergo fundamental and largely irreversible shocks, such as consolidation and a move toward online shopping. the fact that canada imports much of its fresh produce requirements does not insulate it from these shocks. rather, the price of imported produce will rise with the cost of production in the united states and with any changes in the structure of the exporting industry. these changes, while being rational responses to short-term incentives, may change fresh fruit and vegetable distribution forever. https://orcid.org/ - - - study: online sales to hit $ billion by . the spoon heterogeneity in the demand for fruits and vegetables: how much can price and quantity reveal? working paper eat vegetables and fruits why covid- will change canadian grocery industry forever: expert. retail insider food waste in canada. value chain management centre is there a farm labor shortage now is the time to promote produce. produce business how the coronavirus is affecting the produce industry. the packer retail produce sales rising amid coronavirus concerns. the packer coronavirus: many large grocery chains experiencing online order delays. globalnews demand for food in the united states: a review of the literature, evaluation of previous estimates and presentation of new estimates of demand shopping cost and brand exploration in online grocery immigration reform and farm labor markets hysteresis and the shortage of agricultural labor monthly import value of fruit, nuts and vegetables in canada from table: - - - channels of distribution for horticulture product sales and resales naics for fruit and vegetable preserving and specialty food manufacturing food dollar series farm labor key: cord- -gd va authors: weersink, alfons; von massow, mike; mcdougall, brendan title: economic thoughts on the potential implications of covid‐ on the canadian dairy and poultry sectors date: - - journal: nan doi: . /cjag. sha: doc_id: cord_uid: gd va the dumping of milk, the offering of hospitality size goods in grocery stores, and the closure of processing facilities are examples of the disruptions caused by the pandemic to the dairy, poultry, and egg sectors. these supply management sectors, however, are more resilient to the impacts of covid‐ than other sectors as producers are generally more financially stable, losses are pooled, and production/marketing efforts are coordinated. covid- has shaken the world. the death toll continues to increase, as does the unemployment level as non-essential businesses are forced to shut down in an effort to slow the transmission of the disease. excluded from the mandatory closures are those industries involved in the production and distribution of food, including dairy and poultry. while the food supply chains continue to operate, the shocks imposed on the economy by the pandemic have impacted all components of the agrifood sector. in this paper, we discuss the repercussions of covid- on the supply chain for dairy and poultry in canada. although there are significant short-term disruptions as highlighted by the dumping of milk and the temporary closure of poultry processing facilities, the focus on a domestic market by these sectors along with the stability and coordination of its supply management marketing systems has mitigated, to an extent, the economic implications of covid- . the discussion highlights the importance of distinguishing between the farm output (i.e., milk, chicken, and eggs) and the products stemming from that output, the difference in the demand for those products for home consumption versus dining out, and the difference in the distribution systems for grocery retailers and the hospitality industry. ( ) if the hospitality sector was open for business, the economic fallout from the pandemic has lowered the discretionary spending of many canadians. the consumption patterns for dairy and poultry products have been altered as a result, with implications for the whole value chain. these impacts are discussed below, along with the adjustments required for each part of the distribution system to deal with covid- directly or indirectly through actions to lower its transmission rate. the first change stemming from covid- is the reduction in the demand by the hospitality sector and a corresponding increase at the food retail sector. canning, weersink, and kelly ( ) and kelly, canning, and weersink ( ) calculated the overall farmer share of the food dollar spent at home versus away from home for canada ( %) and the united states ( %). the farm share of expenditures on food for home consumption is approximately % across both countries, but it is % in the united states and % in canada for meals consumed away from home. using these values, it is estimated that canadians spend approximately one-third of their food budget at restaurants and bars, americans spend approximately %. the percentage is higher if beverages are included in the calculations. the one-third reduction in total consumer food dollar from food services would be expected to shift to food retail. the extent of the change in sales in grocery stores for the week ending march in compared to is illustrated in figure . overall sales were % higher in grocery stores-significantly higher than the % suggested if expenditures were simply shifted from hospitality to grocery. as discussed elsewhere in this issue, panic and hoarding behavior without limits on number of items purchased led to sales % higher than that for the typical busiest week of the year in early december (statistics canada, ) . recent reports suggest that the extent of the increase in sales at grocery stores has fallen after consumers loaded up in mid-march, but the volume is still higher than previous years. the resulting higher demand at grocery stores requires greater staff to meet the higher total volume and the higher percentage of online sales with pickup as consumers want to avoid physically entering the store. food retail stores have also limited shopping hours to allow more time to restock shelves and deal with the increase in nightly shipments to deal with the larger volume. milk sales in grocery stores increased by % from the same week a year earlier, while butter increased by %, reflecting an increase in baking at home and hoarding of more storable products. it is expected that fluid milk sales will continue at this rate as the higher milk consumption by individuals at home offsets a decline in food service demand (i.e., school lunch programs). in general, the use of creams and cheeses by the hospitality sector is greater than the corresponding at-home demand, so the initial % increase in sales of cheese in the middle of march compared to is not expected to continue. the volume of fresh chicken sold in grocery stores increased by % in mid-march compared to the same week a year earlier (statistics canada, ). weekly retail chicken sales figures through nielsens from the chicken farmers of canada (cfc) are lower than those reported by statistics canada, but the cfc has more recent data. of particular note is the further increase in chicken sales at grocery stores for the week ending march but then a reduction the following week. discussions with industry personnel suggest that, eventually, total chicken sales will fall compared to pre-covid- as the increase in sales at grocery stores will not offset the loss from food services. in addition to a change in the volume of chicken sold, there has been a change in the demand for chicken products associated with the shift away from hospitality services to grocery stores. prices for various chicken parts in the northeast united states over the last months are illustrated in figure , with the black vertical line indicating the date when new york declared a state of emergency (march ). the relative price movements of alternative chicken parts for the northeast united states are consistent with changes noted through discussions with industry personnel in canada. wing consumption primarily occurs outside the home, and the sharp drop in wholesale wing prices corresponds to the reduction in food service demand. the price for chicken breasts has also fallen due to lower relative use of chicken at home versus dining out and the smaller desired size of chicken breasts at the grocery store versus restaurants. chickens (and parts) sold to the retail chain are generally smaller than those sold into food service. the consumption pattern for eggs has also changed as a result of the spread of covid- . precrisis, % of egg consumption was in shelled eggs and the remainder was through breaker eggs, which are eggs in liquid form (not in shell) used in baking, food manufacturing, and the hospitality sector. liquid eggs are usually broken from shells that are still intact but that have a visible flaw. in times of normal demand, unflawed eggs are sometimes also broken to serve this market. if breaker demand decreases below a threshold, there will be blemished eggs for which there is no demand. given the closure of most hotels, restaurants, and convention centers, breaker egg demand fell between % and % in the weeks leading up to april (bill mitchell, personal discussions, april ). this loss of demand has not been compensated by increases in demand from the shell market, which increased by % in grocery stores for the week ending march compared to the previous year (statistics canada, ). while prices for chicken parts have fallen (figure ) , the wholesale prices for eggs in the united states have tripled from mid-march to early-april (urner-barry, ). lusk ( ) offers several potential reasons for the price increase, ranging from hoarding behavior, the approaching of easter, the difficulty of switching the distribution chain from hospitality to grocery, and industry concentration. grocery store shelves should replenish as limits are imposed on the number of eggs that can be purchased and supply chains adjust, with part of the adjustment involving the size of the egg cartons offered for sale. the shift from food service to food retail and its impact on the type and amount of product required alters the whole supply chain, which cannot adjust instantaneously as the system tends to be operating near capacity with minimal inventory carryover. it also requires an adaptation or re-allocation in the food distribution system that tends to focus on either food retail or food service sectors. the major grocery chains rely on their own distribution systems. processors, including dairy and poultry, tend to ship their products in bulk to distribution centers for the chain, and the needs of individual stores within that chain are gathered and shipped from these warehouses. in contrast, the distribution system for the hospitality sector is not vertically integrated, and the companies that focus on away-from-home outlets are distinct from the system serving grocery stores. the two large players in food service distribution, sysco and gordon food services controls more than two thirds of the market share, with the remainder covered by regional companies. the shutdown of restaurants and conference centers has forced these companies to shift focus. however, it takes time to establish new relationships with agents at the food retail level and to change their operations to meet requirements of new customers at a different part of the value chain (blaze baum, silcoff, & krahshinsky robertson, ) . it is not expected that these distributors will make significant inroads into the retail market as the established and vertically integrated distribution for food retail adjusts. the impact of the changing volume and mix of their offering by individual processors will differ depending upon their portfolio of customers. even when product changes are not required, alterations to packaging may be necessary. for example, a dairy processing plant sells cream to coffee shops in large bags that fit in dispensers, while sales to grocery stores are for households wanting small amounts in a carton that fits in a fridge. in some cases, both processors and retailers are adjusting in the short run. sobeys is now selling flats of eggs in addition to the typical dozen eggs offered in their stores. the flats from burnbrae farms, which is an egg producer and processor supplying to both food service and grocery stores, were originally intended for the hospitality sector (blaze baum et al., ) . another example are the boxes of frozen chicken breasts now offered for sale in grocery stores that were originally slated for the food service sector. chicken processing companies, according to industry personnel, are also simplifying their product offerings to increase operating capacity as they adjust to the higher volume from grocery stores. in addition to the impacts of covid- brought about by the changes in consumer demand discussed above, the processing sector is particularly vulnerable to disruptions caused directly by the virus. the processing sector has significantly less opportunity to physically distance its employees than other parts of the value chain. in addition, there is a relatively high degree of concentration, which means that product flows through a smaller number of players on the way to the consumer. if one of those processing plants were to close or be restricted, then there could be a disruption, with the extent of the impact being largest on perishable goods such as milk and smaller on chicken, which can be frozen and stored. the degree to which the flow would be altered by the closure of a processing plant also depends on the ease of finding other processors, which is influenced by the degree of specialization and concentration. it is not expected that covid- would cause long-term plant closures given businesses in food production are designated as essential. sanderson farms, which is located in mississippi, was the first dairy or poultry processing company to experience a case of covid- . management sent the employee home, along with others working in close proximity, but the plant remained open. more recently, an employee at a tyson poultry processing plant in georgia died from the virus, highlighting the difficulty of containing its spread in a meat processing plant (jordan & dickerson, ) . the first canadian poultry or dairy processing facility to be affected by staff contracting covid- was a maple leaf plant in brampton. maple leaf suspended operations on april and will not open until an investigation and deep cleaning of the plant is completed (maple leaf, ). if the number of closures remains small, it is expected that animals or inputs can be rerouted to other facilities, which increases costs but maintains output. further closures of other, larger processing facilities could significantly disrupt the food distribution chains, leaving producers and their marketing boards searching for other outlets for their commodities. it is more likely that there could be capacity constraints as plants adapt to provide protection and physical distancing between workers. there have been some reports of this in the dairy industry in ireland, for example. another issue could be employees refusing to come in to work because of the risk. food processors often struggle to find sufficient labor under normal circumstances, and it would be difficult to replace skilled workers even in a period of high unemployment with covid- -related layoffs. as individual plants have different portfolios of products, individual plant closures or slowdowns could have an impact on the availability of specific dairy or poultry products. dairy and poultry farms are operating as they were several months ago, aside from the social distancing occurring between visitors to the farm and the farm workforce. input deliveries and output pickups can be done without direct contact among those involved. as discussed in brewin ( ) , the seeds, fertilizers, fuel, and pesticides are all in place for planting this spring. similarly, the supply of feed and other inputs for livestock production have not been affected in the short run. the most direct impact from covid- on livestock feed thus far has not been on the supply of feed in aggregate but rather on the availability and, subsequently, the cost of certain ingredients, such as dried distillers grain (ddgs). the nearby futures price of crude oil fell from above $ (usd) per barrel at the beginning of the year to just above $ (usd) per barrel on march . oil and ethanol prices are correlated, and the low returns have reduced production of ethanol at plants continuing to operate and led to the closure of others. on march , ethanol production plummeted to its lowest levels since june . the fall in ethanol output means a corresponding fall in the supply of its by-products such as ddgs. the subsequent increase in ddg price alters the least-cost ration and feed costs for livestock farmers (skinner, weersink, & delange, ) . prices for another common feed ingredient, wheat shorts, have also increased due to an increase in demand for flour with more in-home baking. while production systems have not been altered in the short term by the pandemic, the level of output has been affected for both dairy and poultry. in the middle of march, it appeared that quota-free days (producers are allowed to ship milk in excess of their quota without penalty) might become available to dairy producers in some parts of the country as a means to create incentives to meet reduced overall supply of milk combined with a run on dairy products resulting from panic buying in the immediate onset of covid- . a few weeks later, dairy farmers were forced to dispose of certain milk shipments (dfo, ). we may see a return to quota-free days depending on total demand once the adaptation has taken place. similarly, chicken farmers are being forced to shorten the production cycle with their current allotment of birds and will likely face smaller production quota levels along with raising smaller birds in the future (cfo, ). the unfortunate situation of dumping raw milk is occurring as the supply chain adjusts to disruptions caused by covid- . some dairy processors require less milk because hospitality customers are demanding less volume of specific goods (i.e., cream) and milk needs to be redirected to products and processors for whom demand is higher. in some cases, the same product is required but the packaging is different (single-serving wraps of butter or large tubs for hospitality to g of butter for grocery stores). this production shift takes planning and time. there will also be logistical issues in redirecting supply to different processors. the process of cutting production for food service is quicker than that of ramping up production for retail. while dairy processors can typically adapt to small increases or decreases, the enhanced demand on retail lines combined with the shutting down of food service lines takes time. during the adjustment, cows continue to be milked and milk is stored by farmers in tanks large enough to hold a maximum of hours of production. the raw, unpasteurized milk is brought by transporters to processors, who now do not have sufficient storage to keep excess milk as they shift their operational focus. typically, fluid milk goes from a farm bulk tank to a retail fridge in a matter of days, but there is no buffer capacity to hold milk that is not immediately processed. since milk is produced on the farm daily, milk needs to be dumped to make room for new production. the phenomenon of dumping milk is not unique to canada as up to % of all milk produced in the united states was dumped in first week of april (newman & bunge, ) . the problem will be particularly acute in markets like wisconsin with a high proportion of processors focused on products (i.e., cheese) particularly affected by the reduction in demand by the hospitality sector. if the need for milk by these processors is lowered and fluid milk processing happens in other states, those dairy farmers will struggle to quickly find alternative markets. milk dumping is likely to continue, and dairy farm returns will subsequently fall. in contrast, the canadian single-desk selling system for dairy, poultry, and egg farmers works in conjunction with processors to coordinate production and marketing, as evident by the joint statement on the milk supply situation issued by the dairy farmers of canada and dairy processors of canada (dpac, ). the canadian system, with central selling and transportation coordination, as well as more localized provincial production, may facilitate quicker adaptation and reallocation than in the united states. producers in supply managed industries are paid based on a cost of production formula and, as such, are less susceptible to the cyclicality of commodity prices. there continues to be an ongoing debate as to the value of supply management. in this circumstance, however, the stability provided by the system insulates producers against the potential disruption. the milk that is dumped at the farm level will be paid for. returns are pooled across all processors and classes of milk. milk is priced to processors based on end-use, with fluid milk products being the highest class. milk is allocated on demand to the highest classes, and then allocated based on historical shares in the lower classes. producers are paid a pooled price based on all the milk sold, so it doesn't matter where an individual producer's milk is shipped and which producers were required to dump milk. in the united states, on the other hand, the loss is incurred by the dairy farmer and/or the cooperative in the region in which processor demand is significantly reduced. this would be similar in canada for products that do not have central desk selling. there have been some clear and significant disruptions to dairy and poultry supply chains that can be directly attributed to challenges arising from covid- . the structure of supply management in dairy, poultry, and eggs may allow the industries to recover more quickly from the disruptions caused by the pandemic. producers in the supply managed sectors are generally more financially stable, which should allow them to weather any decreases in returns more easily than producers in other sectors. losses are shared across individual producers and marketing/transport is coordinated, providing resilience within the system. the supply chain has adapted relatively quickly in the short term to both shortages and surpluses, resulting in the changes in volume and nature of products offered through the shift from hospitality to grocery. there are several longer-term implications on the dairy and supply managed sectors arising from the pandemic. one relates to what will be the new "normal" once businesses, including restaurants, return. by then, the volume and nature of demand for dairy and poultry products may be altered permanently, or at least become slow to adjust due to income effects associated with the job losses suffered by a large number of canadians. the resulting adaptation over the longer term will be easier to manage based on both experience and rate of change. second, the process of automation will accelerate at all levels of the supply chain. the movement to labor-saving technology will be spurred by the increase in wages paid to workers during the crisis and an increased reliance on machines not vulnerable to disease. the third implication is the enhanced desire for local production as opposed to dependence on global distribution chains to supply goods, from food to safety masks. since the supply managed sectors already have a focus on domestic production, the impact of such a shift in preferences will not significantly impact its supply chain but could have implications for other sectors. https://orcid.org/ - - - mike von massow https://orcid.org/ - - - as restaurants close and demand for groceries surges, food distributors shift their focus to retailers. globe and mail the impact of covid- on the grains and oilseeds sector farm share of the food dollar: an io approach for the united states and canada production planning during covid- . covid- information letter to producers, from murray sherk, chair, dairy farmers of ontario dairy processors association of canada. ( , ) poultry worker death highlights the spread of coronavirus in meat plants decomposing the farmer's share of the food dollar meat and egg prices following the covid- outbreak doing our part during the covid- pandemic. around the table-blog farmers dump milk, break eggs as coronavirus restaurant closings destroy demand egg benchmark update impact of dried distillers grains with solubles (ddgs) on ration and fertilizer costs of swine farmers economic thoughts on the potential implications of covid- on the canadian dairy and poultry sectors key: cord- -rsnf ib authors: paquet, mireille; schertzer, robert title: covid- as a complex intergovernmental problem date: - - journal: nan doi: . /s sha: doc_id: cord_uid: rsnf ib federations increasingly face complex policy challenges, from managing climate change to mass migration. covid- is a prime example of this emerging type of problem. this research note introduces the concept of complex intergovernmental problems (cips) to better understand these types of challenges. federations increasingly face complex policy challenges, from managing climate change to mass migration. covid- is a prime example of this emerging type of problem. this research note introduces the concept of complex intergovernmental problems (cips) to better understand these types of challenges. while political leaders and media often describe covid- as a crisis, the concept of cips generates more analytical power to understand the management of this pandemic in federations and multilevel governance systems. the nature of this problem requires intergovernmental coordination and cooperation for effective policy responses. at the same time, covid- will significantly affect intergovernmental relations in canada over both the short and long terms. highlighting how covid- intersects with intergovernmental relations allows us to better assess how governments have responded and will facilitate comparative research. complex intergovernmental problems (cips) are boundary-spanning, irreducible policy problems that unfold within an intergovernmental system (see thomann et al., ; versluis et al., ) . this concept draws upon studies of intergovernmental relations in canada, particularly work on the factors influencing collaboration (cameron and simeon, ; skogstad and bakvis, ) . it also builds upon insights from public policy and multilevel governance research (see, for example, maggetti and trein, ; irepoglu carreras, ; paquet, ) . instead of taking federal arrangements as a starting point, this approach focusses on the nature and characteristics of a policy problem to analyze how governance systems and actors adapt. public policy scholars have long studied how the social construction and the nature of different policy problems affect politics, policy designs and policy outcomes (see, for example, peters, ; béland, ; rochefort and cobb, ) . they have developed typologies of problem attributes and different concepts to account for varying degrees of problem complexity (head, ) . for example, problems that are multicausal and highly interdependent are sometimes characterized as "wicked problems" (peters, ) . we define cips as distinct from wicked problems or crises because of their inherent intergovernmental nature and related consequences. cips-such as the opioid crisis, pandemics or climate change-have three characteristics. first, addressing their root causes is not something that is amenable to resolution by the actions of any one government. instead, governments can generally only address the consequences of the problem on their territory and within their regulatory space. second, the nature of cips requires high levels of coordination and collaboration among implicated governments. responding to their consequences cannot be achieved by a single actor in an intergovernmental system. third, these problems challenge the existing norms and venues of intergovernmental relations. often, the novelty of a cip requires close collaboration from agencies and governments that have not traditionally worked together. they can also create situations where joint interventions are necessary even though the existing mandates, agendas and processes of intergovernmental forums are not well suited to coordinate government action. similarly, a novel cip can exacerbate poorly functioning aspects of intergovernmental relations-representing a stress test that exposes cracks in the system. failure to effectively respond to cips can also have trickledown effects on intergovernmental relations in other sectors, including conflicts or disengagement. in short: cips generate pressure to act in novel ways and to establish new forms of collaboration, which can be difficult even under ideal conditions. these problems create barriers to collaboration because they call into question the existing power equilibriums and dominant narratives about how to work together and share responsibilities within intergovernmental systems. cips are thus somewhat paradoxical: they demand intergovernmental collaboration for effective and legitimate policy responses, while making the necessary collaboration difficult to achieve. in canada and other federations, covid- aligns with all the attributes of a cip. the global spread of the virus has reached a point where government actions are now focussed on managing its consequences. however, mitigation measures cannot be implemented unilaterally by any one government. within canada, the response to covid- requires and challenges the intergovernmental system. the need for intergovernmental collaboration is most acute in the public health sector. this necessity reflects the provincial responsibility for healthcare, paired with a significant role for the federal government in financing the system and leading the pandemic response through the public health agency of canada. this federal role is a clear legacy of the sars outbreak (wilson and lazar, ) . the main policy responses to covid- have been to implement social distancing measures and to ensure the healthcare system has the resources it needs to treat patients. decisions on social distancing measures are derived from information and statistical models shared across jurisdictions. the sharing of resources such as testing kits, masks and ventilators across the country will increasingly be a key determinant of effective responses (chouinard, ) . it is impossible for ottawa to address covid- unilaterally, even if it were to implement its sweeping emergency powers (swiffen, ) . at the same time, the pandemic demonstrates that provinces and territories are dependent on the decisions and capacities of other governments-at all levels-to continue to act within their own regulatory space. but the scope of covid- is so profound that it engages many other aspects of canada's intergovernmental system. indeed, the consequences of covid- extend beyond public health. in the short term, they include mobility control and international and interprovincial trade and supply chains, as well as the provision of basic income security measures for canadians. in the medium term, governments will need to find creative ways to address the economic impact of the pandemic on their revenues and budgets. given the increased spending not only on healthcare but also on other social support measures, these costs will be particularly felt among provinces and municipalities. none of these policy challenges can be addressed by a single order of government. at the same time, the existing intergovernmental processes and norms of working together in canada may pose barriers to this needed collaboration. for instance, the public health sector has eschewed the establishment of dedicated intergovernmental venues. it has favoured ad hoc mechanisms to share specialized knowledge and lacks a legacy of first ministers working closely together and trusting each other on the issue. beyond public health, the dramatic nature of covid- 's impact on our society and economy will represent a stress test for existing peak and sectoral intergovernmental venues, especially considering pre-covid- conflicts within the federation. what are the advantages of labelling covid- as a cip? besides providing a rich descriptive framework, the concept allows us to focus on the inherent intergovernmental nature of the crisis. applying this lens helps to illuminate two sides of the impact of a cip like covid- . on one side is how the intergovernmental system impacts the effective management of the problem's consequences. understanding how the structure, norms, relationships and processes of the intergovernmental system are helping or hindering the response to the crisis is central to explaining policy outputs and the outcomes associated with covid- . how governments in canada work together-or do not-to share critical medical supplies will impact health outcomes. similarly, how governments coordinate to access global capital and credit to shore up strained budgets will shape their ability to continue to provide essential services to canadians. on the other side, cips are likely to significantly impact intergovernmental relations over the short, medium and long terms. in the case of covid- , these effects could range from the creation of new venues for federal-provincial-territorial (fpt) collaboration in public health and emergency preparedness, to a complete rearrangement of power dynamics between ottawa and the provinces in the face of a long global economic crisis in which the federal spending power will be an important mechanism. our research into a previous cip in canada-irregular border crossings-demonstrated a clear pattern of the short-term, medium-term and long-term effects that these types of problems can have on the intergovernmental system (schertzer and paquet, ) . in the immediate face of a surge of irregular border crossings in , governments and public servants rallied and collaborated to ensure that government operations remained effective. they provided innovative responses to the new realities on the ground. in the medium and long term, however, significant political conflicts over fiscal federalism and distribution emergedtensions that are still not resolved. one of the key takeaways from the surge in irregular border crossings in canada is that a cip evolves over time: initial periods of crisis management and collaboration can give way to intergovernmental conflict. often, these conflicts can be exacerbated when the policy issue itself gains political salience. so, while there are reasons to celebrate current fpt collaboration in response to covid- , over time, competing interests, resource constraints, legacies from past conflicts, and weak points in the intergovernmental system are likely to create significant tension. beyond canada, the concept of cips can be used to compare responses to, and the consequences of, covid- in other federations. in the united states, australia, india and germany-to name only a few examples-the pandemic response is clearly being shaped by intergovernmental relations. comparative analysis will help to document how different intergovernmental systems respond to covid- , along with the impact of particular institutional and political variables. furthermore, comparison can identify factors that contribute to different degrees of adaptability of intergovernmental structures and norms, while also tracing over time how conflicts (for example, related to fiscal federalism) become embedded into the management of this cip. likewise, our approach opens the door to fruitful within-case comparisons (for example, multiple cips in a given federation) and cross-case comparisons of other cips. understanding how intergovernmental systems are influencing policy responses to covid- is critical. at the same time, understanding how covid- is impacting intergovernmental systems in federations is also essential. seeing covid- as a cip can help us in both research endeavours. ideas, institutions, and policy change intergovernmental relations in canada: the emergence of collaborative federalism covid- crisis sheds light on blind spot of canadian federalism: interprovincial collaboration forty years of wicked problems literature: forging closer links to policy studies problem-solving across literatures: comparative federalism and multi-level governance in climate change action multilevel governance and problem-solving: towards a dynamic theory of multilevel policy-making? wicked problem definition and gradual institutional change: federalism and immigration in canada and australia what is so wicked about wicked problems? a conceptual analysis and a research program problem definition, agenda access, and policy choice how well is canada's intergovernmental system handling the crisis? conclusion: taking stock of canadian federalism the hermeneutics of jurisdiction in a public health emergency in canada what's the problem? multilevel governance and problem-solving the multilevel regulation of complex policy problems: uncertainty and the swine flu pandemic planning for the next pandemic threat: defining the federal role in public health emergencies covid- as a complex intergovernmental problem key: cord- -qi dkcb authors: wilson, kumanan; graham, ian; ricketts, maura; dornan, christopher; laupacis, andreas; hebert, paul title: variant creutzfeldt–jakob disease and the canadian blood system after the tainted blood tragedy date: - - journal: soc sci med doi: . /j.socscimed. . . sha: doc_id: cord_uid: qi dkcb the transfusion transmission of hepatitis c and hiv to thousands of canadian blood recipients was one of this country's largest public health catastrophes. in response to this crisis, and in an effort to prevent such a tragedy from occurring again, the canadian blood system has undergone substantial reform. variant creutzfeldt–jakob (vcjd) disease was the first infectious threat faced by the blood system since undergoing reform. the response at the time to this risk provides insights into the canadian blood system's new approach to infectious threats. our analysis of the decision-making concerning vcjd identifies two dominant themes characterizing the new blood system's approach to safety: ( ).. the adoption of a precautionary approach to new risks which involves taking action in advance of definitive evidence, and ( ).. risk aversion amongst policy makers, which has contributed to the adoption of safety measures with comparatively high cost-effectiveness ratios. overall the principles governing the new blood system have contributed to the system both providing protection against emerging infectious risks and regaining the confidence of the public and recipients. however, the current set of policy factors will likely contribute to increasingly risk-averse policy making that will contribute to continued increases in the cost of the blood system. the challenge the blood system now faces is to find the appropriate balance between maximizing safety and ensuring the system remains affordable. the transfusion of individuals with products infected with hiv and hepatitis c was, arguably, the largest public health catastrophe in canada's history. estimates suggest that infected transfusions led to more than one thousand individuals acquiring hiv and up to individuals acquiring hepatitis c (krever, a) . a national inquiry into the functioning of the blood system and how it could have led to the tragedy, headed by justice horace krever, precipitated a transformation of the delivery of transfusion services in this country. this transformation involved the replacement of the canadian red cross as the operator of the blood system and the creation of new financial arrangements and operating principles (krever, b) . it has now been years since canada's blood system has undergone reform and the opportunity exists to reflect on how successful the transition to a new system has been. from the perspective of managing infectious threats, the new blood system would have to be viewed as a major success. canada has acted aggressively to protect the blood supply from real and theoretical risks such as variant cjd, west nile virus and severe acute respiratory syndrome (canadian blood services, ) . in this regard, the post-krever blood system has received high marks, including from hemophiliacs who were one of the primary groups affected by the tainted blood tragedy (canadian hemophilia society, ) . however, the blood system has not been without criticism, which has primarily been directed at the introduction of safety measures with prohibitive cost-effectiveness ratios that have contributed to escalating blood costs. there are several opportunities to learn from the canadian blood system's reform efforts and in many ways the blood system provides an important model for other public health sectors which are addressing new and emerging risks in an increasingly risk averse environment. to better understand how decisionmaking has been transformed in the post-krever era we provide a detailed examination of the canadian blood system's management of variant creutzfeldt--jakob disease, its first infectious threat since undergoing transition. while many faults could be found with how blood officials managed affairs leading to the tainted blood tragedy, one of the areas of particular concern was how scientific evidence was utilized to formulate policy. our analysis is therefore assisted by the use of a descriptive policy analysis framework that focuses on the role of information in the policy process. we review our findings in the context of subsequent blood policy decisions to arrive at general principles governing policy making in the post-krever environment. in the late s, the canadian blood system and health officials were confronted with a true policy dilemma: how to manage the theoretical risk of blood transmission of cjd. this challenge emerged just as justice krever was releasing his final report and federal/provincial/territorial officials were creating a new blood system in line with many of the recommendations of this report. the challenge also presented itself as the united kingdom was addressing the outbreak of bovine spongiform encephalopathy, which eventually led to the emergence of vcjd in humans, and dealing with criticism of their response to this crisis. thus, the potential transfusion transmission of cjd combined aspects of two of the highest profile public health controversies at the time. further contributing to the challenge of managing the infections risk posed by cjd to the blood supply was the unusual nature of the disease itself. cjd is a rare infectious condition that is believed to be caused by a new form of infectious agent, an infectious protein, known as a prion (prusiner, ) . the infection is devastating and affected patients suffer progressive neurological deterioration and dementia due to spongiform changes in the brains of the victims. patients inevitably die from the infection, usually within a year of the diagnosis. while extremely rare (o % of all cases), there have also been several documented cases of iatrogenic transmission of cjd. the documented iatrogenic transmission of cjd via human growth hormone, in particular, raised concerns in the united states and canada about whether the condition may also be transmissible via blood products. this concern arose in the canadian blood system, as it was recovering from the tragedy of hepatitis c and hiv blood transmission. as a consequence, the potential transfusion transmission of cjd was viewed as the first major test for the blood system after these infectious threats (vaughan, ) . the challenge of managing the potential transmission of cjd via blood products was further complicated by the discovery, in , of a variant form of cjd in the united kingdom . the condition was believed to have arisen from bovine spongiform encephalopathy (bse). while there was no epidemiological evidence of blood transmission of vcjd, the theoretical risk was considered higher than classical cjd for a variety of reasons (cashman, ) . policy makers in the united kingdom decided to reject donations from their citizens and import their plasma requirements due to concerns over the potential blood transmission of vcjd. this prompted decisionmakers in the united states and canada to evaluate whether they should accept donations from individuals who had traveled to the united kingdom. however, this would potentially reduce the blood supply and cause shortages. ultimately canadian policy makers decided to defer donations from individuals who had spent months in the united kingdom between the years and (the peak period of the bse epidemic). it was anticipated that this policy would reduce the risk of vcjd to the blood supply and ensure that the blood supply remained adequate (wilson et al., ) . these policies have been modified as further evidence has accumulated of the prevalence of bse and donor deferral policies have been instituted for individuals who have resided in france and all of western europe. most significantly, scientific evidence has accumulated which validates the institution of the precautionary policies, both from animal models demonstrating transfusion transmission and from case reports of transfusion transmission in humans (wilson & ricketts, ) . a framework for understanding decision-making on health risks to understand decision-making on issues of risk pertaining to the blood system, analytical tools that provide a comprehensive understanding of the multiplicity of factors that influence policy are required. descriptive policy analyses are well suited to analyzing policy making concerning risks by identifying the critical factors influencing decisionmaking as well as providing insights on where decision-making breaks down and, equally important, where it works effectively (hogwood & gunn, ) . descriptive policy analyses in health, however, have often been based on the assumption that rational decisions are made on the basis of complete information (pal, ) . given the uncertainty of scientific information on potential health risks, these information-based models may not be adequate. alternative models to evaluate decision-making have focused on the role of value systems or institutions. however, to be truly comprehensive, approaches to policy analysis integrating the impact of information, values and institutions are needed to ensure that both the policy makers and the public understand how decisions are made concerning health risks. paul sabatier has compiled some of the available frameworks for conducting descriptive policy analyses (sabatier, a) . one of the criteria used for selecting frameworks is that they address the roles of conflicting values and interests, information flows, institutional arrangements and variations in socioeconomic environment on the policy process. the following frameworks were identified as useful for describing decision-making within a given political system or set of institutional arrangements: the stages heuristic, institutional rational choice, multiple-streams framework, punctuated equilibrium framework and the advocacy coalition framework. the last framework, the advocacy coalition framework (acf), was proposed by sabatier and suggests that decision making occurs in a policy subsystem involving individuals from a variety of public and private organizations who are actively concerned with a policy problem. within this subsystem, individuals aggregate into advocacy coalitions based on shared ideologies and beliefs. the success of the coalitions in translating their beliefs into policy is dependent upon their resources (money, expertise, legal authority and size). policy brokers attempt to mediate the conflict between the various advocacy coalitions. this process of conflict and mediation eventually results in policy outputs by the governing structures in the subsystem (sabatier, ; sabatier, b ). the acf model has been identified as being effective in describing decision-making in a variety of policy sectors (jenkins-smith & sabatier, ) . a modification of the acf model has been put forward by jonathan lomas (fig. ) (lomas, ) . in this model individuals make policy in an ''institutional structure for decision-making''. this structure consists of ''formal'' actors, who actually participate directly in the decision-making process, and ''informal'' actors, who influence decisionmaking through other means. values in this model are divided into ideologies (views on how things ought to be), beliefs (causal assumptions on how things are), and interests (responses to incentives and rewards). in addition, this model pays greater attention to the role of information producers and purveyors. it specifically examines how information is produced and spread and how the value systems of those involved in the policy subsystem influence the interpretation and use of this information. our choice of the lomas framework was based on face and content validity parameters; i.e. the domains we felt would be important are appropriately captured in the framework. the vcjd decision was primarily characterized by how policy makers utilized scientific information. in this sense, the lomas framework is well suited to conducting the analysis given its focus on knowledge development and knowledge transfer. the framework's hypothesis that policy makers resolve conflicts between their various value systems through a process of cognitive dissonance reduction is also well suited to analyzing a policy problem where information is uncertain and value systems would necessarily play a particularly prominent role. the objective of our overall study was to understand and compare the decision-making processes concerning two creutzfeldt-jakob disease-related decisions: a withdrawal of blood products from a classical cjd donor and a decision to defer donations from individuals who had traveled to the united kingdom for months during the peak of the bse outbreak ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . we present, here, the full analysis of the second decision, with the first decision acting as important historical context. our study consisted of a literature review and semi-structured interviews. the literature review included a systematic review of the risk of transmission of cjd via blood products, a content analysis of newspaper reporting as well as a review of important policy documents. in total we conducted semi-structured interviews with key informants of all major decision-making organizations. individuals were asked to describe decision-making leading to the and decisions as well as other relevant decisions. individuals were also asked about the role of information, information purveyors, decision-making organizations and external factors in the decision-making process. all information from the interviews was coded using qsr nudist, a qualitative software program. findings of the study were fed back to decision-makers through member check sessions with key stakeholder organizations. our findings have been presented in a series of papers, initially focusing on information (wilson, code, & ricketts, ) and information purveyors , then institutions (wilson et al., ; wilson, mccrea-logie, & lazar, ) and finally the role of values and changes in ideology (wilson, wilson, hebert, & graham, ) . we synthesized the results of these studies using the lomas framework. based on this synthesis we isolate the key policy factors that are driving current decision-making in the canadian blood system. we then propose mechanisms by which acting on these policy factors could influence future decisions. factors influencing decision-making (table ) in canada three pieces of information played an important role in influencing the decision-making process leading to the donor deferral decision: ( ) the risk of transmission of vcjd via blood products, ( ) the impact of donor deferral on the blood supply, and ( ) the degree of reduction in the blood supply the blood system could sustain. all of these pieces of information had substantial levels of uncertainty associated with them. there were no epidemiological studies on risk of blood transmission of vcjd and an estimation of the risk was based primarily on biological models. based on these models the theoretical risk possibility of blood transmission of vcjd was considered for the following reasons: vcjd had been demonstrated to be transmissible through a peripheral route (gi tract) and thus peripheral transmission via blood products was believed to be possible, the prion concentration in affected tissues was high in vcjd and prions are found in the lymphoreticular system in vcjd which is intimately linked to the blood supply (cashman, ) . scientists argued that this evidence of risk based on biological models was substantial enough to warrant government action to protect the blood supply. given the uncertainty of information on risk of blood transmission of vcjd the impact of a policy on the blood supply needed to be considered before proceeding. this information was obtained from a survey that suggested that a % reduction in the blood supply would occur with a -month deferral policy. previous experience in the blood system indicated that a % reduction was sustainable, although there was considerable uncertainty over this estimate. in an attempt to integrate all of this information, as well as the likelihood of developing vcjd over different residency periods in the united kingdom, a risk modeling exercise was performed. this analysis also suggested that the risk of contracting vcjd increased after months residence in the united kingdom. however, this model was based on infectivity rates of bse that, to this date, remain unclear (elsaadany & giulivi, ) . three major information purveyors influenced the policy process leading to the donor deferral decision: scientists, the media and think tanks. the media's primary role was to disseminate the release of a report by a think tank advisory committee on bioethics, which advocated that the canadian blood (bayer advisory council on bioethics, ) . in combination, this report and the media coverage it received played an important agenda setting function by bringing the emerging issue to the public's attention . scientists also played an important role in communicating information on risk to policy makers. in particular, due to the lack of scientific expertise on the subject, one scientist came to play a prominent role in the decisionmaking process. this individual was a consultant on three separate sources of information that were supplied to the decision-makers. all of these recommended that the government take action to protect the blood supply from vcjd (bayer advisory council on bioethics, ; cashman, ; expert advisory committee on blood regulation, ) . we had a unique opportunity to assess the impact of institutions on decision-making by being able to compare the vcjd donor deferral decision to another cjd related decision that took place prior to institutional change in the blood system; the recall of blood from a classical cjd donor. the major structural changes to the blood system that took place over this time period was the replacement of the canadian red cross as sole operator of the blood system by two separate operators, he´ma-que´bec in the province of quebec, and canadian blood services in the rest of canada. we observed that the movement to a two-operator system had an important impact on the decision-making process. the presence of a second operator introduced a form of ''check and balance'' on the decisionmaking processes of the larger operator by proposing competing policy options to address the vcjd problem. however, it also increased the complexity of the decision-making process and initially produced some inter-institutional conflict (wilson et al., ) . distribution of regulatory authority and funding also played an important role in the decisionmaking process, specifically the separation of these two functions. in canada regulatory authority for blood products exists at a federal level. financing of the blood system is the responsibility of the provinces. in this system, the incentive exists for the regulator to introduce policies that maximize the safety of the blood supply, and the financial considerations of the decision play a secondary role (wilson, mccrea-logie et al., ) . other institutional effects include decisions made by institutions in parallel subsystems, in particular other countries' blood systems. the uk decision to ban plasma donation from its own citizens played a large role in initiating the decision-making process in both canada and the united states as to how to handle donations from individuals who had traveled to the united kingdom. of particular importance, canadian policy makers attempted to coordinate canada's donor deferral policy with that of the united states. this was largely a consequence of the fact that canada imports a substantial portion of its plasma requirements from the united states. in general, canadian policy makers are expected to meet international standards in protecting the blood supply (canadian blood services, ) . we observed that most individuals shared a common belief, defined as a ''causal assumption of what is'', on the risk of transmission of cjd; that transfusion transmission was a theoretical risk with no known documented cases of transmission. however, while the risk was viewed as theoretical, the type of risk which was presented is one to which the public and policy makers would be particularly averse. the factors contributing to this perception of risk include the potentially catastrophic, involuntary nature of the risk, the lack of knowledge of the risk and the lack of trust in the system's ability to manage the risk (slovic, ) . ideologies, defined as ''causal assumptions of how things ought to be'', played an important role in determining how information was interpreted and utilized to develop policy. two dominant ideologies on how decision-making should take place on issues of risk were at play: evidence-based decision-making and the precautionary principle. the precautionary principle came to play a particularly prominent role largely as a consequence of the krever inquiry into the blood system use. however, we observed a clear tension in which decision-makers struggled with the idea of introducing a policy that could create a health risk (blood shortages) to protect against a risk for which no epidemiological evidence existed . at the institutional level, we found competing interest systems at work. the regulator's primary responsibility was to protect the safety of the blood system. the operators, in contrast, were interested in balancing safety with adequacy of supply. however, all players in the blood system recognized the crucial need to reestablish public confidence in the blood system and their responsibility to protect the blood supply on behalf of the public. at the level of the policy-maker, the lasting effects of the krever inquiry played an important role in influencing individuals' actions. the spotlight that was placed on previous decision-makers in the blood system and the legal consequences of the subsequent criminal probe created a climate that encouraged implementation of a risk-averse policy (picard, ) . reconstructing the policy process from the factors we have analyzed presents us with the following explanation of why events unfolded as they did. agenda setting in canada primarily occurred due to policy decisions made in other countries (e.g. the uk blood system). public awareness was raised by the release of a think-tank report and the dissemination of the information from this report via the print media. the decision to introduce a partial measure to protect against the theoretical risk, in the absence of definitive evidence of the risk, was largely influenced by the knowledge that the united states would proceed with a similar decision. the canadian decision-making process was also shaped by the emergence of the precautionary principle as a dominant ideology in public health. however, perhaps the most important driving factors in the decision-making process were the past experience of the blood supply with hepatitis c and hiv, the general shadow cast by the recent krever inquiry, policy maker fiduciary duty to the pubic and their need to re-establish public trust by being seen to be acting pro-actively. the vcjd policy decision deserves closer examination for several reasons. it demonstrated how policy was made to address an, at the time, theoretical risk. the canadian vcjd donor deferral decision was also emblematic of how other nations addressed the vcjd threat. in addition to withdrawing blood products derived from individuals subsequently diagnosed with vcjd and importing fractionated products from abroad, the uk has recently decided to ban donations from individuals who had previously received a transfusion. france also has instituted precautionary policies including the introduction of leukoreduction, which theoretically would remove infectious material from donated blood (lee, ) . the us policy regarding vcjd was similar to canada's, choosing to introduce donor deferral policies for individuals who had traveled to countries in which bse was endemic (fda, january ) . the vcjd decision-making process in all of these countries reflected a paradigm shift in how to manage emerging risks. this new paradigm involved the institution of protective measures at an early stage of the risk identification process and reflected a conscious decision by policy makers to act in advance of complete scientific information. important lessons can be learned from the canadian vcjd policy-making process and the decision-making process stands in stark contrast to the decisions concerning hepatitis c and hiv in the pre-krever blood system. in particular, two key themes that have come to dominate decisionmaking in the post krever era deserve further analysis-the application of the precautionary principle to blood policy and the challenge of rising costs in a risk-averse blood system. blood policy makers, in addressing the potential threat of vcjd, ultimately embarked upon a strategy that they believed balanced the reduction in blood supply with reducing the risk of exposure of canadians to potentially infected blood products. this decision explicitly acknowledged the possibility of risk in the absence of epidemiological studies and represented a critical shift from the previous mechanism of policy making. many criticisms exist of blood policy making in several countries leading to the transfusion transmission of hepatitis c and hiv. particularly, in the instance of hiv, the criticisms surround unacceptable delays implementing policies recognized as providing some protection to blood recipients (gilmore & somerville, ; picard, ; weinberg et al., ) . however, one of the primary limitations of pre-krever decisionmaking in canada was the manner in which scientific information was utilized in the formulation of policy. this was perhaps most glaringly demonstrated when considering the decision-making process concerning the adoption of surrogate testing for hepatitis c. the details of the canadian decision regarding surrogate testing has been well described elsewhere (krever, c) . in summary, blood officials in the s were confronted with the threat of a new form of hepatitis referred to as nona-nonb hepatitis, later discovered to be hepatitis c. this form of hepatitis was known to be transfusion transmissible, however, the virus had not been identified and thus no specific test existed to identify contaminated blood. consideration was therefore given to the use of surrogate tests which could not only identify some infected donations but also would result in the discarding of some donations that were not infected (aach et al., ; alter, purcell, holland, alling, & koziol, ) . canadian officials awaited the results of a prospective trial that compared the rates of post transfusion hepatitis from individuals who received blood from donors who had surrogate testing compared to those who received blood from donors who had not undergone surrogate testing. unfortunately, by the time evidence demonstrating the efficacy of the surrogate testing strategy become available, thousands of individuals had become infected by hepatitis c through blood transfusions, many of which could potentially have been prevented (blajchman, bull, & feinman, ) . on reflection, it becomes apparent that a fundamental failing of the canadian blood system's management of hepatitis c was the adoption or perhaps misapplication of the evidence-based paradigm when developing policy concerning safety. the evidence-based paradigm is dominated with the belief in a hierarchy of evidence that asserts that randomized trials are the highest level of evidence (upshur, ) . in the tainted blood tragedy such an approach was found to be wanting in many respects, primarily related to the consequences of waiting for high quality evidence when the health of populations, as opposed to the health of individuals, is at risk. reflecting this recognition, the ''precautionary principle'' has emerged as a new paradigm governing the use of scientific information. the precautionary principle essentially states that complete evidence of risk does not have to exist before action is taken to protect against the risk, particularly when the risk is potentially catastrophic (wingspread conference participants, ). although there are numerous interpretations of the principle, applications generally advocate an-ticipatory action to protect against harm, prioritize protection of public health and the environment and promote public participation in decision-making (stoto, ) . while the principle has become highly influential in risk decision-making in the environment and in health, it also has been heavily criticized. opponents of the principle point to its lack of clarity, potential to create unnecessary fear and potentially denying the public the benefits of new technology (morris, ) . in addressing the theoretical risk of vcjd, the canadian blood system, and blood systems around the world, was guided by the precautionary principle. however, at the same time they also integrated components of evidence-based policy making in an attempt to find a middle ground between these potentially conflicting paradigms. specifically, they chose to introduce a measured response that would not cripple the blood supply. this response was then calibrated as new evidence emerged on risk of transmission. in doing so they succeeded in accomplishing several policy objectives including reestablishing confidence in the blood system and demonstrating to the public that policy makers were acting proactively to protect the public. most importantly, as evidence accumulated to demonstrate the probable transfusion transmissibility of vcjd, the policy decisions made by canada and other countries appear to have been warranted and likely prevented further spread of vcjd through transfusion (llewelyn et al., ; peden, head, ritchie, bell, & ironside, ) . in hindsight, the integration of precautionary policy making in the new blood system would have to be considered a major success (wilson & ricketts, ) . while the new blood system's precautionary approach to blood safety has received praise it also has not been without some criticism. in canada, over a three-year period since the blood system underwent structural reform, expenditures in the blood system have increased by % . these rising blood system costs have been attributed to several factors including the increase in use of blood products, and the increase in cost of specific blood products such as intravenous immunoglobulin (wilson, macdougall et al., ) . however, attention has particularly been focused on the introduction of new safety measures that have only marginally improved the safety of the blood supply. some transfusion policy analysts have described the introduction of these safety measures as ''irrational''. these individuals point to the normally prohibitive cost-effectiveness ratios of many of theses measures (bayer & feldman, ) . the cost-effectiveness ratios associated with several of the post-krever safety measures has far exceeded the generally accepted cost-effectiveness ratios of $ to $ per qaly (laupacis, feeny, detsky, & tugwell, ) . for example, the cost/quality adjusted life year of nucleic acid amplification testing for hepatitis c is $ million/ qaly and for solvent detergent plasma $ million/ qaly (aubuchon & petz, ) . these tests have also impacted upon the cost of blood. nucleic acid amplification testing for both hepatitis c and hiv has been estimated to contribute - % of the cost of a unit of blood in the united states (weinberg et al., ) . blood systems are also being confronted with the decision of adopting several expensive new safety measures, such as pathogen inactivation technologies (council of europe, ) . in the united states (us) the medicare payment advisory committee identified that blood-related costs have been increasing more rapidly than other hospital costs placing strains on the current diagnosis related group (drg) payment system (medicare payment advisory committee, ) . in canada, provinces, which are responsible for funding the blood system, have expressed unease about rising blood costs and asked for a reconsideration of how policy decisions concerning the introduction of safety measures are being made (ibm consulting, ) . the decision to introduce highly risk averse policies (i.e. the choice of policies with a high certainty of eliminating remote risks) does not appear to be driven by ''public hysteria'' but rather by incentive systems that act directly on the policymakers. evidence for the lack of public demand driving the policy process is provided by the introduction of other similar protective policies. for example leukoreduction, a process by which white blood cells are removed, was introduced to protect against transfusion reactions and potentially other immune mediated effects. the policy met some controversy over its necessity and could not be expected to have been a high agenda issue for the public who would have little understanding of the process and for whom transfusion reactions would not be a major health concern (goodnough, ) . the other explanation for the lack of public influence on blood policy is the absence of welldefined advocacy coalitions representing the public and the interests of consumers of blood products (orsini, ) . the majority of recipients of blood products are members of the general population who cannot necessarily be identified in advance. the canadian blood system has also explicitly involved representatives of various consumer groups in their policy making process which has reduced the need for public lobbying by these individuals. in contrast to the relative lack of risk aversion amongst the public, our analyses suggest that risk aversion on the part of policy makers is likely responsible for the introduction of several of the safety policies. canadian officials are eminently aware of the public health consequences of the transfusion transmission of hepatitis c and hiv. they also cannot help but be aware of the legal consequences of those who were involved in the decision-making processes at the time. the current incentive structure does little to protect against liability because the recommendation of the justice krever to introduce a no-fault compensation system for transfusion related injury was not implemented. such systems have been found to be effective in controlling litigation in pediatric vaccination, an analogous policy area (plotkin, ) . further contributing to risk-averse policy making is the separation of funding from decision-making in the blood system, with the federal government having the authority of introducing safety measures but not the responsibility for paying for them. the impact of this structural factor on blood system costs could have been mitigated if justice krever's recommendation to have hospitals pay for blood products had been introduced since the budget restrictions of the hospitals would have limited their ability to pay for expensive products. despite the growing cost pressures on the blood system, we would expect the canadian blood system's proactive response to threats to blood safety to continue, given the current set of operating principles and policy factors at play. consequently, so will the trend towards the adoption of risk-averse safety measures with marginal cost-effectiveness ratios. if individuals in the blood system are interested in continuing the current practice of ensuring a safe blood supply with cost being a secondary concern, little change needs to occur in the decision-making process. on the other hand, if blood system decisionmakers or provincial officials responsible for funding the blood system desire a change to this approach, it is unlikely that additional studies demonstrating the comparatively poor cost-effectiveness of safety measures alone will have much impact. the current set of institutional arrangements, in which the regulator can introduce safety regulations and not be held directly responsible for the costs of these regulations, will continue to encourage the implementation of safety measures to ensure a high level of blood safety. this is also encouraged by the arms length relationship between the blood system operator and the provincial funders that permits the operator to independently introduce safety measures. to combat the impact of these factors provincial governments will have to make efforts to regain control of the policy making process in the blood system, or perhaps require federal regulators to pay a component of the costs associated with their safety regulations. the scenario of such federal unfunded mandates imposing cost burdens on other orders of government has been observed in the us where it was partially addressed through legislative means (conlan, riggle, & schwartz, ) . a risk-averse approach to blood safety is further encouraged as long as decisionmakers are aware of their potential legal and public accountability and a no-fault compensation program for transfusion injured recipients that limits legal liability may help address this issue. our analysis also suggests that as long as the canadian blood supply is reliant upon importing plasma from the united states, canadian blood policy will be heavily influenced by us blood policy. the continued goal of the canadian blood system to achieve selfsufficiency may address this concern. nevertheless, in an increasingly integrated world, decisions made in parallel policy subsystems of other nations' will play a crucial role in determining policy. standard of care may be defined as the international response to a threat and a decision-maker who disagrees with this response may still be left with little option but to meet the international standard. despite the presence of these factors, the adoption of highly risk averse policies cannot continue endlessly and the opportunity costs of these policies will become increasingly evident. eventually, policymakers will have to decide at what level of uncertainty of risk or at what level of cost/qaly safety measures will not be introduced. the decision of whether to adopt pathogen inactivation technologies, which offer the promise to remove both known and unknown pathogens from transfusions although at a substantial cost, will present an interesting challenge to the continued adoption of new safety measures. in many ways, the canadian blood system serves as a model for a transformed system emerging from a crisis of confidence. vcjd represents the first infectious threat to this transformed system and important lessons can be learned from how this threat was managed. decision-making related to vcjd is representative of the new blood system's approach of aggressively addressing risk in a proactive manner and introducing policies in advance of clear evidence of risk. while this approach was essential in the first stages of reform, and has reestablished the confidence of the canadian public, it has contributed to rising costs. the challenge the blood system now faces is to find the appropriate balance between maximizing safety and ensuring the system remains affordable. serum alanine aminotransferase of donors in relation to the risk of non-a, non-b hepatitis in recipients: the transfusion-transmitted viruses study donor transaminase and recipient hepatitis. impact on blood transfusion services making decisions to improve transfusion safety creutzfeldt-jakob disease, blood and blood products: a bioethics framework understanding the blood feuds posttransfusion hepatitis: impact of non-a, non-b hepatitis surrogate tests. canadian post-transfusion hepatitis prevention study group cbs response and action plan-summary. in performance review of canadian blood services safety of products report card on canada's blood system years after the commission of inquiry on the blood system in canada new variant creutzfeldt-jakob disease and the canadian blood supply: scientific basis of risk deregulating federalism? the politics of mandate reform in the th congress expert committee in blood transfusion study group on pathogen inactivation of labile blood components comprehensive risk assessment for vcjd in france and other countries for canadians and the canadian blood supply. ottawa: division of blood borne pathogens, health canada. expert advisory committee on blood regulation item . ottawa: health protection branch, health canada revised preventive measures to reduce the possible risk of transmission of creutzfeldt-jakob disease (cjd) and variant creutzfeldt-jakob disease (vcjd) by blood and blood products. us department of health and human services from trust to tragedy: hiv/aids and the canadian blood system blood feuds. aids, blood and the politics of medical disaster the case against universal wbc reduction (and for the practice of evidence-based medicine) models of policy making. in policy analysis for the real world executive summary. in performance review of canadian blood services evaluating the advocacy coalition framework the consequences of the contamination of the blood supply the blood system for the future. chapter canada's rejection of surrogate testing how attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations france acts on threat of bse transmission by blood. the french blood transfusion authorities are banning donors who might have become exposed to bse in the uk. the scientist possible transmission of variant creutzfeldt-jakob disease by blood transfusion connecting research and policy blood safety in hospitals and medicare inpatient payment rethinking risk and the precautionary principle the politics of naming, blaming and claiming: hiv, hepatitis c, and the emergence of blood activism in canada public policy analysis preclinical vcjd after blood transfusion in a prnp codon heterozygous patient the gift of death. confronting canada's taintedblood tragedy rcmp lay charges in tainted-blood case. globe and mail lessons learned concerning vaccine safety novel proteinaceous infectious particles cause scrapie knowledge, policy-oriented learning, and policy change. an advocacy coalition framework. knowledge: creation, diffusion, utilization the need for better theories policy change over a decade or more. in policy change and learning. an advocacy coalition approach perception of risk the precautionary principle and emerging biological risks: lessons from swine flu and hiv in blood products are all evidence-based practices alike? problems in the ranking of evidence creutzfeldt-jakob disease latest unknown in struggle to restore faith in blood supply legal, financial, and public health consequences of hiv contamination of blood and blood products in the s and s a new variant of creutzfeldt-jakob disease in the uk the reporting of theoretical health risks by the media: canadian newspaper reporting of potential blood transmission of creutzfeldt-jakob disease risk of acquiring creutzfeldt-jakob disease from blood transfusions: systematic review of case-control studies the challenge of an increasingly expensive blood system a policy analysis of major decisions relating to creutzfeldt-jakob disease and the blood supply how should canada fund the blood system? an evaluation of the chargeback proposal understanding the impact of intergovernmental relations on public health: lessons form reform initiatives in the blood system and health surveillance the success of precaution? managing the risk of transfusion transmission of variant creutzfeldt-jakob disease the application of the precautionary principle to the blood system: the canadian blood system's vcjd donor deferral policy wingspread statement on the precautionary principle this study was supported by a grant from the canadian institutes of health research. thanks also to cathy code and nadya ahmad. key: cord- - vodag c authors: karaivanov, a.; lu, s. e.; shigeoka, h.; chen, c.; pamplona, s. title: face masks, public policies and slowing the spread of covid- : evidence from canada date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vodag c we estimate the impact of mask mandates and other non-pharmaceutical interventions (npi) on covid- case growth in canada, including regulations on businesses and gatherings, school closures, travel and self-isolation, and long-term care homes. we partially account for behavioral responses using google mobility data. our identification approach exploits variation in the timing of indoor face mask mandates staggered over two months in the public health regions in ontario, canada's most populous province. we find that, in the first few weeks after implementation, mask mandates are associated with a reduction of percent in the weekly number of new covid- cases. additional analysis with province-level data provides corroborating evidence. counterfactual policy simulations suggest that mandating indoor masks nationwide in early july could have reduced the weekly number of new cases in canada by to percent in mid-august, which translates into to , fewer cases per week. when government policies to stem the spread of were introduced in early , the best available evidence supporting them was provided by studies of previous epidemics, epidemiological modeling, and case studies (oecd, ). even when the efficacy of a given precaution in reducing covid - transmission has been established, significant doubts regarding the usefulness of specific policy measures may persist due to uncertainty regarding adherence to the rules and other behavioral responses. for example, even though several observational studies, mostly in medical setting, have shown that face masks reduce the transmission of and similar respiratory illnesses (see chu et al. ( ) for a comprehensive review), a face mask mandate may not be effective in practice if it fails to increase the prevalence of mask wearing (compliance), or if it leads to increased contacts due to a false sense of security. it is therefore important to directly evaluate and quantify the relationship between various policy measures and the rate of propagation of . the low cost and high feasibility of mask mandates relative to other containment measures for has generated keen interest worldwide for studying their effectiveness. this attention has been compounded by substantial variation, across jurisdictions and over time, in official advice regarding the use of masks. figure b in the appendix plots self-reported mask usage in select countries (canada, united states, germany and australia) in the left panel, and across canadian provinces in the right panel. the figure shows large differences in mask usage, both across countries and within canada. we estimate and quantify the impact of mask mandates and other non-pharmaceutical interventions (npi) on the growth of the number of covid- cases in canada. canadian data has the important advantage of allowing two complementary approaches to address our objective. first, we estimate the effect of mask mandates by exploiting within-province geographic variation in the timing of indoor face mask mandates across public health regions (phus) in ontario, canada's most populous province with a population of nearly million or roughly % of canada's population (statistics canada, ). the advantage of this approach is that it exploits variation over a relatively small geographic scale (phu), holding all other province-level policies or events constant. in addition, the adoption of indoor face mask mandates in these sub-regions was staggered over approximately two months, creating sufficient intertemporal policy variation across the phus. second, we evaluate the impact of npis in canada as a whole, by exploiting variation in the timing of policies across the country's ten provinces. by studying inter-provincial variation, we are able to analyze the impact of not only mask mandates, but also other npis, for which there is little or no variation across ontario's phus (regulations on businesses and gatherings, schooling, travel and long-term care). in addition, our province-level data include both the closing period (march-april) and the gradual re-opening period (may-august), providing variation from both the imposition and the relaxation of policies. our panel-data estimation strategy broadly follows the approach of chernozhukov, kasahara and schrimpf ( ), hereafter cks ( ), adapted to the canadian context. we allow for behavioural responses (using google community mobility reports geo-location data as proxy for behaviour changes and trends), as well as lagged outcome responses to policy and behavioral changes. our empirical approach also allows current epidemiological outcomes to depend on past outcomes, as an information variable affecting past policies or behaviour, or directly, as in the sir model framework. we find that, in the first few weeks after their introduction, mask mandates are associated with an average reduction of to % in the weekly number of newly diagnosed cases in ontario, holding all else equal. we find corroborating evidence in the province-level analysis, with a to % reduction in weekly cases, depending on the empirical specification. furthermore, using survey data, we show that mask mandates increase self-reported mask usage in canada by percentage points, suggesting that the policy has a significant impact on behaviour. jointly, these results suggest that mandating indoor mask wear in public places is a powerful policy measure to slow the spread of , with little associated economic disruption at least in the short run. counterfactual policy simulations using our empirical estimates suggest that mandating indoor masks nationwide in early july could have reduced weekly new cases in canada by to % on average by mid-august relative to the actually observed numbers, which translates into to , fewer cases per week. we also find that the most stringent restrictions on businesses and gatherings observed in our data are associated with a decrease of to % in weekly cases, relative to a lack of restrictions. the business/gathering estimates are, however, noisier than our estimates for mask mandates and do not retain statistical significance in all specifications; they appear driven by the smaller provinces and the re-opening period (may to august). school closures and travel restrictions are associated with a large decrease in weekly case growth in the closing period. our results on business/gathering regulations and school closure suggest that reduced restrictions and the associated increase in business or workplace activity and gatherings or school re-opening can offset, in whole or in part, the estimated effect of mask mandates on case growth, both in our sample and subsequently. an additional contribution of this research project is to assemble, from original official sources only, and make publicly available a complete dataset of cases, deaths, tests and policy measures in all canadian provinces. to this end, we constructed, based on official public health orders and announcements, time series for policy indicators regarding face masks, regulations on businesses and gatherings, school closures, travel and self-isolation, and long-term care homes. our paper relates most closely to two recent empirical papers on the effects of mask mandates using observational data. cks ( ) and mitze et al. ( ) study the effect of mask mandates in the united states and germany, respectively. cks ( ), whose estimation strategy we follow, exploit u.s. state-level variation in the timing of mask mandates for employees in public-facing businesses, and find that these mandates are associated with to percentage points reduction in the weekly growth rate of cases. this is substantially smaller that our estimates, possibly because the mask mandates that we study are much broader: they apply to all persons rather than just employees, and most apply to all indoor public spaces rather than just businesses. mitze et al. ( ) use a synthetic control approach and compare the city of jena and six regions in germany that adopted a face mask policy in early to mid april , before their respective state mandate. they find that mandatory masks reduce the daily growth rate of cases by about %. our paper has several advantages compared to the above two papers. first, we exploit both regional variation within the same province (like mitze et al., ) and provincial variation in the whole country (like cks, ), and find similar results, which strengthens the validity of our findings. second, we show that self-reported mask usage has increased after introducing mask mandates. we view this "first-stage" result on mask usage as informative, as the effectiveness of any npi or public policy critically depends on the compliance rate. moreover, this result mitigates possible concerns that the estimated mask mandate effect on case growth may be caused by factors other than mask policy. third, a key difference between our paper and cks ( ) is that we evaluate the effect of universal (or community) mandatory indoor mask wearing for the public rather than the effect of mandatory mask wearing for employees only. while other factors such as differences in mask wear compliance between canada and the u.s. may contribute to the different estimated magnitude of the policy impact, our results suggest that more comprehensive mask policies can be more effective in reducing the case growth rate. other related literature abaluck et al. ( ) discuss the effectiveness of universal adoption of homemade cloth face masks and conclude that this policy could yield large benefits, in the $ , -$ , per capita range, by slowing the spread of the virus. the analysis compares countries with pre-existing norms that sick people should wear masks (south korea, japan, hong kong and taiwan) and countries without such norms. in the medical literature, prather et al. ( ) argue that masks can play an important role in reducing the spread of covid- . howard et al. ( ) survey the medical evidence on mask efficiency and recommend public use of masks in conjunction with existing hygiene, distancing, and contact tracing strategies. greenhalgh et al. ( ) provide evidence on the use of masks during non-covid epidemics (influenza and sars) and conclude that even limited protection could prevent some transmission of . leung et al. ( ) study exhaled breath and coughs of children and adults with acute respiratory illness and conclude that the use of surgical face masks could prevent the transmission of the human coronavirus and influenza virus from symptomatic individuals. meyerowitz et al. ( ) present a recent comprehensive review of the evidence on transmission of the virus and conclude that there is strong evidence from case and cluster reports indicating that respiratory transmission is dominant, with proximity and ventilation being key determinants of transmission risk, as opposed to direct contact or fomite transmission. our paper also complements recent work on covid- policies in canada. mohammed et al. ( ) use public opinion survey data to study the effect of changes in mask-wear policy recommendations, from discouraged to mandatory, on the rates of mask adoption and public trust in government institutions. they show that canadians exhibit high compliance with mask mandates and trust in public health officials remained consistent across time. yuksel et al. ( ) use an outcome variable constructed from apple mobility data along period january to february , . in ontario, these location data are available for each of the first-level administrative divisions (counties, regional municipalities, single-tier municipalities and districts). we follow the approach of cks ( ), but modify and adapt it to the canadian context. the empirical strategy uses the panel structure of the outcome, policy and behavioral proxy variables, and includes lags of outcomes as information, following the causal paths suggested by the epidemiological sir model (kermack and mckendrick, ) . specifically, we estimate the effect of policy interventions on covid- outcomes while controlling for information and behaviour. in contrast to cks ( ) and hsiang et al. ( ) , who study variation in npis across u.s. states or across countries, our identification strategy exploits policy variation at the sub-provincial level (ontario's phus) in addition to cross-province variation, and our data captures both the closing down and gradual re-opening stages of the epidemic. . controls, w it -province or phu fixed effects, growth rate of weekly new tests, and a time trend. to assess and disentangle the impact of npis and behavioral responses on covid- outcomes, we estimate the following equation: where l denotes a time lag measured in days. equation ( ) models the relationship between covid- outcomes, y it , and lagged behaviour, b it−l , lagged policy measures, p it−l and information (past outcomes), i it = y it−l . for case growth as the outcome, we use l = . for deaths growth as the outcome, we use l = . the choice of these lags is discussed in appendix d. by including lagged outcomes, our approach allows for possible endogeneity of the policy interventions p it , that is, the introduction or relaxation of npis based on information on the level or growth rate of cases or deaths. also, past cases may be correlated with (lagged) government policies or behaviors that may not be fully captured by the policy and behaviour variables. in appendix table a , we also report estimates of the following equation: which models the relationship between policies p it , information, i it (weekly levels or growth of cases or deaths) and behaviour, b it . it is assumed that behaviour reacts to the information without a significant lag. we find strong correlation between policy measures and the google mobility behavioral proxy measure. equation ( ) captures both the direct effect of policies on outcomes, with the appropriate lag, as well as the potential indirect effect on outcomes from changes in behaviour captured by the changes in geo-location proxy b it−l . in appendix tables a and a , we also report estimates of equation ( ) without including the behavioral proxy, that is, capturing the total effect of policies on outcomes. since our estimates of the coefficient α in equation ( ) are not significantly different from zero, the results without controlling for the behavioral proxy are very similar to those from estimating equation ( ). outcomes. our main outcome of interest is the growth rate of weekly new positive cases as defined below. we use weekly outcome data to correct for the strong day-of-the-week effect present in covid- outcome data. weekly case growth is a metric that can be helpful in assessing trends in the spread of , and it is highlighted in the world health organization's weekly epidemiological updates (see, for example, world health organization ( )). specifically, let c it denote the cumulative case count up to day t and define ∆c it as the weekly covid- cases reported for the -day period ending at day t: the weekly case (log) growth rate is then defined as: that is, the week-over-week growth in cases in region i ending on day t. the weekly death growth rate is defined analogously, using cumulative deaths data. policy. in the ontario analysis, we exploit regional variation in the timing of indoor mask mandates staggered over two months in the province's regions ("public health units" or phus). figure displays the gradual introduction of mask mandates across the phus in ontario. the exact implementation dates of the mask mandates are reported in table c . mandatory indoor masks were introduced first in the wellington-dufferin-guelph phu on june and last in the northwestern phu on august . we also report results using the growth rate of deaths as supplemental analysis in section . . figures b and b in the appendix respectively display the weekly and daily cases, deaths and tests in each canadian province over time. there are markedly lower numbers reported on weekends or holidays. to deal with zero weekly values, which mostly occur in the smaller regions, as in cks ( ), we replace log( ) with - . we also check the robustness of our results by adding to all ∆c it observations before taking logs, by replacing log( ) with , and by using population weighted least squares; see tables a and a . there is no phu-wide mask mandate in lambton as of august , but its main city, sarnia, enacted a mask mandate on july . figure : ontario -mask mandates over time in the province-level analysis, we assign numerical values to each of the policy indicators listed in table c in appendix c. the values are on the interval [ , ], with meaning no or lowest level of restrictions and meaning maximal restrictions. a policy value between and indicates partial restrictions, either in terms of intensity (see more detail and the definitions in table c ) or by geographical coverage (in large provinces). the numerical values are assigned at the daily level for each region (phu or province, respectively for the ontario and national results), while maintaining comparability across regions. many npis were implemented at the same time, both relative to each other and/or across regions (especially during the march closing-down period), which causes many of the policy indicators to be highly correlated with each other (see appendix table a ). to avoid multi-collinearity issues, we group the policy indicators into policy aggregates via simple averaging: (i) travel, which includes international and domestic travel restrictions and self-isolation rules; (ii) school, which is an indicator of provincial school closure; (iii) business/gathering, which comprises regulations and restrictions on non-essential businesses and retail, personal businesses, restaurants, bars and nightclubs, places of worship, events, gyms and recreation, and limits on gathering; (iv) long-term care (ltc), which includes npis governing the operation of long-term care homes (visitor rules and whether staff are required to work on a single site) and (v) mask which takes value if an indoor mask mandate has been introduced, if not, or value between and if only part of a province has enacted such policy. the five policy aggregates are constructed at the daily level and capture both the closingdown period (an increase in the numerical value from toward ) and the re-opening period (decrease in the numerical value toward zero). in comparison, the policy indicators compiled by raifman ( ) for the usa used in cks ( ) are binary "on ( )"/"off ( )" variables. for consistency with the weekly outcome and information variables and the empirical model timing, we construct the policy aggregates p j it used in the regressions (where j denotes policy type) by taking a weekly moving average of the raw policy data, from date t − to date t. figure plots the values of the policy aggregates over time for each of the provinces. travel restrictions, school closures (including spring and summer breaks) and business closures were implemented in a relatively short period in the middle of march. there is some variation in the travel policy aggregate since some canadian provinces (the atlantic provinces and manitoba) implemented inter-provincial domestic travel or self-isolation restrictions in addition to the federal regulations regarding international travel. restrictions on long-term care facilities were introduced more gradually. in the re-opening period (may-august), there is also more policy intensity variation across the provinces, especially in the business and gatherings category, as the different provinces implemented their own re-opening plans and strategies. mask mandates were first introduced in ontario starting from june in some smaller phus and early july in the most populous phus such as toronto, ottawa and peel (see appendix table c ). in quebec, indoor masks were mandated province-wide on july . nova scotia and alberta's two main cities implemented mask mandates on july and august , respectively. there are two empirical challenges specific to our canadian context and data. the first challenge is the presence of small provinces and sub-regions with very few covid- cases or deaths. in section . , we perform a number of robustness checks using different ways of handling the observations with very few cases (in particular zero cases). the second data limitation is that there are only provinces in canada and public health units in ontario, unlike the u.s. jurisdictions in cks ( ). to account for the resulting small number of clusters in the estimation, we compute and report wild bootstrap standard errors and p-values, as proposed by cameron et al. ( ) . on the flip side, our data has the advantage of a longer time horizon (march to august) and non-binary, more detailed policy variables compared to raifman et al. ( ). behaviour proxy. we follow cks ( ) and other authors in interpreting the location change indices from the google community mobility reports as proxies for changes in people's behaviour during the pandemic, keeping in mind that location is only one aspect of behaviour relevant to . the general pattern in the data (see figure b ) shows sharply reduced frequency of recorded geo-locations in shops, workplaces and transit early in the pandemic (march), with a subsequent gradual increase back toward the baseline (except for transit), and a flattening out in july and august. several of the six location indicators (retail, grocery and pharmacy, workplaces, transit, parks and residential) are highly correlated with each other (see tables a and a ) and/or contain many missing observations for the smaller provinces. to address these data limitations and the possible impact of collinearity on the estimation results, we use as proxy for behavioral changes the simple average of the following three mobility indicators: "retail", "grocery and pharmacy" and "workplaces". to be consistent with the weekly outcome variables and to mitigate day-of-week behavioural variation, we construct the behaviour proxy b it by taking a weekly moving average of the (retail + grocery and pharmacy + workplaces) data, from date t − to date t. , as a result, our empirical analysis uses weekly totals (for cases, tests and deaths) or weekly moving averages (for policies and the behaviour proxy) of all variables recorded on daily basis. alternative methods for computing the standard errors are explored in section . . we drop the "transit", "parks", and "residential" location indicators because, respectively, . %, . %, and . % of the observations are missing in the provincial data, and . %, . %, and . % are missing in the ontario data. the "transit" and "residential" variables are also highly correlated with the three indicators we include in our aggregate behaviour proxy b it . furthermore, the "parks" indicator does not have clear implication for outcomes. in the ontario analysis, . % of the b it values are imputed via linear interpolation. in estimation equation ( ), we take moving average from date t − to date t − for policies and behaviour when the outcome is weekly case growth, and from date t − to date t − if the outcome is tables a and a display the correlation between our behaviour proxy b it and the five npi policy aggregates p j it . importantly, the behaviour proxy and mask mandate variables are not highly correlated, suggesting that the effect of mask mandates on covid- outcomes should be independent of location behaviour changes. information. we use the weekly cases and case growth variables defined above, ∆c it and y it , to construct the information variables i it in equation ( ) . specifically, we use as information the lagged value of the weekly case growth rate y it−l (= ∆ log(∆c it−l ) and the log of past weekly cases, log(∆c it−l ). we also use the lagged provincial (ontario analysis) or national (canada analysis) case growth rate and log of weekly cases as additional information variables in some specifications. a two-week information lag l = is used in the baseline results. in the supplementary regressions using the death growth rate as the outcome, we use information on past deaths and a four-week lag (see section . ). control variables. in all regressions, we control for region fixed effects (phu or province) and the weekly covid- tests growth rate ∆ log(∆t it ), where t it denotes cumulative tests in region i until date t and ∆t it is defined analogously to ∆c it above. we include a time trend: our baseline uses a cubic polynomial in days, but we also report results with no time trend and with week fixed effects. robustness checks also include news or weather variables as controls (see section . ). time period. we use the period may to august for the analysis with ontario phu level data and the period march to august for the national analysis with provincial data. the end date reflects data availability at the time of empirical analysis and writing. the start date for the ontario sample (may ) is approximately two weeks after the last restrictive measures were implemented and four weeks before the first mask mandate was introduced in ontario. robustness checks with different initial dates (may , june and june ) are reported in section . , with our results remaining stable. the initial date for the national sample (march ) was chosen as the first date on which each province reported at least one covid- test (so that cases could be potentially reported). again, alternative initial dates are explored in section . . we start with a simple graphical illustration of the effect of mask mandates on covid- cases growth. figure displays the average log case growth, y it = ∆ log(∆c it ) in ontario phus with or without mask mandates. it shows that, on average, the phus with a mask mandate two weeks prior have lower case growth than the phus without a mask mandate two weeks prior. no mask mandate at t - mask mandate at t - notes: the figure plots the average log weekly case growth ∆log(∆c) in the phus with mask mandate (blue) vs. without (red) mask mandate days prior. table shows the estimates of equation ( ), in which we control for other policies, behaviour and information, as explained in section . . we report wild bootstrap p-values clustered at the phu level to account for the small number of clusters. the odd-numbered mask mandates and regulations on business and gatherings vary at the phu level. long-term care policy changed only province-wide. the other policies (schooling and travel) do not vary during the sample period and hence are omitted from the regressions with ontario phu data. table a in the appendix reports alternative standard error specifications: regular clustering at the phu level (stata command "cluster"), wild bootstrap standard errors clustered at the phu level, and wild columns in table use lagged cases and lagged cases growth at the phu level as information; the even-numbered columns also include lagged cases and lagged case growth at the province level as additional information variables. in the tables, variable indicates a -day lag of variable. we present estimates of equation ( ) from three specifications that handle possible time effects differently. columns ( ) and ( ) in table are the most basic specifications, without including a time trend. the estimates in columns ( ) and ( ) suggest that, controlling for behavioural changes, mandatory indoor face masks reduce the growth rate of infections by - log points (p < . ), which is equivalent to a - % reduction in weekly cases. in order to control for potential province-wide factors affecting the spread of covid- such as income support policies or adaptation to the pandemic over time (so-called covid fatigue), we also estimate ( ) with a cubic time trend in days from the beginning of the sample, in columns ( ) and ( ) of table , and with week fixed effects, in columns ( ) and ( ) . columns ( )- ( ) show that our estimates of the mask mandate policy remain robust to the inclusion of a cubic time trend or week fixed effects. the results indicate that, depending on the specification, mask mandates are associated with a reduction of up to log points in weekly case growth or, equivalently, a % reduction in weekly cases. the magnitude of the mask policy estimate is not very sensitive to whether lagged province-level data are included as additional information. the results in table suggest that indoor mask mandates can be a powerful preventative measure in the covid - context. our estimates of the mask mandate impact across ontario's phus are equivalent to a - % reduction in weekly cases. this estimate is larger than the - % reduction estimated by cks ( ) for the u.s. one possible explanation is that ontario's mask policy is more comprehensive: we evaluate the effect of universal indoor mask-wearing for the public rather than the effect of mask wearing for employees only in cks ( ). differences in the compliance rate may also contribute to this difference; we discuss this potential channel in section . . the results in table also show a statistically significant negative association between information (log of past cases, log(∆c) ) and current weekly case growth (p < . in all specifications), indicating that a higher level of cases two weeks prior is correlated with lower current case growth. while b it allows for behavioural responses to information, the negative estimate on log(∆c) in table suggests that our location-based proxy does not capture bootstrap standard errors clustered by both phu and date. our results are robust to alternative ways of calculating standard errors. using equation ( ), a coefficient of x translates into a − exp(x) reduction in weekly cases ∆c it /∆c it− . and in section . 's province-level results), unlike in cks ( ). in appendix table a , we find strong contemporaneous correlations between the policy measures, log cases, and the google mobility behavioral proxy from estimating equation ( ) . this suggests that the information (lagged cases) and the lagged policy variables included in equation ( ) may absorb lagged behavioral responses proxied by b it−l or other latent behavioral changes not captured by b it−l . we next evaluate the impact of npis on covid- cases growth in canada as a whole by exploiting variation in the timing of policies across the provinces. here, we examine npis for which there is no variation across ontario's phus (i.e., schooling, travel, and ltc) in addition to mask mandates. also, provincial data contain variation in the timing of policy changes in both the closing and re-opening phases, allowing us to study both the imposition and relaxation of restrictions. figure : canada -mask mandates and weekly case growth no mask mandate at t - mask mandate at t - notes: the figure plots the average weekly case growth ∆ log(∆c) in the provinces with mask mandate (blue) vs. without mask mandate (red) days prior. we also tried including each location change measure separately and the results are similar (not shown). all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . as in the ontario analysis, we begin with a graphical illustration of mask mandates and covid- case growth across canadian provinces, in the period march to august , . figure plots the average log weekly case growth in the provinces with vs. without mask mandates. while mask mandates are implemented relatively late in our sample period, average case growth in the provinces with a mask mandate (ontario and quebec) diverged from the average case growth in the provinces without a mandate begin roughly four weeks after the mandates are imposed. table displays the estimates of equation ( ) for weekly case growth, along with wild bootstrap p-values, clustered at the province level (see table a for other methods of computing the standard errors). the odd-numbered columns use lagged cases and lagged case growth at the provincial level as information while the even-numbered columns include in addition lagged cases and case growth at the national level as additional information variables. as in the ontario analysis, we present in table estimates from three specifications: no time trend (columns ( )-( )), including cubic time trend in days (columns ( )-( )) and including week fixed effects (columns ( )- ( )). the most robust result is the estimated effect of mask mandates: they are associated with a large reduction in weekly case growth of to log points, which is equivalent to a to % reduction in weekly cases across the different specifications. the estimates are statistically significantly different from zero in all cases, with a p-value of less than . in columns ( )- ( ) . it is reassuring that these results regarding mask mandates are consistent with the ontario analysis in the previous section. table further shows that restrictions on businesses and gatherings are associated with a reduction in the weekly case growth of to log points or, vice versa, that relaxing business/gathering restrictions is associated with higher case growth. the estimate is equivalent to a to % decrease in weekly cases in our sample period. the business/gathering estimates are, however, more noisy than our estimates for mask mandates and do not retain statistical significance in the specifications with week fixed effects (p = . and . ). tables a and a further suggest that the results on business and gathering npis are driven by the smaller provinces and the re-opening period (may to august). still, these results suggest that lowered restrictions and the associated increase in business/workplace activity or gatherings can be an important offsetting factor for the estimated effect of mask mandates on covid- case growth, both in our sample and in the future. we also find that school closures (the school variable in table ) can be negatively figure assumes a july mask mandate implementation date for ontario (when its most populous phu, toronto, adopted a mask mandate, along with ottawa), and july for quebec (province-wide mandate). all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . associated with case growth. however, the estimates are statistically significant from zero only in the specifications with cubic time trend (columns ( ) and ( )). as seen in figure all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . , provincial school closures occurred in a very short time interval during march, so we may lack statistical power to separately identify its effect from other npis (especially the travel-related). hence, we interpret this result with caution. as in table , the level of past cases, log(∆c), is negatively and statistically significantly associated with current weekly case growth in columns ( )- ( ) . since the specification with cubic time trend in tables and allows for possible nonmonotonic aggregate time trends in case growth in a parsimonious way, we choose it as our baseline specification with which to perform robustness checks in the next section. robustness checks with the other specifications are available upon request. a possible concern about our data for the national analysis is that some npis (e.g. international travel restrictions or closing of schools) were implemented within a very short time interval. thus, we may lack enough regional variation to distinguish and identify the separate effect of each policy. collinearity could also affect the standard errors and the signs of the estimated coefficients. to check robustness with respect to potential collinearity in the npi policies, tables a and a report estimates from our baseline specification, omitting one policy at a time, for ontario and canada respectively. first, it is reassuring that the mask mandate estimates are hardly affected by omitting any of the other policies. this is expected since mask mandates were imposed during a period where other npis changed little (see figure ) . similarly, the effects of business/gathering regulations and school closures in table a are not sensitive to omitting other policies one at a time, which suggests that there is sufficient statistical power and variation to identify them in the national analysis. another concern for our empirical strategy is that the usual formula for our dependent variable, ∆ log(∆c it ), cannot be applied when the weekly case total ∆c it is zero. we follow cks ( ) and replace ln( ) with - in our baseline specifications in tables and . we now check the robustness of our estimates to alternative treatments of zero weekly cases. for easier comparison, the first two columns in table a repeat columns ( ) and ( ) for example, table a shows a correlation of . between the travel and school policy aggregates. aggregating the basic policy indicators into five groups mitigates this issue. here, we test whether any remaining collinearity poses a problem. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . from table for ontario. our main results on mask mandates across ontario phus are robust to replacing log( ) with and to adding to all ∆c it observations before taking logs, as shown in columns ( )-( ) of table a . another way to mitigate the issue of phus with very few cases is to estimate a weighted least squares regression where phus are weighted by population. columns ( ) and ( ) in table a show that the resulting mask estimate has a slightly smaller magnitude and, due to the reduced effective sample size, weaker statistical significance. similarly, table a shows that our province-level estimates, in particular for mask mandates, are also robust to the same manipulations as above. in columns ( ) and ( ) of table a , we restrict the sample to only the largest provinces (british columbia, ontario, quebec and alberta), which have only . % ( out of ) zero observation cases. again, the estimated mask effects are little changed. figure b shows that our estimates and confidence intervals for the effect of mask mandates in the ontario baseline regressions do not vary much by the initial date of the sample. similarly, figure b shows that, in the national analysis, our results about mask mandates and business/gathering restrictions are also robust to alternative sample start dates. we explore alternative time lags, either shorter or longer in duration, centered around the baseline value of days. figure b (with ontario data) and figure b (with province-level data) plot the estimates and confidence intervals from the baseline regressions and show that our mask effect estimates remain fairly consistent for different lags. our behaviour proxy variable (google geo-location trends) likely misses some aspects of behaviour relevant for covid - transmission. one factor that may meaningfully impact behaviour is weather. for example, good weather could entice more people to spend time outside, lowering the chance of viral transmission. columns ( ) and ( ) in table a report national estimates with lagged weather variables (daily maximum and minimum temperatures and precipitation for the largest city in each province ) as additional regressors. our npi estimates, in particular mask mandates, are little changed from the baseline results in columns ( ) and ( ) . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . another possible concern is that our information variables, lagged cases and lagged case growth, may not fully capture the information based on which people react or adjust their behaviour, possibly affecting the observed weekly case growth. columns ( ) and ( ) in table a add a national-level "news" variable to the baseline specification. the news variable is defined as the number of daily search results from a news aggregator website (proquest canadian newsstream) for the terms "coronavirus" or "covid- " (see appendix c for more details). in column ( ), the lagged news variable approaches the % significance level (p = . ). our estimates on masks and business/gathering remain very close to those in the baseline. the effectiveness of any npi or public policy crucially depends on whether it affects behaviour. in this section, we use self-reported data on mask usage to examine whether mask mandates indeed increase mask use in canada ("first-stage" analysis). we use data from the yougov covid- public monitor, which includes multiple waves of public opinion surveys fielded regularly since early april in many countries. here, we focus on inter-provincial comparison within canada. our variable of interest is based on responses to the question "thinking about the last days, how often have you worn a face mask outside your home (e.g. when on public transport, going to a supermarket, going to a main road)?" the answer choices are "always", "frequently", "sometimes", "rarely", and "not at all". we create a binary variable taking value if the response is "always" and otherwise, as well as another variable taking value of if the respondent answered either "always" or "frequently" and otherwise. we begin with a simple illustration of self-reported mask usage in canada from april to august . figure b plots the average self-reported mask usage (the response "always") in the provinces with and without mask mandates. the figure clearly shows that selfreported mask usage is higher, by up to percentage points, in the provinces with a mask mandate than in the provinces without mask mandates. since figure b does not account for compositional changes in the data, we formally estimate equation ( ), using self-reported mask usage as the behavioral outcome. notes: the data source is yougov. the outcome is a binary variable taking value if the respondent respectively answered "always" (in the left panel) or "always" or "frequently" (in the right panel) to "thinking about the last days, how often have you worn a face mask outside your home?" the figure plots the estimates from a version of equation ( ) where the mask policy variable is replaced by the interaction of the variables corresponding to being in the treatment group (imposed mask mandate) and a series of dummies for each week, ranging from weeks before the mask mandate to weeks after (t = - to + , where t = is the mandate implementation date). the reference point is week before the implementation (t = - ). wild bootstrap (cgmwildboot) standard errors clustered by province with repetitions are used to construct the confidence intervals. sample weights are used. figure shows a graphical event study analysis on mask mandates and changes in mask usage. the event study approach is appropriate for the mask usage outcome variable, since the policy impact is expected to be immediate, unlike the other outcomes we study, for which any impact is expected to occur with a lag and we use weekly totals or moving averages. we replace the mask policy variable in equation ( ) by the interaction of variables corresponding to being in the treatment group (i.e. under a mask mandate), and a series of dummies for each week, ranging from weeks before the mask mandate to weeks after the mask mandate (t = - to + , where t = is the implementation date of the mask mandate). the reference point is one week before the implementation of the mask mandate (t = - ), and we use the same y-axis scale on both panels. the left and right panels of figure present the results from the event study analysis for the "always" and "always" or "frequently" mask usage answers, respectively. we make several observations. first, neither panel shows a pre-trend -the estimates are close to zero before the mask mandates. this addresses the potential concern that provinces that implemented mask mandates may have had a different trend in mask usage than provinces that did not. second, the effect of mask mandates on mask usage is immediate: an increase all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint of roughly percentage points as soon as the mask policy is implemented at (t = ). third, the effect appears persistent rather than transitory, since mask usage after t = does not revert to its level before t = . notes: the time period is april to august , . p-values from wild bootstrap (cgmwildboot) standard errors clustered by province with repetitions are reported in the square brackets. nc denotes national total cases. the data source is yougov. the outcome is a dummy which takes value if the respondent answered "always" to the survey question "thinking about the last days, how often have you worn a face mask outside your home?" sample weights are used. individual characteristics include a gender dummy, age dummy (in years), dummies for each household size, dummies for each number of children, and dummies for each employment status. ***, ** and * denote %, % and % significance level respectively. table displays the estimates on self-reported mask usage (answer "always") in equation ( ) along with wild bootstrap p-values clustered at the province level. the odd-numbered columns use lagged cases and lagged case growth at the provincial level as information while the even-numbered columns include in addition lagged cases and case growth at the national level as additional information variables. as in table and table , we present estimates all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . without time trend, including cubic time trend (in days), and including week fixed effects. our preferred specification with cubic time trend, column ( ) of table , shows that mask mandates are associated with . percentage point increase in self-reported mask usage (p < . ), from a base of self-reported mask usage without mask mandate of . %. , these "first-stage" results show that mask mandates exhibit significant compliance in canada and establish a basis for the significant impact of mask mandates on the spread of covid- that we find. that said, given that mask mandates do not change everyone's behaviour, our estimates in tables and represent intent-to-treat effects. the full effect of the entire population shifting from not wearing to wearing masks is likely significantly larger. there is a heated debate on whether community use of masks may create a false sense of security that reduces adherence to other preventive measures. we also investigate this question using yougov survey data. as tables a and a indicate, we find no evidence that mask mandates in canada have had an offsetting effect on other preventive measures such as hand washing, using sanitizer, avoiding gatherings, and avoiding touching objects in public during the period we study. on the contrary, mask mandates may slightly increase social distancing in one out of the eight precaution categories (avoiding crowded areas) (p < . ). we evaluate several counterfactuals corresponding to replacing the actual mask policy in a province or canada-wide with a counterfactual policy, including absence of mask mandate. letting t be the implementation date of a counterfactual policy, we set the counterfactual weekly case count, ∆c c it , equal to ∆c it for all t < t . for each date t ≥ t , using the definition of y it from ( ), we then compute the counterfactual weekly cases, ∆c c it and the counterfactual similarly, in table a , column ( ) shows that "always" or "frequent" mask usage increases by . percentage points. the finding that the increase in mask usage among the "always" respondents is larger than among the "always" or "frequent" respondents is consistent with some people switching from wearing masks "frequently" to "always." hatzius et al. ( ) document that state mask mandates in the us increased mask usage roughly by percentage points in days. the compliance with mask mandates may differ across countries or regions based on social norms, peer effects, political reasons or the consequences of noncompliance (e.g., fines). if we take the increase of about percentage points in reported mask usage induced by mask mandates at face value, the full effect of mask wearing (treatment-on-the-treated effect) would be roughly triple our estimates. it could be larger still if there is desirability bias in answering the mask usage survey question, so that the actual increase in mask use may be smaller than our estimate. consistent with this result, seres et al. ( ) find that wearing masks increased physical distancing based on a randomized field experiment in stores in germany. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . case growth rate, y c it , as follows: whereŶ it is the regression-fitted value of weekly case growth; β m ask is the coefficient estimate on the mask mandate variable mask in baseline specification ( ) in table or , depending on the counterfactual; mask c is the counterfactual mask policy (e.g. different implementation date, wider geographic coverage or absence of mask mandate); and β log∆c is the coefficient estimate (- . or - . ) on lagged cases log(∆c) in table or , column . the coefficient β log∆c adjusts the counterfactual case growth rate for the negative statistically significant association between the weekly case total two weeks prior and time-t case growth. this effect may be due to people being more careful when they perceive the risk of infection to be higher or less careful vice versa. notes: the left panel assumes that mask mandates were adopted in all phus on june (date of the first mask mandate in on). the right panel assumes that mask mandates were not adopted in any phu. we use the mask estimate (- . ) from column ( ) of table . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. notes: the left panel assumes that mask mandates were adopted in all provinces on july (the adoption date in toronto and ottawa). the right panel assumes that mask mandates were not adopted in any province. we use the mask estimate (- . ) from column ( ) of table . notes: the left panel assumes that mask mandates were adopted in all provinces on july (the adoption date in toronto and ottawa). the right panel assumes that mask mandates were not adopted in any province. we use the mask estimate (- . ) from column ( ) of table . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . figures , and show results from two counterfactual policy evaluations. the first exercise, depicted in the left-hand side panel of the figures, assumes that masks are adopted everywhere at the earliest date observed in the data. specifically, figure considers the counterfactual of all ontario phus adopting mask mandates on june , while figures and assume that all provinces adopt a mask mandate on july . using our mask policy estimate from table , figure shows that an earlier face mask mandate across ontario phus could have lead to an average reduction of about cases per week as of august , holding all else equal. for canada as a whole, a nation-wide adoption of mask mandates in early july is predicted to reduce total cases per week in the country by to , cases on average as of august , depending on whether we use the more conservative mask estimate (- . ) from column ( ) of table (see figure ) or the larger estimate (- . ) from column ( ) of table (see figure ). in all cases, the indirect feedback effect via β log∆c (lagged cases as information) starts moderating the decrease in cases two weeks after the start of the counterfactual mask policy. in the right-hand side panel of figures , and , we perform the opposite exercise, namely assuming instead that mask mandates were not adopted in any ontario phu or any canadian province. our estimates imply that the counterfactual absence of mask mandates would have led to a large increase in new cases, both in ontario and canada-wide, especially when using the larger mask coefficient estimate from table (see figure ). finally, in figure b in the appendix, we also evaluate the counterfactual in which british columbia and alberta, the third and fourth largest canadian provinces by population, adopt province-wide mask mandates on july . the results, using the mask estimate from table , suggest a reduction of about cases per week in each province by mid-august. the counterfactual simulations assume that all other variables, behaviour and policies (except the mask policy and t − cases) remain fixed, as observed in the data. this is a strong assumption, but it may be plausible over the relatively short time period that we analyze. moreover, the counterfactuals assume that regions without a mask mandate would react in the same way, on average, as the regions that imposed a mandate. therefore, these results should be interpreted with caution and only offer a rough illustration and projection of the estimated effect of mask mandates on covid- cases. june is the date of the earliest mask mandate in ontario. for the national analysis, july , the effective date for toronto and ottawa, is considered ontario's first significant date of mask mandate enactment: phus with earlier mandates account for less than % of ontario's population. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint closing and re-opening sub-periods we investigate whether policy impact varied in different phases of the pandemic by splitting the full sample period into two sub-periods: "closing" (march to may ) and "reopening" (may to august ). the dividing date of may (referring to the npis in place around may ) was chosen because very few policies were relaxed before may , and very few non-mask policies were tightened after may in our sample period (see figure ) . in table a , we report estimates and wild bootstrap standard errors using our baseline specification with cubic time trend, separately for the closing and re-opening periods. we find that the imposition of school closures and travel restrictions early in the closing period is associated with a very large subsequent reduction in weekly case growth, as can be also seen on figure b -the average observed log growth rate of cases ∆ log(∆c) falls from . (ten-fold growth in weekly cases) to − . ( % decrease in weekly cases) between march and april . long-term care restrictions are also associated with reduced case growth two weeks later during the march to may closing period. we interpret these results with caution, however, since many of these policy measures and restrictions were enacted in a brief time interval during march and there is not much inter-provincial variation (see figure ). no mask mandates were present in the closing period. in the re-opening period, our results in table a are in line with our full-sample results for mask mandates and business/gathering regulations (table ) , with slightly larger coefficient estimates and less statistically significant p-values, possibly due to the smaller sample. travel and school closures are not statistically significant in the re-opening period. this is unsurprising: relaxation of travel policies was minor and endogenous (only re-open to safe areas within canada), and the schools that re-opened (in parts of quebec and, on a part-time basis, in british columbia) did so on voluntary attendance basis, yielding smaller class sizes. we also examine the weekly death growth as an outcome. we only have access to disaggregated deaths data at the province level (not at phu levels in ontario). we thus estimate regression equation ( ) using y it = ∆ log(∆d it ) for each province i as the dependent variable. in addition, we use a -day lag for the policy, behaviour proxy, and information variables to reflect the fact that deaths occur on average about two weeks after case detection; see appendix d for details and references. in table , variable denotes the variable lagged by days. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . table reports the estimates from the same specifications as those for case growth in table . in all specifications, mask mandates are associated with a large reduction in the observed weekly deaths growth rate four weeks later (more than log points, or equivalently more than % reduction in weekly deaths). these results are larger than our case growth results, but consistent with them given the substantial uncertainty. see also figure b , which plots the average weekly death growth in the provinces without a mask mandate four weeks prior vs. that for ontario, the only province with mask mandate four weeks prior in our sample period. the robustness checks in table a , however, show that, unlike for case growth, the mask mandate estimates in table are not robust to weighing by population or to restricting the sample to the largest provinces. this suggests that the estimated effect is largely driven by observations from the small provinces, which have a disproportionately larger number of zero or small weekly death totals. furthermore, given the -day lag, there are only days with observations (from ontario only) for which the mask mandate variable takes value of . due to these serious data limitations, the relation between mask mandates and covid - deaths in table is suggestive at best, and we urge caution in interpreting or extrapolating from these results. that said, our main findings about the growth in cases may have implications about future growth in deaths, particularly if the affected demographics become less skewed toward the young in later periods. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the wearing of face masks by the general public has been a very contentious policy issue during the covid- pandemic, with health authorities in many countries and the world health organization giving inconsistent or contradictory recommendations over time. "conspiracy theories" and misinformation surrounding mask wear abound in social media, fuelled by some individuals' perception that mask mandates constitute significant restrictions on individual freedoms. given the absence of large-scale randomized controlled trials or other direct evidence on mask effectiveness in preventing the spread of , quantitative observational studies like ours are essential for informing both public policy and the public opinion. we estimate the impact of mask mandates and other public policy measures on the spread of in canada. we use both within-province and cross-province variation in the timing of mask mandates and find a robust and significantly negative association between mask mandates and subsequent covid- case growth - to % average reduction in weekly cases in the first several weeks after adoption, depending on the data sample and empirical specification used. these results are supported by our analysis of survey data on compliance with the mask mandates, which show that the mandates increase the proportion of reporting as always wearing a mask in public by around percentage points. however, our sample period does not allow us to determine whether their effect lasts beyond the first few weeks after implementation. we conclude that mask mandates can be a powerful policy tool for at least temporarily reducing the spread of mask mandates were introduced in canada during a period where other policy measures were relaxed, as part of the economy's re-opening. specifically, we find that relaxed restrictions on businesses or gatherings are positively associated with subsequent covid- case growth -a factor that could offset and obscure the health benefits of mask mandates. past case totals were also found to matter for subsequent outcomes, suggesting that riskier behaviour based on favourable lagged information may limit how low mask mandates and other restrictions -short of a lockdown -can push the number of new cases. we have deliberately abstained from studying the direct economic impacts of , focusing instead on the unique features of the canadian data for identifying the effect of npis, in particular mask mandates, on covid- case growth. future research combining epidemiological finding with the economic benefits and costs of various public policies or restrictions would enrich the ongoing policy debate and provide further guidance. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. ( ) and ( ) repeat columns ( ) and ( ) from table where we replace log( ) with - . columns ( ) and ( ) replace log( ) with , and columns ( ) and ( ) add to all ∆c it observations. columns ( ) and ( ) report estimates from a weighted least squares regression with weights equal to the phu population sizes. ***, ** and * denote %, % and % significance level respectively. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . ( ) and ( ) repeat columns ( ) and ( ) from table . we drop each policy at at time in columns ( )- ( ) . ***, ** and * denote %, % and % significance level respectively. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . the time period is april to august , . p-values from wild bootstrap (cgmwildboot) standard errors clustered by province with repetitions are reported in the square brackets. nc denotes national total cases. the data source is yougov. the outcome is a dummy which takes one for the respondent who answers "always" or "frequently" to the survey question "thinking about the last days, how often have you worn a face mask outside your home?" sample weights are used. individual characteristics include a gender dummy, dummies for each age (in years), dummies for each household size, dummies for each number of children, and dummies for each employment status. ***, ** and * denote %, % and % significance level respectively. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . notes: the time period is april to august , . p-values from wild bootstrap (cgmwildboot) standard errors clustered by province with repetitions are reported in the square brackets. nc denotes national total cases. the data source is yougov. the outcome is a dummy which takes value if the respondent answered "always" or "frequently" to each survey question in table c . sample weights are used. individual characteristics include a gender dummy, age dummy (in years), dummies for each household size, dummies for each number of children, and dummies for each employment status. ***, ** and * denote %, % and % significance level respectively. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the time period is feb to july (two weeks before the march -august sample period). daily province-level data. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . notes: the data source is yougov. the figure plots the average self-reported mask usage by week (the fraction of respondents who answered "always" to the survey question "worn a face mask outside your home") in the provinces with vs. without mask mandates. sample weights used to compute the averages. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . figure b : canada -behaviour notes: the behaviour proxy b it is the average of the "retail", "grocery and pharmacy", and "workplaces" google mobility indicators. province-level -day moving averages are plotted. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. notes: we plot the coefficient estimates on mask policy, with % confidence intervals, from equation ( ), for different initial dates of the sample. the initial sample date in the baseline specifications reported in table notes: we plot the coefficient estimates on mask policy, with % confidence intervals, in the upper panel and the estimates on business/gathering policy in the lower panel, from equation ( ) for different initial dates of the sample. the initial date in our baseline specification (table ) is march . the left panels correspond to column ( ) in table ; the right panels correspond to column ( ) in table . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. table ; the right panels correspond to column ( ) in table . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure b : canada -weekly cases, deaths and tests (growth rate) week ending preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure b : canada -weekly cases, deaths and tests (level) all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure b : canada -daily cases, deaths and tests - all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure b : counterfactuals -mask no mask mandate at t- mask mandate at t- notes: average log weekly death growth in provinces with vs. without mask mandates days prior. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint used hand sanitiser i health avoided going out in general i health avoided small social gatherings (not more than people) i health avoided medium-sized social gatherings (between and people) i health avoided large-sized social gatherings (more than people) i health avoided crowded areas i health avoided touching objects in public (e.g. elevator buttons or doors) notes: the data source is yougov. possible responses to each survey item are "always", "frequently", "sometimes", "rarely", and "not at all". for table a , we create a binary variable taking value if the response is "always" and otherwise. for table a , we create a binary variable taking value of if the respondent answered either "always" or "frequently" and otherwise. all data used in the paper are available at https://github.com/c -sfu-econ/data. as discussed in section . , we assume a lag of days between a change in policy or behaviour and its hypothesized effect on weekly case growth, and a lag of days between such a change and its effect on weekly death growth. first, we consider the lag between infection and a case being reported. as most identified cases of in canada are symptomatic, we focus on symptomatic individuals. for most provinces cases are listed according to the date of report to public health. in provinces where the dates instead refer to the public announcement, we shifted them back by one day, as announcements typically contain the cases reported to public health on the previous day. the relevant lag therefore has two components: . time between symptoms onset and reporting of the case to public health: the ontario data contain an estimate of the symptom onset date ("episode date") for each case. for our sample period the average difference between the date of report and the episode date is . days (median: days) including only values from to days, and . all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . days (median: days) including only values from to days. we assume that the lags in ontario and in other provinces are similar, and use a value of [ ] [ ] days between symptom onset and report to public health authorities. adding these together implies that the typical lag between infection and a positive case being reported to public health is around days. second, we consider the effect of weekly averaging on the appropriate lag for our analysis. suppose a policy or behavioural change starts on date t, impacting the daily growth in infections between dates t − and t and in each subsequent day. then, assuming a lag of days between infection and case reporting, case counts c are affected from date t+ onward. our outcome variable ∆ log(∆c) thus would react to the original policy or behavioral change on date t + . the change is complete on t + , when the week from t + to t + is compared to the week from t + to t + . the midpoint of the change is t + . choosing a lag of l days implies that the policy/behaviour variable phases in from t + l to t + l + . to match the midpoint of this phase-in to the midpoint of the change in the outcome variable, we set l = . the chosen lag matches the lag used by other authors who study policy interventions, e.g., cks ( ). we explore sensitivity to alternative lags in section . . with respect to deaths, our data are, in most cases, backdated (revised by the authorities ex , that is, two weeks longer than our estimate of the time from symptom onset to reporting of a positive test result. we correspondingly set the lag used in our analysis of the death growth rate (section . ) to days. all rights reserved. no reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint the case for universal cloth mask adoption and policies to increase supply of medical masks for health workers incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china bootstrap-based improvements for inference with clustered errors causal impact of masks, policies, behavior on early covid- pandemic in the physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta-analysis face masks for the public during the covid- crisis the effect of large-scale anti-contagion policies on the covid- pandemic a contribution to the mathematical theory of epidemics the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application respiratory virus shedding in exhaled breath and efficacy of face masks early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data community use of face masks and covid- : evidence from a natural experiment of state mandates in the us transmission of sars-cov- : a review of viral, host, and environmental factors face masks considerably reduce covid- cases in germany public responses to policy reversals: the case of mask usage in canada during covid- flattening the covid- peak: containment and mitigation policies reducing transmission of sars-cov- covid- us state policy database high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus face mask use and physical distancing before and after mandatory masking: evidence from public waiting lines table - - - population estimates, quarterly estimates of the severity of coronavirus disease : a model-based analysis weekly epidemiological update, coronavirus disease (covid- ) estimating clinical severity of covid- from the transmission dynamics in wuhan, china log(∆c) - . *** - . *** - . *** - . *** - . ** - . * - . *** - . *** we show mask usage for the u.s. and germany because related work by chernozhukov et al. ( ) and ( ) repeat columns ( ) and ( ) from table where we replace log( ) with - . columns ( ) and ( ) replace log( ) with , and columns ( ) and ( ) add to all ∆c it observations. columns ( ) and ( ) report results from a weighted least squares regression with the province populations as weights. finally, columns ( ) and ( ) ( ) and ( ) report estimates with lagged weather variables as additional controls. columns ( ) and ( ) add a "news" variable to the baseline specification (see appendix c for more details). ***, ** and * denote %, % and % significance level respectively. weather -we downloaded historical weather data for the largest city in each province from the weather canada website. the data provide daily information on variables: maximum temperature (c), minimum temperature (c), mean temperature (c), heating degreedays, cooling degree-days, total rain (mm), total snow (cm), total precipitation (mm), snow on the ground (cm), direction of maximum wind gust (tens of degrees), and speed of maximum wind gust (km/h). we only use the temperature and precipitation data in table a as possible factors determining outside vs. inside activity.news -we collected data from proquest canadian newsstream, a subscription service to all major and small-market daily or weekly canadian news sources. we recorded the number of search results for each day from feb , to aug , by searching the database for the keywords "coronavirus" or "covid- ". we only counted the results with source listed as "newspaper" since other sources, such as blogs or podcasts, tend to duplicate the same original content. key: cord- -mjgx n authors: brayton, sean title: the migrant monsters of multiculturalism in andrew currie’s fido date: journal: precarious international multicultural education doi: . / - - - - _ sha: doc_id: cord_uid: mjgx n on june , , the canadian house of commons passed an amendment to the immigrant and refugee protection act. titled bill c- , the amendment shifts discretionary powers from parliament to current and future immigration and citizenship ministers. touted by the conservative party as an expedient remedy to the , -applicant backlog and an estimated labour shortage of , , bill c- raised immediate concerns within immigrant and activist communities (cbc news, ). critics contend that the bill caters to the interests of canadian employers and business lobbyists in its provision of “disposable” and inexpensive labour, while “family” and “refugee” applications may be deferred indefinitely and without recourse. in some ways, the changes under bill c- are redolent of the live-in caregiver program in canada as well as the bracero program ( - ), guest worker legislation and h- a initiatives in the us, all of which offered temporary visas to migrant workers but resembled what gilbert gonzalez calls “an imperialist schema of colonial labour” ( , p. ). whereas government policies in north america continue to reduce migrants to economic figures, other conservative discourses depict migrants as self-identical foreigners who flood the economy with cheap labour, deplete welfare resources reserved for “native”citizens and present a possible threat of terror in the “post- / ” era. if “the socalled invasion of immigrants is the exaggerated rhetoric” of political pundits, however, “the increase in global migration within and from third world countries is real” (bakan and stasiulis, b, p. ). on june , , the canadian house of commons passed an amendment to the immigrant and refugee protection act. titled bill c- , the amendment shifts discretionary powers from parliament to current and future immigration and citizenship ministers. touted by the conservative party as an expedient remedy to the , -applicant backlog and an estimated labour shortage of , , bill c- raised immediate concerns within immigrant and activist communities (cbc news, ) . critics contend that the bill caters to the interests of canadian employers and business lobbyists in its provision of "disposable" and inexpensive labour, while "family" and "refugee" applications may be deferred indefinitely and without recourse. in some ways, the changes under bill c- are redolent of the live-in caregiver program in canada as well as the bracero program , guest worker legislation and h- a initiatives in the us, all of which offered temporary visas to migrant workers but resembled what gilbert gonzalez calls "an imperialist schema of colonial labour" ( , p. ) . whereas government policies in north america continue to reduce migrants to economic figures, other conservative discourses depict migrants as self-identical foreigners who flood the economy with cheap labour, deplete welfare resources reserved for "native" citizens and present a possible threat of terror in the "post- / " era. if "the socalled invasion of immigrants is the exaggerated rhetoric" of political pundits, however, "the increase in global migration within and from third world countries is real" (bakan and stasiulis, b, p. ) . in response to an anti-immigrant backlash, on the one hand, and the precarious labour conditions facilitated by government policies, on the other, activists have adopted a variety of tactics-from protests and unionization to boycotts and independent media production. nationwide rallies like "a day without an immigrant" ( ) in the us and "no one is illegal" ( ) in canada draw urgent attention to the contradictions between state and capital that continue to plague immigration legislation and underwrite nativist ideologies of race and nation. as part of a wider protest against conservative immigration reform, the demonstrations called for a boycott of businesses, workplaces and schools by (un)documented immigrants and activists alike. in a similar spirit of opposition, documentary films like anayansi prado's maid in america ( ) and dana inkster's days in brooks ( ) illustrate how migrant workers are instrumental to the economy and image of the multicultural nation-state but are exploited by employers and unwelcomed by "nativists" in north america. we may find aspects of the immigration debate dramatized in unexpected areas of popular culture, including blockbuster comedies, television sitcoms and, perhaps most ominously, zombie films. while the zombie is often read in north america as a caricature of whiteness and mindless consumption, it has recently returned to issues of alterity and labour in ways that conjure its haitian mythological origins. andrew currie's fido ( ) , for instance, presents a canadian satire of suburbia that positions the domesticated zombie as both worker and commodity. here we find a zombie workforce in households of the s, a time when the canadian government and middle-class families turned increasingly to the caribbean for cheap domestic labour. as a result, fido may be read in part as a racial allegory of migrant labour, one that draws on the fantasies of the past to explore and interrogate the anxieties of immigration in the present. by presenting alterity through labour (and vice versa), the film provides an entry point into an historical examination of a conservative multicultural agenda in canada, which presently imagines migrants as an inexpensive remedy to shortages in domestic work, the service industry and healthcare. within and beyond the genre of horror, fido may provide an alternative pedagogy of multiculturalism by engaging the politics of "difference" through the "monsters" of migrant labour. romanticized by the travel writings of william seabrook, the zombie is widely believed to originate in haitian folklore of the early twentieth century (plawiuk, ) . "zombi" tales were especially popular during the american occupation of haiti ( haiti ( - when us investors gained increasing access to sugar plantations and a cheap workforce to form, most notably, the haitian-american sugar company (comaroff & comaroff, ; plawiuk, ) . according to legends, the zombie was a dehumanized plantation worker hypnotized by a vodoun priest or "houngan" to toil "like a robot in the fields" or be "sold to others" (ackermann and gauthier, , p. ) . but the zombie also embodied "a proletarian myth" of a haitian revolt against american employers and forced labour during the s" (plawiuk, , p. ) . more recently, the zombie has been used to describe and deplore "a shadowy alien-nation of immigrant black workers" in south africa, "whose demonization is an equally prominent feature of the postcolonial scene" (comaroff & comaroff, , pp. , ) . despite a range of regional vernaculars, the zombie tradition generally emerges from conditions of enslavement and exploitation of colonial labour by capitalist enterprises, marking the folklore's explicit political-economic origins. the zombie stands in for what is otherwise inconceivable. following a wave of fascination inspired by seabrook's the magic island ( ) , early hollywood films like white zombie ( ) , revolt of the zombies ( ) and revenge of the zombies ( ) featured an "evil sorcerer who ran a caribbean sugar plantation" and "a workforce of resurrected corpses" (beard, , p. ) . despite its political potential, the zombie was adopted mostly as a visual prop with little diegetic significance. early zombie films sensationalized haitian "voodoo" rites and privileged melodrama over any sustained critique of colonial labour practices. not until the s did the zombie film become politically oriented with the release of george a. romero's night of the living dead ( ) and later, dawn of the dead ( ) . romero is said to have modernized the genre, turning the zombie into a poignant metaphor of various social anxieties and afflictions related to the breakdown of the nuclear family (night) and the perils of consumer capitalism (dawn). specifically, dawn has been lauded as a clever critique of hedonistic consumption and commodity fetishism set satirically in a pennsylvanian shopping mall (dendle, ) . indeed, critics and filmmakers alike typically posit the zombie's preternatural consumption of human flesh alongside the shopping frenzy of the "living". in dawn, for instance, we find a "consumer citizenry -figuratively zombified by commercial culture -literally zombified by those who once were us, our simulacral doubles as cannibal consumers" (loudermilk, , p. ) . lacking any concern for the production of material life, zombies are bound by consumptive drives, desires and needs that are said to typify the most vitriolic elements of late capitalism (webb & byrnand, ) . as dehumanized characters, zombies have also been used (on and off screen) to condemn the conditions of production in the us (dendle, ; harper, ; shaviro, ) . from the proletarian diatribes of paul romano ( ) to the activist writings of harvey swados ( ) , "shop rat" memoirs have often denounced the monotony of assembly-line production by using ghoulish descriptions of the dispossessed worker and his "state of suspended being" (swados, , p. ). in the more recent and colourful prose of ben "rivethead" hamper we find a "workforce that was subhuman at best -a slaughterhut full of foul-smellin' mutants who couldn't tell dusk from dawn nor harmony from homicide", not unlike the "brainless ghouls in a george romero flick" ( , pp. , ) . as for the zombies of us cinema, peter dendle describes them as "bluecollar undead" and "the ultimate marxist working-class society" ( , p. ) . if zombies are idealized as mindless and alienated workers fit for a routinized workplace, however, they are always laid off or unemployed in romero's films. in other words, they symbolize "demobilized organization men" of post-fordism in the s (beard, , p. ) . to this end, steve beard describes dawn as a coded critique of outsourcing, unemployment and the antecedents of reaganomics rather than the illusions of consumer culture tout court. as "moaners, idlers [and] scavengers" zombies present "a hysterical class fantasy … filtered through a bourgeois imaginary of disgust" (beard, , p. ). many of these nightmares, however, are laden with racial overtones. both night and dawn, for example, are often described as racial parables where a black hero battles a mob of lower-class "flesh eaters", most of which is white (dyer, ; guerrero, ; harper, ; newitz, ) . in her analysis of "capitalist monsters in american pop culture", annalee newitz draws on an assortment of films -from night of the living dead, blacula ( ) and zombie ( ) to nightbreed ( ) , tales from the hood ( ) and bones ( ) -to explain how a racialized underclass is symbolized by and against a variety of ghastly characters. in such films "'undeath' is implicitly associated with colonial-era social and economic relationships, where one racial group engages in state-sanctioned subordination of others" (newitz, , p. ) . here the trope of the "undead" is used to narrate the overlapping themes of economic and racial injustices, sometimes warning of a symbolic subaltern insurrection by evisceration. such themes reemerge in romero's land of the dead ( ) , where avaricious whites are eaten alive by minoritarian monsters that "embody the contradictions of a culture where making a living often feels like dying" (newitz, , p. ) . while such horrors provide interesting commentaries on reconciliation and the haunting memories of slavery in the us, they are less explicit of racialized labour in the current context of "postindustrialism" and global migration flows. economic dislocations over the past three decades have certainly resulted in widespread layoffs and the outsourcing of north american jobs, but they have also brought a range of "third world" migrants to some of the most undesirable and precarious worksites in canada and the us. in other words, the rampant unemployment and vagrancy used to situate hollywood zombies do not explain an emerging (under)class of "working poor", one that is comprised disproportionately of migrants from developing countries. some of these economic changes are reflected in andrew currie's "throwback" setting of fido. using reanimated corpses in suburban homes and the service sector, fido (re)locates labour at the heart of the zombie tradition, twisting romero's oeuvre by recycling the original themes of exploitation and revolt found in haitian folklore. with the "return" of the indentured zombie, fido provides a curious commentary on a series of "multicultural" developments shaped by immigration policies in canada. to this end, "the poetic particularity of phantom workers" may be a "sensitive register of shifting experiences of labour and its value" (comaroff & comaroff, , p. ) . filmed in the okanagan region of british columbia (kelowna and vernon), fido is a canadian-produced zombie homage starring carrie-anne moss, billy connolly and dylan baker. it is one of several satires produced by currie's own anagram pictures, which includes films that dig at canada's colonial history (elijah), the banalities of parking enforcement (the delicate art of parking) and an eco-horror (thaw). as a social commentary, fido may be situated within a larger historical context of canadian horror films and political allegory. whereas the hysteria surrounding the red menace of the s, for instance, found an energetic outlet in hollywood -from invaders from mars ( ) and war of the worlds ( ) to invasion of the body snatchers ( ) and the angry red planet ( ) -political commentary within canadian horror is a more recent development (vatnsdal, ) . film producer and critic caelum vatnsdal traces the onscreen origin of canadian political horror to david cronenberg's rabid ( ), a film that borrowed from the events of the october crisis in with its depiction of a militarized montréal under a state of martial law. five years later, george mihalka's my bloody valentine ( ) offered a brooding portrait of a small mining town stricken by a stagnant maritime economy and a maniacal miner abandoned by his coworkers. such films illustrate a burlesque convergence of politics, economics and horror in sordid but significant ways. it is perhaps not surprising that several canadian horror films have used monsters to convey various social anxieties, including the perceived disruption of canada's "white settler colony" and the transgressions of racial "otherness" (abu-laban, , p. ) . early monster flicks like the werewolf ( ) and secrets of chinatown ( ) , for example, traded on a popular fascination with indigenous "shape-shifters" and sinophobia, respectively. indeed, the politics of marginality are sometimes at the centre of canadian "monster" productions both on and off screen. the corpse eaters ( ) , for example, relied on homeless people of sudbury for its "undead" extras, epitomizing the notion of cheap zombie labour (vatnsdal, ) . in addition, zombie nightmare ( ) was originally written as a retribution narrative in which a black teenager returns from the dead to exact revenge on the privileged white hoodlums responsible for his death (vatnsdal, ) . here the zombie is a jarring but appropriate narrative prop; "the oppressed remain monstrous, but monsters are celebrated as being more sympathetic than the people who hunt them" (newitz, , p. ) . recently, an apparent subgenre of canadian zombie satires has emerged, one that now includes graveyard alive ( ), rotten shaolin zombies ( ) , eat the parents ( ) and the short canadian zombie ( ) , whose tagline draws implicitly on neoliberal citizenship: "they don't vote. they don't recycle. they eat your flesh!" the purpose here is not to nationalize specific zombie films, but rather to ground fido within the cultural context of its production and consumption. fido presents an allegory of alterity that mocks a variety of moral panics both past and present. when a radioactive cloud engulfs the earth, mysterious "space particles" bring about the reanimation of corpses, which thrive on the consumption of human flesh. funded by the zomcon company, the military engages in a series of "zombie wars" in order to contain the undead. with the invention of the zomcon "domestication collar", however, zombies become as "harmless as a household pet" and are put to work in a variety of dead-end jobs throughout suburbia. but when the robinson family discovers a malfunction in its zombie's collar, fido (connolly) attacks several suburbanites and triggers widespread panic amongst the middle class. after a zombie uprising nearly destroys the town of willard, order is restored to the suburbs and fido returns to the robinsons as not just a family "pet" but also a surrogate father and companion. the zombie, in other words, is ironically incorporated into a white suburban fantasy of the heteronormative family, but not without first eating a hole in the middle class. although fido lampoons a range of social maladies -from suburban conformity and a crisis of masculinity to commodity fetishism and the denigration of the elderly -it is perhaps most effective as a playful commentary on exploited labour signified by the zombie worker. as subhumans, the zombies are ontologically "othered" and forced to perform unskilled labour, freeing the white middle class to enjoy leisurely pursuits. zombies are employed in a series of positions, from servants, groundskeepers and custodians to domestics, machinists and personal escorts. what distinguishes fido from many zombie films, then, is its depiction of zombies at work. the undead are seen mowing lawns, planting flowers, serving beverages, toiling in factories and "playing catch" with the town's children. they resemble "proletarian servants in the paragon of 'postindustrial' society" (rouse, , p. ) . so if some zombie films forecast the impending death of capitalism, as loudermilk ( ) suggests, fido turns death itself into value. indeed, the consumptive terror that eviscerates capitalist society in romero's series is inverted and exploited in currie's satire. in fido "the zombie is transformed into alienated labour power … and made to serve as someone else's privatized means of production" (comaroff & comaroff, , p. ) . as i argue below, currie's exploited zombie is a provocative symbol of difference, one that resonates with the racial politics of migrant labour and the underside of multiculturalism in canada. set in the fictional suburb of willard during the s, fido offers a "stylized social criticism" within a satire of "nostalgic longing" (defalco, , p. ) . it invites the audience to reflect on the anxieties and injustices of the present through an imitative but no less important re-presentation of the past. specifically, currie credits the work of douglas sirk and david lynch for inspiring fido's sardonic technicolor portrait of postwar suburbia (billington, ) . as currie himself explains, the "fable-like quality" of a retro suburban setting provides "satirical moments in the film [that] really reflect our modern world more clearly", including post- / anxieties over homeland security and the construction of "bigger fences" at the border (billington, , p. ) . as a result, we might read fido as a symbolic but highly mobile critique of racial fantasies in north america, which are often channeled by the immigration policies underlying multiculturalism. while multiculturalism in canada is informed by several political streams -including indigenous rights and substate nationalisms -i am primarily concerned with immigration policy and how it contributes to a conservative undertaking of "inclusion" (kymlicka, ) . as habiba zaman ( ) points out, this undertaking narrows the terms of citizenship to economic value by de-emphasizing family reunification and amnesty, which are perhaps the hallmarks of liberal multicultural ideology. such terms are punctuated by the indentured zombies of fido, which may provide a pedagogical space that is both critical and creative. specifically, the film's setting and storyline reflect the systemic use (and abuse) of migrant workers, illustrating (via the zombie) what rey chow calls the "ethnicization" of labour. under the shifting economic conditions of neoliberalism, global divisions of labour, and multiculturalism in the west, ethnicity is often understood and articulated in relation to certain types of work. as chow ( ) contends, a labourer becomes ethnicized because she is commodified in specific ways, because she has to pay for her living by performing certain kinds of work, while these kinds of work, despite being generated from within that society, continue to reduce the one who performs them to the position of the outsider, the ethnic. (p. ) ethnicity, in other words, becomes "society's mechanism of marking boundaries by way of labour" (chow, , p. ) . while chow is referring mostly to neoliberal developments, the "ethnicization" of labour was especially evident in the bracero program , a diplomatic agreement between the us and mexico that relocated more than , mexican workers to farms and factories across the southwestern us (briggs, ; craig, ; gonzalez, ) . although the bracero program ended in it has been revisited through guest worker and h- a initiatives, which continue to encourage migrants from developing countries to fill underpaid and unappealing jobs with potential pathways to citizenship (chang, ; gonzalez, ) . in the us, latina/os, for instance, are now "particularly concentrated in jobs considered unattractive, demeaning, dangerous, dirty, temporary, or comparatively poorly paid -i.e., 'mexican work'" (gomez-quinones & maciel, , p. ) . in canada, the ethnicization of labour has taken a variety of shapes. during the late s, for instance, the canadian government imported thousands of chinese bachelors to build the most treacherous routes of the canadian pacific railway (cpr) (zaman, ; chan, ) . as margot francis suggests, "chinese workers were often described as 'living machines,'" whose supposed docility "justified employers relegating them to the most menial tasks, underpaying them, and often minutely controlling their labour" ( , p. ) . nearing the completion of the cpr in , however, chinese labour became disposable under the terms of the chinese immigration act, which sought to curtail immigration from asia by imposing a "head tax" of $ and, by , $ (zaman, ) . in , the first domestic scheme was introduced to import women from guadeloupe to work as caregivers in canadian middle-class homes. with the passing of the second domestic scheme in , however, the canadian government participated in "the first full-scale recruitment of caribbean domestics" (zaman, , p. ) . because of these programs the relationship between domestic work and women of colour from developing countries became increasingly normalized in the popular canadian imaginary (stiell & england, ) . canada continued to express its labour shortages through immigration policies long after the s. in , for instance, the canadian government introduced the temporary employment authorization program, under which migrant workers were "prohibited from quitting a job without leaving the country" (zaman, , p. ) . since , filipino women have been channeled into domestic work under both the labour export policy in the philippines and the live-in caregiver program in canada, which offers temporary visas and two years of "virtual bonded servitude" (bakan & stasiulis, b, p. ) . as the canadian labour congress notes, some provincial governments have recently lobbied the ministry of health in barbados for temporary workers, adding to what agnes calliste calls the "brain drain" of the caribbean ( , p. ) . such are the understated colonial antecedents of multiculturalism in canada. the immigration policies from which the nation's vaunted image of diversity is derived include an inglorious underside of economic exploitation. as a result, migrant worker programs speak less of the "liberalization" of immigration policy than canada's recurring need for cheap labour in positions that are typically "low-paid, repetitive, temporary and monotonous" (zaman, , p. ) . this conservative arm of "multiculturalism" may be bolstered by bill c- , which aims to increase migrant labour despite ongoing economic uncertainties (citizenship and immigration canada, ). according to the activist group no one is illegal, bill c- "makes clear that poor people, working people, and people of colour need not apply to come to canada as permanent residents unless they are willing to come temporarily as workers in exploitative and marginal jobs" (bonnar, , p. ) . such programs illustrate what abigail bakan and daiva stasiulis call a "global apartheid", which may also be found in fido ( a, p. ) . although fido features no characters of colour, its racial allegory emerges in implicit ways. as newitz explains, "when racial difference cannot be talked about in a narrative -or is willfully ignored -one way it gets described is as a difference between … dead bodies and animated ones" ( , p. ) . the zombie, in other words, stands in for racial and ethnic "otherness" by wearing a fictional disguise. currie's zombie workers, in particular, invite a critique of conservatism and prejudice in ways that deliberately borrow from classic s melodrama, including sirk's imitation of life ( ) and sirk tributes like rainer werner fassbinder's angst essen seele auf ( ) as well as todd haynes' far from heaven ( ) . despite obvious narrative differences, zombies and characters of colour in these films occupy nearly identical roles: domestics, guest workers and gardeners. as such, fido's racial allegory vividly unfolds from a division of diegetic labour that is highly intertextual; the undead are marked in ways that reflect the ethnicization of work within and beyond the s melodrama. nearly every shot of fido's suburbia shows zombies gardening, serving beverages, removing garbage, cleaning yards or tending to children -jobs performed typically (but not exclusively) by migrants of colour. if certain types of work in north america are increasingly ethnicized, as chow suggests, fido's "spectral workforce" constitutes in many ways a metaphor of ethnicity whereby unskilled labour is performed exclusively by zombies (comaroff & comaroff, , p. ). because of their difference, zombies are made to work particular jobs; but their ontological difference is marked by the types of work they perform, making labour and "ethnicity" (though theoretically different) virtually indissociable. in some ways, fido's situation in the robinson home is not unlike the conditions experienced by migrant domestics in canada since the s. incidentally, the film's zombie workers appear at a time in canadian history when the erosion of labour rights and citizenship status "coincided with the shift to third world sources" of female domestic labour (bakan & stasiulis, a, p. ) . specifically, the second domestic scheme subjected caribbean migrants to more precarious terms of citizenship and systematic screening for venereal diseases, underscoring "the canadian government's racist and sexist assumptions about black caribbean women" (calliste, , p. ) . likewise, the zombies in fido are perceived as a contagion in need of invasive examinations to ensure the sanctity (read: whiteness) of willard. suspected of draining the community with their "infectious" broods and "indiscriminate" (sexual) appetites, both the zombie and the migrant are framed by a discourse of "contamination" and "containment". this echoes what carmela murdocca ( ) describes as the racialization of "degeneracy" in which public concerns over infectious diseases like ebola, tuberculosis and sars converge with anti-immigration rhetoric in canada. fido's zombie workers amplify similar racial anxieties of viral infection which also intersect with the "privatization" of labour exploitation: the first shot of suburban willard features a zombie serving lemonade to a white couple, who joyfully watch their daughter "jump rope" with a zombie nanny; fido serves the robinsons dinner and cares for their son, but is repeatedly harassed by the father, whose bigotry towards zombies is trenchant. following the workday, we find fido chained to a tree in the robinson's backyard, an embellished but effective way of emphasizing the plight of the live-in caregiver and the anxieties of infection. symbolically, then, fido contains more than one caribbean import: the zombie and the domestic worker of the postwar period, which converge in the film. and yet, as currie suggests, the political commentary in fido is not limited to a sirkian setting of the s. this begs the question, how can we understand the nostalgic narrative of zombie labour in a contemporary context? incidentally, fido was shot and released at a place and time that coincide with labour turmoil and the use of migrant workers at a large healthcare facility in the city of kelowna. in september of , park place seniors living ltd. laid off twenty percent of its care staff, only to advertise (via a private contractor called advocare) those same positions at twenty-five percent less pay (valiani, ) . after receiving no legitimate applicants, advocare turned to the canadian government's temporary foreign worker program to fill an alleged labour shortage at a reduced cost. as salimah valiani ( ) observes, "temporary foreign labour in canada is predominantly racialized" (p. ) and used by employers like advocare "to provide sub-standard wages, benefits and working conditions in a given sector" (p. ). and so it seems that fido's ominous narrative of precarious "postindustrial" labour speaks to endemic concerns of marginalized workers within and beyond its nostalgic setting. the present conservative government in canada has failed to include any significant measures to protect the rights of migrant labourers within the temporary foreign worker program, despite several grievances filed by the united food and commercial workers canada and intercede (valiani, ) . although the conditions experienced by migrant workers vary by origin, industry and era, fido draws our attention to the continuity of exploitation under temporary foreign worker programs, a theme as relevant today as it was during the s. while the film's ironic suburban fantasy may rest in the past, its workers clearly do not. as a result, fido participates in a discussion of racialized labour in ways that exceed its director's expectations and intent. as national boundaries and borders are said to collapse under market pressures, migrants -"those wanderers in pursuit of work, whose proper place is always elsewhere" -have become valuable economic resources which are, like the zombie, depicted as outcasts of the national imaginary (comaroff & comaroff, , p. ) . this is particularly evident in fido's tension between zombie labour and white suburbia. whilst some zombies are banished to the "wild zone" beyond the town's protective fence, others are indentured as domestics, gardeners and servants, suggesting that the state is "more preoccupied with border control and national security than with migrants' well-being or rights" (zaman, , p. ). in the us, border militarization and the "fence project" were perhaps the most draconian (yet anticipated) elements of the bush administration's "comprehensive" immigration reform, according to which a -mile double-layered barricade was to be erected along the us-mexico border and patrolled by an additional , national guard troops. (while current us president barack obama has shelved the "fence project", he deployed , national guard troops to the southern border in the spring of .) at the same time latin american migrants are demonized in mainstream media, however, they "have become an institutional labour force in such industries as agriculture, construction, and textiles as well as in the service sector" (maciel & herrera-sobek, , p. ) . similarly, fido's zombies are highly ambivalent "internal outsiders", born on earth but reanimated by radioactive particles "from the darkest depths of outer space". as alien workers they are hunted but also domesticated; feared as "an evil no man could predict" yet fetishized as fashionable commodities. for instance, mr. bottoms is a decorated veteran of the zombie wars and head of security at zomcon, but his family owns a pack of zombies as gardeners, servants and housecleaners. evidently, the zombie's presence in willard is highly precarious and contingent upon obedience in the workplace. late in the film, for instance, fido misbehaves and is banished to a zomcon factory on the outskirts of town where a mutiny takes place. promising a "better life through containment", zomcon is responsible for not only the employment of zombies but also their deportation, placing the fate of the zombie workers in the "invisible" hands of the marketplace and the capricious interests of the corporation (which doubles as a neoliberal state). in other words, the narrative dramatizes "an extremely imbalanced relationship in which workers are dependent on employers to maintain their legal status, and employers can disregard their responsibilities toward workers whom they ultimately have the power to deport" (valiani, , p. ) . neither dead nor alive, the zombie cannot qualify for citizenship and is not privy to labour rights offered to "human" workers. it is temporary, expendable and reduced to unfree labour. like the indentured campesino (farm worker) living in squalid american labour camps or the filipino nanny caring for affluent canadian children, the zombie "exists within the boundaries of state regulation, but outside the boundaries of the national collectivity" (arat- koc, , pp. - ) . once their value as labour expires they are swiftly, but not always effectively, repatriated to the "wild zone". that is to say, both the zombie and the migrant worker are spectral entities in suburbia. they are neither living nor dead; neither present nor absent. the "spectral workforce" of fido speaks to a narrative tradition that uses a language of the occult to explain and interrogate capitalism as well as convey grievances to a wider audience. this tradition can be traced to the consortium of ghosts, gravediggers, spectres and vampires that line many of marx's manuscripts. what derrida ( ) calls the "spectropoetics" of marx's writing include the use of ghosts and apparitions to describe and diagnose curiosities of capitalism like the "bodiless body of money" (p. ) and the "metamorphosis of commodities" (p. ). for marx, the ghosts of labour and the social relations of production haunt the commodity-form, which of course takes on a spectral presence of its own. on the one hand, the occult narrative of capital "jolts the reader" into recognizing the "confusion" and "concealment" embedded within the system (smith, , p. ) . in its urgency, the language of horror and fright invites us to condemn the chilling and unspeakable conditions of forced labour and colonial exploitation. on the other hand, the "occultism of accumulation" renders the exploitative origins of value as mysterious as the "space particles" that awaken the dead. because the zombie narrative, for instance, appeals to magic, which is by definition beyond rational inquiry, it may "preclude a deeper examination of the practices in which these figures are engaged" (smith, , p. ) . marx was aware of this and sought a practical end to the ghosts of a bourgeois economy. he was certain that "the whole mystery of commodities, all the magic and necromancy that surrounds … commodity production, vanishes … as soon as we come to other forms of production" (marx, , p. ) . we may find similar "spectropoetics" in fido and its image of working zombies. though "not particularly fast", zombies provide the underlying but undervalued services that sustain willard. to this end, fido is concerned with "the struggle for recognition" of the oppressed (wood, , p. ) . while not conventionally "horrifying", currie's film offers an alternative space of multicultural critique where the disruptive presence of the zombie accentuates the "hidden" labour provided, for instance, by migrant workers in canada and the us. the zombie marks a "hyperbolic return to consciousness" of that which is displaced from dominant multicultural society (schneider, , p. ) . as historical figures, "zombies have ghostly forebears who have arisen in periods of social disruption, periods characterized by sharp shifts in control over the fabrication and circulation of value, periods that also serve to illuminate the here and now" (comaroff & comaroff, , pp. - ) . incidentally, romero's recent installments -land of the dead and diary of the dead ( ) -follow remakes of night of the living dead ( ) and dawn of the dead ( ), all of which illustrate the enduring curiosity and pedagogical potential of zombie metaphors in light of current economic uncertainties and a distended military-industrial complex in the us. as sordid symbols of alienation, zombies provide narrative subterfuge for a biting social critique, which is often overlooked as gruesome but "light" entertainment; the apparent absurdity of zombie films enables and constrains a potentially subversive commentary. if zombies mark a return of the repressed, they may also mark the "return" of exploited colonial labour. but fido contains a series of vertiginous storylines that complicate the coherence of its radical critique. if the plot is driven by zombie labour, for instance, it is also driven by a "boy and his dog". to be sure, fido is more than an alienated worker; he is also a childhood companion, much like richard pryor's character in the toy ( ) and the lovable canines of classic hollywood. (timmy often refers to fido as "boy" -an epithet connected to both chattel slavery and pet ownership.) by this logic, the film's satirical tone could just as easily turn the zombie labourers into a spectral workfarce. indeed, much of the film's humour is derived from the zombies' terrible inefficiency but also their steady employment by the residents of willard. if working zombies are a joke, so is the white middle class that hires them. zombies may be "mindless", but their propensity to consume the middle class of willard is instinctual and, i might add, instructional. though zombies are usually indiscriminate in their appetite for human flesh, they only devour the affluent residents of fido's white suburbia, a trend that sharpens an already acute visual economy of class. and yet the film mocks the insurgent possibilities of the zombie subgenre by absorbing fido into a suburban fantasy of the heteronormative family. if the zombie relieves a housewife of taxing domestic "duties", it also stands in for an unaffectionate father and a dispassionate husband. indeed, fido becomes an improved model of masculinity by performing housework, dancing with mrs. robinson and spending time with timmy. he is the film's "emotional centre" that "suffers, … responds to music, [and] longs to relate to people", unlike "the cardboard representatives of normality" (wood, , p. ) . while this development neutralizes the zombie's "monstrous" alterity, it also "manages" fido's difference by converting him into an ideal replica of the white middle class. in the end, fido has replaced his zomcon coveralls (and his proletarian identity) with a gaudy hawaiian shirt, which he wears while smoking a cigarette and doting on mrs. robinson's newborn. with his impending "fatherhood", fido has also replaced the late mr. robinson. the emergence of this "new" masculinity is foreshadowed by fido's budding romantic interest in mrs. robinson, which appears to be (bashfully) reciprocated. at this stage, the film's symbolic critique of colonial capitalism may collapse under the rhetorical weight of heteronormative desire; fido's acceptance in suburbia is legitimized by his affection for timmy and mrs. robinson, that is, his compatibility with the "normal" family unit rather than his value as commodified labour. although fido mocks middle-class suburban values, its racial allegory can be troublesome. if the monster of science fiction and horror has been "one of the most powerful icons" for representing the other, it is also notoriously slippery (james, , p. ) . in some ways, the subhuman status of the zombie conveniently doubles for a range of oppressed identities, including those of "third world" migrants who continue to struggle for the provision of the most basic but elusive human rights. if the monster invites sympathy for the dispossessed, however, it negates the prospects of agency by reiterating a condition of terminal oppression. zombies and monsters are more often objects of fear and pity than subjects of their own political change. by extension the zombie worker provides a skeptical commentary on the self-activation of labour, which belies the mobilization of migrant domestic workers by activist organizations like the philippine women centre, migrante international and intercede (zaman, ) . as such groups (and "shop rat" memoirs) would suggest, workers may be exploited but they are anything but mindless (or inherently monstrous). in similar ways, the monster plays on the same terrorizing trope of "difference" and disorder found in anti-immigrant rhetoric in north america, from lou dobbs' fear of an aztlán conspiracy to "reconquer" the southwestern us to glenn beck's phobia of mexican "illegals". such fears are often organized along class lines. at an internet movie database (imdb) discussion board, for example, one participant quipped about the dislocation of the (white) working class precipitated by fido's "cheap zombie labour": am i the only one who has a problem with all the jobs [the zombies] are taking? in this movie every low wage or service industry job has a zombie replacement … [which takes] jobs away from hard working living americans (sic). in real life no one would be embracing these zombies, they'd be calling for a wall to be built on the earth/hell border. (markusx x- , , p. ) these remarks are symptomatic of a wider displacement of class struggle in north america, one that is guided by racial anxieties. as juan gomez-quinones and david maciel argue, "during periods of economic crisis … immigrant workers are held up as lightening rods for public discontent, thus diverting antagonism from those actually responsible for the crises" ( , p. ) . another discussant at imdb, however, drew sympathetic comparisons between the plight of the living dead and "hispanic workers in texas", claiming the irrelevance of the wall since america's "republican/wealthy/oligarchy would love zombie labour" (kelticpete, , p. ) . in response, a third discussant emphatically wrote: "stop zombie outsourcing" (ruxxxy, , p. ) . apparently fido and its zombies elicit competing responses surrounding the racial dimensions of labour in north america, dimensions that percolate between canada and the us. if the racial allegory is notoriously elusive, then, the zombie may roam in a variety of political directions. "because the idea of zombie travels so widely, and across so many fields, it has become a very familiar character … that gestures to alterity, racism, species-ism [and] alienation" (webb and byrnand, , p. ) . by this logic, the zombie may offer an inventive critique of multiculturalism because of its twisted and wildly popular spectacle of "difference", which deliberately slips between human and inhuman. indeed, within the general field of horror "the state of being human is fundamentally uncertain" (prince, , p. ) . the zombie violates the same ontological boundaries of humanity that provided the shaky foundations of the eugenics movement and modern racial logic (goldberg, ) . as such, the alterity symbolized by the zombie is tentative not absolute; the undead blurs ontological hierarchies by questioning the very fixity of "difference" upon which "sameness" depends. as a range of programs and policies indicate, the canadian government has a vested interest in procuring temporary labour from a host of developing countries. to this end, bill c- only elevates the government's participation in an expanding global division of racialized labour that relies on "third world" migrants to fill largely unregulated, temporary and exploitable jobs in canada. and yet bill c- has evoked a wave of protest from labour and immigration activists across canada, as illustrated by the "no one is illegal" marches in vancouver, toronto, ottawa and montréal. though former citizenship and immigration minister diane finley claims bill c- will correct the oversight of immigrant education and experience, "third world" credentials are not historically recognized by "first world" employers. as himani bannerji points out, "decisions about who should come into canada to do what work, definitions of skill and accreditation, licensing, and certification, have been influenced by 'race ' and ethnicity" ( , pp. - ) . against this phenomenon, the zombie narrative represents a popular but political riposte. the allegory of the undead may double as a critique of not only thoughtless consumption, but also the "otherness" of unskilled labour. borrowing from both political satire and horror, fido provides an alternative vernacular of multicultural critique by situating "difference" in an imaginary but no less insightful context, one that trades on racist fears and fantasies in symbolic but duplicitous ways. fido is fundamentally concerned with "difference" and its precarious division from the land of the "same". it uses a sardonic nightmare to dramatize what fredric jameson might call the "political unconscious" of the multicultural nation-state ( ) . as a result, fido presents an imaginative space to work out and critique the fears and fetishes of alterity and immigration. the zombie fantasy is a "symptom of something else" (jancovich, , p. ) . it is loaded with "synchronic associations, ideological and social messages that are part of a certain … historical moment" (prince, , p. ) . as a liminal character neither dead nor alive, the zombie may signify some of the complexities and contradictions surrounding citizenship and the anxieties of "otherness". by reading fido within and against a discourse of immigration, we are perhaps better able to grasp not only the fecundity of the zombie trope but also how political constructions of the migrant overlap with popular narratives of the monstrous "outsider" in ways that are neither entirely planned nor wholly coincidental. indeed, "official and popular forms leak into each other and rely upon each other for their constitution" (walcott, , p. ) . together, they represent complementary cultural vernaculars used to condition and comprehend a range of experiences central to the articulation of multiculturalism in canada. underlying these vernaculars is a concern for labour and immigration in late capitalism. by turning to the hyperbolic but compelling imagery of the zombie, fido illustrates some of the prominent contradictions and concerns surrounding migrant labour within conservative iterations of "multiculturalism". indeed, the playful trope of the zombie contains a series of latent barbs that may otherwise be prohibited in more "serious" genres of popular culture. that is to say, fido is both a political commentary and a site of pleasure, which might be used to smuggle its transgressive possibilities into a mainstream media complex; "at the level of plot, action and character … the most dangerous and subversive implications can disguise themselves and escape detection" (wood, , p. ) . perhaps, then, the zombie allegory offers "not just a mode of depiction" but also a defiant vehicle of transformation (shaviro, , p. ) . keeping 'em out: gender, race and class biases in canadian immigration policy the ways and nature of the zombi not one of the family: foreign domestic workers in canada not one of the family: foreign domestic workers in canada foreign domestic worker policy in canada and the social boundaries of modern citizenship the dark side of the nation exclusive interview with fido director andrew currie activists oppose bill c- , demand status for all the 'albatross' of immigration reform: temporary worker policy in the united states canada's immigration policy and domestics from the caribbean: the second domestic scheme tories survive another confidence vote, mps vote in favour of bill c a nation of immigrants: women, workers and communities in canadian history disposable domestics. cambridge: south end minister kenney announces immigration ministers for ; 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o'connor, deborah title: family care across diverse cultures: re-envisioning using a transnational lens date: - - journal: j aging stud doi: . /j.jaging. . sha: doc_id: cord_uid: jxkjn ld in an increasingly globalized world, the importance of developing a more culturally complex understanding of family care has been clearly identified. this study explored family care across three different cultural groups - chinese, south asian, and latin american - living in a metropolitan, pacific-west, canadian city. in-depth qualitative interviews were conducted with family members from one of the three family groups exploring how they practiced ‘care’ for their aging, often frail, relatives. the importance of conceptualizing family care as a transnational, collective undertaking emerged from the outset as critical for understanding care practices in all three cultural communities. three themes identified contributed to this conceptualization: the need to broaden the understanding of family care; the centrality of geographic mobility, and the need to rethink the location of aging and consider its relationship to mobility; and the use of technology by extended family networks to facilitate continuity and connection. an over-riding notion of ‘flow’ or fluid movement, rather than a fixed, static arrangement, emerged as critical for understanding family care. this perspective challenges the dominant approach to studying family care in gerontology that generally conceptualizes family care practice as one local primary caregiver, often female, with some support from other family members. understanding family care from a transnational lens builds support for the importance of a feminist ethics of care lens and has important implications for policy and service delivery practices. canada, like many other western countries, reflects an increasingly globalized world with almost a quarter of adults living in canada selfidentifying as an immigrant (stats canada, ) . of these, % are over age (stats canada, ) , and if they came after , they likely belong to a culturally diverse community, including % from asia and the pacific region and % from south and central america (citizenship and immigration, canada, ) . a majority of older immigrants have come to the country under canada's reunification policy and are more likely to be living with and/or supported by family for at least years after their arrival (mcdonald, ) . the need to understand the implications of this culturally diverse world on the aging experience (phillipson, ; torres, ) and the provision of family care (bryceson, ; chappell & hollander, ; keating & de jong gierveld, ; kirkland et al., ; roberto & anderson et al., ; guo, kim, & dong, ; pinquart & sorensen, ) and the differential uptake of support, both formal and informal (greenwood, habibi, smith, & manthorpe, ) . however, many questions remain. in particular, two gaps in this body of knowledge limit its usefulness. first, at a general level, the strong focus of the stress/burden model has tended to assume one fixed primary caregiver and resulted in an incomplete understanding of the role of the rest of the family in providing care and support (sims-gould & martin-mathews, ) . second, in considering ethnicity and/or culture in family care, this body of knowledge has rarely focused on finding a meaningful way to examine the significant role that immigration and acculturation may have in implicating family care practices (guo et al., ) . a second body of research, found largely outside of the gerontological literature, has focused more explicitly on the role of transnationalism and migration in family care. this body of work has explored intergenerational care across the life-span including a small but growing body of research examining care of aging parents. 'care' in this body of research has generally been extended to capture a diversity of caring arrangements and activities as proposed by finch ( ) and fisher and tronto ( ) . seminal work by a western australian research group (baldassar, baldock, & wilding, ; see also baldassar & merla, ) has been particularly influential as a foundation for considering transnationalism as it relates to family care in the field of aging. their work has explored how care for an aging parent is accomplished and negotiated between family members living far apart and in different countries. during one of their first ethnographic studies, they interviewed australian immigrant families -about two thirds were of european descent with the remainder from new zealand ( ), singapore ( ), iraq ( ), and afghanistan living in iran ( ). to capture the experiences of both the immigrant adult children and older parents in their home countries, the researchers interviewed the immigrants in australia and the parents and other family members still remaining in the home countries. interviews included family and immigration histories, types of communication used, travel, and reciprocal care for care receivers and care givers based on finch's ( ) typology of family care exchange (financial, emotional, personal, practical, and accommodation) . additionally, the researchers observed and recorded how families organized space, tools, and other artifacts used for communication exchanges . the work of this research group has made important contributions for understanding transnational care. in particular, they highlighted the diversity and complexity of how care arrangements were negotiated and managed, drawing attention to issues such as how obligation may be culturally mediated, the impact of the migration process on establishing care capacity, and the importance of technology in these care arrangements. a small literature base has built on this body of knowledge as it relates to aging family care especially in europe (see for example, kordasiewicz, radziwinowiczówna, & kloc-nowak, ; miette sagbakken, spilker, & ingebretsen, ; zechner, ) . findings continue to demonstrate the complexity of understanding these family processes, and miette sagbakken et al. ( ) concluded by recognizing the importance of considering both the availability of kin members but also their understanding of obligation and reciprocity and how that might reflect their embeddedness in more than one society. despite its promise, however, this body of literature is only rarely addressed in the broader gerontological work on family care and a 'substantial void' in the caregiving literature remains in relation to understanding cultural values and processes (lee, chaudhuri, & yoo, ) , especially in relation to examining the experiences of non-western immigrants (dhar, b; wilding & baldassar, ; zhou, zhou, , . this current study bridges these two, somewhat disparate, bodies of research. specifically, drawing on a broad understanding of care that is consistent with fisher and tronto ( ) ; also tronto, ) , the purpose of our study was to explore and compare the relationships between culture and informal family care practices across three diverse ethno-cultural groups: chinese, south asians, and latin americans living in vancouver, british columbia, canada. although transnationalism was not considered at the outset of the study, all three of these groups have unique immigration trajectories, with the latin americans representing a relatively recent group immigrating for political and economic reasons from south and central america while the south asians and chinese have much longer histories in canada. we explored the following questions: ) what are the cultural interpretations and meanings of caring for an older family member within select ethnic minority communities? ) how do cultural meanings of relationships influence the care process? this qualitative study drew on constructivist grounded theory (charmaz, (charmaz, , b charmaz, a) to explore the process and meanings of family care across non-western cultural groups. the constructivist approach is designed to facilitate development of a framework to better understand the processes individuals create around their experiences and ways of being in the world. in keeping with this, the interview was designed iteratively; the researchers began with a few broad questions in order to develop a deeper and richer exploration and understanding of concepts through reflection and theoretical interviewing. throughout the research process, it is important to acknowledge the reciprocity that exists between the participants and researchers as well as the expertise of the participants (charmaz, (charmaz, , b charmaz, a) . this also helps diffuse power imbalances between participants and researchers. adults self-identifying as chinese, south asian, and latin american, and providing unpaid, informal care or support to someone over the age of needing some level of assistance with activities of daily living, were invited to participate. drawing on the work of finch ( ) and fisher and tronto ( ; tronto, ) , we conceptualized care as a "multifaceted complex social phenomenon, entailing both emotional and material (instrumental) aspects" (kordasiewicz et al., , p. )this encapsulated notions of caring for, caring about, providing care, and caring with (fisher & tronto, ) -and left it up to participants to describe what they meant by providing informal care or support. participant recruitment initially took place through researchers' personal networks, ads, and organizations in each of the chinese, south asian, and latin american communities. as the study progressed, snowball sampling was utilized, and participants were purposefully selected to ensure cultural, gender, and relational diversity. the final number of adults included participants: nine ( ) chinese ( males and females) from china, hong kong, and burma. ten ( ) south asians ( males and females) originated from india, east africa, and england. the ten ( ) latin american participants ( males and females) immigrated from chile, colombia, argentina, el salvador, and venezuela. table provides an overview of the family members consenting to participate. with signed informed consent, up to three personal, semi-structured, audio taped interviews were conducted with each of the individuals in the language of their choice. to capture cultural meanings and connotations and ensure carers' comfort and ease of expression, all but four individuals chose to be interviewed in their native language (cantonese, hindi, punjab, or spanish). the interviews were designed as an iterative process where three experienced researchers (each fluent in the respective group's native language/s) began with broad questions focused on family members' experiences and perceptions of providing informal care or support to an older adult, and then developed a deeper and richer exploration of concepts through reflection and theoretical interviewing. topics included exploring how each defined giving care in terms of their own cultural beliefs and backgrounds, and how -from their perspectives -these influenced the assistance or support they provided. consistent with a constructivist grounded theory approach, interview questions were honed and refined throughout the data generation process to explore emerging concepts and understandings. follow up interviews, ranging between a couple of weeks to a month after the first interview per the accessibility and schedule of participants, were conducted, and for some a third meeting, focused on expanding and verifying insights. at the end of the final interview, a demographic questionnaire was completed orally with each participant to collect information about both the carer and care receiver (for example, age, education, health status, financial resources, time in canada, citizenship, and others). ethical approval was obtained through the ethical review board from the university of british columbia. table below provides a picture of care receivers as described by their relatives. each family was caring for or assisting at least one parent, spouse, or relative ranging in age from to . some care receivers were healthy and independent while others had severe health problems such as alzheimer's, heart problems, or other diseases. in keeping with canada's family reunification program (mcdonald, ) , of the older adults had immigrated to canada to reunite with their families. although only two latin americans still resided in south america, visiting their adult children only when economically possible and based on immigration policies, they planned on immigrating at a later date. furthermore, the care receivers had lived in canada for years or more and in some cases, even for to years ( ). also, most care receivers ( ) either lived with the carer or a family member. data analysis was a collaborative (team), iterative process using a strategy consistent with the constant comparative method. first, all taped interviews were translated verbatim, (to capture cultural meanings), into english by the respective research associate who conducted it. next, a three-stage process began with the research associate affiliated with each of the three groups analyzing several interviews and coding them. then, associates with the principal researcher in vancouver met to discuss the interviews to analyze meanings, initial codes, and compare these among the three cultural groups. using these team decisions and codes, a code book was developed. it was then used to conduct a line-by-line coding of each transcript. atlas-ti facilitated this coding process. once data was coded, the research team began looking for links among codes to develop categories, for creating broader themes as they began to emerge. these were then refined and developed through subsequent interviews with the participants and by returning to the data. data revealed a process of family care that was complex and dynamic across all three cultural groups. specifically, a sense of flow and fluidity created a picture of care as a shared phenomenon -across family members and geography -that was highly dependent upon communication technology. hence, a significant theme that emerged across all three groups was the importance of conceptualizing family care as a transnational, collective undertaking underpinned by three themes: broadening the conception of 'family care'; locating family care as transnational; and increasing reliance on technology. in this study, consistent with existing research dhwan, ; flores, hinton, barker, franz, & velasquez, ; guo, li, liu, & sum, ; hsueh, hu, & clarke-ekong, ; pharr, francis, terry, & clark, ) , family care emerged as a normative cultural expectation in all three groups. however, each labelled and described the concept differently. for example, for the chinese (ch) participants, this revolved around the language of filial piety and/or 'ganqing' based on a relational sense of moral duty and responsibility, resulting from confucianism. these values were generally volunteered spontaneously and explicitly: it is our "culture" to "look after" the elder. it's more emphasized in our education from when we were kids....although my parents never said: 'you have to take care of me,'… but from a young age when we were "brought up," you know "ganqing" [you feel you] have to take care of him/her… especially those with alzheimer's (an -ch daughter caring for mother, age , with alzheimer's). supporting this perception as a culturally expected norm, sing mei, caring for her chinese parents, noted: 'i see my other friends, they also doing the same thing to their parents, to take carce of their parents' (sing mei -ch daughter caring for parents, ages +). south asian (sa) participants also positioned family care as a normative cultural expectation, but they were more likely to draw upon a religious understanding: describing caring for seniors and others as part of their religion where caring for others is an ingrained culturally expected religious responsibility to serve god and, thus, others. for instance, depicting this link between 'seva' or religious service and 'farz' note: ⁎ the two chinese caregivers worked outside of canada longer than they resided inside of canada. ⁎⁎ originally, chinese agreed to participate. however, one male dropped out. ⁎⁎⁎ two of the south asians indicated that another person was also the "primary" caregiver with them. ⁎⁎⁎⁎ nr -= no response to request for age ⁎⁎⁎⁎⁎ one wife was also a daughter-in-law to one of the male la participants. of la americans, were only children. or cultural responsibility, kavya, a south asian wife, caring for her husband and living with their daughter stated: 'culture, we are so religious from inside that we are taught from the beginning culture and religions, they are the same, and they run parallel.' kavya explained further: our foundation is such right from the start; serving others is like our religion. it is like serving god when we look after someone who is sick. we are told from childhood to look after sick people. what our children are doing…is part of our culture. in our culture, we teach to share. we shared with them; they are returning it to us. (kavya -sa wife caring for husband, age +) although religion is an important underlying value for the latin american (la) participants in this study, they described and explained caring for elders, family, and friends as 'deber' or duty. here, "family obligation" was based on the notion of collective loving family relationships and loyalty to family cultural values that extended beyond duty to immediate family into the community of friends. sandra, a previously paid health care provider, recently retired to care for her aging chilean mother, captured latin american cultural caring as collective and communal: as a family member, there is the affective aspect. never would i leave a parent, a very good friend, godmother, or whatever, if they don't have a family member or a person close to them. i feel that it is my "deber" (duty and obligation) for feelings for sentiments. i feel it is my "deber" to take care of/be concerned with that person, pay attention to them. (sandra -la daughter caring for mother, age ) caring for elders as a social expectation of being a 'good' son, daughter, or family member in the kin relationship network, then, was consistent across all three cultural groups. these cultural expectations also extended to friend networks described by many participants from all three groups. moreover, participants explained this care was a reciprocal act embedded within the social fabric of the culture. subtle differences in the foundations for understanding these expectations emerged, however. caring obligations appeared to be linked explicitly to religion for south asian participants, but it seemed more related to the teachings of political philosopher, confucius, for the chinese whereas latin americans tended to describe caring as a more collective sense of family extending beyond blood relationships. importantly, across all three cultural groups, this notion of family care was communal, embedded in a loose definition of the extended family network that included friends, blood relatives, and relational family. to illustrate, in our study, carers did not define a primary caregiver, but they discussed caring in terms of networks and relationships. even only adult children like argentinian rossana pointed out that she had created networks from her family (husband, daughter, and grandchildren, among others) and paid companions as well as her -year-old mother's long-time friends to provide support and care. another argentinian, -year-old casimiro, an only adult son, drew on his partner and extended family, like his female cousin living in seattle to provide support and companionship for his aging mother living independently. casimiro commented: my cousin, andrea, who is like my sister, comes from seattle every two months, and sometimes she stays for a week with my mother to keep her company. when i am here at my breaking point, she comes. she takes over. she releases me. for example, she came last week, and she cooked for two weeks. she leaves things prepared. she cares for my mother all the weeks. she takes her; she brings her back. she gives me license… (casimiro -la son, only child, assisting mother, age ) thinking further about his support network, casimiro explained: when i have problems with her [my mother], andera, my cousin, and daniel, my partner, are the two people who assist me…ahhh. i have a very good friend of hers in the [spanish community] group also…. that woman is very, very good also, and she helps me too… yes…she knows her [my mother] very well. she is from ecuador, and she knows the latin culture very well, so she cheers me up. (casimiro -la son, only child, assisting mother, age ) care was often described in terms of friend networks that provided support. for example, yoyi, a colombian business woman and daughter-in-law noted: 'in my country, (laughs) if someone is sick, people arrive to care for them' (yoyi -la daughter-in-law coordinating care for mother-in-law, age ) while a sa daughter, aaliyah, commented, 'my white friends get very surprised that my friends come right away when i need them.' furthermore, aaliyah (sa) explained that friendship was much more: - = = - = diabetes = prostate = mothers = independently - = = glaucoma = hard of hearing ⁎⁎⁎ = father - = = south asians ( ⁎ ) ⁎⁎ = - = - = alzheimer's = mothers = with caregiver ⁎⁎⁎ - = = - = bedridden = fathers = independently - = = - = - = brain hemorrhage = wife = care home - = = - = no health issues reported = husbands = with cg's brother - = = - = mother-in-law += = + latin americans ( ⁎ ) = - = - = alzheimer's = mothers = with caregiver ⁎⁎⁎⁎⁎⁎⁎ - = = - = pace maker ⁎⁎⁎ = father = independently - = = - = diabetes = husband -nursing homes - = = - = prostate cancer = daughter-in-law - = = - = stroke = aunt = ⁎⁎⁎⁎⁎ = old age = visit c& live in south america = healthy note: ⁎ number of care receivers is greater because some caregivers are caring for more than one person. ⁎⁎ one south asian caregivers was also a care receiver. ⁎⁎⁎ chinese indicated health issues; chinese indicated health problems; latin americans reported illnesses ⁎⁎⁎⁎ although some of the south asians indicated that the cr lived with them, in actuality, a number would live part-time with others in the family assisting with care. ⁎⁎⁎⁎⁎ one cr was a canadian by birth but had lived outside of canada for a number of years. ⁎⁎⁎⁎⁎ one latin american cr was born in south american but resided in the us ⁎⁎⁎⁎⁎⁎⁎ some started out living independently and then lived with cg or returned to independent lving, or started out living with cg and then moved o a nursing home. i went to india after years, believe it or not, my friend kept my mother with her for a full month. who would do that? i can't imagine. my mother was very happy. if she [friend] hadn't, we couldn't have gone to india. we both had to go, me and my daughter, we couldn't have thought of it. we didn't worry at all. it is our culture. if there is anything, i know that my friends are here, i don't have family, but my friends will be there. (aaliyah -sa daughter caring for mother, age +) in essence, two types of friend networks emerged during conversations with participants: friends of carers (as pointed out above) and friends of care receivers. although care receiver friend networks may not have provided direct care for their aging friends, they offered different types of support. this 'care' was more supportive and reinforcing companionship. five of the la participants spoke directly to the importance of this support: for example, rossana, an only child, maintained: [my -year-old mother] has two friends, well, she had. she has another friend who telephones her every so often…..sometimes she goes to visit her, but only once a month, but my mother counts on that. my mother has a little book where she has everyone's telephone number written down, and she calls… she asks people to call for her because she can no longer dial because she has lost her dexterity, so someone dials for her, and so she can talk. (rossana -la daughter, only child, caring for mother, age ) the deeply embedded cultural values, perceptions, and actions held by these three ethnic groups regarding family care created tensions within the canadian context for some, especially for those individuals dealing with relatives suffering from alzheimer's or severe illness. for instance, a recently retired chinese daughter, an, whose mother with alzheimer's lived with her and her retired chinese husband recognized the stress of this tension as she talked about how she had visualized her retirement quite differently: …after i retired, i was hoping to live the life of a retiree, hoping to do some traveling and enjoying life in retirement, doing more activities. but because i have to take care of an elderly [ -year-old] person with "alzheimer," i can't do what i want to do personally. (an -ch daughter caring for mother, age , with alzheimer's) for an, even though caring for her aging mother was causing stress in her marriage, as a chinese wife and daughter, pointed out: this situation is -…because she's my mother, and she's very afraid of going into a seniors' home, and i can't -my heart myself -basically i'm chinese, so "until" she really cannot "manage" one day, i mean when i cannot "handle" her "at home," i cannot bear to send her away to a seniors' home. (an -ch daughter caring for mother, age , with alzheimer's) other participants from the three cultural groups articulated views about cultural tensions between the canadian context and embedded cultural values of their elders. according to abhijeet, a retired south asian son, caring for his -year-old mother, 'there is culture in us,…a -year culture…we brought with us [when we immigrated to canada], …still alive in us. we know, it is not for us, we know…elders from india, after , when their life is almost over, they cannot change' (abhijeet -sa son caring for mother, age ). sandra, the la retired health care worker, addressed the necessity of balancing canadian beliefs and way of life with her cultural values since she has a canadian born son and her -year-old chilean mother living with her. sandra was clear, however, that she would ensure that her chilean mother's cultural family caring beliefs would be respected and honored despite what others might say. the doctor told me, "…well… there are institutions where you can put your mother." i said, "forget it! forget it! my mother is never going to be in an institution either." because the doctor is also chilean, and he would say, "forget what i said. forget it." because i would just look at him, "do you really think my mother would accept going there?". (sandra -la daughter caring for her mother, age ) nevertheless, as a -year immigrant to canada, sandra's changing values were reflected in her views of her own future old age in canada. i say to my son, "forget it. i am canadian now. the day that i begin to fail, in front of my house, there is a nursing home, you don't have to do any more than cross the street, and you put me there" (laughs). because my son is canadian, and he's going to marry a canadian girl, so then i must accept that the canadian family is different so his wife might think, ya the woman [mother-in-law sandra] is very slow, and there [nursing home] she will be very calm. (sandra -la daughter caring for mother, age ) other participants expressed similar change s in their values the longer time they spent in canada. participants despite some accepting the changes in cultural values, abhijeet, retired south asian son and husband, a long-time resident ( years) of canada, expressed the tensions that emerged in all three groups in this way: my parents, my father, her [wife] parents, my grandfathers, these are their pictures. when they were aged, they were looked after. at that time, the culture was different. now, it has changed. people over here are westernized, who bothers? go and leave your mother there [nursing home]. we'll pay money there. your attachment?. (abhijeet -sa husband and son caring for wife, age , and mother, in summary, family, kin, and friend care networks often were bounded, at least loosely, along cultural lines in their beliefs, intentions, perspectives, and actions. participants across all three cultural groups in this study drew firmly upon cultural beliefs about family care to make sense of their actions and responsibilities. for many, cultural perspectives about family care helped them explain their own sense of responsibility. importantly, however, cultural values also set the foundation for caring arrangements that were much more communal and relational. the sense of responsibility, however, could create tensions as participants experienced perceived cultural clashes regarding the understanding and meaning of familial care. a surprising theme to emerge early in this study was related to the relevance of geography and mobility to the flow of care. care processes were fluid, often transcending national, international, and geographical boundaries. mobility involved all members of the care network, including the person being cared for. geographical flow of care often consisted of the care receiver being cared for or supported across multiple households and geographical borders -both within the immediate locality as well as across different countries. furthermore, individuals providing some type of support or 'care' varied in terms of the type of relationship (immediate family; extended family; or friend networks) and location. one description of the mobility of the flow and fluidity of care between households by the immediate family was explained by chaaya, a south asian daughter, sharing care of their mother with her sister: mummy, from the time she came from india, first she lived with me, and later my sister moved out, and now she lives with my sister. half the week she lives here, and the other half she lives with my sister, and she has a very flexible schedule, and we are happy to keep her with us. there is joy in the house, that there is an elder in the house. (chaaya -sa-daughter caring for mother, age ) while the movement of this flow of care often occurred with immediate families at the local level, particularly for frail care receivers, surprisingly, mobility of care receivers took place fluidly across transnational borders. it was not uncommon for older adults, particularly if health allowed, to spend time (often months) with family members either between different households locally or dispersed throughout north america and/or transnationally in a former country of origin. often, it was difficult to determine what country or geographic location was 'home' to the older adult care receiver given the frequency and regularity of these mobile relocations. although some chinese and south asian individuals were mobile locally and nationally, this transnational movement phenomenon tended to be more frequent among latin americans. what was clear in the data was the complexity of facilitating this geographical movement. to illustrate the intricate and complicated support arrangements created by extended families, margarita, chilean only daughter, caring for her -year-old mother later diagnosed with alzheimer's, described: i have a cousin who lives in los angeles. she is my mother's niece, and she called me one day and said, "i'm going to chile. do you want me to take my aunt?" i said, "yes," so that we bought her a ticket so that she could go to chile, and so that afterwards she would be able to go to brazil. i have a son in brazil. we bought her the ticket. i, my boyfriend, and my mother travelled to los angeles where my cousin lives, and from there my cousin took her to chile, and, initially, she was going to stay with her brother there, but it didn't work out, and before she left, we looked for another arrangement, and a distant relative, said that she could have her in the house, and for a reasonable amount of money so much so that she went there for a month, and after a month, she went to my son's house in brazil. (margarita -la only daughter caring for mother, age , with alzheimer's) as explained above, planning trips was extremely cumbersome. participants not only had to take into account the complicated nature of planning travel for their aging parents, but they needed to account for other factors influencing movement across international and national borders. for example, ignacio, the youngest son of three colombian brothers, explained that although his -year-old mother was independent and able-bodied, she is afraid of airplanes, so she cannot come alone. she is very frightened of airplanes, [and] she speaks absolutely nothing of english, or rather, for her to come alone is not an option either…" to counteract these issues, "we need to go there and bring her here, …" and then accompany her back when she returns to colombia. (ignacio -la son assisting mother, age ) ignacio pointed out the importance of revising immigration, airline, and health policies, and programs to facilitate travel for aging immigrant parents: 'if they [policymakers, healthcare professionals, airline owners, or others] would simplify the way to bring parents, that way they would not have to become permanent residents or citizens.' he described ways travel could be facilitated and more accessible for older as well as frail adults. ….a program,…, where someone could bring them [older adults], and one wouldn't need to go and bring them here, rather that there would be a system where someone could bring various at a time, accompanying them in the airplane and helping them with running around for immigration. that would exist a way in that they could have tickets, a discount on the air fares….in the future an easier and faster way would exist that if the children are here, and the parents are alone there to make the immigration process faster because the time that they are there alone, well, it could become a risk that they experience other inconveniences because they are alone. (ignacio -la youngest son assisting mother, age ) finally, not only was the older adult mobile, carers also travelled within or between cities nationally or internationally to help provide care for aging relatives. jasmine, a chinese canadian daughter, stated: [when i was] away in toronto for a brief period, about a bit more than a year, my sister came to live with her' [their mother]. …, my sister, my brother-in-law, and my father were with my mother. in the end, they left, went back to hong kong. in , i came back from toronto to be with my mother. (jasmine -ch daughter caring for mother, age +, with alzheimer's) a prevalent theme underpinning the data from all three ethnic family networks indicated the importance of technology for facilitating an approach to family care that promoted a geographically fluid caring experience. in its least sophisticated form, technology included regular telephone contact -both locally and transnationally -with other family members and the care receiver. however, it also involved taking advantage of 'newer' technologies such as email and skype. the importance of telephone connection was highlighted by many: 'comfort was just a phone call away,' noted chaaya, a counselor and sa daughter. it enabled sibling and kin caring for older adults to be in 'communication all the time, absolutely, all the time, so that, well, or rather directly with her and through my sisters…' (chaaya -sa daughter sharing care with her sister of their mother, age ). low cost international calling was relied upon extensively. regular phone contact -sometimes daily -was maintained between family networks. this ensured all members were involved in daily life and decision making for the senior and family. it also helped reduce stress for those currently providing hands-on care and ensured all family members had an understanding of the older adult's care needs. this allowed each family member to contribute to care decisions as they emerged daily based on each person's abilities and time to assist with and participate in the care and support process. meiling, -year-old chinese wife, caring for her -year-old husband with dementia e pointed out: our daughter came two years ago to see her daddy, but she has work and children and family, so they can't come every year….they have to wait for the right time, the children's summer holidays, to come over. so we rely on telephoning. they call , , or times a week to talk with us. it's good. at least with the phone call, you get to know the situation. you can talk…now, they ask how's life with daddy, how he's deteriorating, get to know his conditions, that can help me reduce my stress [laughs heartily]. (meiling -ch wife caring for husband, age , with dementia) illustrating the many ways phone calls were used strategically, one son, ignacio, − a physician working in canada as a researcher -telephoned not just to keep his mother in colombia close to him but also to assist in monitoring her health: in actuality, we do it [call] once a week, and i ask her how her health is, if she has had medical appointments. i always find out what happened during the medical appointment, what medicines, what exams they ask for, what prescriptions she is taking, how she is feeling. perhaps, her health is the most important thing that i am aware of in addition to that, her emotional state. (ignacio -la son assisting mother, age ) while not a replacement for actual physical contact and recognizing the complexity and financial cost associated with travel, phone calls were helpful. much of the calling was, not unexpectedly, between members of the family kin network, but the potential value of using telephone contact with health professionals strategically to keep family aware and involved, was also raised. thinking about his mother, ignacio suggested: -to find a way that the doctors there [in colombia] can communicate with the children here [in canada]…one could send them an email or tell them…a communication bridge to tell them how he found my mother, what needs to be done, because my mother goes to the doctor, and the doctor explains a mountain of things in medical terms that she is not going to understand. she goes home, and i ask her how it went, and she tells me fine. (ignacio -la son assisting mother, age ) frequently, telephone calls were used to share news, keep in touch, and communicate -often daily. usually, these calls dealt with the mundaneness of daily living and celebrations. some extreme examples demonstrated the importance of contact as a lifeline. for instance, one venezuelan niece, leila, described how a visa problem limited her ability to travel, so she had to rely on an international call to talk with her dying aunt. previously, leila had cared for her aunt for more than years in the us. devastated that she could not be by her aunt's side in her last moments, leila remembered saying as she listened over the phone to her aunt's labored breathing: little aunt, you are with god. never be afraid because god is with you. you will see that you are going to be super well. god loves you. i don't know how much. i love you so much, you know. (leila -la niece caring for aunt, age , with alzheimer's) leila recognized the importance of emotional caring by an extended family member as a fundamental aspect of care. the warmth of family caring could not be replaced by professional caregiving -and her simple use of telephone contact allowed leila to continue providing loving, heartfelt, emotional support, connection, and comfort. not being able to be there…, it was like disappearing from her life. before that…, we talked, and all, but……it was that i was there at every moment for her [when she had been caring for her aunt with alzheimer's on a daily basis in the us]. the woman [professional caregiver] she had was excellent, but it was not the same quality, or rather the love, or rather the quality of care could have been very special, very professional, and all, and…very affectionate, latina, …, quality, but nothing like the love of the family. (leila -la niece caring for aunt, age , with alzheimer's) despite its utility and importance for emotional support, comfort, and communication, technology had some downsides. even with reduced costs of international calling cards, daily international calls still remained expensive. moreover, telephone calls could be intrusive to one's personal life as explained by casimiro, argentinian son, an only child: if she [my mother] needed something, she would call me a number of times. i tell you that because if not, she becomes another of the things; this …is very interesting. with her, one must have balance because i visit her every day. she becomes very possessive, and afterwards, she thinks i have the obligation! at the same time, when i answer the telephone every time, but i do not answer one time, she says to me, "why didn't you answer the telephone!" …i say, "mami, i am working. i am doing business. sometimes, i cannot attend to you. leave me a message, and i will answer you." it is something very interesting. it is like an education…if i answer her immediately every time, sometimes when i do not answer, it is "oh, lala!" (laughs). (casimiro -la son, only child, assisting mother, age ) beyond the telephone, other types of technology -for example, skype -emerged as an important facet for facilitating more traditional views of collective caring and played a key role in uniting local, national, international, and transnational 'carers.' it brought family members at a distance closer together in terms of proximity, particularly for some latin american participants. a vivid illustration of how technology facilitated day-to-day involvement was offered by antonia. despite residing a continent away, this -year-old female doctoral candidate described the continued closeness between her two sisters living in venezuela, her mother, and herself in canada. antonia pointed out that through technology, she, as the youngest daughter, was in constant communication with her mother in order to be part of and share experiences with her mother's daily life: by…using skype, we also see each other. then, if she goes saturday to have lunch at my sister's, my nieces turn on the computer. i say, mami, get on so that i can show you the little flower that bloomed on the plant. then, i show her through the house with the computer showing her the little flower, and it is so wonderful…it feels wonderful because she knows… as if she had come to actually see how it is doing, what the house is like here, and if the plant, and if it grew or if it didn't grow. i show her how…i hung a few new pictures. then, through skype, i can see the paintings. this makes it easier. (antonia -la youngest daughter supporting mother, age ) technology played an important role in facilitating and fostering the fluidity and flow of care for cultivating a sense of closeness, proximity, and presence of family, kin, and friend networks caring for and involved in the life of the older person and family. as described by all three family cultural groups, technology spanned local, national, and geographical distance and transnational borders to bring comfort, support, presence, closeness, and involvement in decision making while allowing family, extended kin, and friends to participate in seniors' daily lives and experiences at a distance. recognizing the importance of culture within a context of informal family care, the research team for this study sought to better understand the process of family care within three ethnic communities in vancouver, bc, canada. a broad understanding of giving care was adopted, allowing participants to self-identify their role in the care process from their cultural perspectives. this, perhaps, set the stage for the importance of fundamentally challenging conventional ideas associated with the study of family care in north america that has often focused on one 'primary' caregiver. specifically, across all three cultural groups, our findings support an understanding of family care as truly occurring within broader family kin (and friendship) networks that tended to be culturally bounded, often loosely, but not geographically constrained. this meant that in all three cultural groups, but especially with the latin american participants, it was often difficult to name a 'primary' caregiver since even only children, like rossana and casimiro, created extended kin and friend support networks that aided in the provision of support and care. consistent with this approach, none of the family carers identified themselves as the 'primary' caregiver. the notion of a primary carer was further disrupted by the mobility and use of extended travel by both the older adult to live with other family members and/or by family members spending time with the older adult making it difficult to even determine the location where primary care was being provided. our participants described complex negotiated decisions made by kin networks as a collective family undertaking about how, when, where, why, and by whom care and support would be provided to aging seniors. care was fluid and flowing throughout individuals, networks, time, space, distances, and ages. this suggests to us the need to extend ideas about aging in place -a term that commonly directs policies and practice -to consider more specifically the notion of 'aging-across-place' (r. beard, personal communication, august , ) as a relevant concept for understanding care within culturally diverse, immigrant groups. these findings position family care using a lens that is far broader and relational than the narrow focus on the provision of instrumental care that has typically dominated understanding of family care within conventional gerontological literature. hence, our findings support the much more inclusive and complex approach to care offered by scholars, such as finch ( ) and tronto ( ) . tronto has developed the concept into an ethics of care framework. grounded in feminist relational theory, an ethics of care lens captures the reciprocity of care in that we are all interdependent, both receiving and giving care throughout our lives. in this framework, tronto identifies five principles to guide the provision of care: attentiveness, responsibility, competence, responsiveness, and solidarity. these correspond to five phases of care: 'caring about,' 'caring for,' 'care giving,' 'care receiving,' and 'care with.' these phases are fluid and can operate simultaneously and sometimes contradictorily, across different relationships. pragmatically, the phases and corresponding principles capture the complexity of the caring process and provide a useful lens for exploring relationships: purpose, needs, emotions, and power. this framework lens may be especially important for understanding the interface between the experiences of family and formal care, particularly within ethnically diverse communities where underutilization of formal supports has, in many cases, been identified as a problem. second, our findings raise questions about how place of residence may be re-interpreted and understood as a more fluid concept than is typically assumed with movement occurring at the local, national, and international levels. in raising these insights, the study contributes to the understanding of family care as a transnational global phenomenon and bridges two important bodies of research. as identified in the introduction, migration scholars introduced the importance of a transnational perspective to describe and conceptualize relationships individuals and communities develop and sustain across geographical distances and national borders (baldassar, ; horne & schweppe, ) . with few exceptions (baldassar, ; baldassar et al., ; merla, ) , this lens has rarely been applied to the study of aging and/or understanding family care of older adults (amin & ingman, ; horne & schweppe, ; näre, walsh, & baldassar, ; zechner, ) , especially related to non-western cultural groups (dhar, b; torres, ; wilding & baldassar, ; zhou, zhou, , . this lens did not initially inform our research. however, the importance of it emerged early on in the data generation phase, and, consistent with a grounded theory approach, was used to help question, refine, and develop understanding. for example, we began to explore the fluidity and flow of care, role of technology, and describe how some ethnic older adults experience this notion of aging across different geographical places. our research suggests that this lens has much to offer to the study of family care in gerontology and supports findings by baldassar et al. ( , baldassar, and merla, ) that family care does not need to be proximate in order to be effective. a transnational lens draws attention to a number of areas that require further exploration and development. first, consistent with the work of baldassar, nedflcu, merla, and wilding ( ) ; wilding, ; wilding & baldassar, ) , and others (see for example, ahlin, ; lee, lee et al., ) , the promises and challenges of information communication technology (ict) for facilitating a more holistic understanding and enactment of 'family care' emerged as a critical aspect of family care that requires further examination. our findings lend texture to wilding's ( ) suggestion that technologies blur lines of imagined proximity and physical separation as families creatively incorporate diverse types of technologies into their provision of care to meet cultural, social expectations, and health needs in these contexts that tend to be particular to specific points in time. it supports the value of ict for 'enacting everydayness' (ahlin, ) , p. as a key theme related to 'good care at a distance.' one powerful example of the blurring of distance and time in this study was the graduate student, antonia, having lunch with her mother daily via skype. an understanding of the importance of ict also highlights ways of re-visioning the provision of formal support. for example, family conferences using supportive technology may help ensure that the entire family -irrespective of geographic location -has the necessary information to provide quality care and support, particularly for ethnic collective cultures. ensuring both the availability and uptake of effective communication technology infrastructures and digital literacy for older adults and their families will be an important area for research and service development. this is especially urgent in these times of covid . our study also supports the works of bryceson ( ), wilding and baldassar ( ) , and zhou ( zhou ( , that focused on the need to better understand how structural issues may impede the process of family care. transnational care or 'distant care' has received little recognition in the area of policy development (baldassar & merla, ) , and yet, as identified by at least one participant, ignacio, in our study, policies and practices, for instance around travel, may deter families from being able to care and provide culturally appropriate support in the way that they want while residency requirements may act as barriers for use of health and social care support services. future research is needed to understand how diverse health and social policies in both the home country as well as the country of immigration impact family care ( lee et al., ) . finally, attention to the notion of care as fluid and flowing for both able-bodied as well as those who are frail or ill emerged from our study as an important finding. 'flow of care' related to the presentation of negotiated, reciprocal, and shared family collective informal care was based on ability, availability, and capacity to care, occurring in motion, fluidly, through time and space as the care receivers transitioned and moved geographically to be with family as they aged and/or family moved to be with them. in addition to being consistent with an ethics of care framework, this notion develops further the work related to the circulation of care being developed by baldassar and merla ( ) ; . the concept of care circulation offers a broad view on transnational care through its focus on 'the reciprocal, multidirectional, and asymmetrical exchange of care that fluctuates over the life course and within transnational family networks subject to the political, economic, cultural, and social contexts of both sending and receiving societies' (baldassar & merla, , p. ) . in some of their work, they have examined how the older adult contributes in this circulation of care: an important limitation of our study is that we did not explicitly explore the role of the older person in the family care process except in relation to receipt of care. further research is needed to broaden and deepen the picture of family care, addressing more explicitly the role of reciprocity within the process. through this study, we explored the process of providing informal care to a family member within three diverse, non-western cultural immigrant communities. findings highlight the importance of recognizing family care as more communal and geographically fluid, supported by the innovative use of technology. the study suggests the need for a reframing of our understandings of family care -for example broadening moving from a notion of 'aging in place' to one of aging across geographical locations -and the need for policies and practices that can accommodate a different way of providing family care. we need to reinterpret care as flowing freely and fluidly throughout family, kin, and friend networks of informal, collective, and communal care through space, time, and distances locally, nationally, transnationally, and globally. no conflict of interest existed by the authors. good care" with icts in indian transnational families eldercare in the transnational setting: insights from bangladeshi transnational families in the united states transnational families and aged care: the mobility of care and the migrancy of ageing de-demonizing distance in mobile family lives: co-presence, care circulation and polymedia as vibrant matter families caring across borders: migration, aging and transnational caregiving transnational families, migration and the circulation of care: understanding mobility and absence in family life ict-based co-presence in transnational families and communities: challenging the premise of face-to-face proximity in sustaining relationships comments about a concept in the text of a manuscript from the editor of the research 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with social care services in the community: a systematic review of qualitative and quantitative literature sense of filial obligation and caregiving burdens among chinese immigrants in the united states family relations, social connections, and mental health among latino and asian older adults transnational aging: toward a transnational perspective in old age research acculturation in filial practices among us chinese caregivers a year portrait of theorizing in family gerontology: making the mosaic visible families and aging: from private troubles to a global agenda mining a unique canadian resource: the canadian longitudinal study on aging ethnomoralities of care in transnational families: care intentions as a missing link between norms and arrangements caring from afar: hib migrant workers and aging parents theorising about ageing, family and immigration la circulación de cuidados en las familias trasnacionales (the circulation of care in transnational families) concluding reflections: 'care circulation' in an increasingly mobile world: further thoughts dementia and migration: family care patterns merging with public care services ageing in transnational contexts: transforming everyday practices and identities in later life culture, caregiving, and health: exploring the influence of culture on family caregiver experiences placing ethnicity at the centre of studies of later life: theoretical perspectives and empirical challenges differences between caregivers and non-caregivers in psychological health and physical health: a meta-analysisanalysis at the intersection of culture: ethnically diverse dementia caregivers' service use diverse family structures and the care of older persons theorizing in family gerontology: new opportunities for research and practice family caregiving or caregiving alone: who helps the helper? immigration and ethno-cultural diversity highlight tables. immigrant status and period of immigration, counts, both sexes, age ( years and over), canada, provinces and territories, census - % sample data expanding the gerontological imagination on ethnicity: conceptual and theoretical perspectives caring democracy: markets, equity and justice virtual' intimacies? families communicating across transnational contxts ageing, migration and new media: the significance of transnational care care of older persons in transnational settings space, time, and self: rethinking aging in the context of immigration and transnatonalism time, space and care: rethinking transnational care from a temporal perspective we would like to thank dr. daniel lai (formerly of the university of calgary and now the hong kong polytechnic university) and acknowledge his leadership for this project.we would like to thank research assistants sonia andhi, msw for her work with the south asian interviewees and dr. sing mei chan for her assistance with the chinese participants as well as their help during the research process. a special thank you goes to, vancouver public librarian marilyn macpherson for her help in locating some of the statistics canada data.we are especially grateful to the chinese, south asian, and latin american participants and their families for sharing their experiences of caring and supporting their elderly relatives. this research was made possible by a canadian institutes health research grant (cihr # -npi: dr. daniel lai) canada. this research was approved by the ethics committees from the university of calgary (calgary, ab) and the university of british columbia (vancouver, bc). key: cord- -n omnki authors: hassan, ansar; arora, rakesh c.; adams, corey; bouchard, denis; cook, richard; gunning, derek; lamarche, yoan; malas, tarek; moon, michael; ouzounian, maral; rao, vivek; rubens, fraser; tremblay, philippe; whitlock, richard; moss, emmanuel; légaré, jean-françois title: cardiac surgery in canada during the covid- pandemic: a guidance statement from the canadian society of cardiac surgeons date: - - journal: can j cardiol doi: . /j.cjca. . . sha: doc_id: cord_uid: n omnki on march , , the world health organization declared that covid- was a pandemic.( ) at that time, only , cases had been reported globally, % of which had occurred in countries.( ) since then, the world landscape has changed dramatically. as of march , , there are now nearly , cases, with truly global involvement.( ) countries that were previously unaffected are currently experiencing mounting rates of the novel coronavirus infection with associated increases in covid- –related deaths. at present, canada has more than cases of covid- , with considerable variation in rates of infection among provinces and territories.( ) amid concerns over growing resource constraints, cardiac surgeons from across canada have been forced to make drastic changes to their clinical practices. from prioritizing and delaying elective cases to altering therapeutic strategies in high-risk patients, cardiac surgeons, along with their heart teams, are having to reconsider how best to manage their patients. it is with this in mind that the canadian society of cardiac surgeons (cscs) and its board of directors have come together to formulate a series of guiding statements. with strong representation from across the country and the support of the canadian cardiovascular society, the authors have attempted to provide guidance to their colleagues on the subjects of leadership roles that cardiac surgeons may assume during this pandemic: patient assessment and triage, risk reduction, and real-time sharing of expertise and experiences. a visual abstract of the main principles underlying our recommended approach is provided in figure . le mars , l'organisation mondiale de la sant e a d eclar e que l' epid emie de covid- etait une pand emie . À ce moment, on rapportait seulement cas à l' echelle mondiale, dont % s' etaient d eclar es dans quatre pays . depuis, la situation dans le monde a radicalement chang e. au mars , on comptait près de cas r epartis partout dans le monde . des pays qui n'avaient jusque-là pas et e touch es voient le nombre de nouveaux cas d'infection monter en flèche, les d ecès li es à la covid- augmentant par le fait même. À l'heure actuelle, plus de cas de covid- ont et e as the number of covid- cases continues to increase across canada, the canadian society of cardiac surgeons (cscs) and its board of directors strongly support the need to contain covid- and to limit its transmission through social distancing, self-isolation, and self-quarantine, as directed by the public health authorities. we also fully endorse the efforts taken at every level of the health care system (hospital, local health authority, provincial department of health, federal health ministry) to prepare for the potential surge in patients with covid- and any clinical needs that may come as a result. unfortunately, few have been able to estimate accurately the extent to which covid- will affect the population of canada in terms of rates of incidence, duration, and recovery. even less is known about how the impact of covid- will vary from hospital to hospital and from province to province. amid all this uncertainty, cardiac surgeons from across the country are being required to scale back their clinical practices in anticipation of an eventual scarcity of resources, including shortages in personal protective equipment (ppe); surgical drapes; mechanical ventilators; extracorporeal membrane oxygenation (ecmo) circuits; and, ultimately, health care personnel. despite this, cardiac surgeons nowdmore than ever beforedhave an incredibly valuable role to play during these challenging times. the cscs believes that it is imperative that cardiac surgeons maintain an active leadership role on health care teams during this pandemic and contribute their skill sets, both within and outside their traditional scopes of practice. to this effect, the cscs has proposed the following guiding statements in an effort to guide cardiac surgeons over the short term, as the covid- pandemic continues to unfold: . cardiac surgeons should be actively engaged in the emergency response teams of their respective institutions during the pandemic response. . the first priority of the cardiac surgery team is to ensure that the cardiac surgery needs of the hospital, the health region, anddin certain instancesdthe province, are met within the context of the covid- burden within their jurisdictions. however, cardiac surgeons, in this time of need, should also be willing to take on additional responsibilities, includingdbut not limited todperforming noncardiac surgery, caring for nonsurgical cardiovascular patients, and caring for critically ill patients irrespective of their covid- status. rates of infection among provinces and territories. amid concerns over growing resource constraints, cardiac surgeons from across canada have been forced to make drastic changes to their clinical practices. from prioritizing and delaying elective cases to altering therapeutic strategies in high-risk patients, cardiac surgeons, along with their heart teams, are having to reconsider how best to manage their patients. it is with this in mind that the canadian society of cardiac surgeons (cscs) and its board of directors have come together to formulate a series of guiding statements. with strong representation from across the country and the support of the canadian cardiovascular society, the authors have attempted to provide guidance to their colleagues on the subjects of leadership roles that cardiac surgeons may assume during this pandemic: patient assessment and triage, risk reduction, and real-time sharing of expertise and experiences. a visual abstract of the main principles underlying our recommended approach is provided in figure . and critical care colleagues to evaluate resource availability to ensure the appropriate utilization of potentially scarce resources includingdbut not limited todward and intensive care unit beds, ventilators, ecmo circuits, operating rooms, equipment, drapes, ppe, medications, blood products, and health care personnel. . cardiac surgeons should triage patients that are in hospital or on the elective wait list in a manner that is based not only on the patient's clinical status and risk-factor profile but also on the extent to which services are available or have been reduced in response to the covid- pandemic (fig. ). this is a strategy similar to the one recently adopted by the canadian association of interventional cardiology (caic). undoubtedly, there is concern that the proposed prioritization strategy will result in a surgical delay and may put patients at significantly increased risk. as such, it is critically important that cardiac surgeons ensure the presence of a robust wait-times database at their institutions that captures rates of adverse events in these patients while on the wait list so that decisions around the reallocation of resources may be made in a timely fashion. . cardiac surgeons should advocate for a continued role for the heart-team model to solicit the input of clinical cardiology, interventional cardiology, interventional radiology, and critical care in determining the optimal intervention for patients: in particular, those who cases are complex or who are at high risk. . in an effort to minimize risk to patients, cardiac surgeons should employ virtual clinicsdusing either a secure form of teleconferencing or videoconferencingdto assess patients from home who are either new referrals, postoperative follow-ups, or currently on the wait list. similar technology may be used, if available, to assess inpatients from other institutions to avoid potentially unnecessary hospital-to-hospital transfers. . when it is feasible, cardiac surgical programs should make every effort to maintain areas within their institutions for cardiac surgery patients that are completely separate from patients with covid- , given the vulnerability of the average cardiac surgery patient (increased biological age and cardiovascular risk factors) were they to become infected with covid- . . nonemergent cardiac surgical interventions for patients suffering from acute viral infections (such asdbut not limited todcovid- ) are largely discouraged, based on the belief that this could significantly elevate the risk of postoperative acute respiratory distress syndrome and mortality in that setting. in the event that a cardiac surgical procedure is performed on presumed or confirmed covid- epositive patients, cardiac surgeons must be closely engaged with their hospital administrations and infection control personnel to ensure the safety of the health care team. . cardiac surgeons should take the necessary steps (eg, donning and doffing ppe), as mandated by their institution and their local health authorities, to ensure their own health and well-being as well as the health and wellbeing of the members of the health care teams that they work with. . cardiac surgeons and their health care teams must be aware of procedures and techniques that may potentially generate increased quantities of aerosol matter includingdbut not limited toddouble-lumen vs single-lumen endotracheal intubation, reoperative minimally invasive surgery requiring lung dissection, and redo sternotomy vs traditional sternotomy. . cardiac surgeons across canada are encouraged to share their expertise and novel experiences as they relate to the covid- pandemic in a timely manner to improve overall outcomes. for example, protocols for triaging of patients on the wait list, ecmo use, and the operatingroom management of covid- epositive patients should be posted online, using readily available webbased platforms that would allow for cardiac surgeons and their teams to learn from each other in real time . who-director-general-s-openingremarks-at-the-media-briefing-on-covid covid- ) situation dashboard. world health organization public health agency of canada. government of canada. canada.ca, government of canada precautions and procedures for coronary and structural cardiac interventions during the covid- pandemic: guidance from canadian association of interventional cardiology influenza season and ards after cardiac surgery these are challenging times, and the cscs is looking for leadership and equanimity. we, as a community, need to continue to rise to the persistently evolving challenges posed by this historic event. we need to employ all of our skillsdclinical, academic, administrative, and otherwisedto ensure optimal care for our patients while offering a safe environment for our health care teams. understanding fully that these listed guiding statements may change over time, given the fluidity and scope of the current pandemic and appreciating that there are geographic differences in practice patterns and the delivery of health care across canada, it is our hope that this document will be of assistance to our colleagues as the covid- pandemic continues to unfold. the authors have no funding sources relevant to the contents of this paper. the authors have no conflicts of interest to disclose. key: cord- - v y j authors: nishiura, hiroshi; klinkenberg, don; roberts, mick; heesterbeek, johan a. p. title: early epidemiological assessment of the virulence of emerging infectious diseases: a case study of an influenza pandemic date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: v y j background: the case fatality ratio (cfr), the ratio of deaths from an infectious disease to the number of cases, provides an assessment of virulence. calculation of the ratio of the cumulative number of deaths to cases during the course of an epidemic tends to result in a biased cfr. the present study develops a simple method to obtain an unbiased estimate of confirmed cfr (ccfr), using only the confirmed cases as the denominator, at an early stage of epidemic, even when there have been only a few deaths. methodology/principal findings: our method adjusts the biased ccfr by a factor of underestimation which is informed by the time from symptom onset to death. we first examine the approach by analyzing an outbreak of severe acute respiratory syndrome in hong kong ( ) with known unbiased ccfr estimate, and then investigate published epidemiological datasets of novel swine-origin influenza a (h n ) virus infection in the usa and canada ( ). because observation of a few deaths alone does not permit estimating the distribution of the time from onset to death, the uncertainty is addressed by means of sensitivity analysis. the maximum likelihood estimate of the unbiased ccfr for influenza may lie in the range of . – . % within the assumed parameter space for a factor of underestimation. the estimates for influenza suggest that the virulence is comparable to the early estimate in mexico. even when there have been no deaths, our model permits estimating a conservative upper bound of the ccfr. conclusions: although one has to keep in mind that the ccfr for an entire population is vulnerable to its variations among sub-populations and underdiagnosis, our method is useful for assessing virulence at the early stage of an epidemic and for informing policy makers and the public. when an emerging influenza virus appears in humans, an early concern is whether the virus has the potential to cause a devastating pandemic, i.e., the global spread of an infection killing a substantial number of people. to assess the pandemic potential, two critical aspects need to be studied: the transmission potential and the clinical severity of the infection [ ] [ ] [ ] . it is widely known in epidemiology that the former aspect, the transmission potential, can be quantified by the reproduction number, i.e., the average number of secondary cases generated by a single primary case [ , ] , by characterizing the heterogeneous patterns of transmission (e.g. age-specificity) [ ] , and by measuring other epidemiological quantities such as household secondary attack rate. there are two different approaches to assessing the latter aspect of a pandemic, the virulence of infection. one is to explore specific genetic markers of the virus that are known to be associated with severe influenza (e.g. the pb gene) [ ] , although the absence of a known marker, as was for example the case in a novel swine-origin influenza a (h n ) virus (s-oiv), does not necessarily indicate that the virus is benign [ ] . another is an epidemiological approach to quantification of the case fatality ratio (cfr), the conditional probability of death given infection (or disease; see below). the cfr in general is vaguely defined as the ratio of deaths to cases, whose denominator should ideally be the total number of infections, but is frequently taken to be only the diagnosed cases due to the impossibility of counting all infected individuals. because in the early phase of an outbreak information is often limited to confirmed cases, we concentrate on confirmed cases only, and refer to the cfr as the confirmed cfr (ccfr) for clarity. as the world has experienced a global spread of s-oiv since april , methods have been sought for the real-time assessment of virulence by measuring the ccfr which is a representative of the epidemiological measurements of virulence [ , ] . nevertheless, a much-used crude estimate of the ccfr, i.e. the ratio of the cumulative number of deaths to cases at calendar time t, tends to yield a biased (and mostly underestimated) ccfr due to the time-delay from onset to death [ ] ; similar estimates of such a biased ccfr for severe acute respiratory syndrome (sars) have shown how such estimates can vary substantially as an epidemic progresses, stabilizing only in the later stages of the outbreak [ , ] . in the following we will use the terms biased and unbiased ccfr when we refer to this particular source of bias. improving an early epidemiological assessment of an unbiased ccfr is therefore crucial for the initial determination of virulence, shaping the level and choices of public health intervention, and providing advice to the general public [ ] . to obtain an estimate of the ccfr, the lesson from the sars outbreak is that a statistical technique is required that corrects the underestimation, e.g. a technique addressing censoring [ , , ] . nevertheless, in the case of novel s-oiv, an early unbiased estimation of the ccfr has appeared particularly challenging. initial reports from the government of mexico suggested a virulent infection, whereas in other countries the same virus was perceived as mild [ ] . in the usa and canada there were no deaths attributed to the virus in the first days following a declaration of a public health emergency by the world health organization. even under similar circumstances at the early stage of the global pandemic, public health officials, policy makers and the general public want to know the virulence of an emerging infectious agent. that is, a simple method for assessing ccfr is called for, even when only a few deaths have been reported, or even when there has been no report of deaths. except for another unbiased ccfr estimate in mexico ( . %, range . - . %) [ ] , this early assessment has been missing. in the usa, a technical discussion has taken place on the crude measurement of the biased ccfr using the cumulative numbers of deaths and confirmed cases so far [ ] . in line with this, an epidemiological method and its practical guide for early assessment of virulence are called for. the present study aims at developing a simple method to assess the virulence of an emerging influenza virus at the early stage of the epidemic, even when there have been only a few deaths or none at all. the method takes into account the time from the onset of symptoms to death, while differing from previously published statistical methods which employ censoring techniques [ , ] . as an example, we give an early prediction of the ccfr of s-oiv infection in the usa and canada, and show that the unbiased ccfr, as estimated by our method at the early stage of the epidemic in these countries, was in fact comparable to that estimated for mexico [ ] . our unbiased estimation of the ccfr does not address all sources of error in data (e.g. underdiagnosis of infected individuals) and we summarize the relevant issues in the discussion. we assess the virulence of s-oiv by measuring the risk of death, expressed as the ccfr. the ccfr is interpreted as the conditional probability of death given confirmed diagnosis [ ] . since the data of s-oiv infection we use in the present study are only confirmed cases, we have replaced ''infection'' in the denominator of cfr by confirmed diagnosis of infection (see discussion). accordingly, an unbiased estimator of ccfr would be the proportion of deaths among confirmed cases at the end of an epidemic. although one could instead assess the virulence by measuring the proportion of hospitalized cases among a total number of confirmed cases, criteria for hospital admission are not universal, being influenced by isolation policies and in some regions by cultural and social differences. in the following, the notation used to represent the three different statistical measurements of ccfr is: (i) b t , which is a crude, biased estimate of the ccfr calculated at time t; (ii) p, which is an unbiased ccfr to be estimated in the present study, and is the unknown parameter that governed the outbreaks; and (iii) p t , a random variable, which yields an estimator of p (see below) and is regarded as the realized value in one particular outbreak. first, b t , a crude and biased estimate of ccfr, calculated at time t, is given by the ratio of the cumulative number of deaths d t to the cumulative number of confirmed cases c t : during the outbreak of severe acute respiratory syndrome (sars) in - , it was shown that this estimator, b t , considerably underestimates the ccfr [ ] . this is easily demonstrated by relating c t and d t to the incidence function c t (i.e. the number of new confirmed cases on day t), and the conditional probability density function f s of the time from onset to death, given death. first, c t is the cumulative number of confirmed cases up to time t: second, d t is the cumulative number of deaths up to time t: as we mentioned above, p t is the realized proportion of confirmed cases to die from the infection, and is a random variable, which would be an unbiased estimator for p. therefore, b t can be rewritten as as can be observed in equation ( ), the estimator b t is smaller than the realized p t , because the time delay from onset to death, expressed in the double summation in the numerator, results in the numerator being smaller than the denominator (note that f s is a probability distribution). therefore we refer to b t as the biased estimator of the ccfr: it gives a biased estimate, calculated on day t, of the ccfr [ , ] . when we observe the entire course of an epidemic (i.e. tr'), b t tends to p t and becomes an unbiased estimator. the aim is to obtain an unbiased estimator ''well before'' observing the entire course of the outbreak. an adjustment of the estimator b t by a factor of underestimation is achieved by rearranging equation ( ): we use p t as the unbiased estimator of p, which is informed by three pieces of information: the cumulative number of deaths d t ; the incidence c t ; and the distribution of the time from onset to death f s . the former two are observed during the course of an epidemic. when there are a few deaths or none at all, an assumption has to be made for f s , e.g. from literature based on previous outbreaks (see below for detailed descriptions of f s ). we call the multiplicative factor in equation ( ) the factor of underestimation, u t , defined by the estimator p t can be written as p t = b t /u t . figure depicts the concept of the sampling scheme. the cumulative number of cases c t is regarded as the total population size. of these, only a proportion u t has been at risk for dying by time t, whereas the outcome for the remaining proportion -u t is still unobserved. among the u t c t cases that have been at risk, d t have died and u t c t -d t have survived the infection. this is a sample from a binomial distribution with sample size u t c t and probability p: an alternative way of deriving this probability is by first considering the total number, y, of people in the sample c t that will ultimately die from infection, which is binomially distributed with sample size n = c t and probability p. however, because of the time delay from onset to death, we do not observe this outcome by time t: only for a proportion u t is the outcome observed. hence our observation is a hypergeometric sample from a population of size c t , with sample size u t c t , and number of deaths y [ , ] : which is equivalent to equation ( ). we can use equation ( ) as a likelihood function to obtain the maximum likelihood estimate of p t : the % confidence interval of p t is derived from the profile likelihood. further technical details, especially where an exponential growth of incidence is observed, are given in the supporting information s . for calculation of the factor of underestimation u t , two pieces of information are needed: the incidence function c t and the distribution of time from onset to death f s . for c t , we use the published dates of onset among confirmed cases, while f s is assumed known. we analyze empirical datasets of two different infectious diseases: sars in hong kong ( ) and s-oiv infection in the usa and canada ( ). first, we examine a simplified version of our method by using only deaths and cases from an early stage of the sars epidemic, and compare our estimate against the eventual stable estimate at the end of the epidemic. for simplicity, we employ an exponential distribution for the distribution of the time from onset to death, f(s), with a mean of . days [ ] , and f s is subsequently calculated as the daily increase in f(s), i.e., f s = f(s) f(s ). second, we use the most recent published datasets of s-oiv epidemics in which the dates of illness onset for confirmed cases are known [ , ] . the latest such reports for the usa and canada were at may and june , , respectively. in the usa, there were confirmed cases by may , with known dates of onset ( figure a ). among confirmed cases, cases resulted in death by may . in canada, there were confirmed cases, with known dates of onset by june , among which cases died by june ( figure b ). the biased ccfr estimates, b t in these countries were . % ( = / ) and . % ( = / ), respectively. the six deaths are insufficient to determine the distribution of time from onset to death for these countries. we therefore employ a gamma distribution for f(s) (to calculate f s ), with reference to historical data for h n [ ] , with a mean length of days and a variance of . days (coefficient of variation %, shape parameter . ) [ ] . to address the uncertainty, we examine the sensitivity of our unbiased ccfr estimate to different means ( - days) and variances ( - days ). see supporting information s for further technical details. for the unbiased ccfr, we use and cases, respectively, as our c t in equation ( ) for the usa and canada. the population and sampling process for estimating the unbiased confirmed case fatality ratio during the course of an outbreak. at time t we know the cumulative number of confirmed cases and deaths, c t and d t , and wish to estimate the unbiased case fatality ratio p, by way of the factor of underestimation u t . if we knew u t we could specify the size of the population no longer at risk (u t c t , shaded), although we do not know which surviving individuals belong to this group. a proportion p of those in the group still at risk (size ( -u t )c t , unshaded) is expected to die. because each case no longer at risk had an independent probability of dying, p, the number of deaths, d t , is a sample from a binomial distribution with n = u t c t , and p t = p. doi: . /journal.pone. .g similarly, d t is and deaths, respectively. nevertheless, since the adjustment of underestimation requires dates of symptom onset, we use and cases for computing u t . although this has little impact on the estimate for the usa, the ccfr in canada is likely to be underestimated by our estimator, because the majority of the cases whose dates of onset have yet to be clarified, may have experienced their symptom onset close to the latest time point of observation. we subsequently compare ccfr estimates between the usa and canada by means of fisher's exact test. for the hypothesis testing, the number of deaths, d t , as well as the number of those survived, calculated as u t c t d t , is compared between two countries. the factor of underestimation u during the exponential growth phase is independent of time t and given by where m(-r) is the moment generating-function of f(s), given the exponential growth rate r which is estimated via a pure birth process (see supporting information s ). that is, when f(s) is the density of an exponential distribution with mean t, we have u = m( r) = /( +rt). figures a and b show the cumulative numbers of cases and deaths of sars, and figure c the observed (biased) ccfr estimates as a function of time, i.e. the ratio of the cumulative number of cases to deaths at time t. due to the delay from onset of symptoms to death, the biased estimate of ccfr at time t underestimates the realized ccfr at the end of an outbreak (i.e. / = . %). nevertheless, even by only using the observed data for the period march to april, equation ( ) yields an appropriate prediction (figure d ), e.g. the unbiased ccfr at mar is . % ( % ci: . , . ). an overestimation is seen in the very early stages of the epidemic, but the % confidence limits in the later stages include the realized ccfr (i.e. . %). when only a few deaths have been reported at the early stage of an epidemic, the unbiased ccfr estimate is given by minimizing the negative logarithm of the likelihood (see equation ( )). given and deaths in the usa and canada, respectively, and employing a gamma-distributed time from onset-to-death, the unbiased estimates of the ccfr are . % ( % confidence interval (ci): . , . %) and . % ( % ci: . , . %) in the usa and canada, respectively. the estimate in the usa appears significantly higher than that in canada (fisher's exact test; p, . ). the uncertainty bounds on the unbiased ccfr estimates in both countries overlap with that estimated for mexico [ ] . sensitivity analysis suggests that the expected values may lie in the range of . - . % and . - . % in the usa and canada, respectively ( figure ). even when there has been no observation of death by time t, it would be useful for policy makers to understand the implication of no deaths for interpreting virulence in a conservative way. when d t = equation ( ) simplifies to: which would result in an unbiased ccfr estimate of . because sampling a finite number of cases during the course of an outbreak cannot prove that infection never results in death, a more useful result would be the maximum ccfr with a certain level of confidence if no deaths are observed after c t cases. to obtain this result, we rearrange equation ( ) to obtain where p max is the maximum ccfr given c t cases and no deaths, at a confidence level of -a, e.g. % if a = . . equation ( ) is useful for obtaining a conservative estimate of virulence (i.e. upper bound of possible ccfr estimates) when no deaths have been reported by time t. in particular, during the early exponential growth phase the factor of underestimation, u, is independent of t. assuming that the exponential growth phase of influenza continued until april and , , respectively, in the usa and canada, r in these countries is estimated at . ( % ci: . , . ) per day and . ( % ci: . , . ) per day, it should be noted that confirmed cases include substantial numbers of imported cases from abroad. in canada, a few cases whose dates of onset were unable to be traced are also included according to their dates when a specimen was collected (the exact number of such cases is not known). assuming that their impact on our estimation procedure is negligibly small, we regard all cases in b as representing the dates of onset. doi: . /journal.pone. .g respectively (see supporting information s ). the resulting p max in the usa and canada (based on and cases and no deaths) is shown in figure . these upper bounds are examined for confidence levels at % and %. if the mean and variance of the time from onset to death are days and . days , and we employ a gamma distribution, p max is estimated at . % and . % at a = . and . in the usa. similarly, p max in canada is estimated at . % and . % at a = . and . , respectively. we propose a new epidemiological method for assessing the virulence of an emerging infectious disease at the early stage of an epidemic. the results with the hong kong sars dataset prove the usefulness of this method that corrects the biased ccfr estimator which is simply the ratio of cumulative deaths to cases. early in the epidemic, the ultimately realized ccfr is within the confidence interval obtained by our method. the proposed method is particularly useful when an epidemic curve of confirmed cases is the only data available (i.e. when individual data from onset to death are not available, especially, during the early stage of the epidemic). our estimates suggest that the virulence of s-oiv h n infection is comparable to the virulence observed in past influenza pandemics of the th century (, . % for the - pandemic and, . % for the - pandemic [ ] ). although our estimates may not be as high as . %, and even though the unbiased ccfr estimate for the usa is a likely overestimation (see below), we should emphasize that antiviral treatment and other medical interventions have been instituted from the beginning of this pandemic. our results show that the few observations of death in the usa and canada give us no reason to believe that the unbiased ccfr, and therefore the virulence of the novel pandemic strain, is smaller in the usa and canada than in mexico. nevertheless, given that the cfr of seasonal influenza is equal to or less than . % [ ] , our estimates (with the lower bound of ccfr close to the . %) do not offer conclusive results to indicate that the s-oiv is more virulent than seasonal influenza, but do point in that direction. it should be noted that our method only adjusts underestimation due to time delay from onset to death, and other epidemiological characteristics associated with unbiased estimation of the ccfr have yet to be addressed. in the present study, we estimated the ccfr as the proportion of deaths among confirmed cases. this definition was chosen, because of our aim to use the minimally available data, and so we were not able to estimate the proportion of deaths among all symptomatic cases, and not able to estimate the proportion of deaths among all those infected (symptomatic and asymptomatic). the issue of defining the correct denominator population can never be completely resolved, but it is essential to realize how the obtained estimate relates to other situations [ ] . by only using confirmed cases, it is clear that all cases will be missed that do not seek medical treatment or are not notified, as well as all cases that are asymptomatic. this means that our ccfr estimate is higher than the proportion of deaths among infecteds, and may be considered an overestimate. however, when relating our estimate to previous pandemics, it should also be realized that the current pandemic is the first where many confirmatory diagnoses of influenza have been recorded using rt-pcr techniques, allowing improved precision of ccfr estimates over those for previous influenza epidemics. whereas the use of rt-pcr in the current pandemic may yield a smaller denominator (and thus an overestimate of cfr compared to previous pandemics), other pandemics could have involved substantial numbers of falsepositive cases in the denominator. developing a method which permits comparable assessment of virulence is ongoing. the comparisons between the realized ccfr (horizontal grey line), the unbiased ccfrs based on observations by calendar time t, and the biased ccfr estimates, b t , given by the ratio of deaths to cases. each prediction was obtained by using the exponential growth rate r up to time t and the cumulative numbers of deaths and cases at time t, and the mean time from onset-to-death of . days [ ] which is assumed to follow an exponential distribution. overestimation is seen in the early stages of the epidemic, but the % confidence limits in the later stages include the realized ccfr. doi: . /journal.pone. .g figure shows the time course of biased ccfr estimates in the usa and canada based on the reporting date of confirmed cases and deaths to the world health organization. note that the estimates in figure c are different from our b t due to unavailability of the date of onset, although they give an approximate indication of the time-course of the biased ccfr. it is striking to see that the biased ccfr during the very early stage (i.e. from late april to mid-may) showed a declining trend following a single spike. the biased ccfr estimates at later time points show a slight increase as a function of time, which is consistent with our knowledge of underestimation of the ccfr [ ] . the early spike may be explained by a time-varying coverage of confirmed diagnoses which could have increased as a function of time (i.e. cases in the very beginning of the epidemic were less likely to be confirmed). other plausible explanations include ( ) demographic stochasticity, ( ) effective treatment, and ( ) heterogeneous risk of death among subpopulations. as for ( ), because the number of deaths in the usa and canada was very small during the early stage, the spike may reflect (unpredictable) probabilistic variations in the number of deaths among a small number of confirmed cases. if that is the case, our unbiased ccfr estimate for the usa (with data until may ) may be too high, not because of a systematic bias but just by chance. in relation to factor ( ), it is plausible that cases diagnosed in later stages of the epidemic receive treatment at an early stage of illness (or even before symptom onset). with respect to ( ), the risk of dying is likely to be different for different subpopulations [ , , , ] . it should be noted that the composition of sub-populations (e.g. agegroups and those with a specific underlying disease) is likely to vary as a function of time, and a ccfr estimate for the entire population, such as ours, is influenced by this variation. these points need to be addressed in future studies. to fully clarify the virulence and its epidemiological characteristics (e.g. variable risks by age and underlying diseases), two lessons for surveillance and data sharing should be noted. first, rather than updating the data based on date of reporting, it is critically important to summarize the data according to the date of onset both at local and global levels. knowing the date of symptom onset is a key to applying our proposed estimation framework to empirical observation. second, epidemiological data should be updated in a precise reporting interval at least during the early stage of an epidemic (so that the data permit estimation of the unbiased ccfr). given that mean time from onset to death is around days, weekly data do not enable us to make our explicit adjustment. optimal reporting for the early ccfr estimation may be incorporated into official pandemic response plans. moreover, in addition to using death as an outcome of virulence, the usefulness of other epidemiological measurements of severe manifestation (e.g. the number of admissions to intensive care unit) needs to be explored. despite a need to further clarify heterogeneous risks of death for the s-oiv pandemic, early assessment of virulence by means of our unbiased ccfr estimator is useful for informing policy makers and the general public about the potential severity of an infectious disease (of course, one needs to ensure an understanding of the above mentioned bias among non-experts). we have shown that underestimation can be adjusted in a very simple manner, and our approach enabled us to obtain an unbiased ccfr estimate by only minimizing a binomial deviance. these methods are particularly useful when there have been only a few deaths or even no death at all by time t during the course of an epidemic. uncertainties surrounding the unbiased estimate of ccfr based on a few deaths can partly be addressed by sensitivity analysis of the estimate to different lengths of time from onset to death. an observation of zero deaths in a given country (or a specific setting) should not be deemed a signature of a ''benign'' virus without observing a substantial number of cases. we have shown that a conservative upper bound of ccfr is a more useful interpretation of the observed number of cases without death. in this way, given that we have some prior knowledge or a few observations of death which permit us to assume f(s) is known, epidemiologists and biostatisticians in each country or locality can directly apply our method to assess the virulence of an infection at the early stage of any emerging infectious disease. during the final stages of revision, it came to our attention that an epidemiological study on ccfr of s-oiv with similar techniques and statistical philosophy has been published online [ ] , indicating that the preliminary estimate of ccfr for a combination of the usa, canada and mexico is . % and emphasizing a need to accurately capture the cases for the denominator. supporting information s given by the ratio of deaths per confirmed cases. the data were extracted from irregular situation updates of the world health organization [ ] , and the horizontal axis (time) corresponds to the date of reporting. therefore, it should be noted that the estimate suffers reporting delay, and in this sense, the calculated biased ccfr is different from our b t (based on date of onset) in the main text. the most recent report was made on june . since the interval of update has been irregular, the cumulative number of cases and deaths is kept the same as the latest report when there was no update on the corresponding date. doi: . /journal.pone. .g pandemic potential of a strain of influenza a (h n ): early findings how severe will the flu outbreak be? swine flu goes global mathematical epidemiology of infectious diseases: model building, analysis and interpretation transmission potential of the new influenza a(h n ) virus and its age-specificity in japan pathogenicity of highly pathogenic avian influenza virus in mammals epidemic science in real time methods for estimating the case fatality ratio for a novel, emerging infectious disease severe acute respiratory syndrome: temporal stability and geographic variation in case-fatality rates and doubling times managing and reducing uncertainty in an emerging influenza pandemic epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong non-parametric estimation of the case fatality ratio with competing risks data: an application to severe acute respiratory syndrome (sars) mexico's mystery: why is swine flu deadlier there? case fatality proportion strategies and statistics of sampling for rare individuals a new probability formula for surveys to substantiate freedom from disease emergence of a novel swine-origin influenza a (h n ) virus in humans available at: www deaths from bacterial pneumonia during - influenza pandemic time variations in the transmissibility of pandemic influenza in prussia textbook of influenza update: novel influenza a (h n ) virus infections -worldwide serum cross-reactivity antibody response to a novel influenza a (h n ) virus after vaccination with seasonal influenza vaccine assessing the severity of the novel influenza a/h n pandemic epidemic and pandemic alert and response (epr), world health organization ( ) influenza a(h n ) key: cord- -qy ttbkx authors: puddister, kate; small, tamara a. title: trial by zoom? the response to covid- by canada's courts date: - - journal: nan doi: . /s sha: doc_id: cord_uid: qy ttbkx covid- has made videoconferencing a regular occurrence in the lives of canadians. videoconferencing is being used to maintain social ties, run business meetings—and to uphold responsible government. on april , , members of the house of commons sat virtually using zoom. the virtual sitting was the first of what will become a stand-in for regular proceedings, allowing the members to fulfill some of their parliamentary duties while complying with physical distancing (see malloy, ). as the legislative and executive branches look to digital technology to allow the business of government to continue, what about the judicial branch of canada's government? courts are an essential service. this is best articulated by the chief justice of nova scotia: “the fact is, the courts cannot close. as the third branch of government, an independent judiciary is vital for our canadian democracy to function. it is never more important than in times of crisis” (wood, ). in this analysis, we seek to understand how courts have responded to covid- and the challenges of physical distancing through the use of digital technologies. this is accomplished through a systematic review of covid- statements and directives issued from all levels of court across canada. we briefly compare canada to the united states, a jurisdiction that demonstrates greater openness to technology. covid- has made videoconferencing a regular occurrence in the lives of canadians. videoconferencing is being used to maintain social ties, run business meetings-and to uphold responsible government. on april , , members of the house of commons sat virtually using zoom. the virtual sitting was the first of what will become a stand-in for regular proceedings, allowing the members to fulfill some of their parliamentary duties while complying with physical distancing (see malloy, ) . as the legislative and executive branches look to digital technology to allow the business of government to continue, what about the judicial branch of canada's government? courts are an essential service. this is best articulated by the chief justice of nova scotia: "the fact is, the courts cannot close. as the third branch of government, an independent judiciary is vital for our canadian democracy to function. it is never more important than in times of crisis" (wood, ) . in this analysis, we seek to understand how courts have responded to covid- and the challenges of physical distancing through the use of digital technologies. this is accomplished through a systematic review of covid- statements and directives issued from all levels of court across canada. we briefly compare canada to the united states, a jurisdiction that demonstrates greater openness to technology. there is a debate in the literature about the extent to which courts should embrace digital technologies. much of the discussion focuses on the open court principle-that courts must be open (metaphorically and physically) to litigants and the public (puddister and small, ) . some argue that digital technologies can enhance and change court reporting by allowing journalists to live-tweet or live-blog from the court (hall-coates, ) . others look to social media to allow courts to create more engaging and transparent relationships with the public (olsen and o'clock, ) . however, concerns have been raised. former chief justice beverly mclachlin ( ) wondered if court reporting would fall short of journalistic standards of accuracy and fairness if courts allowed the public to use social media to engage in live text-based communication from the courtroom. others suggest digital technologies and the courts are a clash of cultures, with the former being innovative and the latter being inherently conservative in nature (ccpio, ) . while the circumstances around the use of digital technologies during the pandemic are unique, courts, in canada and elsewhere, have long reflected on the appropriate use of technology in the justice system. the story of canadian courts and technology is, at best, a story of slow adaptation, and at worse, one of active resistance. in most canadian courts, television cameras and live photography are expressly prohibited, and livestreaming of proceedings only regularly occurs in the supreme court. this analysis is part of an ongoing effort to understand the canadian courts in the digital age. in other work, we analyze policies that govern live, text-based communication in courtrooms and the twitter feeds of canadian courts (mattan et al., in press; puddister and small, ) . our research finds that the canadian judiciary is very conservative in its approach to digital technology. we find a similar approach during covid- . the judicial system reflects canada's federal structure. according to the constitution act of , provinces have exclusive jurisdiction over lower courts (section courts), the federal government has exclusive jurisdiction over federal courts (section courts), and jurisdiction is shared over superior courts and provincial courts of appeal (section courts). this means each level of court can set policy regarding court administration, which could result in varied approaches to the continuation of service during the covid crisis, even within a single provincial or territorial jurisdiction. while digital technologies could assist courts in addressing administrative concerns such as the filing of documents, evidence, and scheduling during the pandemic, our analysis focuses only on the adjudicative role or the hearing of legal matters in court. our comprehensive analysis reviews the policies of all section , (trial and appeal), and (trial only) courts, for a total of courts. overwhelmingly, we find that canadian courts have pivoted to provide access to limited essential legal services during the crisis. almost per cent of courts reviewed are hearing matters deemed "urgent" and "emergency" via technology. while there is some minor variation as to what constitutes urgent and emergency, this commonly covers urgent criminal matters, bail or release from custody, and urgent family matters (ontario court of justice, ). courts are fulfilling their essential service mandate by providing access to matters that are deemed essential, such as the protection of the right to habeas corpus (a defendant's right to be brought before a court to justify imprisonment) and the protection of vulnerable individuals within the context of family law. this said, canadian courts are not necessarily providing "trial by zoom." courts are just as likely to suggest teleconferencing alongside videoconferencing. the decision as to what technology will be used varies. for some courts, a judicial administrator will canvass for the availability of technology among counsel and judges, while others allow the presiding judge to choose. of note, the ontario court of appeal is using courtcall, a pay-per-use, third-party service for telephone and video conferencing, and the nova scotia supreme court recently piloted virtual court using skype and the court's existing audio system. canadian courts are only providing a minimum service during covid- . routine trials, jury trials, and other proceedings have been cancelled or adjourned. the matters that are being heard are largely the jurisdiction of lower trial courts (section and courts); the higher courts of appeal have been slower to adapt, rescheduling matters for summer and fall. for example, the supreme court, perhaps canada's most technologically equipped court, has responded to the covid- challenge by delaying many hearings (supreme court of canada, ). arguably appellate courts should be better suited to transition to online hearings, given the nature of their work, which generally only includes written and oral submissions from counsel (without witnesses or physical evidence). the substantial delay within the legal system that existed prior to covid- will only increase. the case backlog is a serious concern in the family system (smith, ) , and in the criminal system, it has been considered a constitutional crisis (see r. v. jordan, ) . delay is even more problematic for in-custody individuals due to the institutional transmission of covid- , where two-thirds of inmates have tested positive in some institutions (ivison, ) . thus, it is a very real (and potentially deadly) concern that courts cannot continue routine work during the covid- crisis. the very cautious approach we see in canada is in marked contrast to the united states. while is it beyond the scope of this analysis to fully discuss what is occurring in the us, american courts are making use of videoconferencing beyond emergency and urgent matters. some states mandate the use of videoconferencing, while many others are strongly encouraging courts to do so. for instance, texas issued an emergency order authorizing courts to conduct proceedings (civil or criminal) through teleconferencing, videoconferencing, or other means, with the exception of jury trials (texas judicial branch, ) . the emergency order requires that courts ensure public access to court proceedings via technology. texas judges were provided training on zoom trials. one possible explanation for the difference in approaches between the two countries is technological; compared to canada, american courts have been more open to the use of television cameras among other technology (metz, ) . notwithstanding real concerns regarding delays in the justice system, moving to virtual spaces during covid- is not without its challenges. indeed, a report produced in collaboration with several american court administration organizations highlights technical and constitutional issues with virtual hearings in the us (joint technology committee, ). in terms of technology, privacy issues have been raised regarding the use of zoom (joint technology committee, ). there are also concerns about the quality and reliability of digital technology, which proved to be a concern for canadian parliamentarians (malloy, ) . this raises questions about the digital divide-the inequalities between those who have regular and quality access to digital technologies and those who do not, as well as inequalities in technical competence and skill. many canadians, particularly those in rural and remote areas, do not have adequate access to broadband, nor do many indigenous communities (crtc, ; hyslop, ). these challenges could be potentially insurmountable for an individual attempting to access the court system. virtual-only proceedings create particular constitutional challenges. for criminal defendants, the rights to a jury and defence, enshrined in sections (f), , and (d) of the charter, respectively, are undoubtedly limited by online-only proceedings with restrictions placed on legal arguments and evidence, and the complete inability to facilitate a jury trial. moreover, when proceedings are conducted by telephone or videoconferencing, the ability for the public and the media to participate is limited and open court is restricted. as paciocco argues, the principle of open court becomes most pressing during times of crisis and when "constitutional rights seem too extravagant to endure" ( : - ), although texas appears to have found a technological solution to allow for open court. the covid- crisis has created a considerable challenge for the operation of the judicial system. across canada, legal proceedings have been delayed and rescheduled. most of the work has been at the lower trial courts, which are largely responding only to urgent criminal and family matters. unlike parliament, the supreme court of canada has delayed going virtual. however, the covid challenge presents an opportunity for the court system to innovate and, where appropriate, embrace the capabilities of digital technology. court administrators might find e-filing and e-scheduling to be more efficient, while correctional and remand institutions might expand video-bail capabilities. as justice pringle (ontario court of justice) noted, "one of the silver linings … we feel that we have been booted into the st century of technology by this crisis" (in powell, ) . canadian radio-television and telecommunications commission (crtc). new media and the courts: the current status and a look at the future following digital media into the courtroom: publicity and the open court principle in the information age closing bc's indigenous internet gap prisoners are sitting ducks as ottawa lets covid- sweep through canadian jails conference of state court administrators, the national association for court management and the national center for state courts the adaptation of parliament's multiple roles to covid- tweet justice: the canadian court's use of social media supreme court of canada -speech by beverley mclachlin justice through the eye of a camera: cameras in the courtrooms in the united states the role of social-networking tools in judicial systems covid- pandemic-definitions of urgent matters when open courts meet closed government we have been booted into the st century': what covid- could mean for ontario's strained and outdated courts navigating the principle of open court in the digital age: the more things change, the more they stay the same losing ground on the backlog supreme court of canada coronavirus (covid- ) court operation guidance: chief justice issues new emergency order renewing, clarifying and amending previous emergency orders judicial stability in times of crisis trial by zoom? the response to covid- by canada's courts acknowledgements. the authors thank the anonymous reviewers for their helpful feedback, as well as graham brown. key: cord- -srpg h authors: lavoie, maxime; renard, aurélie; larivière, serge title: lynx canadensis (carnivora: felidae) date: - - journal: nan doi: . /mspecies/sez sha: doc_id: cord_uid: srpg h lynx canadensis kerr, , commonly called the canada lynx, is a medium size felid and is the second largest of the four species in the genus lynx. it is distributed throughout the boreal forest of most of canada and alaska and across portions of the northern united states. it prefers dense, regenerating coniferous forests with moderate canopy and understory cover. l. canadensis is a snowshoe hare specialist, and its ecology, morphology, and behavior closely reflect that of its main prey. it is listed as “least concern” by the international union for conservation of nature and natural resources, is on appendix ii of the convention on international trade in endangered species of wild fauna and flora, and its population size trend is considered stable. however, the status of united states subpopulations, being largely peripheral to the canadian population, is more tenuous and the species is protected. lynx canadensis (fig. ) is the tallest lynx in north america and can be differentiated from the sympatric bobcat l. rufus by its larger size (head-body length . - . cm versus - cm in l. rufus- sunquist and sunquist ), its large, widely spreadable and furry feet (feet are smaller, < cm , and pads are naked in l. rufus), longer legs (height at shoulder > cm versus < cm for l. rufus), longer ear tufts (> . cm versus < . cm in l. rufus), shorter tail (< . length of hind foot versus > . length of hind foot in l. rufus) and more imprecise spotting on the belly fur (parker et al. ; larivière and walton ; rezendes ) . on average, l. canadensis is heavier (mean body weight, males: kg; females: . kg) than l. rufus (mean body weight, males: . kg; females: . kg- anderson and lovallo ) although the opposite has been noted in some areas (parker et al. ; buskirk et al. ) . the tip of the tail of l. canadensis is black all around and that of l. rufus is black on the dorsal surface only (larivière and walton ) . pelage of l. canadensis typically is more grayish (werdelin ; sunquist and sunquist ; anderson and lovallo ; hansen ) . because of geographic variation across populations and even within a single region, distinguishing the skull of l. canadensis from that of l. rufus and other felids often requires a combination of generalizations (characters that do not always hold across the entire geographic range) and specific measurements. the skull of l. canadensis (fig. ) differs from that of l. rufus by its typically larger size, relatively smaller auditory bullae, wider interorbital breadth (> mm), larger presphenoid (> mm at its widest portion), typically smaller and more anterior position of the postorbital processes of the frontal bones, longer upper carnassial (> mm), and by the separation of the anterior condyloid foramen from the foramen lacerum (jackson ; hoffmeister ; elbroch ) . the skull of l. canadensis can typically be differentiated from other felids by the narrower nasal branch of the premaxilla, the thinner, less depressed, and sharper postorbital processes, less deeply notched suborbital margins of the palate, and closeness to the canine and more forward placement of the first large upper premolar (pocock a ). lynx canadensis is a medium-sized ( - kg) felid that possesses a round head, short nose, long, pointed ears, long limbs, large feet, and short tail (sunquist and sunquist ) . pelage is gray to silver-gray, with a blueish tinge in young animals. summer pelage is darker (saunders ) . some l. canadensis have the blue or dilute mutation characterized by bluish-gray replacing black in the pelage (jones ; schwarz ; denis ) . white fur occurs on eyelids, inside of ears, chin, throat, and dorsum. the outside fur of the ears is brown with a white central spot and the facial ruff is well developed (hall ) . pads become fully furred in winter (denis ) . males are larger than females. mean (except where noted) body mass (kg; n, range or sd) of l. canadensis males and females, respectively, was: . ( , . - . ), . ( , . - . ) in alaska (berrie ; stephenson et al. ); . ( , . - . ), . ( , . - . ) in alberta (van zyll de jong ) ; (single male), . ( , . , . ) in manitoba ( )-lynx canadensis mammalian species (carbyn and patriquin ); . ( , . - . ), . ( , . - . ) in michigan (erickson ; beyer et al. ) ; . ( , . - . ), . ( , . - . ) in minnesota (mech (mech , moen et al. ) ; mean not given ( , . - . ), mean not given ( , . - . ) in nova scotia (parker et al. ); . ( , ± . ), . ( , ± . ) in the northwest territories (murray and boutin ; poole et al. ); . ( ), . ( ) in wisconsin (schorger ; doll et al. ); . ( , . - . ), . ( , . - . ) in nova scotia (saunders ) ; and . ( , range not given), . ( , range not given) in yukon (slough and mowat ; o'donoghue et al. ) . additional body masses (kg) of individual l. canadensis were: . (adult, male) in british columbia (poszig et al. ); . (adult, male) in iowa (rasmussen ); . (adult, male) in maine (fuller ); . (kitten) in november in manitoba (carbyn and patriquin ) ; . (adult, male), . (adult, female), . (juvenile, female) in montana (koehler et al. ) ; . (adult, male), . (kitten, male), . (kitten, female) in wyoming (blanchard ) ; . (yearling, female), . (kitten, male) in january, . (kitten, female) in january, . (kitten, female) in april, . in yukon mowat and slough ) . mean measurements (mm, n, range or sd) of males and females, respectively, were: total length , ( , - , ), ( , - , ); length of tail ( , - ), ( , - ); length of hind foot ( , - ), ( , - ) in alaska (berrie ) ; total length ( , - , ), ( , ; length of tail ( , - ), ( , ; length of hind foot ( , - ), ( , in alberta (van zyll de jong ) ; total length . ( , . - , . ), . ( , . - . ); length of tail . ( , . - . ), . ( , . - . ); length of hind foot . ( , . - . ), . ( , . - . ) in newfoundland (saunders ) ; height at chest ( , ± . ), ( , ± . ) in the northwest territories (murray and boutin ) ; total length . ( , ± . ), . ( , ± . ) in ontario (quinn and gardner ) . hall ( ) presented the following ranges of measurements (mm, mixed sexes, sample size not specified): total length ( - ), length of tail ( - ), length of hind foot ( - ). parker et al. ( ) reported the following ranges of measurements (mm) for males and females, respectively, from nova scotia: total length - , - ; length of hind foot - , - ; height at shoulder - , - . additional measurements (mm) of individual l. canadensis were: total length . (adult, male), length of tail (adult, male), length of hind foot (adult, male) in iowa (rasmussen ) ; total length , . (adult, male) in michigan (erickson ) ; total length . (adult, female), length of hind foot . (adult, female), length of ear . (adult, female), neck circumference . (adult, female) in minnesota (mech ) ; total length . (adult, female), length of hind foot . (adult, female), length of tail . (adult, female), length of ear (adult, female) in wisconsin (doll et al. ) ; total length . (adult, male), length of hind foot . (adult, male), height of shoulder . (adult, male), length of ear tuft . (adult, male) in wisconsin (schorger (blanchard ) . mean skull measurements (mm, n, range or sd) of males and females, respectively, were: greatest length of skull ( , ± . ), ( , ± . ); basilar length ( , ± . ), ( , ± . ); zygomatic breadth ( , ± . ), ( , ± . ); maxillary toothrow ( , ± . ), ( , ± . ); canine width ( , ± . ), ( , ± . ) in newfoundland (saunders ) ; greatest length of skull . ( , . - . ), . ( , . - . ); condylobasal length . ( , . - . ), . ( , . - . ); basilar length, . ( ), . ( , . - . ); palatilar length . ( , . - . ), . ( , . - . ); zygomatic breadth . ( , . - . ), . ( , . - . ); interorbital breadth . ( , . - . ), . ( , . - . ); braincase breadth . ( , . - . ), . ( , . - . ); mastoidal breadth . ( , . - . ), . ( , . - . ); maxillary toothrow . ( , . , . ), . ( , . - . ); mandible length . ( , . - . ), . ( , . - . -elbroch ) . hall ( ) presented the following ranges of skull measurements (mm, mixed sexes, sample size unknown) greatest length of skull ( - ), zygomatic breadth ( - ), alveolar length of maxillary toothrow ( . - . ). in juveniles, the sagittal crest is not developed, the humerus is small (males < mm, females < mm), and the epiphyseal suture is not ossified (saunders ) . foot measurements (n, sd) of males and females, respectively, were: foot area . cm ( , ± . ), . cm ( , ± . ) and footloading: . g/cm ( , ± . ), . g/cm ( , ± . ) for specimens in the northwest territories (murray and boutin ) . the geographic range of lynx canadensis extends throughout the boreal forests of most of canada and across the northern parts of the united states (fig. ) . the northern distribution of l. canadensis is limited by tree line in alaska, labrador, northwest territories, nunavut, quebec, and yukon, whereas it is limited by snowfall and competition with l. rufus and the coyote canis latrans in the south (buskirk et al. ; ruggiero et al. ) . the northern limit of its range has not changed significantly for at least the past two centuries, but the southern limit has been pushed northward in the great plains, ontario, and quebec (poole ) . in canada, l. canadensis is present in all provinces and territories except prince edward island. it is also absent from mainland nova scotia, the canadian west coast, and the southern prairie. however, historically, l. canadensis occurred in mainland nova scotia and prince edward island. in the continental united states, it was formerly found in states and as far south as utah during the mid- s (mckelvey et al. a) . currently, l. canadensis only occurs in some southern extensions of boreal forest (mckelvey et al. a; hoving et al. ) there are two different hypotheses concerning lynx evolution, one based on fossils and morphology, and a more recent one based on genetics. the hypothesis based on fossils and morphology suggests that the genus lynx probably originated in africa during the early or mid-pliocene (werdelin ) . the lynx ancestor, lynx issiodorensis migrated into the northern hemisphere during the villafranchian and gave rise to the eurasian lynx l. lynx in asia (werdelin ) . l. lynx then spread eastwards in north america giving rise to l. canadensis probably during the sangamonian or the early wisconsinan (werdelin ) . in contrast, the genetic hypothesis states that the genus lynx probably originated in north america around . million years ago (mattern and mclennan ; johnson et al. (janczewski et al. ; johnson et al. ). this common ancestor gave rise to l. rufus . million years ago and then differentiated into l. canadensis and the progenitors of l. lynx and the iberian lynx l. pardinus . million years ago (johnson et al. ) . lynx canadensis was present in refugia in beringia and south of the ice edge (kurtén and anderson ) . the oldest fossil, found in the southern refugium, dates from the sangamonian interglacial, , - , years ago (kurtén and anderson ) . fossils of l. canadensis are reported from the late pleistocene deposits at bighill creek formation and near medicine hat, alberta (wilson and churcher ; harrington ) , near american falls, idaho (pinsof ) , near silver creek, utah (miller ) , and from the aftonian deposits near delight, washington (fry and gustafson ) . l. canadensis started utilizing the snowshoe hare lepus americanus as its main prey probably in the late pleistocene or early holocene (breitenmoser et al. ) . it probably immigrated to newfoundland early in the postglacial period (cameron ) but was rare until (bergerud ) . form.-dental formula of lynx canadensis is i / , c / , p / , m / total of , and deciduous dentition formula is i / , c / , p / , m / total of (saunders ) . the ( )-lynx canadensis mammalian species external morphology of the brain, especially the position and shape of the sulci, is different from other species of felids (radinsky ) . l. canadensis seems to have a rounder and larger brain than most felids and the mean endocast volume of the brain of four specimens is cm (radinsky ). the temporal ridges on the parietal bones have a lyre shape with a width of % and % of the braincase for males and females, respectively (saunders ) . in adults, the temporal ridges join together to form the sagittal crest (saunders ) . the sagittal crest and the lambdoidal ridge increase in dimension with age and size, the ossification of the humerus is completed by the end of the second year, and the skeletal growth of males around the th month (saunders ) . the auditory bulla is broader in the anterior portion of the inner chamber and narrower in its posterior portion compared to that of l. lynx (pocock ) . lynx canadensis is digitigrade with sharp, retractile claws. front and hind feet have four functional toes. the plantar pad of the front foot is short compared to its width and the claw sheaths are well developed. toes are united by a deep web (pocock b) . female l. canadensis have four mammae (two inguinal and two abdominal) and males have a small baculum. bregmatic bones occur rarely ( / and / museum specimens examined -pratt ; manville ) . lynx canadensis is similar in winter and summer (casey et al. ) . l. canadensis maintains its body temperature at . °c and increases its respiratory frequency in response to increasing temperature ranging from respirations per minute at − °c to respirations per minute at °c (casey et al. ) . males have higher concentrations of fecal glucocorticoid metabolites at the onset of the breeding season, whereas the increase occurs toward the end of the breeding season for females (fanson et al. ) . the webbing uniting the toes helps l. canadensis walk on snow (pocock b) . males and females have similar mean foot-loads (ratio of body mass to foot area) but yearlings have a lower foot-load than adults (murray and boutin ) . the large paws, long limbs, and low foot-load of l. canadensis likely provide an advantage for travel in deep snow compared to other predators which have smaller limbs and paws (koehler and brittell ; murray and boutin ; buskirk et al. ) . l. canadensis has both long legs and low footloading (buskirk et al. ) . snow hardness affects sinking depth of lynx but not snow depth and l. canadensis sinks on average . cm in snow (murray and boutin ) . one male l. canadensis penetrated from to cm in snow (poszig et al. ). map drawn with information from slough and mowat ( ) , schwartz et al. ( ) , anderson and lovallo ( ) , poole ( ) , hoving et al. ( ) . yearlings have lower body fat than adults (brand and keith ; parker et al. ) . females have less subcutaneous fat than males and yearlings have less renal fat than adults because of the higher energy requirement during growth (brand and keith ) . renal and subcutaneous fat seem to be affected only by snowshoe hare abundance during late winter (brand and keith ) . fat reserves generally decline from november to january and increase from january to february (parker et al. ). blood parameters of l. canadensis are available (weaver and johnson ) . evidences from captive l. canadensis showed that olfaction might be poorly developed but auditory and visual senses are good (saunders a) . l. canadensis has a solid mandibular symphysis allowing it to cut flesh proficiently (scapino ) . ontogeny.-kittens of lynx canadensis are born reddishbrown with stripes and spots (merriam ; denis ) ; newborns have eyes closed, no teeth, poorly developed ear tufts, ears folded forward, but pelage well developed with guard hairs and underhairs (saunders ) . the pelage of newborn kittens has longitudinal streaks more apparent on the back than the flanks, with dark horizontal bars on the front legs (merriam ; saunders ) . eyes open after days (denis ) . mass of three newborns was g (slough and mowat ) , g, and g (saunders ). kittens gain - kg during the first days of life and may double their weight within days (moen et al. ) . lengths of two neonates were and mm (saunders ) . lynx canadensis often gives birth and rears young in different dens (slough ; squires et al. ) . female l. canadensis use dens from birth until the kittens are foraging at about - weeks old (slough ) and decrease their movements while denning (moen et al. ) . kittens usually stay close to their dens the first days after parturition and start gradually following their mother further away until they reach their mother's predenning movements around days after parturition (moen et al. ) . they can hunt by themselves by the spring following their birth (brand et al. ) . lynx canadensis reaches adult size during its second year (saunders ; parker et al. ). the environment during the growing period is important for adult body size (yom-tov et al. ). l. canadensis reaches sexual maturity sooner during high snowshoe hare densities (brand et al. ; parker et al. ). female l. canadensis can conceive during their first year at about - months of age but usually do not give birth before their second breeding season (brand et al. ; parker et al. ; breitenmoser et al. ; moen et al. ). male l. canadensis generally do not breed before their second year and gametogenesis is reduced during summer and autumn (anderson and lovallo ) . reproduction.-lynx canadensis is capable of ovulating spontaneously but female ovarian activity increases between february and april (fanson et al. ) . breeding occurs in march and april (saunders ; poole ) but may take place as late as may in alberta (nellis et al. ) . pair bonds are short, and males do not provide parental care. pregnancy rate ranges from % to % (brand and keith ; quinn and thompson ; slough and mowat ; vashon et al. ) . productivity of l. canadensis is directly linked to snowshoe hare numbers (nellis et al. ) , with larger litters observed in years of higher snowshoe hare density (brand and keith ; slough and mowat ) . at all densities, adult females produce higher litter size and have higher pregnancy rates than do yearlings (parker et al. ; mowat et al. a) . females can have one litter per year but during low snowshoe hare densities, interbirth intervals may be years (anderson and lovallo ) . in the yukon, adult females reproduced each year except the second and third years following snowshoe hare decline. in contrast, yearling females reproduced only during years of high snowshoe hare density (slough and mowat ) . similarly, in alberta, % of adult females gave birth in years of high snowshoe hare abundance compared to % in snowshoe hare scarcity (brand and keith ) . gestation lasts - days (denis ; hemmer ). young are born in late may to early june (saunders ; slough ) but l. canadensis can give birth weeks later than normal during years when snowshoe hare abundance is elevated (mowat and slough ) . litter size ranges from to (nellis et al. ; brand et al. ; mowat and slough ; moen et al. ) . corpora lutea persist for more than one breeding season (nellis et al. ). population characteristics.-lynx canadensis is a snowshoe hare specialist, and its ecology, morphology, and behavior reflect closely that of its main prey (o'donoghue et al. a (o'donoghue et al. , b . mortality is higher during winter (poole ) , especially the first winter of low snowshoe hare density (poole ; slough and mowat ) and death from starvation often coincided with temperatures below − °c (poole ) during this period of decreased snowshoe hare density. it can survive through two -year density cycle peaks (breitenmoser et al. ) . in some areas l. canadensis cycles may be affected by disease (gilpin ; but see finerty and vik et al. ) , or intrinsic self-regulation factors (zhibin et al. ) . lynx canadensis can be killed by coyote , wolverine gulo gulo slough and mowat ) , wolf canis lupus , mountain lion puma concolor (koehler et al. ) , and fisher pekania pennanti (vashon et al. ) . collision with vehicles can also be a significant cause of mortality (kloor ; steury and murray ) and is an important factor in reintroduction failure (aubry et al. ) . l. canadensis may also die from cannibalism (elsey ; o'donoghue et al. ; poole (rich ) and it can live up to years in the wild (kolbe and squires ) . lynx canadensis is highly susceptible to trapping (mech ; carbyn and patriquin ; parker et al. ; bailey et al. ; quinn and thompson ) , particularly males (quinn and thompson ) . furthermore, l. canadensis may be more vulnerable to trapping during periods when snowshoe hare density is low (brand et al. ). trapping mortality, where trapping is legal, seems density dependent (brand and keith ) and is thought to be additive rather than compensatory (bailey et al. ; quinn and thompson ; slough and mowat ) , especially during high and declining snowshoe hare densities (poole ) . however, during the first two winters of low snowshoe hare density, trapping may be partly compensatory (ward and krebs ; poole ) . slough and mowat ( ) proposed that local extinctions of l. canadensis populations may be prevented by establishing a system of untrapped versus trapped areas. these untrapped areas would allow l. canadensis populations to respond more naturally to decreasing snowshoe hare densities. lynx canadensis populations undergo density cycles (krebs et al. ) . cycles have been detected in more than years of fur sales from the hudson's bay company (elton and nicholson ) . it follows a periodicity between and years (brand et al. ; krebs et al. ; korpimäki and krebs ; ranta et al. ) with an average of . years (elton and nicholson ) . the interval between two lynx cycles is more constant than the amplitude of each cycle (moran a; bulmer ) . across canada, the cycle in density is not geographically synchronous but can be separated into three regions: the atlantic, the continental, and the pacific (stenseth et al. a ). these regions match the three climatic-based geographic regions (stenseth et al. ) and the border between the atlantic and the continental region is correlated with the geographic pattern of warm spells (stenseth et al. b ). the cycle reaches its peak first in the central provinces (saskatchewan and manitoba), then year later in the western provinces (british columbia and alberta) and years later in the eastern provinces (ontario and quebec-butler ). the cycle may be synchronized by l. canadensis dispersal patterns (butler ; lack ) . the cycle is caused by a high postnatal mortality, reduced reproduction rates among yearlings (nellis et al. ; brand and keith ; parker et al. ) , and changes in recruitment (stuart-smith and boutin ) , combined with high adult mortality (brand and keith ) . autoregressive (tong ) , fixed frequency (moran a) , and a combination of both models (bhansali ) have been used to analyze l. canadensis data, to explain the cyclic fluctuation in mathematical terms. autoregressive models can describe random changes in frequency, phase, or amplitude of oscillations, whereas fixed frequency models assume a fixed predetermined period. several models have been tested such as using ( ) the logarithms of the total animals trapped to reduce both the degree of asymmetry of the oscillations in the original data and the effect of ignoring the fact that the real population abundance is not exactly proportional to the number of animals caught (moran a) , ( ) a pure autoregressive model of order without a fixed component (tong ) , ( ) a pure sine wave of a period of . years superposed with a first-order (bulmer ) or ( ) second-order autoregressive process (campbell and walker ) , ( ) an autoregressive model of order combined with a sine wave of a period of . years (bhansali ), ( ) a self-exciting threshold autoregressive model, that allows more flexibility in model parameters by switching from one regime to another when a threshold is reached, with two regimes of order and (lai ) or ( ) with two regimes of order (stenseth et al. ). the previously mentioned models assumed the oscillations to be an autonomous phenomenon and external factors as perturbations only. other models describe the oscillations as being generated by external factors. examples of these models follow: ( ) a stepwise multiple regression analysis including precipitation in may and temperature in june, september, and october (arditi ) , ( ) a three-dimensional phase portrait with a deterministic period of years with noise superimposed (schaffer ) , ( ) a model incorporating plant-herbivore and prey-predator interactions as density ratios (akçakaya ) , ( ) a bivariate time-series model fitted to snowshoe hare and l. canadensis data to consider within-and between-population interactions (vik et al. ) , and ( ) a uniform phase evolution and chaotic amplitude model to evaluate the presence of a bifurcation process caused by increase trapping pressure or alternative prey (gamarra and solé ) . the l. canadensis density cycle is primarily induced by fluctuations in snowshoe hare density (butler ; stenseth et al. ; vik et al. ) and usually follows or years behind the snowshoe hare cycle (bulmer ; brand et al. ; boutin et al. ; o'donoghue et al. ). between the low and peak abundance periods for snowshoe hare, l. canadensis density increased from . to times in the yukon slough and mowat ; o'donoghue et al. ) and times in the northwest territories (poole ) . the speed and magnitude of l. canadensis recovery from low snowshoe hare densities depends on the number of l. canadensis that survive the years of snowshoe hare scarcity (brand and keith ) . the l. canadensis cycle is more obvious in northern environments but is still apparent in the southern portion of its geographic distribution, likely due to dispersal of northern individuals (mckelvey et al. b) . l. canadensis dynamics might differ in populations in southern latitudes because fluctuation in snowshoe hares is more stable than in the north (koehler ) because alternate preys are more abundant (roth et al. ) . the cycle in l. canadensis also may be influenced by weather (moran b; arditi ; stenseth et al. ; yan et al. ) . sunspot numbers are not correlated with the l. canadensis cycle (moran ) but solar activity could indirectly, through the effects of the climate cycle on the ecosystem, modulate the snowshoe hare cycle and thus the l. canadensis cycle (sinclair et al. ). forest fire, through plant succession favoring snowshoe hares (fox and bryant ; trostel et al. ; krebs et al. ) , and snowfall may also cause oscillation in l. canadensis densities (fox ) . finally, climate can affect l. canadensis population cycles by the relationship of foot-loading to snowfall, by affecting snowshoe hare, and by affecting forest composition (hoving et al. ) . however, it has not been shown that l. canadensis cycles result from cycle in fur prices (de vos and matel ; gamarra and solé ) that modulate trapper harvest effort (gilpin ; weinstein ) . the southern range of l. canadensis appears to have contracted during the last decade (bayne et al. ) and it has been suggested that climate change may have a negative impact on the distribution of l. canadensis populations (carroll ; bayne et al. ) . age and sex ratios of the harvest data usually differ from the population data and will change seasonally and dependently of the cycle (quinn and thompson ) . yearlings are overrepresented in harvest, especially in autumn and winter, while kittens are underrepresented but increased after december, when they become more independent (slough and mowat ) . among yearlings, males are more vulnerable to trapping due to their higher mobility (saunders a; mech ; quinn and thompson ) . sex and age ratios of the harvest vary with the cycle, with kittens being absent during the decline and numerous during the peak (nellis et al. ; brand et al. ; brand and keith ; poole ) . most studies of harvested populations have observed sex bias toward males (quinn and gardner ) , but an even sex ratio or a bias toward females have also been observed (brand and keith ; bailey et al. ; quinn and thompson ) . it seems that during peak densities in l. canadensis populations, males are predominant and during low densities, females are predominant (poole ) . through the cycle, sex ratios usually do not significantly differ from equality (parker et al. ; poole ; slough and mowat ) . sex ratios (males:females; n in parenthesis) were: for kittens : ( ), for yearlings : ( ), and for adults : ( ) in minnesota (mech ); : ( ) in the northwest territories (poole ) ; for kittens : ( ), for yearlings : ( ), and for adults : ( ) in nova scotia (parker et al. ); for kittens : ( ), for yearlings : ( ), and for adults : ( ) in ontario (quinn and thompson ) ; for kittens : ( ), for yearlings : ( ), and for adults : ( ) in yukon (slough and mowat ) . during snowshoe hare scarcity, age distribution of l. canadensis shifts toward an older cohort due to a lower recruitment (brand and keith ; slough and mowat ) . the main cause of the decrease in recruitment is kitten mortality ranging from % to % (brand et al. ; poole ; mowat et al. b) . during periods when snowshoe hare density is low, l. canadensis either does not conceive or aborts litters (mowat and slough ) and survivorship of kittens of yearling females is lower than that of kittens of adult females (mowat et al. b; slough and mowat ) . when snowshoe hares are abundant, late born kittens can survive winter (mowat and slough ) . lynx canadensis densities vary greatly during a snowshoe hare cycle ranging from . to . / km . densities were / km during periods of high snowshoe hare density in alaska (bailey et al. ), - / km in alberta (nellis et al. ; brand et al. ), . - . / km during a l. canadensis peak in maine (vashon et al. a ), . - . / km in newfoundland (bergerud ) , - / km in the northwest territories (poole ) , / km during periods of high snowshoe hare density in nova scotia (parker et al. ), . - . / km in quebec (in slough and mowat ) , . / km during periods of low snowshoe hare density in washington (koehler ) , and . - . / km in yukon (slough and mowat ; o'donoghue et al. ; boonstra et al. ) . l. canadensis density may be limited in the southern portion of its distribution where the snowshoe hare is restricted by habitat availability (koehler ) , thus its densities are typically higher in the north portion of its distribution (o'donoghue et al. ) . space use.-lynx canadensis occupies habitats where snowshoe hares are abundant (parker et al. ; koehler ; poole et al. ; o'donoghue et al. a; hoving et al. ; bayne et al. ) . usually, l. canadensis occurs in dense coniferous forests with moderate canopy and understory cover, and elevation between , and , m but can live at elevations up to , m (koehler et al. ; koehler and brittell ; paragi et al. ; mowat and slough ; koehler et al. ) . it avoids deciduous forests, open habitat, steep slopes, and recent burns (murray et al. ; hoving et al. ; koehler et al. ; vashon et al. b) . l. canadensis also selects early and late successional habitat like -to -year-old burns or -to -year-old forests regenerating from clear cutting and tends to avoid recent clear-cuts and partial harvests (koehler et al. ; parker et al. ; thompson ; poole et al. ; paragi et al. ; mowat and slough ; hoving et al. ). mature forest is used for denning, travel corridors, cover, socialization, or to seek alternate prey (koehler ; paragi et al. ; o'donoghue et al. a ) but it will also den in young forest if that is the densest cover available (organ et al. ) . deep snow areas are also important to l. canadensis probably because snowshoe hares prefer these areas and competition with other predators is diminished (murray and boutin ; hoving et al. ) . l. canadensis is more selective in its habitat use in winter than summer, or when snowshoe hares are scarce (poole et al. ; mowat et al. ; mowat and slough ) . lynx canadensis natal and maternal dens are usually fairly close together (squires et al. ), distances range from to , m (moen et al. ; organ et al. ; olson et al. ) . maternal dens typically occur in coarse woody debris, deadfalls or wind-thrown trees, boulder fields, slash piles, and live trees (koehler ; slough ; gilbert and pierce ; organ et al. ; squires et al. ) . in montana, dens were usually located on northeastern slopes averaging °, in concave or drainage-like areas, had higher horizontal cover and log volume than the surrounding area, abundant woody debris, and were away from forest edges (squires et al. ) . l. canadensis prefers habitat with less than m visibility for denning (organ et al. ) . den chambers are usually lined with forest litter ( )-lynx canadensis mammalian species and needles and average cm width, cm depth, and cm height (squires et al. ). relocation of dens may be common (slough ) but each den is usually used only once (slough ; squires et al. ). dens of neighboring females or dens used the following year can be as close as m (slough ) . l. canadensis may use caves for rest (saunders a) . home range size is correlated with snowshoe hare densities but not in a linear pattern (brand et al. ; slough and mowat ; mowat et al. ) . home ranges increase during the second year of snowshoe hare decline (slough and mowat ) or during the first full year of snowshoe hare scarcity (poole ) . at the end of the first winter of low snowshoe hare densities, l. canadensis either disperses or dies if its home range does not encompass a prey refugium (poole (poole , (poole , . a resident l. canadensis maintain its home range year to year (koehler et al. ; poole ) ; however, a threshold below which prey densities cannot support any size of home range has been estimated at . snowshoe hare/ha and this results in l. canadensis becoming nomadic (ward and krebs ) . lynx canadensis home ranges may also vary according to sex, season, topography, and age. home ranges of males are generally larger than females (mech ; parker et al. ; vashon et al. b ) and males may select mature conifer more than females because they travel more (vashon et al. b ). home ranges are usually larger in winter than in summer (parker et al. ; burdett et al. ) because male l. canadensis travel more during the breeding season (vashon et al. a ) and females decrease their movements during parturition (burdett et al. ). the shape of home ranges is influenced by topography (saunders a) . in newfoundland, the home range of an individual coincided almost exactly with a band of - years old growth timber (saunders a) . females tend to select areas with higher densities of snowshoe hares (vashon et al. ) , and those with kittens tend to have smaller home ranges than adults travelling alone (saunders a; brand et al. ) and yearlings have less home range fidelity (quinn and thompson ) . overlapping home ranges occur more frequently with females but males usually exclude other males, especially in the core area (nellis et al. ; brand et al. ; vashon et al. a) . home range overlap between sexes may be common (ward and krebs ; poole ) or rare (mech ; carbyn and patriquin ) . home ranges of males and females average about and km , respectively (aubry et al. ) . average home range size (km ; n in parenthesis) for adult males and females, respectively, were: . ( ), . ( ) in alaska (bailey et al. ); - ( ), - ( ) in minnesota (mech ; burdett et al. ); . ( ), . ( ) in newfoundland (saunders a); . ( ), . ( ) in the northwest territories (poole ) ; . ( ) and . ( ) in summer, . ( ) and . ( ) in winter in nova scotia (parker et al. ); . ( ), . ( ) in maine (vashon et al. a) ; ( ), ( ) in washington (koehler ); . ( ), . ( ) in the yukon (slough and mowat ) . a single male in montana had a home range of km (koehler et al. ) . home range core areas in km (n) for adult males and adult females, respectively, were: . ( ), . ( ) in maine (vashon et al. a) ; ( ), ( ) in minnesota (burdett et al. ); . ( ), . ( ) in nova scotia (parker et al. ) . daily movements of male l. canadensis are greater than those of females (saunders a; mech ) . daily movements (km; ranges or means) for males and females, respectively, were: . and . in british columbia (apps ) , . and . in manitoba (carbyn and patriquin ) , . - . and . - . in montana (squires and laurion ) , . - . and . - . in the northwest territories (poole ), . and . in nova scotia (parker et al. ), . - . and . - . in wyoming (squires and laurion ) . l. canadensis travels on average for min (ranging from to min) at an average speed of . km/h (ranging from . to . km/h) and this rate does not differ between low and high snowshoe hare densities (o'donoghue et al. b) . daily movements of l. canadensis are typically greater in summer than in winter (parker et al. ) , though movement increases when snowshoe hare densities are low (ward and krebs ; poole ) . daily movements increased from . to . km in the yukon (ward and krebs ) and from . to . in alberta (nellis and keith ; brand et al. ) when snowshoe hare densities decreased. dispersal increases during periods of snowshoe hare decline (slough and mowat ; o'donoghue et al. ) . there is no difference in dispersal distance between sexes, age classes, or resident status (mech ; slough and mowat ; poole ) . dispersal occurs mainly during march through june and rarely in september and october (slough and mowat ) . during increasing l. canadensis populations, immigration is greater than emigration (slough and mowat ) . dispersal distance ranged up to km in newfoundland (saunders a) , and , km in yukon (slough and mowat ) . the longest recorded dispersals for l. canadensis are km in alberta (nellis and wetmore ) , km in maine (vashon et al. ) , km in minnesota (mech ) , km in the northwest territories (poole ) , and , km in the yukon (slough and mowat ) . during dispersal, daily travel of l. canadensis varies from . to . km (slough and mowat ; poole ) . highways might be a barrier to movement for l. canadensis (alexander and waters ) . diet.-lynx canadensis is a strict carnivore. throughout its range, diet is comprised from % to % of snowshoe hares (brand and keith ; o'donoghue et al. a) . snowshoe hares compose - % of l. canadensis diet in alberta (nellis and keith ; nellis et al. ; brand et al. ; brand and keith ) , % in maine (vashon et al. ) , % in montana (squires and ruggiero ) , % in newfoundland (saunders b) , - % in the northwest territories (van zyll de jong a; more ), % in nova scotia (parker et al. ), % in washington (koehler ) , and - % in the yukon (murray et al. ; o'donoghue et al. b) . l. canadensis depends more on snowshoe hares during the winter than summer (saunders b; van zyll de jong a; nellis et al. ) and shifts to alternate prey during the snowshoe hare decline (brand et al. ; o'donoghue et al. b) or during the summer months in the southern portions of its distribution (vashon et al. ) . the two main alternate prey eaten by l. canadensis are ruffed grouse (bonasa umbellus) and red squirrel (tamiasciurus hudsonicus-van zyll de jong a; o'donoghue et al. b; vashon et al. ) . other mammalian prey may include squirrels (glaucomys sabrinus-northern flying squirrel, spermophilus columbianus-columbian ground squirrel, spermophilus parryii-arctic ground squirrel, spermophilus richardsonii-richardson's ground squirrel), mice (peromyscus maniculatus-north american deermouse, zapus hudsoniusmeadow jumping mouse), shrews (sorex cinereus-cinereus shrew), and voles (microtus pennsylvanicus-meadow vole, myodes gapperi-southern red-backed vole-van zyll de jong a; nellis et al. ; o'donoghue et al. b) . larger rodents such as muskrat (ondatra zibethicus), beaver (castor canadensis), and porcupine (erethizon dorsatum) also may be consumed (saunders b; brand et al. ) . additional species of birds such as grouse (canachites canadensis-spruce grouse, dendragapus obscurus-dusky grouse, pedioecetes phasianellus-sharp-tailed grouse), fox sparrow (passerella iliaca), chickadees (poecile), grey partridge (perdix perdix), ducks (anas carolinensis-green-winged teal, anas platyrhynchos-mallard, anas rubripes-american black duck), willow ptarmigan (lagopus lagopus), northern flicker (colaptes auratus) also may be eaten (saunders b; van zyll de jong a; nellis and keith ; squires and ruggiero ) . lynx canadensis may prey on white-tailed deer (odocoileus virginianus- parker et al. ; fuller ; squires and ruggiero ) , reindeer (rangifer tarandus-saunders b; bergerud ; stephenson et al. ), dall's sheep (ovis dalli- stephenson et al. ) , and mule deer (odocoileus hemionus- poszig et al. ). on occasion, l. canadensis may kill and eat other carnivores such as red fox (vulpes vulpes- stephenson et al. ; o'donoghue et al. b -mech ; mowat and slough ) . l. canadensis may eat carrion (nellis and keith ; parker et al. ; murray et al. ) . other food includes insects (saunders b) . lynx canadensis needs . snowshoe hares per day to meet its daily metabolic requirements (nellis et al. ). food requirements have been estimated to be g per day for adults, g for juveniles in winter (nellis et al. ) , and g per day for captive adults (saunders b) . consumption rates vary according to prey availability and were evaluated for snowshoe hares and range from g per day during periods of low snowshoe hare density to g per day during high snowshoe hare density (brand et al. ) . l. canadensis eats about . - . snowshoe hares per day in alberta (nellis and keith ; brand et al. ), between . and . snowshoe hares per day in newfoundland (saunders b) , about one snowshoe hare per day in nova scotia (parker et al. ) , and between . and . snowshoe hares per day in the yukon (o'donoghue et al. b) . the shift to alternate prey during periods of snowshoe hare decline does not compensate for the decrease in biomass of snowshoe hares killed and thus lynx consume % less in biomass (brand et al. ) . diseases and parasites.-in a free-ranging situation, lynx canadensis appears to rarely encounter common feline pathogens or infectious diseases (biek et al. ) . nevertheless, adults can be infected by salmonella arizonae (macri et al. ) , feline coronavirus, canine distemper virus, feline calcivirus, feline herpesvirus, francisella tularensis, yersinia pestis, oral papillomatosis (wild et al. ; wolfe and spraker ; devineau et al. ) , or feline parvovirus (fvp) which is more common in southern populations and in males (biek et al. ) . adult lynx can also be affected by hypothyroidism (greer et al. ) . although parasite prevalence and abundance may be high, parasites do not seem to negatively influence the physical condition of individual l. canadensis (van zyll de jong b). l. canadensis is frequently infected by helminths particularly in the small intestine but also in the stomach and the lungs (van zyll de jong b; smith et al. ). l. canadensis can also be host to protozoans, nematodes, cestodes, trematodes, and acanthocephalans (chitwood ; rausch et al. ; van zyll de jong b; schmidt ; forest et al. ; labelle et al. ; simon et al. ) . the nematode trichinella nativa is widespread in wild l. canadensis and its prevalence is correlated with age (zarnke et al. ) . l. canadensis may be infected by ectoparasites such as fleas and louse (hopkins ; van zyll de jong b) . the low occurrence of fleas may be related to l. canadensis behavior which, instead of using dens regularly, beds on snowshoe hare trails (van zyll de jong b). interspecific interactions.-where both species co-occur, exploitation competition may occur between lynx rufus and l. canadensis (buskirk et al. ) because the diets of both predators include snowshoe hares. l. canadensis populations may decline when l. rufus populations increase (de vos and matel ; parker et al. ; hoving et al. ) . furthermore, exploitation competition may occur between l. canadensis and birds of prey or coyote (buskirk et al. ) . however, l. canadensis is positively associated with the presence of large canids such as wolf (litvaitis and harrison ) as they may dampen coyote populations (buskirk et al. ) . l. canadensis can be affected by human activity and roads that provide access to generalist predators (aubry et al. ; bayne et al. ) , competition with l. rufus or other carnivores (buskirk et al. ; bayne et al. ) , and changes in landscape features facilitating generalist predators (aubry et al. ; buskirk et al. ) . miscellaneous.-presence of lynx canadensis can be detected via dna analysis of hairs (mills et al. ; pilgrim et al. ; mckelvey et al. ) or during winter via snowtracking (koehler ; koehler and brittell ) . l. canadensis is considered easy to capture, and can be harvested with kill-type traps, snares, or restraining traps (saunders a; nellis et al. ; mowat et al. ; proulx et al. ) . l. canadensis is attracted by flesh bait such as meat of snowshoe hares, beaver (castor canadensis), or game birds, and lured with scents such as catnip oil (mcdaniel et al. ) . l. canadensis may be captured incidentally in traps set for red fox, coyote, american marten, or fisher (de vos and matel ; quinn and thompson ) . lynx canadensis has long been prized for its soft and valuable fur, and wherever it is common, l. canadensis is harvested for its pelt (quinn and thompson ; poole ) . it has been harvested for fur since and before the th century, a distinction between l. canadensis and l. rufus was not always made. the highest number of l. canadensis harvested was reached in with a total of , individuals. the average pelt price in canada has fluctuated greatly, decreasing from $ . in from $ . in - from $ . in to $ . in from $ . in - from $ . in before increasing from $ in from $ . in - from $ . in to $ in from $ . in - from $ . in (novak et al. . the meat of l. canadensis is succulent and highly prized locally (denis ) . age and sex structure of the harvest can be changed by modifying the period of the open harvest season (quinn and thompson ) . two strategies have been suggested to manage l. canadensis: first, its tracking strategy suggests limiting or eliminating trapping for a period of - years during periods of low snowshoe hare density (second year after the peak in harvest- parker et al. ; ward and krebs ; poole ) to allow greater harvest during peak (brand and keith ) . the second strategy consists of maintaining untrapped refugium all year long or at least during periods of low snowshoe hare density (ward and krebs ; bailey et al. ) without suspension of trapping (poole ) . l. canadensis harvest may also be regulated by quotas (quinn and thompson ) . managers should monitor l. canadensis recruitment instead of snowshoe hare trends to make decisions (mowat et al. b ) which can be done using the total length of the pelt measured from tip of nose to base of tail (quinn and gardner ) . lynx canadensis may be aged by tooth replacement and cranial characteristics (saunders ) , tooth cementum layers (nellis et al. ; chubbs and phillips ) , or ossification of epiphyseal plates of long bones (saunders ) . kittens may be differentiated from yearlings and adults by the presence of an apical root foramen in canines (saunders ) or by the total length of the pelt, measured from tip of nose to base of tail (< cm-quinn and gardner ) . recommended minimum enclosure size per lynx canadensis is by by . m (l by w by h) and floor area should be increased by % for each additional cat (mellen ) . individuals should have access to at least % of the vertical space (mellen ) along with several hiding locations (fanson and wielebnowski ) . clawing activity should be stimulated by providing rotting logs in the enclosure (mellen ) . feeding l. canadensis days per week with bones with meat attached, helps stimulate teeth and gums; fasting days are not recommended (mellen ) . in captivity, l. canadensis seems less likely to reproduce when maintained in groups larger than as a pair (mellen ) . however, interactions between the cats and their keepers increased successful reproduction (mellen ) . captive born kittens should never be intentionally handreared but if done, they should remain with their mother until at least - days of age (edwards and hawes ; p. andrews, in litt.) . kittens can be feed with commercial milk replacers and electrolytes can be given to weak neonates (p. andrews, in litt.). solid food can be gradually introduced at - weeks (p. andrews, in litt.). for research, l. canadensis can be chemically immobilized using ketamine (ward and krebs ; koehler ), phencyclidine hydrochloride (berrie ) , a mixture of ketamine and xylazine (squires et al. ; burdett et al. ), ketamine and medetomidine (rockhill et al. ) , tiletamine hydrochloride and zolazepam hydrochloride (poole et al. (poole et al. , , ketamine hydrochloride and midazolam hydrochloride (forest et al. ) , or phencyclidine hydrochloride and promazine hydrochloride (carbyn and patriquin ) . l. canadensis can be euthanized with yohimbine (greer et al. ) or pentobarbital (poole et al. ) . vaccination with porcine zone pellucida does not work for contraception in captive l. canadensis (harrenstien et al. ). grouping behavior.-lynx canadensis is generally solitary except mother-kit groups (carbyn and patriquin ; parker et al. ; mowat and slough ) . hunting groups are more efficient in killing snowshoe hares (o'donoghue et al. a) and success increases with group size (parker et al. ) . adult groups of - individuals occur especially, during low snowshoe hare densities (barash ; mowat and slough ; o'donoghue et al. a) . l. canadensis groups usually travel single file in areas where prey are scarce and spread apart when entering habitat with an abundance of prey (saunders b; parker et al. ) . during hunting, individuals fan out up to m apart and reunite after a kill (mowat and slough ) . reproductive behavior.-lynx canadensis kittens stay with their mother generally until the next breeding season (carbyn and patriquin ) . kittens spend a lot of time playing (saunders a) and related females maintain a bond (breitenmoser et al. ; slough and mowat ; mowat and slough ) . litter mates may stay together after leaving their mother (mowat and slough ) but female offspring tend to remain within their mother's home range while young males disperse away from their mother's area (breitenmoser et al. ; slough and mowat ) . female kittens can even stay with their mother if the mother has given birth again (mowat and slough ) . after a snowshoe hare crash, male and female offspring are tolerated in the mother's home range (breitenmoser et al. ; slough and mowat ) . kittens have been observed to disperse in march (quinn and thompson ; poole ) , april (mowat et al. b) , may, october, and november (poole ) . kittens generally disperse - weeks before their first birthday (poole ) and the earliest kitten dispersal was at months of age (parker et al. ; mowat et al. b; slough and mowat ) while the latest was at months old (poole ) . communication.-adult lynx canadensis mark their home ranges using feces, sprayed urine, or anal secretions (saunders a) . urine scent marks are made every - m (saunders a) . kittens bury scat, contrary to adults (saunders a) . l. canadensis also communicate by using three different vocalizations: long wailing calls during the mating period (march-april), warning growls when captured, or - short barks when in family groups (mowat and slough ) . miscellaneous behavior.-hunting behavior of lynx canadensis varies according to snowshoe hare densities. during snowshoe hare abundance, l. canadensis uses more snowshoe hare trails and kills more than required (o'donoghue et al. a (o'donoghue et al. , b . l. canadensis may cache snowshoe hares during years of great abundance (nellis and keith ) and return to caches within days (o'donoghue et al. b) . during snowshoe hare decline, l. canadensis does not increase its active time (o'donoghue et al. b ) but may increase its foraging time and concentrate its foraging effort in areas of high snowshoe hare densities (ward and krebs ) . during a decline, l. canadensis uses four times more hunting beds (o'donoghue et al. a ) and chases are longer (o'donoghue et al. b) . during declines in snowshoe hare density, l. canadensis also expands its home range (ward and krebs ) and becomes more territorial (stenseth et al. ) . however, below a certain density of snowshoe hares, l. canadensis becomes nomadic and concentrates in abundant snowshoe hare pockets (bergerud ; brand et al. ; ward and krebs ) or where carrion is abundant (saunders b) . they also become more tolerant of others (brand et al. ). most adult l. canadensis disperse in the first two winters after snowshoe hare population decline (poole ) . during that time, its physical condition deteriorates (parker et al. ), leading to reduction and complete cessation in reproduction (nellis et al. ; brand et al. ) . at the end of the second winter of declining snowshoe hare number, most of the remaining l. canadensis have died (poole ; slough and mowat ; o'donoghue et al. ) . during periods of declining l. canadensis densities, trapping vulnerability (ward and krebs ) and starvation increase (brand et al. ; parker et al. ) while cannibalism may appear (mowat and slough ) . morphology and hunting behavior of l. canadensis is specialized for snowshoe hares (brand et al. ) and it is an efficient predator because of the lower foot-load of hares (murray and boutin ) . it hunts primarily by sight but also by sound (saunders a (saunders , b . l. canadensis hunts snowshoe hares by stalking, ambushing (murray et al. ; o'donoghue et al. a; squires and ruggiero ) , following snowshoe hare runways, concentrating movements or using waiting beds (brand et al. ) . l. canadensis uses the ambushing method more when the canopy is dense and the stalking method in sparse cover (murray et al. ) . when l. canadensis enters snowshoe hare habitat it travels in a more sinuous pattern . after stalking as close as possible to its prey, l. canadensis usually covers the remaining distance with powerful bounds. the number of jumps depends on the species of prey pursued, the capture success, or the prey density (nellis and keith ; squires and ruggiero ) . it can make up to jumps to capture its prey . the distance between two jumps varies between . m (murray et al. ) and . m (squires and ruggiero ). lynx canadensis hunting success varies according to many factors. when hunting snowshoe hares, l. canadensis has better success when ambushing than stalking (murray et al. ) . the distance from the snowshoe hare at the beginning of the chase is an important factor for successful kills (nellis and keith ) . length of the chase also influences hunting success. unsuccessful chases are longer than successful ones (o'donoghue et al. b) . l. canadensis chases snowshoe hares . - m but successful chases seldom exceed - m (saunders b; o'donoghue et al. b; squires and ruggiero ) . consistency of the snow and sinking depth are also related to the success of the hunt (nellis and keith ; murray and boutin ; stenseth et al. b) . successful kills are influenced by the l. canadensis age and its knowledge of the area (nellis and keith ) or with the season, increasing during winter (parker et al. ) . success also varies according to the snowshoe hare cycle, with success being lower during periods of increasing snowshoe hare densities as surviving l. canadensis become skilled at hunting alternative prey species during the low phase and there is a lag before it switches back to its main prey (o'donoghue et al. b ). however, hunting success is more dependent on hunting conditions than snowshoe hare abundance (parker et al. ) and is similar among habitats and vegetative cover (murray et al. (murray et al. , . lynx canadensis hunting success varied from % to % in alberta (nellis and keith ; brand et al. ), % in newfoundland (saunders b) , and from . % to . % in yukon (murray et al. ; murray et al. ; o'donoghue et al. b) . during increasing and peaking snowshoe hare densities, l. canadensis is more successful from hunting beds ( %) than not from beds ( %- murray et al. ) . l. canadensis kills on average every km traveled per night (saunders b) ranging from to km (nellis and keith ) . lynx canadensis hunts larger animals in various ways. it approaches bedded white-tailed deer and then rushes to subdue and kill (fuller ) . wounded deer may be followed until later captured and killed (fuller ) . l. canadensis ambushes caribou and then bites on the head, neck, or shoulders (stephenson et al. ) . it attacks mule deer by stalking and biting the neck ( )-lynx canadensis mammalian species - cm behind the ears (poszig et al. ) . l. canadensis first feeds on big game by starting on the neck, then moving to the shoulders and rib cage, and finally consuming the haunches and internal organs (poszig et al. ) . it may drag ungulate carcasses before eating (poszig et al. ). extent of consumption of prey was related to the time between kills rather than prey abundance (parker et al. ) . lynx canadensis uses ambush beds that consist of loosely packed and ice-encrusted snow (murray et al. ) . beds may be separated by only m (saunders a ) and are at a density between . and . beds along a -km trail (o'donoghue et al. b) . ambush beds of l. canadensis are usually closer than m from the starting point of the chase (murray et al. ) . l. canadensis also makes resting beds near recent snowshoe hare activity (saunders b) . lynx canadensis can use snowshoe hare runways to travel (keith and meslow ) . they usually use harder and shallower snow to walk (murray and boutin ) but may be negatively impacted by snowmobile tracks as they give a competitive advantage to the coyote (bunnell et al. ) . although l. canadensis can be active through the day, it travels mostly during the night from h before dark to h after dawn (saunders a) . however, in montana, activity patterns were different between seasons. during winter all l. canadensis were more active during the afternoon and early evening when temperatures were highest (kolbe and squires ) . during summer, males and females without kittens were active around the crepuscule and avoided high temperatures, while females with kittens remained active throughout the day (kolbe and squires ) . l. canadensis is active . % of the time (o'donoghue et al. b ) and is mostly in search of food during its active hours (brand et al. ) . a kill is usually followed by a period of inactivity (parker et al. ) and hunting is resumed following consumption of its last kill (saunders b) . it is more active at its kill around midnight and late in the morning (poszig et al. ) . l. canadensis decreases activity during a storm (saunders a) . lynx canadensis is a good swimmer (denis ) . when swimming, it may be low in the water or have its back raised and can cover up to . km (denis ) . cycle (steury and murray ) as each individual requires at least . - . snowshoe hares/ha to persist (steury and murray ) . this allows the l. canadensis population to increase along with the hare population. the success of the reintroduction may be increased by placing individuals in holding facilities for a minimum of weeks, or until physical condition is optimal and the animals have acclimated to the new area (shenk ) . reintroduction should be performed in central areas of l. canadensis habitat range before trying at the periphery (scott et al. ) . the conservation and recovery of l. canadensis populations in the southern portion of its range require the protection of large snowshoe hare habitat and ensuring connectivity between l. canadensis populations (murray et al. ; squires et al. ) . forests should be managed to give a temporal and spatial mosaic of forest age classes, which can be done with fires, logging, and timber thinning (koehler and brittell ) . thus, fire management has the potential to have an impact on l. canadensis abundance (paragi et al. ) . climate change, through climate warming and snowfall decrease, may give l. canadensis less competitive advantage over bobcats and decreases prey vulnerability (hoving et al. ) . in the future, this could result in stronger declines for populations at the southern edge of their distribution due to climate change than projected logging or exploitation rates (carroll ) . during the last century, l. canadensis distribution has contracted (mckelvey et al. a) , this might be due to the reduction of large forest fires, with human-caused fire suppression, resulting in limitation of early successional forest, which are an important habitat for snowshoe hares (koehler ). other hypotheses are: climate change (koen et al. ) , competition with terrestrial predators, roads and 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hematologic and serum chemistry values of captive canadian lynx das fellmuster der wildlebenden katzenarten und der hauskatze in vergleichender und stammesgeschicher hinsicht hares, lynx and trappers the evolution of lynxes plague as a mortality factor in canada lynx (lynx canadensis) the late pleistocene bighill creek formation and its equivalents in alberta: correlative potential and vertebrate palaeofauna oral papillomatosis in canada lynx order carnivora: felidae. pp. - in mammal species of the world: a taxonomic and geographic reference order carnivora. pp. - in mammal species of the world comparative cytogenetic studies in the order carnivora the interrelationships of chromosome banding patterns in canids, mustelids, hyena, and felids linking climate change to population cycles of hares and lynx population cycles and changes in body size of the lynx in alaska prevalence of trichinella native in lynx (felis lynx) from alaska factors affecting hare-lynx dynamics in the classic time series of the hudson bay company food habits of the lynx in alberta and the mackenzie district parasites of the canada lynx, felis (lynx) canadensis (kerr) differentiation of the canada lynx, felis (lynx) canadensis subsolana we thank c. barrette for providing the skull and h. jolicoeur for the photograph of a live animal. sl is thankful to nserc for support through a discovery grant, and to the cree hunters and trappers income security board for logistic support. the karyotype of lynx canadensis is indistinguishable from that of the domestic cat. it has a diploid number ( n) of chromosomes, a fundamental number of , with pairs of metacentrics, pairs of submetacentrics, and acrocentrics (benirschke et al. ) . the y and x chromosomes are, respectively, a small meta-or submetacentric and mediumsized submetacentric (wurster and benirschke ; hsu and benirschke ) . g-banded karyotypes can be used to differentiate l. canadensis from the domestic cat but g-bands are identical among lynx species (wurster-hill and certerwall ) .microsatellite loci may be useful in population genetic studies of l. canadensis (carmichael et al. ) . in a comparison between core populations and peripheral populations using nine microsatellite loci, peripheral populations exhibited decreased genetic variation in the form of fewer mean numbers of alleles and lower expected heterozygosity (schwartz et al. ) . the genetic structuring of l. canadensis is similar over large distances (schwartz et al. ; row et al. ) ; however, the rocky mountains and the coastal mountains represent east-west and north-south barriers to gene flow in l. canadensis (rueness et al. ) . the existence of a geographically invisible barrier in eastern canada also influences its genetic structure (rueness et al. ) . thus l. canadensis genetically seems to be divided into the same three regions (atlantic, continental, and pacific) that synchronize its cycle in density. restriction fragment patterns of the s rrna can be used to differentiate l. canadensis from all other north america felid species (mills et al. ) .the mitochondrial genome and the nuclear genome have been sequenced. the mitochondrial genome (ncbi, bioproject, accession number nc_ ) and nuclear genome (ncbi, bioproject, accession number prjna ) are entered in genbank.wild female l. canadensis can mate with wild l. rufus males (schwartz et al. ; homyack et al. ) . hybrids of l. canadensis-l. rufus may reproduce successfully (homyack et al. lynx canadensis is listed as "least concern" by the international union for the conservation of nature and natural resources, is on appendix ii of the convention on international trade in endangered species, and its population trend is considered stable (united nations environment programme-world conservation monitoring center ; vashon ). however, it is listed as "endangered" in new brunswick and nova scotia under the new brunswick species at risk act and nova scotia's endangered species act. in the united states, l. canadensis was listed in as "threatened" under the endangered species act (vashon et al. a) .lynx canadensis has successfully been reintroduced to colorado (devineau et al. ) even though the first attempt most likely failed because of high mortalities due to starvation (shenk ) . in the adirondack mountains of new york, the failure of its reintroduction appears to be related to high road mortality (hoving et al. ) . when planning a reintroduction program for l. canadensis, five factors should be examined to increase the success: ( ) a release protocol focused on reducing dispersal rates from the reintroduced population, ( ) mortality induced by anthropogenic factors, ( ) phase of the snowshoe hare cycle when reintroduction occurs, ( ) duration of the release program, and ( ) number of animals released (steury and murray ) . l. canadensis should be released during the decline phase of the snowshoe hare key: cord- - obqdbh authors: percy, edward; luc, jessica g.y.; vervoort, dominique; hirji, sameer; ruel, marc; coutinho, thais title: post-discharge cardiac care in the era of coronavirus : how should we prepare? date: - - journal: can j cardiol doi: . /j.cjca. . . sha: doc_id: cord_uid: obqdbh the novel coronavirus (covid- ) pandemic has placed intense pressure on healthcare organizations around the world. amongst others, there has been an increasing recognition of common and deleterious cardiovascular effects of covid- based on preliminary studies. furthermore, patients with pre-existing cardiac disease are likely to experience a more severe disease course with covid- . as case numbers continue to increase exponentially, a surge in the number of patients with new or comorbid cardiovascular disease will translate into more frequent, and in some cases, prolonged rehabilitation needs following acute hospitalization. this manuscript describes the current status of post-discharge cardiac care in canada and provides suggestions with regards to steps that policymakers and healthcare organizations can take to prepare for the covid- pandemic. canadian women's heart health centre university of ottawa heart institute -ottawa, on, canada email: tcoutinho@ottawaheart.ca abstract: the novel coronavirus (covid- ) pandemic has placed intense pressure on healthcare organizations around the world. amongst others, there has been an increasing recognition of common and deleterious cardiovascular effects of covid- based on preliminary studies. furthermore, patients with pre-existing cardiac disease are likely to experience a more severe disease course with covid- . as case numbers continue to increase exponentially, a surge in the number of patients with new or comorbid cardiovascular disease will translate into more frequent, and in some cases, prolonged rehabilitation needs following acute hospitalization. this manuscript describes the current status of post-discharge cardiac care in canada and provides suggestions with regards to steps that policymakers and healthcare organizations can take to prepare for the covid- pandemic. summary: as covid- case numbers continue to increase worldwide, many additional patients with new or comorbid cardiovascular disease will benefit from cardiac rehabilitation and post-discharge care following acute care hospitalization. we describe the current status of cardiovascular rehabilitation in canada and provide suggestions on steps that policymakers and healthcare organizations can take to optimize post-discharge cardiac care in the covid- era. the coronavirus disease (covid- ) pandemic, caused by the severe acute respiratory syndrome coronavirus (sars-cov- ) virus, has placed tremendous pressures on healthcare organizations around the world. as of april th, , there were , confirmed cases in canada spread across the country (figure a) , with estimates suggesting that - % of the canadian population could eventually become infected. , appropriately, much attention to date has focused on addressing the surge of critically ill patients in acute care settings. less emphasis has been paid to the post-acute healthcare system capacity to manage numerous cardiac patients after covid- , i.e. as patients transition from hospital to long-term care facilities or home. in canada, post-acute cardiac care includes outpatient and inpatient cardiac rehabilitation facilities, long-term care hospitals, and nursing homes. along with a growing body of knowledge underlying covid- , there has been an increased recognition of common and deleterious cardiovascular effects of the novel coronavirus. furthermore, patients with pre-existing cardiovascular disease (cvd) are likely to experience a more severe course. as case numbers continue to increase exponentially, it is plausible that there will be a massive surge in the number of patients with new or comorbid cvd who will require cardiac rehabilitation after acute care hospitalization. the objectives of this manuscript are to describe the current status of post-acute cardiac care in canada, and to provide suggestions with regard to the steps that policymakers and healthcare organizations can take to achieve preparedness in this area, in order to reduce care fragmentation in the post-covid- era. several reports have denoted the incidence and types of adverse cardiovascular events associated with covid- . in one early experience from wuhan, china, arrhythmias were present in . % of hospitalized patients, with . % experiencing acute cardiac injury. in a subsequent report, cardiac injury, defined as high-sensitivty troponin i levels above the th-percentile upper reference limit, occurred in . % of patients, occurring most frequently among older patients and in those with comorbidities. the presence of cardiac injury was associated with a more severe disease course, with a higher proportion of patients with acute respiratory distress syndrome, acute kidney injury, and coagulation disorders, compared to those without cardiac injury. furthermore, cardiac injury was an independent predictor for mortality, with a hazard ratio of . . although this injury does not necessarily indicate myocardial infarction, and its long-term significance remains unknown, its high prevalence and associated mortality has raised significant concern within the cardiovascular community. in addition to the development of covid- -related cardiovascular complications, there are implications of covid- infection on patients with preexisting cvd. in patients with covid- , cvd is associated with a higher death rate ( . %) compared to other comorbidities including diabetes ( . %), chronic respiratory disease ( . %), and cancer ( . %). in general, the development of new cardiac injury or the presence of prior cvd are associated with a more severe disease course. the pathophysiology of this interaction remains poorly characterized. however, preliminary data suggest that acute inflammation superimposed on pre-existing cvd can precipitate cardiac injury, acute coronary syndrome, and myocardial dysfunction, and trigger arrhythmias in patients with covid- . , furthermore, there is evidence of direct myocardial infiltration, potentially as a result of the affinity of the sars-cov- virus for the angiotensinconverting enzyme receptor. given the frequency of cardiac manifestations and injuries, the cardiac rehabilitation system will likely be overwhelmed by an unprecedented number of discharged patients with new or exacerbated cvd. canada has a long history of outstanding post-acute cardiac care. currently, there are approximately cardiac rehabilitation programs, serving over , new patients annually ( figure b) . funding for cardiac rehabilitation varies by provincial and local resources, according to their unique population densities and funding structures. given these differences, along with the geographic diversity of the country, access to cardiac rehabilitation remains variable. newfoundland has the least access, with . facilities per , individuals, while nova scotia has the most with . per , . in addition to outpatient cardiac rehabilitation programs, inpatient rehabilitation facilities play a crucial role in supporting the convalescence of patients who no longer require acute care hospitalization. there are , nursing home or continuing care facilities in canada, with a similar geographic distribution as cardiac rehabilitation centers ( figure b) . and cvd, we expect that this proportion will increase as patients are discharged from acute care with new or exacerbated cardiac issues. as of march , . % of ontario's critical care beds were occupied, of which . % were related to confirmed or suspected cases of covid- . several models have been developed to study the potential trajectories of resource use during this pandemic. although these models focus on acute care resources, they provide a reliable resource to help predict the range of potential impacts on the post-acute care sector as well. using the total number of inpatient beds, icu beds, and ventilators in ontario, barret et al. have examined three potential scenarios (figure ) . in the worst-case scenario, which assumes a growth rate of % in daily cases (similar to that in italy), the number of available hospital beds in ontario could fall to by early-to-mid april , without recovery through mid-may. in another scenario, assuming an initial growth rate of % in daily cases (similar to that initially seen in ontario) until the of end march, followed by a . % decrease to account for successful public health measures (school closure, social distancing, testing, and isolation), the maximum impact on inpatient acute hospital care would occur in early april, followed by a sustained recovery. finally, in a third scenario which assumes an initial % daily increase, with a similar subsequent . % decrease, the overall impact would be reduced; however, the timing of patient influx to post-acute care would likely be unchanged. the post-acute care sector will play a key role in alleviating pressures on hospitals; however, these facilities and programs themselves will face challenges as they attempt to reduce care fragmentation. in the midst of this global crisis, healthcare facilities are adapting to deliver care in safer and more efficient ways. post-acute care facilities will be increasingly challenged by a rising influx of patients with serious, incompletely resolved cardiac problems. fortunately, as a large country with a significant rural population, canada has experience with various alternative models for post-acute cardiac care. in fact, several cardiac rehabilitation programs in the country already deliver home-based programs, which have been shown to have similar clinical outcomes, cost, and completion rates compared to clinic-based programs. the maximization of these services, in order to treat patients at home, will be an extremely important component of managing resources during covid- . to accomplish this, open communication between cardiac rehabilitation centres will be needed for knowledge exchange, allowing centres not currently offering home-based programs to quickly learn from other centres where this practice has been successfully implemented. additionally, there is a need to maximize mobile health technology to minimize patient and healthcare personnel exposure to covid- . in the context of this pandemic, telehealth technology can be leveraged to reduce the need for in-person care, for apporopriate patients. specifically, this technology can be applied to patient follow-up after discharge, to perform remote cardiac monitoring, and to administer cardic rehabilitation curriculums remotely. digital health interventions -such as the virtual care program from the university of ottawa heart institute (https://pwc.ottawaheart.ca/programs-services/virtualcare)-provide services such as self-monitoring tools, reminders, and notifications, as well as peer support groups for those undergoing remote curriculums. healthcare systems that will leverage these technologies to manage the upcoming influx of patients could see a reduction in in-person care needs and be in a better position to serve their patients. these technologies will play a particularly important role in filling gaps present in areas with limited access to current cardiac rehabilitation care. patient-level factors should also be taken into consideration for the prioritization of inpatient space. in particular, cognitive impairment, paralysis, and those requiring a ventilator or dialysis are among the factors associated with a greater risk of prolonged in-patient rehabilitation stay. the repurposing of unused buildings such as hotels, convention halls, clinics, and other spaces to establish temporary post-acute care settings, where appropriate, could rapidly expand the supply of space, particularily in areas which are currently underserved by post-acute care facilities. covid- places an unprecedented strain on healthcare resources in canada. given the association of this infection with comorbid cardiac disease and the high rate of new cardiac conditions among infected patients, the post-discharge cardiac rehabilitation sector will be particularly impacted. there is a pressing need to address the impact of covid- on post-acute cardiac care. early preparation and thoughtful planning may help limit this impact. an interactive web-based dashboard to track covid- in real time coronavirus could infect to per cent of canadians, experts say association of cardiac injury with mortality in hospitalized patients with covid- in wuhan, china. jama cardiol clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china sex, demographics (covid- ) -worldometer association of coronavirus disease (covid- ) with myocardial injury and mortality cardiac rehabilitation series: canada key: cord- -xhem l authors: tulchinsky, theodore h. title: bismarck and the long road to universal health coverage date: - - journal: case studies in public health doi: . /b - - - - . - sha: doc_id: cord_uid: xhem l the sustainable development goals (sdgs) state that all united nations member states have agreed to try to achieve universal health coverage by . this includes financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. universal health coverage (uhc) means inclusion and empowerment for all people to access medical care, including treatment and prevention services. uhc exists in all the industrial nations except the us, which has a mixed public-private system and struggles with closing the gap between the insured and the uninsured population. middle- and low-income countries face many challenges for uhc achievement, including low levels of funding, lack of personnel, weak health management, and issues of availability of services favoring middle- and upper-class communities. community health services for preventive and curative health services for needs in populations at risk for poor health in low-income countries must be addressed with proactive health promotion initiatives for the double burden of infectious and noncommunicable diseases. each nation will develop its own unique approach to national health systems, but there are models used by a number of countries based on principles of national responsibility for health, social solidarity for providing funding, and for effective ways of providing care with comprehensiveness, efficiency, quality, and cost containment. universal access does not eliminate social inequalities in health by itself, including a wide context of reducing social inequities. understanding national health systems requires examining representative models of different systems. health reform is necessarily a continuing process as all countries must adapt to face challenges of cost constraints, inequalities in access to care, aging populations, emergence of new disease conditions and advancing technology including the growing capacity of medicine, public health and health promotion. the growing stress of increasing obesity, diabetes, and other chronic diseases, requires nations to modify their health care systems. learning from the systems developed in different countries helps to learn from the processes of change in other countries. the world health organization (who) defines a health system as: "the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people's legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. it is a set of elements and their relationship in a complex whole, designed to serve the health needs of the population. health systems fulfill three main functions: health care delivery, fair treatment to all, and meeting health expectations of the population." who's world health reports ( , , ) focused on health systems financing and management in the search for universal health coverage. under the globally endorsed sdgs, universal health coverage (uhc) is designated goal (health and wellbeing), target . : "achieve universal health coverage (uhc), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all". box . outlines who building blocks for uhc. universal access is a means of assuring that the economic barrier to health care is mostly if not completely removed for the total population and may lead to increased access to medical and hospital services for those previously excluded. while uhc increases access to medical care and health indices, it does not, of itself, guarantee achievement of many important health targets. allocation of resources is an even more fundamental problem to address the needs of those with the highest risk of early disability or avoidable premature death. a system of national health must be able to allocate resources to meet those needs and must not simply be a payment system for doctors and hospitals. changing demographics, medical advances and epidemiological challenges including social and health inequalities also be addressed with high priority. this case study provides the background and experience of the development of uhc over the past century and a half, with lessons learned for consideration in how-and what-is done to achieve this goal. most industrialized countries have implemented national health programs such as health insurance systems or national health services. each system developed in the political, social, and historical context of the country-and continues to evolve. medium-and lowincome countries are also struggling to achieve universal access to care and health for all by expanding primary health care and social security plans which provide benefits to workers and for certain vulnerable populations-primarily mothers and children. as they move up the scale of economic development, developing countries must also address the problem of how to decrease morbidity and mortality, achieve equity in access to health care, and expand the funding basis for health care through national health insurance. some countries experience rapid economic development, but lag behind in directing increased national wealth towards improving health status. this is often due to a lack of focused political commitment, trained policy analysts, and cultural adaptation to the crucial importance of public health. each national health system has its own characteristics and challenges. systems management requires continuous evaluation based on welldeveloped information systems, trained health management personnel, societal involvement through all levels of government, as well as the private sector, professional organizations and advocacy groups. there is no defined "gold standard" plan for providing universal access to health care that is suitable for all countries. each country develops and modifies a program of national health appropriate to its own political and cultural needs and available resources. however, there are evolving patterns in health care organization, so that networking within and between countries ensures that they can-and do-learn from one another (box . ). barriers to necessary health care can be geographic, ethnic, cultural, social, lack of information and awareness, psychological, financial, and poverty. removing financial barriers to care is necessary and constructive, but not sufficient to address the health problems of individuals and of a society. equity in financial access with universal coverage is vital to population and individual health since anyone can have serious illness at any time. but equally important, long-term preventive care and health promotion are essential to good population and individual health standards. inequities exist in all societies, but many countries have successfully reduced these by poverty alleviation, job creation, education, and other programs that reduce interregional, socioeconomic, and demographic differences in health. special attention to high-risk groups in a population is essential. groups at-risk may be based on age, gender, ethnicity, genetic legacy, occupation, risky lifestyle, location of residence, religion, sexual orientation, economic status, or other factors that increase susceptibility to disease, premature death, or disability. services must be based on need and not only demand, which can escalate costs by over-servicing. health systems planning needs to promote access to patient care, but also those services that reach the entire population, especially people at high risk who are often least able to seek and access appropriate care. a program that provides equal access for all may not achieve the objective of better health for the population unless accompanied by other box . key elements of national health systems . a tradition of government and nongovernmental initiatives to improve health of the population. . public administration and regulation; public-private partnerships. . intersectoral cooperation with education, social services and the private sector. . demographic, economic, and epidemiologic monitoring. . health targets monitored with accessible data systems. . public health programs, including strong elements of health promotion. . universal coverage by public insurance or service system. . access to a broad range of health services. . strategic planning for health and social policies. . monitoring health status indicators. . recognition of special needs of high-risk groups and related issues. . portability and accessibility of benefits when changing employer or residence. . efforts to reduce inequity in regional and socio-demographic accessibility and quality of care. . adequacy of financing. . cost containment. . efficient use of resources for a well-balanced health system. . consumer satisfaction and choice of primary care provider. . provider satisfaction and choice of referral services. . promotion of high-quality service. . promote patient and staff safety. . comprehensive public health and health promotion programs. . comprehensive primary, secondary, and tertiary levels of medical care. . well-developed information and monitoring systems. . continual policy and management review. . promotion of standards and accreditation of services, professional education, training, research. . governmental and private provision of services. . decentralized management and community participation. . assurance of ethical standards of care for all. . conduct epidemiological, basic sciences and health systems research. . preparation for mass casualties from disasters and terrorism. important governmental, community and personal self-care activities. these include enactment and enforcement of environmental and occupational health laws, food safety, nutrition standards, clean water, improved rural care, higher educational levels, and provision of health information to the public. additional national programs are needed to promote health generally and to reduce specific risk factors for morbidity and mortality. responsibility for health lies not only with medical and other health professionals, but also with governmental and voluntary organizations, the community, the family, and the individual. individual access to an essential "basket of services" as a prepaid insured benefit is fundamental to a successful national health program. each country addresses this issue according to its means and traditions, but cost-effective evidence-based methods of meeting a countrys epidemiologic and demographic needs should be prioritized. coverage and payments for heart transplantation, for example, may be beyond the means of a health system, but early and aggressive management of hypertension, smoking, poor diet, physical inactivity, and rapid care for acute myocardial infarction are effective in saving lives at modest cost and containing the need for more intrusive health care interventions. prevention is cost-effective and should be integral to the development of service priorities within the insured benefits with incentives included in the "basket of services". globalization affects health systems around the world not only in the ease of spread of infectious diseases, but in increased access to modern preventive, diagnostic, treatment modalities. access to antiretroviral drugs has dramatically changed the face of hiv/aids globally, including in low-income countries with support of international and bilateral donors. the same is true for vaccines, including the mmr (measles, mumps, rubella, doses), hib (hemophilus influenza b), rotavirus, pneumococcal pneumonia and hpv (human papillomavirus) vaccines, which will save millions of children's lives and foster well being in the coming decade. information technology, migration of medical professionals, and internalization of educational standards are all global health issues affecting national health systems. health systems in all countries are facing common problems in population health, with rising population age, hypertension, obesity and diabetes prevalence, and rising health care costs. health systems research capacity is important in each country as it attempts to cope with rapid changes in population health and individual health needs with limited resources. development of research capacity enables improved capacity of decision-makers for informed, cost-effective decisions. in developing countries, low levels of funding for health in general-including research-impede evidence-based health system development and training of the new health workforce. strengthening reporting systems of data aggregation, as well as economic and epidemiologic analysis, are vital for health policy and management. national health systems from germany, uk, canada, us and russia are presented here as representing major models of organization. these organizational models influence health care system formulation in both developing and developed countries, as well as for countries restructuring their health services. health care systems and financing are under pressure everywhere, not only to assure access to health for all citizens, but also to keep up with advancing medical technology, and contain the cost increase at sustainable levels. because a health system is judged by more than its cost and measure of medical services, indicators of health status of the population, as well as morbidity and mortality are vital and should be available for the public through community organizations and the media. this topic has developed a complex terminology of its own. the world health organization (who) helps development of national health systems as shown in box . . universal health coverage is defined as ensuring that all people have access to needed health promotion, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services. g good health is essential to sustained economic and social development and poverty reduction. g access to needed health services is crucial for maintaining and improving health. g at the same time, people need to be protected from being forced into poverty because of the cost of health care. g a well-functioning health system working in harmony is built on having: trained and motivated health workers; a well-maintained infrastructure; a reliable supply of medicine and technologies; backed by adequate funding; strong health plans; evidence-based policies. who assists in creating resilient health systems by supporting countries to: g "develop, implement, and monitor solid national health policies, strategies and plans. g assure the availability of equitable integrated people-centered health services at an affordable price. g facilitate access to affordable, safe, and effective medicine and health technologies. g strengthen their health information systems and evidence-based policy-making, and to provide information and evidence on health-related matters." source: world health organization. health systems. available at: http://www.who.int/ healthsystems/about/en/ (accessed may ). health systems are meant to improve health and quality of life, as measured by quantitative and qualitative methods. the human development index (hdi) provides a standard method of comparison which combines many health and social indices into a summary figure for social development of countries. these include life expectancy at birth, gross domestic product (gdp) per capita, child mortality, education and others. table . shows life expectancy, still a valued health status indicator, for some industrialized, mid-level, and developing countries. comparisons between countries health indicators are useful to portray relative international health status among nations. the foundations of public responsibility for health care systems go back to ancient greece and rome where city states employed municipal doctors to service the poor and slaves. in the medieval and renaissance periods, monasteries and nunneries provided charitable care to the poor while professional guilds provided prepaid medical care and other social benefits to members and their families. these later evolved into the friendly (benevolent) societies, as mutual benefit programs that provided for burials, pensions, and payment for health services for members. in the twentieth century, these developed through collective bargaining into health insurance plans through private or professionally sponsored insurers, and labor unionÀsponsored health plans. governmental responsibility for health systems evolved in public health and health protection systems in the nineteenth and twentieth centuries and continues to evolve to face new challenges as well as preventive and treatment capacities. the health systems described highlight the unique and common features of national health systems in the search for "health for all", and policies for making health a priority in resource allocation, policy priority for human rights, and for socioeconomic development. figure . indicates the À trends in total health expenditures as percent of gross domestic products of selected countries in the european region of who. german and swedish expenditures rose to between % and %, in the united kingdom to over % while israel is relatively stable under % and the russian federation expenditures rose to % of gdp. germany's health care system today is characterized by participation as well as sharing of decision-making powers between the states (la¨nder), the federal government and civil society organizations. since , statutory health insurance (shi) has been mandatory for all citizens and permanent residents pay a uniform contribution of . percent of their income (gesetzliche krankenversicherung) with sickness funds (krankenkassen, january ). shi covers percent of the population, who have the right to choose their preferred sickness fund for a comprehensive range of services. the sickness funds are linked to associations of physicians accredited to treat patients covered by shi. private health insurance (phi) covers percent of the population for designated groups such as civil servants. others ( %) such as the military are included in other specific governmental programs. since the s financial incentives are being introduced to improve quality and efficiency of care along with beneficiaries right to choose between sickness funds increasing competition and a market orientation. hospitals are paid by diagnosis related groups (drgs)-i.e., payment by diagnostic category rather than hospital length of stay, adopted from us experience. physicians are paid by a capitation system-i.e., a fixed payment for each person registered for care with a doctor for a fixed period of time (as opposed to fee-for-service) in the doctor's medical associations. longterm care is covered by a federal mandatory program. germany expends . percent of gdp ( ) on health, one of the highest levels among eu members, with percent from public sources and percent privately sourced. in , germany had . acute care beds per , beds per population, nearly percent above the rate for the original eu countries ( . per , ). of these, percent of beds were in publicly owned, percent in private nonprofit, and percent in private for-profit hospitals. busse et al. ( ) describes reforms since its founding in gradually achieving universal coverage. the system is also seeking greater cost effectiveness as compared to neighboring countries. in europe, many countries developed taxation or social security models based on the bismarckian approach, with compulsory contributions by workers and their employers to a national social security system. this then financed approved services usually paid through private medical practice with fee-for-service payment. many european countries and japan gradually developed similar forms of compulsory health insurance for workers and their families following world war i, or later after world war ii, expanding to universal coverage health insurance systems. this model is used in france, belgium, the netherlands, japan, switzerland, and latin america as well as post-soviet health reforms and countries of eastern europe (cee). the israeli system, adopted in , based on the bismarckian model is mandatory national health insurance in which everyone must choose one of four long-standing sick funds now called health organizations. they compete for members, and are paid a per capita sum for which they are obliged to provide comprehensive services including hospital, primary care, and preventive services. the services improved vastly under national health insurance, with services kept up to date with annual additions to the statutory "basket of services." health statistics show israel as among the top countries for life expectancy, with rapidly falling mortality from strokes, coronary heart diseases, and cancers. consumer satisfaction is high, maternal and child health are stressed, a low hospital bed to population ratio, while health expenditures are relatively modest and a stable per capita health expenditure just under eight percent of gdp (lancet ). william beveridge was born in in bengal, india, where his father was a judge in the indian civil service. he trained as a lawyer coming to prominence in the british liberal government of À when he advised david lloyd george (chancellor of the exchequer from to , prime minister from to ) on old age pensions and national insurance. in , initiated by lloyd-george, influenced by the german compulsory health insurance scheme, the liberal government of great britain introduced the national health insurance act. it was compulsory for all wage earners between and years of age. this was a two-part plan based on a worker and employer contributory system for both unemployment insurance and for medical care for workers and their families. administration was through approved mutual benefit societies (the friendly societies), some based on insurance companies, and others by professional associations and trade unions. general practitioner services were paid on a capitation basis rather than a salary, preserving their status as self-employed professionals. initially this plan covered one-third of the population increasing to half by , however there was disruption due to mass unemployment during the great depression starting in and continuing to the late s. in the early days of world war ii, the british government established a national emergency medical service for hospitals in preparation for the anticipated large-scale civilian casualties that were expected during the blitz bombing by nazi germany. this established national health planning and rescued many hospitals from near bankruptcy due to the effects of the great depression in the united kingdom (uk). during world war ii, at the behest of prime minister winston churchill, beveridge developed a postwar social reconstruction program. the beveridge report of , social insurance and health services, outlined the concept of a future welfare state including a national health service, placing medical care in the context of general social policy for the total population. the wartime government coalition approved the principle of a national health service, which had wide public support, despite opposition from the medical association. in , the newly elected labour government of clement attlee took up the recommendations of beveridge to introduce the national insurance act ( ) as a comprehensive system of unemployment, sickness, maternity, and pension benefits funded by employers, employees and the government. the national health service (nhs) act was instituted in under the leadership of aneurin bevan, against continued opposition from medical organizations, as a universal state health service in britain. the nhs provides a nationally tax-based financed, universal coverage system providing free care by general practitioners, specialists, hospitals, and public health services. this includes diagnosis and treatment of illnesses at home or in hospital, including dental and optometric care. the original nhs structure was divided into three separate services: hospital, general practitioner, and community health services. the hospital and specialist services were under the authority of regional boards. general practitioners worked under national contracts, and community health services, such as public health, home nursing and health visitors, midwives, maternal-and child care, came under the control of the county and city local authorities. all units reported to the minister of health and his staff. the hospital bed supply in the uk in was just under half the rate in france and one third of the rate of beds in germany per , population. hospital based specialists are salaried but highly independent; general practitioners ran their own practices and provided the foundation of the nhs system. over time, this tripartite structure evolved to some degree of integration of gp and community health services, along with hospitals under hospital trusts reporting to regional health authorities. the nhs, with periodic reforms, is still in place in the uk and well accepted by the population and-over time-even by conservative governments and by the medical profession. there are differences between the nhs systems of the uk: england, scotland, wales and northern ireland each operate their own nhs, albeit with funding and structure of the central nhs. regional disparities in health indicators still exist despite changes in funding giving greater resources within regions (north-south divide) of england; each of the four has their own, policy directions. social class and geographic inequities in health within the nhs have been recognized since the s with a series of reports and analyses showing large gaps in life expectancy, avoidable (i.e., preventable) mortality between the south and north of england and even more so with scotland and significantly poorer health indicators. the marmot report on inequalities from indicated the scope of the problem: "people living in the most deprived neighborhoods will on average die seven years earlier than people living in the richest neighborhoods. even more disturbing, people living in poorer areas not only die sooner, but spend more of their lives with disability-an average total difference of years. the review has estimated the cost of health inequalities in england: productivity losses of d À billion every year; lost taxes and higher welfare payments in the range of d À billion per year; and additional nhs healthcare costs well in excess of d . billion per year." the "beveridge model" is a term used for the national health service model, which has since been adopted by many european countries and should be regarded as a strong model for countries reforming their universal health care systems, such as spain and italy. the scottish nhs diverges from the central english nhs in addressing inequalities by a focus on the health sector as the sole responsibility for reduction of inequalities. the english nhs and other government agencies see the problem more broadly and adopted poverty-fighting measures with some success in improving mortality and morbidity social and health disparities since . the nhs system remains generally popular in providing health security for all, and reaching good outcome measures despite regional inequities. no change of governing political party has led to dismantling the nhs for a privatized health system over the seven decades since its inception. canada: national health insurance tc (tommy) douglas was born in falkirk, scotland and immigrated at the age of with his working class family to winnipeg, manitoba, canada. he developed osteoarthritis and the doctors were going to amputate his leg as the family lacked funds for long-term medical care. his leg was saved by a senior surgeon who refused the amputation. this made tommy a lifelong advocate and fighter for publicly administered, universal health care for all. he became a baptist minister and entered politics winning the saskatchewan general election of for the ccf party in a massive victory. it was the first democratic socialist government elected in north america. he held the office for years, during which time he pioneered many major social and economic reforms. canada (population . million) is a federal state and a constitutional monarchy with parliamentary systems at national and provincial/territorial levels. health is primarily a provincial responsibility, but federal funding and standards play an important role in the canadian health system. local authorities also carry out many primary public health services including sanitation, water safety, and supervision of food safety, among other responsibilities. the provinces/territories are responsible for the funding of hospital, community, home and long-term care, as well as mental and public health services. starting in the s, federal grants-in-aid were given to the provinces/ territories for categorical health programs, such as cancer and public health services programs. since the sars (severe acute respiratory syndrome) epidemic in , the canadian federal government has increased its capacity in public health with a new federal department of public health, regional laboratories and encouragement of many schools of public health across the country. canada's national health program evolved as a system of provincial health insurance with federal government financial support and standards. initiatives for national health insurance in canada go back to the s, but definitive action occurred only after world war ii. the federal government regulates drug and medical device safety, funds research and provides services to the native indigenous population groups, the military, rcmp (royal canadian mounted police) and federal prison inmates. services for veterans were later transferred to provincial medicare programs. the development of national health insurance was largely due to the bitter experience of the great depression of the s, a strong agrarian cooperative movement, and the collective wish for a better society following world war ii. in , the social democratic cooperative commonwealth federation (ccf) party under the leadership of tommy douglas formed the government of saskatchewan, a large wheat-growing province of one million people on the western prairies. the national universal health insurance program evolved from the provincial initiatives led by tommy douglas, now considered "the father of canada's universal medicare plan." douglas established the saskatchewan hospital insurance and diagnostic services act in under provincial public administration. in a federal cost-sharing formula began providing approximately percent cost-sharing with greater levels of funding going to the poorer provinces. by , all provinces and two territories had implemented hospital insurance plans, in a twotiered national health insurance plan-i.e., universal provincial/territorial health plans with federal standards and cost-sharing. in , again in saskatchewan, the medical care insurance plan (medicare) was implemented after a bitter doctors' strike. in , the federal government appointed a royal commission on health services (the hall commission) which in recommended adoption of the saskatchewan model across the country with federal support and standards. the saskatchewan plan was rapidly followed by similar plans in other provinces encouraged by generous federal costsharing. the federal government cost-shares provincial and territorial programs. provinces/territories must adhere to the standards of the canada health act ( ), which defines services to be covered for hospital, diagnostic, and physician services. there is federal funding support for provincial/territorial public health, long-term care, home care and community mental health services. this federal legislation was expanded to provide co-funding for provincial/territorial medicare plans, which over a short period brought all canadians into provincially administered systems of publicly financed health care, while retaining the private practice model of medical care. hospital care is provided mostly through non-profit, non-governmental hospitals. developed over the period À , the provincial/territorial health insurance plans were promoted by federal governmental cost-sharing, political support, and national standards. the plans were initially financed by taxation and premiums, but later solely by general tax revenues with federal support under the canada health act of . federal standards required the provincial plans to be: publicly administered; comprehensive in coverage of health services; universal; portable across provinces; and, accessible without user fees. federal reimbursement to the provinces/territories initially covered percent of national average medical care expenditures per capita and percent of the actual expenditures by each individual province. this provided higher-than-national-average rates of support to poorer provinces as well as portability between provinces/territories. by , all provinces had implemented such plans, and a high degree of health services equity was achieved across the country. care is provided by private medical practitioners on a fee-for-service basis under negotiated medical fee schedules with no extra billing allowed. hospitals are operated by nonprofit voluntary, religious organizations or municipal authorities, with payment by block budgets. per capita spending on health in canada is relatively modest in comparison with that of the us, but above oecd averages. public spending as a percent of total health expenditures is close to the oecd average (see box . ). this medicaretype plan was later adopted in a number of other countries including australia. medicare is still popular in canada, with support from all political parties and by most medical professionals. medicare and federal cost-sharing weighed in favor of the poorer provinces, allowing these to catch up in health care services and standards with the richer provinces. the canadian health program differs substantively from those of the united kingdom and the united states. health systems are important in the political and cultural life of a country. each within its own tradition is attempting to ensure population health through public or private means, to constrain the rate of cost increases. comparisons using various health indicators can be controversial, but the canadian universal health service or insurance coverage seems to have improved the health status of the population more rapidly than similar indicators for the total us population, but not necessarily for all segments of the population. after decades of focus on developing national health insurance, canada became a leading innovator in health promotion prevention (see chapter ) . the canadian health program established universal coverage for a comprehensive set of health benefits without changing the basic practice of medicine from individual medical practice on a fee-for-service basis. poorer provinces were able to use the federal cost-sharing mechanism to raise standards of health services, and a high degree of health services equity was achieved across the country. rapid increases in health care costs led to a review of health policies in (the federalÀprovincial committee on the costs of health services). the resulting report stressed the need to reduce hospital beds and develop lower-cost alternatives to hospital care, such as home-based care and long-term care. federally-led initiatives during this period extended coverage to include home-based care and long-term nursing home care, while restricting federal participation in cost-sharing to the rate of increases in the gross national product (gnp). since then, many provincial and federal reports have examined the issues in health care and recommended changes in financing, cost-sharing, hospital services, development of primary care, and other community services. in , a new approach to health was outlined by the federal minister of health, marc lalonde, in a landmark public policy document, a new perspective on the health of canadians. this report described the health field theory in which health was seen as a result of genetic, lifestyle, and environmental issues, as well as medical care itself. as a result, health promotion became a feature of canadian public policy, with the objective of changing personal lifestyle habits to decrease cross-cutting risky behaviors such as smoking, obesity, and physical inactivity. the pioneering work in nutrition from the national nutrition survey published in led to the adoption of federal mandatory enrichment regulations for basic foods with essential vitamins and minerals. this and other initiatives in the s led to the ottawa charter on health promotion (see chapter ) , which has had a global impact with the foundation of health promotion as a crucial new aspect of public health and health system policy. the canadian health system being primarily the responsibility of the provinces/territories had a down side. during the sars pandemic of , the provinces dealt with it and were found to be lacking strong public health institutions adequate to the task. following high level reviews of the sars episode the federal government established a cdc-like institution, regional laboratories capable of infectious disease challenges and eight schools of public health across the country to ensure continuing development of a competent public health workforce. universal health care needed to be supplemented by introduction of lalonde-initiated health promotion and equally so a strong microbiologic public health component to ensure rapid and competent responses to new emerging health challenges. how does the canadian public view the universal public single payer medicare run by the provinces with federal guidelines and cost-sharing program? despite complaints, mostly from us sources, the canadian public appreciates their health protection very much. in , the canadian broadcasting corporation (cbc) television conducted a program over many months called "the greatest canadian," with candidates and advocates. this included a call to all people in canada to nominate their greatest canadian. canadians from coast to coast were asked to vote and chose tommy douglas, known as the "father of medicare" and selected by national polling as "the greatest canadian of all time." the canadian public is proud of their medicare plan, and appreciates the security and social protection as a great achievement for everyone in the country. australia, taiwan, and south korea have adopted national health insurance systems similar to the canadian model. the us (population million, gdp per capita usd $ , in ) has a system of government based on the federal constitution, with states each having its own elected government. the constitution gives primary responsibility for health and welfare to the states, while direct federal services are provided to armed forces, veterans, and indigenous (native) americans. the federal government has established a major leadership role in national health by the development of national standards, national regulatory powers, funding, and information systems. the federal level has many governmental structures for regulation of food, drugs, and environment, as well as for research, public health services, training programs and health insurance systems for the elderly and the poor. the us has the world's costliest health care system with over percent health insurance coverage, but universal access remains elusive, and population health indicators are well below many less-wealthy countries. however, the us has through trial and error experimentation made major contributions to the content and organization of public health systems, which are important for strengthening health systems in medium-and low-income countries as well as influencing countries with universal health systems (see chapter ) . clearly, the us can learn from other countries as well (see box . ) . in , the federal government established the us marine hospital service to provide hospitals for sick and disabled merchant seamen. this later became the uniformed us public health service commissioned corps (usphs) headed by the surgeon general ( ). services were added for native americans, military personnel and their families (through the veterans affairs department), the food and drug administration (fda), the national institutes of health (nih), the centers for disease control (cdc) and many other world class federal programs of research, service and teaching. other departments and legislation were added to promote nutrition and hygiene, establish state, municipal, and county health departments, and regulate drugs and health hazards. in , the sheppard-towner act established the federal children's bureau that administered grants to assist states to operate maternal and child health programs. from the s, labor unions won health insurance benefits through collective bargaining, which became the main basis for prepayment for health care in the united states until today. in , the committee on the costs of medical care recommended a universal national health program. this initiative was set aside during the great depression of À . the us social security act (ssa) of was introduced by president franklin d. roosevelt as part of the "new deal" to alleviate the mass suffering of the people during this very traumatic period in the us (and europe). the ssa was intended to include national health insurance, but this part of the ssa was set aside largely due to strong opposition of the insurance industry and the organized medical profession. the ssa provides financial benefits for widows, orphans, and the disabled, as well as pensions for the elderly, and provided a base for future reform including health insurance. with the outbreak of world war ii, a significant percentage of eligible military recruits were found unfit for compulsory service due to preventable health conditions. this, and the wish to maintain population health, led president roosevelt to initiate regulations in for fortification of "enriched" foods reaching a majority of the population including salt with iodine, flour with iron and vitamin b complex, and milk with vitamin d. during world war ii ( À ), governmental health insurance was provided to many millions of americans serving in the armed forces, along with their families. at the same time, health benefits through voluntary insurance for workers were vastly expanded in place of wage increases and this became the major method of prepayment for health care for a majority of the population. at the end of the war, millions of veterans were eligible for health care through the veterans administration (va), which established a national network of federal hospitals and primary care services. in , president truman attempted to bring in national health insurance, but the legislation (the wagner-murray-dingell bill) failed in the us congress. one section of the bill was approved, enabling the federal government to initiate a program to upgrade country-wide hospital facilities, while limiting the beds to population ratio, under the hill-burton act (see chapter ) . legislation also provided massive federal funding for the newly established national institutes of health (nih) to fund and promote research to strengthen public and private medical schools, teaching hospitals, and research facilities. in , president truman established the federally-assisted school lunch program through the department of agriculture bringing nutritious meals to many (millions increasing from million in to million in ) of school children throughout the us. in the s, the federal government also established the centers for disease control and prevention (cdc) and increased assistance for state and local public health activities and encouraged expansion of schools of public health across the country. in the us during the s through to the s, rapid health cost increases were attributed to many factors including the lack of a national health insurance mechanism. the plethora of health insurance systems fostered high costs and restrictions on access due to pre-existing conditions. other factors for rapid cost increases included an increasing elderly population, high levels of morbidity in the poor population, the spread of aids, rapid innovation and costly medical technology, specialization, high laboratory and diagnostic imaging costs, and large-scale public investment in medical education, research and health facility construction. the us system includes a mix of public health insurance and service programs (medicare, medicaid, veterans administration, indian health services, and military health coverage) which provide for a significant part- . percent in -of the us population. however, the majority ( %) is covered by the private insurance industry through employer-employee contracts which developed rapidly as the dominant health insurance sector with minimal government regulation. the cost of private health insurance to employers included in labor contracts of their employees and pensioners has become very high. in , general motors reported to a senate hearing that the cost of health insurance per car produced was double the direct cost of labor and more than the cost of steel per car. this impinged on competitiveness in price with for example with japan which has a successful universal governmental health insurance plan with public-private mix of services. the affordable care act (aca) introduced by president barack obama in brought some million previously uninsured persons into public and private insurance, increased governmental regulation to ensure fair pricing and payment and, especially, to abolish the past abuses of the "pre-existing condition" exclusions from insurance. other equally important factors were high levels of preventable hospitalization, institutional orientation of the health system, high administrative costs due to multiple private billing agencies in the private insurance industry, high incomes especially for specialist physicians, and high medical malpractice insurance costs. the pressure for cost constraint came from government, industry, and the private insurance industry. (see chapter ). private medical practice, with payment by fee-for-service, was the major form of medical care in the us until the s. most hospitals were operated through a mix of nonprofit agencies, including federal, state, and local governments, and voluntary and religious organizations, but a growing percentage are privately owned, for-profit (from . % of beds in to . % in ). in an effort to contain costs, the diversity of insurance systems promoted experimentation with organizational systems. health maintenance organizations (hmos) and other forms of managed care systems grew rapidly to become the predominant method of organizing health care in the united states. prepaid group practice (pgp) originated from private companies contracting to provide medical care, especially in remote mining camps and construction sites. in the s, new york city sponsored the health insurance plan of greater new york to provide prepaid medical care for residents of urban renewal and low-income housing areas. this was later extended to include organized union groups such as municipal employees and garment industry workers. pgp became best known in the kaiser permanente network developed for workers of henry j. kaiser industries, at the boulder dam and grand coulee dam construction sites in the s. kaiser permanente health plans now provide care for millions of americans in many other states. initially opposed by the organized medical profession and the private insurance industry, pgp gained acceptance by providing high-quality, less-costly health care. this became attractive to employers and unions alike, and later to governments seeking ways to constrain increases in health costs. since the s, the generic term health maintenance organization (hmo) was promoted by the federal government in the hmo act by president richard nixon in . hmos, which operate their own clinics and staff (i.e., the staff model), or through contracts with medical groups as preferred provider organizations (ppos), have become an accepted, if criticized, part of medical care in the united states and an important alternative to fee-for-service, private practice medicine. in , . million americans were registered in hmo plans or . percent of the total us population. in recent years, the terms accountable care organizations (aco), patient-centered medical home (pcmh) and population health management system (phms) have come into wide use to denote organizations that take responsibility for comprehensive care for enrolled patients, with payment based on a form of capitation rather than fee-for-service. acos are present in all states, washington, dc, and puerto rico, with the population covered increasing from . million in to . million in . the aco comes in different models, but many include a hospital base and may be linked to independent practice associations (ipas), and specialty groups, or hospital medical staff organizations, or in a network of hospitals linked with other providers as an organized delivery system. these are not-for-profit group practices led by doctors who are salaried and subject to rigorous annual professional review. this model may be adaptable on a wider scale to improve quality and cost effective care to improve health of americans. in , a prospective payment system, called diagnosis-related groups (drgs), was adopted for medicare, to encourage more efficient use of hospital care, with payment by categories of diagnosis. the drg is a classification system, for inpatient stays, categorizing possible diagnoses into more than major body systems and subdivides them into almost groups for the purpose of medicare reimbursement. this replaced the previous system of paying by the number of hospital days, or per diem or by itemized billing which encouraged longer hospital stays. drgs provided incentives for hospitals to diagnose and treat patients expeditiously and effectively. payment for medicare and medicaid patients shifted to this method placed the public insurance plans in a stronger position for payments to hospitals. in many states this has also become standard for patients with private health insurance as well. during the late s, the term managed care was introduced, expanding from hmos of the kaiser permanente type to include both non-profit and for-profit systems. these include independent practice associations (ipas), which operate with physicians in private practice, and preferred provider organizations (ppos), which provide insured care by doctors and other providers associated with the plan to the enrolled members or beneficiaries at negotiated prices. the drg payment system and hmos or managed care systems reduced hospital utilization. while total costs of health care increased in this period, without reduction of hospital utilization the increase would have been considerably higher. in , president clinton tried to introduce a health plan based on federally administered compulsory universal health insurance through the place of employment. a state could opt to form its own health insurance program including through its own department of health. physicians could contract with health insurance plans to provide care on a fixed-fee schedule, or in hmos, whether based on group or individual practice. the clinton health plan failed in congress mainly due to well financed opposition by the insurance industry and the organized medical community. in addition, opposition was also widespread among the majority of the population who already had good insurance benefits under their employment-based health insurance plans or medicare. their interest was in keeping the status quo so that the bill was defeated. following the failure of the clinton national health insurance proposal, managed care experienced tremendous growth. managed care systems have been able to cut costs in health care in ways that the us government could not. in the us as a whole, in addition to the nearly million persons enrolled in hmos, another million persons are enrolled in ppos, with percent of medicaid and percent of medicare beneficiaries in various "managed care plans". the search for cost containment led to the development of a series of important innovations in health care delivery, payment, and information systems. hmos demonstrated that good care provision can be operated efficiently with lower hospital admission rates than care provided on a fee-for-service basis. the managed care systems brought about profound changes in health care organization in the united states. in , president barack obama established the patient protection and affordable care act/health care and education reconciliation act of , widely known as the affordable care act (aca or obamacare) bringing health insurance to millions of previously uninsured americans when it went into effect in (see box . ). the aca requires most companies to cover their workers, and mandates that everyone has coverage or pay a fine. aca also requires insurance companies to accept all newcomers, regardless of any preexisting conditions, and assists people unable to afford insurance. this legislation covers young people under their parents' health insurance plans until the age of , covering . million young americans. it eliminated other limits on coverage, allowing those who had already reached a lifetime limit to be eligible for coverage. the affordable care act introduced discounts as large as percent for pharmaceuticals for seniors. health care reform is currently a contentious issue with the donald trump government planning to repeal the obama health care reforms to be replaced with a plan still under development. us health care spending increased from . percent of gdp in to . percent in , threatening the ultimate insolvency of medicare and cutbacks in medicaid in the near future. lack of universal access and the empowerment it potentially brings encourages an alienation or non-engagement with early health care for the socially disadvantaged sector of the population. this promotes inappropriate reliance on emergency department care and hospitalization in response to under-treated health needs. with large numbers of uninsured persons and many others lacking adequate health insurance, access and utilization of preventive care are below the levels needed to achieve social equity in health in the us. this is especially true for maternal-and child-health and for chronic diseases such as diabetes, hypertension, cancer, and heart disease. infant mortality rates in the united states vary greatly by race and ethnicity. as measured by the infant mortality rate, the rate among non-hispanic black mothers was . times higher than the rate for white non-hispanic mothers. a significantly higher rate of infant mortality exists among puerto rican and american indian populations compared with the national average. cdc reports that maternal mortality rates have increased in the united states between and from . to . per , live births possibly due to changes in reporting and increase in chronic illnesses and influenza during pregnancy particularly in the african american population. in , the department of health and human services (dhhs) released healthy people with two main goals: "increase the quality and years of healthy life" and "eliminate health disparities." these goals focus on specific areas developed by over national membership organizations and state health, mental health, substance abuse, and environmental agencies. many states have adopted use of these targets as their own measures of health status and performance. the us public health service, in cooperation with the national center for health statistics, regularly make available a wide set of data for updating health status and process measures relating to these national health goals. various preventive health initiatives are in place to try to alleviate health disparities, which successfully improved immunization coverage of us infants to meet national health targets, as well as for lead and other efforts directed toward poor population groups. in , a program called racial and ethnic adult disparities in immunization initiative was introduced in order to improve influenza and pneumococcal vaccinations among minorities aged and over. the us department of agriculture's women, infants and children (wic) program enables millions of poor americans to have good nutritional security. the wic program covers pregnant women, breastfeeding women (up to infant's first birthday), non-breastfeeding postpartum women (up to months after the birth of an infant or after pregnancy ends) and infants and children (up to their fifth birthday). wic serves percent of all infants born in the united states. the benefits include: supplemental nutritious foods, nutrition education and counseling at wic clinics, screening, and referrals to other health, welfare and social services such as completion of immunization and special needs counseling. school lunch programs are widespread under a federally assisted meal program operating in over , public and non-profit private schools and residential child care institutions, providing nutritionally balanced, low-cost or free lunches to more than million children each school day in . nutrition support for pregnant women and children in need, alleviates some of the ill effects of poverty in the united states, but lack of health insurance affects these groups severely especially in chronic disease, trauma, and other diseases of poverty. health disparities are a complex problem that goes beyond the issue of uninsured americans. low-income and illegal immigrants face challenges to access medical insurance. new immigrants must wait five years before they are eligible for medicaid. the structure of the medical system plays an important role in an individual's ability to obtain medical care. this includes convenience of making an appointment, office hours, waiting times, and transportation. a lack of health literacy also plays a role in an individual's ability to seek medical attention. individuals not fluent in english experience communication gaps. in , it was estimated that an excess of usd $ billion a year is spent on health care in the united states as a result of low health literacy. in certain areas of the country, medical facilities are scarce. minorities are under-represented in medical professions. black, latino, and native american populations make up approximately six percent of the physician workforce, although these populations represent over percent of the population in the united states. health disparities remain an important social and political issue in the united states. the office of minority health (omh) of the department of health and human services was established in to address issues of health disparities among racial and ethnic minorities. important health disparities exist in america in relation to region of residence, with the southern states having high rates of obesity, stroke, and coronary heart disease mortality, which are thought to be due to customary diets rich in fatty and salty foods. state health departments will need to address these issues in order to reduce gaps in life expectancy due to lifestyle factors which are grounded in tradition and poverty as well as lack of health insurance. one of the main goals of healthy people is to eliminate health disparities. the us has developed extensive information systems of domestic and international importance. the cdc publishes the mmwr (morbidity and mortality weekly report), which sets high standards in disease reporting and policy analysis. the us national center for health statistics (nchs), the health care financing administration (hcfa), the us public health service (usphs), the food and drug administration (usfda), the national institutes of health (nih), and many nongovernmental organizations (ngos) carry out data collection, publication, and health services research activities important for health status monitoring. national nutrition surveillance and other systems of health status monitoring are reported in the professional literature and in publications of the cdc. national monitoring of hospital discharge information facilitates the understanding of patterns of utilization and morbidity. these information systems are vital for epidemiologic surveillance and managing the health care system. us surgeon general reports have an important influence on health systems not only in the united states, but also internationally. the cdc created the national center for public health informatics (ncphi) in to provide leadership and coordination of shared systems and services, to build and support a national network of integrated, standards-based, and interoperable public health information systems. this is meant to strengthen capabilities to monitor, detect, register, confirm, report, and analyze data, as well as provide feedback and alerts on important health events. this will enable partners to communicate evidence that supports decisions that impact health. electronic medical and personal health records are now widely used. these protect patient privacy and confidentiality, and serve legitimate clinical and public health needs. media coverage of health-related topics is extensive, and is important to promote health consciousness in the public. however, the sheer volume of information may make it difficult to discern which information is most relevant, and due to misinformation on internet sites, can also create opposition to public health initiatives such as the refusal to vaccinate children. public levels of health knowledge grow steadily, but vary widely by social class and educational levels. in , the us surgeon general's report healthy people set a series of national health targets for a wide variety of public health issues. the program defined objectives in program areas within the three categories of prevention, protection, and promotion. these goals and objectives were formulated based on research and consultation by experts in different fields who participated in a conference by the us public health service. consensus is based on position papers, studies, and conferences involving the national governmental health agencies, the national academy of science institute of medicine, and professional organizations such as the american academy of pediatrics (aap), the us preventive health services task force, and the american college of obstetrics and gynecology (acog). many private individuals and organizations contribute to this effort, including state and local health agencies, representatives of consumer and provider groups, academic centers, and voluntary health associations. these targets are periodically assessed as performance indicators of the us health system and then updated. progress made during the s included major reductions in death rates for three of the leading causes of death: heart disease, stroke, and unintentional injuries. infant mortality decreased, as did the incidence of vaccine-preventable infectious diseases. the latest iteration, healthy people , identifies national health priorities. it strives to increase public awareness and understanding of the determinants of health, disease, disability, and opportunities for progress. it defines measurable objectives and goals for federal, state, and local authorities in the areas of health promotion, health protection, preventive services, surveillance and data systems, and age-related and special population groups. the final reviews of healthy people showed significant decreases in mortality from coronary heart disease and cancer. healthy people renews this effort to establish national targets which are adopted by state level governments and strongly influence policy in health insurance systems. the us has managed to achieve many of the targets set by the surgeon general's healthy people report. at the same time, the average annual increases in health care expenditures in the united states slowed markedly from the À period with average annual increases of . percent, falling to under percent annually between and . this is partly due to lower general inflation rates (, %), but also cost-containment measures being adopted by government insurance (medicare and medicaid) programs, the health insurance industry, the growth of managed care, and rationalizing the hospital sector by downsizing and promoting lower-cost alternative forms of care. national health insurance was delayed by congressional rejection of the clinton health plan. president barack obama's affordable care act (aca) provided millions of previously uninsured americans health insurance within better regulated private insurance or in state-run medicaid plans, but in is facing "repeal and replace" efforts by the president trump administration and republican congress. a number of possibilities exist to extend health insurance coverage: state health insurance initiatives with federal waivers and cost-sharing; a federal single payer universal coverage plan based on the federal medicare model or a federal-state medicaid model. the us health system is often called a costly and inefficient nonsystem. there are many stakeholders and providers, high costs, and poorer population health results than those achieved in other industrialized countries such as britain, germany, and canada. the health system is diffused with high levels of coverage for diverse insurance plans through employment-based insurance along with publicly financed and administered health insurance (e.g., medicare, medicaid, aca). inequalities are a significant health challenge in the us along with the uninsured, poverty, aging of the population, rising levels of obesity and diabetes. the principle of universal access through public insurance for all is still a highly politicized issue in the united states, although public acceptance seems to be gradually growing. the us has a reputation for good to outstanding quality of medical care, but for those without insurance, services are limited to hospital emergency care only. important ethnic, social, and regional inequities in health status are still present, but not necessarily greater than in countries with universal access health care plans such as the uk nhs. further, there are many parallel programs in the united states that have important positive public health content, such as universal school lunch programs, nutrition support for poor women, infants, and children (the wic program); food stamps for the working poor; fortification of basic foods, free care for the uninsured in emergency departments, medicare for the elderly, medicaid for the poor, and aca coverage for the near-poor. box . shows the challenges of the us health system. despite rapid increases in health care expenditures during the s and s, despite improved health promotion activities and rapidly developing medical technology, the health status of the american population g preventive programs strong tradition; screening for cancer; smoking reduction; food fortification, school lunch programs; nutrition support for poor pregnant women and children (wic); g hospitals obliged to provide emergency care to all regardless of insurance status, citizenship, legal status or ability to pay has improved less rapidly than that in other western countries and universal coverage has not been achieved. us performance measures are lower than many middle-and high-income countries with much lower per capita health expenditures, including measures such as infant mortality rates and life expectancy. infant mortality in the us remains high in comparison to oecd countries and ranks th among all countries in (estimated). even the rate of infant mortality of the white population of the united states was higher than that of countries that spent much less per person and a lesser percentage of gnp per capita on health care. life expectancy at birth in the united states in was below that of countries, just behind costa rica, portugal and slovenia. in , the us life expectancy at birth was . years, well below the oecd average of . years. social inequities in these health status indicators are further evidence of failures of the united states health system to reach its full potential, despite its being the costliest system in the world and its high quality for those with access (commonwealth fund, ) . the advent of the aca (obamacare) introduced in brought health insurance to millions of americans, but is challenged as unaffordable. the us still lacks a universal single payer health plan of canadian or european tradition, but the aca is a huge step forward in america where the working poor are in large measure excluded from access to health care except for emergencies. the struggle for universal access and cost containment are still formidable political and societal challenges for the united states. in , following the russian revolution, the soviet union (ussr) introduced its national health plan for universal coverage within a state-run system of health protection. the soviet model, designed and implemented by nikolai semashko, provided free health care for all as a governmentfinanced and -organized service. it brought free health services to the population, with a system of primary-and secondary-care based on the principles of universal and equitable access to care through district organization of services. it achieved control of epidemic and endemic infectious diseases and expanded services into the most remote areas of the vast under-developed country. this model was also applicable in countries included in the ussr following world war ii until the collapse of the ussr. the model developed in the former soviet union in by semashko brought free health care with governmental management by republic and regional authorities according to national norms set out by the ministry of finance. since the s health care became available for all with mostly underdeveloped basic infrastructure for health care including human resources. the semashko plan provided universal access to preventive and curative care, and control of infectious disease in a uniform plan, with many republics previously having only primitive care available, achieving national standards of services and improved health indicators. since the s, an "epidemiologic transition" was occurring characterized by declining mortality from infectious diseases and rising death rates from non-infectious diseases. life expectancy increased since , still remains far below levels in many medium-income developed countries. the transition in health systems following the collapse of the soviet union in took different paths for the socialist central and eastern european countries (cee) as compared to the core countries of the soviet union, called the commonwealth of independent states (cis). the cee countries moved rapidly to dismantle their soviet, centrally managed sanitary-epidemiological system (sanepid) system with decentralization while retaining universal coverage with central funding, but with local authority participation in some cases. most cee and cis countries have introduced health insurance systems, with more out-of-pocket payments (both formal and informal), and efforts to strengthen primary health care, with family medicine delivered by general practitioners. in most cases central authorities also maintained responsibility for epidemiological surveillance and environmental monitoring with some transferring responsibilities for environmental health in other ministries. the cee and cis countries maintained similar levels of health expenditures as percent of gdp between six and seven percent over the past decade, while the original european union (eu) countries reached an average of percent of gdp. the cis acute care hospital bed capacity ratio declined to six per population in far higher than cee countries (declined to . per ), which were higher than the western countries, although all country groups were declining (see chapter ) . the importance of these differences lies in the fact that total resources allocated for health in the soviet system was relatively low while the allocation allowed hospital care to consume some percent of total expenditures compared with less than percent in western countries. the outcome of this allocation of resources was weakness in development of primary care, prevention and community care in favor of an over-developed hospital bed supply. the russian federation adopted a mandatory health insurance (mhi) plan in to open up additional funding for health care in the face of severe governmental funding constraints. it remains a highly centralized system and is struggling to provide universal access to basic care. despite this, death rates from avoidable causes such as stroke and coronary heart disease have declined in the past decade and life expectancy has risen modestly, but remaining far below western as well as former socialist countries of central and eastern europe. developing national health systems with universal access has been a long process in high-income countries and is an important goal for all countries including medium-and low-income countries to promote improving access to health for the total population. the commonwealth fund published an outstanding international profile of selected health care systems in highincome countries ( ) including: australia, canada, china, denmark, england, france, germany, india, israel, italy, japan, the netherlands, new zealand, norway, singapore, sweden, switzerland, and the united states. global spending on health is expected to increase from us$ . trillion in to $ . (uncertainty interval . À . ) trillion in (in purchasing power parity-adjusted dollars). we expect per-capita health spending to increase annually by . % ( . À . ) in high-income countries, . % ( . À . ) in upper middle-income countries, . % ( . À . ) in lower middle-income countries, and . % ( . À . ) in low-income countries. low-and medium-income countries face major difficulties in developing universal health coverage, especially in terms of financial and professional resources. a study of global health care financing (dielman et al lancet ) reported on health expenditures from countries, including public, donor, and private ("out of pocket") payments between and . high-income countries spent more, and mostly from public sources, increasing expenditures by an estimated three percent per year. medium income countries increased their health spending more than three-four percent per year and low-income countries by two percent. economic development was positively associated with total health spending and a gradual shift away from a reliance on development assistance and out-of-pocket spending towards government spending. in , . percent of all health spending was financed by the government, although in low-income and lower-middleincome countries, percent and percent of spending was out-of-pocket, . percent and three percent respectively was with development assistance. recent growth in development assistance for health has been tepid. between and , it grew annually at . percent, and reached usd $ Á billion in . nonetheless, there is a great deal of variation revolving around these averages. in countries spending less than five percent of gdp on health, included many in asia, the middle east and sub-saharan africa (institute of health metrics and evaluation, ). while there is wide variation in health spending in low-and lowermiddle-income countries and there is overall increased spending in absolute terms, there is still a heavy reliance on out-of-pocket spending and development assistance, which itself is growing very slowly. this indicates that medium-and low-income countries are not providing the financial means to develop universal health access insurance plans. economic growth also does not translate into adequate funding for universal health care without dramatic changes in policy and decreased dependency on donor aid. international agencies-such as who-are promoting the search for ways to provide universal and equitable care, while controlling costs and improving efficiency in low-and middle-income countries. the universal declaration of human rights, article states: "( ) everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. ( ) motherhood and childhood are entitled to special care and assistance. all children, whether born in or out of wedlock, shall enjoy the same social protection." the universal declaration of human rights specific inclusion of access to medical care for all should be seen as a priority in planning universal health insurance (uhi) for promotion of access to health needs for remote rural populations as well as urban poor, and displaced persons. this also applies to conditions of warfare, civil strife, natural disasters as well as incitement to and actual genocide. as said previously, the global consensus of the mdgs ( À ) and the sdgs ( À ) have undertaken to implement key elements of this important declaration. it is easier to be pessimistic than optimistic in the potential for success, but the significant achievements of the mdgs in poverty reduction, educational equity between the genders and in reduction of child and maternal mortality as well as in control of hiv, malaria and tuberculosis are signs of important progress and future possibilities. national governments must take up the financial burdens and management of expanding health systems as well as contributory advances in education, environment and other government sectors toward achieving these goals. bilateral aid and international donors are vital, but they cannot achieve or sustain all this without national commitments and resources. national health systems are essential to provide universal access to health care, but must be developed recognizing that restraint in increasing costs, equity in access and quality, as well as efficiency and effectiveness in use of resources are vital to achieve health targets and equity in population health. in the united states, a study of ethnic differences in utilization of services among medicare beneficiaries who have the same entitlements show significant differences indicating lesser use of preventive services such as mammography and higher rates of lower limb amputation for diabetes indicating poorer management of diabetes. studies in the united kingdom also show sharp differences in mortality rates by region of residence that correlate with socioeconomic gradations. universal access alone does not guarantee equality so that the design of service systems needs to take into account differing needs of groups or regions at higher risk and greater need. universal access by itself is important, but not sufficient to reduce inequalities, which have more complex needs than medical care alone. universal coverage health insurance must be developed with great care to avoid mistakes made in many countries in previous decades of promoting rapid increase in health expenditures to the benefit of the middle class while rural and poor urban populations linger in relatively poor health. a universal health insurance plan without strong incentives for prevention and community health will find itself in a trap of punishing the poor for the benefit of the rich. population health experience of the past century has shown the power of public health, in all its aspects, to raise life expectancy and quality, yet inequalities still plague all health systems. this provides an ethical challenge in planning, resource allocation and political support. beyond financing and resource allocation, there are many "nontariff" barriers to health. even in highly developed national health systems, social class, place of residence, education level, and ethnicity play significant roles in morbidity and mortality rates. addressing important health risk factors other than medical or hospital care is vital. the disease-risk factors of diet, smoking, physical fitness, nutrition status including obesity, and untreated hypertension. such conditions are not necessarily managed even where all residents of a country are insured for health care. social class, ethnic and regional differences in morbidity and mortality exist due to povertyassociated factors, such as insecurity, lack of control over one's life, lack of financial means or knowledge to purchase healthy foods, as well as fear, loneliness and depression. these are issues that are important and must be addressed in public health policy to reduce inequalities in health and the achievement of national health goals and equity. models of financing of universal health insurance include a variety of methods: general taxation; social security by employee-employer payments through payroll deductions; private insurance under contracts between employee and employer; and private out-of-pocket payments. taxation financing can be mainly through progressive income tax, resource taxes, surcharges or "sin taxes" (e.g., on cigarettes, alcohol, gasoline) and excise taxes along with local property and business licensing taxation where local authorities have a management role. funding by general tax revenues at national or state levels or shared between the two levels provides for more local administration while sharing in costs may be the most equitable way of raising funds. many countries use social security systems based on employerÀ employee contributions to pay for health services. the who, the world bank and oecd promote universal health insurance (uhi) for middle-income countries. the advantage will be to reduce the heavy burden of out-of-pocket payments, which are percent of health expenditures in many emerging countries. universal health insurance provides security for individuals and families against catastrophic health events, for regular medical and hospital care, and for ageing populations with increasing health needs. oecd recommends increasing health expenditures, which improves life expectancy, and to allow uhi implementation. even a percent increase in national health spending has been shown to reduce child mortality across many countries. universal health insurance must include promotion of greater efficiency in health care, such as shifting of services from hospital care to outpatient and primary care along with community and home-based care (see chapter ) . the process requires developing new health care provider roles with emphasis on outreach to groups with greater than average need, promoting public health and preventive care such as for underserved rural or urban communities or groups at special risk for disease such as cardiovascular disease (cvd) and diabetes, making use of epidemiologic and sociologic health data and information systems. universal health insurance undoubtedly contributes to improving health indicators such as life expectancy by coverage of the total population, systematizing financing of the health system and providing access to the population. however, without good management of resource allocation, universal health insurance cannot guarantee achievement of important health targets. allocation of resources is a fundamental problematic aspect of universal health insurance. national health policy governing universal health insurance must invest adequately in health promotion and disease prevention in order to reduce excessive allocation and utilization of hospital care. continuous monitoring and evaluation are essential to a health system, but not only for traditional outcome indicators, such as infant, child and maternal mortality rates, and disease-specific mortality rates. these are all valuable indicators of population health, but not sufficient. input, process and outcome indicators are important and necessary to include, such as supply and distribution of resources e.g., primary care, maternity centers, hospital beds; process measures e.g., immunization rates, incidence of vaccine-preventable diseases, growth patterns and anemia rates in infancy and childhood, food fortification, micronutrient supplements to risk group, prenatal delivery and neonatal care. outcome measures include prevalence of disabling conditions morbidity and mortality rates. disability adjusted life years (dalys) and quality adjusted life years (qalys) help change the emphasis from mortality to quality of life measures as part of the evaluation. national health systems require data systems that generate information needed for this continuous process of monitoring. monitoring of hospitalizations, length of stay, health-care facility acquired (nosocomial) infection, readmission rate by diagnosis and many more indicators, compliance with standards of care such as in infection control, surgical and maternal mortality, including infection and error rates, and other qualitative measures are now part of monitoring and payment systems. high-quality academic centers are needed for training epidemiologic, sociologic, and economic analyses professionals as well as health system managers and to carry out the studies and research vital for health progress. health systems are large-scale employers and among the largest economic sectors in their respective countries, with À percent of gdp in middle-and high-income countries and, therefore, a major factor in the total national economy. but the gap between countries is very high. many countries have per capita spending of less than usd $ per year, so that inadequate resources prevent people from receiving quality health care, without unaffordable out of pocket expenditures. in contrast, in many high-income countries annual health expenditures are above usd $ , per capita. donor aid to low-income countries from bilateral or international agencies or other donors rose rapidly from with an estimated $ billion usd to a peak of usd $ billion in , with only a modest change up to . low-income nations, many of which are undergoing important economic development, are under-spending in national allocations to the health sector and remain highly reliant on international aid. a goal of five to six percent of gdp spent on health is widely regarded as a minimum to provide the health care needed in any country. a study published in lancet by the institute for health metrics and evaluation, indicates that only one of low-income countries, and out of of middle-income countries, are expected to meet the target of five percent. low rates of national health expenditures in countries will be a serious limiting factor in improved health and universal access, especially if preventive care is unable to compete for resources as compared to clinical and hospital services. all countries face problems of financing, cost constraint, overcoming structural inefficiencies, and funding incentives for high quality and efficiency in health services. national health systems are necessarily complex, but go well beyond medical and hospital care. the quality of the community infrastructure-sewage, water, roads, communication, urban planning-social support such as pensions and welfare for the disabled, widows, orphans and others in need are essential for population health. attention to the quantity and quality of food (i.e., food and nutritional security), levels of education, and professional organization are all parts of this continuum. national health systems are not only a matter of adequacy and methods of financing and assuring access to services; they must also address health promotion, national health targets, and adapt to the changing needs of the population, the environment, and with a broad intersectoral approach to health of the population and the individual. the structure, content, and quality of a health system plays a vital role in the social and economic development of a society and its quality of life. universal access is increasingly widely accepted as essential to reduce the social inequalities in health. even when income gaps are high. however, vulnerable populations with higher levels of risk than those of the general population are still relatively deprived even under classical universal insurance systems. the key common factors of elevated vulnerability are poverty, isolation by geographic location, physical access by reasons of residency location, ethnicity, education and institutional barriers which reduce access. these inequality factors are the achilles heel of classical universal health insurance and service systems most of which have sought health promotion measures. there can be little doubt that universal access to health insurance or service systems reduces inequalities, but they require imaginative and outreach-oriented approaches to reach those urban and rural poor, people of aboriginal descent, those with an income lower than the poverty threshold, the unemployed, the homeless, and those who have not completed secondary education. societal programs to increase family disposable income for the poor are effective in reducing the health inequities. the two are complementary and equally important in social policy. in the united states more than ten percentages of the population are without any, or have inadequate, health insurance. loss of health coverage with change of place of employment and the rapidly increasing cost of private health insurance generated widespread pressure for a national health program. the business community, too, loses confidence in voluntary health insurance as costs of health insurance mounted rapidly and as a cost of employment in an increasingly harms the competitive international business climate. narrow planning for health systems ignores this message at the risk of missing their targets of improved health indicators, such as those adopted by the united nations-i.e., the millennium development goals and sustainable development goals. the mdgs and sdgs represent a growing movement of globalization of health with economic and political dimensions and greater stress on human rights to health policy. they are particularly relevant to lmics (low-and middle-income countries), but high-income countries have health inequalities that require new approaches based on outreach poverty abatement, and health promotion concepts. mdgs and sdgs presented a challenge to establish common data systems for performance measures to monitor effectiveness of policies and programs. this helps to build capacity for target-oriented health planning in low-and middle-income countries (lmics). a holistic view of health for all must take into account the many reasons for health disparities and disadvantage to the poor in health status. insurance to pay for doctors, hospitals, laboratories and imaging centers is necessary, but not sufficient, to raise population health standards for all. the "nontariff barriers"-i.e., issues beyond payment for services which may be addressed with incentives in payment systems, not only to reduce hospital length-of-stay, but to reduce health-care acquired infections, reaching out to chronically ill people with health promotion measures such as nutritional support, pneumonia and influenza immunization, hypertension control, cancer screening, and many other features of public health promotion. since the s, when bismarck introduced national health insurance in germany as part of social security with funding though sick funds, many countries have grappled in unique ways with developing health care systems. national health insurance systems developed through social security and social welfare systems, by national health insurance, or options to provide access to health services. in canada national health insurance provides universal coverage through national support for provincial health plans, paid for by general taxation, with national criteria. in the united states, president lyndon johnson established social security-based health insurance for the elderly and the poor through amendments to the social security act of , and president barack obama extended health insurance through the affordable care act of . the uk national health service-with the northern ireland, scottish and welsh nhs run semi-independently-was established in , providing a state-run system of medical, hospital, preventive, and community health care. though not discussed here, nordic and other european health systems provide universal coverage with involvement from all three levels of government, but over percent of expenditures are funded through public sources. in denmark, norway and sweden county councils are central to funding and management; in finland, the municipalities provide most of the health care. the former socialist countries have gone through painful periods of transition. many of these countries have developed free-market systems with dynamic growth in national economies along with health system reform. health systems in transition have adapted with great gains in longevity and reduced mortality from preventable diseases in many former socialist countries in central and eastern europe. others have had difficulties addressing the "missed epidemiologic transition" from infectious disease to control of noncommunicable disease but have begun to make progress in the st century. globally, public and private donor partnerships have emerged to help the poorest countries cope with overwhelming health problems of raising immunization coverage levels, reducing child and maternal mortality, managing hiv, tuberculosis, malaria, diarrheal and respiratory diseases and vaccinepreventable diseases in keeping with the mdgs based on a consensus of all member nations of the un. the objectives and specific targets included: reducing poverty, improving equal access of boys and girls to primary education, reducing child and maternal mortality, managing significant diseases such as hiv, tuberculosis, and malaria, along with improving the environment. reaching the targets for achieving these goals depends on developing infrastructures of health systems that provide access for all and distribution to meet geographic and social inequities in health. each country needs to develop its own system, but can learn from the experience of others. the purpose of this case study is to highlight the unique and common features, including positive and negative lessons learned from national health systems. observing and learning can help in defining needs for countries lacking but aspiring to achieve universal health systems, including positive and negative challenges. universal access is an important means of assuring that the economic barrier is removed for the total population, leading to increased access to medical and hospital services for those previously lacking the means to reach these services. universal access systems have been achieved in most industrialized countries. however, the us has not achieved this goal even with, by far, the highest health expenditures of oecd countries. this is due mainly to political gridlock despite success with its single payer system for medicare for the elderly. for low-income countries, the rates of health expenditures at present and forecast for the coming decades will be insufficient to achieve universal access systems. there must be a fundamental political change in national policies with health as a higher priority for funding and leadership. universal healthcare access is still a work in progress. the goal of universal access is a worthy one: to make health care accessible to all. the advent of universal access, however, is not assured given low levels of funding in many countries most in need of improved access but strengthening health systems: the role and promise of policy and systems research. geneva: global forum for health research alliance for health systems policy and research. world health organization. what is health policy and systems research (hpsr)? . geneva: world health organization achieving a high-performance health care system with universal access: what the united states can learn from other countries health spending in the united states and the rest of the industrialized world the publicÀprivate pendulum-patient choice and equity in sweden uk health dividesÀwhere you live can kill you disease and 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geneva: world health organization health systems: improving performance european health report : charting the way to well-being. copenhagen: world health organization research for universal health coverage world health organization. european health for all database (hfadb) world health organization. health systems: health system financing universal health coverage: sustainable development goal , health relying heavily on donors and out-of-pocket payments. the devil is in the details. . universal health insurance (uhi) or national health service systems are essential for advancing population health and should be give high priority in policy and funding by national governments and international aid agencies in middle-and low-income countries in the coming decades. . universal health insurance or service systems cannot be expected to succeed without continuing development of public health and health promotion as equal needs for population health and to achieve sdgs. . all countries seeking health development will need to raise public support for financing health systems by raising health expenditures to more than five -six percent of gdp. . all countries addressing these issues should endeavor to expand training to include bachelor and master degree training in public health and health systems management in order to raise the professional leadership and management levels to lead in the complexities of health systems in the challenges ahead. health promotion to hospice care on par with acute and rehabilitation care hospitals as essential, but managed so as to avoid unnecessary economic domination of the health system and potentially damaging health-care infections and trauma. . reaching out to populations-at-risk and in need of preventive care and health promotion by multi-professional and paraprofessional teamse.g., community health workers, is vital to address chronic care needs and prevent their complications, for remote villages or urban poverty areas, or to groups of people with chronic disease conditions. . health information systems including development and implementation of epidemiology and information technology for monitoring of disease and quality of care require emphasis. . immunization and nutritional support for prevention of infectious diseases, chronic diseases and micronutrient deficiency conditions are crucial for population health and should be given high priority in health system development. . health policy management is vital to achieving universal health coverage to advance population health, but it must be seen as part of health in all strategies and the sdgs to be effective within financial limitations and cost restraint. . health promotion must be developed in all its aspects to raise population and professional awareness with educational and legal means to reduce risk factors in population health. health systems to promote efficient use of resources and achievement of specified health targets? . what methods may be incorporated into national health systems to promote quality of care? . how can developing countries achieve universal health care, and at the same time work toward national health targets such as upgrading maternal and child heath, control of infectious diseases and preventing chronic diseases? . how can low-income countries address the low public expenditure on health to reduce dependence on global financial aid for sustainable development goals (sdgs)? key: cord- -ze t authors: patel, mahomed s.; phillips, christine b.; pearce, christopher; kljakovic, marjan; dugdale, paul; glasgow, nicholas title: general practice and pandemic influenza: a framework for planning and comparison of plans in five countries date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: ze t background: although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. we aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from australia, england, usa, new zealand and canada. methodology/principal findings: we adapted the haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. we used the framework to analyse publicly-available jurisdictional plans at similar managerial levels in the five countries. the framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. no plan addressed all four domains. most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. conclusions: this is the first study to provide a framework to guide general practice planning for pandemic influenza. the framework helped identify critical shortcomings in available plans. engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. we identify implications for practice and for research. primary health care, and in particular general practice, will be at the frontline in the response to pandemic influenza. preparedness planning for this sector has lagged behind public health planning, despite evidence from sars [ , ] and influenza epidemics [ ] of the important role played by general practice. preparedness may be defined as the capacity to respond to a range of public health threats including natural disasters and infectious disease outbreaks, human-caused accidents and intentional attacks [ ] . there is an increasing recognition of the need for an 'allhazards' approach to planning that integrates acute clinical care, public health, and emergency management systems [ ] . since september , the us government has invested about $ billion to upgrade preparedness plans for emergency management systems [ , ] . there are three challenges for pandemic planning by general practice. first, there is no systematic framework for planning this sector's response. preparing for health threats and emergencies is an essential function of public health, but is not core business for general practice. second, the way in which ambulatory health services will interact with each other and with the broader health system response to a pandemic is unclear. general practitioners (gps) in canada [ ] , australia [ ] and the uk [ ] have expressed uncertainty about how to participate in such a response. third, planning and implementing changes for pandemic influenza across the health system is complex. although there is little evidence linking specific preparedness activities to effective system-wide responses to pandemic influenza [ , ] , change management theories point to a need for dynamic partnerships between general practices and other ambulatory care services, hospitals and public health departments [ ] . the strength and structure of these linkages vary around the world, depending on decentralisation processes, the regulatory and legal system, and financing within health systems [ , ] . although general practice, or family medicine, is organised differently in different countries, there is considerable potential for transferable learning at the meso-level of management planning [ ] . we aimed to develop a framework that will facilitate systematic planning for the general practice response to pandemic influenza and used it to appraise coverage of key elements in publicly available pandemic plans from australia, england, usa, new zealand and canada. to guide planning and to appraise available plans, we adapted the haddon matrix, a planning tool developed in the field of injury research and intervention [ ] , and more recently applied to the public health response to bioterrorism, sars [ ] , and pandemic influenza [ ] . the matrix consists of a grid of columns of four factors (human, agent, and physical and organisational environment) impacting upon the event [ ] . pandemic influenza may be perceived as a form of injury on a mass scale and the matrix helps us understand the multi-dimensional nature of epidemics and of the associated challenges that could be expected by general practice. the framework can be readily shared with public health units and other parts of the health system, as it identifies the general practice contributions to primary health care services and to public health surveillance and control. because all disasters are local, the matrix is flexible enough to allow a focused analysis of the smallest unit of study, such as an individual, or group of general practitioners. the methods used to construct the cells of the modified haddon matrix have been detailed elsewhere [ ] . in brief, a team with expertise in social science, public health and general practice reviewed objectives and strategies in who guidelines for preparing and responding to a pandemic [ ] to define the context and potential contributions of general practice. next, we undertook a narrative review of the peer-reviewed and grey literature on pandemic influenza to identify papers that elaborated strategies relevant for general practice. a search of the peerreviewed literature through pubmed using the terms 'general practice', 'family physician', 'family medicine' and various combinations of the terms 'influenza', 'epidemic', 'preparedness' and 'pandemic' yielded eligible papers from search results . the process of constructing the framework and populating the cells was informed by organisational theories that emphasise multilevel approaches to change from the individual to the broader health system [ , ] , and by methods for measuring [ ] and improving the quality [ ] of public health emergency preparedness. we tested our framework through interviews with a purposive sample of health professionals engaged in pandemic planning. nineteen general practitioners and practice nurses with expertise in pandemic planning were nominated by the two participating divisions of general practice, each of which was a national leader in disaster preparedness and response. eight general practice policy leaders were identified by representative organisations (australian medical association, royal australian college of general practitioners, australian general practice network). group interviews were held with state and territory public health leaders attending a national pandemic preparedness meeting. we held two workshops, attended by representatives of state and territory health services, commonwealth policymakers, non-government organisations, and general practice organisations. in addition, we conducted two focus groups of gps and nurses working in aged care in two cities. finally, we undertook four desktop exercises [ ] attended by gps, practice nurses and administrative staff. the five countries in this study had national response plans. contextualised detail about health-sector responses is contained in plans at the level of administrative decentralisation where decisions are made about patient-service groupings including general practice. in practice, this level was the state or provincial health departments in federal systems where those jurisdictions have responsibility for health service management and planning (usa, canada, and australia). in england, the managerial level for health services is located at the primary care trust (pct), while in new zealand it occurs at the level of the district health board. although these are not identical loci of health service governance, they were sufficiently similar in the planning aims for comparisons to be drawn. plans were obtained from websites of health departments of states or provinces (usa, australia, canada), district health boards (new zealand) and pcts (england) ( figure s ). for new zealand and england, publicly available records of board meetings were also examined. consumer information and isolated sub plans (e.g. for infection control) were excluded. plans for jurisdictions were identified; six were excluded as they addressed isolated aspects such as only the distribution of medications, or communication with the public, leaving plans suitable for analysis. of the five countries, canada exhibits the most variation between provinces in health system coordination. we examined the websites of canada's provincial regional health authorities (rhas, plans identified) and ontario's public health units ( plans identified) and local health integration networks (no pandemic plans identified). we excluded the rha and public health unit plans from inter-country quantitative analysis, as their level of devolution and/or responsibilities for health management differed from those examined in the other four countries, but have included descriptive details from some of the rha plans where they illustrate innovative approaches. all plans were examined by two clinicians, and searched for the following terms: primary care, primary health, ambulatory, general practice, general practitioner, gp, family practice, family physician. the roles of general practice/family practice in the plans were assessed across the four domains of general practice identified in the first part of this project. no attempt was made to quantify the extent of coverage of general practice in the plans as this rarely extended beyond a few sentences. where there was detailed coverage of an issue, we analysed the text and the health system context. the study was approved by the australian national university human research ethics committee and the national research and evaluation ethics committee of the royal australian college of general practitioners. written informed consent was obtained from participants. a conceptual framework of the general practice response to pandemic influenza is shown in table . the framework identifies four domains of practice: clinical services, public health responsibilities of general practice, internal (physical and organisational) environment of the general practice unit, and the macro-environment of general practice. in each domain, we list the key challenges to be anticipated by general practice during an influenza pandemic, and the type of responses that need to be addressed in the plan. table summarises the organisational levels in the five countries, the proportion of jurisdictions with accessible pandemic plans, and coverage of general practice in these plans. while almost all plans from us jurisdictions were accessible, three quarters of australian states/territories and one third of new zealand's district health boards had accessible plans. only % ( / ) of england's pcts had pandemic plans available in the public domain. figure s shows the jurisdictions and health management systems whose plans were included in this study; they comprise jurisdictions from the usa, from england, from canada, and each from australia and new zealand. table shows the number and rates of coverage of each of the four domains of the general practice response in jurisdictional plans of the five countries. the domain covered most frequently was influenza-related clinical care (in all plans from england and canada). overall less than half the plans mentioned non-influenza clinical care, with the exception being england, where % of pct plans mentioned non-influenza clinical care. public health surveillance was addressed in all plans from canada and new zealand and infection control in general practice in almost all plans from england and canada. functional linkages of general practice with other parts of the health system were addressed in almost all the english plans, but a smaller proportion of other plans. clinical care essential planning elements. this domain includes two sets of clinical care needs. the first, prevention and treatment of influenza, includes care for the surge in patients with acute respiratory illness, and for people at high risk of exposure to, or complications from, influenza. these aspects are discussed extensively in the literature [ ] [ ] [ ] [ ] . most people with influenza can be managed in the community, protecting hospitals by delaying or avoiding admission and facilitating early discharge. the second clinical care need is for non-influenza-related care. general practitioners provide most chronic disease care, though there is inter-country variation in their capacities to do this efficiently [ , ] . while activities like cervical screening may cease in a pandemic, chronic illnesses like diabetes or cardiac disease will still need management. some acute care usually undertaken in hospitals, like acute asthma or injuries, may be transferred to the community. in an earlier paper, we advanced a range of models of practice to balance clinical services for influenza and non-influenza care [ ] . in the recovery phase, the clinical needs of patients are for psychological care and chronic illness management. if the pandemic occurs in waves, as in - , recovery activities may need to be tempered by preparations for the next wave. coverage of essential elements in plans. all canadian and english plans outlined a role for general practice in clinical care for influenza. while only % of plans from the usa addressed clinical care for influenza by primary care practitioners (table ) , every us plan included guidelines on influenza management by hospital physicians. some plans articulated a surge in demand for influenza care as a threat to general practice's survival, and proposed assessment and treatment clinics as a way of protecting them [ , ] . in other plans [ ] [ ] [ ] the response to a surge was to support general practices to become more resilient by collaborating and changing their work practices. in two us state plans, the failure of the ambulatory care sector in the face of a surge was assumed. the planning challenge became to find ways to redeploy workers into other health care sectors [ , ] . most plans were sketchy on systems to maintain non-influenzarelated clinical care, with the exception of some pct plans, which included activities like triage, extended prescribing, identifying deferrable reasons for presentation, and management of more acute problems to protect hospitals [ , [ ] [ ] [ ] [ ] . the main non-influenza clinical area was mental health care, mentioned in six plans from the usa [ ] [ ] [ ] [ ] [ ] [ ] (reflecting a focus in the national plan [ ] ) and one canadian plan [ ] . coverage of the needs of vulnerable populations-the elderly, homeless, prisoners and the psychologically unwell -was most detailed in plans from canada and england. essential planning elements. this domain includes surveillance of influenza-like illness and influenza virology, and control of influenza in the general practice and the community. surveillance includes early diagnosis and notification, and specimen collection to confirm clinical diagnosis and to monitor viral characteristics and resistance to antiviral drugs. gps and private specialists are currently central to surveillance activities [ ] [ ] [ ] [ ] . in the early stages of the pandemic, it is likely that public health authorities will undertake contact tracing to facilitate containment, but their capacity to sustain this approach as the epidemic continues will be limited. general practice may then be expected to include contact tracing, and monitoring and support of people in quarantine or home isolation. other responsibilities may include prescribing and dispensing antiviral drugs and participating in mass immunisations against the pandemic strain of the virus. coverage of essential elements in plans. surveillance in general practice was mentioned in % of us plans and in only % of english plans, in all canadian and new zealand plans, and all but one australian plan ( table ). the low rates of coverage of surveillance in pct plans are not in accord with the uk plan which imputes to general practice a role in surveillance, and recommends that pcts operationalise this recommendation [ ] . the college of family physicians in canada is a partner in fluwatch, recruiting sentinel physicians to undertake surveillance, so this role is well understood within the canadian health sector. the role of general practice in contact tracing, in monitoring people in home isolation, and in distributing antiviral drugs is unclear in most plans. home care by gps for people in quarantine is mentioned in two us plans [ , ] , and one english plan [ ] , though the recently released guidelines for pcts anticipate a role for general practices in home care [ ] . in all country plans, dispensing antiviral medications was generally performed by public health units. only % of pct plans and % of us plans mention a role for primary care in dispensing antiviral medications. none of the canadian plans, and only one nz and two australian state plans, mentioned antiviral dispensing by primary care. the only plan to set out contingencies when decisions about dispensing may change was one canadian rha plan [ ] . although immunisation was mentioned most frequently after surveillance as a public health activity by general practices, in most plans the immunisations were against pneumococcal disease and seasonal influenza, but not mass immunisations against pandemic influenza. essential planning elements. this domain includes the physical environment of the general practice and its practice-level organisation. the risk of transmission of infections within the surgery could be minimised through separate waiting rooms and entrances, triage and personal protective equipment and handwashing facilities. hogg has outlined infections control procedures in the practice and the associated financial costs [ ] . some general practices (for example, those with small waiting rooms, or only one consulting room) may be deemed too much of a transmission risk to continue providing face-to-face services. the practice needs to develop strategies to maintain reliable and efficient access to essential drugs and equipment and influenza and pneumococcal vaccines. it also needs to strengthen the capacity of its communication technologies with patients and the broader health system, including telephones, faxes, internet, work-from-home technologies for staff, compatible software for sharing electronic medical records, and recall and reminder systems for patients. preparation at the organisational level relates mainly to business continuity plans. these plans should include leadership delegations, staffing contingencies, safe and flexible working hours and family care plans for staff, criteria for considering clinic closure, recruiting and training ancillary staff, early psycho-social support, support for making difficult clinical decisions, record keeping to ensure accountability for actions and 'inactions', use of antiviral medications, and plans for simulation exercises to complement training, and to evaluate and refine local practice plans. tools [ , ] and desktop simulation exercises [ ] are available to help gps plan for continuity. coverage of essential elements in plans. infection control strategies were well covered in plans from canada and england, but were mentioned in only % of us plans ( table ) . none of the plans provided an inventory of fixed features, such as size and layout of waiting room, or a single entrance, which could compromise infection control. business continuity was a focus of the english plans, which frequently referenced resources available on the uk resilience website [ ] . this aspect of preparedness was enhanced after the exercise winter willow simulation in february , and new pct guidelines addressing workforce planning [ ] . some pct plans addressed the need for general practice resilience in the face of workforce sicknesses [ ] , increased aggression from patients, and threatened loss of capacity in single doctor practices [ ] . few plans from other countries discussed business continuity for primary care in such detail. this may be because such issues are felt to be outside the normal purview of state or provinces, and to be the responsibilities of the businesses themselves or corporate interests. essential planning elements. this domain includes the overall organisation of, and interactions with, the health system that will facilitate or impede effective functioning of general practice services during a pandemic, including adaptation of relevant regulatory and financing systems. the health system requires a plan that adopts the 'all-hazards approach' and integrates roles, responsibilities and actions for acute clinical care, public health, and emergency management systems [ ] . this calls for coordination across general practices and other ambulatory care services to ensure primary health care needs within the community are effectively monitored and addressed; with hospitals to avoid/delay hospitalisation and facilitate early discharge; and with public health units to share responsibilities for contact tracing, monitoring and treating people in home isolation or quarantine, dispensing of anti-viral medications, and participation in mass immunisations against pandemic strains of the virus (when these become available). neighbouring general practices and other ambulatory care services will need local leadership with strategic approaches to collaborate and maintain services through a pandemic. england's pcts and new zealand's primary health organisations (phos) represent two ways of linking general practices under the governance of regional boards. these networks are consolidated by financial relationships between the pct or the pho and general practices. the links between australia's divisions of general practices and gps are purely voluntary. in the usa, managed care systems function as another way of linking ambulatory and hospital services. communication infrastructure between canada's family practitioners, % of whom are solo practitioners [ ], is still being developed, as is the incorporation of general practice into canada's pan-canadian public health network [ ] . the regulatory environment includes accreditation of retired medical practitioners and allied health professionals, laws and regulations which support or hinder the flow of qualified personnel across a jurisdiction's health facilities [ ] , and ensuring an appropriate medicolegal framework to support clinical decisions on prioritising medical care during a pandemic, for example, modifying clinical standards, deferring treatment, and restricting access to certain treatments. funding mechanisms for general practice may impact upon the capacity to provide extra services. in countries with fee-for-service payment systems, general practices may profit from a surge in attendances, but may equally run into business difficulties if they are short-staffed for prolonged periods. gps funded through a capitated system may have more freedom to alter their practice to provide different service mixes. in the post-event phase, patients and gps may require support for psychological recovery. it may be necessary to provide some formal relief through a system of locum gps from areas less affected by the pandemic. organisational partnerships at this stage may need to be with social services and mental health support services. coverage of essential elements in plans. countries with mechanisms for linking general practices with other sectors were more likely to address networking in their plans. ninety five per cent of english plans addressed systems to support collaboration between general practices (table ) . these plans addressed buddy systems, practice networks, and contingency plans for communities of practice. four of the six new zealand plans also addressed collaboration, though only one in significant detail; this plan outlined a distinction between key practices, and other practices which might decide to partner one another [ ] . of the three canadian provincial plans that addressed collaboration, the most comprehensive was from quebec, which identified a need to bridge the gap between salaried practitioners and independent physicians. the plan of the montreal regional authority [ ] operationalises this by setting up a system of active and sustained outreach by the public health department to independent physicians. the absence of plans for networking between general practice and public health is most marked in the usa. with the exception of louisiana [ ] , us plans which mentioned networking did so in one line, generally advocating partnership between private and public services without indicating how this might occur. louisiana's strategic approach built a participatory structure for rural practitioners through a partnership between the state public health department and the bureau of primary rural health care. the canadian national pandemic plan [ ] is framed around a set of ethical precepts incorporated into pandemic planning at the provincial and regional health level. the uk has recently released an ethical framework for policy and planning, though this has not yet been incorporated into planning documents [ ] . the regulatory framework most mentioned was in relation to credentialing for retired gps and other volunteers [ , , ] , and less frequently, indemnity [ ] . although most plans include coverage of the relevant public health legislation, no country's plan included an inventory of legislation relevant to general practice that might need to be amended. only one plan [ ] and the pct guidelines [ ] , canvas the potential of recompense for financial loss to a general practice. the only country in which the planning level coincided with the level that made decisions about funding of health care was canada. one regional health authority plan provided an outline of specific issues likely to affect physicians, and raised the possibility of reviewing funding mechanisms in a pandemic [ ] . there appear to be no ancillary plans addressing principles of altered funding for private physicians in a pandemic. this is the first study to provide a framework that brings together multiple functions, structural relationships and the responsiveness of general practice to prepare for pandemic influenza. the framework provides clarity of purpose and a structure to guide planning through four functional domains: clinical care, public health responsibilities, and the internal and macro environments of general practice. the domains have been structured as integral components of a complex system that can respond to uncertainty [ ] and be adapted for a given local setting and health system context. we draw three conclusions regarding general practice from our analysis. first, none of the jurisdictional plans addressed all domains of the general practice response during a pandemic. second, while many aspects of the first three domains are included in plans for general practice, there are critical gaps and inconsistencies in the fourth domain (macro-environment) that render some elements of the jurisdictional plan ungrounded or unrealistic. third, few plans addressed the broader ambulatory care context, including the need to engage private specialists and other allied health professionals [ ] . planning and implementing change across the health system is complex. targeting individual sectors for change (e.g. public health departments, hospitals or general practices) without securing reciprocal changes and strengthening inter-relationships across the health system, is unlikely to succeed [ , ] . planners must consider how connectivity across the health system might be strengthened to enable optimal use of general practice resources for planning [ ] . while this may be challenging, particularly in countries with weak governance structures for primary health care, omitting general practice input into the planning process may be considered unethical [ ] and counterproductive. limitations of the study: our findings are exploratory rather than definitive, and indicate directions for further planning and research. like any new tool, the framework and its application in a given context needs testing and refinement through simulation exercises targeting ambulatory care services as well as the broader health system. planning is an evolving activity that reflects a 'map' rather than a 'destination', and our findings provide a snapshot of the plans accessible in late . the scope and content of the plans will change over time, as seen in two countries that adjusted their plans after simulation exercises, exercise cumpston in australia [ ] and winter willow in the uk [ ] . interestingly, the former identified specific weaknesses in the involvement of the primary health care sector and made recommendations to better integrate primary health care providers into planning at the national and jurisdictional levels [ ] . national and sub-national pandemic plans may be intended to provide a strategic focus and not to elaborate on operational activities; it is possible the latter may have been addressed, but were not accessible at the time of our study. another potential limitation of our study is that the gaps we identified in many plans were grounded in theories about the ways to enhance the quality and outcomes of clinical care [ , ] or of public health preparedness planning [ ] . the science of preparedness planning is still maturing [ ] [ ] [ ] and there is relatively little systematic evidence for linking specific preparedness structures to the ability to implement efficient and effective responses [ , ] . two important limitations to the implementation of preparedness activities are uncertainties in knowing how much preparedness is enough [ ] and in having a measurable assessment of the outcomes of preparedness activities. it may be more meaningful to perceive of the activities as a 'preparedness production system' in which a variety of processes and activities have been completed to prepare for an optimal response [ ] . we are unable to comment on the extent to which these preparedness plans have been implemented, except in the case of those jurisdictions which have held pandemic exercises [ , ] . general practice response is rarely tested in pandemic exercises, which tend to focus on hospital and public health responses. a notable exception is operation sparrowhawk in singapore, where the feasibility of general practice influenza clinics was tested [ ] the haddon matrix is not a final check-list for preparedness planning but a problem-solving tool used as a starting framework for planning. the contents of each cell of the matrix help identify a particular problem or challenge that needs to be addressed. we recognise that the challenges will be neither static over time, nor uniform across general practices; responses will have to be modified in the context of the general practice setting as the pandemic evolves and as other parts of health system, particularly hospitals and public health units respond to the epidemic. implications of our study for primary health care in developing countries: endemic and epidemic infectious diseases inflict high levels of morbidity and mortality in developing countries because of a combination of poor living conditions, effects of multiple concurrent illnesses particularly in children, fragile national health systems, overburdened and overstressed health workers, and negative work environments [ ] . although our study targeted general practice in developed countries, the conceptual framework we developed (table ) can be used by primary health care services in developing countries to deconstruct the multidimensional challenges posed by pandemic influenza. identifying possible solutions and apportioning responsibilities across components of the health system is more complex. operational guidelines have been developed for the detection and rapid containment of a potentially pandemic strain of influenza to the epicentre of the outbreak [ ] , for example, if this were to occur in a south east asian country. however, because of the immense global implications of such an event, this intensive strategy will need to be supported by extraordinary resources from the global community, an action not sustainable once the pandemic strain spreads beyond the initial epicentre. in an analysis of pandemic influenza plans in asia-pacific countries in , coker found that although all countries recognised the importance of pandemic planning, operational responsibility particularly at the local level, remained unclear; most plans relied on specialised flu hospitals, while few developed the possibility of caring for patients at home [ ] . (the study made no reference to primary health care or the private practice sector). in his analysis of public health emergencies in developing countries, quarantelli identified relatively poor adaptive capabilities to be the key barrier to effective responses at the central and local levels [ ] . possible reasons included poorer public health infrastructures and human and financial resources, organisational structures that functioned mainly in a top-down manner with a strong emphasis on structures more than functions, and lack of planning initiatives the further away one moved from central level [ ] . many poor countries already have a health crisis, and need massive international investments, including mobilisation and strengthening of human resources to build sustainable health systems, strong leadership and political commitment [ ] . in the face of the pandemic threat, primary health care in developing countries will need resources to develop a suite of policies, including: clarification of what essential primary health care will continue through a pandemic, developing health workforce plans that may entail diverting clinicians from other areas of the health workforce, establishing non-hierarchical links between primary health care, hospitals and public health, and injecting funds into hospital and primary care preparedness simultaneously. it may be argued that the absence of general practice elements from pandemic plans is not problematic, that it is outside the responsibility of public health departments that do not have a governance role for general practice. we argue instead that the general practice sector, which is characterised by loose networks between ambulatory care services, and often lacks the appropriate organisational structure and mandate, cannot spearhead many elements of planning for primary care. this calls for actions by health departments as well as by general practices. actions by health departments. ensuring that the community receives appropriate health care during public health emergencies is a government responsibility. consequently, health departments must emphasise in national and sub-national plans, the critical need for all levels of the health system to integrate the general practice sector in the planning process. this should include appropriate general practice representation in high level planning and decision-making committees, in incident-commandcontrol structures and in the management of community-based specialised clinics such as 'fever clinics' or 'community information and assessment centres'. good planning must focus on the planning process rather than the production of a written document [ ] . the process includes collaborative activities such as meetings, drills, exercises, simulations, developing techniques for training, knowledge transfer, identifying and obtaining resource materials, and continually updating materials and strategies. these planning activities are important not only because they inform, but because they also foster collaborative learning and problem-solving, and generate an atmosphere of mutual trust and solidarity among people who will be affected by a pandemic and whose collaboration will be essential in the response. the willing general practitioner sector [ , ] is an essential resource for extending the surge capacity of health departments. health departments should harness and support interactions and networking among general practices, and between them and ambulatory health care providers, hospitals and public health units. the role of general practice in contact tracing, monitoring and treating people in home isolation or quarantine, dispensing antiviral drugs and participating in mass vaccinations -omitted in most plans -needs to be clarified. in addition, health departments should modify or adopt where appropriate, legislation and financing mechanisms to enable general practices to function optimally during the pandemic. action to support planning by general practice. while the diversity of the general practice sector means that there will not be guidelines to cover all scenarios and contexts, a coherent approach would enable multi-actor accountability and more efficient, contextual planning by jurisdictions. the guidelines for pcts [ ] are an example of such an approach, designed for a particular health system. they could act as a useful point of departure for planning integrated general practice plans by other health systems. there is a need for a system of sharing innovations and exemplary solutions to challenges for pandemic planning by general practice, analogous to those targeting mainly hospitals and public health departments [ ] . given the diversity in organisation of general practice systems, a web presence comparing exemplary approaches from different health systems would be a useful resource for planners. an important challenge will be ensuring collaboration and coordination across the health sector during a pandemic. research is needed to identify the prevailing barriers and facilitators to effective collaboration across the health sector, how these may change under the stressor of a pandemic, and how this information could be used to optimise the response. the regulatory environment is founded on a set of ethical principles, often unarticulated. since there is likely to be some dispute between utilitarian philosophical approaches used in public health and deontological or virtue ethical approaches used in clinical medicine [ ] , there is a need for some preparatory work with general practitioners clarifying ethics of clinical behaviour, restriction of liberty under quarantine orders, and resource allocation and distribution. in an established pandemic, it is likely that there will be shortfalls in the gp workforce, due to illness among gps, caring duties or closure of small practices. non-hospital clinical specialists, retired general practitioners, allied health professionals and medical students could be trained to fill the gap in services. research is needed to define the clinical work that can be done by other health personnel in general practice, eligibility criteria and accreditation processes for this cadre of workers, and optimal training processes. all public health problems have a clinical dimension, and all clinical problems have a public health dimension. at present, the plans in the five countries provide more detail on the public health dimension of the pandemic. there are intercountry differences in the emphases provided to different domains of the general practice response. some of this reflects the emphasis on particular elements contained within the relevant national plan. some of the differences are due to the ways in which general practice is structured in a country, and the strengths of its linkages to other components of the health sector. there is an urgent need to incorporate general practice and the broader primary care sector into pandemic planning activities, and to undertake the preparedness activities that would make this sector, which provides the majority of health care work, a true partner in pandemic response. figure s jurisdictions or health management organizations whose plans were included in the study. found at: doi: . /journal.pone. .s ( . mb doc) outbreak of severe acute respiratory syndrome in hong kong special administrative region: case report a study on sars awareness and health-seeking behaviour -findings from a sampled population attending national healthcare group polyclinics assessing the burden of influenza and other respiratory infections in england and wales public health preparedness: a systems-level approach assessing public health emergency preparedness: concepts, tools, and challenges quality improvement in public health emergency preparedness enhancing public health response to respiratory epidemics: are family physicians ready and willing to help? the gp's response to pandemic 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professionals on the provision of healthcare in a community setting in england the costs of preventing the spread of respiratory infection in family physician offices: a threshold analysis a gp work plan for pandemic flu practice pandemic planning resource uk resilience: human flu pandemic pandemic influenza plan executive summary college of family physicians of canada canada's public health system: building support for frontline physicians agence de la santé et des services sociaux de montréal (montreal agency of health and social services) ( ) montreal pandemic influenza plan-health mission statewide draft pandemic influenza plan the canadian pandemic influenza plan for the health sector responding to pandemic influenza: the ethical framework for planning and policy district of columbia department of health ( ) pandemic influenza preparedness plan pandemic influenza contingency plan tasmanian health action plan for pandemic influenza pandemic influenza response plan complexity science: the challenge of complexity in health care preparing for an influenza pandemic: ethical issues national pandemic influenza exercise: exercise cumpston report exercise winter willow -lessons identified roundup: exercise promotes singapore's preparedness for flu pandemic human resources for health: overcoming the crisis interim protocol: rapid operations to contain the initial emergence of pandemic influenza pandemic influenza preparedness in the asia-pacific region quarantelli e major criteria for judging disaster planning and managing and their applicability in developing societies promising practices: pandemic preparedness tools raising the profile of public health ethics in australia: time for debate we are grateful to our colleagues from general practices, public health units and general practice organizations who have contributed to this study, and to ms sally hall, ms marianne shearer, ms hannah walker, dr jonathon anderson, dr ron mccoy, dr chris hogan, dr kathryn antioch, and ms monika thompson. key: cord- - qb zrzh authors: spiegel, samuel j. title: climate injustice, criminalisation of land protection and anti-colonial solidarity: courtroom ethnography in an age of fossil fuel violence date: - - journal: polit geogr doi: . /j.polgeo. . sha: doc_id: cord_uid: qb zrzh as plans for expanding fossil fuel infrastructure continue to ramp up despite threats to the planet, how are geographers to address the criminalisation and prosecution of peaceful acts of defending earth, water and land? reflecting on a courtroom ethnography and debates spanning legal geography, political ecology and social movements studies, this article explores embodied struggles around oil, ‘justice’ and geographies of caring – discussing how indigenous youth, grandmothers in their eighties and others were convicted of ‘criminal contempt’ for being on a road near an oil pipeline expansion project. the project (“trans mountain pipeline expansion”) was created to transport unprecedented levels of heavy oil (bitumen) across hundreds of kilometres of indigenous peoples' territory that was never ceded to settler-colonial authorities in canada. focusing on a controversial injunction designed to protect oil industry expansion, the discussion explores the performativity of a judge's exercise of power, including in denying the necessity to act defence, side-lining indigenous jurisdiction, and escalating prison sentences. courtroom ethnography offers a unique vantage point for witnessing power at work and vast resources used by state actors to suppress issues fundamental to the united nations declaration on rights of indigenous peoples and the paris climate accord. it also provides a lens into the intersectional solidarity and ethics of care among those who dare to challenge colonialism and hyper-extractivism, inviting engagement with multiple meanings of ‘irreparable harm’ at various scales. the article calls for more attention to power relations, values and affects shaping courtroom dynamics in an age in which fossil fuel interests, climate crisis and settler-colonial control over courts are entwined in evermore-complex violent entanglements. courthouses can reflect, perpetuate and reproduce forms of colonialism in a myriad of ways. some may be visible in the arrangement of courthouses themselves (faria et al., ; jeffrey, ) , others through the relations, "performative use of categorisation" (blomley, ) and "spatial tactics" (sylvestre et al., ) in particular cases and decisions rendered. in vancouver, canada, there is a corridor in the british columbia (bc) supreme court building where more than seventy portraits of white male judges appear on the wall, uninterrupted by female or non-white faces. near the middle of the hall, a few women's faces eventually appear, reflecting some judiciary changes, before the remaining portraits show more white male judges. the building sits on the unceded territory of the musqueam, squamish and tsleil-waututh peoples. in the basement of the building, which was designed by a famous architect, a special room, built years ago for the air india bombing terrorism case, has bullet-proof glass dividing the public gallery from the court. on august th, , as part of a research programme on intergenerational environmental justice, i sat in this gallery with other courtroom observers as a seventeen-year old indigenous boy was sentenced by a white male judge for violating an injunction against impeding construction of an oil pipeline expansion project on his ancestral territory. the injunction had been established in march by the same judge, a justice in the bc supreme court who was formerly a lawyer for the tobacco industry (smith, ) . the boy's alleged offence was standing on a road on burnaby mountain, in front of a vehicle, and praying there a few days after the injunction was established. the boy had stood on the road as a matter of principlepeacefullywith others: indigenous youth and elders, grandmothers from different ethnic backgrounds, and people from diverse professional and cultural milieussome homeless, some living nearby, some from far away, some students, retired teachers, professors, city councillors, parishioners, and others. some were also arrested for civil disobedience that day, others not. this injunction was initiated to clear the path for constructing a pipeline owned (then) by a texan oil company, kinder morgan (the parent company linked to the infamous enron scandals), to triple levels of diluted bitumen (heavy oil) flowing through hundreds of kilometres of land from alberta's tar sands in the interior (see schmidt, ) , through indigenous territory, to the bc west coast. the project was one that candidate-justin trudeau, when campaigning to be prime minister, publicly argued needed a whole new review processincluding assessing climate risks and other aspectsbefore he later reversed his stance, asserting a new 'national interest' imperative to build the pipeline (dalby, ) . on the day of sentencing, an indigenous elder argued to the judge that the boy standing on unceded aboriginal land did not constitute a criminal act. the "crime scene," she contended, was the one unfolding in the courtroomdefying the rights of indigenous people to preserve and protect land and water, which was the boy's stated intent. the judge did not take issue with the claim that the boy was only praying peacefully, but asserted that being on this road constituted "criminal contempt" of his injunction. he added that he could not fathom a successful challenge and that there can be no indigenous rights defence because white people of european descent had also been arrested under the injunction; this nullified, for him, the idea that indigenous rights needed any particular attention here. the elder argued that the boy should not be deemed "guilty" of anything, that forced appearance at nine court proceedings, causing repeated sleepless nights and anxiety, was already more than enough punishment, and that the "criminal contempt" label needed to be appealed, with the pipeline violating indigenous people's rights on land never ceded to the british colonisers before the creation of canada nor to any canadian government thereafter. she added that the boy did not know what an "injunction" even was at the time of arrest, should not have been tried in adult court, and should not be punished for opposing a violation of indigenous laws and values. this was the first of more than a dozen cases i witnessed in the bc supreme court and speaks to just one instance of criminalising 'being in the way' of aggressive expansion of the fossil fuel industry. the oil industry has long been shaping legal and political systems, undermining democracy and stopping action on global warming (bridge & le billon, ; dalby, ; huber, ; mitchell, ; taft, ; temper, ) . in an age of fossil fuel extractivism and amid growing concern that it may now be "too late to stop dangerous climate change" (whyte, ) , what do such encounters signify? what does it mean to see values of land and water protectionand what shiri pasternak ( ) calls indigenous ontologies of carecolliding with settler-colonial courts? what are the roles of 'solidarity' in countering corporate and colonial agendas that converge in the courtroom space? how can a critical lens merging anti-colonial political ecology with legal geography help to guide an understanding of the criminalisation of peaceful civil disobedience and indigenous-led resistance? in this article, i unpack some of the dramas that ensued over the next months in this courtrooma critical setting for grounding debate on what it means to contest interlinked climate, environmental, legal and sociocultural injustices (chatterton et al., ) and for reflecting on what some judges preclude from articulation. a plethora of legal manoeuvres, including surprises and inconsistent rationales, would be mobilised to penalise peaceful land and water protectors, while entertaining only narrowly circumscribed legal arguments. diverse resistance strategies would also be cultivated and diverse affects experienced. despite indigenous-led movements seeking to bring respect to indigenous laws (borrows, ; napoleon, ) , courtrooms in canada are routinely places of asserting settler-colonial power over indigenous laws and values, denying indigenous claims, controlling indigenous bodies and definingwith colonial lawwhat is relevant or irrelevant about indigenous land, governance systems and life (coulthard, ; crosby & monaghan, ; daigle, ; hunt, , p. ; mckibben, ; nunn, ; palmater, ) . while courts have been normalising this violence, courtrooms may simultaneously be places of emotional support, anti-colonial solidarity, critical expression, and intergenerational relation-building in the face of neo-colonial capitalism and colonial legal systems. below i reflect on being part of one such diverse multi-generational and multi-cultural group, seeing relations of care built between defendants and observers-in-solidarity, as prosecutors and judges punish pipeline protestors using jarring arguments to keep climate issues and indigenous rightsand truthsout of the legal calculus. linked to the above, this article explores what courtroom ethnography might generate as a vantage point for interpreting wider hegemonic arrangements and counter-hegemonic solidarities. lequesne ( ) advanced notions of "petro-hegemony" using gramsci's theory on hegemony to explore dynamics of consent, compliance, coercion and resistance, exploring the standing rock sioux's fight against the dakota access pipeline (dapl) in north dakota. estes and dhillon ( ) also argue that unpacking hegemony in the standing rock case requires grappling with complex issues of indigenous sovereignty, gender violence and environmental destruction that have all been implicated in threats of pipelines, seeing the more-than-localized nature of protests and their wider politics. in the case of the kinder morgan pipelinebranded the "trans mountain pipeline expansion" (tmx) projectmillions of canadian taxpayer dollars have been spent on security and court costs, and like in the dapl case, taxpayer money has been used to fund secret police infiltration campaigns among peaceful activists, which police spoke about proudly while on the witness stand in the tmx hearings. while participants in the courthouse shared support and prayer, including praying for the prosecutors, wider developments would also be quietly discussed in the corridors and outside. courtroom ethnography offers fertile terrain for exploring the affective and political landscapes in and around a judicial setting, allowing an in-depth examination of colonial performance. it provides a nexus for critically linking a court injunction imposing the hegemony of oil with deep struggles for a 'just transition' from fossil fuels (brown & spiegel, ; le billon & kristoffersen, ) , valuing life, 'place' and approaches to solidarity. while fossil fuel extractivism continues to flourish in canada and globally, exacerbating injustices of settler-colonial violence (bosworth, ; simpson, ) , my overarching objective here is to further critiques of such violence by paying attention to how colonial legal authority is performed and enacted, but also challenged and contested in the space of the courtroom, courthouse corridors and beyond. i argue for the value of courtroom ethnographies to explore politics around oil and ontologies of caring, learning from land defenders and contrasting spectacles of aggressively imposed (neo)colonial order (and their narrative frames) with different affects and values. in addressing blockades and civil disobedience, emphasis in political geography has been on social dynamics around zones of extraction (brock & dunlap, ) and collective street spaces as sites of policing, protest and solidarity-building (daphi, ) . walenta ( ) argues that, broadly speaking, geography as a field has only very minimally engaged courtroom ethnography as a method, despite its considerable potential for interrogating intersections of legal space, political geographies of power and lived experiences. likewise, faria et al. ( ) call for more attention by geographers to the "spatial work of power in and through the legal system, connecting everyday legal goings-on and the transscalar structural machinations of state violence." contextualising the political geographies of one particularly symbolic set of court proceedingsconnected to a highly controversial oil pipeline expansionprovides a way of building upon this. i also extend arguments by while reflecting on 'civil disobedience' -a relational term, i caution against making assumptions about settler court jurisdiction as the appropriate legal jurisdiction. indigenous people defending never-ceded indigenous territory may be understood as obedience to and respect for indigenous legal traditions. actions of land, water and earth defense require contextualization with careful discussions of circumstances, settings, the violence of (settler-)colonial law as well as consideration of indigenous law and legal orders (borrows, ; napoleon, ) . simpson ( ) , who, drawing from deleuze and guattari, suggests thinking about the relation between settler colonialism and bitumen as a "resource desiring machine"; describing the violence of the alberta oil/bitumen story, simpson argues: "the remaking of bitumen as a resource in the athabasca region served a purpose even more immediate than capitalist accumulationit served to consolidate a nascent settler colonial state's claims to authority over territory." this discussion is furthered by schmidt ( ) , unpacking setter-colonial discourses around bitumen, its political geology and temporality, and its dominance. increasingly central to all this, i would add, is the ongoing proliferation of colonial court proceedings and contestable logics to quell civil disobedience and indigenous resistance, involving an elaborate and understudied array of actors, processes and spaces in the use and abuse of court 'injunction' tools. before discussing my methodological approach to courtroom ethnography, the section below first provides some critical background to the fast-eroding public confidence around canadian government "climate leadership" during the pipeline and settler-colonial "court justice" sagas of - . it sets the stage for so-called threats that would be talked aboutpeaceful indigenous youth who would become framed as "criminally contemptuous" and grandmothers who became "sinister seniors" in the media and sent to prison. i then discuss orientations for a courtroom ethnography and bring critical scrutiny to experiences of one particular injunction protecting tmx. section then interrogates the court's theatre of power operating to advance fossil fuel extractivism through contemporary colonial rituals. in section , considering diverse affects and dramas surrounding contested deployment of the term "irreparable harm" in the courtroom, i turn to some of the defendants' challenges to the court, including an eventual theatrical reproduction of courtroom dramas in a play entitled "irreparable harm?" -and reconfigured public debates on injunctions in that put canada's colonialism under new spotlights. i conclude by asking what it means for geographers to study court challenges to colonial violence and hegemonies, engaging an ethics of care. ethnography in courtroom settings requires engagement over time with diverse temporal, political, legal, ethical and relational concerns (walenta, ) . with courts around the world playing diverse roles as theatres of power, notions of courtroom ethnography and critical socio-legal analysis might give rise to any number of points of emphasis in navigating tensions around capitalist interests, environmental justice, indigenous rights and climate concerns (setzer & vanhala, ; williams, ) . in certain contexts, research on climate justice is focusing attention to emerging forms of litigation and related optimism (klaudt, ) . as moves to criminalise peaceful oil pipeline protests (horn, ) reached new levels of intensity in and early , arguments supporting civil disobedience are also receiving increasing attention (rausch, ) . internationally, some judges have both agreed to hear "necessity defences" and upheld these defences when acts of conscience were deemed justifiable. yet, a flurry of new evidence would indicate that industry lobbying to increasingly penalise protest has further weaponized judicial statutes against resistance (johnson, ) . concerns have grown that anti-protest legislation is threatening people and the planet, beckoning critical rethinking of why governments are not using resources to prosecute fossil fuel companies instead of 'protestors' (brown, ; ellinger-locke, ) . the tendency of liberalism has long been to locate violence outside of the law so that "violence and law appear antithetical" (blomley, ) , obscuring specificities of injustice (see barnett, ) . in an age of rampant fossil fuel violence with legal apparatuses aggressively propping up short-term wealth maximization based on unsustainable resource exploitation (christie, ) , there is increasing impetus to theorize violence at play in 'justice' systems and re-situate arguments and actions with regard to the necessity of land, water and earth defence. on land stolen from indigenous people, political and judicial institutions in canada have robust records of legitimising and protecting fossil fuel projects that are heavily opposed. regimes for 'recognizing' the rights of indigenous people are circumscribed by entrenched forms of settler-colonialism that perpetuate institutional racism, ongoing dispossession and narrow visions of environmental justice that tend to keep extractive interests prioritised (mccreary & milligan, ; preston, ). alberta's premier has celebrated and championed aggressive tough punishment for those who seek to oppose and disrupt oil development, arguing that canada should find russian president vladimir putin's approach to crackdowns "very instructive" (pressprogress, ). meanwhile, while subsidies for oil interests persist, legal 'injunctions'-tools courts use to stop what they label as "irreparable harm" -have been used widely by corporations against indigenous groups. a study released in by scholars at yellowhead institute gives ground-breaking analysis of how skewed injunctions are as legal tools in canada, enabling fossil fuel projects and systemic bias in determining who can block whom from land; it found corporations succeeded in per cent of injunctions filed against first nations, while first nations were denied in per cent of injunctions against corporations (pasternak & king, , p. ) . following years of gutting environmental regulations when conservative stephen harper governed as canadian prime minister, there was hope in some quarters that liberal party leader, justin trudeau, would bring meaningful new attention to indigenous consultation and consent requirements for contentious projects and to regulations that would promote climate governance leadership (dalby, ) ). trudeau branded himself a feminist and climate policy leader, and committed publicly to respecting the united nations declaration on the rights of indigenous peoples (undrip). his government's actions around pipelines in and thereafter displayed what many saw as disappointing breaches of campaign pledges. the national energy board (neb) -an industry-focused entity empowered to adjudicate the legitimacy and risks of energy-related projectsbecame a tool of continuity (hunsberger & awâsis, ). trudeau's campaign pledge to overhaul the environmental impact assessment (eia) process for all projects including the trans mountain pipeline did not materialise, while his promoting new fossil fuel infrastructure led to canada being talked about as among the worst environmental criminals on the global stage (mckibben, ) . diverse forms of resistance thus emerged. as (then) green party leader elizabeth may articulated after her arrest for standing on the road in , for example, a massachusetts judge dismissed charges against climate activists, noting the necessity of protest (chow, ) . in , courts in london (uk) upheld "necessity to act" defences for civil disobedience, for example, when a jury absolved two co-founders of the extinction rebellion of charges emerging from subversive acts to pressure divestments from fossil fuels (corbett, ) . by age of fossil fuel violence, i refer here both to the violent material and biophysical impacts (direct and indirect) of fossil fuels themselves and the vast state-corporate apparatuses (see simpson, ) that drive dispossessions and structural violence in the name of promoting extractivism as progress. this term seeks, as with michael watts' 'petro-violence', to refer to ecological and social violence (watts, ) , and can be (as is here) inextricably interlinked with setter-colonial violence (see also whyte, ) . unlike many places in canada, treaties were not entered into with most indigenous nations in british columbia, where the violence of colonization has been particularly ruthless. theft of land has been through various means, including through genocidal smallpox, and the confining of indigenous people to small tracts of reserve land; theft has continued in various forms (manuel & derrickson, ; see also ; coulthard, ; de leeuw, ; schmidt, ; canning ) . in burnaby: "the commitment to build a pipeline in when we are in climate crisis is a crime against future generations and i will not be part of it" (brown, ) . more passive acts of resistance took the form of the city of burnaby refusing to pay costs of policing demonstrators. provincial government authorities in british columbia opposed the pipeline project as well, amid multiple jurisdictional frictions, and also attempted legal challenges, albeit unsuccessfully. yet, even if the hegemony of oil in politics was challenged by thousands of people marching on streets and blocking roads in front of construction, and by positions articulated by some regional authorities, new efforts were also afoot to re-assert oil's hegemony. when in owner of the pipeline, kinder morgan, conveyed "risk concerns" related to the thousands of protestors and ongoing legal challenges by indigenous peoples, trudeau provided . billion canadian taxpayer dollars to this texas-based firm to buy the pipeline, making the state the owner of tmx (lukacs, ) . courthouse moodsand ethnographies they generateare thus invariably shaped by events both near and far. importantly, two weeks after the above -year old boy's sentencing was rendered (and amid many other pending injunction cases in that same court), a different legal drama unfolded, far from this court. tsleil-waututh nation -an indigenous nation especially affected by the oil terminal in the burrard inlet -earlier had mobilised resources to legally challenge the pipeline approval. on august th, , coincidentally the same day as canada's federal government offer to purchase the pipeline was accepted by kinder morgan shareholders in texas, the federal court of appeals ruled that the expansion project's approval was "impermissibly flawed", with unacceptable omissions in the eia review process and fatally lacking "meaningful" consultation with indigenous people or consideration of the impact on an endangered whale population. while notably not addressing all the problems of concern (still omitting global climate threats and indigenous health issues), the federal court required the project construction to be halted. yet, the prime minister within hours, asserted that the project "will" go forwardseemingly regardless of what any new eia review and indigenous consultation processes might reveal. crown prosecutors thereafter began to be seen in bc supreme court hearings for the arrested pipeline injunction defendants, clarifying that prosecutions would continue despite the court decision to halt construction. far from acknowledging that the land and water defenders were in any way vindicated by this ruling, the aforementioned judge began to increase penalties for those he deemed to have breached his injunction. more trials began, and more prison sentences were issued, with more than people charged by this time. as andrew barry reminds us in material politics (discussing the baku-tbilisi-ceyhan oil pipeline linking the caspian sea to the mediterranean sea), oil pipelines are part of structural struggles that need to be studied as dynamic and contingent on multiple positionalities and power relations, reflecting tensions in how histories are told and how knowledge production is approached (barry, ; see also murrey, ) . studying courtroom dynamics around the tmx project indeed brings forward diverse possibilities and dilemmas for grounding ideas of injustice; different timelines, subjectivities, power relations and material concerns may be prioritised. while thousands of people have expressed resistance, this has been in many ways, for many reasons. for some, opposition is a response to concerns that the -fold increase in oil tanker traffic right in the vancouver harbour poses a serious threat to local populations from a spill in this area; for others, effects of tanker traffic on bc's west coast endangering the orca populations is a major motivator, for some, the pipeline's impacts on salmon figures prominently; and for many, including scientists willing to be arrested, increased greenhouse gas emissions that would result from expanded oil exports is central, framing opposition to a global climate disaster as the lead issue. the pipeline also represents the continued destruction of indigenous health, food sovereignty and wellbeing on local scales, with oil impacts already having been shown to have serious consequences in undermining indigenous health and food sources (jonasson et al., ) . broadly, geographers have expressed a need to sensitively think beyond "assumed-affinities" (barker & pickerill, ) that may exist when imagining diverse indigenous and non-indigenous activists in collective struggles. indeed, it is precisely because of deep diversities of concerns, relationships and positionalities (some people more 'anti-capitalist' than others, some more inclined to use legal and/or moral arguments than others, some more focused on greenhouse gases or gender violence associated with 'man-camps' built for pipeline construction, and so forth) that resistance movements against oil pipeline expansion are vastly growing. glossing over positionalities relating to class, culture, ethnicity, gender, and geography-based differences can lead to under-appreciating diverse values linked with what barker and pickerill ( ) call "place-agency" that stands in contrast to settler-colonial jurisdictional control. for many people arrested, the central concern is that the tmx project sits on stolen land and without consent from impacted indigenous communities who actively oppose it. threats of fossil fuel pipelines broadly and intensified oil risks on indigenous land specifically, in a context of climate destruction, all became part of concerns that defendants tried to voice, with some defendants detailing illegalities committed by the pipeline construction company itself and values at stake. i approach courtroom ethnography here as a way of re-imagining contested proceedings, jurisdictional assertions, positionalities and embodied practices. it is, in part, a way of unsettling (see de leeuw & hunt, ) knowledge production in relation to machine-like prosecutorial efforts at categorising and individualising illegality and punishing acts of conscience with colonial law; partly it is about contrasting these moves with the courageous stances of defendants, the collective mobilisation and the ethics of care displayed amid contested regimes of extractivism. as i learned through more than a hundred and fifty hours of attending court proceedings that at times dragged on for hours of judicial jargon, prosecutors often snowed defendants with their version of legal precedents and case law, narrowly circumscribing spaces for defendants to articulate their concerns. constricted space for 'evidence' was central to a system of guaranteeing guilty verdicts and punishment. the injunction here servedlike injunctions elsewhere -"as a blunt instrument in opposition to indigenous law" (pasternak & king, , p. ) with proceedings structured to confirm what a judge knew already: that many people stood or sat (or prayed) on a road. courtroom ethnography became a way of exploring a system mobilised to subordinate indigenous rights and voices to procedural discussions, using vast state resources in the service of oil industry expansion; it also became a process of researcher interactions with people in the court corridors and beyond, where not only issues of this court were explored but also other struggles (beyond this injunction), situated knowledges, and intersecting solidary efforts. over more than a dozen cases (trials and sentencing hearings) from mid to mid , all concerning this one injunction, i met many "sinister seniors" -women and men in their s, s, and s, some of whom regularly came to court sessions to offer solidarity to people on trial. some had trials and sentencing hearings earlier in ; their "sinister" label came initially from the judge telling them that standing on a road was a "sinister act of contempt" (the "sinister senior" label thereafter became self-inflicted -worn as a badge of honour). many grandmothers spoke about solidarity with indigenous rights at trials, and about oil and the future for younger generations. coming to the court was an endeavour to learn, to show solidarity, to see the performance of power in grotesque forms as well as "subtle dramas" (flower, ) with significant and sometimes not-so-subtle meanings, and to talk about what values mattersand what dilemmas exist in framing a "necessity to act" defence. not all defendants chose to advance such defences, which required substantial paperwork. being in the court provided ways of seeing unique choices that each defendant engaged, and that different prosecutors employed, where word choices, tone and affect all mattered. while this methodology thus involved listening in the courtroom and taking notes, at times it explored the creativity of people mobilising against the pipeline expansion. i interacted with defendants, observers, and defence lawyers, as well as reviewed transcripts; these included statements prepared for the judgesome delivered only in part or not at all in the hearings. the evidence that mattered most to the judge was never evidence about conscientious objections or greenhouse gases but rather what members of the royal canadian mounted police (rcmp) showed on the stand -'evidence' such as news articles or facebook posts citing defendants' words, indicating that they engaged in "calculated defiance" or an "organised" plan to be on the road. my task evolved to include revisiting these sources, too, venturing into some of the voluminous legal cases referenced (several thousand pages of which were circulated by the many lawyers involved; a single defendant recounted being given more than pages when charged). conversations in the gallery during breaks and elsewhere in the courthouse, and beyond, explored experiences in hundreds of trials and sentencing hearings. i spoke with courtroom observers and defendants in coffee shops, over meals and on the street, exploring testimonies and meanings around themand also what it means to witness. in being there in the courtroom, day after day, a courtroom ethnographer becomes not merely an observer but inescapably part of the proceedingsat times making unavoidable eye contact with judge and prosecutors as well as becoming part of the camaraderie of the gallery itself. at times the ethnography became a process of reflecting, in an awkward courthouse setting and, if only partially, on urgent needs for geographersefforts toward more meaningful engagement with indigenous ontologies of place, relations with place and legal practices of place (daigle, ) . faria et al. ( ) argued for more work by geographers to interrogate ways of connecting everyday legal activities and "the trans-scalar structural machinations of state violence." indeed, to situate the spatial politics of courts, multiple spaces need to be seen as interconnected. on one occasion, after a court session finished, four fellow courtroom observer-companions and i travelled together from the courthouse in downtown vancouver to a neb hearing in nanaimo on vancouver island, to see a parallel space of pipeline politicswhere efforts were afoot by the federal government to pressure indigenous leaders who opposed the pipeline. neb hearings took place in a conference venue where indigenous groups had to travel considerable distance to make presentations. some indigenous leaders lambasted this venue as an insulting "hilton hotel version" inappropriate for oral traditional evidencehighly inaccessible and not open to the public or easily open to indigenous communities, reflecting the government's poor commitment to genuine consultation. our seeing this 'sterilized' neb environment thus further contextualized the courthouse space. my approach was thus not just about studying the courtroom as a space in itself but also as a nodal point for interacting and interpreting wider events, places of contention and processes unfolding, and seeing solidarities and affects that challenge oil and the dominance of colonialism in governance and judicial systems. separate from but concurrent to the courtroom ethnography work, i also collaborated on a project with members of the tsleil-waututh nation focused on life within tsleil-waututh territory (spiegel et al., ) , which informs engagement on wider inter-relating issues of knowledge production with indigenous youth and elders dialoguing in solidarity. my positionality vis-à-vis this courtroom over the august -january period thus had various dimensions that inflected my learning. as someone who conducts environmental justice-oriented research projects with indigenous communities locally and internationally, i approached this courtroomand the tmx issues at stakeas a locally and globally important space of contention. as someone who grew up in canada in schooling systems that utterly lacked proper education on indigenous histories or on the brutality of colonization, i found being part of the courthouse solidarity group to offer particular vantage points for critical learning; my positionality was also as one who participated in raising legal funds to support those being disproportionately affected by state/corporate violence, while encountering a range of methodological tools for critical learning including interviewing artists on their experiences and histories of social justice work. over time, i went from being a courtroom novice to a 'regular' attendee, allowing appreciation of the sensitive ways in which diverse positionalities were embraced in the group, regardless of whether a person was arrested, or whether one person chose to plead a certain way, or how the 'lead' concerns about the tmx were framed; this also allowed for attentiveness to inconsistencies in the logics mobilised by prosecutors. methodologically, courtroom ethnography can be challenging as it is a time-consuming method (see also walenta, ) ; for me, the returning time and again to the court allowed for not just keeping a diary but more importantly, relationship building that is crucial to this methodology, at times sharing notes (and drafts of this article) with defendants and supporters who also then offered further insights. in the next two sections i reflect mainly on experiences in the courtroom itself, focusing particularly on two recurring and dialectically opposing themes respectively: the court as a theatre of power and place of suppression and punishmentwhere settler-colonial manipulations of both civil and criminal contempt labels play out to suit extractive agendas and arbitrary logic; and the courtroom as a space of contrasting ideas of 'irreparable harm' and a place of critical solidarity-building. these themes are addressed respectively in the following two sections. to deflect indigenous rights issues, oil industry promoters have sought to legitimize the contested tmx project by stating that it is "just" a "twinning" of a pre-existing pipeline built in along with some new routes. this argument rests on the premise that theft of a violent colonial 'past' era justifies ongoing and new dispossession and new destruction. it also assumes that denying indigenous jurisdiction is an acceptable way of doing 'development'. as some defendants sought to remind the bc judge during the injunction hearings, in government systems were also in place to overtly continue genocide and forcibly take indigenous children from their parents and put them in residential schools to extinguish their culture (see also de leeuw, ); for this and a host of other racist colonial practices, "dispossession was the goal" (manuel & derrickson, ) . revisiting histories such as those in the above statement to the court, multiple people on trial noted the existence of indigenous law and queried the court why they were not being adjudicated according to these laws. statements to the judge by an artist and arrestee, spoke of indigenous legal practices engaging oral traditions, efforts by the tsleil-waututh nation at regenerating sustainable futures, and kinder morgan's illegal activities on the land as already witnessed: "our actions at kinder morgan's gates were necessary," his statement noted, "to help press the pause button until real justice is restored." in a juridical context where historical erasures and ongoing systemic violence shaped a judge's (and several prosecutors') embracing of narrow visions of justice, the courtroom here was an "affective theatre of power" (bens, , p. ) in several senses. the judge who created the injunction claimed at one point that his courtroom was "not theatre." he said this to chide people in the gallery after one defendant's words conveying values of respect for nature and indigenous rights led to quiet but audible sounds of support from observers; on that day, proceedings were in a regular courtroom instead of the special basement room with the glass barrier (the usual place for the hearings). yet, theatre is an inescapably relevant notion. as communicated to me by the artist of fig. , the motivation for this drawingcreated right after one of the trialsis partly to render that theatre of power visible, showing the judge performing coloniality. for bens ( ) , the very purpose of courtroom ethnography is to recognise theatres of power and to "keep both the linguistic and the non-linguistic in mind when analysing the law and the state" (bens, , p. ) . courts perform as 'theatre' overtly when their function is primarily showing powers of control. this was the case unambiguously here; this judge's decisions to pursue new trials let alone raise prison sentenceseven after the federal court of appeals ruled the government's approval of the pipeline expansion as illegitimatewas an illustration of his subjective power to perform. he made other subjective and aggressive choices in expanding his injunction orders as well, as discussed below, and turned his court into a theatre for investigating emotions; defendants were repeatedly asked if they would 'purge' their 'guilt' when brought before the judge, and those accused of contempt would have to admit whether they knew about his injunction when standing on the road (some did not know about it) and express remorse in either case. the prison sentence he rendered would hinge in large part on how he felt the defendant performed, how their subservience in his theatre of power played out. on august th -still prior to the federal court ruling -i met people in the bc courtroom lobby after a woman was sent to jail for days. discussions were rife with conversation about the prime minister's campaign pledge reversals, environmental justice matters, and the limited space for mounting defences within the courtroom. as one of the court observers explained to me, this judge did not even allow the first group of people arrested (in march) to read short prepared statements to the court. this restriction was eventually modified, after protest, and only after crown prosecutorswho regularly sought the highest possible prison sentencestold the judge they had no problem with such statements being read aloud. people arrested shortly after the introduction of the injunction were given fines, but prison sentences started to increase significantly as time progressed. i spoke with defendants waiting with anxiety for anticipated -day prison sentences from 'judge pipeline's' injunction. yet sentences were eventually increased up to days, with some later defendants sent to jail for months. some of the people in the bc court gallery had been attending each case since the very start of these contempt trials to show solidarity. i was told that i missed one occasion where this judge responded to an indigenous defendant who tried to explain that his people had been on the land since time immemorial. "what is time immemorial?" the judge was said to have queried. beyond diverse cultural and generational differences among those on trial (reflecting diverse peaceful efforts in defending land, water and earth ), various positionalities in the courtroom observation gallery also were playing themselves out. before i arrived on august th, one of the people who swooped briefly into the public gallery reportedly came because he used to oppose the same judge when that judge was a lawyer for the asbestos and tobacco industry. one person expressed that this judge's injunction was creating a huge embarrassment for the bc judicial system. after the conclusion of the day's sentencing hearing, we talked about how trials for serious offences are being dismissed because of time/resource pressures on the criminal justice system. "but all the time in the world is being made for prosecuting big criminals like grandmothers," a courtroom friend relayed to me. we also discussed developments on burnaby mountain by the pipeline construction site; the "camp cloud" protest camp (a makeshift camp) was closed by police at dawn that very morning. newspapers were not allowed to cover details up close; land and water defenders wished that drones were there to better capture the situation. people charged at camp cloud later saw their charges dismissed as they were under a different judge, underscoring that the performativity of power includes its own subjective and arbitrary logic. a member of parliament who would be elected mayor of vancouver the next year, kennedy stewart, was one of the early arrestees under the injunction; an article on his reaction conveyed a paradoxical sense of maintaining "respect for the court" on one hand and the need for civil disobedience on the other (national observer, ). for many, the role of this court was felt to be a clear abuse of process. a comment written underneath the above article conveyed one of the central frustrations: "just wondering if anyone has had a chance to ask the judge how else is anyone able to register their objections to this whole fiasco and be acknowledged if he (the judge) has refused to entertain any backgroundany environmental concerns, ethics, etc. don't forget, every other avenue of communicating one's objections has been shut down, which is why people are doing all these 'unlawful' actions in the first place." another comment came in the form of reinforcing solidarity: "i am grateful to all the people who have been willing to stand up to the lies, bullying, and manipulations of the state. civil disobedience is a basic necessity of a democracy. this movement is spreading, as more people realize what the situation truly is. protection of our basic rights to clean water and soil is at the heart of our survival." at this point, amid rushed neb hearings for the pipeline's permitting, many were unsure of what resistance possibilities remained. although a victory had just been achieved in the united states with regulators blocking the keystone pipeline (nrdc, ), the neb in canada was speedily granting permission for tmx construction, and just the week prior one seventy-one year old was sentenced to months in jailclose to the longest sentence served in a political case involving criminal contempt in bc. during the logging resistance in clayoquot sound in the early s, at least one person was sentenced to months in jail. people arrested for standing on the roads were consistently peaceful. the injunction's original ' -min warning' system was eliminated after police found that some protestors took turns switching positions as the -min were about to end. indigenous strategies included those of the tiny house warriors, who were protecting land belonging to their ancestors by building houses on the path to tmx. other resistance strategies involved a watch house ("kwekwecnewtxw" or "a place to watch from" in the henqeminem language, used by members of the coast salish peoples) as a place to monitor activities of the pipeline construction in sensitive ecological and spiritual places. some defendants were told they could not return to the location that encompassed the watch house, even though it was not blocking tmx access in any way. declared that it approved more than per cent of the route (calgary herald, ). a critical issue looming throughout these - trials was the question of what truth and evidence, if any, matter in a colonial justice system of an extractivist state. to speak about a new 'post-truth era'now fashionable (almost cliché) in geographyis, as one indigenous activist told me, potentially quite misleading, given that colonization has long been served by post-truth narratives. at various moments in these 'contempt' trials, the judge called the tmx construction a pipeline "enhancement" rather than "expansion" -distorting truth through manipulating language. yet, certain truths were also being indelibly felt, even if words could dance around them. on august th, , those who came to the courthouse had to travel through thick smoke from forest fires that engulfed vancouveran increasing impact of climate disaster; air quality in the city reached unprecedented danger levels. some choking in the court corridor wondered if trudeau would finally meaningfully feel fossil fuels as creating imminent peril when he comes to bc where he was scheduled to soon visit. the juxtaposition of what was transpiring outside and inside the courthouse added to the alreadyexisting sense of absurdity in the hearings. at this point, around half those charged so far had pled guilty to obtain reduced sentences. while the mistreatment of indigenous people was dismissed by the judge as irrelevant, it was obvious to those who were at the burnaby protest sites that indigenous people were treated more violently, physically, and subjected to derogatory statements from rcmp officers. during the break, the solidarity group assembled talked about incidents when police were seen to be violent with indigenous people. we also talked about fears some had of losing their houses due to a "slapp" suit (strategic lawsuit against public participation) from kinder morgan, designed to intimidatea corporate tactic that led to the initiation of this injunction in the first place. importantly, until november all the cases were tried under "criminal contempt" -not "civil contempt"; the judge was adamant that pleading "civil contempt" was not an optionhe reiterated this frequently. the public and symbolic nature of resistance acts, he stressed, made it a criminal contempt issue, despite efforts by some defendants to plead otherwise. on november rd, it thus took me some time to appreciate that the judge had turned his logic entirely around. "the judge is having it both ways," one courtroom observer whispered to me, explaining that the change regarding civil versus criminal contempt that day was intended to facilitate new intimidation. the day before, an after using lawsuits to threaten people, kinder morgan was caught having made errors in marking certain land as 'its' land, and thus lawsuits were dropped. however, the effect of the lawsuits, people understood, was to bolster the granting of the injunction so as to have crown prosecutors take the role of going after those who the company felt was interfering. indigenous woman had tried to argue that she should be heard in indigenous courts, not in this court, and the judge stressed that it was only in this court and only under the criminal contempt charge that these cases could be considered. yet on that day, trans mountain corporation lawyers argued for "civil contempt" charges for the two new defendants, an anglican priest and her parishioner, who, the lawyers argued "have not apologized and purged their contempt" and referenced "exhibition a" and "exhibition b" -local newspaper articles, where one defendant was quoted as expressing "the absurdity of a texas company on unceded territory"; the lawyer read it aloud as if it was incriminating. these defendants had chained themselves to a tree because, as they explained, they were respecting pre-existing coast salish law. the trans mountain corporation lawyers were using this as a testing ground for new mechanisms of inflicting fear, threatening a prohibitively exorbitant "special cost" component which defendants could be forced to pay. therefore, arguments that day were all reversals of previous positions. a defence lawyer tried to remind the judge that the "public component" and "symbolism" of the actions of these defendants made it "criminal contempt" -not "civil contempt" -according to the judge's own rigidly embraced logic in hearings so far. she read brief biographies of the women charged: a -year old mother of two whose biography was brimming with contributions to her community; and a -year old minister, also mother-of-two, whose biography was equally replete with extensive laudable community work. the priest and parishioner shared stories that warned against making bad moral choices, countering the trans mountain corporation lawyer's ridicule for coming within m of a "property line" by re-articulating this territory in spiritual and environmental terms. the intimidation tactics at play here were powerful components of what valdivia ( , p. ) calls "petroleum colonization" (in her context, discussing ecuador) -where authority is never just about controlling land and resources but also entangling people, emotion and social relations in asymmetrical power relations. critiquing the use of injunctions, contempt hearings and cost awards as tactics of intimidation in canada, mayada ( ) argued a decade ago for adopting measures to make it "more difficult for private individuals, corporations, and government to use the threat of imprisonment and crippling cost awards to dissuade aboriginal and environmental protestors from vindicating their rights"; he noted that "it is not unusual for the crown to take over private prosecutions" in controversial cases around moral and indigenous rights matters and stresses benefits of that. here, the reverse was done. one defendant expressed her understanding that she could face a -day jail term if she took action on burnaby mountain but she fully expected to face the crown, which cannot seek court costs. by professing his willingness to award costs the judge set yet another new precedent in this sagaa precursor to larger looming conflicts ahead, as discussed below, amid reconfigured solidarity-building and ethics of care linking the court space and beyond. the inconsistent rationales and dynamics of intimidation here reflect how the injunction was used to suspend not simply norms about the public's relation to territory or the socio-political possibilities of rights, but also truth and time itself. -defence counsel's words to the bc supreme court, december the final part of my analysis here focusses in on one of the most striking reoccurring power dynamics in these courtroom proceedings: a judge's strident suppression of "necessity to act" defences and awkward characterizations of defendants as uncaring troublemakerscontrasting markedly with land and water protectors' deep intergenerational concerns for the future of the planet and anti-colonial solidarity-building. framings of care, irreparable harm and imminent peril have become critical points of debate in climate justice discussions globally, from examinations of greta thunberg's influences to actions by extinction rebellion, greenpeace and far beyond (fallon, ) . discussions of direct action in response to the imminent threats of climate changeand the irreparable harm with which it is associatedare reshaping geography as a field in significant ways, raising questions about academic priorities in supporting radical change (castree, ) . in the bc supreme court's "contempt" trials, various efforts at advancing necessity defences were tersely dismissed by the court, despite abundant evidence that this was a last resort not taken by defendants without careful consideration, with all alternatives thoroughly exhausted in attempting to influence the neb prior to standing on the road in burnaby mountain. it is instructive to consider the political geographies of care and justice that emerged in response to the judge's disregard for the issues at handvital inter-related notions in critically challenging narrow visions of "imminent peril." prosecutorial discourses here, in targeting land and water defenders, revolved around settler-colonial logics that assume the desirability of resource extraction; though unsurprising, the abrasive words were spectacularly incongruent to the demeanour of those being targeted. prosecutors in early december aggressively statedas if factthat women elders showed "no concern for the community" when they stood on the road in burnaby mountain to resist the pipeline expansion. the defendants were said by the prosecutors to have engaged in "excessive lawlessness", "foolish bravery," with "no concern for the impact of their actions on community resources." prosecutorial language hereapparently copy-and-pasted from other legal cases to show precedent in a colonial system that works precisely through logics of territorial and social de-contextualizationsuggested that the words "community resources" and "concern" have no meanings besides those favouring an oil company's use of state resources to enforce an injunction. using this jargon, the crown prosecutor spent more than an hour detailing, uninterrupted, legal precedents on sentences, to ensure that no appeals could succeed. contrasting values and notions of care underpinning the 'necessity' defense were then ushered forward on december rd, when cases were heard of a -year old retired lawyer (eventually handed a -day sentence) and a retired high school science teacher, whose affidavit noted that her actions were a response to the monstrous failure of the canadian political system to prioritize the climate emergency. a robust legal defence was presented with two key arguments: first, that these proceedings were an abuse of process, and second, that the defendants' actions more than meet the evidentiary requirements for a "necessity defence." for the latter, only the "air of reality" has to be met to advance this argument to trial. the defence provided a detailed outline of proposed evidence, including science on greenhouse gases and lists of famous scientists ready to testify. nonetheless, a senior crown prosecutorbrought in specially to rebut necessity defence argumentsargued that a "reasonable alternative" could be "to not act at all" in the face of climate concerns or to employ "alternative" actions such as writing to parliament, as if they were not already exhausted, and that the necessity case should be "summarily dismissed" as a situation "where the future harm is not probable." to nobody's surprise, the judge sided with the prosecution; but his wording and the swiftness of his response was startling: he did this within seconds of the conclusion of preliminary arguments and memorably stated that while dire consequences of climate change may be foreseeable or likely, they are not yet a "virtual certainty." intertwined matters of settler-colonial language, jurisdiction and judgement raised immediately jarring questions for those in attendance. did the crown prosecutors and judge really have to deny the certainty of climate change? was the suspension of climate change as an imminent peril vital to make this injunction seem legitimate? several inter-relating issues converge here. canada's legal system has less case law on the necessity defence compared to some other countries, including the united kingdom (uk). after the defence's case referenced legal precedents from the uk and the united states where some courts have upheld necessity defences, the crown argued that laws internationally are not relevant to canada's "imminence" requirement. prosecutors also contended that since some cases cited by the defence were not "injunction"-specific civil disobedience (even if they were cases of civil disobedience doing far more disruption), they were not relevant. the crown's argument that there was no "close temporal connection" between perceived threats and climate impacts further underscored how an injunction can be used to advance "the production of colonial ecological violence" (bacon, ) by more than simply burying truths but actively fomenting untruths in de-linking time and climate crisis. my purpose here is not to prognosticate as to whether the canadian supreme court will hear an appeal on "necessity to act" arguments, although given the vast scale of oil production increases linked to the tmx project and its incompatibility with the paris climate accord, some political geographers might well focus here on the necessity arguments. more central to my point here is emphasizing the other of the two main defence argumentsthat the injunction and how it was used constituted an abuse of process; it functioned as a judicial tool to deny rights and responsibilities. while legal geographers and political ecologists write about legal pluralism and multi-level jurisdiction (o'donnell et al., ) , and indigenous law as a component of justice is (to an extent) acknowledged by the canadian supreme court, proceedings in the bc courthouse showed an injunction being used to close down all such pluralistic principles, values and ethics, even before they could be articulated. as articulated by other scholars (peel & osofsky, ; simpson, ; wong & richards, ) , indigenous legal traditions are deeply rooted in place and in the ontologies of care that underlie responsibility for land protection. in this regard, intergenerational care, necessity to act, and indigenous responsibilities for land protection weaved throughout the arguments of various defendants. john borrows, a member of the anishinabe ojibwe nation and leading scholar on indigenous law, stressed that closer linkage between canadian and indigenous legal systems would be vital: "indigenous legal principles form a system of 'empirical observations and pragmatic knowledge' that has value both in itself and as a tool to demonstrate how people structure information. first nations laws embrace ecological protection, and they could be woven into the very fabric of north american legal ideas" (borrows, , p. ) . while 'reconciliation' with indigenous people is rhetorically promoted by canadian politicians and often part of an acutely superficial 'solidarity' discourse (boudreau morris, ; daigle, ), the abuse of injunctions now arguably stands as among the most symbolically powerful illustrations of the triumph of a colonial system above other systems, and a blunt tool for fortifying oil interests. injunctions in canada are repeatedly being used to deny indigenous law, values and necessity defences point blank. injunctions thus ultimately have to be understood as more than just corporate weaponry in an arsenal of tactics to manipulate law around oil projects. they are partly that; but far more than that, pro-extractive injunctions here have been predicated on moving to a different terrain that of a political space of exception beyond 'normal' law, where rights can be suspended and new, tailor-made 'justice' can be fashioned to the judicial preferences of politically-appointed judges, who take on their own troubling interpretations in defending their very own injunction orders. in this exceptional space, a 'new normal' is created for the purposes of criminalising indigenous and non-indigenous resistance alike and "easing the operation of extractive capitalism" (ceric, ) . in this new normal, past precedents that have to do with necessity defences or indigenous rights are deemed irrelevant and the only 'irreparable harm' that is pertinent is harm to corporate profits and the hegemonic 'order' it seeks. political geographies of care were, however, reconfigured and dramatically remade in responding to injunction violence. people attending trials as participants and observers found, in the courthouse corridor and gallery, spaces for building anti-colonial solidarities and linking concerns about tmx to other struggles internationally, other indigenous rights struggles near and far, and for fortifying intergenerational support in a context of multiple overlapping global crises. figs. - provide an illustration of some of thesedepicting, respectively, the extensive attendance in the courtroom gallery there to support defendants on trial, with words of defendants captured by the artist in the drawing itself (fig. ) ; the pain at seeing the settler-colonial court's contempt for indigenous truths (fig. ) ; and the moment of collective revulsion at a judicial system's exclusion of scientific evidence that was readily available for presentation (fig. ) . solidarity-building also took on other creative forms. "irreparable harm?", a play created after some of the trials, was performed by the "sinister sisters ensemble", a group composed of activists and theatre folk, young and old, indigenous and settlers, including people who were arrested for breaching the tmx injunction. the play re-performed court scenes and testimony, revisiting emotions, solidarities and judgments, as well as the twists and turns in the courtroom sagas. a project of public educating became pivotal in this process, seeking to both recontextualise what "rule of law" means in real terms and re-frame who is doing "irreparable harm" to whom and to the planet, challenging settler-colonial court's mantras. by february , tmx injunction trials were still going on for arrests from as early as august -and in some cases, repeat arrestees. very little news media attention had been dedicated to tmx court proceedings in this period, which involved moves by rcmp to contravene official injunction protocol by arresting people based just on their review of video surveillance several days after the alleged infractions, with no face-to-face warnings. subtle forms of resistance were now increasingly playing out. an indigenous elder who had been watching over the land in burnabyand witnessing illegal company construction activitieson january tth defied the judge's instructions to plea, instead expressing concerns about what happened as a result of the crimes of the crown kidnapping indigenous children. although these encounters were relatively hidden from public view, public discourse about bc court injunctions would suddenly be remade, thrust into national and global spotlights the very next week. on february th, militarised police began intensifying raids and arrests in indigenous communities elsewhere in bc, in wet'suwet'en territory, to remove wet'suwet'en people from obstructing the construction of long-resisted gas pipelines on their (also never ceded) land (bliss & temper, ) . aggressive injunction "enforcement" was caught on video, capturing police pointing guns and belligerently manhandling women. rcmp violence on wet'suwet'en territory catapulted public consciousness about injunctions; solidarity movements linking indigenous and non-indigenous people together sprouted across the country. trains throughout the land were cancelled by indigenous-led blockades thousands of miles away, with slogans such as "when justice fails, block the rails"; ports, bridges and roads were also shut down, for some representing a "watershed moment" (the star, ) and a recognition that "reconciliation is dead" unless there are major state changes on indigenous rights. the colonial imposition of state violence was thus laid bare through injunctions and their court enforcement. simultaneously, care was being nurtured through solidarity actions. state efforts were already heavily ramping up to monitor "persons of interest"; some people i met in the courthouse were well aware of being monitored by rcmp, online and physically. immediately following the mass solidarity actions with wet'suwet'en, the ever-expanding phenomena of 'injunctions to protect injunctions' took hold. new injunctions to stop solidarity-blockade actions emerged to address the "inconveniences" for businesses. a prominent academic writing on these unfolding developments, shiri pasternak, tweeted: "i'm waiting for an injunction to be issued that encompasses the whole country. #wetsuweten #shutdowncanada" (tweet, january ). some have pointed out the "breath-taking hypocrite of the howls for rule of law" (ditchburn, ) , accentuating the failure to recognise that "for most of canada's history, the rule of law has been openly flouted when it comes to indigenous land and rights." to this i add that critically studying what transpires in courtrooms helps dispel any residual assumptions that the legal system in canada proceeds with neutral objective processes, illuminating asymmetrical power relations and cultural imperialism at playas well as how these are experienced viscerally. both the tmx and wet'suwet'en injunctions illustrate how judges routinely exude bias in favour of the fossil fuel industry's narratives when defining "irreparable harm" and in rigidly enforcing forms of legal territorialisation that "invert traditional expectations of justice" (sylvestre et al., ) . even within confined visions of an economic-profits-above-all-else philosophy, industry narratives that blocking pipeline construction constitute "harm" to the taxpaying public have themselves been shown to be untenable. a judge's moves during injunction proceedings not only routinely side-stepped evidence on financial matters, including financial harms of climate change itself, but also countless other more-than-merely-financial harms that are unequally distributed by race, gender and class, with more than human ecosystems at stake. for settler-colonial courts, care for corporate interests routinely trumps forms of caring that are central to indigenous lawscare for land, water, fig. . depiction of the courtroom gallery and witnessing words by one defendant telling the judge "my time on the mountain with the people was healing", defiantly but gently, as well as about the anxiety linked to the oil pipeline and arrests. artist joe pepper, reproduced with permission. fig. . the truth is not a defence -"i get pain in my bones thinking of the charge: that a corporate … entity which has no life except on paper, can hold a human being of blood and bones in contempt for being indigenous and human and representative of the living …. the black sludge, bitumen … will obliterate knowledge of our life blood connection to the flow of blood and water. the injunction disavows the truth for indigenous people who have lived experience long forgotten … who are "they" to hold the living in contempt? (june , ) . artist and writer -joe pepper, reproduced with permission. despite the injunctions purportedly created to stop financial harm, assessments reveal that several billion dollars of taxpayer subsidies would be needed for the tmx project (with costs considerably more than double the originally quoted amount [www.wcel.org/media-release/federal-government-hiding-true -cost-trans-mountain-pipeline and https://www.cbc.ca/news/canada/britishcolumbia/trans-mountain-pipeline-expansion-support-cost-survey- . ]), highlighting that significant financial harms would occur to the broad taxpaying public if the project is to advance. both defendants on trial and those in the gallery often noted that the billions of dollars linked to the costs of climate change should figure into 'financial assessments' -as well as the moral questions linked to why the canadian government is not devoting the tmx subsidisation money to benefit clean energy industries and indigenous safe drinking water programmes. people and other inhabitants of the planet; and for many people who came to the bc courthouse, each day in the court seemed to make it increasingly clear that far too sparse attention was being paid to every one of the critical concerns. as one fellow courtroom observer and supporter of land and water protection remarked in a letter to the office of the b.c. attorney general, amid the systemic racism on display: "the blatant bias and privileging of the crown throughout the proceedings has been offensive and disturbing to witness. the power differentials that exist between the well-moneyed crown working in tandem with the trans mountain pipeline expansion against the indigenous land defender on legal aid are clear to the members of the public watching the trial … we can see that no justice will be served in these courts, and that the crown is a well-oiled tool in the ongoing systemic discrimination against indigenous peoples and all who hold values that respect the land." at the centre was the ethical problem of a judge's injunction enabling a company to clear indigenous people and others from roads on land never ceded by indigenous people in the first place. amid deceptive news media reportage that helped to distort public debate on harm, political geographies of care in the courtroom have thus become about reclaiming, pointing to more than inconsistencies and omissions under settler-colonial law itself, but more importantly, taking seriously the foundational point that theorizing pipeline governance ultimately necessities engaging with indigenous modes of care and jurisdiction over development (mccreary & turner, ; see also asch, ) . being an ethnographer in the court gallery inexorably leads to reflecting on what jurisdiction a settler-colonial court actually has on land that was stolen from indigenous people, and that remains stolen. it also leads to an interrogation of affectincluding how harms are felt, what these harms do to the future, and why these harms are not guiding 'injunctions'. perhaps most importantly of all, attending the courtroom dramas in these injunction hearings raises the question of what it would mean to start the conversation from the point of view of indigenous lawsprofoundly different premises for grounding understandings of harm and care. in this vein, indigenous laws of the people of the inlet, the tsleil-waututh nation, command engagement with "a sacred obligation to protect, defend, and steward the water, land, air, and resources of the territory" (tsleil-waututh nation legal principles as cited in: curran et al., ) . in one court appearance, the defence counsel for three indigenous defendants pointed to section of the trans mountain injunction order, which excludes "persons acting in the course of or in the exercise of a statutory duty, power or authority." the defence argued for recognizing the co-existence of multiple systems of law, and cited the foundational belief in indigenous law held by the defendants that they carried the duty and authority to act as they did to protect the land, water, and all the reckless endangerment of neighbourhoods make the mountain particularly vulnerable … an expert witness, directly affected who is also a university professor, bio-chemist and cancer research specialist was not allowed to give her expert testimony due to court interference." artist-witness-writer: joe pepperreproduced here with permission. this article was originally submitted in march prior to further court proceedings for three indigenous land defenders i attended in august and september . the letter cited here (by dr. rita wong in september ) during the final revisions to the article was written in relation to these latter trials and sentencing hearings as the land defenders faced -days in jail during a pandemic. two of the land protectors were quite surprised that they were being prosecuted based on surveillance camera footage of them in ceremony and praying for min in front of a tmx road before leaving on their own, with authorities not following the injunction's own procedures (that require a -step process including notification by police and opportunities to leave before arrest). living things. the argument was immediately rejected by the judge. notably, at sentencing hearings in september , indigenous elders from the tsleil-waututh nation and chief judy wilson of the union of bc indian chiefs again re-confirmed that these defendants had been given the responsibility to act exactly as they did, and that their action was in keeping with indigenous laws and sacred obligations with which they were explicitly entrusted. despite the bc provincial government passing undrip legislation, the crown and judge's vocabularies, epistemic starting points, jurisdictional assumptions and relational practices in the court all remained rigidly alignedthrough the tmx injunctionas anathematic to sacred obligations. while talk of 'decolonial' approaches widely circulate in political discourses outside of courts, settler-colonial violence in the courtroom continues to flourish in the most blatant of ways, denying truths and rigidly embracing fossil fuel-friendly conceptualisations of 'care' and 'harm' to drive the punishing of those peacefully resisting. this article has provided just a glimpse into what is at stake in challenging court injunctions designed to advance the narrowest ideas of 'justice' as framed by the expanding fossil fuel industry. diverse moments in the trials and sentencing hearings brought out different points of emphasismoves of prosecutors and the judge toward denying the imminent threats of climate change, mocking indigenous values and laws, aggressive word choices to characterise defendants, and arbitrary impositions based on ever-changing rationales of criminal versus civil contempt to inflict maximum distress to those courageous enough to stand up. building on political ecology scholarship that scrutinizes the hegemony of oil and bitumen in contemporary political relations, particularly work by simpson ( ) and schmidt ( ) , i have argued that critical attention is needed to settler-court performances of power in criminalising land and water protectors, through both subtle and overt courthouse manoeuvres. while it is possible to argue that civil disobedience and direct action is now becoming increasingly 'mainstreamed', the efforts of land and water defence often remain poorly understoodand strategically misrepresentedby those watching from the sidelines. with growing numbers of people willing to put their bodies on the line in anti-colonial solidarity, courtroom ethnography generates spaces of contextual and intersectional interaction for viscerally understanding the ethos of collective care in the midst of violent processes of colonial 'rule of law', providing avenues for thinking carefully about geographies of justice and injustice, fossil fuels and spatial politics. the period of - saw unprecedented levels of controversy around pipeline expansion in canada and globally, with diverse narratives, power relations and frames for de-/re-contextualising protest, civil disobedience and direct action associated with defending indigenous rights, earth, land, water and future generations. in january of , the united nations committee on the elimination of racial discrimination implored canada to immediately stop the construction of tmx and two other large projects until it obtains approval from affected first nations; failing to engage with this urging, government leaders responded that enforcing injunctions is the first priority, reflecting its primary commitment not to climate justice nor to indigenous rights but to the fossil fuel industry. given rising tensions created by court injunctions as systemic weapons of structural racism and injustice (pasternak & king, ) , courtroom ethnography offers an increasingly needed terrain for witnessing and critically understanding state violence, subtleties of brute instruments of power, and also nuances of resistance and affective landscapes both within and surrounding courthouses. such approaches require learning through being presentwith eyes openpaying careful attention to various scales of spatial politics and the inter-linkages of different jurisdictional propositions, affects and struggles. the tmx hearings illustrate how contemporary judicial uses of injunctions in canada's settler-colonial state do not bear anything resembling a "reconciliation" era with indigenous people; and experiencing injunction hearings over time, over the protracted proceedings, offers a vantage point for seeing vast resources dedicated by state institutions to suppressing issues fundamental to both undrip and the paris climate accord. in this age of fossil fuel violence, the task for critical geographers is to engage with the various positionalities, struggles and identities at play, as well as the plethora of mobilisations and articulations of science, history and local knowledge thatin theorycould guide fundamentally different understandings of "irreparable harm" -and of care. ultimately, if courtroom ethnography offers avenues for challenging "petroleum colonization" (valdivia, ) and de-centring the logics of settler-colonial laws through alternatives voices, dilemmas thus also emerge. critical attention will be needed in the years ahead on legal geographies, social movements and changing political ecologies of ongoing climate disaster. but writing about setter-colonial courtroom proceedings requires commitment to epistemologies of difference and ontologies of care that are already subordinated by eurocentric 'justice' systems. starting with a settler-colonial courtroom space, even if showing its own inconsistencies and violence, risks mirroring its form and further denying agency to spaces of indigenous law as the rightful starting points of the conversation. methodological lesson-learning during the process of courtroom ethnography underscores the importance of building relations that transcend courtroom milieus, exploring a myriad of histories, solidarities, and forms of expression that give meaning to value systems that link social and ecological justice, destabilizing assumptions about legal contestation, civil disobedience and jurisdictional authority. now, in the midst of a resurgence of indigenous legal scholarship, political geography as a field needs urgently to heed calls for engaging indigenous values and law more centrally, to better understand struggles faced in land and water protection, to disrupt ongoing colonial violence, and to guide fundamentally different visions for 'climate justice' and the spatial politics of the future. no conflict of interest. on unceded traditional territories of the tsleil-waututh, musqueam and squamish first nations, many people have advanced and supported deeply important movements to address the struggles discussed here. i particularly acknowledge all the courageous land and water defenders who came to the court as defendants. i wish to thank george rammell the defence also cited the royal proclamation of , and a meeting held the following year in niagara between approximately indigenous leaders and the british official william johnson establishing an agreement between the british crown and first nations that recognized and respected nation-to-nation relationships. the judge argued that these and agreements occurred before bc was part of canada and dismissed their relevance in these proceedings. for in-depth discussion of these early documents, see pasternak ( ) "jurisdiction and settler colonialism: where do laws meet?" and borrows ( ) "wampum at niagara: the royal proclamation, canadian legal history, and self-government." fossil fuel violence around the tmx pipeline took on new forms in march of , as the coronavirus pandemic accomplished what the injunctions could not dokeep land and earth defenders from preventing pipeline construction. while stay-at-home orders for public good required an end to blockades, tmx construction was deemed by the government "an essential service" and continued despite concerns about bringing disease onto indigenous territory. meanwhile, as of september , injunction court hearings from resistance are still continuing. and joe pepper for kindly allowing their artistic work to appear here, and also to the many people who shared insights, including land and water defenders, lawyers, fellow courtroom observers, and others. any views expressed or errors here are solely my own responsibility. the research was made possible thanks to a uk economic and social research council (esrc) future research leader award, for which i am also grateful. undrip, treaty federalism, and self-determination settler colonialism as eco-social structure and the production of colonial ecological violence radicalizing relationships to and through shared geographies: why anarchists need to understand 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production of settler colonial space, violence, and the making of a resource in the athabasca tar sands green party of canada leader elizabeth may pleads guilty to criminal contempt and receives $ , fine. georgia straight visual storytelling, intergenerational environmental justice and indigenous sovereignty: exploring images and stories amid a contested oil pipeline project red zones: criminal law and the territorial governance of marginalized people oil's deep state: how the petroleum industry undermines democracy and stops action on global warming-in alberta, and in ottawa blocking pipelines, unsettling environmental justice: from rights of nature to responsibility to territory the star governing relations between people and things: citizenship, territory, and the political economy of petroleum in ecuador courtroom ethnography: researching the intersection of law, space, and everyday practices petro-violence: community, extraction, and political ecology of a mythic commodity settler colonialism, ecology, and environmental injustice too late for indigenous climate justice: ecological and relational tipping points. wiley interdisciplinary reviews: climate change the impact of climate change on indigenous people-the implications for the cultural, spiritual, economic and legal rights of indigenous people acting under natural laws key: cord- - uu dh authors: ford, lea berrang title: climate change and health in canada date: - - journal: mcgill j med doi: nan sha: doc_id: cord_uid: uu dh nan national governments from around the world met in poznan, poland in december at the th conference of the parties to the united nations framework convention on climate change ( ). this conference came at a time of increasing political and scientific confidence in the role of human-induced greenhouse gas emissions in changing global temperatures. the most recent ( ) report of the intergovernmental panel on climate change ( ) states that climate change is now "unequivocal", based on increasing evidence from global average air and ocean temperatures, melting of snow and ice, and rising global average sea level" ( ) . while there remains uncertainty regarding the specific nature and rate of climatic changes and their impacts, there is negligible scientific doubt that the global climate is changing and that these changes will have significant and potentially profound impacts on a wide range of ecological and human systems across the planet ( ) ( ) ( ) ( ) . that climate change predictions are both scientifically and politically daunting lessens neither their verity nor implied imperative ( , ) . climate change will involve an average increase in global temperatures of approximately . - . °c by the end of the century ( ); this range reflects both uncertainty in climate modeling, as well as a range of possible scenarios for how we will respond to climate changes, including mitigation, technology development, economic development and population growth. this temperature shift will be manifest in average global climatic changes, including higher maximum temperature, more very hot days, increased occurrence and severity of heat waves, fewer cold and frost days, fewer cold spells, more intense precipitation events, increased risk of drought in continental areas, increased cyclone intensities, and intensified enso events. these effects will, however, vary significantly by region and act within existing climate conditions. for example, while parts of latin america will see minimal changes in temperature, arctic regions are expected to experience an average temperature shift of - °c by the end of the century ( ) and recent research suggests that even these projections may be conservative ( , ) . changes in our global and regional climate systems will have important implications for health and health systems ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the world health organization estimated that in the year , climate change caused approximately , excess deaths worldwide, as well as million disability-adjusted life years ( ) . temperature and weather have direct effects on mortality and morbidity through the occurrence of extreme weather events, including heatwaves, cold periods, storms, floods, and droughts ( , ( ) ( ) ( ) . such events can, in turn, affect the incidence of food-borne and water-borne disease ( , ) . the habitat and survival of insect species capable of transmitting many vector-borne diseases are affected by temperature and water regimes ( , ) . many pathogen replication cycles are also determined by temperature conditions. indirect impacts of climate change on livelihoods, such as increased economic vulnerability, reduced availability of food resources, and reduced allocation of government funding for health systems, may also have important, though unquantified, impacts on global health systems ( , , , , , ) . health impacts due to climate change have already been documented, including changes in the range of some vector-borne diseases ( , , ( ) ( ) ( ) and an increase in heatwave-related deaths ( , , ) . indirect effects will also include increases in regional food insecurity, migration resulting from environmental degradation, and loss of environmental-dependent livelihoods resulting from ecological shifts in weather or species distributions ( ) . table summarizes the reported and projected health impacts of climate change documented by the intergovernmental panel on climate change (ipcc). the ipcc, an intergovernmental body open to all united nations member countries, comprehensively assesses existing literature related to climate change science, potential impacts, and options for adaptation and mitigation. the published reports represent the consensus of thousands of scientists around the world contributing as authors and reviewers, as well as political consensus required by member countries for the acceptance, adoption and approval of the final document. these projections and measures of confidence are therefore believed to be conservative ( ) ( ) ( ) . current climate change effects on global health are small but increasing in most countries ( ) . this is due to the lag effect between greenhouse-gas emissions, climate system warming, and the weight of evidence documenting health impacts. while the burden of negative health impacts will be disproportionately high in poorer countries, even high-income countries will be vulnerable to morbidity and mortality related to increases in the number and severity of extreme weather events such as storms, heatwaves, and floods ( ) . vulnerable populations in all countries include the urban poor, the elderly and children, traditional communities, subsistence farming communities, and coastal populations ( , , ( ) ( ) ( ) . evidence does not support the potential for economic development to combat the health impacts of climate change ( ) . canada will not be immune to the health impacts of climatic change ( ) ( ) ( ) ( ) . canada has observed approximately °c rise in temperature since the beginning of the century, and we can expect this to continue by about . degree per decade, up to °c over the next century ( ) . this temperature change is not insignificant; the earth's temperature was, for example, only - degrees cooler during the last ice age ( ) . the effects of climate change in canada will differ between regions ( ) . while the prairies are expected to experience warmer, drier summers and more sever summer droughts, ontario and quebec can expect decreased snow, increased rainfall, and an increase in the incidence of severe summer storms ( ) . the greatest changes will occur in the canadian north, where temperature changes are projected to be among the highest in the world, and where traditional, resource-dependent communities are considered highly vulnerable ( , , , ) . indeed, for northern inuit communities, climate change poses a significant threat to traditional livelihoods in the short to medium term ( , ( ) ( ) ( ) . canada will experience a number of significant direct and indirect impacts of climate change ( ) ( ) ( ) ( ) . extreme heat events are expected to become more frequent, longer in duration, and more intense ( ) . extreme heat events can exacerbate health conditions, such as asthma, as well as lead to an increased number of deaths ( , , , ) . heat waves were responsible for over five hundred deaths in chicago during a -day level of uncertainty * alter the distribution of some infectious disease vectors medium confidence alter the seasonal distribution of some allergenic pollen species high confidence increase heatwave-related deaths medium confidence increase in malnutrition and consequent disorders, including child growth and development high confidence increase in morbidity and mortality related to heatwaves, floods, storms, fires, and droughts high confidence continued changes in the ranges of some infectious disease vectors high confidence mixed effects on malaria incidence and distribution (expansion in some areas, contraction in others) very high confidence increase in the burden of diarrhoeal diseases medium confidence increase in cardio-respiratory morbidity and morality associated with ground-level ozone high confidence increase in the number of people at risk of dengue low confidence health benefits include fewer deaths due to cold high confidence ( ) . children and the elderly are particularly vulnerable during heat wave events ( ) . the increasing number of summer days in urban areas of quebec and ontario declared unsafe for outdoor activity due to smog and heat can be expected to negatively impact public health through reduced outdoor and exercise activities ( ) . poor air quality, resulting from smog and air pollution, is associated with asthma, chronic respiratory disease and cardiovascular disease, and is a serious public health issue in canada. smog and air pollution are expected to continue to increase with climatic change ( , ) . toronto public health recently predicted that climate change would cause a % increase in air-pollution related deaths in the city by ( ). many regions are expected to see an increase in summer storms. this may affect risks associated with flooding, and will have implications for water quality and contamination ( , ( ) ( ) ( ) . a prolonged drought followed by a high rainfall event -such as a summer storm -can pick up surface contaminants and flush them into local waterways, causing a 'pulse' in the contaminant load of local water treatment facilities ( , ) . this scenario was determined to be one of the factors contributing to the e. coli outbreak in walkerton, ontario in ( ) . in addition, higher than normal rainfall events may exceed expected norms for sewage treatment facilities, overwhelming treatment systems. in the inuit community of arctic bay, increased rainfall has been observed to overflow the local sewage ponds, contaminating the bay and roads ( ) . these scenarios are consistent with climate change predictions and can be expected to occur more frequently. the distribution of vector-borne diseases will change ( , , ( ) ( ) ( ) . warmer and wetter summers will affect the distribution and survival of pathogens and some disease vectors such as mosquitoes and ticks ( , ( ) ( ) ( ) . research has already documented possible shifts in the distribution of the vector of lyme disease ( , ( ) ( ) ( ) , and possible expansion of the potential range of west nile virus (wnv) ( , , ) . mosquito vectors of wnv will be affected by longer summers ( , ) . increased incidence of the virus coincides with periods of prolonged hot weather and increased mosquito activity ( ) . recent research also indicates the potential for the re-emergence or emergence of exotic pathogens to canada, including locally-transmitted malaria ( ) . emergent disease risks are by nature difficult to predict. despite this, it is sensible to anticipate the spread of known diseases into new areas and the emergence of new diseases. there will also be a number of indirect effects on canadian health and health care. in many cases, these indirect pathways are difficult to identify, predict, and quantify, but may nonetheless be important for changing health systems in canada. for example, changing sea temperatures are likely to impact the distribution and availability of fish and tree species through impacts on local weather, affecting the viability or focus of fisheries and forestry industries, and by extension the community health and well-being of resource-dependent communities. in this case, the concern is not the loss of traditional species per senew species are likely to emerge to fill changing niche conditions -but the rate of change in ecological systems, and the ability of industries and communities to adapt to these changes. similarly, the dramatic spread of the pine beetle has been facilitated -and many suggest triggered -by increasingly favourable weather conditions ( ) ( ) ( ) ( ) . as in the case of the pine beetle, many of the impacts of climate change on health in canada are likely to be the result of indirect causal processes, and in some cases unforeseen events. the implications of climate change for health are not limited to global and national impacts. they will also be manifest at the municipal level (table ) and within canada's health sector ( , , ) . for canada's health system, this will result in changing risks. for example, the increased emergence of new, re-emergent and exotic diseases will mean that conventional expectations of likely diagnoses by family physicians and primary health care providers will be insufficient. the potential for malaria infection in patients with no history of travel is one such example ( ) . the increase in extreme weather events such as heatwaves, floods and storms will increase pressure on disaster preparedness and emergency health services and programming ( ) . program planning for emergency health provision will need to consider future rather than historical experiences or trends in demand and frequency of health crises ( , ( ) ( ) ( ) . increased health surveillance will be required to document baseline health measures and monitor changing health outcomes. this is particularly important in canada's northern communities where health provision and surveillance have faced significant challenges and where climate impacts will develop earlier and more rapidly than in the south ( , ) . the good news is that opportunities for avoidance of, and adaptation to, climate impacts on health are available, feasible, and in many cases of benefit to improved health in canada more broadly ( ) . given the unpredictable nature of many impacts, adaptation, prevention, and preparedness measures that increase overall health system capacity are most sensible and cost-effective -so called 'win win' or 'no regrets' responses ( , ( ) ( ) ( ) ( ) ( ) . these include: increased surveillance, particularly of disease vectors, water quality, and air pollutants; integration of climate projections into emergency planning and disaster preparedness ( ) ; improved access to preventive care and primary physician care to promote early detection of new disease emergence or shifting disease incidence; integration of climate change considerations into education programming for medical students and primary health care workers; integration of climate projection parameters into urban planning to increase protection against extreme weather events ( , ( ) ( ) ( ) ; increased monitoring and evaluation of food production systems and water monitoring safety given climate projections ( , , , ) ; development of heat wave alerts and responses, and mitigation of urban heat islands ( , , , ) , and; increased multi-national support for improved health capacity in low and middle income countries. the risk of health impacts resulting from climate change are not restricted to within our national borders. the impact of climate change elsewhere, particularly in low and middle income nations, will influence the potential for imported infection to canada. for example, the introduction and outbreak of sars in toronto in resulted in cases, deaths and significant economic losses ( , ) . international travel may have been responsible for promoting the introduction of west nile virus in north america ( ) ( ) ( ) . similarly, a canadian outbreak of imported malaria in - may have been brought to canada via travelers arriving from the punjab in india, where a large epidemic had occurred ( , ( ) ( ) ( ) . more recently, concern regarding the potential spread or proliferation of avian influenza has highlighted the interconnected nature of national health to health conditions around the world. as such, the health impacts of climate change in canada will be influenced by the health and response capacity of other nations from or to which canadians, visitors or trade products travel. in this context, adaptation, preparedness and response resources may in some cases be most effectively and efficiently allocated through supporting health capacity in other countries. increased interest and prioritization of health collaborations in asia following the sars outbreak provides a germane example of a developing awareness of such risk priorities. despite the magnitude and scope of climate change, the recent global financial crisis has overshadowed concern for, and prioritization of, climate change science, policy, and action. while the implications of economic crisis at the international and national levels are undoubtedly of legitimate priority and concern, placing climate issues on the back-burner is misguided for two reasons. first, while the financial crisis may be acute and possibly prolonged in the short term -years, but not decades -the climate change crisis will last well into the next century and beyond. investments in health system capacity and surveillance need to be implemented in advance of emerging impacts to avoid and/or mitigate morbidity and mortality. additionally, observed climate impacts will begin to rapidly accelerate over the next decade. in the absence of genuine and dramatic intervention, climate change impacts have the potential to be severe and acute on a scale greatly exceeding the current financial crisis ( , , , ) . the lack of action on climate change -including both mitigation of emissions and adaptation to current and future impacts -is generally rationalized based on the costs of interventions. the costs of a no-action approach, however, will be significant. the stern review, an independent assessment commissioned in the united kingdom, estimated that a - °c warming over the next century could result in losses of up to % of global gdp ( ); the report estimates the cost of mitigating climate emissions and severe impacts at approximately % of global gdp. the health sector, which makes up % of canada's gross national product (gnp) can make a significant contribution to climate change mitigation and adaptation in canada ( , ) . it is no longer sufficient to use our past climate experiences to assess health risks and health system requirements. future health systems and care will need to reflect changing risk conditions; these will differ from what physicians, primary care professionals, and public health professionals are accustomed to. climate will emerge in the next years and decades as an increasingly important determinant of individual and public health in canada. reduced individual and national contributions to greenhouse gas emissions to avoid severe impacts, combined with proactive planning and programming for adaptation will be required. the physical science basis. contribution of working group i to the fourth assessment report of the intergovernmental panel on climate change climate change : impacts, adaptation and vulnerability, summary for policy makers. brussels: intergovernmental panel on climate change global 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province of pakistan stern review on the economics of climate change joint cna/cma position statement on environmentally responsible activity in the health sector.: canadian nurses association (cna) and the canadian medical association (cma) world bank. health, nutrition and population (hnp) stats key: cord- - l qu qx authors: elbeddini, ali; yeats, aniko; lee, stephanie title: amid covid- : the importance of developing an positive adverse drug reaction (adr) and medical device incident (mdi) reporting culture for global health and public safety date: - - journal: j pharm policy pract doi: . /s - - - sha: doc_id: cord_uid: l qu qx amid covid- crisis, reporting adverse drug reactions (adrs) and medical device incidents (mdis) to health canada or health authorities in every country is crucial for monitoring medication safety and improving public health. health canada, for example, through their online database, has facilitated the process of reporting side effects relating to drugs and medical devices. however, several patients and health care professionals still fail to voluntarily report adverse events. for health care providers, some barriers to reporting may include fear of negative feedback, apathy, legal concerns, and uncertainty about whether an incident qualifies as an adr. in the current covid- crisis, it is especially important for health care providers to be diligent about reporting adverse drug reactions (adrs), since misinformation propagated by the media is causing patients to misuse certain medications. we need to shift the current thought process about adr reporting in order to encourage a positive reporting culture by patients and health care providers. is under-reporting is a concern? in canada, we are underreporting adrs, with less than % of adrs being reported [ ] [ ] [ ] . underreporting is a global problem [ ] . in lower and middleincome countries, a priority is securing access to drugs for treatment and limited resources are available for pharmacovigilance [ ] . there are a number of considerations related to adr reporting. for instance, health care providers are more likely to report adrs that are serious and unexpected. it has also been observed that new drug products tend to generate more reports than older products [ ] . as observed in a study by li q et al., healthcare professionals in wuhan, china lack the understanding of properly reporting adrs [ ] . the current covid- crisis has brought about fear and uncertainty in many, resulting in an increased demand for effective antiviral therapies against covid- . there are several potential therapies coming out against covid- , however patients and healthcare professionals must understand that these are only preliminary trial results and they need more study to fully understand their efficacy and side effect profiles [ ] . unfortunately, the media and certain public figures promote therapies that are not yet proven leading to people taking medications inappropriately and experiencing some severe adrs. in an era where medication misinformation is rampant, quality pharmacovigilance has become more important than ever. healthcare professionals generally understand the value of reporting; however, many are not fully aware of the mechanisms for reporting [ , ] . some of the main reasons for not reporting include: lack of time, complex documentation, lengthy reporting procedures, failure to recognize an adr, patient confidentiality concerns, and fear of blame. there is also a lack of routine, structured reporting and shared motivation [ ] . there has been a debate amongst healthcare providers and the public regarding what, when and how to report adrs. there is an opportunity to promote adr reporting and learning through increased educational sessions at schools, universities, medical associations, and in community outreach programs. there is also a need for more guidance from the professional regulatory authorities and associations. effective reporting and education related to adrs is a component of public health and safety. the sample size of the patient population and the limited duration of clinical studies do not provide the full evidence of a drug's safety profile. post-market surveillance is critical. when a larger population of patients use a medication, rare adrs can be captured if they get reported. figure newly marketed medications and devices are important to monitor closely for safety. the side effects of a medication could be well known, but there might be uncertainty about the serious reactions that warrant reporting. serious reactions requiring reporting are those that are fatal, life-threatening, disabling, or require hospitalization. it is always important to keep an open channel of communication between patients, physicians and pharmacists in order to ensure that patients are clear about the reporting process. delayed reactions must also be monitored, as these reactions may not occur immediately after the administration of a medication. delayed reactions may take several days to weeks to appear. adrs in children and the elderly are especially important to report since they are more susceptible to the adverse effects of drugs. elderly populations tend to take multiple medications for a wide range of comorbidities, and they may also have altered pharmacokinetic and pharmacodynamic responses to medications. patients are most affected by medications: therefore it is important to collect their experiences and analyze them. at each communication with a patient, whether in the hospital or community setting, we need to incorporate medication safety questions into our discussions [ ] . adrs are a major concern for patients when they start new medications. adapting to health canada's new mandate will require important changes to ensure quality reporting unfortunately, healthcare settings are plagued with heavy workloads, multitasking, constant interruptions, and labor shortages [ ] . for this reason, patients might feel that they are a burden and may hesitate when it comes to reporting any side effects to medications. patients must be made aware of the " questions to ask about your medications" [ ] . having these questions on a poster board in the pharmacy or hospital might help to remind and encourage patients to actively seek answers to any questions they may have about their medications. if patients are not comfortable speaking to their own health care provider about their medication fig. examples of instances for adr reporting. several types of adrs warrant reporting to health canada. all suspected serious adrs must be reported, as well as delayed or quick onset adrs. even when an adr is not certain, it is best practice to report the event to health canada concerns, there should be a staff member available in the hospital that could readily document their medication concerns and relay that information to a qualified health care professional. improving the safety of medications is one of the most significant ways in which we can enhance the quality of healthcare. ismp canada is an organization put in place to advance medication safety and to ensure reliable medication practices in all points of healthcare. to further improve adr reporting, ismp canada has made an anonymous reporting tool available to health professionals and patients, where they could report any medication incidents [ ] . the new regulation mandating the reporting of serious adrs and mdis by hospitals will have a large administrative and operational burden on hospital pharmacists and other hospital workers. furthermore, mandatory reporting may adversely impact the hospital budget as well as the quality of care offered to patients [ ] . therefore, the involvement of a senior leadership team dedicated to complying with the new regulations will greatly facilitate quality reporting. it would be detrimental to patient care if the current front-line hospital providers were to be diverted from their current roles in order to invest more time into reporting adrs to health canada. hospitals are required to report serious adrs and mdis for prescription and non-prescription medications, biologic drugs, radiopharmaceuticals, disinfectants, medical devices, and drugs needs for emergency public health purposes [ ] . senior leadership teams could be trained on using the various reporting platforms quickly and efficiently so that this new mandate does not compromise the workflow at the hospital. the front-line healthcare professionals must document any serious adrs as always, however the designated leadership team could be given specific internal roles and responsibilities at the hospital to evaluate these adrs, categorize them, and determine whether they warrant reporting to health canada. it is important to note that hospitals are currently required to report all documented serious adrs and mdis, regardless of whether the event initially occurred in the hospital [ ] . these reports must be as thorough and as complete as possible in order to help health canada's assessment of causality. furthermore, if new information becomes available relating to a patient's previous adr or mdi, the hospital must send follow-up information to health canada [ ] . moreover, leadership teams could be involved in implementing a tracking system for the reports made in the hospital. this would be to ensure facilitated communication between health canada and the hospital, in case there are any follow-up questions pertaining to an adr report. furthermore, one of the key roles of pharmacists in the hospital setting is to conduct best possible medication histories (bpmhs), which means that they review the medications that the patient takes prior to coming to the hospital. during this standardized interview, pharmacists can pick up on any drug therapy problems, including adverse effects to medications. as such, having pharmacists in the leadership team conducting bpmhs could be an efficient way in interviewing patients for potential adrs or mdis. this would ensure that there is a standardized protocol in place to gather all of this pertinent information in an efficient manner. some future steps could be to conduct surveys in all provinces to see how this new regulation has been implemented so far. we can also analyze the mechanisms that the various provinces use to report, and subsequently compare the efficiency and quality of individual province reports. with the newly implemented regulations for mandatory reporting of serious adrs, there is an opportunity to utilize technologies and systems to facilitate reporting and capture big data. health care providers have many demands on their time and this is an important factor that warrants discussion at all levels in the organization/facility. this work requires integration of information in technology systems (e.g. electronic health record, incident reporting systems and or health record coding processes) to enable different systems to submit information to health canada. health canada is providing data transfer mechanisms for submission of data [ ] . organizing an adr awareness week and including a national education day throughout canada could help to engage and educate more canadians. creating a positive reporting culture is a shared responsibility and requires more than one individual. healthcare providers may have a different opinions when it comes to deciding whether certain cases require submission as a serious adr. an email back to the identifier or reporter will work as a guidance and education tool for the next reporting, since the one reporting will know whether or not health canada classified their event as an adr. this feedback function will make health care providers feel appreciated and heard, which will allow for an open channel of communication between reporters and heath canada. creating a culture of reporting and culture of safety is important to encourage all to report with no fear. the communication and collaboration between health care authorities and identifiers/reporters will be instrumental in increasing the rate of reporting. the pharmacist has a duty to report adrs, but so do patients. medical and pharmacy schools also have a responsibility for teaching about adr reporting and implementing a culture of public safety to educate students. distributing posters at health care facilities will be an important first step in opening a discussion about adr reporting. additionally, each hospital needs to work out all logistics that become a barrier to reporting by creating free time to report and receive proper education. there seems to be a misconception that reporting an adr is equivalent to reporting the side effect of a medication. it is important to educate nurses and patients on what are the main differences between a side effect, allergies and adr to ensure we do not over-report by mistake. over reporting may be recommended in grey areas when we are in doubt. additionally, for those patients who are not comfortable using internet tools to submit the form, they should have another option such as reporting by phone. caregivers or family members are encouraged to report for their child or for somebody else they care for. lastly, we need to remind our patients to report any adr related to over-the-counter (otc) medicines in addition to prescribed medicines. patients with adrs related to the use of otc medications are recommended to consult a pharmacist or be medically confirmed by a physician if possible. adrs, hence having a tracking centralized tool/function at each hospital, could help to track and monitor for improvement. improved reporting will have an impact on global health and public safety. canada h mandatory reporting of serious adverse drug reactions and medical device incidents by hospitals -overview international drug monitoring: the role of national centres the canadian adverse events study: the incidence of adverse events among hospital patients in canada under-reporting of adverse drug reactions : a systematic review pharmacovigilance in resource-limited countries awareness and attitudes of healthcare professionals in wuhan, china to the reporting of adverse drug reactions attitudes among hospital physicians to the reporting of adverse drug reactions in sweden responses from the canadian society of hospital pharmacists to questions related to mandatory reporting of adverse drug reactions and medical device incidents by provincial and territorial healthcare institutions medication incident data in canada: a strategy for more effective sharing and learning, ismp canada information for clinicians on therapeutic options for covid- patients questions to ask about your medications. questions to ask publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations i would like to acknowledge the support from the pharmacy team in facilitating the data collection. ali elbeddini (primary and corresponding author): original manuscript preparation, conceptualization, data curation, analysis of the paper, literature search, data collection, writing, reviewing and editing, driving for the ideas and thoughts, topic expert as safety officer of the organization. aniko yeats: drafting the manuscript, literature review, editing and review, data analysis, collecting data. stephanie lee: drafting the manuscript, literature review, editing and review, collecting data. the author(s) read and approved the final manuscript.funding i know of no conflict of interest with this publication, and there has been no financial support for this work that could have influenced the outcome. data sharing is not applicable to this article as no datasets were generated or analysed during the current study. no known competing interest to declare. key: cord- -xcre zgh authors: harvey, bart j.; moloughney, brent w.; iglar, karl t. title: identifying public health competencies relevant to family medicine date: - - journal: am j prev med doi: . /j.amepre. . . sha: doc_id: cord_uid: xcre zgh public health situations faced by family physicians and other primary care practitioners, such as severe acute respiratory syndrome (sars) and more recently h n , have resulted in an increased interest to identify the public health competencies relevant to family medicine. at present there is no agreed-on set of public health competencies delineating the knowledge and skills that family physicians should possess to effectively face diverse public health challenges. using a multi-staged, iterative process that included a detailed literature review, the authors developed a set of public health competencies relevant to primary care, identifying competencies relevant across four levels, from “post-md” to “enhanced.” feedback from family medicine and public health educator–practitioners regarding the set of proposed “essential” competencies indicated the need for a more limited, feasible set of “priority” areas to be highlighted during residency training. this focused set of public health competencies has begun to guide relevant components of the university of toronto's family medicine residency program curriculum, including academic half-days; clinical experiences, especially identifying “teachable moments” during patient encounters; resident academic projects; and elective public health agency placements. these competencies will also be used to guide the development of a family medicine–public health primer and faculty development sessions to support family medicine faculty facilitating residents to achieve these competencies. once more fully implemented, an evaluation will be initiated to determine the degree to which these public health competencies are being achieved by family medicine graduates, especially whether they attained the knowledge, skills, and confidence necessary to effectively face diverse public health situations—from common to emergent. introduction e vents such as severe acute respiratory syndrome, and more recently h n , are examples of public health situations faced by family physicians and other primary care practitioners. these events, in conjunction with other public health issues such as vaccinepreventable infections and rising rates of obesity and the associated health challenges, have resulted in an increased interest in the interface between primary care and public health (e.g., the iom's consensus study ) and in better identifying public health competencies relevant to family medicine so that family physicians and other primary care practitioners might better appreciate the population-wide perspectives of public health issues. however, at present there is no agreed-on set of public health competencies that family physicians and other primary care practitioners should attain to better ensure they possess the necessary knowledge, skills, and confıdence to effectively face diverse public health situations-from common to emergent. using an iterative consultative process, the authors developed a set of public health competencies relevant to family medicine and primary care. this process began with planning for a -day, pan-canadian, family medicine-public health symposium that was held in march . this symposium arose out of discussions at the pan-canadian public health human resources task force concerning the role of primary care practitioners in canada's public health workforce. the primary goals of the symposium were to identify: ( ) the public health competencies that family medicine residents should possess at graduation; and ( ) the primary care competencies that community medicine residents should possess at graduation. to help address these goals, a presymposium discussion document was prepared by reviewing existing documents to develop an initial competency draft using a "multi-level competency model" developed by the university of toronto's department of family and community medicine. the resources accessed and reviewed to inform the preparation of the presymposium discussion document included: cation (acgme) statement regarding the community medicine objectives required in family medicine residency programs ; • the acgme statement regarding the requirements for residency programs in public health and general preventive medicine. a search of the literature, coupled with suggestions from individuals consulted, identifıed several other relevant and informative canadian, , american, [ ] [ ] [ ] [ ] [ ] british, - and australian - publications. these were also reviewed and assisted the development of a draft set of public health competencies relevant to family medicine and primary care. four levels of competencies were drafted, following the model developed in toronto's department of family & community medicine, which spans resident-readiness (expected of all md graduates), essential (expected of all family medicine graduates), enriched (achievable by most residents during family medicine residency training), and enhanced (achievable only through additional training after the family medicine residency). following the review of existing documents and preparation of the presymposium discussion document, the authors identifıed and used eight themes to guide the development of the draft set of competencies. these eight themes were: • disease prevention and health promotion; • infectious disease prevention and control; • emergency preparedness and response; • environmental health; • systems thinking, public health leadership, and management; • population health assessment; • policy, planning, communication, collaboration, and advocacy; • scholar and educator. a variety of family medicine and public health educatorpractitioner colleagues reviewed and provided feedback concerning the proposed draft set of competencies. the fırst group of reviewers was the program directors and residents who participated in the march pan-canadian family medicine-public health -day symposium. this group included residency directors (six family medicine, six community medicine) and residents (six family medicine, six community medicine) from across canada. the presymposium discussion document, which included a proposed set of draft competencies, was distributed to the participants for their review prior to the symposium. the draft competencies served as the major item for discussion by the participants during the symposium's plenary and small group discussions. symposium discussions enabled the authors to further revise the discussion document and proposed set of competencies. this revised draft was then sent to all symposium participants for additional review and feedback, which resulted in the proposal of a detailed set of public health competencies relevant to family medicine and primary care (appendix b, available online at www.ajpmonline.org). this detailed set of competencies was presented at the october family medicine forum, canada's annual family medicine conference. feedback received from conference participants suggested further revisions to the competency draft, particularly the need for a more limited, feasible set of "priority" areas to be focused on during residency training, especially because of the limited duration of family medicine residency training programs-being only years in canada and years in the u.s. as a result, the authors sought further feedback from interested family medicine and public health practitionereducators and residents from across canada to identify a more focused set of priority areas to be emphasized during residency training. these colleagues were asked to rankorder the public health competencies that they considered essential for any graduating family medicine resident. with this advice, the authors identifıed a priority list of eight competency areas: • the basic fundamentals of outbreak/emergency preparedness and management; • offıce infection control; • infectious disease reporting and management; • environmental health exposure reporting; • public health aspects of immunization; • public health programs applicable to primary care (e.g., maternal-child health); • addressing and managing one's practice as a population (e.g., developing practice health profıles and using quality assurance to increase the delivery of preventive services); • the principles and practices of screening (i.e., early detection and treatment) of diseases. public health is only one of competency domains in the university of toronto's family medicine residency program's recently developed competency-based curriculum (other domains include child health, women's health, and mental health). to ensure the overall coherence of the proposed sets of competencies, a full review was completed by a diverse group of family medicine leader-educators at a departmental retreat in april . a key fınding arising from this review was that only focused, essential competencies could be realistically identifıed within each of these domains. this resulted in fıve public health competencies being identifıed and approved for inclusion in the competency-based residency curriculum, each accompanied by one or more enabling subcompetencies. these fıve overarching public health competencies are: • demonstrate an effective approach to disease prevention and health promotion; • demonstrate an effective approach to infectious disease prevention and control, including outbreaks; • demonstrate an effective approach to environmental health issues; • develop and apply the knowledge and skills necessary to assess a population's health; • demonstrate an effective approach to public communication, collaboration, and advocacy. this more focused set, with the accompanying enabling competencies and a listing of suggested relevant topics for each, is included in appendix a. it should be noted, however, that the more extensive complete set of public health competencies relevant to family medicine (appendix b, available online at www.ajpmonline.org) is expected to continue to serve as the comprehensive listing to complement the more focused set of essential competencies and as the primary listing of the enriched and/or enhanced public health competencies relevant to family medicine and primary care. the focused set of public health competencies approved by the university of toronto for family medicine (ap-pendix a) has begun to guide its family medicine residency program curriculum, including resident seminars; family medicine clinical experiences, especially identifying teachable moments that occur during patient encounters; elective public health agency placements; and topics selected for the required resident research project (e.g., the prevalence of chlamydia, a profıle of those infected with h n influenza). these competencies will also be used to guide the development of a family medicine public health primer that would complement the association of faculties of medicine of canada's primer on population health developed for medical students, and faculty development sessions to support the family medicine faculty facilitating residents in their achievement of these competencies. once it is more fully implemented, an evaluation will be initiated to determine the degree to which these public health competencies are being achieved by family medicine graduates, especially whether they attained the knowledge, skills, and confıdence necessary to effectively face diverse public health situations-from common to emergent. it is anticipated that the experience gained through the implementation of the proposed set of competencies (and their evaluation), at the university of toronto and other family medicine residency programs where they are implemented, will provide evidence of the utility and suitability of the proposed competencies and of further revisions that might be warranted. publication of this article was supported by the cdc-aamc (association of american medical colleges) cooperative agreement number u cd . no fınancial disclosures were reported by the authors of this paper. college of family physicians of canada. the role of the family doctor in public health and emergency preparedness. mississauga on: college of family physicians of canada study: integrity primary care and public health medical council of canada. objectives for the qualifying examination royal college of physicians and surgeons of canada. objectives of training and specialty training requirements in public health and preventive medicine rcpsc core competencies for public health in canada. ottawa on: government of canada a set of minimum competencies for medical offıcers of health in canada. ottawa on: public health agency of canada moh% competencies% -% final% -% clean-% post-v ( ). pdf?nsnst_floodϭe c e a d b f beee ae accreditation council on graduate medical education. acgme program requirements for graduate medical education in family medicine accreditation council on graduate medical education. acgme program requirements for graduate medical education in preventive medicine college of family physicians of canada. priority topics and key features for assessment in family medicine. mississauga on: college of family physicians of canada designing a curriculum in disaster medicine for canadian medical schools healthcare worker competencies for disaster training public health and family medicine: an opportunity clinical prevention and population health: curriculum framework for health professions public health educational intervention in a family medicine residency training physicians for public health careers public health and primary care: partners in population health royal college of general practitioners. the rcgp-gp curriculum statements general practitioners with a special interest in public health; at last a way to deliver public health in primary care royal australian college of general practitioners. the new curriculum framework enhancing the population health capacity of general practice: an innovative training model for general practice registrars population health and public health training for australian rural general practice registrars: a six year program primer on population health: a new resource for students and clinicians references for appendix a . college of family physicians of canada. priority topics and key features for assessment in family medicine. mississauga on: college of family physicians of canada essential competencies:a. demonstrate an effective approach to disease prevention and health promotion a . assess patient needs for immunization (routine and highrisk patients). a . counsel individuals/families to receive immunizations appropriate to their age and risk status. a . anticipate, recognize, and report potential adverse events. a . assess patients for sociobehavioral risk factors and risk conditions a in relevant populations.a . provide evidence-informed brief contact interventions to reduce the risk of chronic diseases and injuries. a . counsel and reinforce protective behaviors. a a . counsel patients in defıned risk populations to receive recommended routine screening for cancer. a a . identify families at high risk for developmental and parenting challenges and refer them to public health or appropriate agency for follow-up (e.g., home visiting program, dental health program).b. demonstrate an effective approach to infectious disease prevention and control, including outbreaks b . demonstrate routine infection control practices for the care of all patients at all times, including recommended offıce infection control practices. b . demonstrate transmission-based precautions in conjunction with routine practices when patients are suspected or confırmed of being infected with transmissible or epidemiologically signifıcant organisms. b . recognize and report cases of notifıable diseases, conditions, and unusual diseases or patterns to public health authorities. b . coordinate management of individuals and families with broader public health investigation. a b . describe roles and responsibilities in preparing for and responding to infectious disease outbreaks, and other health emergencies and disasters. b . triage patients in an infectious disease outbreak, and other health emergencies and disasters.c. demonstrate an effective approach to environmental health issues c . recognize features of community health determinants, patient history, symptoms, and signs that trigger differential diagnoses that include exposure to an environmental health hazard. c . report potential cases to public health authorities for patients or populations who are likely being affected by an exposure to an environmental health hazard.d. develop and apply the knowledge and skills necessary to assess a population's health d . describe how the determinants of health a affect the health of one's patients and practice population. d . describe how a community's profıle of determinants of health a contributes to the occurrence of selected conditions. d . discuss a community's health needs considering underlying determinants of health, a evidence for effective interventions, and existing services. d . assess a practice population's status for clinical preventive services (e.g., immunization rates, cancer screening rates, and sociobehavioral risk factors and conditions). d . apply evidence-informed practice strategies to improve patient population coverage for preventive services (e.g., routine questions, chart/computer reminders/prompts, patient invitations/recalls). d . describe the complementary roles of family medicine and public health in achieving the prevention and control of conditions of public health interest.e. demonstrate an effective approach to public communication, collaboration, and advocacy e . communicate (when indicated) with individual patients, families, and the practice population regarding public health measures that concern their health and care. • education; • housing; • ses. supplementary data associated with this article can be found, in the online version, at doi: . /j.amepre. . . .did you know? you can listen to podcasts featuring kenny goldberg, health reporter for npr radio in san diego, as he interviews select ajpm authors. go to www.ajpmonline.org/content/podcast_collection to download the podcasts! key: cord- -kl a au authors: majowicz, s. e. title: what might the future bring? covid- planning considerations for faculty and universities date: - - journal: epidemiol infect doi: . /s sha: doc_id: cord_uid: kl a au this paper applies a scenario planning approach, to outline some current uncertainties related to covid- and what they might mean for plausible futures for which we should prepare, and to identify factors that we as individual faculty members and university institutions should be considering now, when planning for the future under covid- . although the contextual focus of this paper is canada, the content is likely applicable to other places where the covid- epidemic curve is in its initial rising stage, and where universities are predominantly publicly funded institutions. at the start of april , the human health and disruptive effects of the covid- pandemic were being felt globally. academia has responded in multiple ways, from suspending in-person classes following social distancing directives, to mobilisation of those disciplines directly related to response efforts. for example, numerous modelling studies have been produced that illustrate the anticipated impacts of various interventions (e.g. social distancing) on the epidemic curve of covid- [ , ] . while these models show epidemic curves that stretch into the fall and into , there are sufficient uncertainties (e.g. how long will immunity last?) and complex dynamics (e.g. how will citizens react as social distancing measures remain in place?), meaning such results should not be used as the sole basis for planning for the future. in , the public health agency of canada (phac) produced a planning document, to help prepare for canada's anticipated fall wave of pandemic h n influenza [ ] . this document contained: (a) descriptions of plausible future scenarios for how canada might experience the pandemic; and (b) planning considerations for phac including factors that could impact human and financial resources. the phac report was underpinned by two planning methodologies: scenario planning [ ] , which aims to describe the range of plausible futures so that decisions and plans can be robust in the face of uncertainty; and a modified political, economic, social, technological (pest) analysis [ ] , a framework for identifying macro-level factors in the wider environment that can impact organisations' abilities to function. its purpose was to prepare phac staff to think about the different ways the future could unfold, and to think about the different factors that could impact the way they did business, so that planning and decisions could be more robust and less likely to be thwarted by surprise. this paper applies a similar approach, in order to: (a) outline some current uncertainties related to covid- , and what they might mean for plausible futures for which we should prepare; and (b) list factors that we as individual faculty members and university institutions should be considering now, when planning for the future under covid- . although the contextual focus of this paper is canada, the content is likely applicable to other places where the covid- epidemic curve is in its initial rising stage, and where universities are predominantly publicly funded institutions. given that the pandemic is rapidly evolving, the applicability of this work to various contexts is also expected to change over time. there are several key 'axes of uncertainty' about how the pandemic will unfold in canada, that we should consider when planning for the future, for time horizons of the fall term (september to december ), the / academic year (september to august ) and beyond. these axes should be considered together, not singly. social distancing/activity restrictions: from 'even more lockdown', to 'returning to usual' will we still be social distancing, like we currently are, in the fall? will we have had to sustain the current level of social distancing from march to september? or will there be some sort of lifting (and reinstating?) of measures and restrictions? will measures be similar to how they are now, or less restrictive, or more restrictive? will measures be applied as broadly as they are now, or become more targeted to specific groups, characteristics or functions? these uncertainties mean that we could find ourselves in situations like 'things are similar to what they are now', or 'things are more restrictive, and we need to deliver upcoming terms even more remotely' or 'things are back to normal, but with uncertainties and the need to change quickly if the virus throws us a curveball or three'. impact on our people: from 'on our radar but rare', to 'big losses, heavy impacts' at the time of writing, most individuals within the university community (and ontario and canada as a whole) are mainly impacted by covid- via the social distancing measures currently in place, but it is reasonable to expect that the direct health impacts of the virus will become more widely felt. how many of our staff, faculty, and students will get sick? will we lose substantial workforce capacity (e.g. capacity for individual research projects, for university-wide operations, or to cover for absent instructors and administrators)? if we lose workforce capacity, will it be widespread or localised, ongoing or sporadic? will we face widespread grief, burnout and mental health impacts related to illness, intensive care, intubation, death or isolation? how will those populations currently marginalised by society or within the university community be disproportionately impacted? how will these impacts intersect with our cultures and customs? these uncertainties mean that we could find ourselves in situations like 'most people are not feeling substantial personal impacts', as we are now, to 'many people are substantially impacted' (e.g. they are sick or dealing with death and grief of family, friends and colleagues, there are deaths among the university community, there is a noticeable loss of workforce). universities as part of society: from 'doing what we usually do', to 'widespread mobilisation' at the time of writing, most of the university community (i.e. staff, faculty and students) are in the same roles and with essentially the same responsibilities as they were pre-pandemic. and although we are seeing academia voluntarily donating goods (e.g. personal protective equipment, reagents, swabs) and services s. e. majowicz (e.g. medical students conducting contact tracing) [ , ] , the vast majority of university physical and human resources are still being used for the same purposes as they were pre-pandemic. a widespread and often subconscious assumption people seem to be making is that our roles and responsibilities as individual faculty or as universities, for example, are guaranteed to continue to be 'business as usual, albeit maybe remotely'. will we all stay in our roles as usual (even if working remotely)? will university resources be called upon in new ways to help the pandemic response, for example using laboratory or dormitory space for testing and community care? [ ] will we 'lose' faculty, staff or students to front-line institutions so they can help aide response efforts, and if yes for how long? will public funding for universities be diverted? will immune individuals be mobilised (e.g. to fulfill essential public/ in-person functions, to donate plasma)? these uncertainties mean that we could find ourselves in situations like 'we are doing the same business we've always been doing', to 'ad hoc or individual volunteering of physical and/or human resources to support pandemic responses', to 'universities are obligated to repurpose resources to aide in the pandemic response', or perhapsin the most extremeeven to 'universities see their public funding diverted to pandemic response'. there are many dynamic factors influencing the pandemic and how it will unfold. considering and organising these factors by characteristics that predispose people to severe outcomes assess which segments of the university community are particularly vulnerable to severe outcomes, and create policies or accommodations to ensure adequate protection. because the duration of immunity is unclear, prepare for a possible future where a proportion of the university community is susceptible (and perhaps in isolation) at any given time. distribution of cases/death (e.g. by age, sex, risk factors) assess which segments of the university community are particularly vulnerable to illness/death; beyond policies/accommodations to protect them, create contingency plans to function in their absence (e.g. the older cohort of faculty and staff). social, economic factors create flexible options (e.g. for remote classes) that function in the face of changing socio-economic disadvantage (e.g. ability to afford internet connections) and broader social forces (e.g. caregiving responsibilities). groups that society/academia marginalises, or excludes from power, privilege create equitable institutional policies that adequately support groups that are typically marginalised or excluded. compliance consider situations where staff, faculty and students may not, or cannot, comply with public health directives or organisational policies, and create incentives for compliance (e.g. adjusting performance assessments so those whose research suffers when on-campus activities are suspended are not disproportionately disadvantaged). workforce availability consider how a proportion of the population ill or unable to work may drive the availability of external or temporary workers (e.g. sessional lecturers paid per course, casual staff), by reducing broader workforce availability while also increasing the demand for highly qualified individuals. political decisions make contingency plans in case political decisions (e.g. restrictions on supplies, protectionist policies) impact activities (e.g. ability to share data, research resources). social, political appetite for new ways of working consider how successfully conducting university activities under pandemic conditions (e.g. delivering remote classes) may lead to post-pandemic views on how universities can/should function (e.g. push for cost-saving, multi-institution online courses). equitable access to technology identify how issues like cost, geographic availability and connectivity to different technologies can (dis)advantage different groups (e.g. rural students with intermittent internet may attend fewer video classes). workforce capacity make contingency plans for classes, research projects and administrative tasks that account for some % of the workforce missing, some % at less than full capacity (overall, and at different times), and absent expertise, experience, authority and skills (e.g. identify instructors to cover different courses in the event of sudden illness/absenteeism). trust and reputation identify core business functions that rely on reputation and trust (e.g. universities' abilities to recruit students; researchers' abilities to build and sustain partnerships), and ensure all actions do not erode said trust/reputation (e.g. ways that students are treated during the pandemic will demonstrate how the institution values students). faculty expertise identify ways to reconsider workload, so faculty experts critical to the pandemic response (e.g. mathematical modelling, epidemiology), and key to the organisation's own planning (e.g. scenario planning, digital pedagogy, crisis communication, ethics) can devote adequate time to new activities. broad categories can challenge us to think broadly and plan for influences from 'unexpected' domains. the pest framework [ ] uses political, economic, social and technological categories, which the phac h n planning document [ ] expanded to also include: the disease; population vulnerabilities; regulatory factors and the capacity to respond. other expansions of the pest framework include environmental, legal and ethical categories [ , ] . a diagram showing the types of factors within these categories is given in figure , and table presents a selection of these factors, together with practical ways that faculty and universities might consider them in their planning. such planning can draw on existing contingency planning literature, including in the areas of outbreaks, disaster and emergency response and business operations, e.g. [ ] [ ] [ ] . as well, such planning can and should be undertaken at all levels within academic institutions, in that individuals, departments and institutions can all evaluate their activities and abilities to deliver core business functions in light of the factors presented here. for example, individual researchers and research groups can conduct continuity and contingency planning for research projects, laboratory functions and graduate student theses. departments and institutions can, for example, create contingency plans for teaching commitments and administrative functions by identifying back-ups, or determining which can be temporarily suspended. additionally, departments and institutions can take a unit-or organisation-wide approach to allocating or redistributing common resources (e.g. online teaching supports) to best serve the needs of the whole. it is important to note that the factors and examples provided here do not form a complete list, and that different individuals, departments and institutions will have specific or unique issues with which they will have to deal (e.g. disruption of in-person data collection such as visit schedules for clinical trials). thus, comprehensive planning should include a full assessment of possible issues specific to each individual, department or institution, and should not be limited to the factors and examples presented here. given the range of uncertainties we currently face with covid- , and the numerous broader forces that will influence how the pandemic will unfold, what concrete actions can we take? first, we can use the possible future situations to 'test' how well the decisions and plans we are currently making could hold up, under a range of different futures. for example, in preparing courses for fall offerings, we might choose to build in flexibility to allow pivoting between in person and remote delivery quickly, should the pandemic shift. second, we can use the possible future scenarios to ask 'what plans would i wish i had implemented now, if this future comes to pass?'. for example, research project supervisors can consider what alternate training to give graduate students and technical staff now, so they can cover for each other in case of illness and absence. third, we can use the broad list of factors to 'test' whether decisions and plans being made now might need to change if these factors change. for example, researchers and departments can consider how they would need to respond to future declines in graduate enrollment, for example to minimise impacts on research projects and teaching assistant capacities. or, as another example, staying abreast of information about predisposing factors (e.g. comorbidities) and immunity will allow institutions to remain flexible so our most vulnerable can continue to self-isolate at home even if social distancing measures lift. fourth, we can apply an equity lens throughout our planning and decision-making, to ensure thatat a bare minimumwe do not perpetuate or amplify existing barriers or disadvantages because of our individual and organisational decisions. covid- is manifesting in a world that is gendered [ ] , ableist [ ] and racialised [ , ] , and it behooves each of us to ensure our individual and organisational responses work to oppose discrimination. specifically, we can work towards equitable policies, plans and decisions by taking three actions, by 'valuing all individuals and populations equally, recognising and rectifying historical injustices and providing resources according to need' [ ] . finally, the axes of uncertainty and macro-environment factors given here can be expanded, both as the pandemic unfolds and new knowledge is generated, and by integrating perspectives from a wide range of backgrounds (e.g. economics, ethics, history, sociology, geography, planning) to identify additional key uncertainties about the future and key planning considerations. additionally, individuals and institutions in locations that are further along in the pandemic (e.g. asia) can delineate additional uncertainties and macro-environmental factors, for example those related to lifting social distancing measures, planning for subsequent potential waves, rebuilding resources or dealing with longer-term health and other impacts of both covid- and our responses to it. it will also be critical to hear how faculty and universities decide to deal with these issues, including in real time and via post-pandemic assessments (such as those aimed at improving pandemic plans). nevertheless, this paper can function as a starting point for individual and institutional planning, and to initiate conversations of how academia can plan for an uncertain future under covid- . report -estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries mathematical modeling of covid- transmission and mitigation strategies in the population of ontario a tool for the potential fall wave of pandemic h n to guide public health decision-making: an overview of the public health agency of canada's planning considerations living in the futures scanning the business environment canadian universities heed the call for help in the fight against covid- university of calgary medical students quadruple province's covid- contact-tracing capacity mayor: new haven asks for coronavirus housing help using the spelit analysis technique for organizational transitions healthcare public-private partnerships in italy: assessing risk sharing and governance issues with pestle and swot analysis contingency planning: preparation of contingency plans clinical review: mass casualty triage -pandemic influenza and critical care economic community of west african states disaster preparedness tabletop exercise: building regional capacity to enhance health security covid- : the gendered impacts of the outbreak preventing discrimination against people with disabilities in covid- response racism and discrimination in covid- responses stop the coronavirus stigma now systems of power, axes of inequity: parallels, intersections, braiding the strands acknowledgements. i thank both referees for their constructive input during their review of this paper. in particular i thank referee for noting some specific issues with which certain departments must deal (e.g. disruption of visit schedules for clinical trials), and referee for the suggestion of the diagram in figure .financial support. this research received no specific grant from any funding agency, commercial or not-for-profit sectors. s. e. majowicz reimbursed travel to attend face-to-face meetings. she has previously provided unpaid expertise as a member of the scientific advisory committee for cancer care ontario's infectious agents and cancer report, and the foodnet canada (formerly c-enternet) advisory committee (phac). key: cord- -kp ik qb authors: blair, a.; warsame, k.; naik, h.; byrne, w.; parnia, a.; siddiqi, a. title: identifying gaps in covid- health equity data reporting in canada using a scorecard approach date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: kp ik qb objective: to assess health equity-oriented covid- data reporting across canadian provinces and territories, using a scorecard approach. method: a scan was performed of provincial and territorial reporting of five data elements (cumulative totals of tests, cases, hospitalizations, deaths and population size) across three units of aggregation (province or territory-level, health regions, and local areas) ( "overall" indicators), and for two vulnerable settings (long term care and detention facilities) and six social markers (age, sex, immigration status, race/ethnicity, essential worker status, and income) ( "equity-related" indicators). per indicator, one point was awarded if case-delimited data were released, . points if only summary statistics were reported, and if neither was provided. results were presented using a scorecard approach. results: overall, information on cases and deaths was more complete than for tests, hospitalizations and population size denominators needed for rate estimation. information provided on jurisdictions and their regions, overall, tended to be more available (average score of %, "b") than for equity-related indicators (average score of %, "d"). only british columbia and alberta provided case-delimited data, and only alberta provided information for local areas. no jurisdiction reported on outcomes according to patients' individual-level immigration status, race, or income. only ontario and quebec provided detailed information for long-term care settings and detention facilities. conclusion: socially stratified reporting for covid- outcomes is sparse in canada. however, several best practices in health equity-oriented reporting were observed and set a relevant precedent for all jurisdictions to follow for this pandemic and future ones. early reporting by regional and provincial jurisdictions in canada suggests that like in other countries such as the united states of america (usa), , social inequities in outcomes have emerged in canada. in ontario, for instance, higher rates of covid- incidence, hospitalization, and death have been observed in lower-income areas and areas with higher densities of immigrant and racialized residents. toronto has reported that % of covid- cases with available race data, identified between mid-may and mid-july , occurred among racialized residents, despite these residents representing % of the city's population. these early reports of social inequities in covid- outcomes beg several questions for public health policy and intervention. since the identification of these inequities is predicated on the availability and release of covid- surveillance data according to social markers, one fundamental question is how canada is doing, overall, in health equity-informed covid- data reporting across jurisdictions? knowing which inequities have emerged, and where, is a necessary first step in planning health equity-informed health policy and interventions. indeed, public release and reporting on surveillance data have been essential to inform epidemiologic research and modelling and public health interventions since the start of the covid- pandemic. presenting data disaggregated by social markers, such as sex or race, can ensure that social and political responses to the health crisis are sensitive to and designed to be effective against social disparities in outcomes. data transparency also serves to protect the public's trust in public health guidelines and ensure accountability. however, given that provincial and territorial rather than federal public health authorities are the primary entities collecting and reporting on health data in canada, public-facing output on local-or social marker-disaggregated data can vary across canadian jurisdictions. an assessment of both overall and health equity-oriented covid- data reporting in each canadian province and territory is needed to identify both best practices and reporting gaps. the objective of this study was to perform an environmental scan of covid- data reporting across canadian provinces and territories and to assess health equity-focused reporting using a scorecard approach. scorecards can be used to help track health-related trends or the quality of data reporting across jurisdictions . here, we build on the usa-based coronavirus in kids (covkid) tracking and education project's recently proposed covkid state data quality report card which was designed to identify gaps in covid- related surveillance in children. we propose the canadian covid- health equity data scorecard as an evaluation framework for the canadian context. a detailed environmental scan of official provincial and territorial public health websites and published reports was performed to identify reporting data content. reference websites used were those provided by the public health agency of canada on their centralized reporting website. provincial and territorial websites were searched for data summaries, figures, tables as well as downloadable reports (most often available in portable document (pdf) format), by navigating through websites and downloading and reviewing reports. the scan was performed between june and august , , and the results are accurate to the latter date. based on the minimum data requirements proposed by extant covid- data quality assessments, such as the covkid project data quality report card, we assessed provinces' and territories' reporting of five data elements: cumulative totals of tests performed, case counts, hospitalizations and deaths, as well as the availability of data on the size of populations of interest (i.e. the necessary denominator for rate estimation). we assessed the availability of these five data elements across three geographic units of population aggregation (overall province or territory-level, health region-or unit-level, and forward sortation area-level or small neighbourhood area equivalent). reporting on various levels of spatial aggregation was assessed given that transmission epidemiology and distributions . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint of risk factors can vary across jurisdictions. we also assessed data reporting across eight equityrelated indicator strata: two settings that have been particularly vulnerable to covid- outbreaks (long term care and detention facilities) , and six social markers (age, sex, immigration status, race/ethnicity, essential worker status, and income groups). the latter social markers have been identified as key social determinants of health and infectious disease burden . , with the five data elements across three units of population aggregation-overall and across eight social strata, indicators were used ( * * ( "overall" stratum + social strata) = ). as done for other scorecards, these indicators were selected for being measurable, relevant for health equity surveillance, actionable, and interpretable. indeed, precedent exists for surveillance reporting across all social markers used, including by race/ethnicity , and essential worker status -if not for covid- than other common health outcomes. , , for each of the indicators, point was awarded if raw, anonymized case-delimited data were released and publicly available (i.e. where each case represented one data row, available in a downloadable, and editable file format, such as in comma separated values (.csv) format). a total of . points were awarded if summary statistics were reported for the indicator, but no raw case-delimited data were publicly available, and a score of was awarded if neither information was reported nor data made publicly available. to contrast surveillance reporting across jurisdictions at a national scale, points were only awarded if the data element was available for the entire jurisdiction (i.e. not if data were only available for certain regions). we used a near-complete ( . points; intentionally higher than a half-point) and complete ( point) scoring system rather than a binary (present/absent, vs. point) method to acknowledge the relevance of summary statistic reporting, while rewarding jurisdictions that opted for full data transparency for public use-as done in peer nations such as the united kingdom and the united states. raw data sharing has been identified as a best practice in supporting innovation and research, advancing government accountability and evidence-informed decision-making. , , it also allows for an intersectional assessment of indicators. for example, the child health-. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint focused covkid scorecard found that though many states report on covid- outcomes by age and race, a limited number of states report on the race of cases by age group (thereby allowing for an assessment of racial disparities among children). the sharing of case-delimited data allows users to pursue these more precise lines of inquiry. a percent score was computed by dividing the sum of points awarded by the total number of indicators (n= ). two sub-scores were also computed, a score for "overall" data available for each level of aggregation overall ( data elements * population aggregation units * "overall" stratum = total score out of ) and an equity indicator score for reporting across the remaining social strata ( data elements * population aggregation units * social strata = total score out of ). we adjusted score denominators to take into account that reporting on some of the indicators, such as the cumulative total of deaths or hospitalizations, is less relevant in jurisdictions without any recorded cases or when case numbers are so low (i.e. n< ) that reporting may jeopardize patient confidentiality. when the total number of observations needed to estimate the indicator was less than , the indicators were removed from the denominator total. in that way, if one jurisdiction had not recorded any covid- cases, for example, it was not penalized for not reporting on cases by age, sex, etc. lastly, the following letter grades were associated with documented percent scores: % to % scores graded as "d", % to % as "c", % to % as "b", and % to % as "a". scores were estimated for each province and territory, and canada overall (figure , with detailed scores and sources in supplementary file, table ). on average, approximately half ( %) of the data elements were available at the overall jurisdictional, health region, and local neighbourhood level, while approximately one in five ( %) equity-related data elements were available. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : total-and sub-scores (for reporting on overall and equity-related data) in canada, by province and territory. note: a grade of "d" was attributed to scores of % to %; "c" to scores of % to %; "b" to scores of % to %, and "a" to scores of % to %. "pei" corresponds to prince edward island, "nwt" to northwest territories. all provinces and territories reported on the total number of tests and cases (figure a-b) , with british columbia and alberta providing case-delimitated data for all cases observed (figure b ). most jurisdictions also reported on the total number of hospitalizations that have occurred, however, these data were not provided by nova scotia, newfoundland, and the yukon ( figure . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint c). all jurisdictions that had identified cases reported on the total number of deaths (figure d ). alberta is the only province that reported on the outcomes (recovery or death) for each case, in a downloadable case-delimited format. lastly, population denominators for all jurisdictions were available through the canadian census. the overall number of tests conducted per health region was only available for half of the jurisdictions (figure a) . reporting on the total number of cases per health region was more complete, with british columbia and alberta both standing out as provinces that provide data on the region of residence for all identified cases (figure b) though population denominators are made available by statistics canada for all forward sortation areas in canada, no province or territory reported on the overall number of tests or hospitalizations at this level of population aggregation. alberta was the only jurisdiction to report on the number of cases and deaths (including the absence of the latter, n= ) for all local areas of residence-these were the only two data elements included in their reporting at the local arealevel. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : overall, province-and territory-level reporting (data availability) on the cumulative total of tests, cases, hospitalizations, and deaths. reporting (data availability) on the cumulative total of tests, cases, hospitalizations, and deaths, overall, for each health region or health unit within the province/territory. reporting, by province/territory, and by health region, on the cumulative total of tests, cases, hospitalizations, and deaths by social markers and vulnerable settings. acronyms: "bc" british columbia, "ab" alberta, "sk" saskatchewan, "mn" manitoba, "on" ontario, "qc" quebec, "nb" new brunswick, "ns" nova scotia, "pe" prince edward island, "nf" newfoundland, "nu" nunavut, "nt" northwest territories, "yu" yukon, "ltc" long-term care settings. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint information on population sizes by age and sex overall, and for regions and local areas is available through the canadian census. of all the social markers studied, age and sex were the characteristics for which covid- data reporting was most common. at the overall-level, almost all provinces reported on cases' age and sex distribution-save for newfoundland, which did not report sex-disaggregated case information (figure ) . british columbia and alberta were the only two provinces that provided age and sex characteristics of all cases, in a case-delimited format. the yukon, the only territory with over five recorded cases, did not report on cases' age nor sex (figure ) at the territory or regional level. in contrast, age-and sex-related information was sparser for testing, hospitalizations, and deaths across all jurisdictions overall and by health regions. only ontario consistently reported on all data elements by age and sex at the overall provincial and health region level (figure ). though information on population sizes by immigration status, race/ethnicity, and income are available for jurisdictions overall, and by region and local area are all available through the canadian census, no province or territory reported on any of the data elements according to these social markers (figure ) . at the overall level, on british columbia, alberta, saskatchewan and ontario provided information on cases among essential healthcare workers-with alberta providing this information at both the province and regional levels ( figure ) . however, the total number of essential workers at the provincial or territorial level, or by region or local area were missing for all jurisdictions. ontario, quebec, newfoundland, british columbia were the only jurisdictions that consistently provided detailed data on cases (and deaths) associated with long term care facilities-with . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint ontario and quebec including listing precise facilities (that could be geolocated in local areas) that had or were experiencing outbreaks. in the latter provinces, however, the total number of tests and hospitalizations recorded for patients or staff in these settings was missing, and only ontario provided data on the total number of beds per facility experiencing an outbreak-which could be used as a proxy for patient population size. quebec and ontario were the only provinces that reported on the total number of cases for each provincial detention facility. of these two, quebec was the only province to report on the total number of tests, deaths, number of prisoners, and cases among staff per facility. missing, however, was information on cases' potential hospitalization status. this paper provides the first summary of health equity-related covid- data reporting in canada. in canada, information on cases and deaths was more complete than for tests, hospitalizations and population denominators for all indicators. jurisdictions tended to report more completely on overall statistics than on information according to population sub-groups. the scan suggests that large gaps in reporting remain, even for more standard social disaggregation markers such as age and sex. though relatively uncommon across the country, certain "best practices" in reporting emerged. for example, two provinces (alberta and british columbia) provided case-delimited data on cases for external users to study. alberta was singular in reporting data elements for each of the three levels of geography: for the province overall, by health region, and by local area-level. ontario and quebec consistently provided detailed information for long term care settings, going as far as listing individual facilities that had or were experiencing outbreakswhich can enable the precise geo-location of facilities within neighbourhoods, for use in socio-spatial analyses of transmission risk. lastly, though ontario and quebec both provided details on cases within provincial detention facilities, quebec was alone in providing detailed information on covid- tests, deaths, prisoner population size, and cases within staff populations per detention facilities. these examples set important precedents and guidance for other jurisdictions to follow, especially as emerging evidence . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint suggests that if covid- outcomes are properly examined across population subgroups, underlying inequities can be revealed and addressed. , heterogeneities in reporting observed across canada are aligned with previous findings that public health surveillance infrastructures and capacities tend to vary across jurisdictions in canada-which had been identified as an area of concern for pandemic planning and preparedness following the sars outbreak in . this variability in resources across jurisdictions may limit capacities to collect necessary social data and report on findings across settings or social markers. exchange of promising practices-be it on equity-related reporting guidelines, questionnaires for social data collection, or data communication-may be beneficial to improve equity-related reporting in canada. the scorecard approach presented here can be used for continued assessesments of covid- surveillance reporting or adapted for use in future infectious disease outbreaks. however, the scorecard approach used has certain limitations. for one, a restricted list of social marker indicators was used. future expanded versions of an equity-oriented scorecard could assess covid- outcome reporting according to indicators such as preferred language, year of immigration, disability status, sexual orientation, housing status, level of social support, gender, indigenous identity, or education level. second, by evaluating provincial or territorial reporting, this scorecard assessment did not address more detailed reporting efforts in smaller public health units. for instance, detailed neighbourhood-level reporting efforts have been made by montreal public health and several public health units in ontario. the present scan was restricted to provincial and territorial reporting in order to contrast between jurisdictions on a national scale. future scans of best practices at the regional level may be warranted. further, this scan excludes information sharing by federal bodies such as the correctional service of canada's reporting on cases within federal penitentiaries. future reporting assessements asessing federal-level reporting may also be warranted. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint though some "best practices" in health equity-oriented reporting were observed in canada, equity data reporting is sparse and large gaps remain. since jurisdictions that have explored potential social inequities in covid- indicators have found stark gradients in outcomes across individual-and local-area level characteristics, the absence of reporting of data according to vulnerable settings or social markers may be concealing broader covid- -related inequities in canada. the proposed scorecard format and examples of "best practices" identified herein can be used to guide surveillance and reporting during this pandemic and in and future ones. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint covid- and the unequal surge in mortality rates in massachusetts, by city/town and zip code measures of poverty, household crowding, race/ethnicity,and racialized economic segregation disparities in incidence of covid- among underrepresented racial/ethnic groups in counties identified as hotspots during covid- laboratory testing in ontario: patterns of testing and characteristics of individuals tested, as of covid- infection in toronto: ethno-racial identity and income. covid- : status of cases in a primer for parliamentary action gender sensitive responses to covid- canada's - national action plan on open government institute for clinical evaluative sciences. mental health and addictions system performance in ontario: a baseline scorecard the coronavirus in kids (covkid) tracking and education project: state report card coronavirus disease (covid- ): epidemiology update testing lags and emerging covid- outbreaks in federal penitentiaries in canada. medrxiv impact of covid- on residents of canada's long-term care homes-ongoing challenges and policy response. ltccovid org, international long-term care policy network a conceptual framework for action on the social determinants of health determinants and drivers of infectious disease threat events in europe new zealand ministry of health. covid- : current situation -current cases covid-net: covid- -associated hospitalization surveillance network iowa department of public health. covid- in iowa: positive case analysis we ask because we care: the tri-hospital + tph health equity data collection research project report challenges and opportunities for surveillance data to inform public health policy on chronic non-communicable diseases: canadian perspectives. public health usa facts. coronavirus locations: covid- map by county and state -covid- deaths dataset accountability and monitoring government in the digital era: promise, realism and research for digital-era governance. canadian public administration open data and open governance in canada: a critical examination of new opportunities and old tensions national advisory committee; . . government of ontario. data standards for the identification and monitoring of systemic racism learning exchange: discussion on local socio-economic data during covid- author contributions: ab, ap, and as designed the scorecard framework. kw, hn, wb, and ab performed the environmental scan and collected the data for the study. ab drafted the manuscript, which was revised by as, ap, kw, hn, and wb. key: cord- -eo olu authors: chimmula, vinay kumar reddy; zhang, lei title: time series forecasting of covid- transmission in canada using lstm networks() date: - - journal: chaos solitons fractals doi: . /j.chaos. . sha: doc_id: cord_uid: eo olu on march (th) , world health organization (who) declared the novel corona virus as global pandemic. corona virus, also known as covid- was first originated in wuhan, hubei province in china around december and spread out all over the world within few weeks. based on the public datasets provided by john hopkins university and canadian health authority, we have developed a forecasting model of covid- outbreak in canada using state-of-the-art deep learning (dl) models. in this novel research, we evaluated the key features to predict the trends and possible stopping time of the current covid- outbreak in canada and around the world. in this paper we presented the long short-term memory (lstm) networks, a deep learning approach to forecast the future covid- cases. based on the results of our long short-term memory (lstm) network, we predicted the possible ending point of this outbreak will be around june . in addition to that, we compared transmission rates of canada with italy and usa. here we also presented the , , , , , and (th) day predictions for successive days. our forecasts in this paper is based on the available data until march , . to the best of our knowledge, this of the few studies to use lstm networks to forecast the infectious diseases. every infectious disease outbreak exhibits certain patterns and such patterns needed to be identified based on transmission dynamics of such outbreaks. intervening measures to eradicate such infectious diseases rely on the methods used to evaluate the outbreak when it occurs. any outbreak in a country or province usually occurs at different levels of magnitude with respect to time i.e. seasonal changes, adaptation of virus over time. usually patterns exhibited in such scenarios are non-linear in nature and this motivates us to design the system that can capture such non-linear dynamic changes. with the help of these non-linear systems, we can describe the transmission of such infectious diseases. in [ ] [ ] a transmission model for malaria and in [ ] a mathematical model for analysing dynamics of tuberculosis has been developed to study the transmission using mathematical models. in [ ] a laplacian based decomposition is used to solve the non-linear parameters in a pine witt disease. a modified sirs model in [ ] successfully helped to control the syncytial virus in infants. similarly mathematical models presented in [ ] , [ ] helped clinicians to better understand the characteristics of human liver and transmission of dengue outbreak. most of the data driven approaches used in previous studies [ ] are linear methods and often neglects the temporal components in the data. they depend upon regression without non-linear functions and failed to capture the regressive (ar) methods overwhelmingly depends on assumptions and such models are difficult for forecasting realtime transmission rates. wide range of statistical and mathematical models [ ] [ ] have been proposed to model the transmission dynamics of current covid- epidemic. in many cases, these models are not able to fit the given data perfectly and accuracy is also low while predicting the growth of covid- transmission. r is a popular statistical method specifically used to model an infectious disease. often referred as âĂŸreproduction numberâĂŹ because, the infections reproduce itself with respect to time. r forecasts the number of people can get the infection from the infected person. in this model, an extra weight is applied to the person who never infected the current disease nor vaccinated. if the value of r of a disease is , then the infected person will spread the disease to other people surrounding him. in [ ] authors used r method to find the infection rate of novel virus on diamond princes cruise ship [ ] . however, in such method it is difficult to find the starting point of the infectious disease by identifying patient zero and the people he interacted with during his incubation period. it is worth noting that mathematical models presented in [ ] , [ ] , [ ] can be used to solve the complex non-linear patterns of infectious diseases. even though these epidemiological models are good at capturing vital components of an infectious disease, parameters of these models required several assumptions. such hypothesized parameters would not fit the data perfectly and precision of such models will be low. meanwhile, in engineering applications [ ] , model parameters are calculated with the help of real-time data. similar approach was used in this research to find the model parameters instead of assumptions. in order to overcome the barriers of statistical approaches, we developed the deep learning based network to predict the real-time transmission. our model could help public health care providers, policy makers to make necessary arrangements to tackle the rush of potential covid- patients. this experiment is based on the data sets of confirmed covid- cases available until march , . artificial intelligence and mobile computing are one of the key factors for the success of technology in health care systems [ ] . in the world of smart devices, data is being generated in the unprecedented way than ever before and promoted the role of machine learning in healthcare [ ] . the world today is more connected than ever before this helped to share the real time infectious data between the countries. the distinctive feature of artificial intelligence is its flexibility, domain adaptation and economical to integrate with existing systems. over the last few weeks, many researchers came up with several mathematical models to predict the transmission of novel corona virus [ ] [ ] . the major drawbacks of the existing models are linear, non-temporal and several assumptions while modelling the network. first of all, the covid- is a time series data set and it is highly recommended to use the sequential networks to extract the patterns from it. second of all, the data we are dealing with is dynamic in nature so by using statistical and epidemiological models, results are often vague [ ] [ ] . in [ ] , [ ] , [ ] , [ ] researchers used deep learning based lstm networks to forecast covid- infections. the lstm models used in the above networks could not able to represent the spatio-temporal components simultaneously. in this paper we addressed the above problem by modifying the internal connections. in our modified lstm cells, we have established the alternative connections between the input and output cells. this type of connections not only helps the networks to preserve spatio-temporal components, but also to transfer the historical information to the next units. in this paper, we made an effort to predict the outbreak of covid- based on past transmission data. first of all, coherence of input data needs to be analyzed in order to find the key feature i.e. number of new cases reported with respect to the previous day infections. after selecting the key parameters of the network, several experiments was conducted to find the optimal model that can predict future infections with minimum error. previous studies on covid- predictions, did not considered the recovery rate while developing the model. in this research, we considered the recovery rate as one of the features while building our model. from the design point of view, when a crisis occurs, algorithms tend to assign high probability and completely neglects the previous information which leads to biased predictions. we addressed this issue in our literature and solved this by using lstm networks. our results are expected to alert the public health care providers of canada to prepare themselves for the crisis against covid- . with the help of this real-time forecasting tool, front-line clinical staff will be alerted before the crisis. the rest of this paper is structured as follows: section ii describes methods, datasets and lstm models used in this paper. in section iii, we have discussed our findings and in section iv, concussion and future work was discussed the covid- data used in this research is collected from johns hopkins university and canadian health authority, provided with number of confirmed cases until march , . the data set also includes number of fatalities and recovered patients by the end of each day. the dataset is available in the time series format with date, month and year so that the temporal components are not neglected. a wavelet transformation [ ] is applied to preserve the timefrequency components and it also mitigates the random noise in the dataset. the fundamental point to represent and forecast the trends of current is to select conventional functions to fit the data. the covid- dataset is divided into training set ( %) on which our models are trained and testing set ( %) to test the performance of the model. a large part of real-world datasets are temporal in nature. due to its distinctive properties, there are numerous unsolved problems with wide range of applications. data collected over regular intervals of time is called time-series (ts) data and each data point is equally spaced over time. ts prediction is the method of forecasting upcoming trends/patterns of the given historical dataset with temporal features. in order to forecast covid- transmission, it would be effective if input data has temporal components and it is different from traditional regression approaches. a time series (ts) data can be break downed into trend, seasonality and error. a trend in ts can be observed when a certain pattern repeats on regular intervals of time due to external factors like lockdown of country, mandatory social distancing, quarantines etc. in many real-world scenarios, either of trend or seasonality are absent. after finding the nature of ts, various forecasting methods have to be applied on given ts given the ts, it is broadly classified into categories i.e. stationary and non-stationary. a series is said to be stationary, if it does not depend on the time components like trend, seasonality effects. mean and variances of such series are constant with respect to time. stationary ts is easier to analyze and results skilful forecasting. a ts data is said to nonstationary if it has trend, seasonality effects in it and changes with respect to time. statistical properties like mean, variance, sand standard deviation also changes with respect to time. in order to check the nature (stationarity and non-stationarity) of the given covid- dataset, we have performed augmented dickey fuller (adf) test [ ] on the input data. adf is the standard unit root test to find the impact of trends on the data and its results are interpreted by observing p-values of the test. if p is between - %, it rejects the null hypothesis i.e. it does not have a unit root and it is called stationary series. if p is greater than % or . the input data has unit root so it is regarded as non-stationary series. before diving into the model architecture, it is crucial to explain the internal mechanisms of lstm networks and reasons behind using it instead of traditional recurrent neural networks. recurrent lstm networks has capability to address the limitations of traditional time series forecasting techniques by adapting nonlinearities of given covid- dataset and can result state of the art results on temporal data. each block of lstm operates at different time step and passes its output to next block until the final lstm block generates the sequential output. as of this writing, rnns with blocks (lstm) are the efficient algorithms to build a time series sequential model. the fundamental component of lstm networks is memory blocks, which was invented to tackle vanishing gradients by memorizing network parameters for long durations. memory block in lstm architecture are similar to the differential storage systems of a digital systems. gates in lstm helps in processing the information with the help of activation function (sigmoid) and output is in between or . reason behind using sigmoid activation function is because, we need to pass only positive values to the next gates for getting a clear output. the gates of lstm network are represented with the following equations below: where: = function of input gate = function of forget gate = function of output gate = coefficients of neurons at gate (x) − = result from previous time step = input to the current function at time-step t = bias of neurons at gate (x) input gate in the first equation gives the information that needs to be stored in the cell state. second equation throws the information based on the forget gate activation output. the third equation for output gate combines the information from the cell state and the output of forget gate at time step âĂŸtâĂŹ for generating the output. the internal block diagram of lstm block used in this study is shown in the motivation behind initiating self-loops is to create a path so that gradients or weights can be shared for long durations. especially, this is useful while modelling deep networks where vanishing gradient is a frequent issue to deal with. by adjusting weights as self-looped gates, we can adjust the time scale to detect the dynamically changing pa- rameters. using the above techniques, lstms are able to produce the state-of-the-art results in [ ] . the network architecture used in this study is shown in the methods used in this study are based on data guided approaches and are completely different from previous studies. our approaches and predictive outcomes will provide assistance for restricting the infections and possible elimination of current covid- pandemic. we trained our network with data until march , reported by canadian health authority. in this study we found that policies or decisions taken by government will greatly affect the current outbreak.several studies on forecasting of coid- transmission are based on the r method however, they didn't include the sensitivity analysis to find the important features. we examined our model predictions using mean square error (mse). in figure we plotted the total number of confirmed cases and forecasted covid- cases in canada as a function of time. from the figure we can observe that, canada didnâĂŹt witness its peak yet and it is expected number of cases will soon increase exponentially despite the social distancing. although our model achieved better performance when compared with other forecasting models, it is unfortunate that transmissions are following increasing trend. the rate of infections in usa, italy and spain are growing exponentially meanwhile, the number of infections in canada are increasing linearly in figure . if canadians follow the regulations strictly, the number of confirmed cases will soon decline. in our lstm model- we trained and tested our network on canadian dataset; the rmse error is . with an accuracy of . % for short term predictions in canada. meanwhile, based on our testing/validation dataset the rmse error is about . with an accuracy of . % for long term predictions. the predictions of lstm model are shown in with solid red line. it shows that our model was able to capture the dynamics of the transmission with minimum loss. from the figure we can say that canada witnessed linear growth in cases until march after its first confirmed case. the current epidemic in canada is predicted to continue until june . our second lstm model- is trained on italian dataset to predict short-term and long-term infections in canada. for short term predictions, the rmse error is about . which is higher than previous model. accord-covid- forecasting using lstm networks ing to this second model within days, canada is expected to see exponential growth of confirmed cases. it was a challenging task to forecast the dynamics of transmission based on small dataset. even though covid- outbreak started in canada around early january, the consistent epidemiological data wasn't released until early february. because of small dataset several statistical models struggled to select the optimal parameters and several unknown variables led to uncertainty in their predictions. lstm model is different from statistical methods in many ways for instance, the proposed lstm network fits the real-time data and without any assumptions while selecting hyperparameters. it was able to overcome the parameter assumptions using cross validation and achieved better performance by reducing the uncertainty. after reaching the inflection point, the recovery rate will start decrease rapidly and death rate may increase at the same time as shown in figure . in order to find the trend of the infections we decomposed the given series and the trend of infections is increasing with respect to time. further, number of infections followed increasing trend from sunday to tuesday and followed decreasing trend until saturday as shown in figure . as we are still under the stage of dilemma about the current situation of covid- because, the accuracy of our estimates is bounded with a lot of external factors. so, it is recommended to conduct the follow-up study after this experiment to be more precise about the dynamics of this novel infectious disease. the actual number of cases might be higher than the cases reported by the government because, of the backlog of test results and some people will be immune before even testing. all the above factors may lead to discrepancy of our model estimations. even though we addressed data imbalance by using statistical methods like interpolation and re-sampling yet we couldnâĂŹt represent patients who are on incubation period or not tested. other problem while modelling current pandemic is that, people covid- forecasting using lstm networks figure : predictions of the lstm model on current exposed and infectious cases (red solid line). the red dotted lines represents the sudden changes from where number of infections started following exponential trend. the black dotted lines in the figure represents the training data or available confirmed cases travelling between the provinces. based on our sensitivity analysis our projections may go down if current trials on potential vaccines achieves fruitful results. finally, in order to minimize the bias on our training algorithm we introduced regularization. further, by training our network inversely, we found that outbreak in canada started around early january but, it was not reported until january last week. even without the knowledge of st case, our inverse training will help governments to better understand the outbreak of covid- and helps then to prevent such outbreaks in future. the patterns from the data reveals that prompt and effective approaches taken by canadian public health authorities to minimize the human exposure is showing a positive impact when compared with other countries like usa and italy . rate of transmission in canada is following linear trend while in usa is witnessing an exponential growth of transmissions. however, it is too early to draw the conclusions about the current epidemic. after simulations and data fitting, our model predicted canada would reach peak within weeks from now. however, the current outbreak resembles early th century spanish flu [ ] , which killed millions of people and lasted for covid- forecasting using lstm networks years. based on our model simulations, the current covid- pandemic is expected to end within months from now. due to some unreported cases, a small number infection clusters may appear until december . however, recent technological improvements and international cooperation between countries may even reduce the duration current pandemic. to sum up, this is the first study to model the infections disease transmission model to predict the gravity of covid- in canada using deep learning approaches. based on our current findings, provinces that have implemented social distancing guidelines before the pandemic has less confirmed cases than other provinces . for instance, saskatchewan issued social distancing guidelines weeks ahead than quebec which has half of the confirmed cases in canada. our results could help canadian government to monitor the current situation and use our forecasts to prevent further transmissions. we confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. in so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. we further confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. irb approval was obtained (required for studies and series of or more cases) written consent to publish potentially identifying 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gravitational wave detection and parameter estimation: results with advanced ligo data covid- forecasting using lstm networks the âĂIJinconvenient truthâĂİ about ai in healthcare preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak transmission potential and severity of covid- in south korea updating of covariates and choice of time origin in survival analysis: problems with vaguely defined disease states strong consistency of least-squares estimation in linear regression models with vague concepts machine learning approach for confirmation of covid- cases: positive, negative, death and release multiple-input deep convolutional neural network model for covid- forecasting in china prediction for the spread of covid- in india and effectiveness of preventive measures neural network based country wise risk prediction of covid- wavelet transform domain filters: a spatially selective noise filtration technique lag order and critical values of the augmented dickey-fuller test insights into lstm fully convolutional networks for time series classification a pandemic warning? no funding was received for this work. vinay kumar reddy chimmula: conceptualization of this study, methodology, software, writing -original draft preparation,critical revision of the manuscript for important intellectual content. lei zhang: data curation,critical revision of the manuscript for important intellectual content,supervision and material support, regular feedback after each update. manuscript title: the authors whose names are listed immediately below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), 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therapy. please indicate the specific contributions made by each author (list the authors' initials followed by their surnames, e.g., y.l. cheung). the name of each author must appear at least once in each of the three categories below. conception and design of study: vkr chimmula acquisition of data: vkr chimmula analysis and/or interpretation of data: vkr chimmula; l zhang drafting the manuscript: vkr chimmula, revising the manuscript critically for important intellectual content: l zhang; vkr chimmula approval of the version of the manuscript to be published (the names of all authors must be listed):vkr chimmula, l zhang. key: cord- -wplz o k authors: sanders, chris; burnett, kristin; lam, steven; hassan, mehdia; skinner, kelly title: “you need id to get id”: a scoping review of personal identification as a barrier to and facilitator of the social determinants of health in north america date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: wplz o k personal identification (pid) is an important, if often overlooked, barrier to accessing the social determinants of health for many marginalized people in society. a scoping review was undertaken to explore the range of research addressing the role of pid in the social determinants of health in north america, barriers to acquiring and maintaining pid, and to identify gaps in the existing research. a systematic search of academic and gray literature was performed, and a thematic analysis of the included studies (n = ) was conducted. the themes identified were: ( ) gaining and retaining identification, ( ) access to health and social services, and ( ) facilitating identification programs. the findings suggest a paucity of research on pid services and the role of pid in the social determinants of health. we contend that research is urgently required to build a more robust understanding of existing pid service models, particularly in rural contexts, as well as on barriers to accessing and maintaining pid, especially among the most marginalized groups in society. personal identification (pid) serves multiple and frequently contradictory purposes within the context of the modern state. establishing the identity of individuals by connecting them to key information such as age, sex/gender, birthdate, nationality, and residence, pid has the potential to confer certain rights and privileges on individuals. common forms of pid, like birth certificates, passports, driver licenses, and government-issued health cards, grant access to important benefits, such as health and social services, while non-government pid (e.g., private club membership card, credit cards) typically allow situational access or benefits to the bearer. however, the loss and misuse of personal identity can have devasting consequences for individuals. state record keeping also makes individuals visible to the polity and, thus, governable and subject to the loss of freedoms. recent conversations about the significance of pid and identification security processes, especially since the events of / and the ongoing collection and sale of personal data through large online social media platforms, have largely centered on fears about increased state and corporate surveillance, as well as identity theft and fraud [ ] [ ] [ ] . while it is extremely important to acknowledge that these circumstances have had and continue to have enormous and detrimental impacts on the lives and well-being of individuals and communities, largely overlooked in these conversations is the central role played by pid in accessing essential state services, particularly among people who are socially and economically disenfranchised. taylor and colleagues have astutely described this phenomenon as the inherent ambiguity of viewing citizens as both a "risk to be managed, and thereby an object for surveillance (and) a consumer deserving the best possible public service" [ ] (p. ). after all, without pid it is nearly impossible to access health care, housing, income maintenance, education, banking services, employment, and pension benefits, among other essential programs and services. it is also frequently impossible to access something as simple as emergency food services, like a food bank, without providing government-issued pid and proof of residence. while access to and possession of pid does not of itself guarantee education, health, protection, and participation in society for marginalized people, not having certain forms of government-issued pid ensures that access to essential health, social, and financial services is nearly impossible [ ] . possession of pid, in effect, becomes the gateway to accessing the social determinants of health, particularly in rural settings [ ] . thus, what we refer to as the "problem of personal identification" occurs when populations that are already marginalized and underserved are made further vulnerable because they lack forms of official identification that enable them to secure vital benefits and resources, effectively making them invisible to health and social services. literature on pid in the north american context that does not examine this issue from a security/governmentality perspective tends to focus on populations that are precariously housed or homeless and living in urban spaces. barriers to pid associated with people living in rural and northern settings in north america have not been adequately explored. additionally, relatively little attention is paid to the particular pid challenges experienced by people who are racialized and indigenous, and further, how those identities operate alongside space and gender. these multiple and intersecting identities are important to explore with regard to pid because, as audre lorde points out, "we do not live single-issue lives," [ ] meaning that it behooves us to understand the dynamic ways that lived identities and structural systems intersect to the detriment of the most marginalized individuals and social groups. through this scoping review, we seek to enter into this conversation regarding barriers to obtaining pid by highlighting the ways in which the problems posed by a lack of pid are particularly pronounced for people living in rural, northern, and remote access communities-people whom we already know experience poorer health outcomes than residents in metropolitan and suburban areas, and whom to date have been largely ignored in the scholarship [ ] . further, in canada, indigenous people are more likely to reside in the provincial north and territories than non-indigenous people [ ] [ ] [ ] . given the higher proportion of indigenous people and communities located in rural and remote areas, we contend that health disparities and a lack of access to health and social services resulting from a lack of pid exacerbate inequalities between indigenous and non-indigenous people, broadly speaking. a better understanding of the problem of pid is needed, particularly as it pertains to accessing health and social services for the most marginalized people and groups in society. the aims of this scoping review are as follows: first, to provide readers with a clear understanding of the current research on this topic by providing a comprehensive review and analysis of the academic and gray literatures on the barriers to attaining pid in north america. second, this review aims to show the significance that a lack of pid has for people's ability to access health and social services. third, this review aims to identify gaps in the existing research, particularly in regards to rural and indigenous peoples and communities. fourth, we discuss the implications for rural and indigenous communities and identify future directions for research on pid. scoping reviews aim to provide a survey of studies on or related to a topic rather than to assess the quality of each study. a scoping review was considered an appropriate strategy for this research topic because it was not previously comprehensively reviewed [ ] . this scoping review was conducted following guidelines for scoping studies outlined by colquhoun and colleagues involving a stepwise process of search, selection, extraction, and synthesis of the literature [ ] . a separate protocol for this review does not exist; below, we provide a detailed roster overview of the review process. to ensure the quality of scoping review reporting, we used a checklist developed by tricco and colleagues [ ] . other than the assessment of and secondary analysis of the studies, this scoping review complies with the preferred reporting items for systematic reviews and meta-analyses (prisma) statement and checklist. we use the term "pid" to refer to all types of government-issued personal identification used to recognize citizens and denizens for the purposes of granting access to vital services. common forms of pid include "identity documents" (e.g., birth certificates, passports) and "identity cards" (e.g., driver licenses, provincial health cards, hunting licenses). by contrast, the term "id" includes non-government issued forms of identification (e.g., student body card, private club membership, employment id cards) and may not grant access to vital services provided by the government. we only use the term "id" when quoting studies or in reference to specific identification cards. because existing studies sometimes use these terms interchangeably, or simply use the more common term id, our search strategy employed the term "identification" to search databases. a search string was developed (table ) and used to search the following citation databases: web of science™ (clarivate analytics, philadelphia, pa, usa), core collection (ebsco, ipswich, ma, usa), medline ® (national library of medicine, bethesda, md, usa), cabdirect© (cabi, wallingford, uk), and ebscohost© (ebsco, ipswich, ma, usa). these databases cover health, sociology, anthropology, and psychology disciplines, thereby providing the opportunity to capture the broad literature, as well as approach the research question from different perspectives. no search restrictions were placed (e.g., language, date, publication type). a complementary search for gray literature documents, such as government research reports, was also conducted using a series of simple search strings in google (e.g., "barriers to obtaining identification in north america"). as google returns results based on relevance criteria related to the search term entered, only the first hits of each search were examined [ ] . the reference list of all relevant studies was also hand-searched to identify any further relevant studies not captured in the search. records were uploaded into endnote x ® and de-duplicated. table . search strategy to identify peer-reviewed articles on barriers and facilitators to obtaining identification. identification ("photo identification" or "personal identification" or "government-issued identification" or "civil identification" or "birth identification" or "birth certificat *" or "birth registration" or "photo id") and barriers and facilitators ((barrier * or challenge *) or (facilitator * or opportunit *)) * boolean operator symbol for truncation used to broaden search by capturing all variations of words. the titles and abstracts of studies were screened according to a priori inclusion criteria. to be included in the scoping review, studies needed to report on barriers or facilitators to obtaining pid in the north american context. studies were excluded if they were not relevant to this topic or were not in the english language. in some cases, a full-text review was conducted in order to assess suitability. sources of evidence included primary studies published in english as journal articles, books, research reports, dissertations and theses, or conference proceedings. to ensure the availability of data for charting purposes, we excluded newsletters, news articles, and summaries. we developed and used a charting form to capture data from each study. key information extracted included author, year of publication, country of origin, purpose, publication type, study scale, study population, methodology/methods, and key findings that related to the scoping review question. charting followed an iterative process in which the data were extracted and the charting form was updated continuously. of note, study screening and data charting were done by one author (s.l.), presenting possible concerns over reviewer bias. to address this bias, this author discussed challenges and uncertainties related to the reviewing strategy with the co-authors and refined the approach in the process. the data analysis included quantitative analysis and qualitative analysis. for quantitative analysis, we used descriptive statistics to present the characteristics of the study, methodology, and findings. to characterize and summarize factors which act as barriers to and facilitators of obtaining identification, we used thematic qualitative analysis following a process outlined by braun and colleagues [ ] . first, studies were read in full and notes were written to facilitate data familiarization. then, codes were assigned to portions of the text that discussed identification. we used an inductive approach to coding, with no pre-formulated assumptions of how codes should be defined. similar codes were then grouped into descriptive themes that illuminate patterns in the data across studies. we selected quotations that exemplified these themes and presented them in the results to provide a rich and nuanced description of the data [ ] . to ensure the validity of the qualitative analysis, we held regular discussions among the authors surrounding the developed themes. data were stored in a spreadsheet (excel , microsoft corporation, redmond, wa, usa) to facilitate analysis. the initial search returned studies; after the removal of duplicates and non-relevant studies, a total of studies were included ( figure ). a summary of the descriptive characteristics of these studies is shown in table . the median publication year of relevant studies was (range - ). there was a near equal balance of publications from canada ( %) and the united states ( %). most of the studies were from the academic literature, though a significant portion ( %) were from the gray literature. many of the studies ( %) were purely qualitative and used interviews to collect qualitative data from participants. most studies focused on homeless youth, adults, or people in general ( %, n = ). a detailed summary of the studies, including relevant findings, can be found in appendix a. three descriptive themes were identified across the relevant studies that capture barriers to, and facilitators for, obtaining identification: ( ) gaining and retaining identification, ( ) access to health and social services, and ( ) facilitating identification programs and services. these themes are described in detail below and are supported by illustrative quotations from study participants and/or study authors. one of the biggest challenges identified in the literature that individuals faced was the acquisition and retention of pid. according to many studies ( %, n = ), the main reason people reported for not having identification was that it had been either lost or stolen (e.g., [ ] [ ] [ ] ). this is particularly true for many people who are precariously housed or homeless. campbell and colleagues, for example, conducted one-on-one interviews and focus groups with individuals in calgary that were homeless and health and social services providers in which one participant without housing identified pid as a key barrier: "one of the things i just thought of that could be a potential barrier is missing or stolen id" [ ] (p. ). further support is provided by a survey of people who were homeless in toronto, which found that ( %) were not in possession of their health card [ ] , and in the united states, an estimated % of voting-age citizens lacked identification, with estimates higher among those experiencing homelessness [ ] . additionally, it is common in homeless shelters to have one's personal belongings, where ids and other personal documents are typically stored, taken if left unattended for even a short period of time or while sleeping [ ] [ ] [ ] . consequently, whether living on the streets or staying in a shelter, maintaining possession of one's belongings requires constant vigilance, which is challenging for many people living in precarious circumstances. in addition, many people experiencing homelessness do not possess the means of replacing their pid (e.g., money for fees, knowledge of application process, competency with bureaucratic forms). other studies ( %, n = ) highlighted the requirement of an address or an existing piece of identification in order to apply for additional identification (e.g., [ ] [ ] [ ] ); yet, many homeless people frequently are unable to provide either of these. gordon interviewed people visiting identification clinics in edmonton, alberta, and reflected: "nine people spontaneously told me 'you need id to get id,' or similar words" [ ] (p. ). in a study exploring the lived experiences of adolescent women in seattle who were homeless, the authors reported: [the young women] claimed that the biggest structural barriers to care [that they identified] at many hospitals or clinics not designed for homeless youth were questions over consent for care, being asked to provide addresses and an identification (id) card, and source of insurance or payment [ ] (p. ). still more studies ( %, n = ) emphasized the high cost of obtaining identification (e.g., [ , , ] ). for example, one study from toronto, canada finds: even a modest fee can make it difficult for a homeless young person to obtain identification-and in many states, the cost of obtaining an id card is far from modest [ ] (p. ). for people who are economically marginalized and/or precariously housed, even seemingly minor fees constitute a financial hardship that makes the acquisition of pid prohibitive. in the province of ontario, for example, higher fees are charged for replacement birth certificates, and if people go through "third party" providers rather than state agencies to obtain this form of id, additional service fees are incurred. this means that people who have little or no money and who are likely to lose or have their pid stolen due to being precariously housed are further burdened with higher replacement fees. ultimately, people regularly prioritize the immediate needs of food, transportation, or rent rather than the costs of replacing a lost or stolen document. furthermore, additional costs are required if individuals must take public transportation or live in rural or remote locations and have to travel to service centers. according to a united nations report, the "greater the distance to the registration center the higher the financial costs to the family" [ ] . other scholarship outlined those barriers to obtaining identification that were unique to specific social groups. for example, a lack of legal identity is a barrier among immigrants who are undocumented [ ] . in some us states and canadian provinces, youth are required to obtain the consent of their parents or legal guardians and need to be a certain age in order to apply for identification. for instance, in ontario, youth have to be at least thirteen years of age to apply for many forms of pid on their own behalf, and for youth who are minors and estranged from parents or guardians, age-related restrictions present significant barriers [ , ] and potential danger for those individuals trying to avoid foster care or the return to a less than safe environment. young women who are homeless reported facing judgement and censure from health care providers [ ] . one study also reported stigmatizing attitudes towards people who were homeless in general [ ] . for female sex workers in miami, a lack of space for the storage of identification posed a problem; without storage space for possessions, "women are often assaulted or otherwise robbed of the few goods they own," including their ids [ ] (p. ). in some canadian provinces (e.g., ontario, british colombia, new brunswick), there is a three-month waiting period for a provincial health card for newcomers [ ] , leaving people in a vulnerable position should they require emergency services during the window of no coverage. a few studies ( %, n = ) also reported barriers in the accurate and complete reporting of personal information, like date of birth and the incorrect recording of names and place of birth [ ] [ ] [ ] . a study by melnik and colleagues explored the accuracy of birth data collected in new york state facilities, and found barriers including incomplete information provided by medical staff, birth data located in multiple systems, conflicting birth data from different sources, and inadequate staff resources [ ] . in california, smith and colleagues found the misclassification of ethnicity and race in administrative records in . % and . % of children, respectively [ ] . the authors reported two major causes of this misclassification, including missing information in administrative records and the classification of children of multiple races based on information from only one parent. while many studies ( %, n = ) included the socio-demographic characteristics of participants, such as age, gender, and ethnicity [ , , ] , few attempted to differentiate people's experiences and perspectives that result from these characteristics. for example, adults in toronto who were homeless that participated in a survey included, but were not limited to, % white, % black, and % indigenous [ ] . however, while the study found that % of participants had a health card, it did not indicate whether this outcome corresponded with a particular racial identity. information on which ethnic groups possessed a health card would help inform more nuanced efforts to increase access to identification and health care more generally. a notable exception where this information was included is a qualitative study in edmonton, where % of interviewees (n = ) were estimated to be indigenous, with the majority being men [ ] . the study found that indigenous men and women experienced more barriers to identification on average compared to non-indigenous men and women. in a different study from california, smith and colleagues found that children of minority groups are more likely than non-minority groups to experience the misclassification of ethnicity and race in administrative records, presenting possible consequences for data misinterpretation and over/underestimated health disparities, as well as presenting further difficulties later in life if and when people have to replace their pid [ ] . the challenge posed by pid was further exacerbated for sexual minorities, particularly transgender individuals [ , ] . in a study exploring the lived experiences of transgender youth that were homeless in new york city, many either did not have identification or had identification documents that did not match their self-designated gender and presentation, resulting in "transgender and gender expansive young people facing harassment and discrimination when applying for jobs" [ ] (p. ). following from the inability to acquire or maintain pid are the social and health consequences that directly result. the lack of identification was reported by many studies ( %, n = ) as a factor impacting the ability of individuals to access health services (e.g., [ , , ] ). for example, one provider in calgary, canada reported: identification is something that you often need when you go to clinics and a lot of our [clients] do not have id-whether or not they even have alberta health care cards with them or have even applied for their alberta health care cards. we have a lot of out-of-province clients that come through, a lot of immigrants that come through so then that whole issue is do they even get access to certain types of care just due to not having the proper documents [ ] (p. ). a lack of pid becomes both a direct and indirect barrier to accessing services. in ontario, for example, residents must present an ontario health card in order to receive benefits through provincially funded health coverage [ ] . to receive a health card, however, an individual must provide three key documents (proof of citizenship, proof of ontario residency, and some form of personal identification from a specified list), which poses significant difficulties for people with precarious housing. bureaucratic structures with onerous requirements for applying for pid can further complicate matters for many people. in a qualitative study involving youth in los angeles who were homeless and drug-dependent, the authors reported: perhaps surprisingly, structural barriers cited by the youth stemmed not from a paucity of agencies or resources but conversely from the presence of too many agencies with endless bureaucratic requirements involving interagency referrals, the need for identification cards, time-consuming paperwork, and lack of continuity of care [ ] (p. ). this was also echoed in a qualitative study involving young women in seattle experiencing homelessness: so you have to go to a regular clinic and they take forever to register you and they want to know why you don't have insurance and then they make you sit there another minutes until they call someone to figure out what it is. i've had so many bills from places like that so many notices. i always told them from the beginning, 'i'm homeless. i don't have an id. you can't call my parents; they will not say they're my guardians. they will not take responsibility for me. i don't have insurance.' you know-it's like, 'can you please? i'm bleeding here -can you help me'? [ ] (p. ). according to some studies ( %, n = ), government-issued identification is also required to access food banks (e.g., [ , , ] ). a survey of service providers across us states found that when individuals who were homeless could not provide photo identification, % were denied food stamps [ ] . another survey of homeless adults in downtown toronto reported that % of adults that were homeless were unable to access the food bank due to a lack of identification [ ] . in new york city, out of the ( %) food pantries surveyed had an identification requirement [ ] . in an unnamed city in the us, individuals living with mental health disabilities and facing homeless were found to face further challenges to accessing services as a result of the lack of pid: returning offenders who have mental illness are often eligible for several public assistance programs, including general assistance, food stamps, and medicaid. in the state where the study site is located, all such programs are administered by the state's public assistance department, which also oversees the application process and thereby controls access to services. identification requirements are a central feature of the application process, and these requirements emerged early in the study as a source of problems for clients" [ ] (p. ). indeed, a lack of pid was identified by several studies ( %, n = ) as a serious barrier to accessing social housing and income support (e.g., [ , , ] ). for example, the lack of personal identification was reported as a barrier of many people who were either homeless or precariously housed that were applying to the ontario disability support program [ ] . in a survey of adults in toronto that were homeless, ( %) reported that the lack of pid was the main reason for remaining homeless [ ] . suggestions for reducing barriers to accessing health and social services include: welcoming other forms of identification (e.g., non-government issued identification) [ ] , providing alternative verification processes for proof of identity or residence (e.g., allowing people who were homeless to use the address of a shelter as their mailing address) [ , ] , building mechanisms to improve access to services that do not require individuals to present identification (e.g., databases that transfer medical data between sites) [ , ] , building the cultural competencies of health care providers [ , , , ] , and improving the access and availability of information on how to obtain identification and reducing or eliminating fees [ , ] . finally, a number of studies exploring pid facilitators ( %, n = ) recommended funding programs at social service agencies to support the replacement and storage of identification [ , , , ] . kopec and cowper-smith described four organizations in canada that provide a space to store identifications (sometimes referred to as "id banks") [ ] . most of these organizations also help clients apply for their identification and cover the associated fees. similarly, goldblatt and colleagues described two identification programs that provide a mix of support services at no fee [ ] . in one case, the regional municipality of york region in ontario provides a mailing address for clients when necessary, delivers identification to clients, and connects individuals with other services such as housing, food resources, and financial support. in the second case, the city of toronto provided funding to support the id bank located at street health. other studies argued that id fees for people who were homeless should be waived [ ] [ ] [ ] [ ] . in one state, south carolina, people that were homeless were not required to pay fees associated with pid: in order to get a fee waiver, a homeless person provides a letter from a shelter employee or other service provider indicating that he is homeless and requesting a fee waiver [ ] (p. ). within the modern bureaucratic state, personal identification serves many, often contradictory, purposes. on the one hand, establishing identity can connect individuals to vital health and social services, while, on the other hand, the theft and misuse of identity can have devastating consequences, ranging from breaches in personal privacy and financial fraud to the loss of democratic freedoms when governments use personal data to surveil individuals and populations. recent conversations about pid have tended to focus on the latter issues, precipitated mainly by the events of / and recent high-profile cases of cybertheft and the sale of personal data by major corporations. while it is important to acknowledge the validity of these concerns, this scoping review focuses on the former issue by drawing attention to the central role played by pid in accessing essential state services, particularly among the most socially and economically marginalized people and groups in society. we started this research prior to the outbreak of, and public health response to, the covid- global pandemic, an event that makes it more apparent than ever how a lack of pid impacts access to the social determinants of health for the most marginalized people in society. at the time writing, local emergency food banks require valid identification, not only for the individual directly receiving the food, but for everyone living in the household [ ] [ ] [ ] . many people simply do not have access to pid documents and information at this tumultuous time, let alone are they able to afford the cost of a pid application at the moment. marginalized people without pid are unable to travel home by air or bus, nor can they access many emergency housing supports, as these options all require pid, leaving some with no alternative but to live on the streets where physical distancing and other protective measures, like hand-washing, cannot be practiced [ ] . government service centers that normally process pid applications have limited both their business hours and their provision of services [ ] , and while these measures are important in helping to flatten the curve of covid- , they also further marginalize people in need of emergency services by making it exceedingly difficult to obtain pid at a time when it is needed most. the results of this scoping review illustrate the paucity of research on what may be termed the "problem of personal identification," especially in regards to the barriers and facilitators faced by groups that are particularly marginalized in the acquisition and retention of pid. our review also finds that the existing research, while limited, focuses primarily on people who are either homeless or precariously housed; to a lesser extent, the review also finds that sex workers and select sexual minorities face significant pid challenges, namely transgender people. it is also worth pointing out that almost one-third of our results come from the gray literature, in the form of reports and policy briefs produced by nonprofit organizations, like street health in toronto, canada. this suggests that a significant portion of the work on pid is being conducted by frontline organizations and that more academic involvement could support these organizations to study the issue more comprehensively. among the most common barriers to pid, the scoping review finds that homelessness creates obstacles to the acquisition of pid, as often an address is required to apply for pid, as well as to maintaining the possession of pid, as theft of and damage to personal belongings is an ever-present problem. another key barrier associated with a lack of pid is an inability to access social and health services, which, in turn, makes people who are marginalized further vulnerable by limited access to the social determinants of health; this problem is particularly marked among women and youth. finally, regarding facilitators, the review finds that identification programs, such as "id banks," are positively associated with people's ability to acquire and maintain pid. these findings highlight important sociological interactions, ranging from economic deprivation and homelessness to gender and sexual identity, that contribute to people's ability to acquire or maintain key forms of pid that are the gateway to accessing vital services. another notable finding of the scoping review was a pointed statement shared by several interviewees of one study: "you need id to get id . . . you can't do anything without id" [ ] (p. ). this reality speaks to the importance of birth registration and maintaining the possession of a birth certificate. in canada, for instance, a birth certificate is required to acquire most forms of identification, such as a social insurance number (sin) or an indian status card, which is required under the indian act to confirm the indian status of indigenous people. even for forms of pid that do not directly require a birth certificate, such as an ontario health card or driver license, a birth certificate is necessary to get the prerequisite identification needed to apply for a health card or driver license. thus, in canada, as in many other nations, the birth certificate becomes the foundational piece of pid that enables access to all other identification documents. that many pid applications require a permanent residence in order to be issued becomes a "catch " situation of sorts, wherein people who are precariously housed require a home in order to obtain pid that will enable them to access housing or health and social services. conspicuously absent from the existing literature was research that focused on northern and rural populations, indigenous people, and the relationship between the two. in canada, for instance, indigenous people make up a significant proportion of the population in the rural and provincial north, and further clarity is needed on the unique pid problems facing this population, such as birth registration and the acquisition of birth certificates, as well as the difficulties of obtaining pid in areas with extremely limited access to state social and health services [ ] . our preliminary work, for example, has shown that % of the clients seeking birth certificates and other forms of pid in thunder bay and the surrounding district identify as indigenous [ ] , indicating that this is an important area of further study. likewise, the structural barriers that exist in fly-in and road access first nations have not been addressed, nor is there any sustained analysis of the historical and ongoing impacts of settler colonialism on access to and the meaning of pid. although a few studies identified the reporting of inaccurate birth information by medical staff or other administrative personnel as a barrier to acquiring pid, the particular experiences of indigenous peoples in the north and the implications have not yet been fully fleshed out. for instance, indigenous children forced to attended residential schools frequently had their names changed, misspelt, or dates of birth recorded incorrectly [ ] . records of these activities, which would help substantiate claims of identity, have often been lost to fires and flooding that frequently occur in rural settings. that this is a historical problem, dating back to the s, means that elders from rural areas are even less likely to have access to original documentation required to acquire pid. furthermore, these problems have persisted for indigenous children, who continue to be removed from their families and communities at alarming rates by child welfare agencies. in canada, indigenous children account for % of the children in foster care, while constituting only . % of the canadian population [ ] . the fear of possible child apprehension may also pose a further barrier to birth registration for indigenous peoples, if parents are afraid to report new births [ , ] . long histories of settler violence enacted through systems of education, health care, policing, and child welfare have ensured that indigenous people and communities have been over-policed and under-serviced by the state. as a result, mechanisms, like birth certificates and other forms of pid, which make citizens visible to state structures and services, can often be problematic and fraught with anxiety and distrust for indigenous people. more research is also needed on the implementation and use of "id banks" as a facilitator for acquiring and maintaining pid. storage programs are particularly promising for people who are homeless, especially as the conditions of living unhoused frequently leads to the damage and permanent loss of pid [ , ] . such programs exist in different forms in urban areas, offering a variety of storage options for pid. options include the storage of original copies of pid, official duplicates, and unofficial photocopies, as well as the storage of digital copies on secure servers. in some instances, an unofficial photocopy of pid may be adequate to prove personal identity or, at least, to begin the process of applying for certain services contingent upon the client returning with the original identification document to complete the process. in other cases, agencies that host id banks can also be contacted to vouch that the photocopy is accurate and on file; this model can be particularly effective among partnering agencies or those with a memorandum of understanding (mou) for specific issues. importantly, there are examples of agencies that work with people who are homeless to create their own form of "agency id card" for clients, which is recognized by local law enforcement due to the agency's reputation (e.g., street health in toronto, on, canada). furthermore, some agencies with id banks have staff with registered notary status, enabling them to make notarized copies of pid on site. a staff member who can serve as a notary alleviates one more complicated, if not costly, step, as notary services can be prohibitive for people who are economically disadvantaged. using an id bank service means that clients know their pid is safely stored and can be accessed during agency business hours (or whatever access schedule is in place). some agencies also serve as a mailing address where clients may have identification documents sent for official receipt and safe storage. id banks may be one way that frontline service agencies with extremely limited resources can begin to address the pid problem among their clientele. research on this topic should focus on the structure and design of id banks, common/best practices, who uses them and why, which agencies have established them and to what effect, and barriers to implementation. it is also important to further explore the ways in which different national and provincial/state jurisdictions and policies affect the implementation and design of id banks. if the process of instituting an id bank is too costly or bureaucratically onerous, many community agencies with limited resources will be deterred from attempting to provide this important service. finally, it is important to better understand the implementation and use of id banks in rural areas, as the current literature deals exclusively with urban settings. it is important to consider the potential risk of bias within this review. first, this scoping review was limited to english-language articles, which most obviously biases findings toward higher income western nations but also, in the case of canada, excluded francophone areas like quebec. while many of the themes identified in the literature are likely national and therefore also exist in quebec, pid barriers and facilitators that are particular to that province require further investigation prior to the development and implementation of federal policy. second, in general scoping reviews, including this one, do not evaluate the methodological quality of the studies nor the quality of the evidence, but rather focus more broadly on the outcomes presented by the studies [ ] . third, a further limitation of this study was the decision to limit the scope of analysis to pid in north america. this decision was anchored in our particular research project that examines the pid experiences of indigenous people in canada and the us-nations that have similar policies and practices. undoubtedly, expanding the scope of the analysis to include places like europe and australia, for example, would shed additional valuable light on the experiences of other marginalized groups, including ethnic minorities and refugee and migrant communities, as well as the bureaucratic practices of other nations with respect to pid. finally, as with any scoping review, some literature may have been missed as a result of the keyword search strategy and the limitations of the selected databases, which may, for instance, limit the ability to locate key gray literature. the google search alone, for example, might not capture all of the relevant gray literature [ ] . for a more comprehensive analysis, future analyses might look at websites of key organizations or contact organizations to inquire if they have unpublished sources available. nevertheless, this scoping review is rigorous and provides insights into some of the pid key barriers and important facilitators in north america. this scoping review is the first step toward investigating the problem of pid through an intersectional lens. our findings indicate that pid is an important influence on the ability of people who are marginalized to acquire and maintain pid that, among other things, enables access to the social determinants of health. it is our position that a more complete understanding of the barriers and facilitators to pid is imperative, particularly in different local, regional, and national contexts, as well across a diverse range of social identities. such research will benefit multiple disciplines in the social and health sciences and nursing, as well as policy-oriented fields. interweaving this understanding with a more sophisticated understanding of the social determinants of health would further highlight ways that poverty and social factors, like racism and colonialism, help reproduce one another. this would not only provide a more nuanced understanding of the problem of pid, but contribute to evidence-informed policy aimed at ameliorating the problem and improving health outcomes among people that are the most underserved and marginalized in society. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. appel explore common sources of advice, health-seeking behaviors, and access to care issues of homeless adolescent women participants said that the biggest structural barriers to care at many hospitals or clinics not designed for homeless youth were questions over consent for care, being asked to provide addresses and an id card, and source of insurance or payment identity crisis: how identification is overused and misunderstood playing the identity card: surveillance, security and identification in global perspective protecting and proving identity: the biopolitics of waging war through citizenship in the post- / era identification practices in government: citizen surveillance and the quest for public service improvement birth registration: right from the start. innocenti dig a case study in personal identification and social determinants of health: unregistered births among indigenous people in northern ontario sister outsider: essays and speeches health in rural canada the embodiment of inequity: health disparities in aboriginal canada indigenous health part : determinants and disease patterns social transformations in rural canada: community, cultures, and collective action scoping studies: towards a methodological framework scoping reviews: time for clarity in definition, methods, and reporting prisma extension for scoping reviews (prisma-scr): checklist and explanation applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in canada thematic analysis. in handbook of primary healthcare needs and barriers to care among calgary's homeless populations universal health insurance and health care access for homeless persons it takes id to get id: the new identity politics in services restrictive id policies: implications for health equity risk factors, endurance of victimization, and survival strategies: the impact of the structural location of men and women on their experiences within homeless milieus perspectives of homeless people on their health and health needs priorities more sinned against than sinning? homeless people as victims of crime and harassment meeting the health care needs of female crack users: a canadian example expanding id card access for lgbt homeless youth policy brief on government identification community, use it or lose it? anthropologica barriers and bridges to care: voices of homeless female adolescent youth in national law center on homelessness & poverty. photo identification barriers faced by homeless persons: the impact of the 'rights' start to life: a statistical analysis of birth registration healthcare access and barriers for unauthorized immigrants in el paso county national network for youth. a state-by-state guide to obtaining id cards barriers to health and social services for street-based sex workers i spent nine years looking for a doctor': exploring access to health care among immigrants in association of missing paternal demographics on infant birth certificates with perinatal risk factors for childhood obesity barriers in accurate and complete birth registration in new york state. matern health plan administrative records versus birth certificate records: quality of race and ethnicity information in children access to primary health care among homeless adults in toronto, canada: results from the street health survey transgender youth homelessness: understanding programmatic barriers through the lens of cisgenderism barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders the health bus: healthcare for marginalized populations attitudes of homeless and drug-using youth regarding barriers and facilitators in delivery of quality and culturally sensitive health care the street health report. the street health report. the health of toronto's homeless population food insecurity: limitations of emergency food resources for our patients final report: systemic barriers to housing initiative failing the homeless: barriers in the ontario disability support program for homeless people with disabilities; street health barriers to care: the challenges for canadian refugees and their health care providers physician payment for the care of homeless people toronto report card on housing and homelessness; city of toronto guelph-wellington taskforce for poverty elimination: avenues for creating an id bank greater vancouver food-bank users will soon need to prove low-income status food bank deals with location change. the chronicle journal sudbury food bank updates guidelines for new users can't go home: no id strands indigenous man on vancouver's downtown eastside. cbc ottawa shuts service canada centres after employees refuse to work. the globe and mail the challenges of accessing personal identification in northwestern ontario national centre for truth and reconciliation (nctr) aboriginal peoples in canada: first nations people, métis and inuit, part living arrangements of aboriginal children province reports st decrease in child welfare numbers in years child apprehension laws to be amended so kids can't be taken because of poverty the struggle to end homelessness in canada: how we created the crisis, and how we can end it. open health serv can i see your id? the policing of youth homelessness in toronto advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps harm reduction through a social justice lens key: cord- - gpkb nm authors: appireddy, ramana; jalini, shirin; shukla, garima; boissé lomax, lysa title: tackling the burden of neurological diseases in canada with virtual care during the covid- pandemic and beyond date: - - journal: the canadian journal of neurological sciences. le journal canadien des sciences neurologiques doi: . /cjn. . sha: doc_id: cord_uid: gpkb nm nan approximately % of canadians are affected by neurological disorders based on canada's national population health study of neurological conditions, and this number is projected to increase in the coming decades. those with chronic neurological conditions have higher stress levels and a higher prevalence of selfdiagnosed mood or anxiety disorders. many suffer functional impairments with regard to cognition, mobility, dexterity, bowel, and bladder control. taken together, these factors lead to significant impacts on quality of life. neurological disease can also affect one's ability to work or work productively, which can lead to financial insecurity. it can also result in a significant loss of the number of years ( - years based on condition) of healthy living. based on the results from the living with the impact of a neurological condition (linc) project, those with chronic neurological conditions use more health care services across the continuum compared to other chronic health conditions. in a study from british columbia, physician service utilization is . - . times higher in people with chronic neurological conditions, as are the total direct health costs and out-of-pocket expenses for people affected by chronic neurological conditions. there are also limitations in health care services for this population with the physical environment cited as one of the significant barriers to the provision of adequate services. thus, the burden of neurological diseases is not only shared by the individuals and families affected by it but also by the health care system. there is an urgent need within our health care system to address the unmet needs of individuals suffering from neurological disease. though it is not always easy to address the underlying biological mechanisms of these conditions, the health system performance can be optimized by adopting the institute for healthcare improvement's triple aim. this constitutes ( ) reducing the per-capita cost of health care (out-ofpocket expenses and health system cost), ( ) improving patient experiences of care (including quality and satisfaction), and ( ) improving the health of populations. virtual health care solutions are one way we can offer transformative changes to the practice of neurological ambulatory care in canada, in order to meet some of the unmet needs of this challenging patient population. , compounding the challenges mentioned above, the impact of covid- on our health care is perceived by all. the covid- crisis has resulted in temporary cancellation of elective clinics and all non-urgent/emergent clinical encounters in mid-late march across the country. a similar policy has resulted in cancellation of hundreds of outpatient encounters across all neurology clinics over the last few weeks. some urgent and essential clinics like stroke prevention clinics and multiple sclerosis clinics were also indirectly affected by the covid- crisis due to patients' hesitation to come to a health care facility during the crisis. their concern is genuine given the demographics (seniors in the stroke clinic) and patient characteristics (immunocompromised patients on multiple sclerosis medications). to meet the clinical needs of the patient care, the division of neurology at queen's university had completely transformed to a virtual care service to be able to provide the care. the transformation was significantly facilitated by the ontario ministry of health's decision to develop virtual care billing codes. virtual care has been defined as any interaction occurring remotely between patients and/or members of their circle of care, through any form of communication or information technology with the aim of facilitating or maximizing the quality and effectiveness of patient care. , this can include secure messaging, secure email, or secure personal videoconferencing. secure personal videoconferencing, also referred to as evisit, is the use of personal internet-enabled devices like smartphones and tablets to videoconference with patients, with the goal to keep the patient at home or their preferred location. digital health solutions are also adopted by the federal and provincial authorities as a key priority area of innovation to reduce health care costs. , there is also growing demand by patients to have access to such services, as seen in a nationally representative survey of canadians' opinions on health care access. we have successfully implemented evisit pilot project in in the stroke clinic. the results of our pilot study demonstrated a very high degree of patient satisfaction, reduction in per capita health care costs, out of pocket expenses [mean(sd): $ . ( . ) cnd; median(iqr): $ . ( . - . ) cnd], health system costs (range between $ , to $ , dollars, just from the pilot), and statistically significant reduction in wait times for an evisit follow-up compared to in-person follow-up. physicians were able to assess patients more quickly via evisit than via an in-person encounter, thus increasing the timely availability of health care. adopting virtual care solutions can also result in a significant reduction in costs. the cost saving is a conservative estimate, and the actual figures are likely higher if other factors and social determinants like childcare, income status, other personal factors, and visit characteristics were accounted for. our evisit pilot project in neurology has made a provincial impact and is considered as an innovative model by the ontario telemedicine network. provided through the ontario telemedicine network, evisits were used exclusively for follow-up of clinical activities like the review of investigations, symptom management, therapeutic decisions, medication titration, other specialist consultations, patient counselling, and education. following the successful experience from the pilot, the evisits were scaled to other clinics in neurology (sleep, epilepsy, and stroke). the evisits were done from physicians' offices using the office computers. the neurological examination is completed by following standard protocols adopted in other teleneurology settings like stroke and parkinson's disease. [ ] [ ] [ ] patients are advised to record their blood pressure at home. the medication reconciliation is done by verifying the medications at home against a medication list obtained from the pharmacy prior to the evisits. the scheduling of evisits differs across physicians: from sprinkling the evisits in -minute slots during their week to scheduling them for an entire afternoon. in the epilepsy clinic, the evisit follow-ups have replaced an entire in-person follow-up clinic for two physicians (lbl, gs). clinic space that was freed up by the evisits was allocated to other physicians in need of clinic space. the high uptake in these clinics is due to multiple factors including the nature of the disease, patient barriers to accessing outpatient care (lack of driving privileges, physical disability, etc.), as well as the limited requirement for detailed hands-on neurological examination during follow-ups for epilepsy and sleep. we are also using the platform to reduce inter-hospital transfers from a local rehabilitation facility to the outpatient clinic for follow-up appointments. virtual care modalities are hugely patient centric and enable physicians to identify risks and patient vulnerabilities sooner, improve treatment adherence, support behavioral and care interventions to improve speech, mobility, and arrange timely access to home care or community-based care/allied health services. some of the other patient-related factors specific to neurological conditions like epilepsy and sleep are the driving restrictions, the limited requirement for detailed neurological examination during follow-up, ease of assessing speech, eye movements, coordination and gait through evisit, cognitive and psychiatric co-morbidities causing frustration in waiting areas and the general hospital environment in general, privacy concerns due to accompaniment by family members for transportation needs. evisits allow patients and providers to avoid traffic and congestion. it also allows patients to avoid adverse weather and road conditions, which is a challenge in both urban centers and remote communities, where sheer distances to travel for appointments are significant. this is particularly important for patient populations with neurological conditions, who often have driving restrictions or limitations. evisits also allow patients the flexibility of scheduling their follow-up evisit at a time and location convenient for them and their families. family members are able to join the evisit remotely, offering increased support to patients, which is particularly crucial for seniors. overall, the evisit model of care aligns with picker's principles of patient-centered care. evisits also have the potential to improve population health by reducing barriers to care, reduce wait times, and improve access to timely care. physicians and other health care providers benefit from evisit's flexible scheduling, which allows being more productive with their time, enabling them to distribute their clinical activity to accommodate other commitments, including teaching, research, and administration. in addition to increased productivity, evisits have the potential to address some of the significant contributors to physician burnout (work and organizational factors), which, in turn, can have consequences on patient care and health care costs. evisit also reduces the need for admin/nursing support typically needed in the clinic setting, thus further reducing the overhead costs. suitability of patients and their follow-up plan for evisits should be an individualized decision made mutually by the physician and the patient to ensure safety. virtual care uptake has been significant in canada and has facilitated safe, timely, and accessible ambulatory care during this covid- crisis. this has resulted in capacity issues for the existing ontario telemedicine network, the provincial telemedicine provider. the ministry of health has allowed health care providers to use video visits and telephone for providing ambulatory care during the covid- crisis. broadly, the virtual care platforms fall under regulated and unregulated categories and guidance on appropriate use, the disclaimer, and consent are available here. a comprehensive list of guidance on virtual care and platforms available across canada is available here. use of regulated platforms that meet the privacy and security standards for safeguarding personal health care information is strongly recommended. at queen's university/kingston health sciences center, reacts (www.reacts. com) and otn are being used for providing virtual care. since the covid- crisis, we have expanded the scope of evisits to include new consultations. patients are seen in-person only if the attending neurologists feel that a reasonable diagnosis cannot be made via evisit, and if the clinical situations warrant an urgent/emergency consultation. in our experience, we have faced many challenges and barriers to convert and sustain patients to receive virtual care, especially video visits. the challenges span across the spectrum of adoption regarding a new technology by patients and include the lack of access to technology (smart devices, computers), reliable internet connection, know-how of using technology, and ease of navigating the user interface of the virtual care platform. we have been using the telephone for contacting the patients that are not capable of doing virtual visits. telephone visits are remunerated on a temporary basis in some provinces, and are ideal for follow-up visits to convey results and answer questions. the limitations of telephone calls include the inability to properly validate the patient and physician identification, lack of physical examination, and accurate medical reconciliation. despite the limitations of telephone visits, they offer a very convenient option for many and further study of the safety, efficacy should be tested. current clinical practice standards, regulatory standards, and physician remuneration are based around traditional forms of medical care performed through in-person interaction. extensive guidelines and frameworks exist around these issues to guide clinicians. yet, a similar framework for various virtual care modalities is yet to exist and is perceived as an immediate need by the canadian medical association, royal college of physicians and surgeons (canada), and college of family physicians of canada. , , another significant barrier is physician remuneration. this, however, looks promising, given the ongoing work by the canadian medical association led virtual care task force as well as new digital health policies adopted by provincial health care authorities. , , conclusion many of the chronic neurological diseases need long-term and regular follow-up for clinical activities like symptom management, medication titration, review of investigations, patient education, and counselling. as a community of health care providers caring for the people and families affected by neurological diseases, it is our duty and responsibility to leverage the existing technologies available to reduce the burden on the patients, families, health care system, and ultimately society. extraordinary times require extraordinary measures. as the current covid- pandemic is projected to last for a few more months, it is imperative for the neurology community to embrace virtual care to continue to provide care to patients affected by neurological conditions. the adoption of virtual care into a neurological practice at this time will ensure that timely care is provided to patients simultaneously avoiding contact with the hospitals, avoiding long wait lists in the future. mapping connections: an understanding of neurological conditions in canada. ottawa: public health agency of canada the everyday experience of living with and managing a neurological condition (the linc study): study design a guide to measuring the triple aim: population health, experience of care, and per capita cost. ihi innovation series white paper modernizing canada's healthcare system through the virtualization of services billing for virtual physician services and technical guidance virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique virtual care: recommendations for scaling up virtual medical services: report of the virtual care task force ontario health teams: digital health playbook ottawa: ministry of health access : canada health infoway connecting patients for better health home virtual visits for outpatient follow-up stroke care: cross-sectional study how virtual care can increase your practice's roi toronto: on.call valuing citizen access to digital health services: applied value-based outcomes in the canadian context and tools for modernizing health systems connected care update ottawa: ministry of health remotely assessing symptoms of parkinson's disease using videoconferencing: a feasibility study role for telemedicine in acute stroke. feasibility and reliability of remote administration of the nih stroke scale telemedicine in general neurology: interrater reliability of clinical neurological examination via audio-visual telemedicine video conference technology helps connect patient to care providers picker principles of person centred care one hospital's experiments in virtual health care: harvard business review factors related to physician burnout and its consequences: a review expanded access to virtual care for all physicians. ontario medical association telemedicine and virtual care guidelines (and other clinical resources for covid- ): royal college of physicians and surgeons of canada iit reacts | interactive audio-video platform task force launching to examine national licensure for virtual care virtual care in canada : discussion paper. cma health summit key: cord- -ssv arr authors: hodgkinson, tarah; andresen, martin a. title: show me a man or a woman alone and i'll show you a saint: changes in the frequency of criminal incidents during the covid- pandemic date: - - journal: j crim justice doi: . /j.jcrimjus. . sha: doc_id: cord_uid: ssv arr objectives: to investigate the effect of the covid- pandemic on the frequency of various crime types (property, violent, and mischief) in vancouver, canada. methods: crime data representing residential burglary, commercial burglary, theft of vehicle, theft from vehicle, theft, violence, and mischief are analysed at the city level using interrupted time series techniques. results: while covid- has not had an impact on all crime types, statistically significant change has been identified in a number of cases. depending on the crime type, the magnitude and direction of the change in frequency varies. it is argued that (mandated) social restrictions, shifted activity patterns and opportunity structures which are responsible for these findings. conclusions: we find support for changes in the frequency of particular crime types during the covid- pandemic. this is important for criminal justice and social service practitioners when operating within an extraordinary event. which can allow the federal government to quarantine canadians. this means that canada went into lockdown efficiently and, arguably, effectively in comparison to other nations. this creates an opportunity to explore the preliminary effects of this lockdown on crime trends in one of canada's major cities, with the intention of determining if the shift in opportunity structures have changed crime trends and to improve planning for safety and crime prevention for potential further outbreaks of the pandemic and future exceptional events. this research contributes to a growing literature on crime trends and exceptional events, suggesting that addressing the opportunity structures presented by particular exceptional events, the social costs of these events can be reduced. exceptional events, such as natural disasters, riots, blackouts, and pandemics are unusual incidents that often result in a significant shift in human behavior. these events create an opportunity to explore our understandings of the world. in particular, as the social order shifts and human behavior shifts with it, these events enable us to test the bounds of social theories and policies (andresen & tong, ; barton, ; drabek, ) . these incidents are acute, stressful, often unanticipated, and can disrupt the informal regulatory processes of social life (ritchie & gill, ) . while the effects can sometimes be transitory, some exceptional events can have long term impacts on both population composition and behavior in affected communities. exceptional events usually fall into three spheres, the lithosphere, atmosphere and biosphere (tipson, ) . lithosphere events include changes to the earth's crust which can cause volcanic eruptions, earthquakes, and tsunamis. atmosphere events involves temperature changes in the water or air that can result in droughts, wildfires, hurricanes, tornadoes, and floods (tipson, ) . pandemics, such as covid- , are biosphere disasters in which microorganisms can shift or evolve and potentially lead to a significant loss of life. biosphere disasters also emphasize the vulnerabilities of social and political systems, including access to health care, safety and economic security. these exceptional events can result in competition and hoarding, social instability and unrest, and competition for health care and vaccines (tipson, ) . covid- has exposed the impacts of a succession of neoliberal governments in the western world as political leaders fight for access to ventilators and masks (martin, ) , vulnerable citizens lack access to social safety nets and protections, and others are forced to work for inadequate compensation while putting their lives on the line (north, ) . these situations make it difficult to respond to needs in an efficient and effective way, devoid of corruption. indeed, the world has already witnessed the extent of corporate greed and disaster/monopoly capitalism (klein, ; robinson, ) as ceos capitalize on insider information to sell off stock and prey on small businesses unable to weather the economic impact of a global shut down (neate, ) . there are three main theoretical explanations of how crime emerges or shifts during an exceptional event. these theoretical explanations include social cohesion and altruism, social disorganization, and opportunity theories. interestingly, these explanations produce contradictory predictions about crime trends during an exceptional event. social cohesion, or altruism theories, predict that crime rates decline or remain stable during an exceptional event (zahran, shelly, peek, & brody, ). this argument has largely emerged from natural disaster research, in which proponents of the theory argue that during an emergency, people are more likely to help each other and act altruistically (barton, ) . for example, quarantelli ( ) argues that an increase in opportunistic crime, such as looting or theft, is rare after a disaster. after the earthquake in los angeles, violent crime did not increase (siegel, bourque, & shoaf, ) . furthermore sweet ( ) found a temporary increase in the levels of social support and cohesion after the ice storm in new york in january . a similar situation occurred the same year in quebec, canada, in which the ice storm there led to electrical blackouts. lemieux ( ) found that property crime dramatically decreased as instrumental altruism (government financial support) increased. however, this theoretical perspective has been heavily critiqued as many groups do not receive equal assistance during exceptional events such as earthquakes, ice storms, or blackouts. indeed, fothergill and peek ( ) found that exceptional events often exacerbate social inequality. this was evident in the lack of support provided to non-white americans in the aftermath of hurricane katrina (craemer, ) . furthermore, exceptional events can lead to changes in police reporting practices as front-line officers redirect their efforts to other, more pressing, issues (barsky, trainor, & torres, ) , and this can affect crime trends more broadly. this is particularly the case in natural disasters where the police role is expanded. another theoretical explanation of crime in exceptional events is social disorganization theory, which would predict an increase in crime rates as the social order is disrupted. as mentioned, exceptional events tend to exacerbate social inequality and emphasize the disadvantage of certain groups. advocates of this explanation argue that social cohesion and collective efficacy are not strengthened by an exceptional event, but rather weakened. in turn, these systems are unable to control antisocial behavior (curtis, miller, & berry, ; davila, marquart, & mullings, ; harper & frailing, ; prelog, ) . for example, in the new york city blackout in , genevie et al. ( ) found increases in looting in neighborhoods that already had higher levels of violent crime, illicit economy activity, and unemployment. however, in their study of the floods in brisbane in , zahnow, wickes, haynes, and corcoran ( ) found a displacement effect (in which crime incidents move from one location to another) for property crime to affluent, non-flood affected neighborhoods, suggesting that crime may shift as opportunity changes. this leads us to the final theoretical explanation, which accounts for the variations in findings from the other two theoretical perspectives. opportunity theories, such as routine activities theory, would predict that during an exceptional event, crime rates will both increase and decrease depending on the crime type and the shift in opportunity structure (leither et al., ) . routine activity theory argues that in order for a crime event to occur, a suitable target, a motivated offender, and the lack of a capable guardian need to come together in time and space (cohen & felson, ) . this theory emerged in response to the inability of other sociological and criminological theories to explain how a dramatic increase in financial prosperity had paralleled a dramatic increase in crime in the s and s in the united states. cohen and felson ( ) reasoned that the increase in crime was not a result of disadvantage or strain, but rather an increase in opportunities. peoples' routine activities had changed. entertainment options increased and this shifted people into the public sphere. women moved into the workforce in droves and were no longer at home to act as capable guardians. there was also an increase in the manufacturing and proliferation of lightweight durable goods that were cheaper to purchase and easier to steal (felson & cohen, ) . this research suggests that as the balance between suitable targets, motivated offenders, and capable guardians shift, this will have an indirect effect on crime trends (lebeau, ) . exceptional events can increase or decrease target availability by destroying, moving, or shifting targets (zahran et al., ) . for example, as capable guardianship decreases, as people leave their homes during a flood or hurricane, opportunities for burglary may increase (lebeau, ) . opportunity theories can also explain an increase in altruism as a protective factor against crime through the creation of informal guardianship (curtis & mills, ) . in the aftermath of hurricane andrew in florida, in , informal control mechanisms emerged to protect these properties (citizen-led patrols), which prevented an increase in opportunities and, in turn, property crime (cromwell, dunham, akers, & lanza-kaduce, ) . research on the long-term trends of crime after an exceptional event also suggest that when the opportunity structure returns to its pre-event status, crime trends in the affected areas also return to pre-event levels (zahnow et al., ) . exceptional events can have an important impact on crime. as the social composition of the community changes, so too can crime rates. the research on the impact of exceptional events on crime rates explores hurricanes, floods, earthquakes, blackouts, and more. however, as noted above, the findings of this research are mixed. for example, in , hurricane hugo resulted in a higher rate of property crime (quarantelli, ) . hurricane katrina, in , also led to a significant increase in burglary rates (harper & frailing, ) . however, varano, schafer, cancino, decker, and greene ( ) found that violent crime rates, such as robbery and homicide, did not change in the aftermath of hurricane katrina. in fact, they demonstrated that the increase in other crimes was a result of a shift in population, because a large number of survivors moved into one area. leitner, barnett, kent, and barnett ( ) and leitner and helbich ( ) found that crime rates after hurricane katrina remained relatively stable or even declined. hurricane rita, which hit later that same year, resulted in an increase in burglaries. interestingly, this increase did not occur after the hurricane hit, but after the evacuation notice was given (leitner & helbich, ) . changes in crime trends in exceptional events are not limited to hurricanes. the electricity blackouts in and in new york city led to dramatically different experiences of crime. the blackout had a negligible impact on crime rates (farrell, : montgomery, , while the blackout resulted in an increase in property crime and arson (corwin & miles, ) . the earthquakes in christchurch, new zealand in and resulted in a significant decline in crime in the central business district (cbd) after the earthquake, in particular where alcohol outlets had disappeared. however, a displacement effect occurred to some areas outside of the cbd that were not hit as hard by the earthquake and where alcohol was still available (breetzke & andresen, ) . during the flood in brisbane, australia in , zahnow et al. ( ) found that crime fluctuated across neighborhoods during the flood but returned to previous levels soon after the event was over. similarly, a flood in nigeria in , that killed ten times the number of people compared to brisbane and displaced over million others, led to an increase in violent crime rates. however, these rates also returned to pre-existing levels after the disaster (kwanga, shabu, & adaaku, ) . the research focusing on the effects of pandemics on crime rates is relatively scarce. importantly there is minimal criminological research about how pandemics affect other types of crime, such as corporate crime and corruption, cybercrime, and environmental crimes. at the time of writing, some research has emerged to say that the trends of certain crime types are changing. for example, eisner and nivette ( ) commented on the increase in hate crimes against east asian persons and care providers. they also reported dramatic increases in domestic violence and child abuse (eisner & nivette, ) . mcdonald and balkin ( ) have found some increases in rape, arson, and auto theft in five major cities in the united states. mohler et al. ( ) , investigated crime in los angeles and indianapolis, found that vehicle stops notably decreased and domestic violence was increasing. however, other crime types had minimal changes, and most were modestly decreasing. and ashby ( ), in a study of cities across the united states, found no increases in violent crime with mixed results for property crime. however, many of these preliminary findings require additional research. shifting crime trends alone should not guide policy or practitioners. it is possible that these early changes could be an anomaly. it is necessary to explore both how crime rates may be changing, but also how these changes occur within the context of other controls such as seasonal and yearly trends. in , outside of asian countries, canada was hit the hardest by the sars epidemic. while the death toll seems insignificant compared to that of covid- globally, the outbreak led to several changes in how the government of canada responded to pandemics. importantly, canada created the public health agency of canada to monitor outbreaks of disease, appointed a chief health officer to advise on health care precautions, prepared a set of guidelines to respond to a pandemic, enhanced research capacity, and improved their working relationship with the world health organization (who). as covid- started to spread in march of , canada moved quickly to bring canadians abroad home, shut down borders, and provide ongoing financial support to canadians who lost employment. these decisions supported canadians in staying home and isolating. additionally, they differ dramatically from the united states, in which leadership made inconsistent decisions and offered few protections to citizens who had lost employment or were unable to access health care. it is likely that these decisions will affect the nature of crime in canada during the pandemic. the current study examines crime trends across vancouver, british columbia during the initial twelve weeks of the covid- shutdown and compares these trends with projections of previous years. eight crime types are examined. this is conducted at the city level, in order to explore if the global pandemic is having a city-wide effect. additionally, most policing services operate at this level and a larger geographic area will be useful for helping to guide practitioners and policy in a rapidly changing environment. we examine eight different crime types as research suggests that different crime types will have different patterns during an exceptional event (prelog, ) . we believe these early studies are necessary to inform resource distribution and pandemic response strategies and better aid in a thoughtful and effective recovery. the city of vancouver is part of the vancouver census metropolitan area (cma), the third most populated metropolitan area in the country and the most populated in western canada, had a population of approximately . million in . over the past years, - , the vancouver cma's total crime rate decreased by %. however, from the previous year, , the total crime rate in the vancouver cma has only decreased by %, with an increase in violent crime ( %) and a decrease in property crime ( %). of the three largest metropolitan areas in canada, the vancouver cma had the highest total crime rate ( criminal code offenses per , people). this is slightly more than two times the rate of crime in the toronto cma ( per , people) and the montreal cma ( per , people). similar differences are present for property crime, but violent crime is at similar levels for all three cmas (moreau, ) . the city of vancouver had a population of approximately , in , making it the largest municipality within the vancouver cma. vancouver's total crime rate has only fallen % from to , currently at per , ), approximately double compared to toronto ( per , ) and montreal ( per , ). however, vancouver has experienced a notable drop in violent crime over this time period ( %) with a more conservative drop in property crime ( %) at the city level. vancouver's violent crime rate is similar to that of toronto and montreal, but twice the rates of both cities for property crime. fig. shows daily covid- infections in british columbia, most of which occurred in the vancouver area. evident from this bar graph is that covid- infections began to rise significantly late february and early march . daily infections reached their peak by the end of march and have been decreasing, albeit slowly, until the th of may . march is marked on fig. to indicate changes in routine activities and, therefore, opportunities for criminal activity as that is the day the bc public health emergency was declared, and restrictions began to be put in place. on march , grade school students began spring break and were instructed to not return to school once the break was over. on march large gatherings were banned and significant travel restrictions were put in place. on march the province declared a state of emergency, with restrictions on food and with the rise of covid- infection rates and public health warnings, followed by significant government policy changes and enactments, we expect any changes in temporal crime patterns to emerge at or around late february and early march when sharp increases in covid- infections and public health policy changes occurred, consistent with decreases in activity patterns outside of the home (google, ) . the current study is a time series analysis of crime at the city level, vancouver. these data are available from may to may . the crime incident data used for this study were obtained from the vancouver police department's geodash crime map website (https://geodash.vpd.ca/). in the analyses below we consider the following crime types: total crime, residential burglary, commercial burglary, theft of vehicle, theft from vehicle, theft, mischief, and violent crime. weekly counts of each criminal incident type are used for the analyses to identify any changes in the frequencies related to the timing of covid- . in order to identify short-term changes in the volume of criminal incidents in vancouver, we use weekly crime counts to maximize the number of observations while minimizing volatility. we analyse one year of data, weeks, and search for breaks in the trends of these time series, as outlined below. however, though the time before covid- may serve as a control, and trend-related control variables are used in the analyses, there may be unaccounted for phenomena that occur in march/april/may each year that may make it appear as though a change in trend has occurred when it is simply a recurring annual change in trend. to account for this, we undertake a similar analysis for the previous years to add another dimension of control into our evaluation. as noted above, weekly criminal incident counts are used in the analyses. however, as seen in the figures below, weekly crime counts are still rather volatile. as such, we use a data smoothing technique to abstract the trend of the data and, subsequently, identify deviations from trend, related to the timing of covid- . we use the hodrick and prescott ( ) filter to identify the trend component of the time series. extensively used in the macroeconomics literature, the hodrick and prescott ( ) filter separates the trend, cyclical, and error components of a time series: where y t is the time series of interest, τ t is the trend component, c t is the cyclical component (weekly pattern, for example, and ϵ t is the error ( ) the first term in eq. ( ) is the sum of squared deviations of the original times series and its trend; the second term is the sum of squares of the squared second differences, penalizing variations in the growth rate of τ t . the hodrick and prescott ( ) filter can be specified such that it can be used in all temporal frequencies: daily, weekly, monthly, seasonally, annually, and so on. all hodrick-prescott filter calculations are undertaken in r using the mfilter library, developed by balcilar ( ) . the benefit of using the hodrick and prescott ( ) filter is that it smooths/identifies the trend in the data without the loss of observations that occurs when using more traditional methods such as moving average calculations. however, the hodrick and prescott ( ) filter is not without its critiques, particularly around its identification and analysis of the cyclical component in a time series (hamilton, ) . but because we are not using the hodrick and prescott ( ) filter to identify and analyse the cyclical component of times series, but rather smooth volatile (weekly) time series data, is a lesser concern. and the ability to maintain all data points is of particular importance given the recency of potential changes in crime trends. interrupted times series is used to identify any changes in the trends of these time series, in conjunction with a chow ( ) testing methodology. interrupted time series tests are increasingly being used within the criminological literature to evaluate policy changes and crime reduction programs (hodgkinson, andresen, & saville, ; piehl, cooper, braga, & kennedy, ; reid & andresen, ) . moreover, these tests can be adapted for both known (exogenous) and unknown (endogenous) trend changes. in the current context there is a known policy intervention through the restriction of large gatherings, as discussed above. however, because we do not know how well these restrictions were enforced at their commencement date, march , we use a sequential chow ( ) test to endogenously search for a change in the trends of the criminal incident types: we account for the known seasonal component in crime data breetzke & cohn, ; cohn & rotton, ; farrell & pease, ; linning, andresen, ghaseminejad, & brantingham, ; mcdowall, loftin, & pate, ) through the inclusion of both week and week-squared variables that are represented by sequential values ( , , , …, ) representing the weeks may to may , for example; the week-squared variable is the square of week, allowing for any seasonality in the data to be identified. these two variables measure the underlying trend in the data. the interrupted times series (break in trend) variables (break, break trend, and break trend-squared) allow us to identify any changes in the frequency of criminal incidents, as both a sudden increase at the timing of the policy change (break) and changes in the trend at the timing of the policy change (trend and trend-squared). with weekly observations there are potential break points to identify; however, we exclude the first and last observations in order to facilitate the actual calculation of the break trend variable. as such each break-based variable has the value of zero before its representative break time and unity (break dummy variable) or sequential values (break trend variable) thereafter. for each of the crime variables (counts of total crime, residential burglaries, commercial burglaries, thefts of vehicle, thefts from vehicles, theft, mischief, and violence), we estimate possible break points. the actual structural breaks are determined at the time period that has the greatest value t-statistics for the break variables using robust standard errors (heteroskedastic and autocorrelation consistent). all estimation for the sequential chow tests is undertaken using r: a language and environment for statistical computing, version . . (r core team, ). the weekly time series for the various crime types in vancouver are shown in figs. - . all crime types have control years ending may and may , respectively, in order to identify changes in vancouver's temporal crime patterns that are not expected. table summarizes the results from the interrupted times series analyses. figs. to show that there is a clear seasonal pattern to crime in vancouver that is consistent with previous research (andresen & malleson, , . the seasonal pattern is not as strong as found in some research (e.g. mcdowell et al., ) but is present, nonetheless. the typical pattern, present for most crime types in most years, is an increase in event frequency during the summer and early fall, with subsequent declines in the winter months. as such, there is an expectation for most crime types to have (moderate) increases in their frequency at the time covid- restrictions were put into place. this is evident (in figs. , , , and ) for total crime, theft of vehicle, theft from vehicle, and theft, particularly in . the remaining crime types (violence, mischief, residential burglary, and commercial burglary) exhibit non-obvious or non-notable changes at this time of year given expected seasonal changes. this is not the case, however, for the temporal crime patterns from march to may . considering figs. to and table , there are a number of unexpected changes that occurred in march/april/may that did not occur in previous years. this is most easily seen in the hodrick and prescott ( ) trends, despite the volatility of weekly crime data. what can be seen from these results (graphed data and the breaks in trend identified by the interrupted time series analyses) is that total crime, theft from vehicle, and theft. all present decreasing trends in march/april/may when they are expected to be increasing or stable during these months. additionally, theft of vehicle has no obvious change in temporal trend march/april/may when it would be expected to increase, particularly based on the two most recent previous years. perhaps most dramatic is the significant increase, and of particular interest is the timing of the breaks in trend identified by the interrupted time series analyses. because of the volatility of weekly crime data, even those data smoothed by the hodrick and prescott ( ) filter, the timing of the breaks in trend are not always at or after week when a public health emergency was declared. for example, in the years ending in and , see table , breaks in trend have almost no consistency crime type to crime type. however, in the year ending in , there are notable changes in trend that occurred well within the covid- related restrictions in british columbia when health warnings were underway. collectively, the consistency in the timing of the breaks in trend and the changes in the expected directions of those trends (a lack of change in trend for the case of theft of vehicle) shows that covid- and its corresponding implications on opportunity structures have had significant impacts on crime in vancouver. consistent with opportunities theories, such as routine activities, the results demonstrate that as the nature of social life shifted into isolation, crime rates fluctuated accordingly. unlike social cohesion or altruism theories that predict crime would remain stable or decrease, or social disorganization theories that would predict crime would increase, routine activity and opportunity theories suggest that crimes may increase or decrease depending on the opportunity structure and the character of the exceptional event. in vancouver, we found that there was a significant decrease in total crime, when the previous seasonal patterns suggest we should have found an increase or stability. when we broke that pattern down by crime type, we found that there was a significant increase in commercial burglary, followed by a decrease, when in previous years it remained relatively stable during this time. theft and theft from vehicle decreased despite typically stable trajectories for these crime types in previous years. auto theft was stable when it would be expected to be increasing. violence, mischief, and residential burglary had no obvious change over this time period compared to previous control years. according to routine activity theory many of these changes in crime trends are unsurprising. as motivated offenders, suitable targets, and a lack of capable guardianship converge differently, crimes trends should fluctuate. for example, commercial burglary increased during the covid- shut down because businesses were forced to close, and owners and employees were no longer present to act as capable guardians. subsequent decreases would be expected if capable guardians reacted to this shift in crime. in vancouver, the police responded to the surge in calls for commercial burglary by arresting offenders and urging business owners to increase securitywhich many did by boarding up their shops (cbc, ) . this provides not only support for routine activity theory, but also the importance of natural surveillance (cozens, saville, & hillier, ) . theft and theft from vehicle likely declined, and auto theft failed to increase as expected, as suitable targets were t. hodgkinson and m.a. andresen journal of criminal justice ( ) relocated, and capable guardianship increased. for example, it might be more difficult to steal or steal from vehicles that are now parked in the garage of the owner, rather than an above ground parking lot during the workday (hodgkinson, andresen, & farrell, ) . the theory could predict that mischief would increase as young persons have more time outside of school to engage in troublemaking. however, because of the nature of the pandemic restrictions, capable guardianship actually increases as youth are expected by both parents and government officials to not leave the home. if they were witnessed out alone or in a group, this may increase their likelihood of being caught, because this behavior may appear more suspicious. thus, the findings are consistent with routine activity theory. counterintuitively, violence and residential burglary trends did not demonstrate a significant change over the study period, aside from expected seasonal patterns, as would be predicted by routine activity theory. residential burglary should have witnessed a significant decrease. as residents are home throughout the day, they can act as capable guardians making it very difficult to break in. however, vancouver had experienced significant declines in residential burglary across all neighborhoods prior to covid- (hodgkinson & andresen, ) and, thus, residential burglary counts may have already been too low to demonstrate any change. regarding violence, routine activity theory would predict that assault may decline as there are fewer opportunities for motivated offenders and suitable targets to converge in certain locations, such as alcohol outlets (bars, pubs, etc) or schools (fights). at the same time, the theory would predict that domestic assault would increase as offenders and victims are now consistently in the same space without capable guardianship. in our study, rates of violence do not change over the study period. however, violence is a combined measure of all crimes against person. thus, maintaining its expected seasonal trajectory is unsurprising as the decrease in assault may counter with the expected increase in domestic violence. it may also be useful to consider that women may be even less likely to report domestic violence if their access to social services in the pandemic is limited. as a result, they would be unlikely to find shelter if reporting leads to an escalation in violence. unfortunately, the data here do not provide us with the opportunity to explore this issue, but it is an area that desperately needs further attention. outreach services may be in a better position to understand what is happening in this area and how to address this gendered aspect of community safety during an exceptional event like a pandemic. overall, however, the changes in crime trends in vancouver are consistent with the change in routine activities. we believe this research may be useful in guiding policy and practice. for example, as opportunities for commercial burglary increase, so too must alternative forms of capable guardianship. this may include the police or citizenled patrols. in vancouver, many businesses boarded up their storefronts to add additional layers of security (singh & chan, ) . in a more creative response, a local printing shop has encouraged local artists to cover these boarded-up storefronts with art that celebrates front-line workers in order to reduce the "fortress" look of these business areas (crawford, ) . as the opportunity structure of crime changes during an exceptional event like a pandemic, it is important to address opportunities for crime early in the outbreak. as with any analysis, ours is not without its limitations. because of the source of our data, vancouver police department, we are limited to the impact covid- has on criminal incidents reported to the police. estimates for such reporting are not available at the city level, but in canada the average reporting rate to the police is % in (perreault, ) , a percentage that has been decreasing since the late- s (perreault, ; perreault & brennan, ) . moreover, reporting rates vary significantly from % (sexual assault) to % (burglary). as such, we cannot know the full impact of covid- on all criminal victimizations. additionally, the classification for violent crime is not available in a disaggregated format. because of this, we are not able to differentiate between different violent criminal incidents. in the current context, this could be quite important. as mentioned, with self-isolation and the closure of liquor establishments, we expect decreases in assaults, particularly those related to alcohol (grubesic & pridemore, ) ; similarly, with increased time together coupled with the stress of a pandemic, we expect increases in domestic violence (parkinson, ) . depending on their changes in frequency, one may cancel out the other in the aggregate such that there is no identifiable change overall. however, without disaggregated crime data we cannot assess this possibility. there are also unknowns at this point in the research. we are unable to say if calls for service and police activity have been affected by the virus. police may change their behavior to protect themselves from contracting the virus. furthermore, police may change how they respond to calls as it becomes increasingly irresponsible to arrest and incarcerate people who may then be at an increased risk of contracting the virus. we were unable to explore these changes to police behavior in this study. importantly, the research is limited by its focus on the city-level. this means any changes to opportunity structures at the local level, such as shifts in land use, are unable to be investigated here. additionally, in many countries, academics, legal practitioners, and social workers are demanding de-incarceration and improved housing policies for the homeless, in order to prevent the spread of the virus (bartels & anthony, ; kim, ; kirby, ) . the changes in land use, coupled with shifts in social policy will likely affect the nature of routine activities at both the local and city levels and require further examination. directions for future research follow from the limitations outlined above. first, qualitative research that can more thoroughly investigate victimization should be undertaken in order to establish a deeper understanding of the impacts of covid- on criminal victimization. second, research that disaggregates violent crime into its component parts is necessary to identify any changes that are more nuanced than total violent crime. third, researchers should attempt to obtain and analyse disaggregated data that account for shifts in land use and opportunity structures as a result of local shifts in covid- related policies. and fourth, though the impacts over time of covid- may not be known for some time, continued research in this area should be undertaken to identify medium-and long-term effects, if any, of the pandemic. we predict that as the pandemic ends, and routine activities return to their pre-pandemic state, so too will crime trends. this will include the return of informal social controls such as the capable guardians of commercial establishments, that have already resulted in decreases in commercial burglary. we expect that other crime types described above such as theft and auto theft will likely return to their previous seasonal trajectories as well. we may witness an increase in cybercrime, as many systems have moved online in order to cope with the crisis and some may remain there. however, as potential victims become more computer savvy, this may actually decrease (e.g potential victims may be become capable guardians). at the point of writing we do not know how long the pandemic will last. routine activity theory assumes motivated offenders as a constant. however, as the economy changes, and people are unable to work and become more desperate, it is possible that crime trends may increase to match changes in motivation. there are parts of the world that are suffering already, where staying indoors is not an option and corporations and politicians are beginning to meddle in covid- related decisions (wilson, ) . furthermore, there are certain groups who are already marginalized and struggling who will be affected more deeply by continued restrictions on work and the economy. indeed, it would be unfair to claim that the shift in routine activities alone may be driving crime rates, when other countries do not experience the same institutionalized altruism from which many canadians benefit (lemieux, ) . comparative research is necessary to determine if similar social support policies may benefit other countries who are experiencing greater rates of social inequality and, subsequently, increased motivation, during the pandemic. finally, early and continued methodologically rigorous research is necessary on crime and exceptional events to not only identify how crime is changing, but how to better prevent it. regardless of these limitations, and subsequent directions for future research, we contribute to the literature on exceptional events and crime through the analysis of a (ongoing) pandemic as a natural experiment. similar to previous research that has investigated the impact of natural disasters on crime, this topic is not to be taken lightly. rather, given its presence we can use it to better understand social phenomena, hopefully making cities safer during the crisis and in its aftermath. while we have yet to know the full extent of the economic impact globally, with small businesses closing, and people 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social cohesion: a longitudinal study natural disasters as threats to peace, special report a tale of three cities: crime and displacement after hurricane katrina canada and covid- : learning from sars. the lancet the rightwing groups behind wave of protests against covid- restrictions disasters and crime: the effect of flooding on property crime in brisbane neighborhoods natural disaster and social order: modelling crime outcomes and disasters in florida key: cord- - dpsggwx authors: gillen, david; morrison, william g. title: regulation, competition and network evolution in aviation date: - - journal: journal of air transport management doi: . /j.jairtraman. . . sha: doc_id: cord_uid: dpsggwx abstract our focus is the evolution of business strategies and network structure decisions in the commercial passenger aviation industry. the paper reviews the growth of hub-and-spoke networks as the dominant business model following deregulation in the latter part of the th century, followed by the emergence of value-based airlines as a global phenomenon at the end of the century. the paper highlights the link between airline business strategies and network structures, and examines the resulting competition between divergent network structure business models. in this context we discuss issues of market structure stability and the role played by competition policy. taking a snapshot of the north american commercial passenger aviation industry in the spring of , the signals on firm survivability and industry equilibrium are mixed; some firms are under severe stress while others are succeeding in spite of the current environment. in the us, we find united airlines in chapter and us airways emerging from chapter bankruptcy protection. we find american airlines having just reported the largest financial loss in us airline history, while delta and northwest airlines along with smaller carriers like alaska, america west and several regional carriers are restructuring and employing cost reduction strategies. we also find continental airlines surviving after having been in and out of chapter in recent years, while southwest airlines continues to be profitable. in canada, we find air canada in companies creditors arrangement act (cca) bankruptcy protection (the canadian version of chapter ), after reporting losses of over $ million for the year and in march . meanwhile westjet, like southwest continues to show profitability, while two new carriers, jetsgo and canjet (reborn), have entered the market. looking at europe, the picture is much the same, with large full-service airlines (fsas hereafter) such as british airways and lufthansa sustaining losses and suffering financial difficulties, while value-based airlines (vbas) like ryanair and easyjet continue to grow and prosper. until recently, asian air travel markets were performing somewhat better than in north america, however the severe acute respiratory syndrome (sars) epidemic had a severe negative effect on many asian airlines. clearly, the current environment is linked to several independent negative demand shocks that have hit the industry hard. slowdown was already underway in , prior to the - tragedy, which gave rise to the 'war on terrorism' followed by the recent military action in iraq. finally, the sars virus has not only severely diminished the demand for travel to areas where sars has broken out and led to fatalities, but it has also helped to create yet another reason for travellers to avoid visiting airports or travelling on aircraft, based on a perceived risk of infection. all of these factors have created an environment where limited demand and price competition has favoured the survival of airlines with a low-cost, lowprice focus. in this paper we examine the evolution of air transport networks after economic deregulation, and the connection between networks and business strategies, in an environment where regulatory changes continue to change the rules of the game. the deregulation of the us domestic airline industry in was the precursor of similar moves by most other developed economies in europe (beginning - ) , canada (beginning in ) , australia ( ) and new zealand ( ) . the argument was that the industry was mature and capable of surviving under open market conditions subject to the forces of competition rather than under economic regulation. prior to deregulation in the us, some airlines had already organized themselves into hub-and-spoke net-works. delta airlines, for example, had organized its network into a hub at atlanta with multiple spokes. other carriers had evolved more linear networks with generally full connectivity and were reluctant to shift to hub-and-spoke for two reasons. first, regulations required permission to exit markets and such exit requests would likely lead to another carrier entering to serve 'public need'. secondly, under regulation it was not easy to achieve the demand side benefits associated with networks because of regulatory barriers to entry. in the era of economic regulation the choice of frequency and ancillary service competition were a direct result of being constrained in fare and market entry competition. with deregulation, airlines gained the freedom to adapt their strategies to meet market demand and to reorganize themselves spatially. consequently, huband-spoke became the dominant choice of network structure. the hub-and-spoke network structure was perceived to add value on both the demand and cost side. on the demand side, passengers gained access to broad geographic and service coverage, with the potential for frequent flights to a large number of destinations. large carriers provided lower search and transactions costs for passengers and reduced through lower time costs of connections. they also created travel products with high convenience and service levels-reduced likelihood of lost luggage, in-flight meals and bar service for example. the fsa business model thus favoured high service levels which helped to build the market the market at a time when air travel was an unusual or infrequent activity for many individuals. building the market not only meant encouraging more air travel but also expanding the size of the network which increased connectivity and improved aircraft utilization. on the cost side the industry was shown to have few if any economies of scale, but there were significant economies of density. feeding spokes from smaller centres into a hub airport enabled full service carriers to operate large aircraft between major centres with passenger volumes that lowered costs per available seat. an early exception to the hub-and-spoke network model was southwest airlines. in the us, southwest airlines was the original 'vba' representing a strategy designed to build the market for consumers whose main loyalty is to low-price travel. this proved to be a sustainable business model and southwest's success was to create a blueprint for the creation of other vbas around the world. the evolution has also been assisted by the disappearance of charter airlines with deregulation as fsas served a larger scope of the demand function through their yield management system. (footnote continued) of economies from manufacturing to service economies and service industries are more aviation intensive than manufacturing. developed economies as in europe and north america as well as australia and new zealand, have an increasing proportion of gdp provided by service industries particularly tourism. one sector that is highly aviation intensive is the high technology sector. it is footloose and therefore can locate just about anywhere; the primary input is human capital. it can locate assembly in low-cost countries and this was enhanced under new trade liberalization with the wto. canada's deregulation was not formalised under the national transportation act until . australia and new zealand signed an open skies agreement in , which created a single australia-new zealand air market, including the right of cabotage. canada and the us signed an open skies agreement well in but not nearly so liberal as the australian-new zealand one. in contrast to deregulation within domestic borders, international aviation has been slower to introduce unilateral liberalization. consequently the degree of regulation varies across routes, fares, capacity, entry points (airports) and other aspects of airline operations depending upon the countries involved. the us-uk, german, netherlands and korea bilaterals are quite liberal, for example. in some cases, however, most notably in australasia and europe, there have been regional air trade pacts, which have deregulated markets between and within countries. the open skies agreement between canada and the us is similar to these regional agreements. meanwhile, benefits of operating a large hub-andspoke network in a growing market led to merger waves in the us (mid- s) and in canada (late- s) and consolidation in other countries of the world. large firms had advantages from the demand side, since they were favoured by many passengers and most importantly by high yield business passengers. they also had advantages from the supply side due to economies of density and economies of stage length. in most countries other than the us there tended to be high industry concentration with one or at most two major carriers. it was also true that in most every country except the us there was a national (or most favoured) carrier that was privatized at the time of deregulation or soon thereafter. in canada in the open skies agreement with the us was brought in. around this time we a new generation of vbas emerged. in europe, ryanair and easyjet experienced rapid and dramatic growth following deregulation within the eu. some fsas responded by creating their own vbas: british airways created go, klm created buzz and british midland created bmibaby for example. westjet airlines started service in western canada in serving three destinations and has grown continuously since that time. canadian airlines, faced with increased competition in the west from westjet as well as aggressive competition from air canada on longer haul routes, was in a severe financial by the late s. a bidding war for a merged air canada and canadian was initiated and in , air canada emerged the winner with a 'winners curse', having assumed substantial debt and constraining service and labour agreements. canada now had one fsa and three or four smaller airlines, two of which were vbas. in the new millennium, some consolidation has begun to occur amongst vbas in europe with the merger of, easyjet and go in , and the acquisition of buzz by ryanair in . more importantly perhaps, the vba model has emerged as a global phenomenon with vba carriers such as virgin blue in australia, gol in brazil, germania and hapag-lloyd in germany and air asia in malaysia. looking at aviation markets since the turn of the century, casual observation would suggest that a combination of market circumstances created an opportunity for the propagation of the vba business model-with a proven blueprint provided by southwest airlines. however a question remains as to whether something else more fundamental has been going on in the industry to cause the large airlines and potentially larger alliances to falter and fade. if the causal impetus of the current crisis was limited to cyclical macro factors combined with independent demand shocks, then one would expect the institutions that were previously dominant to re-emerge once demand rebounds. if this seems unlikely it is because the underlying market environment has evolved into a new market structure, one in which old business models and practices are no longer viable or desirable. the evolution of business strategies and markets, like biological evolution is subject to the forces of selection. airlines who cannot or do not adapt their business model to long-lasting changes in the environment will disappear, to be replaced by those companies whose strategies better fit the evolved market structure. but to understand the emerging strategic interactions and outcomes of airlines one must appreciate that in this industry, business strategies are necessarily tied to network choices. the organization of production spatially in air transportation networks confers both demand and supply side network economies and the choice of network structure by a carrier necessarily reflects aspects of its business model and will exhibit different revenue and cost drivers. in this section we outline important characteristics of the business strategy and network structures of two competing business models: the full service strategy (utilizing a hub-and-spoke network) and the low cost strategy model which operates under a partial point-to-point network structure. the full service business model is predicated on broad service in product and in geography bringing customers to an array of destinations with flexibility and available capacity to accommodate different routings, no-shows and flight changes. the broad array of destinations and multiple spokes requires a variety of aircraft with differing capacities and performance characteristics. the variety increases capital, labour and operating costs. this business model labours under cost penalties and lower productivity of hub-and-spoke operations including long aircraft turns, connection slack, congestion, and personnel and baggage online connections. these features take time, resources and labour, all of which are expensive and are not easily avoided. the hub-and-spoke system is also conditional on airport and airway infrastructure, information provision through computer reservation and highly sophisticated yield management systems. the network effects that favoured hub and spoke over linear connected networks lie in the compatibility of article in press unit costs decrease as stage length increases but at a diminishing rate. there was a phase in period for select airports in canada as well as different initial rules for us and canadian carriers. flights and the internalization of pricing externalities between links in the network. a carrier offering flights from city a to city b through city h (a hub) is able to collect traffic from many origins and place them on a large aircraft flying from h to b, thereby achieving density economies. in contrast a carrier flying directly from a to b can achieve some direct density economies but more importantly gains aircraft utilization economies. in the period following deregulation, density economies were larger than aircraft utilization economies on many routes, owing to the limited size of many origin and destination markets. on the demand side, fsas could maximize the revenue of the entire network by internalizing the externalities created by complementarities between links in the network. in our simple example, of a flight from a to c via hub h the carrier has to consider how pricing of the ah link might affect the demand for service on the hb link. if the service were offered by separate companies, the company serving ah will take no consideration of how the fare it charged would influence the demand on the hb link since it has no right to the revenue on that link. the fsa business model thus creates complexity as the network grows, making the system work effectively requires additional features most notably, yield management and product distribution. in the period following deregulation, technological progress provided the means to manage this complexity, with large information systems and in particular computer reservation systems. computer reservation systems make possible sophisticated flight revenue management, the development of loyalty programs, effective product distribution, revenue accounting and load dispatch. they also drive aircraft capacity, frequency and scheduling decisions. as a consequence, the fsa business model places relative importance on managing complex schedules and pricing systems with a focus on profitability of the network as a whole rather than individual links. the fsa business model favours a high level of service and the creation of a large service bundle (inflight entertainment, meals, drinks, large numbers of ticketing counters at the hub, etc.) which serves to maximize the revenue yields from business and longhaul travel. an important part of the business service bundle is the convenience that is created through fully flexible tickets and high flight frequencies. high frequencies can be developed on spoke routes using smaller feed aircraft, and the use of a hub with feed traffic from spokes allows more flights for a given traffic density and cost level. more flights reduce total trip time, with increased flexibility. thus, the hub-and-spoke system leads to the development of feed arrangements along spokes. indeed these domestic feeds contributed to the development of international alliances in which one airline would feed another utilizing the capacity of both to increase service and pricing. like the fsa model, the vba business plan creates a network structure that can promote connectivity but in contrast trades off lower levels of service, measured both in capacity and frequency, against lower fares. in all cases the structure of the network is a key factor in the success of vbas even in the current economic and demand downturn. vbas tend to exhibit common product and process design characteristics that enable them to operate at a much lower cost per unit of output. on the demand side, vbas have created a unique value proposition through product and process design that enables them to eliminate, or ''unbundle'' certain service features in exchange for a lower fare. these service feature trade-offs are typically: less frequency, no meals, no free, or any, alcoholic beverages, more passengers per flight attendant, no lounge, no interlining or code-sharing, electronic tickets, no pre-assigned seating, and less leg room. most importantly the vba does not attempt to connect its network although their may be connecting nodes. it also has people use their own time to access or feed the airport. there are several key areas in process design (the way in which the product is delivered to the consumer) for a vba that result in significant savings over a full service carrier. one of the primary forms of process design savings is in the planning of point-to-point city pair flights, focusing on the local origin and destination market rather than developing hub systems. in practice, this means that flights are scheduled without connections and stops in other cities. this could also be considered product design, as the passenger notices the benefit of travelling directly to their desired destination rather than through a hub. rather than having a bank of flights arrive at airports at the same time, low-cost carriers spread out the staffing, ground handling, maintenance, food services, bridge and gate requirements at each airport to achieve savings. another less obvious, but important cost saving can be found in the organization design and culture of the company. it is worth noting at this point that the innovator of product, process, and organizational redesign is generally accepted to be southwest airlines. many low-cost start-ups have attempted to replicate that model as closely as possible; however, the hardest area to replicate has proved to be the organization design and culture. extending the ''look and feel'' to the aircraft, there is a noticeable strategy for low-cost airlines. successful vbas focus on a homogeneous fleet type (mostly the boeing but this is changing; e.g. jet blue with a fleet). the advantages of a 'common fleet' are numerous. purchasing power is one-with the obvious exception of the aircraft itself, heavy maintenance, parts, supplies; even safety cards are purchased in one model for the entire fleet. training costs are reduced-with only one type of fleet, not only do employees focus on one aircraft and become specialists, but economies of density can be achieved in training. the choice of airports is typically another source of savings. low-cost carriers tend to focus on secondary airports that have excess capacity and are willing to forego some airside revenues in exchange for non-airside revenues that are developed as a result of the traffic stimulated from low-cost airlines. in simpler terms, secondary airports charge less for landing and terminal fees and make up the difference with commercial activity created by the additional passengers. further, secondary airports are less congested, allowing for faster turn times and more efficient use of staff and the aircraft. the average taxi times shown in table (below) are evidence of this with respect to southwest in the us and one only has to consider the significant taxi times at pearson airport in toronto to see why hamilton is such an advantage for westjet. essentially, vbas have attempted to reduce the complexity and resulting cost of the product by unbundling those services that are not absolutely necessary. this unbundling extends to airport facilities as well, as vbas struggle to avoid the costs of expensive primary airport facilities that were designed with full service carriers in mind. while the savings in product design are the most obvious to the passenger, it is the process changes that have produced greater savings for the airline. the design of low-cost carriers facilitates some revenue advantages in addition to the many cost advantages, but it is the cost advantages that far outweigh any revenue benefits achieved. these revenue advantages included simplified fare structures with - fare levels, a simple 'yield' management system, and the ability to have one-way tickets. the simple fare structure also facilitates internet booking. however, what is clearly evident is the choice of network is not independent of the firm strategy. the linear point-topoint network of vbas allows it to achieve both cost and revenue advantages. table below, compares key elements of operations for us airlines fleets. one can readily see a dramatic cost advantage for southwest airlines compared to fsas. in particular, southwest is a market leader in aircraft utilization and average taxi times. if one looks at the differences in the us between vbas like southwest and fsas, there is a : cost difference. this difference is similar to what is found in canada between westjet and air canada as well as in europe. these carriers buy the fuel and capital in the same market, and although there may be some difference between carriers due to hedging for example, these are not structural or permanent changes. the vast majority of the cost difference relates to product and process complexity. this complexity is directly tied to the design of their network structure. table compares cost drivers for fsas and vbas in europe. the table shows the key underlying cost drivers and where a vba like ryanair has an advantage over fsas in crew and cabin personnel costs, airport charges and distribution costs. the first two are directly linked to network design. a hub-and-spoke network is service it should also be noted that the vba model is not generic. different low cost carriers do different things and like all businesses we see continual redefinition of the model. intensive and high cost. even distribution cost-savings are related indirectly to network design because vbas have simple products and use passengers' time as an input to reduce airline connect costs. in europe, ryanair has been a leader in the use of the internet for direct sales and 'e-tickets'. in the us southwest airlines was an innovator in ''e-ticketing'', and was also one of the first to initiate bookings on the internet. vbas avoid travel agency commissions and ticket production costs: in canada, westjet has stated that internet booking account for approximately % of their sales, while in europe, ryanair claimed an internet sales percentage of % in march . while most vbas have adopted direct selling via the internet, the strategy has been hard for fsas to respond to with any speed given their complex pricing systems. recent moves by full service carriers in the us and canada to eliminate base commissions should prove to be interesting developments in the distribution chains of all airlines. to some degree, vbas have positioned themselves as market builders by creating point-to-point service in markets where it could not be warranted previously due to lower traffic volumes at higher fsa fares. vbas not only stimulate traffic in the direct market of an airport, but studies have shown that vbas have a much larger potential passenger catchment area than fsas. the catchment area is defined as the geographic region surrounding an airport from which passengers are derived. while an fsa relies on a hub-and-spoke network to create catchment, low-cost carriers create the incentive for each customer to create their own spoke to the point of departure. table provides a summary of the alternative airline strategies pursued in canada, and elsewhere in the world. the trend worldwide thus far indicates two quite divergent business strategies. the entrenched fsa carriers' focuses on developing hub and spoke networks while new entrants seem intent on creating low-cost, point-to-point structures. the hub and spoke system places a very high value on the feed traffic brought to the hub by the spokes, especially the business traffic therein, thereby creating a complex, marketing intense business where revenue is the key and where production costs are high. inventory (of seats) is also kept high in order to meet the service demands of business travellers. the fsa strategy is a high cost strategy because the hub-and-spoke network structure means both reduced productivity for capital (aircraft) and labour (pilots, cabin crew, airport personnel) and increased costs due to self-induced congestion from closely spaced banks of aircraft. the fsa business strategy is sustainable as long as no subgroup of passengers can defect from the coalition of all passenger groups, and recognizing this, competition between fsas included loyalty programs designed to protect each airline's coalition of passenger groupsfrequent travellers in particular. the resulting market structure of competition between fsas was thus a cozy oligopoly in which airlines competed on prices for some economy fares, but practiced complex price discrimination that allowed high yields on business travel. however, the vulnerability of the fsa business model was eventually revealed through the vba strategy which (a) picked and chose only those origin-destination links that were profitable and (b) targeted price sensitive consumers. the potential therefore was not for business travellers to defect from fsas (loyalty programs helped to maintain this segment of demand) but for leisure travellers and other infrequent flyers to be lured away by lower fares (fig. ) . figs. and present a schemata that help to summarize the contributory factors that propagated the fsa hub-and-spoke system and made it dominant, followed by the growth of the vba strategy along with the events and factors that now threaten the fsa model. in this section we set out a simple framework to explain the evolution of network equilibrium and show westjet estimated that a typical ticket booked through their call centre costs roughly $ , while the same booking through the internet costs around cents. airlines were able to reduce their costs to some degree by purchasing ground services from third parties. unfortunately they could not do this with other processes of the business. vbas will also not hesitate to exit a market if it is not profitable (e.g. westjet's recent decision to leave sault st. marie and sudbury) while fsas are reluctant to exit for fear of missing feed traffic and beyond revenue. how it is tied to the business model. the linkage will depend on how the business models differ with respect to the integration of demand conditions, fixed and variable cost and network organization. let three nodes {y ; y ,y ; ( , ), ( , ), ( , )}, form the corner coordinates of an isosceles right triangle. the nodes and the sides of the triangle may thus represent a simple linear travel network that defines fully connected network hub-and-spoke network partial point-to-point network congestion or other factors affecting passenger throughput at airports. this simple network structure allows us to compare three possible structures for the supply of travel services: a complete (fully connected) point-to-point network (all travel constitutes a direct link between two nodes); a hub-and-spoke network (travel between y and y requires a connection through y ) and limited (or partial) point-to-point network (selective direct links between nodes). these are illustrated in fig. below. in the network structures featuring point-to-point travel, the utility of consumers who travel depends only on a single measure of the time duration of travel and a single measure of convenience. however in the hub-andspoke network, travel between y and y requires a connection at y ; consequently the time duration of travel depends upon the summed distance d c ¼ d þ d ¼ þ ffiffi ffi p : furthermore, in a hub-and-spoke network, there is interdependence between the levels of convenience experienced by travellers. if there are frequent flights between y and y but infrequent flights between y and y ; then travellers will experience delays at y : there has been an evolving literature on the economics of networks or more properly the economics of network configuration. hendricks et al. ( ) show that economies of density can explain the hub-andspoke system as the optimal system in the airline networks. the key to the explanation lies in the level of density economies. however, when comparing a point-to-point network they find the hub-and-spoke network is preferred when marginal costs are high and demand is low but given some fixed costs and intermediate values of variable costs a point-to-point network may be preferred. shy ( ) shows that profit levels on a fully connected (fc) network are higher than on a hub-and-spoke network when variable flight costs are relatively low and passenger disutility with connections at hubs is high. what had not been explained well, until pels et al. ( ) is the relative value of market size to achieve lower costs per available seat mile (asm) versus economies of density. pels et al. ( ) explore the optimality of airline networks using linear marginal cost functions and linear, symmetric demand functions; mc ¼ À bq and p ¼ a À q= where b is a returns to density parameter and a is a measure of market size. the pels model demonstrates the importance of fixed costs in determining the dominance of one network structure over another in terms of optimal profitability. in particular, the robustness of the hub-and-spoke network configuration claimed by earlier authors (hendricks et al., ) comes into question. in our three-node network, the pels model generates two direct markets and one transfer market in the huband-spoke network, compared with three direct markets in the fully connected network. defining aggregate demand as q ¼ q d þ q t ; the profits from a hub-andspoke network, are: y while the profits of a fc network are: y more generally, for a network of size n, hub-and-spoke optimal profits are: y and fc profits are: under what conditions would an airline be indifferent between network structure? the market size at which profit maximizing prices and quantities equate the profits in each network structure is where, the two possible values of a à implied by ( ) represent upper and lower boundaries on the market size for which the hub-and-spoke network and the fully connected network generate the same level of optimal profits. these boundary values are of course conditional on given values of the density economies parameter (y) fixed costs (f), and the size of the network (n). these parameters can provide a partial explanation for the transition from fc to hub-and-spoke network structures after deregulation. with relatively low returns to density, and low fixed costs per link, even in a growing market, the hub-andspoke structure generates inferior profits compared with the fc network, except when the market size (a) is extremely high. however with high fixed costs per network link, the hub-and-spoke structure begins to dominate at a relatively small market size and this advantage is amplified as the size of the network grows. importantly in this model, dominance does not mean that the inferior network structure is unprofitable. in (a; b) space, the feasible area (defining profitability) of the fc structure encompasses that of the hub-and-spoke structure. this accommodates the observation that not all airlines adopted the hub-and-spoke network model following deregulation. where the model runs into difficulties is in explaining the emergence of limited point-to-point networks and the vba model. it is the symmetric structure of the model that renders it unable to capture some important elements of the environment in which vbas have been able to thrive. in particular, three elements of asymmetry are missing. first, the model does not allow for asymmetric demand growth between nodes in the network. with market growth, returns to density can increase on a subset of links that would have been feeder spokes in the hub-and-spoke system when the market was less developed. these links may still be infeasible for fsas but become feasible and profitable as independent point-to-point operations, providing an airline has low enough costs. second, the model does not distinguish between market demand segments and therefore cannot capture the gradual commoditization of air travel, as more consumers become frequent flyers. to many consumers today, air travel is no longer an exotic product with an air of mystery and an association with wealth and luxury. there has been an evolution of preferences that reflects the perception that air travel is just another means of getting from a to b. as the perceived nature of the product becomes more commodity-like, consumers become more price sensitive and are willing to trade off elements of service for lower prices. vbas use their low fares to grow the market by competing with other activities. their low cost structure permits such a strategy. fsas cannot do this to any degree because of their choice of bundled product and higher costs. third, the model does not capture important asymmetries in the costs of fsas and vbas, such that vbas have significantly lower marginal and fixed costs. notice that the dominance of the hub-and-spoke structure over the fc network relies in part on the cost disadvantage of a fixed cost per link, which becomes prohibitive in the fc network as the number of nodes (n) gets large. vbas do not suffer from this disadvantage because they can pick and choose only those nodes that are profitable. furthermore, fsas variable costs are higher because of the higher fixed costs associated with their choice of hub-and-spoke network. it would seem that with each new economic cycle, the evolution of the airline industry brings about an industry reconfiguration. several researchers have suggested that this is consistent with an industry structure with an 'empty core', meaning non-existence of a natural market equilibrium. button ( ) makes the argument as follows. we know that a structural shift in the composition (i.e., more low-cost airlines) of the industry is occurring and travel substitutes are pushing down fares and traffic. we also observe that heightened security has increased the time and transacting costs of trips and these are driving away business, particularly short haul business trips. as legacy airlines shrink and die away, new airlines emerge and take up the employment and market slack. the notion of the 'empty core' problem in economics is essentially a characterization of markets where too few competitors generate supra-normal profits for incumbents, which then attracts entry. however entry creates frenzied competition in a war-of-attrition game environment: the additional competition induced by entry results in market and revenue shares that produce losses for all the market participants. consequently entry and competition leads to exit and a solidification of market shares by the remaining competitors who then earn supra-normal profits that once again will attract entry. while there is some intuitive appeal to explaining the dynamic nature of the industry resulting from an innate absence of stability in the market structure, there are theoretical problems with this perspective. the fundamental problem with the empty core concept is that its roots lie in models of exogenous market structure that impose (via assumptions) the conditions of the empty core rather than deriving it as the result of decisions made by potential or incumbent market participants. in particular, for the empty core to perpetuate itself, entrants must be either ill advised or have some unspecified reason for optimism. in contrast, modern to model a such a demand system we need a consumer utility function of the form, u ¼ uðy ; t; v Þ ¼ gv ðy pÞ; where y represents dollar income per period and t ½ ; represents travel trips per period. v is an index of travel convenience, related to flight frequency and p is the delivered price of travel. this reduces each consumer's choice problem to consumption of a composite commodity priced at $ , and the possibility of taking at most one trip per period. utility is increasing in v and decreasing in p, thus travellers are willing to tradeoff convenience for a lower delivered price. diversity in the willingness to trade off convenience for would be represented by distribution for y, g; and v over some range of parameter values. thus the growth of value-based demand for air travel would be represented by an increase in the density of consumers with relatively low value of these parameters. the empty core theory is often applied to industries that exhibit significant economies of scale, airlines are thought generally to have limited if any scale economies but they do exhibit significant density economies. these density economies are viewed as providing conditions for an empty core. the proponents however only argue on the basis of fsas business model. industrial organization theory in economics is concerned with understanding endogenously determined market structures. in such models, the number of firms and their market conduct emerge as the result of a decisions to enter or exit the market and decisions concerning capacity, quantity and price. part of the general problem of modeling an evolving market structure is to understand that incumbents and potential entrants to the market construct expectations with respect to their respective market shares in any post-entry market. a potential entrant might be attracted by the known or perceived level of profits being earned by the incumbents, but must consider how many new consumers they can attract to their product in addition to the market share that can appropriated from the incumbent firms. this will depend in part upon natural (technological) and strategic barriers to entry, and on the response that can be expected if entry occurs. thus entry only occurs if the expected profits exceed the sunk costs of entry. while natural variation in demand conditions may induce firms to make errors in their predictions, resulting in entry and exit decisions, this is not the same thing as an 'empty core '. in the air travel industry, incumbent firms (especially fsas) spend considerable resources to protect their market shares from internal and external competition. the use of frequent flier points along with marketing and branding serve this purpose. these actions raise the barriers to entry for airlines operating similar business models. what about the threat of entry or the expansion of operations by vbas? could this lead to exit by fsas? there may be legitimate concern from fsas concerning the sustainability of the full-service business model when faced with low-cost competition. in particular, the use of frequency as an attribute of service quality by fsas generates revenues from high-value business travellers, but these revenues only translate into profits when there are enough economy travellers to satisfy load factors. so, to the extent that vbas steal away market share from fsas they put pressure on the viability of this aspect of the fsa business model. the greatest threat to the fsa from a vba is that a lower the fare structure offered to a subset of passengers may induce the fsa to expand the proportion of seats offered to lower fares within the yield management system. this will occur with those vbas like southwest, virgin blue in australia and easyjet that do attempt to attract the business traveller from small and medium size firms. however, carriers like ryanair and westjet have a lower impact on overall fare structure since their frequencies are lower and the fsa can target the vbas flights. while fsas may find themselves engaged in price and/or quality competition, the economics of price competition with differentiated products suggests that such markets can sustain oligopoly structures in which firms earn positive profits. this occurs because the prices of competing firms become strategic complements. that is, when one firm increases its price, the profit maximizing response of competitors is to raise price also and there are many dimensions on which airlines can product differentiate within the fsa business model. there is no question fsas have higher seat mile costs than vbas. the problem comes about when fsas view their costs as being predominately fixed and hence marginal costs as being very low. this 'myopic' view ignores the need to cover the long run cost of capital. this in conjunction with the argument that network revenue contribution justifies most all routes, leads to excessive network size and severe price discounting. however, when economies are buoyant, high yield traffic provides sufficient revenues to cover costs and provide substantial profit. in their assessment of the us airline industry, morrison and winston ( ) argue that the vast majority of losses incurred by fsas up to that point were due to their own fare, and fare war, strategies. it must be remembered that fsas co-exist with southwest in large numbers of markets in the us. what response would we expect from an fsa to limited competition from a vba on selected links of its hub-and-spoke network? given the fsa focus on maximization of aggregate network revenues and a cognisance that successful vba entry could steal away their base of economy fare consumers (used to generate the frequencies that provide high yield revenues), one might expect aggressive price competition to either prevent entry or to hasten the exit of a vba rival. this creates a problem for competition bureaus around the world as vbas file an increasing number of predatory pricing charges against fsas. similarly, the ability of this has led some to lobby for renewed government intervention in markets or anti-trust immunity for small numbers of firms. however, if natural variability is a key factor in explaining industry dynamics, there is nothing to suggest that governments have superior information or ability to manipulate the market structure to the public benefit. there are some routes in which westjet does have high frequencies and has significantly impacted mainline carriers. (e.g. calgary-abbotsford) a standard result in the industrial organization literature is that competing firms engaged in price competition will earn positive economic profits when their products are differentiated. the beyond or network revenue argument is used by many fsas to justify not abandoning markets or charging very low prices on some routes. the argument is that if we did not have all the service from a to b we would never receive the revenue from passengers who are travelling from b to c. in reality this is rarely true. when fsas add up the value of each route including its beyond revenue the aggregate far exceeds the total revenue of the company. the result is a failure to abandon uneconomic routes. the three current most profitable airlines among the fsas, qantas, lufthansa and ba, do not use beyond revenue in assessing route profitability. fsas to compete as hub-and-spoke carriers against a competitive threat from vbas is constrained by the rules of the game as defined by competition policy. in canada, air canada faces a charge of predatory pricing for its competition against canjet and westjet in eastern canada. in the us, american airlines won its case in a predatory pricing charge brought by three vbas: vanguard airlines, sun jet and western pacific airlines. in germany, both lufthansa and deutsche ba have been charged with predatory pricing. in australia, qantas also faces predatory pricing charges. gillen and morrison ( ) points out three important dimensions of predatory pricing in air travel markets. first, demand complementarities in hub-andspoke networks lead fsas to focus on 'beyond revenues'-the revenue generated by a series of flights in an itinerary rather than the revenues generated by any one leg of the trip. fsas therefore justify aggressive price competition with a vba as a means of using the fare on that link (from an origin node to the hub node for example) as a way of maximizing the beyond revenues created when passengers purchase travel on additional links (from the hub to other nodes in the network). the problem with this argument is that promotional pricing is implicitly a bundling argument, where the airline bundles links in the network to maximize revenue. however when fsas compete fiercely on price against vbas, the price on that link is not limited to those customers who demand beyond travel. therefore, whether or not there is an intent to engage in predatory pricing, the effect is predatory as it deprives the vba of customers who do not demand beyond travel. a second dimension of predatory pricing is vertical product differentiation. fsas competition authorities to support the view that they the right to match prices of a rival vba. however, the bundle of services offered by fsas constitutes a more valuable package. in particular, the provision of frequent flyer programs creates a situation where matching the price of a vba is 'de facto' price undercutting, adjusting for product differentiation. a recent case between the vba germania and lufthansa resulted in the bundeskartellamt (the german competition authority) imposing a price premium restriction on lufthansa that prevented the fsa from matching the vbas prices. a third important dimension of predatory pricing in air travel markets is the ability which fsas have to shift capacity around a hub-and-spoke network, which necessarily requires a mixed fleet with variable seating capacities. in standard limit output models of entry deterrence, an investment in capacity is not a credible threat to of price competition if the entrant conjectures that the incumbent will not use that capacity once entry occurs. such models utilize the notion that a capacity investment is an irreversible commitment and that valuable reputation effects cannot be generated by the incumbent engaging in 'irrational' price competition. however in a hub-and-spoke network, an fsa can make a credible threat to transfer capacity to a particular link in the network in support of aggressive price competition, with the knowledge that the capacity can be redeployed elsewhere in the network when the competitive threat is over. this creates a positive barrier to entry with reputation effects occurring in those instances where entry occurs. such was the case when canjet and westjet met with aggressive price competition from air canada on flights from monkton nb to toronto (air canada and canjet) and hamilton (westjet). the fsa defense against such charges is that aircraft do not constitute an avoidable cost and should not be included in any price-cost test of predation. yet while aircraft are not avoidable with respect to the network, they are avoidable to the extent they can be redeployed around the network. if aircraft costs become included in measures of predation under competition laws, this will limit the success of price competition as a competitive response by an fsas responding to vba entry. in the current environment, competition policy rules are not well specified and the uncertainty does nothing to protect competition or to enhance the viability of air travel markets. however there has been increased academic interest in the issue and it seems likely that given the number of cases, some policy changes will be made (e.g., ross and stanbury, ) . once again, the way in which fsas have responded to competition from vbas reflects their network model, and competition policy decisions that prevent capacity shifting, price matching and inclusion of 'beyond revenues' will severely constrain the set of strategies an fsa can employ without causing some fundamental changes in the business model and corresponding network structure. . so where are we headed? in evolution, the notion of selection dynamics lead us to expect that unsuccessful strategies will be abandoned and successful strategies will be copied or imitated. we have already observed fsas attempts to replicate the vba business model through the creation of fighting brands. air canada created tango, zip, jazz, and jetz. few other carriers worldwide have followed such an extensive re-branding. in europe, british airways created go and klm created buzz, both of which have since been sold and swallowed up by other vbas. qantas has created a low cost long haul carrier-australian airlines. meanwhile, air new zealand, lufthansa, delta and united are moving in the direction of a low-price-low-cost brand. we are also seeing attempts by fsas to simplify their fare structures and exploit the cost savings from direct sales over the internet. thus there do seem to be evolutionary forces that are moving airlines away from the hub-and-spoke network in the direction of providing connections as distinct from true hubbing. american airlines is using a 'rolling hub' concept, which does exactly as its name implies. the purpose is to reduce costs through both fewer factors such as aircraft and labour and to increase productivity. the first step is to 'de-peak' the hub, which means not having banks as tightly integrated. this reduces the amount of own congestion created at hubs by the hubbing carrier and reduces aircraft needed. it also reduces service quality but it has become clear that the traditionally high yield business passenger who valued such time-savings is no longer willing to pay the very high costs that are incurred in producing them. however, as an example, american airlines has reduced daily flights at chicago so with the new schedules it has increased the total elapsed time of flights by an average of min. elapsed time is a competitive issue for airlines as they vie for high-yield passengers who, as a group, have abandoned the airlines and caused revenues to slump. but that -min average lengthening of elapsed time appears to be a negative american is willing to accept in exchange for the benefits. at chicago, where the new spread-out schedule was introduced in april, american has been able to operate daily flights with five fewer aircraft and four fewer gates and a manpower reduction of - %. the change has cleared the way for a smoother flow of aircraft departures and has saved taxi time. it is likely that american will try to keep to the schedule and be disinclined to hold aircraft to accommodate late arriving connection passengers. while this may appear to be a service reduction it in fact may not, since on-time performance has improved. the evolution of networks in today's environment will be based on the choice of business model that airlines make. this is tied to evolving demand conditions, the developing technologies of aircraft and infrastructure and the strategic choices of airlines. as we have seen, the hub-and-spoke system is an endogenous choice for fsa while the linear fc network provides the same scope for vbas. the threat to the hub-and-spoke network is the threat to bundled product of fsas. the hub-and-spoke network will only disappear if the fsa cannot implement a lower cost structure business model and at the same time provide the service and coverage that higher yield passengers demand. the higher yield passengers have not disappeared the market has only become somewhat smaller and certainly more fare sensitive, on average. fsas have responded to vbas by trying to copy elements of their business strategy including reduced inflight service, low cost [fighting] brands, and more pointto-point service. however, the ability of fsa to co-exist with vba and hence hub-and-spoke networks with linear networks is to redesign their products and provide incentives for passengers to allow a reduction in product, process and organizational complexity. this is a difficult challenge since they face complex demands, resulting in the design of a complex product and delivered in a complex network, which is a characteristic of the product. for example, no-shows are a large cost for fsa and they have to design their systems in such a way as to accommodate the no-shows. this includes over-booking and the introduction of demand variability. this uncertain demand arises because airlines have induced it with service to their high-yield passengers. putting in place a set of incentives to reduce noshows would lower costs because the complexity would be reduced or eliminated. one should have complexity only when it adds value. another costly feature of serving business travel is to maintain sufficient inventory of seats in markets to meet the time sensitive demands of business travellers. the hub-and-spoke structure is complex, the business processes are complex and these create costs. a huband-spoke network lowers productivity and increases variable and fixed costs, but these are not characteristics inherent in the hub-and-spoke design. they are inherent in the way fsa use the hub-and-spoke network to deliver and add value to their product. this is because the processes are complex even though the complexity is needed for a smaller, more demanding, higher yield set of customers. the redesigning of business processes moves the fsa between cost functions and not simply down their existing cost function but they will not duplicate the cost advantage of vbas. the network structure drives pricing, fleet and service strategies and the network structure is ultimately conditional on the size and preferences in the market. what of the future and what factors will affect the evolution of network design and scope? airline markets american has also reduced its turn around at spoke cities from . h previously to approximately min. as a result of smoother traffic flows, american has been operating at dallas/fort worth international airport with nine fewer mainline aircraft and two fewer regional aircraft. at chicago, the improved efficiency has allowed american to take five aircraft off the schedule, three large jets and two american eagle aircraft. american estimates savings of $ million a year from reduced costs for fuel, facilities and personnel, part of the $ billion in permanent costs it has trimmed from its expense sheet. the new flight schedule has brought unexpected cost relief at the hubs but also at the many ''spoke'' cities served from these major airports. aviation week and space technology, september , and february , . interestingly, from an airport perspective the passenger may not spend more total elapsed time but simply more time in the terminal and less time in the airplane. this may provide opportunities for nonaviation revenue strategies. with their networks are continuously evolving. what took place in the us years ago is now occurring in europe. a 'modern' feature of networks is the strategic alliance. alliances between airlines allow them to extend their network, improve their product and service choice but at a cost. alliances are a feature associated with fsas not vbas. it may be that as fsas reposition themselves they will make greater use of alliances. vbas on the other hand will rely more on interlining to extend their market reach. interlining is made more cost effective with modern technologies but also with airports having an incentive to offer such services rather than have the airlines provide them. airports as modern businesses will have a more active role in shaping airline networks in the future. empty cores in airline markets bundling, integration and the delivered price of air travel: are low-cost carriers fullservice competitors the economics of hubs: the case of monopoly the evolution of the airline industry a note on the optimality of airline networks dealing with predatory conduct in the canadian airline industry: a proposal the economics of network industries the authors gratefully acknowledge financial support for travel to this conference, provided by funds from wilfrid laurier university and the sshrc institutional grant awarded to the university. key: cord- -q ce pi authors: nicholas, david; patershuk, clare; koller, donna; bruce-barrett, cindy; lach, lucy; zlotnik shaul, randi; matlow, anne title: pandemic planning in pediatric care: a website policy review and national survey data date: - - journal: health policy doi: . /j.healthpol. . . sha: doc_id: cord_uid: q ce pi abstract objectives this study investigates current policies, key issues, and needs for pandemic planning in pediatrics in canada. methods online pandemic plans from national, provincial and territorial government websites were reviewed to identify: plans for children and families, and psychosocial and ethical issues. a survey was administered to gather participants’ perspectives on the needs in pediatric planning, as well as important elements of their organizations’ and regions’ pandemic plans. a thematic analysis was conducted on qualitative survey responses. results the majority of existing plans did not adequately address the unique needs of pediatric populations, and mainly focused on medical and policy concerns. several gaps in plans were identified, including the need for psychosocial supports and ethical decision-making frameworks for children and families. similarly, survey respondents identified parallel gaps, in their organization's or region's plans. conclusions although many plans provide guidelines for medical and policy issues in pediatrics, much more work remains in psychosocial and ethical planning. a focus on children and families is needed for pandemic planning in pediatrics to ensure best outcomes for children and families. the impact of pandemic h n ( ) has raised public awareness of the threat of a severe influenza outbreak, as the public health agency of canada, provincial, and territorial bodies continue to bolster their contingency plans. in , severe acute respiratory syndrome (sars) revealed gaps in ontario's emergency response capability, and highlighted the need to prepare for future epidemics. the effects of this outbreak resulted in a total of probable cases and deaths in canada [ ] . sars heavily impacted the health care system in ontario and in affected areas across the globe. recent memories of this outbreak, coupled with the threat of pandemic h n ( ) warn of the impacts of a major outbreak in canada. accordingly, planning has become a pressing issue for stakeholders in government, industry and community. while the exact timing, pattern and impact of a future pandemic is unknown [ , ] , in canada an influenza pandemic could result in as many as . million people ( %) who become clinically ill, , ( . %) who require hospitalization, and up to , deaths ( . %) [ ] . such concerns have become a high profile public health issue, and fears of a potential global pandemic continue to grow. governments, policy makers, and health care providers (hcp), are planning for future pandemics, in part, based upon the lessons learned from sars. health canada [ ] has identified gaps in the response to sars that should influence current policies and planning. for example, there is still a need to address ethical concerns during a pandemic, for instance, governments may be required to infringe upon civil liberties to ensure infection control, and policy makers need to establish frameworks for decisionmaking to allocate scarce health care resources [ ] . a lack of coordination and communication, the poor management of resources, and the absence of a clear leadership structure within organizations and government also had a detrimental effect on the effort to control the sars outbreak [ ] [ ] [ ] . outside of canada, critical gaps have been identified in european union (eu) plans. these concerns include a lack of cooperation among eu countries and poorly delineated roles and responsibilities of central and regional health authorities. in addition, gaps exist in preparation for the impact on health care systems, the maintenance of essential services, and public health interventions to curb the spread of an epidemic [ ] . similar issues have been highlighted by researchers and planners world wide [ , ] . recently, pandemic h n ( ) has reignited these concerns about preparedness. in an effort to learn from sars and to prepare for a future pandemic, the government of canada has released the "canadian pandemic influenza plan for the health sector" [ ] . similarly, the majority of provincial and territorial governments have also released their regional plans [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (see table for selected features of pandemic plans in various jurisdictions). these documents guide health planning and responses at provincial and local levels. government plans cover topics ranging from influenza surveillance, to the distribution of antiviral supplies, to communication and information dissemination. although these plans are designed to protect all canadian citizens, there continues to be a lack of dialogue or guidance to address the specialized needs of a pediatric population. children may require specialized supplies, medications, and treatment. they also require additional supervision and family support [ ] . additionally, pandemic planning for children and families is often addressed locally, with little coordination among the various levels of planning [ ] . this continued neglect of pediatrics, both by policy makers and researchers in pandemic planning, is problematic, as difficulties associated with psychosocial concerns or ethical decision-making are magnified for hcp, children and families [ ] . in this paper, we present both provincial and territorial policy statements as they relate to pediatrics based on a website review of plans. we also present the qualitative results from a survey administered to pediatric pandemic planning practitioners and policy makers. the goal of the project is to assess the comprehensiveness of existing pandemic plans in canada and to identify what professionals identified as important and needed in pediatric plans. there is little dialogue about ethical concerns in pandemic planning for pediatrics. as such, the literature about ethics in pandemic planning focuses primarily on adult care [ ] [ ] [ ] . thompson and colleagues have identified general values to guide care and policy for pandemic planning. these values include: the duty to provide care, equity, individual liberty, privacy, proportionality, protection of the public from harm, reciprocity, solidarity, stewardship, and trust [ ] . although these values are central to ethical planning and decision-making, many may be interpreted differently in pediatrics. for example, individual liberty does not apply to children in the same way as adults. compared to adults, children lack autonomy and parents must advocate and make health care decisions on their child's behalf. due to the lack of literature on this topic, policy makers must individually interpret the ethical issues in pediatric care. as such, policy makers who strive to maintain ethical care in pediatrics should be guided by ethical values, and stay aware of the needs of children and families. in this paper, participants identify situations where such ethical policy making must be implemented. in this paper, we present a website review of provincial and territorial pandemic plans with respect to pediatric policies. additionally, we present the qualitative results from a national survey on pandemic planning. websites of all canadian provinces and territories, and the public health agency of canada were reviewed to identify online and publicly available pandemic plans. each website was surveyed to identify the availability of a pandemic plan. subsequently, these plans were reviewed to assess their comprehensiveness and to identify unique plans for children and families, and psychosocial and ethical issues. the review was completed in june by a reviewer with a background in health policy. the reviewer used content analysis to record all references to pediatrics in a database. to verify this information, the plans were read by a second reviewer, and a search function was used to ensure that available pediatric plan information was included in the review. the web-based survey included open-ended questions that asked participants' opinions on the processes of planning, comprehensiveness and essential elements of pandemic plans in their organization or region. the survey was hosted by survey monkey (http://www. surveymonkey.com/), an online application that administers questionnaires to participants. this method was chosen to increase the response rate from participants across canada, particularly in more remote regions. an email with a link to the online survey was sent to potential participants between may and june . participants received a reminder email at and months after the initial request. the survey was available online in english and french. survey participants included individuals with expertise in pediatric care and pandemic planning, including: ( ) members of national, provincial and territorial pandemic influenza committees; ( ) professionals working in infection control and pandemic planning; and ( ) professionals working with children, youth and families in crisis. the participants were recruited using snowball sampling. email invitations to complete the survey were sent to individuals, with n = participants, with a response rate of . %. given this low response rate, the survey data presented is not intended to be representative. the demographic data, however, show that there are participants from all areas of pediatric care and pandemic planning. in addition, respondents from all provinces and territories participated in the survey (see table ). as such, the data identifies issues that are salient for participants who are interested and involved in the area, which may be important to consider in pandemic planning for children and families. open-ended survey responses were analyzed using qualitative data analysis software. a thematic analysis was conducted for each survey question using open coding. qualitative rigor was ensured through the use of referential adequacy, negative case analysis, and peer debriefing. government decision-makers have learned from sars, using this knowledge to plan for future pandemics, evidenced by the release of detailed pandemic plans. largely, however, the application of this knowledge to pediatrics has been lacking. specific references to pediatrics are seen in a minority of pandemic plans [ , , ] , but a greater focus on pediatrics has been noted in some recently released plans [ , ] . some plans do not acknowledge pediatrics as a need [ , , ] , while other plans suggest that the needs of this vulnerable population are being planned for, yet they do not articulate many concrete strategies to accomplish this task [ , , , [ ] [ ] [ ] . this omission of pediatric care in pandemic plans continues despite concerns of a potential outbreak, and the responsibility of governments to coordinate a pandemic influenza response for canadian children and families (see table ). governments with pandemic plans that address needs in pediatrics have solid contingency plans for medical and policy issues, but less so for psychosocial and ethical issues. medical components of plans focus on key issues such as: pediatric specific medical supplies; stockpiling of antivirals and vaccines; and differences in symptoms, triage, treatment and isolation [ , [ ] [ ] [ ] ] . policy issues included in current plans address needs for coordination with other agencies as well as the public. these issues are often coupled with guidelines on school closures [ , [ ] [ ] [ ] [ ] [ ] , [ ] [ ] [ ] [ ] , and only ontario's plan addresses child care provisions for hcp [ ] . chiefly, psychosocial and ethical concerns focus on communication [ , [ ] [ ] [ ] ] ; potential stressors for children and families [ , [ ] [ ] [ ] [ ] , , ] ; grief and bereavement counselling [ , , ] ; and family centred care [ ] . nevertheless, even these more thorough plans lack consideration of certain psychosocial and ethical issues, for example, 'how will decisions be made regarding children whose parents are unable to consent due to treatment?'. and 'how will children and families cope with these stressful events?'. many such concerns, relevant to pediatric patients, families and hcp, are not documented in pediatric pandemic plans. notably, the above mentioned plans all contain a pediatric specific focus; in contrast, a majority of plans do not thoroughly consider these issues and tend to focus on medical and policy matters in pediatrics [ ] [ ] [ ] [ ] [ ] [ ] , , ] . as a • notes that pediatric specific supplies will be needed • agencies must "determine support needed for orphaned children and the need for grieving and counselling services" • mentions different needs of children in terms of vaccinations, isolation, treatment • importance of supporting staff "through critical incident debriefing, grief counselling, child care support, etc." • children's/pediatric unit is one area in which the demand may increase markedly and continuing operation is crucial-health authority and facilities should consider these areas and determine which are critical to keep them operational result, many provinces may be under prepared to deal with the increased demand for pediatric services, especially the need for psychosocial and ethical supports. although many plans note differences in symptoms or treatment of children, and the need for school closures, still a number of these medical and policy needs are inadequately addressed and often psychosocial or ethical concerns are not touched upon at all. in fact, these issues present challenges often left unaddressed by government plans, resulting in a significant gap in pediatric pandemic planning. stakeholders in pediatric services and pandemic planning participated in this cross-canada survey and sharing written responses to open-ended survey questions, providing their suggestions for pediatric pandemic planning. participants identified four overarching themes about important needs in pediatric planning. main themes include: essential elements to a pediatric pandemic plan; importance of children and families in planning; importance of communication; and accounting for missing or rudimentary plans. participants identified plan elements they thought were central to any organization's pediatric pandemic plan. they identified concerns from resource allocation to ethical decision-making, illustrating the complexity and heterogeneity of these issues. participants provided a wide range of elements they thought should be included in a pediatric pandemic plan. many expressed the importance of child care measures during a pandemic. a variety of concerns pertaining to child care were identified, such as how to manage school and day care closures for working parents. by the same token, participants felt plans should provide support for hcp, in managing child care, family and job responsibilities, in addition to providing for occupational health concerns, including the psychosocial and physical well-being of hcp. moreover, participants felt that ensuring the availability of psychosocial supports for various stakeholders was also an essential plan element. they suggested that plans should make provisions to provide psychosocial supports for children, families, and hcp and their families. providing education and information were important to participants, to promote understanding and preparation during a pandemic. similarly, they identified communication with stakeholder groups as essential in a pediatric pandemic plan. participants felt that policies should provide guidance in infection control in pediatrics. coupled with these concerns, clinical guidelines were also identified as a central and complex issue in a pediatric pandemic plan. participants saw the need for treatment guidelines specific to pediatric populations, including guidelines for assessment and treatment, for children with an infected or absent parent or guardian, and for prevention, such as vaccination protocols. guidelines for the treatment of routine non-influenza health care cases were viewed as especially important to maintain care and to optimally treat the largest numbers of people. a participant stated, "we must have specific pre-set criteria on questions such as: when to stop performing elective surgeries, when to stop performing marrow and organ transplants, etc." resource allocation plans were a major concern, particularly for pediatric care, to ensure that resources are available for children and families during an outbreak. participants noted that community supports are required for stakeholder groups, for example, child care and psychosocial supports for children with an ill parent or guardian. another key issue was coordinating plans to include home care for those who are infected if hospitals are over capacity. a large portion of respondents also raised concerns about ethical decision-making during a pandemic, and the need for a framework for decision-making in pandemic plans. one respondent indicated the need for an ethical framework, specific to pediatrics: discussion/guidance [is needed] on ethical decisionmaking processes for the pediatric population. are these different than they will be for the adult population? will the philosophy of family centred care be impacted during a pandemic event? in essence, participants identified a range of issues that must be considered in pediatric pandemic planning, in order to manage the heavy burden an outbreak will place on health care systems and resources (see table ). participants were asked to identify missing elements in their organization's pandemic plan, and many responded with similar issues as when questioned regarding the key elements of a pediatric plan. these missing elements include: child care plans; communication and information sharing; ethical guidelines; needs of hcp (psychosocial, medical, workforce); organizational coordination; pediatric focus; continued plan development; post-pandemic planning; psychosocial needs; and resource planning and allocation. participants were asked to identify if their organization actively involved children and families in pandemic planning. those who responded affirmatively provided a range of strategies to incorporate the voices of children and families in plan development. such strategies include input from: family advisory committees, community organizations, family representatives, and research findings. consultation with children and families ranged from extensive involvement in planning, where a "family representative was involved as a key stakeholder on the steering committee," to minimal, such as consulting research studies on pediatric needs. conversely, participants who responded that children and families were not involved in planning provided a variety of explanations regarding why this occurred. these explanations include: pediatrics are not within the organization's mandate, the organization has a small pediatric population, plans are in development, and planners and staff are also parents. the most common response has that staff and planners are also parents, and that they can apply this experience to plan development. as an example, a participant stated, [children and families were] not [involved] to my knowledge, other than in the capacity that many of the people that have been involved in administrative or clinical care roles are also parents. they may have also been thinking in terms of being a parent. accordingly, based upon these survey responses, participants provided suggestions for, and noted barriers to, incorporating the voices of children and families in pandemic planning. participants provided information on preferred sources and methods of information dissemination during a pandemic. these sources include: business and industry, community organizations, government, hcp, professional organizations, the media, pandemic planning organizations, public health networks, schools and daycares. government was seen as a major source of information during a pandemic. one respondent suggested that, "information on the flu would be put together by those responsible at the ministry of health." methods of sharing information were varied, but largely web-based solutions were suggested by participants. participants also identified media (e.g. television, radio, print) and interactive information sharing (e.g. town hall meetings) as key strategies. survey respondents belonging to organizations without, or lacking a well-developed plan, were asked to identify why their organization was wanting in the area of pediatric pandemic planning. participants suggested that they were missing strong leadership in pediatrics and that this was a major factor contributing to a minimal or nonexistent plan. they felt that they had little guidance in what was required for pediatric pandemic planning. participants also expressed that they did not have access to resources for plan development, resulting in a "skeleton plan" focused on the adult population. lastly, not having adequate pediatric services or facilities within the organization or region contributed to the lack of a pediatric pandemic plan, as pediatrics was not a priority. while most respondents advocated pediatric planning, some participants were doubtful about the need for specific plans. these dissenting participants suggested that there are no unique pediatric issues to be addressed and that general plans are sufficient for pediatric care. other participants suggested that a pediatric plan was unnecessary because of a minimal focus on pediatrics, or due to a small pediatric population in their organization or region. the respondents who did not see the need for a specific plan provided responses such as, "my belief is that it should not be a separate plan-i would need evidence or rationale why a separate pediatric pandemic plan is required." on balance, the majority of respondents saw the need for a pediatric plan, but a substantial number of others did not see the implications or relevance of planning that is specific to children and families. participant responses indicate that pediatric pandemic planning is an important and salient issue across canada. based upon qualitative analyses of survey data, participants have provided important and useful feedback on the needs and essential elements in a pediatric pandemic plan, the importance of listening to children and families, the need for communication with stakeholder groups, and factors resulting in under-developed or missing plans. unfortunately, however, not all recommendations from participants are currently being implemented in provincial and territorial plans. this is exemplified in the congruence between what respondents felt were essential plan elements and the elements they identified as missing from their organizational or regional plans. there are clear and notable gaps in pediatric planning, both in terms of elements reported as missing by participants in their organizations' or regions' pandemic plans and in the parallel gaps in the provincial, territorial and national policy documents that were reviewed. for example, a lack of psychosocial and ethical policies in planning for pediatric care were identified as major gaps by survey respondents, and confirmed by our policy review. these discontinuities in identified key elements, and existing policies, point to the need for consideration of children and families at all levels of the planning process. moreover, this lack of pediatric specific considerations is noted in the perceptions of survey respondents who indicated that children do not have unique needs in the event of a pandemic and in the lack of policies across provinces and territories pertaining directly to the care of children and families. to address the needs of this population effectively, the authors suggest the incorporation of pediatric plans within broader provincial, territorial and national plans. the international literature on needs in pandemic planning notes the importance of cooperation and the need to identify roles and responsibilities in plans [ , ] . similarly, participants identified the importance of resource allocation, guidelines and communication in pediatric plans. it is clear that these issues are salient and must guide policymakers as they develop or update plans. based upon the web-based policy review, provinces with a combination of factors are often substantially more prepared based upon an analysis of their provided policies. for instance, british columbia's (bc) [ ] pediatric pandemic plan is a well-developed and readily available document which addresses the unique issues of children and families and touches upon some psychosocial concerns. likewise, bc is an example of a province with relative wealth, and a high population density in urban areas, for instance, bc reported the third highest population growth among the provinces during ( . per ) to reach a population of , , , one of the more populated provinces in canada [ ] . bc's major cities are easily accessible via commercial travel, and the province has welldeveloped health care and government infrastructure, all of which likely contribute to the resources available for the development of a pediatric pandemic plan. in contrast, northern communities appear to be at the greatest risk, given current rudimentary plans that are potentially influenced by a lower population density, few major cities, and a lack of reserve human, medical, supply, policy and financial resources. these disparities require greater consideration of factors influencing inequities in pediatric pandemic preparedness, including population density, socioeconomic status, relative isolation, and available resources. regardless of the factors that may influence the lack of pediatric contingency plans, there remains the possibility of severe outcomes for children and families in the event of an outbreak. it appears that greater attention and resources must be allocated to northern communities to ensure adequate preparation in the event of a pandemic. participants suggested that web based communication will be key in the event of a severe outbreak, allowing information to be distributed remotely [ ] . posting pandemic information on websites will be critical, as identified by survey respondents, to allow quick access to up-todate information. the majority of provincial, territorial and national pandemic planning bodies have responded to this method of information dissemination, in posting pandemic plans and information on their websites. public and political awareness of a potential pandemic has raised concerns over resource allocation and contingency planning, but in some jurisdictions, relatively little attention has been paid to planning in pediatrics. a review of the pandemic plans of the public health agency of canada, provincial and territorial governments has identified needs in pediatric planning. these issues and concerns were also supported by survey respondents, who are experts in pediatric care and pandemic planners, qualified to note such gaps in contingency plans. to overcome these gaps, a focus on the unique needs of children and families is required, while support and resource redistribution to less advantaged provinces and territories is needed to ensure the health and well-being of all canadians. consideration of the factors that influence pandemic preparedness (such as population density, affluence, relative isolation, and available resources) may be helpful to inform research and policy decisions. finally, the dissemination of information online, especially via government websites, is essential to communicate with the public during a pandemic. in brief, the findings presented here provide important suggestions to guide pandemic planning in pediatrics, in the hope that a pandemic response can ensure the safety of canadians. summary of probable sars cases with onset of illness from responding to pandemic influenza: a local perspective fortune favours the prepared mind: a national perspective on pandemic preparedness public health agency canada. the canadian pandemic influenza plan for the health sector learning from sars-renewal of public health in canada severe acute respiratory syndrome and critical care medicine: the toronto experience lessons learned from a provincial perspective ensuring a broad and inclusive approach. a provincial perspective on pandemic preparedness how prepared is europe for pandemic influenza? an analysis of national plans influenza pandemic preparedness action plan for the united states: update pandemic influenza preparedness in the asia-pacific region alberta pandemic influenza plan for the health system for health care professionals bc pandemic influenza preparendess plan preparing for pandemic influenza in manitoba pandemic influenza: preparedness guidelines for manitoba school divisions and schools (k- new brunswick pandemic influenza plan: for the health sector pandemic influenza: planning guidelines, roles and responsibilities for the health sector government of the northwest territories. pandemic influenza: contingency plan nova scotia health system pandemic influenza plan nunavut part of national pandemic preparedness effort developing healthy communities: a public health strategy for nunavut ministry of health and long-term care. ontario health plan for an influenza pandemic prince edward island pandemic influenza contingency plan for the health sector quebec pandemic influenza plan: health mission government of saskatchewan. public pandemic influenza plan press release: more cases of h n confirmed in yukon challenges facing pediatric preparedness the next influenza pandemic: will we be ready to care for our children? pediatric epidemic crisis: lessons for policy and practice development pandemic influenza preparedness: an ethical framework to guide decision-making preparing for an influenza pandemic: ethical issues moral principles for allocating scarce medical resources in an influenza pandemic report on the demographic situation in canada blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education this research was funded by the canadian institutes for health research, funding reference number . key: cord- -ji suirn authors: ciupa, kristin; zalik, anna title: enhancing corporate standing, shifting blame: an examination of canada's extractive sector transparency measures act date: - - journal: extr ind soc doi: . /j.exis. . . sha: doc_id: cord_uid: ji suirn canada's extractive sector transparency measures act (estma) is the culmination of a series of proposals and consultations with government, industry and civil society organizations to address conflict over canadian extractive industry. created in the context of a global call for extractive industry accountability, as well as increasing scrutiny of canadian mining activities for alleged human rights and environmental abuses, the estma aims to deter corruption via financial reporting requirements for canadian extractive firms operating in canada and abroad. by mandating that firms publicly disclose payments to various levels of government, however, the estma is constructed atop global corruption discourse that identifies host states in the global south as the source of social pathologies that facilitate corruption, largely excluding a critical analysis of extractive firms in the global north. drawing on interviews, document analysis of material related to the estma and case studies of extractive firm financial reporting, this paper argues that under the estma's financial reporting processes, corporate risk management trumps meaningful social regulation. while the act does mandate disclosures useful to the advocacy community, limited oversight, a lack of standardized reporting and excluded activities under the act mean that the estma offers limited leverage to substantively address the human and ecological cost of canada's extractive industry. as has resulted from transparency policies more broadly, however, the estma provides firms a means to counter broader critique and, in complying with audit culture, promotes investment security. in late the former harper government enacted canada's extractive sector transparency measures act (estma). the act came into effect on june , four months prior to the election of a liberal majority government under prime minister justin trudeau. the estma fulfilled the commitment made by the canadian government to implement the extractive industries transparency initiative (eiti) at home. canada was among the global proponents of eiti implementation in 'host states' of the global south and had served on the eiti board from its inception. the estma also made canada compliant with key terms of the european union (eu) transparency directive issued in (modified in ) and the us dodd frank act and consumer protection act. the ngo publish what you pay canada (pwyp) advocated strongly for the estma, and convoked and facilitated the multi-stakeholder resource revenue transparency working group (rrtwg) whose negotiations significantly contributed to the legislation. in , the estma completed its first round of implementation and reporting by canadian extractive sector firms operating domestically and internationally. within the context of domestic legislation, the estma may be viewed as a major step forward, requiring firms listed on a stock exchange in canada, or which conduct business in canada that meets a particular minimum threshold, (thus incorporating some firms that are not publicly traded), to publicly disclose payments to various levels of government (guidance, ) . in principle international policies entailing global transparency practice are directed at reshaping relations between the northern extractive industry and so-called 'host states' in the global south as well as controversial industries at home. discussed in various articles in this special issue, the key global example is the extractive industries transparency initiative implemented by domestic governments in varied jurisdictions. while the canadian government had been an eiti supporter since , it has never implemented it incountry. nevertheless, given that the estma's reporting requirements are mandatory, the legislation is viewed by some as more stringent than the voluntary dynamics undergirding the eiti. in the case of the eiti, domestic implementing legislation may be rudimentary and thus neither obligatory nor enforceable at the firm level. in canada and elsewhere the content of twenty-first century extractive sector transparency legislation, with its emphasis on reporting and formal financial procedures, responds to public calls for greater accountability on the part of polluting and frequently violent industry. yet is also offers measures of security to both the firm and state as a form of industrial audita topic that received important critical attention at the turn of the millennium from scholars from business to anthropology (power (power , strathern strathern , a . critiques of audit influenced analyses of various practices -in accounting, public management and education, and has been revisited in recent work, including on the extractive sector (kemp et al. ; welker ; shore and wright ; gilbert and zalik, ) . as michael power emphasized, audit practice operates primarily as a form of social reassurance regarding largely under-regulated, and potentially high-risk, industrial and institutional processes. in addition to audit and risk management, however, the estma and eiti also are constructed atop global corruption discourse (haufler, ) , itself a function of a broader context of global systemic racism. herein, critical race theory draws attention to how an investment in white supremacy entails justifying the overall impoverishment of indigenous and racialized peoples through racist tropes. scholars such as doshi and ranganathan ( ) and bratsis ( ) discuss the roots of corruption discourse in modernization theory and orientalist and racist depictions of global south governance. the eiti discourse of corporate 'home' state (global north) and operational 'host' state (typically global south), which characterized the initiative at its inception, set up an uneven application between extractive sites in the south and sites of corporate headquarters in the north, as bracking ( ) delineates. the so-called 'host states' of the global south or non-west are thus identified as the source of social pathologies that facilitate corruption, a problem to be remedied by revenue transparency confirming the amounts firms pay to government institutions. the broader international financial architecture that historically favoured massive wealth transfers from less to more industrialized sites or to unnamed 'beneficial owners' are left external to interrogation. while elites globally have benefited from wealth transfers, financial accumulation has tended to accrue in the north or in offshore havens that protect funds these elites control (palan, ; osuoka and zalik, ) . although practices of insider trading and nepotism in the global north received increased scrutiny after the financial crisis, the term 'corruption' is not typically applied to refer to these practices. rather, 'corruption' is largely reserved for practices that occur in the non-west and zones 'overseas' (gillies, ) , a notable discrepancy given that the oil and gas sector is an essentially global industry. the duplicity in this position has not gone unnoticed even by mainstream policy makers. clare short, former eiti chair and one time uk minister for international development implied as much when calling on the us, uk and canada to pass domestic legislation and implement the eiti at home in . on the basis of interviews and primary documents related to the estma, this paper views the estma as an expression of 'audit culture transparency' (gilbert and zalik, ) . above we placed our analysis of estma in conversation with some literatures on extractive sector transparency and the eiti, as well as the re-regulation of the us and eu financial sectors following the financial crisis. as discussed further below, we offer a critical view on how transparency and anticorruption discourse pathologize states and southern bureaucracies and indigenous governments, subjecting them to imperial relations. the pathologizing of social and political relations in these spaces -and their economic and ecological role as capital and nature exporter -intersects with global logics of racism and white supremacy. the next section examines the estma in the context of (section ) canadian domestic and international calls for greater oversight of canada's oil, gas and mining sectors given the canadian industry's complicity with growing human rights abuses. subsequently the paper reviews (section ) the emergence of the estma legislation in relationship to broader transparency discourse and eiti scholarship, and the role played by both civil society and the business sector in shaping it. our particular focus of attention is the estma legislation and guidance documents. through this analysis we draw parallels with attributes of 'audit culture', including how anti-corruption discourse largely upholds the power of global capital, and serves to manage risk on the part of financial institutions. on this basis we then consider (section ) actual reporting under the estma to date, including both affirmations of its role in lifting the veil on corporate actions, as well as a less optimistic account of how information gaps could render the estma a hollow example of transparency without substantive disclosure. as is typically the case in the corporate world, boards of directors and ceos may overlap across firms engaged in activities that are and are not covered by the estma; notably extraction and production on which the estma mandates disclosure of payments, and exploration and processing activities which are not covered under the estma. while the estma, importantly, legally mandates reporting by firms, it also creates various loopholes that make disclosures either less useful to communities and civil society, or revocable. we attend to three examples -(i) that of goldcorp/ tahoe's/pan american silver -which publish what you pay canada has featured among its case studies, as well as (ii) that of de beers/anglo american, including de beers' use of reporting under another jurisdiction to fulfill estma requirements. we end with reflections on (iii) africa oil corporation, part of the broader lundin group of companies that includes within it firms engaged in both exploration and development. the specific projects that prompt our attention to these firms are the el escobal mine in guatemala, the victor mine in northern ontario and africa oil's recent acquisition of assets in nigeria and guyana in joint ventures. in the past decade, the global relations of canada's extractive industry have come under increasing scrutiny. with the rise in value of the canadian dollar in the first decade of the millennium, canada's foreign direct investment in the global south increased. due to rising commodity prices, the mining industry, which has long been significantly traded on the canadian stock exchange, became a particularly profitable arm of canadian capital (deneault and sacher ; zalik ) . while canadian mining activity increased internationally in this period, its presence in latin america became particularly problematic. canadian civil society organizations, among them mining watch, rights action and kairos paid particular attention to human rights abuses associated with the activities of canadian mining firms. attention to questionable security practices, destruction of three formal interviews ( - . hours) with key informants were conducted: one with a government representative and two with civil society representatives. in addition, the paper draws on notes from discussions with civil society and academic researchers over a two year period. primary document (footnote continued) analysis draws on transcripts of formal legislative debates as recorded in the canadian senate and house of commons hansard. communities, use of paramilitary forces and divide and rule tactics by canadian firms increased while resisance at mining sites was met with aggression and outright repression. film maker steven schnoor provided footage of the destruction of communities by security contracted by a canadian mining company in guatemala; in response the canadian ambassador claimed this film was based on false testimony by actors. following a legal suit, the ambassador retracted. activist scholars deneault et al. ( ) documented practices of canadian mining firms in the african context in their book noir canada and were subsequently faced with a slapp (strategic lawsuit against public participation) suit by barrick gold. among others, scholars such as north et al. ( ) , campbell ( ) , nolin and stephens ( ), imai ( , , deonandan and dougherty ( ) , gutierrez-haces ( ) , macdonald ( ) and weisbart ( ) have documented the practices of canadian extractive firms, as have gordon and webber ( ) in their account of canadian imperialism in latin america. in the context of increasing attention to canadian firms abroad, violations of first nation rights in canada garnered increasing attention. in , the band council of the ki first nation was jailed for refusing to allow mineral prospecting on their territory (kuyek, ) . in , the canadian government under prime minister harper described ngos challenging resource extraction in western canada as 'enemies of the state' (zalik, ) . in new brunswick the community of elsipogtog had a direct stand-off with the rcmp over a fracking company's access to their territory, while in alberta, various first nations, including the athabasca chipewyan first nation, launched legal suits again firms and government for violations of their territorial rights. nation-wide movements against major pipeline projects also emerged in this context. these successfully halted a number of projects including the enbridge northern gateway and energy east pipelines. significantly, a major global movement against tar sands extraction in alberta and its implications for climate change and indigenous rights had a real effect on the presence of transnational industry at home (haluza delay and carter, ) . assisted by a major drop in oil prices, this ultimately prompted the exodus of major transnational operators from northern alberta, including shell. most recently, mining giant teck indicated that its cancellation of a proposed tar sands project was due to canada's unclear approach to questions of climate and indigenous rights. over this period various regulatory proposals sought to address conflict over canadian extractive industry. the first major initiative was the extractive sector roundtable. intended to bring about substantive monitoring of human and ecological rights associated with canadian extractive industry, various advocates felt that the process was thwarted and minimized through the creation of the 'devonshire initiative'. the initiative was named for the address of the munk centre at the university of toronto where it was to be housed. the munk centre is financed by a major endowment from barrick gold, at the time canada's largest mining company, of which peter munk, now deceased, was founder and former ceo. the initiative resulted in the creation of an 'extractive sector counsellor' in charged with the receipt of complaints from affected communities concerning the mining industry. ultimately, in and after considerable criticism from civil societynotably the canadian network on corporate accountability, government and the mediathe office of the extractive sector corporate social responsibility counsellor (herein csr counsellor) was left vacant after counsellor marketa evans' resignation. counsellor evans had accepted only six complaints in the years the office was open and of these, five were closed without resolution (saunders, ) . in a new csr counsellor was appointed, a former rio tinto executive, but ultimately the critique of this office led to its permanent closure in may . overlapping with this initiative, from canada's national contact point for implementing the oecd guidelines for multinationals, chaired by global affairs canada and co-chaired by natural resources canada in partnership with five other ministries, also accepted complaints regarding canadian extractive firms, but its own procedures were critiqued as providing insufficient protection to those who lodge a complaint (above ground/mining watch canada/oecd watch, ). over these years, legislative initiatives such as john mckay's private member bills (discussed below) aimed to address the gap in extractive sector regulation, human rights and transparency but were not passedaccording to various commentators, due to private sector interference. as coumans ( ) describes, the devonshire initiative and the csr roundtables in canada were dominated by industry and the former harper government. the dissolution of the office of the csr counsellor prompted further advocacy by legal and human rights and academic advocates, including a petition calling for the establishment of an ombudsperson for the extractive sector. the trudeau government announced in january that a canadian ombudsperson for responsible enterprise (core) would be established; an ombudsperson was hired in april who had previously worked as a lobbyist for the oil industry. the ngo community resigned from the government advisory board for core en masse in august . key concerns are that the office is insufficiently independent from industry, would not have powers to compel evidence from corporations or investigate but rather only 'review' cases, that the anonymity of complainants from affected communities abroad could not be guaranteed, and significantly that core would accept from companies complaints against human rights defenders , muzzling criticism and putting community members at risk (dwyer, ) . the broader regulatory context in canada underlines our argument concerning the estma's role in legitimating and offering security for industry, rather than substantively reforming its activities. given that transparency discourse elides the role of powerful states in shaping discussions of 'corruption' and in constituting the eiti (bracking, ) , it is perhaps unsurprising that the academic literature on the eiti has centered on eiti implementation as a global and domestic governance issue and institutional problem, largely involving policy elites (haufler, ; furstenberg, ; arond et al., ) . within accounts of procedural transparency mason ( ) and gupta ( ) importantly called for, and convened, greater interrogation of the political economic implications of the discourse (gupta and mason, ). recent studies in extractive industries and society have assessed the effect of eiti adoption on gdp and the role of the eiti in reducing corruption. the results of this research are mixed. interestingly some results point to the importance of a higher degree of perceived corruption in a particular state as a factor associated with eiti compliance, given the initiative's role in attracting investment to a country's mining sector (magno and gatmaytan, ) . other texts have also discussed the eiti as part of a broader set of global anti-corruption institutions (gillies, ) . in a more critical direction, Öge's ( ) work on 'transparent autocracies' points at the ways in which civil society's whistleblowing functions have been weakened even with eiti implementation. much of the more critical recent literature on the eiti assesses its ability to enact greater accountability from implementing states, those in which oil and gas extraction occurs. these studies measure the extent to which the costs and resources associated with the initiative bring about better accountability performance among implementing states than existed prior to eiti implementation (sovacool et al., ) . despite the eiti's initiation by elites, social accountability theory argues that it can and has been used to build stakeholder (civil society and local community) power in the global south. significantly for our analysis herein, however, the autocratic nature of host states in the global south remains the central problematic (akonnor and ohemeng, this issue; Öge, ) , disregarding global power relations and historical and contemporary transnational wealth transfers that extractive industries have entailed. while the accountability-oriented literature importantly identifies the problems of secrecy (florini, ) that undergird industrial payments to governments and affected communities, these discussions are meant to further secure and regulate processes of financialization and audit in which the eiti is embedded, rather than critique or displace them. our approach in contrast, critiques the unequal application of corruption discourse (laufer, ) , as it is embedded in broader orientalist and racist depictions of southern states and indigenous peoples generally. we consider, rather, the functional role that estma plays in corporate audit practice as a means to reduce risk for the firm, what may be understood as 'audit culture transparency' (gilbert and zalik, ) , a practice that draws attention away from industrial violence and obscures calls by colonized peoples for substantive reparations for wealth extracted from their lands. as per the watts and zalik ( ) paper in this issue, the time taken by advocates to review corporate disclosures reduces capacity available for systemic critique of global industrial systems. our research suggests that various aspects of the estma are congruent with audit culture transparency. first of all, while the estma mandates reporting by firms, there is little or no oversight by canadian government bodies responsible for collecting the data. thus, ultimately, reporting or assessment in the estma seeks to achieve a further end, but without clear oversight and due to corporate exclusions, much information is protected and confidential. blocking access to data may be understood as a form of 'legal enclosure' (szablowski, ) . second, there is limited or no standardization of reporting among firms, making it difficult to evaluate results in divergent spatial and national contexts, or to make comparisons between the kinds of payments that firms make to national or local governments. through the estma, as apparent in its treatment in scholarship and ngo practice to date, public discontent with profit-driven, rights-violating, and environmentally harmful extraction is translated into legal and regulatory frameworks that produce highly technical information. while incorporating a number of contested interests and actors, these processes do not address the underlying concerns regarding social violations and wealth extraction that prompted industrial regulatory initiatives; arguably these are funneled into transparency regulations and voluntary codes of conduct for industry, protecting the interests of industry. the estma was introduced to the house of commons on october , as part of omnibus bill c- under the title economic action plan act , no. , before it received royal assent less than two months later on december , . the estma paralleled the cardin lugar provision of the dodd frank act (section ) which was subsequently repealed under the trump presidency ( global witness, ) . section directed the us security and exchange commission to require oil and gas industry disclosure of payments to us and foreign governments. as discussed above, among canada's precursors to the estma were private member's bills introduced by liberal mp john mckay. these were narrowly defeated in (bill c- ) and (bill c- ). the changes from these earlier proposals were double edged: they increased the scope of reporting requirements to payments made to all governments not only abroad, but also in canada. however a major difference between the aforementioned bills and the estma legislation was that reporting oversight and reporting requirements to the public were scaled back under the estma. omnibus bills, defined by the house of commons as those which seek to amend, repeal or enact several related, but separate, initiatives have been around since (dodek, ) . since , however, budget bills have become longer and more complex. under the harper government in particular, 'omnibudget bills' (omnibus budget implementation bills) grew exponentially to an average of . pages between and , from an average of . pages between and (ibid). using a practice referred to as "tacking", seemingly unrelated provisions are included upon the logic that they are loosely connected to the budget; a practice sanctioned by speakers in the house of commons. the increase in the size and scope of omnibus bills, however, makes it difficult for mps to properly scrutinize a bill's content, and therefore to consider and debate before enacting laws proposed by government. this, dodek ( ) argues, undermines the democratic process whereby elected citizens' representatives consider different viewpoints when proposing, debating and enacting laws. bill c- and the estma embedded within it are illustrative of this practice. the bill was a -page document proposing wide-ranging legal reforms. these included, for example, legislation restricting the ability of refugee claimants to access social assistance, to the establishment of the canadian high arctic research station, and the reform of canada's intellectual property laws. with debates in the canadian house of commons pivoting on the bill's proposed cuts to social assistance, the estma received scant attention. critique of the massive omnibudget was a frequent topic of debate from opposition party mps, but a motion to decline the bill a third reading because it "amends dozens of unrelated acts without adequate parliamentary debate and oversight" was defeated - , with conservative representatives almost unilaterally responsible for its defeat (parliament of canada, ). mckay noted that "…the irony is quite resplendent. that bill demanded of the extractive sector accountability and transparency and was put in an omnibus bill…which has no accountability and no transparency." (house of commons, ) . the proposed estma, found under division , part of bill c- , received the most attention from the standing senate committee on energy, the environment and natural resources. these consultations occurred prior to the bill coming before the senate. hearing from representatives of the canadian association of petroleum producers (capp), the assembly of first nations, mining association of canada (mac), and publish what you pay -canada (pwyp), these debates centred around the issues of reporting requirements, the role of aboriginal governments, and canadian alignment with international transparency standards and legislation. quite explicitly these legislative proceedings illustrate that while extractive entities are responsible for reporting under the act, the purpose of the legislation is to hold governments to account for money transferred to them from such entities. mark pearson, director general, external relations, of the ministry of natural resources canada stated that "…the purpose of this legislation… is to hold the governments to account for the money. oftentimes you have industry working in countries abroad; the resource gets developed, the taxes, royalties and so forth have been paid to the government; the money does not seem to go back into the economy; the people are questioning what happened to the money; and then the industry can get the blame for it. this way, it's out there; the information is provided publicly; citizens in those countries can hold their governments to account: what happened to the money? where did it go? it provides that element of transparency." (senate of canada, ). canadian and foreign companies operating within canada must report transfers to the canadian government under the act. however, as per doshi and ranganathan ( ) and bratsis'( ) positions above, canadian state officials promoting the estma were most concerned with monitoring transfers to foreign governments by canadian companies as a means of deterring corruption. in principle, such reporting would enable citizens in foreign countries to hold their governments to account for transfers such as taxes and royalties paid by canadian extractive companies to governments which did not accrue to broader public accounts (ibid). the focus of the estma in effect, is to monitor and undo elements of the resource curse associated with undemocratic governance regimes in the global south. the senate committee proceedings also demonstrate that private, corporate interests were generally supportive of the way the estma was taking shape, as a piece of legislation that could advance their k. ciupa and a. zalik the extractive industries and society xxx (xxxx) xxx-xxx interests. arguing that the estma goes 'hand in hand with the corruption of foreign public officials act', ben chalmers of the mac stated that the act could be used as a tool for canadian extractive companies to use against foreign governments when being asked by them for a bribe. such companies could cite the requirement to report these illicit transfers under the act. as stated by chalmers, "it provides an opportunity for us to say, ''we can pay you that money, but we're going to have to report it, so if you want us to report it, then let's have a conversation, but i don't think you want us to report that, so let's move on and do business above board.''" (senate of canada, ). further, reporting under estma could increase extractive companies' standing within communities: "…(as) it provides a mechanism for us to credibly and independently communicate the benefits that mining can bring to communities and countries where we operate, wherever that might be in the world." (ibid). in this way, estma deters corruption via reporting, rather than regulating and monitoring extractive industry's human rights and socio-ecological practices. this purpose diverges from, and fails to address, the original concerns that prompted the creation of transparency legislation: public discontent with profitdriven, rights-violating, and environmentally-harmful extraction. estma's congruence with audit practice is also revealed in these debates. first, while the estma mandates reporting by firms, there is no direct enforcement mechanism to ensure that the reporting requirements are achieved. rather, the obligation is on entities to report, and it is up to the minister of natural resources of canada (nrcan) to then deem whether the reports are accurate and appropriate (estma, article ). while an independent audit of an estma report can be requested by nrcan (estma, article ), the ministry website indicates that such verification compliance will only be conducted if there are multiple errors or data anomalies in a report, or if a company fails to report, for example, a joint venture (nrcan, ). as such, nrcan uses a 'risk-based approach', where companies found to be at higher risk of non-compliance may be asked for further verification, rather than systematic oversight of each report. accordingly, the purpose of the estma is to act as a deterrent against corruption, explained ekaterina ohandjanian from justice canada (senate of canada, ), with little guaranteed oversight, where reporting operates as a form of social reassurance in an under-regulated industry. the limitations of this form of industrial audit on increasing accountability were succinctly articulated by senator ringuette in these debates: you may have serious evidence that the money spent within canada by the extraction company or outside of canada is being used in a corrupt manner, but this entire piece of proposed legislation has no policing. there's no way you can go elsewhere in the world to see if canadian company x is providing any kind of funding to a government entity" (ibid). still, representatives from nrcan, pwyp and the mac agreed on the merit of the reporting scheme to deter corruption overall. chalmers of the mac noted that 'making sure this information sees the light of day' is a 'business imperative' since it is more difficult for companies to communicate the benefit of resource extraction to communities when money is misspent by governments. for pearson from nrcan, and woodside from pwyp, the merit of the reporting scheme lies in "making this information public…to provide to those who want to hold governments to account the information they need to do so" (pearson, senate of canada, ). both noted that it is civil society organizations that are committed to seeing this information disclosed by companies operating in their countries (woodside, ibid), and that such organizations would be monitoring disclosures and holding their governments to account (pearson, bid). nrcan considers requests by parties to further examine a report if there are 'reasonable grounds to believe that the report merits further scrutiny', according to their website (nrcan, ), though there is no formal legal recourse by third parties themselves. the penalties imposed for non-disclosure however are minimal for larger firms (estma, article ( )). as we discuss in specific examples below, the estma also lacks systematized reporting requirements for firms which undermines the ability of civil society organizations to monitor and hold governments accountable based on company disclosures. the precise content for inclusion in estma reports is not spelled out in the act, but instead outlined in the guidance document first published by the ministry of natural resources in in which industry was highly influential (interview ). to align with similar legislation in the us and uk, outlining reporting requirements in accompanying rules, such as the estma guidance, makes the content easier to amend in future (senate of canada, ). pwyp canada expressed concern that the lack of detail could limit the ability of citizens, communities, journalists and parliamentarians to interpret information project-by-project, particularly since the regulations give the governor in council the power to grant exemptions on reporting: "citizens, communities, journalists and parliamentarians cannot use this information to hold their governments to account if they cannot access disaggregated payment information on a project-level basis. …our perspective is that the legislation needs to be strengthened to reference the type of disaggregation that will be required and to include a main date to require project-level reporting" (ibid). ultimately, pwyp was successful in bringing about project based disaggregation. as we discuss below, however, the project level information is not disaggregated by community requiring analysts to compare and make assumptions about firm reporting disclosed on a governmental and project level basis; a tedious undertaking. the final version of the legislation also increased discretionary powers for exemptions to standardized reporting through the inclusion of a substitution provision (estma, article ). this provision enables the minister of nrcan to accept reports employed in another jurisdiction as acceptable substitutes for those set out in section of the act (estma, article ( )), so long as the entity provides a copy to the minister within the other jurisdiction's specified reporting period (estma, article ( )). this amendment reflects concerns expressed in the oral testimony of the capp (senate of canada, a), and a written report submitted by sections of the canadian bar association, wherein both argue that preparing a second report to fulfill reporting requirements under the estma would create an administrative burden for companies already filing a report in a foreign jurisdiction (cba, ) . in particular, the capp noted that there are frequently confidentiality clauses between extractive companies and foreign governments concerning payments to state institutions; therefore stringent reporting conditions could force reporting entities to choose between complying with canadian or foreign legislation (senate of canada, a). consequently the standardization clause incorporated industry's preferences while also creating paid work for legal counsel. although standardization exceptions on extractive company reporting across different jurisdictions lessen the administrative burden for business entities, they make evaluating the results for civil society organizations more difficult. this dilutes the pretext that such legislation empowers civil society organizations to access and interpret information disclosed by companies as a means of exacting government accountability. missing in the debates in the house and senate on the bill, and in the legislation itself, are provisions for civil society organizations to hold extractive entities themselves to account. a number of exclusions from the estma are also notable. the pipeline and processing sectors are not subject to the estma, an exclusion these sectors sought early in the negotiations in the rrtwg that led to the legislation. yet given their much larger spatial and indeed material footprint in canada, pipeline projects have been domestically highly controversial in recent years, particularly in their economic relationships with communities -including indigenous impact benefit agreements -along the extension of their operations. further, only extractive and not exploratory firms are subject to estma's terms. this author's interview, key informant, . the extractive industries and society xxx (xxxx) xxx-xxx may facilitate partnerships between firms engaging in each of exploration and extraction, which allows the former to conceal problematic cash transfers associated with securing a contract under the category of exploration, a possibility we discuss further below in relation to africa oil corporation. transparency in various forms of impact benefit agreements, for instance, could be highly controversial in the context of broader divide and rule policies pursued by the oil and gas industry (caine and krogman, ; zalik, ; pasternak, ) . exploring particular firms and data to further explore the above mentioned attributes of the estma, we turn to a number of examples of current estma reporting. an exploration of examples of canadian extractive firms (including tahoe resources, debeers and africa oil corporation), and their relationship to the estma reporting requirements, reveals the contradictions we have discussed above concerning estma reporting as audit culture transparency. it is also suggestive for the way in which the marker of corruption is employed in the global south while the absence of full disclosure by firms is protected as corporate exclusion. this section situates these examples within the context of three aspects of audit culture transparency outlined above: little or no oversight by canadian government bodies responsible for collecting data; limited standardization of reporting among firms; and the failure of transparency regulations to address underlying societal concerns about human rights violations and environmental degradation. although estma reporting is meant to achieve increased transparency and accountability, there is no direct enforcement mechanism to ensure that reporting mandates are met. rather, natural resources canada only mandates an independent audit when a report is submitted with numerous unrectified errors, and the reporting entity is thus deemed to be at higher risk of non-compliance. this means that in the vast majority of cases, reporting becomes an end in itself; a concern echoed in senate committee debates on the proposed estma. during the senate committee debates, both the government and publish what you pay anticipated that civil society organizations would play a key role in reviewing corporate reporting made public under the estma. civil society oversight was anticipated to hold foreign governments to account, rather than the extractive firms themselves. in practice, however, public use of estma reports is constrained by a series of exclusions, blocked access to data, and exceptions to standardized reporting requirements, as well as by the often shifting and overlapping ownership structure of extractive activities. first, the exclusion of pipeline, processing and exploratory firms under the estma means that only the extractive subsector of oil, gas and mineral production is subject to reporting requirements. what is notable is that the exclusion of these activities from the estma allows firms to divide up potentially controversial activities into excluded sector companies in order to shield them from scrutiny. for example, africa oil corporation -part of the lundin group of companies -has recently acquired major offshore holdings in nigeria and guyana including both production and exploratory leases. offshore holdings in both countries have been under considerable scrutiny for issues of tax avoidance and corruption. the manner in which sectoral activities are divided, however, has protected them from further analysis under the estma since exploration is exempt. in addition, africa oil corporation's acquisition involves the purchase of a petrobras stake in the project, but was initially facilitated by a consortium headed by private oil trading firm vitol whose dealings in nigeria and elsewhere have been the subject of scrutiny for non-disclosure (somo forthcoming). as vitol is a private firm that is not headquartered in canada, the business dealings that preceded and led up to the acquisition are unlikely to be subject to estma reporting. in guyana, africa oil corporation's partnership with eco atlantic, an exploratory firm headquartered in the us, similarly indicates that payments made around acquisition will not be subject to estma. yet, a review of board and management structure reveals the close connection between these firms. the ceo of africa oil corporation, keith hill, sits on the eco atlantic board as an independent director but as a non-canadian firm eco atlantic is not subject to estma, and with changes to section of the dodd frank act is not subject to disclosure in the us either (ostfeld, ) . the africa oil corporation case is thus suggestive of the narrow role of estma in strengthening global financial transparency in extractive industry. in addition to those activities excluded under the estma, reports from extractive firms normally subject to the estma may become publicly unavailable under specific exclusions. reporting by tahoe resources is an example of this. tahoe resources was founded by former goldcorp ceo kevin mcarthur and is headquartered in reno nevada (pwyp, ); its canadian entity is registered to its lawyer's office mcmillan llp. tahoe is subject to estma reporting requirements, and its and reports are publicly available. tahoe's solely-owned guatemalan subsidiary, minera san rafael, operated a highly contentious project in guatemala, the el escobal mine, which was previously owned by goldcorp. in , claims were brought against the el escobal project to british columbia (b.c.) courts in a civil case by guatemalan protesters seriously injured when the firm's security shot unarmed community protesters at its gates in (weisbart, ) . the el escobal project has also been the subject of a publish what you pay ( ) case study, which notably had to be rereleased following complaints from the firm that the initial pwyp report did not use language they consider acceptable to describe charges against them. a retraction published by pwyp states that its reporting should have used the term 'alleged' to describe that the firm's security shot protesters. following a b.c. court of appeal's decision which found that canada was the preferred forum to hear the claims of guatemalan protesters given the risks posed to plaintiffs if the case were tried in guatemala, and the subsequent refusal in june by the supreme court of canada to hear tahoe's appeal of that decision, the path was cleared to try the case in canada. from this time, tahoe's estma reports would no longer be available on estma's public database given that they were subject to legal proceedings. although the legal proceedings pertain to guatemala, no tahoe report is available for on any of its operations. in , tahoe resources announced that it was to be acquired by vancouver based pan american silver (canadian press, ) . after the pwyp case study of el escobal was completed, and in the midst of the lawsuit delineated above, the pan american silver/tahoe acquisition was completed in february , making pan american silver the world's largest silver mining firm. on july , , pan american silver reached a settlement with the guatemalan plaintiffs, though the mine remains closed pending a consultation process with the local xinka community. pan american silver estma reporting is available for through , and as of july the pan american silver report indicates payments to the guatemalan government (taxes) and the municipality of san rafael las flores (royalties). the el escobal mine (earth works, ) and pan american silver (environmental justice atlas, ) are subject to considerable ongoing criticism from civil society (moore, ) ; estma reporting does not address these crucial concerns. second, public access to data is limited by the manner in which financial transfers are reported, which can make their interpretation difficult. for example, according to pwyp's ( ) study of the el escobal project, two types of royalties were paid: statutory royalties to the guatemalan government and the san flores municipality, and voluntary royalties paid to both the government and affected communities in the area of the mine. the voluntary royalty paid to municipalities ranges from percent split between three communities and . percent owed to one of them. the voluntary royalty is not required on sales of silver at a price lower than $ /ounce. pwyp explains that since the company does not disclose the voluntary royalty paid, pwyp cannot ascertain how much of the royalty payment disclosed in the estma report was paid due to the voluntary, as opposed to the statutory, royalty. important here is that the dispute over the el escobal mine revolves considerably around the exclusion of the indigenous xinka, who have consistently opposed its development, from the consultation process (earthworks, ). the affected municipalities, in a form sharing parallels with dynamics around industry relationships with indigenous band councils and indigenous hereditary chiefs in canada through impact benefit agreements (caine and krogman, ; scott, ) , have received this voluntary royalty in principle as part of the company's 'support' to communities, providing a superficial means for a firm to claim a 'social license to operate'. as per the canadian context, the acceptance of the royalty has also created the conditions for divide and rule, with communities ousting leadership that had accepted these payments (maritimes-canada breaking the silence network et al., ) , and fewer mayors accepting the payment than tahoe had publicly announced. as a recent legal case in canada demonstrates (axmann and cassidy, ) , payments for community development subject to legal privilege have been used to argue against affected communities (in this case an indigenous community's) claims for damages from resource projects. this, along with other forms of excluded data, can be understood as a form of what szablowki ( ) calls 'legal enclosure'. that is, blocking access to data on (in this case voluntary) royalties closes off potential spaces of legal recourse, and inhibits residents of extractive territories from seeking justice from resource firms. third, due to estma's substitution provisions, there is limited standardization of reporting requirements among firms. as discussed above, this enables companies operating in multiple jurisdictions to file reports in other formats, if approved by the minister. a lack of standardization makes it difficult to evaluate results in divergent spatial and national contexts, or to make comparisons between the kinds of payments that firms make to national or local governments. the case of the de beers victor mine near attawapiskat is suggestive of the implications for reporting in varied jurisdictions. de beers' estma reports consist of filings that anglo american -debeers' majority ownermade elsewhere. the cover letters to the report indicate that it was prepared for the united kingdom, and one assumes this reporting was required by the uk to comply with the eu transparency directive. the estma cover letter does not specify where the uk reporting is posted or available and thus cross-referencing of the data is not straightforward and requires the user have specialized knowledge of estma and other legislative guidelines and reporting locations. as the victor mine was closed in may , payments arising from clean-up or remediation concerns may be excluded from reporting. again such exceptions to reporting requirements lessen the administrative burden on extractive firms, but undermine the ability of civil society organizations to monitor and hold governments accountable based on company disclosures. lastly, estma reporting produces highly technical information, but does not address the underlying concerns regarding social violations and wealth extraction. this is consonant with a gramscian understanding of civil society's role in undergirding elite hegemony, wherein the development of transparency regulations and codes over the extractive industry serve as private initiatives to garner ongoing consent (cox, ) . mac, indeed, identified estma reporting as a means to enhance extractive company standing in local communities. division between communities is a frequent outcome of extractive sector activity, where blame is shifted away from firms and to neighboring settlements. some scholarship suggests that attawapiskat has benefited more than surrounding communities from the victor mine's presence (whitelaw et al., ) , and the payments themselvesdisclosed as of when estma's application to indigenous government took effecthave the potential to lead to intra-community conflict given the significant discrepancy in amounts paid to some communities over others. no explanation is available in the reported information for this variance. while it likely arises from the relative assessment of 'impact' associated with various first nations impact benefit agreements, this is not specified. similarly the el escobal case indicates that estma reporting could increase conflict amongst local communities affected by extraction where there are internal tensions over royalty payments. in this way, the estma may serve the interests of extractive firms by increasing their reputation in contrast to a perceived deficit of transparency in local community governance. this does little to protect the interests of local communities, while deepening intra-community tensions. the challenges civil society faces in navigating this data obscure more fundamental controversies over physical and ecological violence. both the debeers' victor mine and tahoe resources' el escobal project raise questions around the estma's ability to address socioenvironmental justice particularly around private security contracting and ecological disclosure. the victor mine has been highly contentious given its siting at an indigenous community which has faced a major drinking water crisis. it is a quintessential example of disputes over questions of environmental justice in ontario's ring of fire region. the victor mine is the subject of a legal case in ontario for mercury contamination, brought by the wildlands leagueformerly canadian parks and wilderness. the case has been in ontario provincial courts since and concerns the mine's failure to report data on mercury monitoring. in both the victor mine and el escobal cases, estma reporting has not assisted in identifying or addressing human rights and environmental violations. rather, legal proceedings on these violations served to diminish estma reporting requirements. while the scope of the estma is arguably confined to financial transparency, this legislation was created in the context of a call to end human rights abuses by canadian extractive companies. the fact that the legislation, guidance document and reporting requirements contain little that could be used to monitor, or advocate for, human rights and environmental protections is indicative of the way in which the final product was reshaped to protectand was in fact strongly supported bythe interests of industry. the relations described in the aforementioned examples of firms required to report on the estma are not exceptional. they offer an example of a number of the broader financial, judicial, and environmental regulatory structures excluded under the legislation and guidance provisions but which should be central to any form of substantive transparency. they are suggestive for the estma as a form of broader audit culture within the extractive industry where highly technical information is produced with little guaranteed oversight, and limited standardization of reporting. rather, reporting serves as a form of social reassurance in an under-regulated industry, while the drawbacks of this reporting structure inhibit civil society organizations from holding reporting firms accountable. see p. of the disclosure complaint filed by shin imai for the justice and corporate accountability project at https://justice-project.org/wp-content/ uploads/ / /final-bcsc-disclosure-complaint-re-tahoe-may- - .pdf. the extractive industries and society xxx (xxxx) xxx-xxx as we conclude this paper, the role of systemic racism in the broader socio-economic system is receiving long overdue attention in mainstream media. this attention sheds light on how the broader contours of corruption discourse operate in a form that 'blames the victim' for an industrial system that has accumulated capital through the oppression of racialized peoples. the global extractive industry is a long standing profiteer of this system (rodney, (rodney, / . our analysis of legislative debates and specific reporting examples herein indicates that the estma in canada offers some terrain to critique and gain access to the inner workings of financial capitalism which protect corporate privacy. yet the broader systemic violence upon which the industry is built remains shielded from view, with scrutiny of minutiae drawing attention away from a broader context of substantive injustice wherein the wealth extracted from specific landsnotably those of indigenous peoples -entails the overall impoverishment of those who reside there. the canadian implementation of estma shares attributes with the global implementation of eiti, in particular where more stringent requirements than those of the eiti have been implemented through civil society pressures, as per the example of nigeria. these create space for further research on corporate activity that by necessity requires detective work. but despite the ways in which access to such corporate information may 'lift the veil' on secrecy, corporate disclosure most pertinent to the work of human rights advocates is not proffered through this legislation. as argued by bratsis ( ) with regard to anticorruption discourse generally, the broader context of transparency discourse can serve to justify northern intervention into economic activities of global south governments and indigenous nations by suggesting mismanagement of funds. on the basis of the above analysis we see that estma's terms prompt reporting by firms that may indeed be useful to the advocacy community and thus broader struggles for equality. yet the patchy additional documentation it makes available to those affected by extractive sector activities requires inordinate analysis from corporate monitors, producing information that is just as notable for its absences as for what it reveals (weisbart ; see also watts and zalik, this issue). above we identified key limitations to the estma that may render it an example of 'audit culture transparency' (gilbert and zalik )where limited oversight by government bodies means that reporting becomes an end in itself, and where financial requirements for corporate risk management trump substantive social regulation and disclosure. in the context of particular examples of estma reporting, the problems entail: i) the exclusion of extractive adjacent activities from estma mandated reporting; ii) the employ of financial categories that act as obstacles and exclusion to public access and interpretation of data; iii) limited standardization across international reporting jurisdictions and between parent/subsidiary firms; and iv) the production of technical data that distracts attention from more fundamental questions of human and environmental rights violations and systemic injustice. ultimately, the estma offers limited leverage to substantively address the ecological and human cost of extractive industry. including more systematized disclosure of information that is publicly available in estma reportingsuch as the frequently changing ownership structure among firms, and overlapping relationships between board and managementis a key area wherein the value of actual estma data for substantive transparency might be improved. such reporting would begin to respond to civil society demands for clear beneficial ownership information, although given the centrality of secrecy to global corporate management (bracking, ) , much more is required. the panama papers disclosures demonstrated the extent to which offshore havens employ ownership systems to exploit taxation and regulation. beneficial ownership disclosure is a demand of the publish what you pay coalition internationally and in canada (johnson, ) , an issue on which the canadian government is now making legislative overtures (lim, ) . nevertheless, the trudeau government's lobbying scandal over prosecution of the firm snc lavalin and controversial purchase of the transmountain pipeline demonstrate the extent to which corporate elites remain central to state decision-making post-harper (lukacs ), a long-standing critique among political economists (sklair, ; strange, ) . indeed, the most significant gaps in the estma data are privileged materials that firms are not required to disclose. in the context of proposed and implemented canadian and alberta government bailouts of the broader mining, oil and gas and pipeline sectors (riley, ) , the dilution of environmental monitoring (weber, ) , ontario's declaring mining essential during the covid- pandemic, and ceo stock sell-offs prior to the covid lockdown, calls for substantive corporate disclosure are eclipsed by global corporate profiteering and its attendant racist inequalities (amin, (amin, / . returning to the questions of systemic racism as a feature in the repression of racialized and indigenous peoples and of nature exporting (southern) states, we recall once more that corruption (and transparency as an antidote) may serve as a pathologizing trope and distraction. the time has come to seek substantive reparations (nwajiaku et al., ) , from the industrial/economic actors who have profited from global structural injustice. canada is back maldevelopment: anatomy of a global failure ngos as innovators in extractive industry governance. insights from the eiti process in colombia and peru first nation ordered to produce private agreements with industry -update on blueberry river first nations treaty infringement proceedings hiding conflict over industry returns: 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oil the offshore world: sovereign markets, virtual places, and nomad millionaires wet'suwet'en: why are indigenous rights being defined by an energy corporation? in: the conversation the audit explosion the audit society: rituals of verification a bailout for the oil and gas industry? the narwhal march available at how europe underdeveloped africa oh no canada: the canadian mining sector's lack of response to human rights abuses abroad comes to a head extraction contracting: the struggle for control of indigenous lands proceedings of the standing senate committee on energy, the environment and natural resources, issue -evidence -november available at proceedings of the standing senate committee on energy, the environment and natural resources, issue -evidence -november available at governing by numbers: audit culture, rankings and the new world order somo (forthcoming) vitol's business operations in nigeria energy governance, transnational rules, and the resource curse: exploring the effectiveness of the extractive industries transparency initiative (eiti) the retreat of the state: the diffusion of power in the world economy new accountabilities: anthropological studies in audit, ethics and the academy. audit cult the tyranny of transparency legal enclosure" and resource extraction: territorial transformation through the enclosure of local and indigenous law alberta suspends environmental reporting requirements over covid crisis diplomacy at a canadian mine site in guatemala enacting the corporation: an american mining firm in post-authoritarian indonesia the victor diamond mine environmental assessment process: a critical first nation perspective vicious transparency: contesting canada's hydrocarbon future the extractive industries and society xxx (xxxx) xxx-xxx the authors would like to thank the anonymous interviewees for their participation. the authors are grateful to caren weisbart as well as isaac asume osuoka and two anonymous reviewers for comments on this piece. all errors are ours. key: cord- - uk y authors: fischer, benedikt title: some notes on the use, concept and socio-political framing of ‘stigma’ focusing on an opioid-related public health crisis date: - - journal: subst abuse treat prev policy doi: . /s - - - sha: doc_id: cord_uid: uk y canada has been home to a longstanding public health crisis related to opioids, including an extensive mortality and morbidity toll in the face of substantive intervention gaps. recently ( ), two extensive reports from preeminent federal authorities – the chief public health officer and the mental health commission of canada – have been tabled with detailed, core focus on the phenomenon of ‘stigma’ and its impacts on substance/opioid use and harms. the reports present extensive descriptions of the nature and effects, as well as a multitude of prescriptions for remedial measures and actions to “stop the cycle of stigma”. closer reading of the documents, however, suggests substantial conceptual and empirical limitations in the characterization of the – multi-faceted and challenging – nature and workings of ‘stigma’ as a socio-political, structural or individual process or force, specifically as it applies to and negatively affects substance use and related outcomes, primarily the wellbeing of substance users. concretely, it is unclear how the remedial actions proposed will materially alleviate stigma process and impacts, especially given apparent gaps in the issues examined, including essential strategies – for example, reform of drug user criminalization as a fundamental element and driver of structural stigma - for action that directly relate to the jurisdictions and privileged mandates of the report sources themselves as health and policy leaders. the commentary provides some concrete while subjective notes and observations on the dynamics of stigma as applies to and framed for substance/opioid use, as well as strategies and measures necessary to both tangibly address the material health and wellbeing of substance users, and related forces of stigma, in the distinct context of the opioid crisis in canada. in at a recent peak-point of opioid mortalitytwo prominent, federal-level reports, ) the chief public health officer's (cpho) report on the 'state of public health in canada' [ ] , ) the mental health commission of canada's (mhcc) report on 'stigma and the opioid crisis' [ ] were tabled and widely disseminated. both these elaborate reports centrally focus on the role of 'stigma' for chronic disease and public health, and specifically 'substance use' and the 'opioid crisis' (the mhcc report with such exclusive focus, the cpho report within a broader focus on stigma and public health). 'stigma', at its foundations, is a sociological concept, crucially furthered by the canadianborn sociologist erving goffman [ , ] . essentially, it indicates the ascription of negative attributes or assumptions (or 'stereotypes' or 'mark of disgrace') on a person because of certain properties or behaviours outside their control, and consequential loss in social status, opportunity, and care or support (including possible 'discrimination') [ ] . luoma provides some essential conceptual and practical characteristics of stigma. stigma is produced and reproduced in many ways, including common 'cultural practices' of everyday life, and highly resistant to change. it can be helpful to distinguish between 'organizational' or structural level, and individual-level processes of stigma, both of which include (structural or individual, respectively) 'prejudice' and 'discrimination' as ways of enactment of stigma. for example, organizational/structural stigma, through related power processes, involves (intentional or un-intentional) policies or organizational rules, restrictions or opportunity barriers towards stigmatized group; whereas individual-level stigma can be divided into public (e.g., the individual reactions or judgments) about a stigmatized group (e.g., 'addicts') as well as 'self-stigma' (e.g., the internalization of negative selfvalue and status, and consequential self-preclusion from key opportunities (e.g., treatment) or negative outcomes experienced by the stigmatized individual themselves. a large variety of different strategies and approaches to reduce stigma have been identified and tried, with however limited demonstrated effects on reducing stigma [ ] . 'stigma' has been given distinct (while limited, e.g., when compared to mental health) attention in the psychoactive substance use realm, in part also related to the conflicting underlying social concepts or explanations (e.g., crime versus moral failure versus disease models) of 'addiction', and consequential implications for the social identities, status and interventions geared at the user [ ] . luomo notes that research on stigma in the addiction realm is in its "infancy", and that even less is known on "how to reduce stigma in this area." [ ] two pre-eminent 'anti-stigma' manifests both above-mentioned reports ascribe fundamental and sweeping cause-effect agency, as well as necessary remedial prescriptions to the phenomenon of 'stigma' as applied to the current public health crisis of substance/ opioid use in canada. for example, the cpho's report lays out in elaborate detail [ ] ; pp. how 'stigma' creates a fundamental "us versus them" between substance users and society, resulting not only in "significant economic costs, barriers to housing, employment, health care, productivity loss", functions as the root of "discrimination", wrongfully blames substance users for "poor willpower", and projects them to be "dangerous and reckless" and implies them to be not suffering from "real illness". beyond, stigma is listed as a driving factor of decreased service use, concealment of substance use, and health-harming coping behaviours (e.g., isolation, needle sharing), poorer health and quality-of-life (qol), limited treatment uptake and poorer outcomes for substance users. based on remedies prescribed for the stigma "cycle [to be] effectively stopped" and for "resisting the impacts of stigma" it is emphasized that required action need to occur on many (e.g., individual, institutional, population) levels, yet concretely by changing "biased and outdated language", "strengthening resilience" (e.g., through education), and devising "cultural competence" interventions for health care providers towards the development of "awareness, knowledge and attitudes". all the while it is then categorically acknowledged in the report that "it is difficult to know 'what works', in what context, to address stigma and discrimination" (p. ). similarly, the mhcc's report [ ] including a related review paper from one of the authors as integrated elementary content material [ ] -purports "broad agreement […that…] stigma surrounding opioid use is both significant and consequential" and has acted "as a barrier to reframe the opioid crisis as a public health issue", concretely as it "affects how we conceptualize, frame and prioritize [the opioid] crisis." stigma is furthermore stated to lead to "hiding and creates barriers to helpseeking, [… and that it] contributes to ongoing system mistrust and avoidance of services […and…] results in poorer quality care and response". for principal remedies, these campaign documents thenspecifically also as actions geared towards "health leaders" -prescribe "comprehensive stigma reduction and intervention strategies for frontline providers", "address[ing] the ethical dilemmas experienced by … front-line providers regarding high-recidivism clients and the emergency-relief measures (e.g., narcan) that may increase riskbehaviors"; and "increas[ing] the use of non-stigmatising language and establish[ing] best practice guidelines for opioid-related terminology and language"; ensuring "stigma-informed … prevention and policies efforts"; and removal of "organizational and policy-related barriers … to a full range of care interventions and services". yet here also, it is then acknowledged that "the evidence base supporting anti-stigma interventions in this [opioid] area is thin, and first requires a "more robust body of evidence". in related media release-statements, the cpho publicly called on "health leaders to tackle stigma [and] that we are all responsible for stopping it" [ ] , and the mhcc's ceo declares that "naming stigma as a public health crisis is brave, bold and necessary." [ ] one could be left with the distinct impressions, based on the above documents and statements, that the opioid crisis and its grave health and social toll in canada are primarily a product of forces of 'stigma', and that implementing the suggested remedies will reliably guide and bring about much awaited, tangible improvement and solutions. while 'stigma' is a certainly present phenomenon and social dynamic in the substance use realm, and adversely affects substance users' lives, behaviors and care in a multitude of ways, the above observations and remedies appear to be problematically narrow if not simplistic at key ends, while selective and featuring essential gaps in key elements and elaborationsespecially also when considering their originating sources. these impressions sit uneasily, and warrant some basic while subjective consideration and comments as per the following brief summaries of main illustrative examples: ) an (if not the) essential root driver and determinant of 'stigmatization', or the enactment of a fundamentally divisive 'us versus them' disposition for psychoactive substance usersfor example, opioid users in the specific context of the opioid crisis, but beyond involving other illicit substances in other contexts --is the fact that such use is categorically defined as a (criminally) illegal. this is so the case in canada specifically per definition of the controlled drugs and substance act (cdsa). arguably, there is no more powerful and impactful social tool to create, and project stigma on a structural level, and its direct and indirect adverse consequences, than through criminalizing a specific behavior and the people such criminalization identifies and targets [ ] . the criminal law, by definition, non-negotiably defines and enshrines most fundamental and shared social norms and values, and identifies actions and behaviors that violate and harm the social body of common rules which are then prescribed punishment as the state's most powerful form of power [ ] . the criminal law, therefore constitutes the authoritative, statesanctioned basis and seal of stigma in the context of a law-based society: for primary examples 'murder', 'treason' or 'assault' carry irrevocable, heavy, official 'stigma' for the law-breaking act, and those who commit it. moreover, the criminal law, or the process of crminalization, defines socially harmful and shunned actions, both by official and formal definition and its every-day enactment (e.g., enforcement); additionally, criminalization serves as the ultimately legitimate reference or justification for certain behaviorsor their 'actors'to be differentiated, excluded, or penalized from many realms of life. beyond, there is extensive scientific evidence on how 'criminalization' adversely affects substance use-related risks, harms and help seeking or service access [ ] [ ] [ ] . yet, nowhere do either report centrally name this quintessential link, or provide explicit recommendations that the 'criminalization' of drug use as a root driver of 'stigma' consequences ought to be materially corrected for the "cycle of stigma" to be slowed or stopped. this is particularly surprising since both reports come from leading federal government (cpho) or arms' length (mhcc) entities located at the very jurisdictional level of the cdsa as federal law in canada. both entities would be in a preeminent position to recognize, and emphasize for the explicit criminalization of substance (opioid) use as a primary, fundamental foundation of stigma that requires revision in order for the desired 'stigma reduction' to occur. ) similarly, there are other concrete, major intervention and policy actionsor gaps, rathertowards opioid-related public health measures along the lines of barriers and obstacles mentioned in theory that, for long, have been resisted by the very anti-stigma campaign protagonists. tangibly, federal government authorities, for considerable time, have refused to formally call a 'public health emergency' (under the emergencies act in canada) in response to the opioid crisis that would have allowed considerably more flexible and substantive measures to address and reduce related health risks and adverse outcomes, including the massive overdose mortality toll [ , ] . related, federal authorities have long resisted the implementation of broadbased, systematic provisions and measures for comprehensive 'safer opioid' distribution programming towards better protecting the numerous 'at-risk' opioid users from increasing exposure to highly toxic/ potent, illicit opioid supply and elevated risk for overdose and death [ ] [ ] [ ] . both types of measures reflect and mimic standard interventions applied and enacted elsewhere (e.g., for vaccinations for influenza, or acutely extensive transmission control measures covid- etc. [ ] ). on this basis, seemingly, preeminent health leaders emphasizing the exceptional burden from and need to "end the stigma cycle" themselves appear to be hindered or hesitant in their own efforts by 'stigma-related policy barriers' with substantial room for change towards more determined, concrete action. to present a questionably one-directional or simplistic perspective on the mechanics and nature of 'stigma'. while the reports' analyses suggest multiple 'pathways' or 'layers' of stigma, they essentially appear to suggest that 'stigma' is an exclusively negative force in functioning and outcomes, and brings on extensive harm in whatever it touches or affects; therefore, any available measures ought to be deployed for it to be 'purged' for its major, consequential harms to be reduced in desirable ways for general benefit. but the dynamics and workings of 'stigma', if considered more fulsomely, are much more complex, or multidimensional. for example, while surely there should not be genuine intent to negatively label, or categorically stereotype, drug users as 'bad persons', there are many behaviorsin the social realities of daily life, health, or substance usethat are widely recognized and agreed as factually unhealthy and undesirable, and therefore feature legitimate reason (e.g., for the benefit of interventions) to be negatively labelled. for example, 'drinking and driving', smoking in front of children, sharing injection paraphernalia, or stealing are generally agreed-upon risky or harmful behaviors which are for education or prevention messaging or deterrence purposesnegatively labelled and so conveyed for arguably good reason [ , ] . it cannot be in anyone's (and especially not prominent health leaders') real interest to suggest correction of these behaviors to positive, or even neutral status or messaging in the interest of all-encomassing 'stigma reduction'. rather, the real, while presumably more complex challenge for a meaningful addressing of stigma appears to be, as far as possible, to disassociate concrete, while undesirable or shunned behaviors and their negative labels from the general identity of those individuals or human beings who engage in or are associated with them, or least better consider and contextualize their real-life contexts, but not have their social or health or other existential opportunities categorically labelled or negatively burdened by them [ , ] . this separation of value attributions is not an easy task, also given that negative behaviors do not exist without people associated with them, and one that will likely never be perfectly possible; however, to imply or invoke a functioning social world in which everything and anything will be free of negative labelsi.e., without any negative association or labelsis neither meaningfully possible nor workable. ) specifically in the realm of the opioid crisis and its distinct evolution, there have been other, powerful forces of social 'labelling' or associations at work that may be (perhaps somewhat clumsily) referred to as 'false' or 'reverse stigma' (i.e., suggesting misguided positive signals or properties on behaviors where the opposite, or at least active prudence or caution would have been warranted); these can be assumed to have led to at least as much, but likely far more, opioid-harms in the population as the genuine (adverse) 'stigma' drivers and effects laid out in the reports. as a key example, an essential causal driver of the opioid crisis, specifically as it unfolded in north america, has included the widespread, excessive medical availability, prescription and usage of potent opioid medications starting in the early s. the vast increases in general population-wide opioid use, initially under the premise of improved population-wide pain care and featuring new -supposedly effective and side effect-free -opioid medications (e.g., oxycodone) aggressively promoted by pharmaceutical companies and facilitated by skewed prescription guidelines, insufficient regulation and prescriber practices alike, pushed large sub-populations into hazardous trajectories of opioid use, with many resulting in misuse, dependence or overdose deaths [ ] [ ] [ ] . later opioid formulationsincorrectlywere claimed to be 'abuse-deterrent' or 'tamper-resistant', and therefore safe from harm [ , ] . all this related to government-licensed and -approved drugs, and occurred under the knowing eye of government monitoring and regulatory control. for (too) long, key government and regulatory authorities provided no relevant policy responses, and then did 'too little too late', to stop the detrimental dynamics of the opioid crisis and its massive population health harms unfolding in slow-motion [ ] . as much as negative 'stigma' may push some opioid users into riskier behaviors or contribute to help or service access barriers and inferior care quality, as much did misleadingly, or simply false systemic positive social messages, images and pervasive assumptions about opioid medications and their alleged benefits, and related harmful (e.g., over-prescribing) practices endorsed or tolerated by key authorities contribute to the present opioid public health crisis. (notably, one of the reports considered points out that users of 'prescription opioids' "also" experienced negative stigmatization, making users feel "addicted … as much as a heroin addict"implying a needed differentiation in stigma attribution between users of 'medical' and 'non-medical' drugs) ( [ ] , p. ). these above factors ought to be taken into account especially when examining 'stigma' as one form of a social process influencing behaviors and adverse outcomes, whereas these are complemented by other social processes leading to and contributing to the same problem's formation and consequences. ) there is a sizeable, recent body of scientific literature e.g., specifically including systematic reviews from the past decadedevoted to stigma, substance use and related interventions. surprisingly, little of these evidence-based insights appear to be considered in comprehensive depth in either of the two documents. for example, while respective reviews find ample evidence for a common presence of negative attitudes and beliefs towards substance users among health professionals or policy representatives, and correspondingly ample accounts of such experiences and consequences among substance users themselves, other key elements of empirical knowledge on or understanding of 'stigma', and especially effective counter-actions appear to be much more restricted [ ] [ ] [ ] . concretely, there is a lack of essential construct, measurement and definitional clarity and consistency, and a dearth of rigorous (e.g., longitudinal) studies and other research on stigma [ , ] ; there overall are few consistent findings on the relationship between stigma and substance use, and few studies have evaluated actual consequences of subjective 'stigma' impressions [ ] ; and evidence on effective stigma-reducing interventions is considered limited [ ] . crapanzano et al. ( ) report the notable finding in their (medical student) study sample that these believed that stigma beliefs among health care professionals were indeed common, but that their own beliefs and care practices would not be influenced by these [ ] . there appears to be good reason for some sensible reflection or restraint to be applied on the above stigmafighting campaign and action front, specifically as generously projected on the 'opioid crisis' in canada. there is little doubt that ample stigmatizing forces and experiences exist and crucially work against the health and wellbeing of substance users in many ways, and should be tackled and alleviated. to which extent this can be most effectively achieved mostly by 'language adjustments', 'resilience strengthening' or similar efforts suggested, everyone may consider and guess for themselves also since current scientific knowledge does not provide much conceptual clarity or substantive evidence what such efforts tangible mean or can accomplish in material reality. the dynamics and effects of stigma for substance use, and both meaningful and realistic ways towards addressing and working to resolve these, however, can be assumed to be much more complex and challenging than what the above-cited two documents and their -rather narrow, if not simplistic -accounts suggest. they may be so described, since they present only limited insights on the (e.g., structural, social and individual) causes or drivers of stigma for substance use, and possible promising and effective remedies for material and sustained change in the lives of those concerned (i.e., substance users). these factors require, and deserve, deeper and better examination and analysis for realistic contributions and improvements for the important stigma-related causes and issues at handespecially from the leading and privileged authorities from which have put forward these reports. first and foremost, the quintessential causal role of the criminalization of illicit substance use (and thereby its users) for the pervasive production of structural stigma needs to feature prominent recognition, and related calls for change in such a campaign if sincerely committed to effective and material stigma reduction. there appear, however, a couple of other latent risks or adverse effects associated with this kind of 'en passant'kind of 'anti-stigma' presentation and campaigning that avoids to name core causes and elements. one is that it can be dangerously seductive as a self-righteous, or serving platform on which now 'stigma' is staged as a convenient, general or principal 'scapegoat' for the opioid crisis, and its ongoing massive and persistent harms. calling out, rejecting and fighting 'stigma' as a socially shared villainous forceakin, for example, to n. christie's 'suitable enemy' concept for illicit drugs [ ]is somewhat similar to promoting 'motherhood and apple-pie' (or supporting justice, equality, and peace for all), while rather limited in applied value or impact if mainly remaining at rhetorical or symbolic levels, and not realistically translated into necessary material action or change at the causal foundations. the other is that such social campaigns may (too easily) serve as a distraction from those tangible or structural actions or measures urgently required to improve and protect the existential real-life conditions, and elementary health and wellbeing (including basic, daily survival through effective, comprehensive overdose prevention services) of the many at-risk opioid (or all substance) users. the current, long-lasting fight against the opioid public health crisis will not be won by campaigns against stigma in itself. rather, fundamental drug law and policy reform, i.e. purging the intent criminalization (and related material stigmatization) of drug use/possession as a 'criminal act', and consequentially defining 'the user' as a criminal being with all adverse consequencesincluding fundamentally negative stigmathat entails is a (the) foremost action priority for this end [ ] . much of this, if materially enacted, will provide and bring fundamentally 'de-stigmatizing' effects for substance users in many crucial (direct and indirect) ways. no such measures, however, are clearly laid out in the report documents mentioned, and thus form quintessential gaps towards substantive and effective anti-stigma efforts in this realm. concretely, after > , opioid-related deaths in merely a decade, canada yet in lacks essential elements of a comprehensive, consistent and committed 'public health emergency' strategy, and essential public health interventions, including reliable, national 'safer opioid distribution' provisions, for at-risk opioid users. it is when these urgent, material remedy needs and action gaps are effectively addressed by the health and policy leaders in charge, we should devote resources to an improved, in-depth understanding and effective addressing of what may be the remaining 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international phenomenon the stigmatization of problem drug users: a narrative literature review substance use related stigma: what we know and the way forward stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review the effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review reducing stigma towards substance users through an educational intervention: harder than it looks a quiet revolution: drug decriminalisation policies in practice across the globe. united kingdom: release -drugs, the law & human rights publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable.author's contributions bf was the sole contributor for conceptualizing, developing and drafting the submitted manuscript. the author read and approved the final manuscript. dr. fischer acknowledges research support from the endowed hugh green foundation chair in addiction research, faculty of medical and health sciences, university of auckland; he furthermore reports topic-related research grants and contract funding from public only (e.g., public funding, government agencies) sources.availability of data and materials not applicable. ethics approval and consent to participate not applicable. not applicable. the author declares no competing interests. key: cord- - t q t authors: lamarre, alain; yu, mathilde w. n.; chagnon, fanny; talbot, pierre j. title: a recombinant single chain antibody neutralizes coronavirus infectivity but only slightly delays lethal infection of mice date: - - journal: eur j immunol doi: . /eji. sha: doc_id: cord_uid: t q t the variable region genes of a murine anti‐coronavirus monoclonal antibody (mab) were joined by assembly polymerase chain reaction and expressed in escherichia coli in a single chain variable fragment (scfv) configuration. after induction of expression, the expected ‐kda protein was identified by western immunoblotting with specific rabbit anti‐idiotype antibodies. the scfv fragments were purified from soluble cytoplasmic preparations by affinity chromatography on nickel agarose, which was possible with an n‐terminal but not with a c‐terminal histidine tag. purified scfv fragments retained the antigen‐binding properties of the parental antibody, could inhibit its binding to viral antigens with apparently higher efficiency than monovalent antigen‐binding (fab) fragments, but neutralized viral infectivity with lower efficiency (about sevenfold at a molar level). to evaluate the usefulness of these smaller and less immunogenic molecules in the treatment of viral diseases, mice were treated with purified recombinant scfv fragments and challenged with a lethal viral dose. a small delay in mortality was observed for the scfv‐treated animals. therefore, even though the scfv could neutralize viral infectivity in vitro, the same quantity of fragments that partially protected mice in the form of fab only slightly delayed virus‐induced lethality when injected as scfv fragments, probably because of a much faster in vivo clearance: the biologic half‐life was estimated to be about min. since a scfv derived from a highly neutralizing and protective mab is only marginally effective in the passive protection of mice from lethal viral infection, the use of such reagents for viral immunotherapy will require strategies to overcome stability limitations. coronaviruses are members of the coronaviridae virus family that includes important pathogens of the respiratory, gastrointestinal and neurological systems of humans and various animals [ l , . neurotropic strains of the murine coronavirus mhv can induce neurological disorders in rodents that are similar to multiple sclerosis [ ] , providing an excellent animal model for the study of human nervous system diseases and immune protection mechanisms. passive protection from mhv infection has been achieved by administration of mab specific for all received feb. , ; revised aug. , ; four major structural proteins of the virus [ - . we have recently shown that f(ab'), and fab fragments of mab - oa specific for the viral surface glycoprotein can also neutralize the virus in vitro and protect mice in vivo [ ] . the utilization of mab in the treatment of important viral diseases is an attractive approach because of their wide specificities and potent biological effects. however, their clinical use has been hampered by their immunogenicity in humans [lo] . the development of molecular biology techniques which make it possible to express antibody fragments in bacteria and eukaryotic cells offers the possibility of developing immunological reagents with very high specificity and sensitivity, with even less immunogenicity than antibody fragments obtained by enzymatic digestion [l l- . to explore the possibility of using antibody fragments expressed in bacteria for the treatment of viral diseases, an scfv was constructed from the sequences of mhv-specific mab - oa and its in vitro neutralization and in vivo protection properties were evaluated. the variable regions of the heavy and light chains of mab - a were amplified by pcr with vh-and v,-specific primers using cdna synthesized from rna extracted from - a hybridoma cells (fig. ) . assembly of the variable regions of heavy and light chains of mab - a was done by splicing with overlap extension [ ] . a linker molecule (gly, ser), was used to bridge the two chains together in an scfv configuration [ ] . the assembly product of the correct size ( bp) was gel-purified and cloned into the bacterial expression vector pet- b. the nucleotide and deduced amino acid sequences of scfv - oa were determined (fig. ) expression of the recombinant scfv was induced with mm iptg for h at "c and total cellular proteins were analyzed by sds-page (fig. a) . coomassie blue staining of induced cells revealed a major protein band of kda corresponding to the predicted size of the scfv and that was undetectable in uninduced cells. fractionation of soluble and insoluble material revealed that the majority of the recombinant protein was contained in insoluble inclusion bodies (data not shown). the identity of the scfv was verified by western immunoblotting with polyclonal anti-idiotype antibodies produced against the parental - oa antibody [ ] . these antibodies reacted with a -kda protein present only in induced cells (fig. b ). attempts to affinity purify the recombinant scfv expressed in the pet- b vector by ni-nta agarose column chromatography under either non-denaturing or denaturing conditions failed. it is possible that the cterminal histidine tag was so embedded in the protein core even under denaturing conditions that it was inaccessible to the ni'+ cations. we subcloned the scfv into the pet- b vector which expresses the histidine tag at the n-terminal end of the protein. although most of the recombinant scfv was also produced in insoluble inclusion bodies, enough soluble protein was present in cytoplasmic extracts to be purified on the ni-nta agarose column, with a yield of about . mg/l of bacterial culture. adsorbed proteins were eluted with rnm imidazole and the fractions were analyzed by sds-page and western immunoblotting. coomassie blue staining of the eluted fractions revealed a unique band of kda ( fig. c) , which was also revealed in western immunoblotting with the anti- - oa anti-idiotype antibodies (fig. ). microtiter plates were coated with ng/well of viral antigen preparations ( . ) or uninfected cell lysates ( ). the binding of threefold dilutions of purified scfv fragments was detected using - oa-specific anti-idiotype antibodies and horseradish peroxidase-labeled goat anti-rabbit igg antibodies. to verify whether the purified scfv fragments had retained the antigenic specificity of the bivalent parental immunoglobulin, their binding to viral antigen prepara- ) or control antibody ( ) were added to the plates and the binding of a fixed concentration of the parental antibody was detected using fc-specific horseradish peroxidase-labeled antimouse antibodies. tions was tested by ellsa using the specific anti- -loa anti-idiotype antibodies for detection (fig. ) . the scfv could indeed bind in a concentration-dependent manner to viral proteins present in infected cell lysates whereas no specific interaction with preparations from uninfected cells was observed. in order to determine the relative affinity of the scfv fragment for antigen, its ability to inhibit the binding of the bivalent natural antibody was examined (fig. ) . fifty percent inhibition of - a binding was achieved with . mg of purified scfv fragments. in contrast, we have previously shown that the same amount of purified fab fragments inhibited less then % of the intact antibody binding [ ]. the neutralization capacity of the recombinant scfv fragment was evaluated and compared to that of the fab fragment by incubating pfu of virus with dilutions of purified fragments and determining the residual viral infectivity on murine fibroblast cells (fig. ) . the neutralizing titer of scfv fragments ( x mole) was about sevenfold lower than that of fab fragments ( x mole). balb/c mice were treated with pg of purified scfv or fab fragments and were challenged min later with lds of infectious mhv. no mice survived the viral infection but a small delay in the mortality of the animals treated with the scfv was observed, which contrasted with the protection of about % of animals treated with fab fragments (fig. ) . given the relatively efficient in vitro virus-binding properties of scfv compared to fab fragments, we evaluated whether the limited in vivo protective capacity of the scfv fragments was due to faster clearance. indeed, we estimated the half-life of scfv - a to be only about min (fig. ) . murine antibodies that neutralize virus infectivity and have the capacity of protecting against viral infection are attractive candidates as potential immunotherapeutic agents. however, their large scale use has been hampered by allergic immune reactions in humans ( and the difficulty and costs of producing large quantities of antibodies. recombinant antibody fragments present several advantages over conventional monoclonal antibodies: they are less immunogenic in humans and can be produced in large amounts and at lower costs. these advantages have encouraged the development of a number of genetically engineered virus-specific antibody fragments with neutralizing properties [ - . as a model for the utilization of recombinant antibodies in the treatment of viral diseases, we tested whether the same antibody engineering technology could be employed for the production of a scfv that could protect from virus infection in a convenient animal model. we report the construction and expression of a scfv rescued from a hybridoma line that secretes anticoronavirus igg a mab which can neutralize virus infection in vitro and protect mice against a normally lethal dose of virus. we show that the location of the histidine tag, either at the cor n-terminal end of the recombinant protein, may have a major importance for purification by affinity chromatography on a nickel agarose column. indeed, we have observed that the scfv fragment produced in this study could only be purified when the histidine tag was expressed at the n-terminal end. in contrast, lake et al. [ ] have reported the purification on a nickel agarose column of an anti-insulin scfv with a cterminal histidine tag. this demonstrates that the con-formation of the particular scfv will determine whether the expression of a cor n-terminal histidine tag will be accessible to the ni + cations and will allow purification by metal chromatography. the scfv described in the present report showed biological properties similar to fab fragments obtained by papain digestion. in fact, they exhibited much better inhibition of parental antibody binding to viral antigen than fab fragments, which is consistent with a higher affinity. indeed, % inhibition of binding of the parental antibody to viral antigen was achieved with only . pg of scfv whereas pg of fab fragments only inhibited % of binding [ ]. however, this did not correlate with a better neutralization activity of the scfv, with molar titers about sevenfold lower than these of fab fragments. even with an apparent higher affinity than fab fragments, the scfv was less effective in the passive protection of animals against lethal viral infection. this was most likely due to a shorter half-life, which we measured to be about -fold shorter ( min the very fast blood clearance of scfv fragments represents an advantage for some clinical uses such as tumor immunotargeting for diagnosis or treatment of cancer but represents a major limitation for their utilization in viral immunotherapy. however, some reports have suggested that the in vivo stability of these small antibody fragments can be significantly prolonged, for example by disulfide stabilization [ , or the identification and introduction of stabilizing mutations [ ] . importantly, the results presented in the current study with a murine coronavirus have very recently been confirmed in another animal model, vesicular stomatitis virus [ ]. these authors also concluded that a short half-life of the antibody fragments hampered passive protection of mice against lethal infection and showed that protection required pre-incubation of the challenge virus with antibody fragments. this confirms that monovalent antibody fragments may be able to passively protect against viral infections and emphasize the need to engineer more stable molecules before clinical uses can be envisaged. male or female, -to -week-old, mhv-seronegative balb/c mice (charles river, st-constant, canada) were used in the protection experiments. the neurotropic a strain of mhv (mhv-a ) was obtained from the american type culture collection (rockville, md), plaque-purified twice, and passaged on dbt cells as described previously [ ] . total cellular rna was isolated from - a hybridoma cells as described previously [ ] . of jkl '-ccglltgalltccagcltggtgcc- ', jk : '-ccglltalltccagcltggtccc- ', jk : '-ccgtt-tatitccaacttgtccc- ' and jk : '-ccgtitcagct-ccagcltggtccc- ') and vk back ( '-gacalt-gagctcacccagtctcca- ') [ ] to amplify vk. the linker dna was similarly amplified from the plasmid psw scd . [ ] using primers mo-link-back and mo-link-for (complementary to vh for- and vk back respectively). gel purified vh and vk amplicons ( ng each) were mixed with ng of the linker dna fragment encoding the peptide (gly ser), in a -pl reaction mixture without primers and cycled times ( "c for min, "c for . min) with vent dna polymerase (new england biolabs, ltd., mississauga, canada) to randomly join the fragments, then amplified for cycles ( "c for rnin, "c for rnin and "c for min) using pmol each of vhlback and vk for primers to which ncol and not restriction sites where appended, respectively. the amplification product was digested with ncol and not for cloning into the pet- b vector (novagen, inc., madison, wi) containing a c-terminal histidine tag. the scfv product was also cloned into the pet- b vector (novagen) for the expression of an nterminal histidine tag. the scfv - oa insert contained in the pet- b plasmid was amplified using primers vh bnde ( '-ggmltccatatggccgaggtcaagctgc- ') and and the pcr product was digested with ndel and sall and ligated into the ndel-and sall-digested pet- b vector. the ligation products were used to transform the xl -blue strain of e. coli (stratagene, la jolla, ca). positive clones were subcloned into e. coli strain bl (de ) (novagen) for expression. transformed bl (de ) cells were grown at "c in lb containing pg/ml ampicillin (boehringer mannheim canada, laval, canada) until the od at nm reached . , at which time mm isopropyl-p-dthiogalactopyranoside (iptg) was added (clonetech laboratories inc., palo alto, ca). following induction, the cultures were grown for an additional h at "c. induced cells were centrifuged for min at x g and resuspended in / volume of mm nacl and mm tris-hci, ph . . lysozyme (boehringer mannheim) was added to a concentration of pg/ml and the suspension was incubated at "c for min. to shear the dna, the suspension was sonicated on ice for rnin or until the solution lost viscosity using a braun-sonic sonicator. the lysate was centrifuged at x g for min and the supernatant filtered through a . -prn sterifil-d membrane (millipore canada, nepean, canada) for column chromatography. the pcr assembly product of scfv - oa was cloned into the pcrll ta cloning vector (invitrogen corporation, san diego, ca). nucleotide sequencing was performed on both strands of two pcr products by the dideoxynucleotide chain terminating method [ ] using t dna polymerase ltd., montreal, canada) according to the manufacturer's instructions (pharmacia). a soluble cytoplasmic extract was used for the purification on a ni-nta agarose column (qiagen inc., chatsworth, ca). the column was washed with ten volumes of binding buffer ( mm nacl and mm tris-hci, ph . ) and loaded with the prepared cell extract at a flow rate of about column volumes per hour. after loading, the column was washed with binding buffer until the od at nm reached the base line level, after which time the bound proteins were eluted with binding buffer containing mm imidazole (sigma-aldrich, canada, ltd., mississauga, canada). elution fractions were analyzed by sds-page and western immunoblotting. fractions containing the purified scfv were pooled and dialyzed against pbs for the biological assays. induced cell extract preparations and elution fractions were separated by sds-page [ ] and stained with coomassie blue for direct visualization or electrotransferred onto hybond-c extra nitrocellulose membranes (amersham searle corp., oakville, canada) for h at v. membranes were blocked for h with pbs-t and incubated for min with a pg/ml solution of purified anti- -loa rabbit antiidiotype antibodies [ ] in pbs-t. membranes were washed five times with pbs-t and incubated for min with horseradish peroxidase-conjugated goat anti-rabbit igg antibodies (diluted / , ; kirkegaard & perry laboratory, gaithersburg, md). membranes were again washed five times with pbs-t and incubated with hydrogen peroxide (sigma) and -chloro- -naphtol (bio-rad laboratories ltd.). all incubations were performed at room temperature (about °c). each well of -well microtiter plates was coated with ng of viral antigen prepared from mhv-a infected cells, as described previously [ ] . after overnight incubation, the remaining binding sites in the wells were blocked with pbs containing % (v/v) fcs and . % (v/v) tween- for min. serial threefold dilutions of purified scfv fragments were added to the wells and incubated for min. the wells were washed five times with pbs-t and a pg/ml solution of purified rabbit anti- - oa anti-idiotype antibodies in blocking solution was added and incubated for min. the wells were washed as described above and peroxidase-labeled goat anti-rabbit igg antibodies (kirkegaard & perry laboratories, inc) were then added and the plates incubated for another min. the plates were washed five times with pbs-t and the bound peroxidase revealed by incubation with o-phenylenediamine (sigma) and hydrogen peroxide. the reaction was stopped with n hci and the absorbance read at nm using an slt ear at plate reader. the wells of -well microtiter plates were coated with viral antigen as described above and incubated overnight at room temperature. serial threefold dilutions of purified scfv fragments were added to the wells and incubated for min, after which the wells were emptied and purified mab - oa added without any previous washing. after incubation for min, fc-specific peroxidase-labeled goat antimouse igg (icn) was added and the plates incubated for min. all subsequent steps were performed as described above. the amount of purified mab - oa added in this test was determined in a binding elisa in which an absorbance value at nm of about .o was achieved in the absence of inhibition by antibody fragments. duplicate serial dilutions of scfv or fab fragments were incubated with approximately fifty pfu of mhv-a for h at "c. the mixtures were transferred onto -well plates containing confluent monolayers of dbt cells. after an adsorption period of h at "c, the virus-scfv mixtures were removed and cells were overlaid with . % (w/v) agarose in earle's minimum essential mediummank's m ( : , v/v) (gibco canada, burlington, canada) supplemented with % (v/v) fcs. plates were incubated for h at "c in a humidified atmosphere containing % (v/v) go , after which the cells were fixed with formaldehyde and stained with crystal violet. viral neutralization titers are expressed as the amount of antibody fragments that could neutralize % of input viral infectivity. mhv-seronegative -week-old balb/c mice (charles river) were injected intraperitoneally with pg of antibody fragments rnin prior to challenge with x o pfu ( ld , , ) of mhv-a injected intracerebrally. the purification of scfv - a was as described above except that it was performed in batch, using -ml tubes. two milliliters of ni-nta agarose resin were washed three times with ml of binding buffer and mixed with ml of bacterial cell extract for min at "c on a rocker platform. the resin was washed twice with binding buffer and three times with wash buffer (binding buffer containing mm imidazole). the scfv - a were then eluted from the resin with ml of elution buffer (binding buffer containing m imidazole). purified scfv fragments were analyzed by sds-page and western immunoblotting as described above, concentrated with aquacide ii (calbiochem-novabiochern corporation, la jolla, ca) and dialyzed against pbs. radioiodination of the purified scfv - a was performed with the lodo-beads radioiodination reagent (pierce, rockford, il). three beads were washed in . m phosphate buffer, ph . , dried on filter paper and resuspended in . ml of the same buffer, to which mci na' (icn) were added. after min incubation, mg of purified scfv - a was added and iodination was allowed to proceed for rnin at room temperature. the reaction was stopped by removing the beads. radioiodinated scfv - a were separated from free iodine by sephadex g- chromatography (pharmacia) and their purity reverified by sds-page followed by autoradiography of the dried gel using a kodak x-omat ar x-ray film. to measure biological half-life in vivo, two balb/c mice (charles river) were injected intravenously with pg of radioiodinated scfv - a. after , , , , , , and min, yl of blood was collected from the retroorbital plexus into heparinized capillary tubes. plasma samples were analyzed by sds-page and autoradiography and the -kda scfv bands were quantitated by videodensitometry using an alphalmagertm documentation and analysis system with alphalmagertm . software (applied innotech, san leandro, ca). the validity of this densitometric procedure was ascertained using classical laser densitometry (bio-rad), with identical results. immunochemistry of viruses. the basis for serodiagnosis and vaccines proc. natl. acad. sci proc. natl. acad. sci proc. natl. acad. sci sequences of proteins of immunological interest proc. natl. acad. sci proc. natl. acad. sci proc. natl. acad. sci centre de recherche en virologie, lnstitut armand-frappier acknowledgment: the authors are grateful to dr. greg winter (cambridge, u.k.) for providing primer sequences and the psw scdl. plasmid and to dr. jean-francois laliberte and dr. christopher d. richardson for helpful discussions. this work was supported by grant mt- from the medical research council of canada (mrcc) which also provided studentship support to a. lamarre. p. talbot and f. chagnon acknowledge senior scholarship and studentship support, respectively, from the fonds de la recherche en sante du quebec. m. yu received a studentship from the fonds pour la formation et i'aide a la recherche du quebec. key: cord- -v ncshav authors: moghadas, seyed m.; pizzi, nick j.; wu, jianhong; yan, ping title: managing public health crises: the role of models in pandemic preparedness date: - - journal: influenza other respir viruses doi: . /j. - . . .x sha: doc_id: cord_uid: v ncshav background given the enormity of challenges involved in pandemic preparedness, design and implementation of effective and cost‐effective public health policies is a major task that requires an integrated approach through engagement of scientific, administrative, and political communities across disciplines. there is ample evidence to suggest that modeling may be a viable approach to accomplish this task. methods to demonstrate the importance of synergism between modelers, public health experts, and policymakers, the university of winnipeg organized an interdisciplinary workshop on the role of models in pandemic preparedness in september . the workshop provided an excellent opportunity to present outcomes of recent scientific investigations that thoroughly evaluate the merits of preventive, therapeutic, and social distancing mechanisms, where community structures, priority groups, healthcare providers, and responders to emergency situations are given specific consideration. results this interactive workshop was clearly successful in strengthening ties between various disciplines and creating venues for modelers to effectively communicate with policymakers. the importance of modeling in pandemic planning was highlighted, and key parameters that affect policy decision‐making were identified. core assumptions and important activities in canadian pandemic plans at the provincial and national levels were also discussed. conclusions there will be little time for thoughtful and rapid reflection once an influenza pandemic strikes, and therefore preparedness is an unavoidable priority. modeling and simulations are key resources in pandemic planning to map out interdependencies and support complex decision‐making. models are most effective in formulating strategies for managing public health crises when there are synergies between modelers, planners, and policymakers. influenza pandemics have historically been devastating to humanity with significant morbidity, mortality, and socioeconomic costs. the - pandemic, the so-called ''mother of all pandemics,'' was responsible for over million deaths among countless infections worldwide. today, years after the last pandemic in , the world may be on the brink of another major global pandemic, with a toll that could exceed that of the - pandemic. while the nature of the next influenza pandemic cannot be predicted with certainty, the identification of strategies to effectively curtail the spread of disease is an unavoidable priority in responding to this global threat. in light of this, the university of winnipeg hosted a multidisciplinary workshop on the role of models in pandemic preparedness. the workshop brought together public health experts, key decision makers, and infectious disease modelers to: (i) identify the strengths and weaknesses of mathematical models, and suggest ways to improve their predictive ability that will ultimately influence policy effectiveness; and (ii) provide an opportunity for the discussion of priority components of a pandemic plan and determine key parameters that affect policy decision making. the first day of this workshop consisted of several outstanding presentations by modelers with the purpose of forging strong links between theory, policy and practice. these included evaluations and model predictions for antiviral strategies and their implications for drug stockpiling; the role of population contact networks in the emergence and spread of drug-resistance; targeting influenza vaccination at specific age groups; optimal control of pandemic outbreaks; and the usefulness of non-pharmaceutical interventions in disease mitigation. dr. chris bowman (institute for biodiagnostics, national research council canada) presented the findings of two modeling studies for the management of drug-resistance in the population, , especially when concerning the scarcity of antiviral supplies. these studies suggest that an adaptive antiviral strategy with conservative initial treatment levels, followed by a timely increase in the scale of drug-use, can minimize the final size of a pandemic while preventing the occurrence of large resistant outbreaks. dr. bowman emphasized that the strategic use of drugs may involve decisions for rationing of limited stockpiles and prioritizing high-risk individuals, and therefore ethical considerations should be taken into account for maximum protection of community health. a comparative evaluation of antiviral strategies in homogeneous and heterogeneous population interactions was presented by dr. murray alexander (institute for biodiagnostics, national research council canada). he underscored the importance of prolonging the effectiveness of antiviral drugs through an adaptive treatment strategy, in particular for heterogeneous community structure in which the wide-spread of resistance is more likely to take place. these presentations also provided a brief overview of some recent studies carried out by canadian modelers in the subject of pandemic preparedness. [ ] [ ] [ ] [ ] [ ] dr. babak pourbohloul (director, mathematical modeling, bc centre for disease control) proposed an important question regarding ''a forced marriage'' or ''necessity for integration'' between mathematical models and public health policy. in his summary of the day, dr. pourbohloul acknowledged that the talks were very encouraging and pointed towards integration and development of modeling platforms that could inform policy in canada. he also highlighted the significant progress evident since the first pandemic meeting in vancouver, , during which very little could be communicated to policymakers regarding the value of modeling perspectives. dr. pourbohloul drew attention to various models presented in the workshop, which attest to the fact that we are not lagging behind the current methodology in canada, but rather are in the forefront. [ ] [ ] [ ] [ ] [ ] [ ] [ ] however, the central issue is not this, but integration with public health, which is the approach taken by us and uk colleagues for disease modeling and management. a major drawback for canadian modelers is the lack of appropriate infrastructure, and this calls for investments from healthcare departments and government organizations that could provide modelers with the impetus to continue development of more realistic models. with regard to models used for pandemic planning, we need to critically evaluate their implications for policy implementation. there are two major reasons underlying this evaluation: first, data are limited and prior to the emergence of a novel pandemic strain, it is not possible to study the epidemiological impact of disease or interventions in a real world environment; second, public health authorities would need to be prepared for all the likely scenarios that could influence the outcome of preparedness strategies. models, by definition, are not supposed to be perfect; approximations are necessary and predictions are made on this understanding. however, a more important question is how much of the knowledge of canadian modelers has been employed to support policy decision-making? is it all based upon experience of other countries? perhaps in canada, there has not been much communication between modelers and policymakers and therefore modeling results have not been translated into the context of public health. the time has now come to build a pandemic consortium in canada to have a unified voice from modelers, and close the gaps with infectious disease experts and public health colleagues. dr. susan tamblyn (co-chair, canadian pandemic antivirals working group) also emphasized the importance of making progress on linking the modeling with decision making within canada. these enterprises are still really separate in canada, whereas the value of modeling groups working very closely with the government and health departments is clearly evident in a few countries. we seem to have this linkage in a couple of provinces in canada, but it is not elevated to the national level. as planners, they understand that modeling can help formulate pandemic policies; however, the lack of collaboration with canadian modelers obliged them to turn to outside results from published models. hopefully, the two groups can work closer together to have beneficial impact with regards to pandemic preparedness. dr. tamblyn also expressed her concern about public health questions, which often are not amenable to modeling, and about modeling studies that use unrealistic assumptions and scenarios. therefore, modelers should also be fully engaged in the process of formulating the questions that policymakers need to address in planning for a pandemic. the point was highlighted by dr. ping yan (centre for communicable disease and infection control, public health agency of canada) that models should be based on realistic assumptions to create fundamental knowledge in all aspects of pandemic research. on the second day, the workshop comprised several presentations by participants from the public health domain. these included unanswered questions concerning the emergence of novel infectious diseases; understanding the space-time dynamics of influenza spread; influenza mortal-ity in pandemics and seasonal outbreaks; the impact of global air transportation on the spread of diseases; the role of models in public health planning and decision making; the evolution of pandemic influenza viruses; and the potential for novel means to prevent these pandemics. dr julien arino (university of manitoba) outlined the objectives of an ongoing data-driven project that aims to draw out the likely patterns of disease spread through the network of all international airports in the world with direct and indirect connections. this investigation can have important implications for heading off a global pandemic, with a particular focus on the optimal allocation of containment resources in the most probable ports of disease introduction and spread in canada. this presentation was followed by an overview of the ontario government's pandemic preparedness plan (allison stuart, assistant deputy minister of the ontario ministry of health and long-term care), which provides the most comprehensive provincial plan in canada, having undergone five iterations developed over a -year period. this plan details guidance to local planners and specific strategies for health sector sub-groups (critical care, pediatrics, laboratories, long-term care, persons with chronic diseases, mental health settings), first responders, faith groups, private sector organizations, and first nations communities. this presentation also included a list of concerns which modeling should address relating to acute care services (e.g., estimated hospital surge capacity for a given jurisdiction during a pandemic); local implementation (e.g., identification of the tipping point when primary care will not be able to meet the - hour standard of care); and antivirals (e.g., identifying the optimal use of drugs and distribution methods for treatment and prophylaxis to decelerate the spread of a pandemic). dr. joanne langley (co-chair, canadian pandemic vaccine working group) presented a detailed analysis of the potential benefits and uncertainties relating to the standard pillars of pandemic influenza contingency plans, covering antiviral drugs; healthcare delivery planning; vaccines; public health measures; and infection control practices. this included the importance of personal protective equipment such as the n mask in the healthcare setting, the need for regular and frequent hand washing, and a risk analysis of potential amantadine resistance. dr. langley also stressed the need for ''real time'' modeling to provide a rapid analysis of alternative tactical decisions following the onset of a pandemic. dr. mark walderhaug (associate director, us center for biologics evaluation and research, fda) discussed a stock-and-flow model used for simulating the impact of an influenza pandemic on the us blood supply. the model assumes that susceptibility to the pandemic virus will be universal; multiple waves of infection can occur and each wave adversely impacts infected communities for - weeks; and absenteeism may reach as high as % dur-ing the peak periods. model simulations for the entire us blood supply were presented, and the need for acquiring detailed data of inter-regional flow of blood was emphasized. these data are essential for projecting various scenarios, including run-out for hospitals despite adequate national supplies and time frames for elective surgery cancellations while the blood supply recovers, which highlight the significant challenges involved in supply distribution. dr. paul gully (senior advisor, world health organization) emphasized the fact that models are essential for guiding public health, but may also raise more questions for policymakers. he expressed growing concerns about being able to fulfill the requirements for pandemic containment that come from modeling studies: ''models lead to policy but have to confront political reality''. previous work suggests that a nascent influenza pandemic can be contained at the source if antiviral therapy for a sizable proportion of affected individuals ( - %) is accompanied by a rapid implementation of non-pharmaceutical measures (such as movement restriction) over a very short period of time (days to weeks). , on serious discussions from a political standpoint, dr. gully demonstrated the significant challenges involved in building the capacity for a timely response to meet the condition for averting a global pandemic. despite these challenges, he acknowledged that models are invaluable tools for making assumptions explicit and for best using limited data, highlighting key factors determining policy needs, and providing quantitative predictions. discussions of the day were then expanded to the implementation of various strategies from a transmission dynamic standpoint. in their capacity, what models offer should be taken along with other health and economic factors to guide sound public health policies. they are not meant to make decisions on managing public health crises, but rather provide recommendations to policymakers. however, for rapid decision making, one would need to consider the interface between simple, interactive, and relatively complex models that may encapsulate population demographics pertaining to the location of a pandemic outbreak. dr. tamblyn chaired the summary and discussion session of the workshop on day , and acknowledged the true interdisciplinary nature of the meeting, enriched discussions, very interesting and relevant presentations, with kudos for planning long health-breaks that allowed for interactions and flow of emerging ideas. she distinguished the meeting as the one that has met its objectives and provided an opportunity for effective communications between modelers and public health authorities on the subject of pandemic preparedness in canada. dr. ying-hen hsieh (china medical university, taiwan) offered his perspectives on the workshop with great potential for expanding collaboration with canadian colleagues in future work. the meeting highlighted important aspects of canadian public health that will be useful for creating an effective venue to communicate with public health in taiwan. dr. hsieh, as a prominent modeler in taiwan, shared his experience with sars (severe acute respiratory syndrome) and exemplified the opportunities missed by public health to engage modelers: ''by the time they called me in, it was weeks before the end of sars outbreaks''. in , there was a cabinet agreement to promote an influenza vaccine r&d program in taiwan, partly for the economic opportunities it offers; he was brought in after the decision was made with the hope that ''modelling results will be in line with government policy''. he depicted that in public health in taiwan, a highly challenging task has been to establish collaborative efforts, but the important lesson from this workshop is to understand the process of making decisions, identify its key parameters, and determine effective ways to communicate with policymakers. dr. benjamin ridenhour (us center for disease control) acknowledged that the workshop had been successful in bringing together the communities involved in pandemic preparedness, to share their various viewpoints and expertise in modeling and public health, in a very congenial and friendly environment. the us center for disease control has made substantial efforts to co-ordinate pandemic activities through synergism between public health officials and modelers, which has led to benefits for planning strategies in the united states. as modelers, we need to strengthen our ties to public health, and exploit our potential for developing models that can inform and optimize health policy decisions. this workshop has demonstrated that strong networking is required to adequately prepare for the pressure of real time crises, and cope with surging demands in a pandemic-related emergency. in closing the workshop, dr. seyed moghadas (institute for biodiagnostics, national research council canada) valued the time and efforts of participants and appreciated their contributions to the success of this event. key points inferred from presentations and discussions include: . in canada, the pandemic goals are to (i) minimize serious illness and overall deaths; and (ii) minimize social disruption. pandemic containment has not been a priority to date and may not be feasible. development of a pandemic vaccine may take up to months following pandemic detection. however, as novel influenza strains most often emerge in asia, strong surveillance leading to early detection there can increase our lead time for pandemic vaccine production. . immunization of children can result in significant changes in contact patterns and attack rates. age is a surrogate for individual behavior that influences pathogen transmission in the population; vaccine efficacy may also vary in different age groups. . antiviral therapy is the cornerstone of the pandemic response in canada until vaccine is available; however, implementation of the strategy is determined by pandemic planners at the provincial level. the meeting provided an opportunity for modelers to engage in detailed discussions about modeling strategies that can be employed for gaining new insight into disease processes at the population level and making findings of public health significance. while models serve to synthesize data and suggest optimal scenarios in public health, they can also promote dialogue between modelers and policymakers about alternatives, uncertainties, and assumptions that underlie critical decisions. the workshop revealed that pandemic planning requires involvement of communities across disciplines with firm commitment to the notion that research must ultimately influence policy. a history of influenza influenza: the mother of all pandemics avian influenza h n : is it a cause for concern? workshop on managing public health crises population-wide emergence of antiviral resistance during pandemic influenza antiviral resistance during pandemic influenza: implications for stockpiling and drug use emergence of drug-resistance: implications for antiviral control of pandemic influenza a delay differential model for pandemic influenza with antiviral treatment simple models for containment of a pandemic the impact of prophylaxis of healthcare workers on influenza pandemic burden management of drug-resistance in the population: influenza as a case study strategies for containing an emerging influenza pandemic in southeast asia containing pandemic influenza at the source the workshop was funded by the mathematics of information technology and complex systems (mitacs), public health agency of canada (phac), international centre for infectious diseases (icid), national research council canada's institute for biodiagnostics (nrc-ibd), and the university of winnipeg. we wish to express our appreciation to all the participants for their significant contribution to the workshop. the authors, as the organizing committee, would like to thank margaret montague, sarah dietrich, and justyna swistak for assistance with meeting logistics. the authors declare that they have no competing interests. sm, np, jw, and py proposed and organized the workshop. sm summarized and drafted the preliminary version of this manuscript based on presentations and round-table discussions. all the authors have contributed to this manuscript, and approved its final version. key: cord- - rbxdimf authors: narushima, miya; kawabata, makie title: “fiercely independent”: experiences of aging in the right place of older women living alone with physical limitations date: - - journal: j aging stud doi: . /j.jaging. . sha: doc_id: cord_uid: rbxdimf this study explores the experience of aging among older canadian women with physical limitations who live by themselves. while aging in place has been a policy priority in rapidly greying canada, a lack of complementary public supports poses challenges for many older adults and their family members. employing a qualitative methodology, and drawing from the notion of aging in the right place, we collected personal narratives of women (aged to ) in two geographic areas in ontario, including residents of regular houses, apartments, condominiums, assisted living and community housing for seniors. through thematic analysis, we identified four overarching themes: ) striving to continue on “at home”, ) living as a “strong independent woman”, ) the help needed to support their “independence”, and ) social activities to maintain self. our findings illustrate how, despite their mobility limitations, older women can change their residential environment and their behavior by deploying the coping strategies and resources they have developed over time. however, we also found that older women are largely silent about their needs, and that experiences varied depending on life histories, health conditions, and the availability of supports in their wider environment (home care, alternative housing options, accessible transportation, opportunities for social and physical activities). we hope these findings will incite further studies and discussion to help make aging in the right place a real choice for anyone who wishes to do so. population aging in canada will keep accelerating over the next decade. the ratio of "senior citizens" (aged years and older) is expected to grow from . % in to . % by (statistics canada, ) . "old-old" canadians in their late s and above are among the fastest growing age group (hudon & milan, ) . like many countries, canada's policy response to this demographic change is the promotion of aging in place, generally understood as being able to remain in familiar homes or communities for as long as possible. the premise is to promote independent living in later life, while shifting care for the older adults from institutions to home and community (dalmer, ; lehning, nicklett, davitt, & wiseman, ) ; a shift long criticized by social gerontologists for being part of the devolution of aging and long-term care policies. policy makers have largely supported this strategy as a cost-effective long-term care alternative. more than anyone, however, it is older adults themselves who are in favor of the idea. aging in place has become common in canada. comparing the and censuses, the ratio of people aged and older living in "collective dwellings" (e.g., assisted living, supportive housing, retirement residences, seniors' apartments, continuum care facilities, and nursing homes) has dropped from . % to . % (garner, tanuseputro, manuel, & sanmartin, ; statistics canada, ) . given the increasing numbers of older canadians, one would expect this number to grow, not decline. the census found only . % of seniors had moved in the past year, a much lower rate than the general population ( . %). this should not, however, be assumed to reflect older adults' satisfaction with their housing. in fact, almost a quarter of seniors reported their housing as "below standard" in terms of either affordability, adequacy, or suitability (federal/provincial/territorial ministers responsible for seniors, ). although health status among older adults is heterogeneous, chronic diseases and physical limitations increase with advancing age. more than three-quarters of canadians aged and older reported having at least one chronic condition, and one quarter reported three or more. one out of four of those aged and over reported a need for support in instrumental activities of daily living (iadl), while one in ten needed support in activities of daily living (adl). like the rest of the world, older women are disproportionately represented in these groups (canadian institute for health information, ) . older women in general are more likely to face challenges since women live longer and are more likely spend their later years with mobility problems and pain (bushnik, tjepkema, & martel, ) and nearly twice as likely to live alone than their male counterparts. the census found . % of seniors lived alone, . % of who were women (tang, galbraith, & truong, ) . in addition, women living alone comprised . % of seniors with "core housing needs" (federal/ provincial/territorial ministers responsible for seniors, ). given these demographic, health, and socio-economic trends, more research on the experience of aging in place among older women, especially those living alone with physical limitations, is needed (gonyea & melekis, ) . from "aging in place" to "aging in the right place" the conceptual development of aging in place began when american environmental gerontologists (lawton & nahemow, ) introduced the "ecological model of aging" to examine the relationship between people and their environments. in this model, an older person's functioning is determined by the "fit" between "personal competences" (e.g., physical, psychological, and social functions) and "environmental characteristics" (e.g., the immediate and wider environments). as changes happen in either or both, older adults can try to adapt their physical and social environments to find a comfort zone by deploying their resources (greenfield, ; lawton & nahemow, ; peace, holland, & kellaher, ; stafford, ) . this theoretical framework helps us to understand aging in place as a dynamic process of personenvironment interactions. wahl, iwarsson, and oswald, and their collogues in germany and sweden have extended this framework to, "maintaining the highest autonomy, well-being, and preservation of one's self and identity as possible, even in the face of severe competence loss" (wahl, iwarsson, & oswald, , p. ). this process is influenced by two concepts: "belonging" and "agency". belonging involves an older person's sense of connection with others and the environment and preserved identities over time. agency refers to sufficient control of their environment to maintain autonomy. belonging grows in importance as people get older, especially when they develop functional impairments (oswald, wahl, schilling, & iwarsson, ; wahl et al., ) . this model reminds us of the benefits of taking a life-course perspective to understand the experience of aging in place. in the same vein, golant ( golant ( , , an american environmental gerontologist, has put forward the notion of aging in the right place. pointing to the unequal capabilities and resources among older adults, golant ( golant ( , criticizes how aging in place has been promoted as a cultural imperative in america, emphasizing an individual's self-reliance in sustaining a healthy active lifestyle. even when older adults have chronic health problems, disabilities, or cognitive deficits, he argues, if they are offered "enabling residential and care opportunities that strengthen their coping skills to achieve their evolving needs and goals", they can still "age successfully" (golant, , p. ). golant thus advocates shifting public discourse, and older adults' thinking, from aging in place to aging in the right place, which includes expanding the various alternative housing options being consideredsuch as group housing, active adult communities, senior apartments, assisted living residences, continuum care, and the like. in this model, regardless of residential type, older adults can achieve "residential normalcy" where they feel comfortable, competent, and in control. older adults may use various coping strategies when their residential normalcy becomes incongruent. moving to alternative housing such as assisted living, active adult communities, and nursing homes can be seen as adaptive responses to aging. golant ( ) also noted that enriched coping strategies are products of the resilience of both older persons and their environments. despite this theoretical development, the public discourse surrounding aging in place in canada seems to have stagnated. for example, in a public guide issued by the federal government, "aging in place" is defined as "having access to services and the health and social supports and services you need to live safely and independently in your home or your community for as long as you wish and are able" (federal/provincial/territorial ministers responsible for seniors, , p. ). the guide also notes that an individual can achieve this goal through early planning in such areas as home, community, transportation, care and support services, social connection, healthy lifestyle, finance, and information. as dalmer ( ) has noted, such neoliberal rhetoric frames aging in place as "a matter of choice" that can be responsibly managed by individuals. given the lack of affordable housing alternatives and the unmet need for long-term home care services for many older canadians, however, this so-called choice is often illusory. as mentioned, according to the census, only . % of canadians aged years and older lived in "collective dwellings," including nursing homes (the most common) and other alternative senior residences such as assisted living and retirement homes. this suggests that moving to alternative housing, as advocated by aging in the right place, is still uncommon in canada. this is partly due to a lack of affordable senior residences. in ontario, the average monthly rent for a standard space for a resident without high-level care needs was $ canadian in (canada mortgage and housing corporation, ). given seniors' average annual income -$ , for men and $ , for women (statistics canada, ) -alternative housing is unaffordable for most older canadians, especially women. as more and more older adults age in place, their homes and communities increasingly become locations for health and social care services (hereafter "home care"). since long-term home care is not universally insured under the canada health act, older adults who don't qualify need to resort to community agencies that often require a co-payment or privately hire help (armstrong, zhu, hirdes, & stolee, ; gilmour, ; government of ontario, ; johnson et al., ; lee, barken, & gonzales, ) . according to the / canadian community health survey, over one-third ( . %) of people with home care needs did not have their needs met, especially among those with home support services for maintenance of daily living (gilmour, ) . the current policy of aging in place needs more complementary public supports to reduce the challenges facing many older adults and their families. it is within this context that we explore the experiences of aging in place among older canadian women with physical limitations who live alone. our research questions include: ) what is it like to live at "home" alone for older women with physical limitations? ) what support do they receive and how? and ) what are the enabling and disabling factors for their independent living? this study employed a qualitative research methodology (merriam & tisdell, ) , more specifically, combining personal narrative analysis (maynes, pierce, & laslett, ) with a narrative gerontology approach (de medeiros, ) . a qualitative approach lets us explore inductively how older women construct and make sense of their experience of aging in place (merriam & tisdell, ) , connecting their individual experience and life trajectories with broader cultural and social forces (maynes et al., ) . this reinforces what narrative gerontology advocates: listening to older people's lives as stories to understand their social world -personal, interpersonal, structural and cultural (de medeiros, ) . this study is part of a larger study, and ethics clearances were obtained from the research ethics boards of both researchers' universities. we recruited participants in two areas (a large metropolitan area and a medium sized city) in southern ontario. the criteria for inclusion were: women years and older, who lived by themselves at home with chronic physical conditions, and who were using or had used home care services. following the notion of aging in the right place, we included both regular house, condominium, and apartment, as well as alternative housing such as assisted living and community housing for seniors. we created a flyer, noting we were "looking for participants in a research study to learn their experience of and opinions about living with chronic physical conditions." approximately flyers were either posted in their residences or directly delivered to potential participants through personal support workers (psws) in collaboration with five different community organizations. recruitment was harder than we had expected. since only two participants voluntarily called back, we asked our participants, colleagues, and friends to deliver the flyer to whoever might meet the criteria. eventually, we had interviewees. although every interview will be used in our larger study, participants met all the criteria for this study. the participants ranged between and (the average age was ), and lived in various residential types in varying states of health. all have been given pseudonyms (see participants' profiles in table ). the data collection was conducted in the spring and summer of . the first author and a student research assistant conducted all interviews together. eleven interviews were conducted in participants' homes and one was in a public space. visiting their residences let us observe their daily living and neighborhood environments. each interview lasted from to min. we began by asking participants to tell us their life histories, followed by questions about their daily and weekly routines, current physical condition, strategies and challenges for managing their independent living, the support they receive, and their opinions about aging in place in general. since one chinese immigrant participant (hong, ) had difficulty speaking english, her daughter (lin, ) joined the interview as a translator, also providing some of her own insights as a family carer. following each interview, we provided a gift card of $ with a thank you note. then the two interviewers debriefed each other, recording what they had noticed in the field notes. all interviews were audio recorded, transcribed verbatim, and sent to participants to check accuracy and to modify if requested.the twelve transcripts comprised pages in total. following the steps of thematic analysis (merriam & tisdell, ) , we started open coding by reading the first participant's data set (transcript and field notes), then underlined any segments that might be meaningful and attached labels (i.e., code and themes). next, we moved to axial coding by sorting these codes and themes into more comprehensive groups (i.e., categories). then, we created a matrix to display the categories, themes, and supporting quotations for the first participant transcript. we went through the same procedures for the second data set, and compared the two matrices to create a master list of crosscase categories and themes. this master list was used as a basis for analyzing the other participants' data. comparing all participants' matrices, we generated four overarching themes as findings. to increase trustworthiness, our design included data triangulation, member checking of interview transcripts, a reflexive journal, and peer debriefing with research team members (creswell, ; merriam & tisdell, ) . we found the following four overarching themes: ) striving to continue on "at home", ) living as a "strong independent woman", ) the help needed to support their "independence", and ) social activities to sustain self. these overarching themes contain several subthemes. the first theme involves our participants' efforts to live in their homes comfortably and safely. as shown in table , many participants had lived in the same residence for decades, while a quarter had moved in the past four years due to changes in their mobility or marital status. in any event, all participants seemed comfortable in their residence, which they called "home". the first thing that we noticed was that these homes preserve their personal histories and identities. their well-kept living rooms were stuffed with vintage furniture, family photos, art, crafts, books, instruments, souvenirs, plants, pets, etc. participants four participants mentioned they might have to move in the future when they could no longer take care of themselves. yet their narratives suggested the difficulty of moving to alternative housing. certainly, i couldn't afford one of these fancy private assisted retirement homes. i've been to one of them to visit a friend of mine. she pays about $ a month for one room. i cannot afford that on my pension (dorothy, ). my mom [hong, ] is on the waiting list. well, it's been years already since she registered. it's one of the chinese long-term care homes. […] oh, yes, it's common. they say it normally takes over years! (lin, ). these comments underline the lack of affordable alternative housing many older adults face. during our visit, we were also impressed by their efforts to control their home environment to live safely. all participants had at least one chronic health condition. however, their biggest challenges were mobility issues -especially difficulty in walking, falls, and the fear of falling. despite their use of mobility aids (e.g., cane, walker, wheelchair), many participants talked about their occasional falls. all had made some home adaptations by installing safety features (e.g., staircase railing, grab bar, special chair and non-slip mat for bathrooms). they were also using assistive devices. ten of participants carried an emergency alert pendant or had installed an alert system with pull cord for their bathrooms. this was a lifesaver for some. valerie, , who has had multiple falls, related: i've used it twice. one time, they were able to get in through the kitchen window. the other time, i was doing christmas decorations when my daughter phoned, and when i turned, i fell. my daughter phoned a friend's husband to come, but before he arrived, i phoned the emergency alert and asked them if there was a particular way he should pick me up. they immediately sent somebody and got me on the chair. valerie's story suggested how unexpectedly and easily falls can happen at home, and how the assistive device helps in those instances. many participants were also using other technologies to help increase their sense of control and autonomy. half used a tablet or a computer for frequent communication with their families, reading news, and searching information. a participant with vision problems showed us a sight enhancement reading machine. one had a mobile chair lift for the staircase. the most advanced case of impairment was renelsa, who at spent most of her day in bed due to her frailty, but she could still live alone in her one-bedroom apartment in community housing. her building had a security camera to screen visitors, and her apartment door could be opened with a remote control beside her bed. we had no idea about how limited her mobility was until she greeted us in her bedroom. participants in assisted living appreciated similar safety features in their units, and the railings in the hallways and elevators. in addition, mei lien, , explained how her residence gave her "peace of mind": "last year, in the middle of night, i had to call somebody, and they [staff] came up. i don't have family in canada, so at least you know somebody is there if you call". margaret, , who was recently widowed, reflected on her decision to move from her house to a seniorfriendly condo: the very last thing i wanted to do was move into this building… do i want to live here? no! but should i live here? absolutely! … if you think your health is going to be the same tomorrow as it is today, you are wrong. we all progress to some extent from day to day … i did not know the presence of a garbage disposal in the hallway was so convenient. so in the big picture, it was a very wise thing. in this way, each participant was negotiating their own physical and social conditions, and actively managing to control their home environment as best they could. the second theme involves our participants' distinctive shared character. although their life histories and current conditions varied, we were struck by their positive, spirited, and persevering attitudes. contrary to our expectation, participants rarely brought up their needs. we thus had to ask if there was anything to complain about. dorothy, , who had just recovered from a fall on ice, laughed and said: well, i think, oh, god, i ache, i ache, i ache, but i shouldn't complain, especially when i see other people… at least, i can still walk around, i can still look after myself, and do my own thing in my own house. so you know, i would say i'm fortunate. […] well, you have to make the choices yourself, don't you? you either sit there and wither away, or you get involved and do something. luisa, , mentioned that she had learned it from her role model: i am a contented person. i am not always looking for what i don't have. i learned that from my mother. she independently lived in her own apartment until , climbed stairs to the fourth floor, and always baked and cooked for visitors. you know, she never complained about her situation. she was fiercely independent. as these comments imply, many of our participants held to a similar principle in their lives. in fact, participants commonly described themselves as brave, independent women. their life stories were full of personal and historical events: the great depression, world war ii, immigration, marriage, divorce, separation, accident, the deaths of spouses, children, and friends, and their own health problems. every participant had an occupation at some point, and many repeatedly used the word "independent" to describe themselves. as hannah, , who had immigrated from germany with her husband after world war ii, put it: i was always this independent (laughter). i was married, and i was independent. i became a widow at the age of , and raised three children. when my husband got sick, i had a job [a lab aid in a hospital] and i took a year of absence to take care of him at home. but i needed the money, so i cleaned houses, took in other people's clothes. i wanted my children to have a better education. i never went on welfare, i worked and all my children went to university. if you came from a different country, you help yourself, you don't rely too much on the country. it's my job to look after the family. a former university professor, margaret, who was mourning her husband's death and managing her own health problems, described her efforts to be a strong role model for others at years old: i am very strong-willed person. i was always a determined youngster. even as a girl, i was an independent child (laughter). even now, i just have to get really strong to be a good role model for women. i always try to be, because who is going to be the one to make me look and feel strong? me! you will only be strong if you work to be that way. […] i just live today, that's exactly how i think. i believe you stay the strongest person you can be each day you are alive. as these comments suggested, our participants' self-identity as strong independent women developed through various life experiences, sustains them in the face of the challenges of later life. nevertheless, we also learned that participants' "independent" lifestyles were supported by many other people in a mix of formal and informal care. due to our recruitment criteria, all participants had had an experience of publicly funded "formal" home care. however, at the time of our interview, only four were eligible for long-term home care, receiving min to . h a day. for the other eight participants, publicly funded home care ended two to three months after a hospitalization. once this post-acute care was over, they were back on their own. the four participants who could afford it hired a paid housekeeper a few hours a week. two more, thanks to their retirement benefits, continued regular physiotherapist visits at home or attended weekly exercise classes through community agencies. compared to those living in regular houses or apartments, participants in assisted living had an advantage in the availability of and accessibility to long-term home support services right in their own buildings. however, some expressed hesitation to use additional support services due to their worry about the additional cost: "if you need the extra service, you have to pay. it depends if you or your family can afford it. so you just hope and pray you won't need more services" (mei lien, ). like mei lien, many participants saw cost as a barrier to longer-term formal home care. as mentioned before, however, none explicitly advocated a more affordable publicly supported long-term home care system. in contrast, participants talked much more openly about informal care and support -their reliance on their family members, friends, and neighbors for regular help for transportation and household chores. ten out of participants, regardless of residential type, had at least one close family member nearby. while most participants still managed to clean their homes, do laundry, and cook simple meals, carrying groceries and to taking public transportation were getting harder. family members were the primary source for a wide range of household chores. luisa, , described the support from her son's family: it helps me a lot that my son and daughter-in-law live here [in the same city]. i've been calling them to do things. he installed the railing on the basement stairs, because i've had three falls since last december. it just makes me feel more secure. and my daughter-inlaw takes me to a rheumatologist in another city, because i don't drive highways anymore. for participants whose family members lived far away, friends and neighbors were crucial sources of social support: "i have a good friend who takes me grocery shopping and to doctors' appointments" (hannah, ); "when i had the cancer, i had radiation times in december. every morning i told my friends, i cannot do it one more day, but i did thanks to them" (elizabeth, ). as these comments suggest, most participants were grateful for the informal support and care provided by family members, friends and neighbors. clearly, these provided crucial instrumental and emotional support to all participants. overall, participants' narratives suggested an imbalance between formal and informal home care and support. even for participants receiving publicly funded long-term home care, that was not enough to live alone at home with disability and frailty, due to the limited time and tasks performed by the personal support workers (psws). for example, although psws help renelsa three times a day for a total of . h, it is her brother who brings over meals twice a week to store in her freezer. for hong ( ), who speaks limited english, communication with the psw is challenging. as her daughter said, "the agency working in this building has no psw who speaks chinese. for showering, communication is very important. that's why i need to translate. otherwise, i could be preparing breakfast during that time" (lin, ). participants in assisted living also reported regular informal support from their family members. katharine, , who no longer cooks for herself, mentioned: "i can have dinner at the dining hall downstairs, but my niece and nephew do weekly shopping for my breakfast and lunch." compared with participants living in houses, however, those in assisted living did not have to rely family and friends for daily personal care. overall, regardless of residential type, our participants' narratives suggest their independent life was unattainable without support from many others. the fourth theme involves the benefits of opportunities for continued social participation. despite noticeable physical discomfort, most participants kept trying to maintain the activities and the relationships that they valued, which were clearly an important part of their social identity. three participants living in houses were still earning a small income. many participants also kept volunteering in their communities. in particular, participants in assisted living had many opportunities within their own buildings. for example, tami, , a master of d origami, taught it to her fellow residents while volunteering at a nursing home once a week. as she explained: in , when i got this problem [a rare and progressive degenerative disease], i started volunteering. the volunteer work makes me happy. sometimes, it's just sitting and talking to them [the residents in a nursing home]. but if i talk to them, they smile. they are losing their smile all day, so i want to make them smile. smile … like cheeks up. their smiles make me happy. like tami, many participants mentioned their joy at making themselves useful to others, despite, or possibly because of, their own mobility and health challenges. tami also appreciated the wheel-trans system that made her volunteering possible. most participants also stayed active in the groups to which they belong. elizabeth, , a former entrepreneur, described her monthly routine: "i go to church on sundays, probus club and torch club once a month…i also go to all sorts of classes". although elizabeth had no family members in canada, her long-term involvement in her local community had helped her develop a circle of good friends who she could rely on. renelsa, , a former nurse and devoted christian once nicknamed "the sister in the operating room", could no longer attend church, so three fellow congregants visited her twice a month: "on sunday, we have church right here in my apartment! i really look forward to when they come". many residents in assisted living had an even busier schedule of social, cultural, and physical activities. emily, , showed us her monthly calendar on which she had circled her activities. on some weekdays, her schedule is packed from : am to pm! we also noticed a notable difference in the accessibility for exercise between those living in their own house and apartment and those in assisted living. most participants in assisted living continued to attend using their canes and walkers, while those living in their own houses stopped going to exercise classes in their communities due to a lack of transportation and coverage for long-term physiotherapy. participants' narratives make it clear that these opportunities for civic engagement and social and physical activities give them a routine to leave their "homes" to socialize, and enable them to keep playing a social role in their communities. moreover, older women mutually support each other in various ways by giving rides, bringing soups, etc. they not only receive support from others, they kept providing support to each other. overall, our study's findings illustrate how older women living alone with physical limitations can, with support from others, manage to maintain their independence in places where they feel "at home". all were achieving "residential normalcy" (golant, ) in "homes" that were "uniquely their individual domain" (kontos, , p. ) , where they could feel comfort, autonomy, security, self-identity, and continuity of self (golant, ; stones & gullifer, ; wiles, leibing, guberman, reeve, & allen, a) . their familiar belongings-what coleman and wiles's ( ) termed their "objects of meaning"-symbolically connected their past, present, and perhaps future selves. this also overlaps with the concept of "belonging". as wahl et al. ( ) noted, familiarity, routines, and emotional attachment developed over time help preserve identity and enable aging well in the right place. despite their physical discomfort, all were "fiercely independent", a phrase used by two participants (elizabeth, ; louisa, ) . as prescribed by aging in place policy, they strove to alter their home environment to live as independently and safely as possible, deploying the strategies and resources available and affordable in their contexts. they practiced problem-focused "assimilative coping", but many also used emotion-focused "accommodative coping" by accepting and being content with what they have (golant, , p. ) . these conscious behaviors exhibit our participants' "competences" (lawton & nahemow, ) and "agency" (wahl et al., ) , another enabler in person-environment interactions. one unexpected finding is their emphasis on being strong-willed "independent women". this self-image, developed over their life course, provides a psychological resource to cope with challenges in later life. clearly, they are "resilient" people (golant, , p. ) who are motivated and confident, with the physical capabilities, mental stamina, and flexibility to find appropriate solutions to the environmental obstacles they face. yet, based on their life stories, we suspect that their resilience is not an innate personality trait so much as an ability to "adapt well" learned and developed over time in relation to others and to their environments ( van kessel, ; wiles, wild, kerse, & allen, b) . we found this learning process to be resilient operating even among very old and frail participants. this supports peace et al.'s ( ) finding that, while frailty and decline of personal competence are related, they are not synonymous. older adults can confront challenges by bringing their life experiences to their person-environmental interactions. despite their limited mobility, many stayed involved in social and volunteer activities, using their skills and sustaining and developing relationships. importantly, our participants did not passively receive care. they also actively provided it to others. this finding overlaps with the concepts of "vitality and agency in frailty" for preserving selfidentity and continued self-development in later life (bjornsdottir, ; latimer, ) . it also highlights the crucial role of opportunities for social participation, meaningful and reciprocal contribution, and relationship building to aging in place. a recent increase in innovative community-based participatory approaches to aging in place, such as the naturally occurred retirement community (norc), for example, includes this reciprocal exchange of support and care by creating resourceful community environments (greenfield, scharlach, lehning, & davitt, ; sixsmith et al., ) . nonetheless, our findings also suggest some disabling factors. the constant "balancing act" (golant, , p. ) person-environment interactions in later life demands was difficult for some, especially for those with severe mobility limitations, multiple comorbidities, few close family members and friends, and low income. also, the quality of our participants' aging in place was influenced by local environments, including the availability of affordable home care services, physical activities, and safe and reliable public transportation (e.g., wheel-trans). most notably, our participants were facing the challenges of pain and balance: falling posed a real threat, as found in previous studies (e.g., bushnik et al., ) . nevertheless, for many participants -especially those living in houses and apartments without transportation and private home care insurance -regular exercise classes, physiotherapy, and fall prevention programs were neither affordable nor accessible. given the proven benefits of interventions for falls and fear of falling (e.g., whipple, hamel, & talley, ) , it is essential to develop strategies to make those programs more available. policies in aging, health, and social services should support greater collaboration between community-based formal and informal care (ryser & halseth, ) . in the current discourse surrounding aging in place, independent living tends to refer to an autonomous lifestyle achieved through the personal efforts of individuals. in reality, however, as our findings show, aging in place for older women with physical limitations inevitably requires a view of "independent living" which promotes reciprocity and interdependence between individuals and their communities, including both formal and informal supports. in other words, as golant ( , p. ) advocated, we need to adopt an "it takes a village" perspective. nevertheless, consistent with previous studies (johnson et al., ; kadowaki, wister, & chappell, ) , publicly supported long-term home care -especially for maintenance and prevention purposes, such as home support services and physiotherapy -was still unavailable for many of our participants. our study adds further contextual evidence to canada's need for the publicly supported long-term home care system many have advocated over the past decade (canadian home care association, ; gilmour, ; kadowaki et al., ; special senate committee on aging, ; turcotte, ) . overall, the findings of our study support the notion of aging in the right place proposed by golant ( ) . they suggest that, despite their tireless individual efforts to be independent in a place of their own, older women can reach a point where the changing balance between personal competence and environmental pressure requires a new strategy to maintain self-identity, what peace et al. ( ) term "option recognition" (p. ). participants who could afford it or were eligible for public subsidy often moved into assisted living to regain control. given the lack of a universal long-term home care system in canada, moving to assisted living helps reduce the heavy burden placed on some older adults and their family members (ryser & halseth, ) . at the same time, our participants' narratives reaffirm that alternative senior residences -such as active adult communities, assisted living, and continuum care retirement communities -are not a readily available or affordable option for many middle-income older canadians (dalmer, ) . finally, the most unexpected finding in our study is the collective silence of older women, the so-called "shadow story" (de medeiros & rubinstein, ) , about their unmet need for more formal and structural support reported in previous studies (e.g., canadian home care association, ; gilmour, ; turcotte, ) . this may be partly because the interviewers were "others" (dorothy, ), making it hard for participants to reveal their true feelings, and partly because respondents wanted to present themselves as role models for their interviewers, who were of their daughter's and granddaughter's generation. complaining and demanding that their needs be met contradicted their core principle of "being independent". finally, adopting the neoliberal rhetoric of being self-reliant and autonomous model citizens, older women may see their growing care need for daily activities as an individual matter that they should take care of themselves, rather than a structural issue connected to the long struggle over public policy. further study is required to clarify these points and investigate how a "sociological imagination," as coined by c. wright mills ( ) , might be used to collectively empower older women and inform public policies alike. this study has several limitations. due to our small number of selfselected participants who are resilient and have positive outlooks, our findings reflect more the experiences of older women who are successfully aging in the right place, despite their physical conditions. the voices of older adults who live with cognitive impairment, depression, and social isolation, or whose lack of resources make them more vulnerable, are missing. furthermore, the data was collected before the covid- pandemic, which has likely altered older women's perceptions and experiences. all these areas are important, and deserve further study. despite these limitations, our research provides a valuable window into experiences of aging in the right place of an understudied groupolder women living on their own with physical challenges in canada. no matter how fiercely and successfully independent older women try to be, framing aging in place as a matter of individual efforts alone is misguided. it is crucial that more structural supports and improved community-based care that is informed by recipients themselves become an integrated part of public policy. the shifting of public perceptions from aging in place to aging in the right place has the potential to foster subjectively-defined aging well among older adults with different needs and resources. we hope these findings will encourage further studies and the political will to make aging in the right place a real option for older adults in canada and far beyond. this study was funded by a grant from the japan society for the promotion of science (# k ). none. rehabilitation therapies for older clients of the ontario home care system: regional variation and client-level predictors of service provision holding on to life': an ethnographic study of living well at home in old age health reports. health-adjusted life ex seniors' housing report -ontario better home care in canada: a national action plan health care in canada, : a focus on seniors and aging being with objects of meaning: cherished possessions and opportunities to maintain aging in place qualitative inquiry and research design: choosing among five approaches a logic of choice: problematizing the documentary reality of canadian aging in place policies narrative gerontology in research and practice shadow stories" in oral interviews: narrative care through careful listening thinking about your future? plan now to age in place -a checklist report on housing needs of seniors transitions to longterm and residential care among older canadians unmet home care needs in canada commentary: irrational exuberance for the aging in place of vulnerable low-income older homeowners the quest for residential normalcy by older adults: relocation but one pathway women's housing challenges in later life: the importance of a gender lens using ecological frameworks to advance a field of research, practice, and policy on aging-in-place initiatives a conceptual framework for examining the promise of the norc program and village models to promote aging in place senior women. women in canada: a gender-based statistical report. catalogue no. - -x. ottawa: statistics canada no place like home: a systematic review of home care for older adults in canada influence of home care on life satisfaction, loneliness, and perceived life stress resisting institutionalization: constructing old age and negotiating home home care and frail older people: relational extension and the art of dwelling ecology and the aging process utilization of formal and informal home care: how do older canadians' experiences vary by care arrangements social work and aging in place: a scoping review of the literature telling stories: the use of personal narratives in the social sciences and history qualitative research: a guide to design and implementation housing-related control beliefs and independence in activities of daily living in very old age option recognition' in later life: variations in ageing in place informal support networks of low-income senior women living alone: evidence from fort st ageing well in the right place: partnership working with older people. working with older people canada's aging population: seizing the opportunity aging and place: clarifying the discourse census in brief no. : living arrangements of seniors statistics canada catalogue no. - -x . ottawa, on: statistics canada the daily. canada's population estimates: age and sex income of individuals by age group, sex and income source, canada, provinces and selected census metropolitan areas at home it"s just so much easier to be yourself': older adults' perceptions of ageing in place living alone in canada. insights on canadian society canadians with unmet homecare needs the ability of older people to overcome adversity: a review of the resilience concept aging well and the environment: toward an integrative model and research agenda for the future fear of falling among community-dwelling older adults: a scoping review to identify effective evidence-based interventions the meaning of "aging in place" to older people resilience from the point of view of older people the sociological imagination we would like to send our heartfelt thanks to all participants in this study for generously sharing their life experiences and insights. our appreciation also goes to the organizations and their staff members, our colleagues and friends, who assisted in our recruitment, and ms. jessica wong and ms. ramesha ali for their assistance in data collection. we extend our acknowledgement to dr. beard and two anonymous reviewers for their encouraging and constructive feedback. key: cord- -r lv zzx authors: st. john, ronald k.; king, arlene; de jong, dick; bodie-collins, margaret; squires, susan g.; tam, theresa ws title: border screening for sars date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: r lv zzx with the rapid international spread of severe acute respiratory syndrome (sars) from march through may , canada introduced various measures to screen airplane passengers at selected airports for symptoms and signs of sars. the world health organization requested that all affected areas screen departing passengers for sars symptoms. in spite of intensive screening, no sars cases were detected. sars has an extremely low prevalence, and the positive predictive value of screening is essentially zero. canadian screening results raise questions about the effectiveness of available screening measures for sars at international borders. t he first cases of severe acute respiratory syndrome (sars) in canada were recognized almost simultaneously in vancouver and toronto. in toronto, the index case was diagnosed on march , , when a cluster of sars cases was identified and traced back to a traveler from hong kong, who arrived in canada on february , ( ) . two epidemic waves of sars occurred in toronto ( ) , which resulted in a national total of probable cases with deaths. in the period that followed the initial reports of this new syndrome from hong kong and vietnam, the disease spread rapidly to other countries by international airline travelers. on march , , the world health organization (who) issued a global health alert ( ) in response to the clusters of sars in the hong kong special administrative region, china, vietnam (hanoi city), and singapore. who recommended increased national and international vigilance to recognize and report suspected cases of sars. subsequently, on march , , who issued the first of several international travel advisories that identified major locations where sars transmission was substantial and ongoing and advised international travelers about travel to affected areas. on march , , who recommended that affected areas begin screening departing airline passengers for symptoms suggestive of sars. health canada monitored the spread of this new syndrome through the who-health canada global public health intelligence network and regular communications with other international and canadian provincial and territorial public health agencies. as soon as the rapid, international spread of sars became evident and after sars was imported into canada, health canada undertook a variety of measures designed to limit importation and exportation of disease and the spread of the disease within canada. we describe the measures taken to mitigate the spread of sars and provide data on the effectiveness of these measures. health canada used a graduated, phased response to additional imported sars cases. the response consisted of an information phase (march -may , ), a screening phase (may -july , ), and a special measures phase (march -july , ). to mitigate the risk of importing sars cases from other internationally affected areas, health canada distributed passenger health alert notices (hans) for incoming passengers from affected areas in southeast asia on march , . on arrival, posters directed passengers to pick up health information about symptoms and signs of sars and advised them to consult a physician if a sars-like illness developed after their arrival in canada. this information was printed in several languages on conspicuous, yellow, ½" x " paper (referred to as "yellow cards") and contained key telephone numbers. the initial posters and yellow hans were placed at arrival sites in the vancouver international airport and toronto's pearson international airport. they were quickly made available in other airports that received international passengers who might have traveled from the far east. hans were provided to inbound passengers at land border crossings between the united states and canada. no record was kept of how many passengers picked up hans. with the advent of sars transmission in toronto, health canada implemented similar hans in a different color (cherry) to mitigate the risk of exporting sars cases. the cherry-colored hans were distributed to persons departing for international destinations from toronto's pearson international airport. passengers with symptoms or signs of sars were asked to self-defer their travel. in these instances, health canada requested airlines to waive their policies on nonrefundable tickets, and while many did so, the refund and rescheduling policies and conditions were not uniform. because of the continuing outbreak in toronto, domestic spread in other affected countries in southeast asia, and international spread to other countries, health canada intensified its initial response by instituting both inbound and outbound passenger screening to identify persons with symptoms or signs compatible with sars. all passengers were now required to obtain, read, and respond to questions on yellow or cherry hans. three questions were added to both hans: do you have a fever? do you have one or more of the following symptoms: cough, shortness of breath, difficulty breathing? have you been in contact with a sars-affected person in the last days? all passengers were required to circle "yes" or "no" responses. their responses were verified either by customs officials (for inbound passengers) or by airline check-in agents (for departing passengers from toronto pearson airport). quality control checks (random sampling and spot checks of prescribed procedures) were instituted to ensure compliance by those responsible for verifying passenger responses. for example, during a -week period, % of departing passengers received a cherry card at check in, and % were questioned about their responses by the check-in ticket agent. secondary screening procedures were established for all passengers who answered yes to any of the questions. it was mandatory for any such passenger to be referred to a screening nurse who administered a standard in-depth questionnaire and protocol. the secondary screening protocol included reasons for assessment, symptoms present at time of assessment, oral temperature, and defined criteria for disposition. on the basis of the responses elicited in the protocol, a passenger was released or referred to a predetermined hospital for an in-depth medical evaluation. in parallel to these measures, health canada initiated a pilot study on may , , on the use of infrared thermal scanning machines to detect temperatures > °c in selected international arriving and departing passengers at vancouver's international and toronto's pearson international airports. thermal scanning complemented other measures in the overall screening process by helping to triage the large volume of passengers who transit airports. any passenger with an elevated temperature reading was referred to the screening nurse for confirmation, completion of the screening protocol, and referral to hospital, if necessary. with previous documentation of transmission of tuberculosis on long flights ( , ) , health canada initiated passenger contact tracing to identify any secondary transmission associated with air travel. health canada's protocols for airplane passenger contact tracing evolved throughout the sars outbreak and were updated as new information became available. from march to march , , contact tracing of passengers included followup of passengers seated in the same row, rows in front, and rows behind someone with a probable case who was symptomatic while in flight. as of march , airplane passenger contact tracing was expanded to include persons with suspected cases who were symptomatic while in flight. as of march , contact tracing was expanded again to include all passengers on a given flight with a probable or suspected case who were symptomatic while in flight ( ) . because of the lack of internationally accepted standards for developing and retaining passenger manifests, health canada personnel encountered excessive delays in obtaining the manifests from various airlines. in response, health canada initiated a traveler contact information form that collected location information and that all inbound passengers were required to complete before arrival. upon landing, all forms were collected from passengers by health canada personnel and retained for possible contact tracing if a case was subsequently identified. the traveler contact information form reduced the time for securing the manifest from weeks to days. all screening measures (hans, thermal screening, and traveler contact information form) continued after july , , when who declared that sars outbreaks had been contained worldwide. this report only includes data up to that date, when international movement of sars was a real possibility. no attempt was made to evaluate the initial information phase. data were collected for the screening phase. table summarizes the screening results for inbound and outbound han screening measures. as of july , , a total of , , persons received either yellow or cherry hans. a total of , persons answered yes to at least screening question on the han and were referred to secondary screening according to protocol. none of the outbound passengers who were referred for secondary screening in toronto were asked to defer their travel. all persons were cleared, and none were referred for additional medical examination. in addition, , persons ( , inbound and , outbound) were screened by the thermal scanners (table ). only persons had an initial temperature reading > °c and were referred for secondary evaluation. no data were collected systematically to correlate thermal scanner results with results of temperature taking by secondary screening nurses. some of the persons arriving or departing toronto and vancouver airports were screened by both han and thermal scanning measures. during this period, no screening measure put in place by health canada detected any cases of sars at border entry points. careful analysis of the travel histories of suspected and probable sars patients who traveled to canada showed that persons became ill after arrival and would not have been detected by airport screening measures. table summarizes the travel histories of persons departing canada whose ilnesses were subsequently diagnosed as sars-like illness. health canada collaborated with many international public health authorities to document travel and illness histories of possible sars patients who departed canada and whose illneses were diagnosed and reported internationally ( ) ( ) ( ) . health canada investigated > such reports, of which are now attributed to canada ( ) . in all but cases (cases and ), onset of illness occurred after departure from canada. of these persons who traveled from canada, all met the who prob-able sars case definition. only of these case-patients met the canadian probable case definition. another casepatients would meet the canadian geo-linked case definition; case met the canadian "person under investigation" category; and case-patients did not meet any canadian sars case definition. of the case-patients who did meet the canadian definition, none would have been detected by exit screening. only (patients and ) of the persons had symptoms at the time of travel, but both would have been cleared by the criteria established in the secondary screening protocol. we identified symptomatic probable or suspected sars patients on flights ( patients traveled on > flights). no documented transmission was identified. detailed results of canada's airplane passenger contact tracing can be found elsewhere ( ) . patterns of international travel continue to increase in complexity and volume. in canada, > million persons enter annually by air; % arrive at international airports. similarly, a large number depart from several international airports. additionally, because of an open land border with the united states, ≈ million persons cross the land border in both directions annually. with travel to canada from anywhere in the world taking < hours, the possibility of detecting a dangerous infectious disease at border points of entry is challenging. given the relatively short travel time, detecting persons at the border who are incubating any of the known infectious disease pathogens is unlikely. the absence of symptoms or signs of infection and a corresponding lack of specific, extremely rapid, easy-to-use diagnostic tests make border detection of infectious diseases unlikely. the effectiveness of screening measures for detecting sars cases at border points of entry was limited by factors. first, screening measures themselves, i.e., han questionnaires and thermal scanning machines, were nonspecific for sars. second, the prevalence of sars among international passengers arriving or departing from canada was low. for example, sars patients entered canada from march through may. none of these patients had signs or symptoms during transit through airports. if the same rate of entry were to continue for year, then cases might be expected among the million persons entering the country annually, for a prevalence of ≈ . sars cases per million passengers. for such a rare disease, the positive predictive value of a positive screening result is essentially zero. the results demonstrate that available screening measures are not effective for detecting sars. despite extending screening measures to all arriving air passengers, no sars cases were identified. these findings raise questions about whether such measures are effective tools for detecting and controlling the spread of sars, and whether, from a public health point of view, other, more effective, strategies might exist. instituting infectious disease screening procedures at border points of entry could have advantages. for example, easily visible measures, such as thermal scanning machines, may generate a sense of confidence or reassurance that disease will be detected and prevented from entering the country. no data are available to assess whether or not the measures implemented at the airports actually generated confidence or reassurance in the public. given the poor positive predictive value of available sars screening measures, any sense of reassurance might be quickly dispelled when the first case is detected in spite of screening measures. we conclude that available screening measures for sars were limited in their effectiveness in detecting sars among inbound or outbound passengers from sars-affected areas. we suggest that in-country, acutecare facilities (hospitals, clinics, and physicians' offices) are the de facto point of entry into the healthcare system for travelers with serious infectious diseases. if a visitor or returning citizen becomes ill after arriving in canada, he or she will likely seek medical care in clinics or emergency rooms. acute-care facilities must consider travel histories of all patients with suspected infectious diseases and implement standard precautions and infection control measures. an estimated can$ . million was invested in airport screening measures from march to july . rather than investing in airport screening measures to detect rare infectious diseases, investments should be used to strengthen screening and infection control capacities at points of entry into the healthcare system. additional useful measures could focus on public education about infectious disease prevention and care. their managers and colleagues, who worked diligently at the border points of entry to implement various screening measures. all funding for deployed screening measures was provided by the government of canada based on policy decisions made by the department of health. identification of severe acute respiratory syndrome in canada health canada centre for infectious disease prevention and control. update: severe acute respiratory syndrome-toronto world health organization. who issues a global alert about cases of atypical pneumonia. press release on the internet transmission of multidrug-resistant mycobacterium tuberculosis during a long aeroplane flight exposure to passengers and flight crew to mycobacterium tuberculosis on commercial aircraft, - assessment of in-flight transmission of sars-results of contact tracing update: severe acute respiratory syndrome-united states world health organization. sars outbreak in the philippines travel associated probable case of sars, finland, with commentary from health canada. eurosurveillance weekly summary of sars cases potentially exposed in canada and diagnosed internationally we acknowledge the contribution of many canadian government-employed quarantine officers, customs officers, screening nurses, thermal scanner operators, data collection clerks, and border screening for sars dr. st. john is director general of the centre for emergency preparedness and response, public health agency of canada. his primary interests include infectious disease prevention and control and emergency preparedness and response. key: cord- - kvaduoq authors: mcmahon, meghan; nadigel, jessica; thompson, erin; glazier, richard h. title: informing canada's health system response to covid- : priorities for health services and policy research date: - - journal: healthc policy doi: . /hcpol. . sha: doc_id: cord_uid: kvaduoq to inform canada's research response to covid- , the canadian institutes of health research's institute of health services and policy research (ihspr) conducted a rapid-cycle priority identification process. seven covid- priorities for health services and policy research were identified: system adaptation and organization of care; resource allocation decision-making and ethics; rapid synthesis and comparative policy analysis of the covid- response and outcomes; healthcare workforce; virtual care; long-term consequences of the pandemic; and public and patient engagement. three additional cross-cutting themes were identified: supporting the health of indigenous peoples and vulnerable populations, data and digital infrastructure, and learning health systems and knowledge platforms. ihspr hopes these research priorities will contribute to the broader ecosystem for collective research investment and action. afin d'éclairer la réponse du canada en matière de recherche sur la covid- , l'institut des services et des politiques de la santé (isps), des instituts de recherche en santé du canada, a mené un processus d'identification rapide des priorités en matière de recherche. sept priorités pour la recherche sur les politiques et services de santé liée à la covid- ont ainsi été identifiées : adaptation du système et organisation des soins; éthique et prise de décision en matière d' allocation des ressources; synthèses et analyses comparatives rapides des résultats et des politiques d'interventions face à la covid- ; personnel de la santé; soins virtuels; conséquences à long terme de la pandémie; et engagement de la population et des patients. trois thèmes transversaux supplémentaires ont été identifiés : soutien à la santé des peuples autochtones et des populations vulnérables; données et infrastructures numériques; et systèmes de santé apprenants et plateformes de connaissances. l'isps souhaite que ces priorités de recherche contribuent à enrichir l'écosystème de l'investissement et des initiatives de recherche collective. the coronavirus disease (covid- ) pandemic has had devastating consequences worldwide and revealed the underpreparedness of systems (health, political, economic) to respond swiftly. health systems are grappling with how to rapidly mobilize, organize and deploy resources to provide effective covid- care while simultaneously attempting to reorganize the provision of non-covid- care effectively and safely. the government of canada' s top priority throughout the pandemic has been to keep canadians healthy and safe (government of canada ), and one mechanism to achieve this has been to mobilize canada' s health research community to respond to the covid- crisis. as canada' s federal health research funder, the canadian institutes of health research (cihr) has played an active role in the covid- health research response along with its tri-council partners, canada' s broader health and science portfolios, provincial and territorial research funders and health systems, charities and hospitals, as well as local, academic, private sector and other funders. on february , , cihr, together with funding partners, launched its first rapid research response funding opportunity (cihr a), which resulted in funded research projects totalling $ . million (cihr b). the government of canada then allocated an additional $ million to cihr in march for a second round of rapid research funding (cihr c). beyond these, cihr has led several other covid- funding calls, including the covid- clinical epidemiology research rapid response, world health organization solidarity trial and opportunities focused on mental health and substance use. additional investments are under way to further support research teams with expiring grants, to maintain income support for trainees whose research has been delayed by the pandemic and to support the retention of research staff at universities and health research institutes. the cihr' s institute of health services and policy research (ihspr) is one of virtual institutes and one of many players in the health research ecosystem. ihspr is aiming to create a shared understanding of health services and policy research (hspr) covid- priorities across the country to help align resources with the most important evidence needs for policies and interventions that contribute to improved health and health system outcomes. ihspr identified covid- priorities for hspr through a rapid and iterative process that included literature and media scans, an environmental scan of covid- research priorities in other countries (table ) , input from leading hspr experts in canada and a brief survey of the hspr community. data from these sources were triangulated, analyzed and summarized to distill core and cross-cutting hspr covid- priorities and validated with the institute advisory board. detailed methods are available in appendix , available online at longwoods.com/content/ . ihspr' s rapid-cycle priority identification process resulted in seven core priority areas and three cross-cutting themes relevant for research and policy analysis within and across each priority. research that informs system adaptation and organization of resources and care in the covid- era is urgently needed as many sectors have been ill-equipped to meet covid- care needs, with community care homes (including long-term care [ltc] homes) being hardest hit. areas of focus include hospitals and the primary, home and community care (including ltc) sectors (basky ; cadogan and hughes ; coccolin et al. ; glauser ; grabowski and joynt maddox ; lin et al. ) . predictive and optimization modelling is needed to inform system resilience, resource planning, disease testing and surveillance systems, patient flow and continuity of care. also critically needed is research that both evaluates innovations in the organization and delivery of care that were catalyzed as a result of the covid- pandemic, and analyzes the policy options and levers that would support the scale and spread of these innovations. covid- has revealed shortages of capacity and resources, including personal protective equipment (ppe) and, in some settings, intensive care unit (icu) beds and ventilators (emanuel et al. ; gostin et al. ; phua et al. ; ranney et al. ; truog et al. ; . non-urgent surgeries have been cancelled, and as reopening commences, decisions will be made about prioritization for care. research, policy analyses and ethical frameworks are required to inform allocative decision-making and the consequences of those decisions (antommaria et al. ; emanuel et al. ; fritz et al. ; gostin et al. ; rosenbaum a) . further analyses are needed to examine the ethical implications of restrictive public health and social distancing measures, use of technology and data for contact tracing and the equity consequences for vulnerable populations (laupacis ; mazumder et al. ; mulligan et al. ; smith and judd ; van dorn et al. ; wang and tang ) . there has been considerable heterogeneity across countries and canadian jurisdictions in the response and timing of policies enacted to flatten the curve (e.g., social distancing, school closures) and reopen society (e.g., non-essential services, return to school). rapid knowledge syntheses and comparative policy analyses are needed to document and understand responses, analyze their intended and unintended consequences and develop response options to inform future planning and preparedness. as covid- -related policies have been enacted at municipal, provincial/territorial and federal levels and implemented by systems, organizations and individuals, analyses will require appropriate targeting to reach policy and decision-makers with differing mandates, accountabilities and contexts (gibney ). the healthcare workforce has needed to adapt quickly to the covid- landscape. enormous pressure due to a lack of ppe, high workloads and safety concerns (xiong and peng ) has added considerable stress to healthcare workers (greenberg et al. ; zhou et al. ), many of whom had high levels of burnout prior to the pandemic (canadian medical association ). research is needed to analyze how the healthcare workforce was deployed and supported to provide covid- care, understand the facilitators and barriers to a coordinated and effective response (basky ; coccolin et al. ; fraher et al. ; lake ) , evaluate the impacts on covid- and non-covid- care, and consider the strategies and policies that could be implemented to improve workforce planning, capacity and safety. research is also needed to understand the role that family and other informal caregivers played, the supports and resources they used and/or needed, the impact that covid- had on their health and mental health and the policy options for supporting informal caregivers in the future. covid- crystallizes the importance of virtual care to meet patient needs and reduce the risk of disease transmission (bhatia et al. ; greenhalgh et al. ; hollander and carr ; webster ) . research is needed to analyze and compare the extent and type of virtual care used across jurisdictions, who provided and received virtual care and for what purpose, the payment policies implemented and the intended and unintended consequences of expanded use. as well, research that analyzes the impact of virtual care on key outcome measures such as access, utilization, continuity, quality and safety, equity, cost and health is important to inform the design of future virtual care models. to respond to covid- , healthcare resources were rapidly redeployed, reducing access to routine and ongoing care and leaving many with cancelled referrals, tests and procedures (angelico et al. ; carter et al. ; rosenbaum b; salako et al. ). due to fear of infection, many canadians did not seek healthcare even when needed. certain sectors, such as ltc, and certain populations, such as the homeless and incarcerated, were disproportionately impacted. gendered consequences include balancing work, childcare and household duties, which fall disproportionately on women (kitchener ; minello ) . longitudinal research is needed to study the long-term and far-reaching effects of the pandemic on health, health equity and health system outcomes, as well as the post-covid- health, social and economic policies that are created. policy analysis is imperative to shed light on why the consequences emerged, why they had a disproportionate impact across sectors and populations and to inform future policy development. citizen response to public health advice and restrictions has profound effects on viral transmission and therefore the covid- pandemic itself. research and policy need to meaningfully engage with the public and patients, including vulnerable and at-risk populations. priorities need to be established through understanding the experience and perspectives of the public and patients with the pandemic, the covid- and non-covid- care received (or not received), caregiver needs and supports and the supports and tools needed as the crisis subsides (e.g., mental health supports and spiritual care). public and patient engagement is also critical for decision-making about removing restrictions and what the "return to the new normal" should look like (immonen ). through ihspr' s rapid-cycle priority identification process, three cross-cutting themes were identified that intersect each of the seven priority areas: . supporting the health of indigenous peoples and vulnerable populations: first nations, inuit and métis populations are at high risk of covid- acquisition and severe disease in both rural/remote and urban settings. people who are homeless, incarcerated and living in poverty are also at high risk. hspr is needed to analyze the impacts of covid- on indigenous peoples and vulnerable populations and the factors that exacerbated those impacts. policy research is also needed to inform the development of post-pandemic health and healthcare policies that are culturally safe and grounded in indigenous knowledges. . data and digital infrastructure: covid- has highlighted the importance of timely access to data for researchers, decision-makers and front-line providers to inform policy and care delivery decisions. access for researchers to linkable data from diverse sources (e.g., covid- testing data linked with clinical and administrative data, consumer wearables, social media and patient reports) and digital infrastructure is needed to enable rapid analysis of the impacts and evidence-informed response strategies. covid- has also revealed critical gaps in data. for example, the lack of race and ethnicity data, and measures and data about racism, hinders researchers' ability to decipher differential impacts of the pandemic and inform targeted policy responses, which risks further exacerbating existing inequities in health and outcomes. . learning health systems and knowledge platforms: knowledge platforms are needed that provide seamless and rapid access to high-quality research studies, synthesize the volumes of research that covid- has spurred and tailor the evidence in ways that meet the diverse needs of policy and decision-makers. covid- illuminates the ability of healthcare delivery systems (e.g., a health authority) and organizations (e.g., a hospital or ltc home) to use covid- and other data to support real-time decision-making, foster continuous learning and evidence-informed planning and implement policies and interventions across the system. ihspr is one of many organizations in a broader ecosystem that funds research and is dedicated to contributing to the covid- research response. the priorities identified in this paper are intended to help align collective hspr investment, activity and collaboration in areas where covid- evidence is critically needed and where it has the most potential to improve the lives of people, the health of populations and the performance of healthcare systems. as shown in table , the seven priorities are not unique to the canadian context and conform closely with priorities identified in other jurisdictions. common priorities include: clinical and health system innovations in the delivery, management and organization of care; deployment of the healthcare workforce and addressing workforce needs; access to care by vulnerable populations; digital health and technological innovations; addressing mental health needs and challenges; and patient and community engagement. canada' s hspr community has capacity, expertise and leadership in each of these common priorities. this presents an opportunity for canadian researchers to leverage the community' s strengths to lead or engage in international hspr collaborations and cross-jurisdictional research. who is best poised to conduct the research? the impact of research on the covid- response will be enhanced if the interdisciplinary nature of the hspr field is harnessed. the health policy and care delivery solutions needed are multifaceted and will need to draw on the interdisciplinary expertise of canada' s health services researchers, epidemiologists, political scientists, economists, lawyers, healthcare providers, embedded scientists, policy and decision-makers and patient partners. their skills in evaluation, health law and policy analysis, health economics, clinical and health informatics, organization and management of care, implementation science and other domains are critical to generating evidence in the identified priority areas that accounts for the complexity of the context and problem and has the potential for real-world impact. who is the covid- -related hspr intended for? given ihspr' s mandate, the research evidence is intended to inform covid- -related policy making within ministries of health and professional associations and decision-making within health authorities and healthcare delivery organizations. the goal is to equip health policy and decision-makers with evidence they can use to design and implement effective policies, programs and interventions that improve the organization, delivery and outcomes of healthcare. the cihr covid- rapid response and mental health knowledge synthesis funding calls included an objective to provide evidence to inform decision-making and the health system response. the calls also ensured that peer review criteria assessed the impact of the research and the quality of the proposed knowledge translation plan, but did not require decision-maker involvement on the research teams (cihr c; cihr d). to inform policy and decision-making, effort will be needed once the research is funded to meaningfully engage decision-makers in the work and develop effective knowledge mobilization strategies. ihspr is committed to this effort. in addition to relevant research as a lever for change, impact within several of the identified priorities will require the use of legislative, regulatory, funding and other policy levers. for example, addressing the covid- crisis that has played out in canada' s ltc homes (brown ) will require timely and relevant research evidence, plus attention to accreditation, regulation and inspection, staffing levels and working conditions, government funding levels and the expansion of public reporting efforts to include measures such as staffing and ownership type. importantly for the hspr community, these covid- priorities are not intended to serve as the sole focus of ihspr or cihr. although cihr' s spring project grant competition was delayed until summer and the institutes' strategic funding initiatives • knowledge translation approaches, practices and platforms applied to inform both population-level and targeted mental health and substance use responses during the pandemic • population-based interventions to reduce potential mental health and substance use impacts of covid- • targeted interventions to address the mental health and substance use issues and needs of high-risk groups • innovative surveillance and monitoring in both the general canadian population and among high-risk groups to assess mental health and substance use needs and system transformations (including the use of learning health systems, other modes of service delivery [e.g., virtual care], alternate remuneration models, etc.) world health organization (who ) • national institute on drug abuse: how potential overcrowding of emergency departments and health services will impact the treatment of opioid overdoses and opioid use disorder • national institute on aging: studies in prehospital, emergency or critical care settings to improve screening, risk stratification, care delivery decisions, resource allocation and clinical outcomes for older adults exposed to covid- ; evaluating strategies used by health systems to reallocate resources, rapidly train practitioners, communicate preventive practices and maintain adherence to public health and clinical guidelines, with a particular interest in those who serve high-risk groups (e.g., nursing homes) and resulting racial, ethnic or regional disparities in access/care • national institute of mental health: studies on the impact (e.g., access, quality, and clinical outcomes) of state, local, federal and guild-specific guidelines and policies around telehealth services and of changes in those policies, with specific attention on the risks and benefits of relaxing those guidelines or policies • national institute on minority health and health disparities: examine the effects of the covid- outbreak on disparities in healthcare utilization and health outcomes among medically and socially vulnerable populations • national cancer institute: impact on cancer-related care delivery due to the covid- pandemic • national institute of biomedical imaging and bioengineering: the nibib is seeking applications to develop life-saving technologies that can be ready for commercialization within one to two years; for example: rapid point-of-care and home-based testing/diagnostics; digital health platforms and models that integrate data, assess risk and provide illness surveillance and management tools • national institute on alcohol abuse and alcoholism: what workforce development and deployment strategies are needed to address emerging challenges in mental health/alcohol use disorder treatment during the pandemic? *not exhaustive; intended to be a snapshot only. within ihspr, we are actively engaged in cihr' s broader covid- efforts (including our work to identify hspr covid- priorities) and will continue to finalize our next five-year strategic plan and initiate planning for large-scale funding programs in areas that align with our institute' s mandate. the implications of this for the hspr community are important: there is space and resources for researchers to lead covid- -related research, pivot their existing research to contribute to covid- and/or continue with their core hspr programs of research. in the face of a pandemic that has placed tremendous demand on resources and generated a significant human toll, hspr is critically needed to inform the path forward. research that evaluates the health system response, analyzes and informs policy options and identifies how to improve the design and delivery of health services is essential for many reasons, including successful navigation out of the current pandemic, improving health system preparedness for future outbreaks and ensuring that the canadian healthcare system that reopens is stronger, resilient, and more accessible, more equitable and of higher quality than the one that existed before the onslaught of covid- . health systems respond to covid- : priorities for rapid-cycle evaluations high-impact studies evaluating health system and healthcare professional responsiveness to covid- (r ) the covid- outbreak in italy: initial implications for organ transplantation programs ventilator triage policies during the covid- pandemic at u.s. hospitals associated with members of the association of bioethics program directors all hands on deck as cases of covid- surge virtual health care is having its moment -rules will be needed how covid- overwhelmed canada's long-term care system on the frontline against covid- : community pharmacists' contribution during a public health crisis canadian institutes of health research (cihr). a. operating grant: canadian novel coronavirus (covid- ) rapid research canadian institutes of health research (cihr). b. canadian rapid research funding opportunity results canadian institutes of health research (cihr). c. operating grant: covid- canadian institutes of health research (cihr). d. operating grant: knowledge synthesis: covid- in mental health and substance use physician health and wellness in canada: connecting behaviours and occupational stressors to psychological outcomes health system, public health, and economic implications of managing covid- from a cardiovascular perspective surgery in covid- patients: operational directives fair allocation of scarce medical resources in the time of covid- ensuring and sustaining a pandemic workforce ethical anchors and explicit objectives: ensuring optimal health outcomes in the covid- pandemic whose coronavirus strategy worked best? scientists hunt most effective policies proposed protocol to keep covid- out of hospitals responding to covid- : how to navigate a public health emergency legally and ethically postacute care preparedness for covid- : thinking ahead managing mental health challenges faced by healthcare workers during covid- pandemic video consultations for covid- . virtually perfect? telemedicine for covid- the views of patients and the public should be included in policy responses to covid- women academics seem to be submitting fewer papers during coronavirus. the lily how effective response to covid- relies on nursing research working together to contain and manage covid- what can early canadian experience screening for covid- teach us about how to prepare for a pandemic? geriatric care during public health emergencies: lessons learned from novel corona virus disease (covid- ) pandemic . covid- rapid response rolling call the pandemic and the female academic race-based health data urgently needed during the coronavirus pandemic. the conversation covid- ): information for nih applicants and recipients of nih funding patient-centered outcomes research institute (pcori). . covid- targeted pfa intensive care management of coronavirus disease (covid- ): challenges and recommendations. the lancet respiratory medicine critical supply shortages -the need for ventilators and personal protective equipment during the covid- pandemic facing covid- in italy -ethics, logistics, and therapeutics on the epidemic's front line the untold toll -the pandemic's effects on patients without covid- upheaval in cancer care during the covid- outbreak telehealth for global emergencies: implications for coronavirus disease (covid- ) covid- : vulnerability and the power of privilege in a pandemic the toughest triage -allocating ventilators in a pandemic covid- exacerbating inequalities in the us challenges to the system of reserve medical supplies for public health emergencies: reflections on the outbreak of the severe acute respiratory syndrome coronavirus (sars-cov- ) epidemic in china combating covid- : health equity matters canada and covid- : learning from sars world health organization (who). . a coordinated global research roadmap: novel coronavirus focusing on health-care providers' experiences in the covid- crisis. the lancet global health the role of telehealth in reducing the mental health burden from covid- -online now. the search for improving value in canadian healthcare the authors would like to thank emma kaplan, ihspr communications and events officer, for her help with the media scan that informed this paper. the authors would also like to thank the members of the ihspr institute advisory board for their insightful and invaluable contributions, comments and feedback regarding the priorities. key: cord- -hkt bt authors: seijts, gerard; milani, kimberley young title: the myriad ways in which covid- revealed character date: - - journal: organ dyn doi: . /j.orgdyn. . sha: doc_id: cord_uid: hkt bt nan making, and empathy. it is not a stretch to say that challenges such as the covid- pandemic are a test of judgment and character. we do not suggest that the performance of leaders in crisis situations is solely a function of character. performance is always determined by competencies, character and commitment to the leadership role. crucial competencies in crisis situations include planning and execution, personal and organizational crisis readiness, communication, performance assessment, and reflection on possible actions required to make the necessary adjustments. we clearly witnessed the importance of commitment (aspiration, engagement, sacrifice) that so many healthcare professionals displayed in responding to the covid- outbreak. however, in this paper we focus on why fighting covid- required character. the word character is often used in cavalier ways. we adopted the framework developed by ivey business school professors mary crossan, gerard seijts and jeffrey gandz to frame our observations. character is a critical and indispensable component of good leadership because of its relevance to effective decision-making and subsequent action. character shapes a number of things, including but not limited to: what we notice within the context we are operating; how we interact with the world around us; who we engage in conversation and how we conduct those conversations; what we value; how we interpret feedback; what we choose to act upon; how we deal with conflict, disappointment, and setbacks; the goals we set for the organizations we lead; how we communicate; and so forth. any crisis exposes both the good and bad in people who find themselves in leadership roles. how leaders respond affects the relationships they have with their followers, including citizens. however, a unique aspect of leader character is that it is linked to an individual's j o u r n a l p r e -p r o o f disposition rather than one's position within an organization. as such, covid- revealed things about the citizens of affected nations as well as their leaders. citizens' singing from open windows, balconies and rooftops, for example, served as a powerful reminder that we as individuals could find creative ways to remain connected as medical experts urged us to remain at least six feet apart. interconnectedness -to sense and value deep connections with others at all levels within organizations, communities, and society -is an important part of the character dimension of collaboration, while drawing upon optimism and appreciating the beauty of art (e.g., music, painting, or poetry) are part of transcendence. as research by martin seligman from the university of pennsylvania has shown, both transcendence and interconnectedness are related to our subjective well-being and happiness. the purpose of this paper is to illustrate how character was revealed -in both positive and negative ways -in the actions that leaders and citizens alike displayed during the covid- pandemic. we believe it is of paramount importance to raise awareness of the construct of character and its dimensions-not just to ensure it is brought to the forefront of leadership development in the public, private and not-for-profit sectors, but so it can be used by citizens to enrich not only their own lives but those of others. in the following sections, we explain the critical role of judgment in human agency and how the unique dimensions of leader character-independently and interactively-influence decision-making and subsequent action. we then share several stories to illustrate character and its dimensions in action and showcase their profound impact on individuals, organizations, communities and societies. we end this paper by issuing a challenge for all of us to find ways to develop strength of character in order to make a difference in our organizations, communities, and society-at-large. the critical role of judgment (or practical wisdom) the world needs leaders with good judgment, or practical wisdom, to address pressing issues that present themselves in highly volatile, uncertain, complex, and ambiguous contexts. in their book practical wisdom: the right way to do the right thing, swarthmore college professors barry schwartz and kenneth sharpe defined practical wisdom as "the right way to do the right thing in a particular circumstance, with a particular person, at a particular time." as crossan and her colleagues explained in their book developing leadership character, judgment has its own set of behaviors that underpin it, but judgment relies also on the ten dimensions that support it. thus, we need leaders who are able to activate each of the eleven dimensions of character at the right time and in the right amount to guide their decision-making and call forth the right behaviors. it is easy to envision how each character dimension matters when leaders are presented with unprecedented challenges. for example, imagine how citizens might feel if a leader fails to exhibit humanity while sharing critical, hard-hitting information with the public. if individuals perceive there to be a lack of compassion for, and understanding of their personal hardships, they won't feel a sense of connection to and trust in their leader nor confidence in the measures announced. in such situations, people's anxiety is likely to increase while their resiliency may suffer. doug ford, the premier of ontario, canada, received praise from all political parties for the way he ran the province's daily press conferences during the present pandemic. observers noted the deep empathy he conveyed for the public he serves, especially when he delivered the grim message that between , and , ontarians might die as a result of the pandemic over the next to months. he brought transparency and candor to his briefings, believing that sometimes knowledge is safer to possess than fear. ford also combined his messages with humanity thereby hoping to keep trust in government agencies alive -which was a very tall order given the trust deficit that existed in many jurisdictions according to the edelman trust barometer. as crossan and her colleagues articulated in their research and outreach, truly great leaders demonstrate strength in each of the character dimensions and, coupled with excellent judgment, are able to call upon and deploy the character dimensions to suit any particular situation: ( ) transcendence to visualize the needed end state and to remain optimistic while journeying the often long and difficult road to get there; ( ) integrity to recognize what needs to be done and to report candidly on the progress to those directly and indirectly impacted by the measures; ( ) drive to deliver results despite obstacles, setbacks, and criticism; ( ) courage to make tough and often unpopular decisions; ( ) humanity to do what needs to be done, all the while caring about and taking steps to assist the many people affected; ( ) justice to recognize and issue the support needed by individuals and/or organizations to help mitigate the negative consequences born of a situation outside of their control; ( ) humility to learn and actively seek the best practices to lead teams, organizations, communities, cities, and nations through the crisis; ( ) temperance to show calm and restraint even under the most dire of situations, especially as emotions, like a virus, tend to be contagious; ( ) accountability to the various stakeholders and bearing responsibility for decisions and the subsequent consequences; ( ) collaboration with a very large and diverse group of parties to achieve the desired outcome; and, finally, ( ) judgment, to bring all these dimensions together into an effective, efficient, and principled process to work through the crisis. judgment, obviously, is a complicated dimension. for one, it means leaders have to be situationally aware and demonstrate a heightened appreciation for circumstances that require page of j o u r n a l p r e -p r o o f unique approaches. furthermore, it requires the skillful analysis of a complex and complicated situation to grasp the essence of the challenges they are facing, and the employment of logical reasoning to determine the requisite action. for example, austrian chancellor sebastian kurz provided a compelling illustration of this in march, when he discussed european efforts to head off a paralysis of public health systems. he specifically noted the associated economic damage, "you have to consider carefully when to adopt these measures, because a national economy cannot handle this over too long a period." the challenge that many people observed was that the coronavirus was dominantly a medical attack on the elderly and an economic assault on the younger generations. therefore, leaders often deal with what academics and design theorists horst rittel and melvin webber coined "wicked problems" -ones that often present themselves in crises -that require both deep insight into the heart of challenging issues and critical thinking about them. the covid- pandemic was a crisis without modern precedent, where typical or even atypical rules did not apply. the situation rapidly evolved continent by continent, country by country, city by city, and hour by hour. amid the uncertainty and insecurity, the fundamental role of any government was to keep its citizens safe and, hence, dramatic measures were takensome previously unseen even during times of war. countriesbanned the entry of non-residents, and even the canada -u.s. land border was closed to all non-essential travel in order to stem the spread of the virus. citizens were encouraged to avoid social gatherings and fined if they ignored the directive. and while religious institutions were closed, imams, rabbis, and pastors began live-streaming worship services. women who were due to give birth during the pandemic explored alternative delivery options, including home births. an increasing number of employees began to work remotely. it is a truism that, in new and unprecedented situations, conversations are often short on facts and hard science, while long on hunches and opinions. the heated discussions surrounding the efficacy of the anti-malarial drug hydroxychloroquine in treating the coronavirus is a case in point. the contrasting views on the effectiveness of wearing face masks in public places was also hotly debated by public health experts, governments, and the public. two things became abundantly clear during the early days of the pandemic. first, as an international community, we had much to learn about the new strain of coronavirus that altered our lives so quickly. second, as an interconnected world, this deadly viral intruder exposed the limitations and inefficacy of traditional borders, and thus demanded new and adaptive measures in response. renowned leadership expert, former president of the university of cincinnati, and former professor at the university of southern california, warren bennis was fond of stressing that leadership and learning go hand in hand. highly effective leaders and teams are eager to learn from their own and others' experiences -both failures as well as successes -to reduce problems, mitigate harm, in a search for creative solutions. research by professor bradley owens at brigham young university reveals that it is critically important that leaders embrace humility: they must be reflective and respectful of other people's experiences and ideas, and, most importantly, must adopt a mindset committed to continuous learning. this is particularly important for an extended crisis like the covid- pandemic that will be with us for months, perhaps more than a year, not days or weeks. but for learning to truly occur, leaders need to be willing to step up and take ownership of challenging issues, including setbacks, mistakes, and a lack of progress. this can be extraordinarily difficult for those leaders who are quick to become defensive because they believe that taking accountability for mistakes can be detrimental to perceptions of their leadership. a compelling example of a leader who resisted taking accountability was u.s. president donald trump, during one of the many white house press conferences. a journalist asked him about the slow rate of testing for the coronavirus. instead of sending a "the-buckstops-here" message, trump denied taking the missteps that some health experts say aggravated the crisis. he attempted to project an air of competence by insisting his administration -which disbanded the pandemic response team in -was doing a "great job" dealing with problems left behind by previous administrations. "i don't take responsibility at all," trump said. "we were given a set of circumstances and we were given rules, regulations and specifications from a different time." this response didn't sit well with many people as the pandemic was certainly not an unforeseen problem that came out of nowhere. we believe any leader in the public, private, or not-for-profit sector should remember a key lesson embedded in dealing with an angry public, the highly popular public relations book written by lawrence susskind and patrick field. they observed that an angry public contributes to an erosion of confidence in our basic institutions. many of us don't like conflict, especially with people higher up in the organizational hierarchy. sadly, an example of a negative outcome borne by a professional who demonstrated both integrity and courage is li wenliang, the first doctor in china to recognize the pandemic threat. his effort to warn fellow doctors led chinese authorities to accuse him of making false comments that disturbed the social order. tragically, because government officials did not heed his early warning, hundreds of chinese citizens died, including li himself. months after his death, he was officially exonerated. the report stated that li had not disrupted public order, and that he was a professional who had fought bravely and made sacrifices. this tragic episode reinforces an important leadership lesson, namely, to protect the voices from below when the quality of decisions matters. it is critical for any leader to create a culture where individuals feel they can speak up without fear of reprisals. research conducted by harvard business school professor amy edmondson has shown that companies with a trusting workplace perform better than firms where there is low psychological safety. countries, communities, governments, organizations, and individuals around the world were forced to rapidly adjust and adapt to the ramifications of the covid- pandemic. as the virus spread and unleashed its damage on the health and well-being of individuals and the global economy, it became evident that there would be no easy way out for individuals and societies. in large part this is because we live in an increasingly interdependent world in which networks of people and organizations form the basis of economic, scientific, security, and political activity. in his address on the th anniversary of the tibetan national uprising, the dalai lama captured the importance of interconnectedness, dialogue, and collaboration, with the following sage advice. "the reality today," he stated while issuing a call for universal responsibility to ensure the future of humankind, "is that we are all interdependent and have to co-exist on this small planet. therefore, the only sensible and intelligent way of resolving differences and clashes of interests, whether between individuals or nations, is through dialogue." dialogue, of course, can be challenging, especially when parties are more interested in determining who can be blamed. while using loaded terms like "the wuhan coronavirus" or "the chinese virus," the trump administration attacked china's handling of the outbreak, in an attempt -many believed -to draw attention away from its initial downplaying of this crisis. the the implication seems straightforward -we need more givers than takers for sustainable, longterm success. the behaviors associated with collaboration are important in and of themselves to facilitate good outcomes. however, the inclination to collaborate creates a conduit of connections to others that support humanity. demonstrating collegiality and open-mindedness, both aspects of collaboration, can facilitate candor and transparency, which are part of integrity. and being cooperative and demonstrating a sense of interconnectedness tends to support justice, which is especially important when particular groups are negatively affected by a crisis at higher rates. it is reasonable to expect that interconnectedness facilitates fairness and social responsibility, while positively influencing the degree to which leaders (or citizens) take into consideration a wide variety of interests in any situation. on april , , the trump administration asked m to stop exporting medical-grade face masks to canada and latin america. officials at m were unhappy with this directive and felit it raised "significant humanitarian implications" that could backfire by causing other countries to retaliate against the u.s. this white house directive was considered by many as a blatant act of unilateralism and a highly unfortunate example of turning on rather than towards each other to deal with a common threat: this devastating pandemic. former british prime minister gordon brown observed in the guardian that we now live in "a divided, leaderless world" because the rise of populist nationalism has given way to "an aggressive us-versus-them unilateralism." this puts us all at risk by limiting international cooperation at a time when covid- shows no respect for national borders. "it used to be said of the bourbons that they would never learn by their mistakes," brown wrote. "centuries on, national leaders still seem unable to apply or even absorb the hard-earned lesson that crises teach us, from the sars epidemic and ebola epidemic to the financial meltdown: that global problems need global, not just local and national, responses." unilateralism is the antithesis of interconnectedness and collaboration. as brown went on to say, if were truly going to make progress in defeating the coronavirus we "need [ed] political leaders in every continent with the courage not just to lead but to work together." queen elizabeth understood this when she stressed the importance of remaining united and resolute to overcome the crisis. in a rare speech to the public, she said that, "this time we join with all nations across the globe in a common endeavour, using the great advances of science and our instinctive compassion to heal. we will succeed -and that success will belong to every one of us." but for this to happen, we would need another of the resulting emanations of interconnectedness and collaboration: trust. as canada's globe and mail columnist andrew coyne recently wrote, "of all the ties that connect us, the most valuable and most fragile one is trust: that willingness, indeed, to let down our guard, to work with rather than against one another." as we look to our elected officials, medical professionals, and business leaders to forge a path through this global crisis, trust will play a critical role in the outcome. but that trust, fostered through a sense of interconnectedness, humanity, and justice, will need to be placed not only in our leaders but also our fellow citizens. as coyne further stated: "a reservoir of trust -respect for leaders, belief in experts, faith in each other -can mobilize individual citizens to meet collective challenges." in canada, the media observed that unity of purpose brought former political foes at the provincial and federal levels together in ways that canada had not always seen in past crises. moreover, perrin beatty, president and ceo of the canadian chamber of commerce, explained that collaboration and partnerships between government at all levels (federal, provincial, and municipal) and business is necessary to protect both the physical and economic health of the country. what began as a calamity in wuhan, china, quickly became a worldwide challenge, and for most people morphed from a vicarious experience into a deeply personal one. the initial response of many citizens world-wide was panic. this led to a frenzied and excessive purchasing of food and other essential items with many stores in many countries being completely cleaned out. however, as resignation slowly set in, people became more conscious of the needs of others when they shopped, by electing to self-isolate or, at least, to carefully assess the need to leave their house. in addition to many national leaders doing their best to remain calm and goal focused, that is, to show temperance, business leaders also stepped up to the plate. while many local stores, gyms, restaurants, and other small businesses voluntarily closed for the protection of their staff and patrons, large corporations adapted their production lines, provided philanthropic support through their foundations, created programs that supported healthcare workers and/or changed pay structures to provide assistance and relief to employees who experienced negative economic impacts. for example, both gm and honda contributed to the production of ventilators and other respiratory products; fanatics mlb, ralph lauren, under armour and jockey produced gowns and masks for hospitals; the jack ma foundation donated . million test kits and million masks to countries in africa and latin america; airbnb provided housing for , covid- responders around the world, while hertz provided free rental cars tonew york city healthcare workers; and the nba, mlb and other sports organizations created programs to financially assist facility workers who were laid off due to stadium closures and the suspension of sports seasons. through their corporate communications, not only did many of these ceos detail the measures they felt required urgent action, they often conveyed a sense of transcendence (future-orientation, optimism, purpose). they acknowledged that the measures needed to slow the pace of covid- 's transmission would have a negative economic impact on their businesses, at least in the short term, but made it clear that "weathering the storm" was the priority. in other words, they focused on the end game: the eradication of the virus coupled with the recovery of individuals, systems, and societies. the character dimension of transcendence helps us to maintain a future-orientation because it draws upon optimism, creativity, and a sense of purpose. scholars from fields such as psychology, health, and management agree that optimism is especially important in challenging times; optimistic people believe that not only is change possible, but -more importantly -they are capable of creating it. within this covid- pandemic, that certainly applied to politicians, business leaders, and scientists who were faced with dire challenges, but it also applied to ordinary citizens as they sought to be individual change agents by doing their part to contribute to the whole. as we endured the sometimes mundane monotony of voluntary isolation, it is with the optimism that we know there will be a tomorrow. we must appreciate that even the most dire situations present opportunities. however, it is essential to reflect on the actions taken as well as to reflect on additional or alternative possiblities while we work through myriad issues -health, social, economic, scientific, political, technological, and so forth -to truly seize those opportunities. reflection is a necessity for learning and progress. years ago, television personality fred rogers said: "i'm very concerned that our society is much more interested in information, than wonder; in noise, rather than silence. how do we encourage reflection? oh my, this is a noisy world." we therefore end our paper with expressing the hope that individuals reflect on at least two issues. first, at a general level, to consider which behaviors are best left behind in order to progress in today's deeply interconnected world. to put it bluntly, if one community cannot prevent or manage the outbreak of a highly contagious disease then everyone is at risk; we need a coordinated approach to defeat a common threat. second, to reflect on the importance of character. and, most importantly, consider how each of us can raise the bar in our respective personal and professional lives by working to develop strength of character, striving to make a difference, and contributing to the flourishing of teams, organizations, communities, and societies. the quote from sebastian kurz is taken from the article "coronavirus: more countries will adopt italy's measures, says austrian leader" which appeared in the guardian, , march ; https://www.theguardian.com/world/ /mar/ /coronavirus-more-countries-will-adopt-italysmeasures-says-austrian-leader the ideas behind wicked problems can be found in the article written by horst w. j. rittel and melvin m. webber, "dilemmas in a general theory of planning," , policy sciences, , - . warren bennis has written extensively on the topic that leaders are made, not born. one example of his work is learning to lead: a workbook on becoming a leader, co-written with joan goldsmith (basic books, ny: addison-wesley, ). bradley owens' research on the effect of leader humility on individuals and teams is published in the major journals in the field of leadership and organizational behavior. an article that is reflective of his work is "how does leader humility influence team performance? exploring the mechanisms of contagion and collective promotion focus," , academy of management journal, , - . the quote from president donald trump is taken from the article "'i don't take responsibility': trump shakes hands and spreads blame over coronavirus" which appeared in the guardian, , march ; https://www.theguardian.com/us-news/ /mar/ /donald-trump-coronavirusnational-emergency-sketch lawrence susskind and patrick field analyzed numerous private and public-sector cases and showed how resistance to both public and private initiatives can be overcome in their book dealing with an angry public: the mutual gains approach to resolving disputes (new york, ny: the free press, ). the quote from federica saini fasanotti is taken from her article "knowledge is power: lessons learned from italy's coronavirus outbreak" which appeared as a blog on the website of the brookings institution, , march ; https://www.brookings.edu/blog/order-fromchaos/ / / /knowledge-is-power-lessons-learned-from-italys-coronavirus-outbreak/ the quote from anthony fauci is taken from the article "coronavirus testing in u.s. not geared for 'what we need' -fauci" which appeared in the national post, , march ; https://nationalpost.com/pmn/health-pmn/coronavirus-testing-in-u-s-not-geared-for-what-weneed-fauci amy edmondson has written extensively on the topic of psychological safety. in her book the fearless organization, she discusses how organizations may go wrong because of a lack of perceived psychological safety and individuals failing to speak up (hoboken, nj: john wiley & sons). the full statement of his holiness the dalai lama on the thirty-eighth anniversary of the tibetan national uprising day can be retrieved here; https://www.dalailama.com/messages/tibet/ thmarch-archive/ the quote from peter wehner is taken from his article "the trump presidency is over" which appeared in the atlantic why canada's response to covid- is so different from that of the u.s." which appeared in the ottawa citizen three reasons why jacinda ardern's coronavirus response has been a masterclass in crisis leadership" which appeared in the conversation the first author has written on leader character in several publications including m. crossan, g. seijts and j. gandz, developing leadership character toward a framework of leader character in organizations character matters: character dimensions' impact on leader performance and outcomes martin seligman has written extensively about positive psychology and well-being. much of his pioneering work is captured in his book with christopher peterson, character strengths and virtues: a handbook and classification kenneth sharpe explain the importance of practical wisdom and how to identify and cultivate our own innate wisdom in our daily lives in practical wisdom: the right way to do the right thing an example of an article on the leadership of doug ford is "the pandemic numbers out of ontario are horrifying -and we needed to hear them the results of the edelman trust barometer can be retrieved here the work of adam grant on how a giving orientation toward others can serve as a formula for producing successful leaders and organizational performance has been captured in give and take: why helping others drives our success matthew syed discusses the work of grant in a blog posted on bbc news m says trump officials have told it to stop sending face masks to canada. trudeau responds" which appeared in the national post the quote from gordon brown is taken from the article "in the coronavirus crisis, our leaders are failing us" which appeared in the guardian gordon-brown the words from queen elizabeth were taken from the article "'we will meet again': queen urges britons to stay strong" which appeared in the guardian lockdown the quote from andrew coyne is taken from his op-ed "our way of life is fragile. only trust can preserve it" which appeared in the globe and mail his perspective embedded in the article was taken from that interview he holds the ian o. ihnatowycz chair in leadership. he received his ph.d. in organizational behavior and human resource management from the rotman school of management at the university of toronto. his areas of research include leadership, teams, performance management, and organizational change. he is the author of four recent books developing leadership character (with mary crossan and jeffrey gandz) practice: theory and cases in leadership character kimberley young milani is the co-founder of the women's leadership and mentoring program and the manager of operations, projects and stakeholder engagement, for the ian o. ihnatowycz institute for leadership at the ivey business school at western university in we are grateful to the ian o. ihnatowycz institute for leadership at the ivey business school for the funding that has supported much of the research on leader character and subsequent knowledge translations. key: cord- -w pe pz authors: dubé, mirette; kaba, alyshah; cronin, theresa; barnes, sue; fuselli, tara; grant, vincent title: covid- pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in canada date: - - journal: adv simul (lond) doi: . /s - - -w sha: doc_id: cord_uid: w pe pz healthcare resources have been strained to previously unforeseeable limits as a result of the covid- pandemic of . this has prompted the emergence of critical just-in-time covid- education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. the individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. our provincial simulation program in the province of alberta, canada (population = . million; geographic area = , km( )), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over acute care simulations across our province in both urban and rural emergency departments, intensive care units, operating rooms, labor and delivery units, urgent care centers, diagnostic imaging and in-patient units over a -week period to an estimated , learners of real frontline team members. unfortunately, the speed at which the covid- pandemic has emerged in canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of covid- patients. our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. the goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of covid- simulation data across the largest health authority in canada. with the emergence of the covid- pandemic of , healthcare resources have been strained to unforeseeable capacities, promoting the need for rapid, effective, and efficient preparedness. this has prompted the emergence of just-in-time preparedness strategies, including simulation for systems evaluation and healthcare provider (hcp) learning to support planning across healthcare sectors [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . simulation has been pivotal for systems testing and integrating new and improved components such as novel workflows, protocols, and cognitive aids with rapid changes to practice and care delivery. finding clear approaches to rapidly collect and report what is working well and what needs to change is urgently required for hcp and patient safety to ultimately reduce preventable harm. the provincial simulation program, named esim (educate, simulate, innovate, motivate) in the province of alberta, canada (population = . million; geographic area = , km , [ ] ), has rapidly responded to preparedness training by establishing a central esim provincial covid response team (similar to an emergency command center operations team for simulation) to facilitate a large-scale project managing the initiation, planning, execution, and performance/monitoring of a provincial covid- simulation response [ ] . over just weeks, this response team enabled a harmonized intake process, design, and development of a robust covid- simulation curriculum, mobilized a data collection/outcome reporting team, and a response plan to facilitate over acute care simulation session requests across alberta's broad geographical zones. this coordinated approach and infrastructure enabled an integrated provincial multi-site simulation response, allowing the ability to rapidly theme and categorize a mass number of simulation findings (over , systems issues) from over , learners (hcp) on the frontline. the simulation "command center" served to disseminate the outcomes across a large single health authority to further support ongoing planning, develop and refine the curriculum, and remain a specialized contact team of simulation experts for all health sectors (primarily acute care; urban and rural). the goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of covid- simulation data across the largest health authority in canada. alberta health services: largest integrated healthcare system in canada alberta health services (ahs) has a centralized approach to its leadership and core operational functions (e.g., human resources and information technology) and provides medical care at over facilities across the province, including acute care hospitals and , continuing care beds/spaces, five stand-alone psychiatric facilities, addiction and mental health beds and community palliative and hospice beds. ahs has over , employees and over , physicians and service accountability zones are divided into five geographical areas: north, edmonton, central, calgary, and south [ ] . there are few organizations in the world, which are comparable to ahs' integrated healthcare system relative to its size and capacity [ ] , making it a unique opportunity to glean insights and lessons learned from covid- pandemic preparedness. while disaster planning has become core content within some training curricula, the majority of health professionals remain ill prepared to deal with large scale disasters and will not encounter these critical scenarios in practice [ , ] . simulation is one method that has been identified to improve readiness and preparedness in times of disaster through deliberate practice and exposure to rare situations [ ] [ ] [ ] [ ] . simulation-based learning has historically focused on individual and team training of practicing hcps [ ] [ ] [ ] [ ] [ ] [ ] [ ] , although it has evolved to include just-in-time in situ training within the actual clinical environment [ ] [ ] [ ] including simulation for systems integration (sis), targeting the testing and integration of systems and processes (e.g., workflows, care pathways) that are uniquely important to disaster preparedness [ ] [ ] [ ] [ ] . the esim covid- response team has been involved in pioneering work in sis [ , , ] systems integration, an engineering term defined as bringing many subsystems together into one better functioning system, has the potential to improve the safety and quality of care through re-engineering of the processes and systems in which hcp work [ ] . the system engineering initiative for patient safety (seips) . model provides a framework outlining how the work system components (e.g., tools/technology, tasks, environment, people/teams) provide a matrix for thematically categorizing systemfocused debriefing (sfd) outcomes in a complex adaptive healthcare system [ ] . sis/sfd allows testing of new processes within healthcare systems to inform design and utility, and to identify system issues proactively to prevent harm [ , [ ] [ ] [ ] . the rapid onset of the covid- crisis is having a profound impact on global health, increasing demand, and risks on healthcare systems due to rapidly changing and unpredictable circumstances. the use of in situ simulation as a proactive risk mitigation strategy to prepare healthcare organizations for pandemic planning is well supported in the literature [ , , [ ] [ ] [ ] . pandemics place high demands on clinical care and potential risk of contamination for hcp, which increases the fear of spread to others [ , , ] . deliberate practice through simulation can reduce the cognitive load of hcp involved in direct frontline patient care, potentially mitigating latent safety threats (lsts) (e.g., errors in design, organization, and/or training that may have a significant impact on patient safety) in times of extended pressure, exhaustion, and burnout [ ] . as recently illustrated in both italy [ ] and singapore [ ] , simulation is key to preparedness by optimizing work flow structures, developing new processes, managing staffing levels, procuring equipment, bed management, and enforcing consistency of medical management of patients. in those ways, simulation can be used as both a learning and evaluation tool (e.g., sis/sfd) [ ] . diekmann et al. also described the potential of using simulation to improve hospital responses to the covid- crisis [ ] . recently published covid- simulation papers [ , ] share lessons learned in an attempt to support organizations that may seek to use simulation for diagnosing, testing, and embedding these approaches within pandemic constraints. while these papers do not provide specific outcomes from their system simulations, they share practical tips, tools, scenarios, debriefing questions, and resources which can be used to analyze the current needs and responses to potentially mitigate the negative impacts of the covid- crisis. similarly, chan and nickson [ ] , published an example of practical considerations for organizations in the development for just-in-time simulation training, including the scenario development, prebriefing, and debriefing, using system and process simulation for the testing of airway management for suspected/confirmed cases of covid- . while many of the findings in the emergent literature above glean insights into the use of simulation as both a learning and evaluation tool to prepare for covid- , a key gap identified is that many of these outcomes are unique to the experience of one specific site or one unique institution, which limit the generalizability and scalability of the findings. this is especially important when using simulation for pandemic preparedness to rapidly test systems and processes and prepare frontline teams to care for potential covid- patients. therefore, an identified need in the literature is the ability to proactively identify systems issues, while testing new pandemic processes in real time, and sharing these organizational learnings and system-level outcomes on a mass scale to both anticipate and plan for covid- . this is an invaluable opportunity to support healthcare organizations' preparedness during a global pandemic. our provincial simulation program rapidly mobilized to respond to our organization's need by establishing a central simulation covid response team and a large-scale evaluation project to manage the initiation, planning, execution, and performance/monitoring for all simulation-based requests. the following sections will summarize our project evaluation approach based on common project phases [ ] : (a) project initiation and planning; (b) project execution; (c) project performance and monitoring; (d) organizational learning; and (e) reporting of outcomes. rapidly designating the esim covid- response team allowed a centralized contact and triage system across the province for all simulation-based requests coming from hundreds of centers, allowing coordination, planning, and resource oversight for simulation training. team members included a team lead, geographically dispersed esim consultants (clinicians whose workplace role is to lead the design, delivery, faculty development, and evaluation of simulation methodologies and projects at ahs) and a designated data and outcomes team solely responsible for theming and categorizing thousands of simulation data points from covid- simulations. the simulation infrastructure in place in ahs prior to covid- (e.g., esim consultants positioned in every zone (rural, urban, and mobile program) and > esim-trained simulation educators across ahs) ensured every geographical zone was supported. the intake process was maintained through a central spreadsheet accessible to the entire provincial team and a needs assessment facilitated by an esim consultant (additional file intake form) to ensure the needs and objectives aligned with established simulation-based methodologies and capacity. requests were prioritized as they were processed and whenever possible, prior relationships with simulation-trained educators comfortable with the use of simulation-based methods were leveraged to help facilitate the large number of sessions. esim consultants either fully led the sessions, initiated sessions while mentoring others to replicate delivery on an on-going basis (especially when large numbers of hcp were involved), and/or shared resources with faculty who had the capacity and experience to lead sessions independently. the first wave of intake requests (and patients) in alberta, organically flooded from emergency departments, followed by intensive care units, operating rooms, labor and delivery units, and neonatal icus in calgary. simulations were triaged for covid- training and preparedness for the highest risk locations and activities across acute care. a second wave of requests included diagnostic imaging and inpatient medical units (including newly created inpatient units for covid- , among others). a similar pattern of requests followed from all of the five geographic zones in alberta in concordance with the number of covid- cases starting to move through the system. daily response team meetings ensured strategic planning with esim consultants to then specifically target and reach out to acute care sites with no simulation trained champion, those who had not made any requests, and to ensure simulation support and curriculum resources were shared across all zones. a novel part of our approach was the creation of a robust, centrally located simulation curriculum, which was rapidly developed and mobilized over a -day period at the onset of the covid- simulation response. curriculum content was vetted through medical experts, clinical leaders, infection prevention and control consultants, and the organization's emergency command center to ensure accuracy, alignment, and validity before application. new emerging curriculum resources for covid- were reviewed daily to ensure the most relevant up-to-date information was reflected within current best practice recommendations. the curriculum included covid- simulation scenarios for all sectors, and included a prebriefing script, debriefing tools [ ] , cognitive aids, "how-to" guides and shared webinars. curricular materials were shared over the -week period with over teams across ahs. objectives for the covid- simulation scenarios were based on the highest risk and highest impact system issues identified and prioritized by integrated interprofessional teams of clinicians, managers, and educators-based on their units/departments greatest needs. table provides samples of frequently used scenario objectives across all simulations and their related work system categories [ ] . central to our unique approach was the planning and execution of three common simulation-based methods to prepare teams and the healthcare system during covid- preparedness (table ). these methods include ( ) surge planning and table top debriefing; ( ) process walkthrough and environmental scans; and ( ) rapid cycle simulation and debriefing. both learnerfocused and system-focused debriefing approaches were used across these three methods [ , ] . in some instances, esim consultants and human factors (hf) specialists led the co-facilitation and debriefing of table top surge planning exercises. these exercises allowed for proactive pandemic surge planning assessment of facility, departments, programs, and services related to covid- patient flow. esim and hf were then utilized for designing decision algorithms, observation of new work processes and work environments, and identifying further improvement opportunities. early preparatory work focused on using a systems approach to co-design new covid- processes and spaces. these physical walkthrough simulations were based on day-to-day movement, case-specific patient presentations, and workflows that would be impacted by covid- . they were also used to train multiple hcps to orientate them to the new covid- response for their areas (see additional file for key points to consider in a process walkthrough environmental scan planning exercise). the primary focus was on identifying lsts prior to the first patient experience which allowed for application of a new processes in a plan, do, study, act (pdsa) cycle [ ] . the team moved through a department/clinical area, doing an environmental scan for barriers, identification of missing equipment, testing of communication pathways, and identification of new tasks/roles/responsibilities. any changes to the space and processes were actioned to leadership. once final covid- processes and workflows were established, departments/clinical areas progressed to rapid cycle simulation training followed by debriefing [ ] . this involved rapid training sessions (average min scenario duration followed by -min debriefings) to ensure small groups of interprofessional team members were able to apply new processes in the live clinical environment prior to use with actual patients. all questions related to medical management, infection, prevention and control (ipac) and process were also debriefed during these sessions. a data outcomes team was designated to rapidly process and analyze data collected from all provincial covid- simulations. figure outlines a systematic iterative process developed for intake and entry of data. an initial coding scheme for categorization of data was created. data analysis included the theming of system-focused debriefing outcomes [ ] based on the seips . system categories (e.g., tools/technology, tasks, environment, people/teams) [ ] . all outcome data were analyzed to determine convergence of themes and repeated expression of reoccurring constructs. discrepancies in the codes and labeling of themes were discussed by the core project team regularly and resolved; with themes simplified and altered accordingly until complete agreement was reached. saturation of emergent themes was reached across > simulation sessions provincially. the number of learners/participants and simulation sessions was collected using a standardized intake spreadsheet and was collated biweekly. when using a simulation for systems integration approach, the collection and sharing of systems issues and learnings is key to informing a parent organization. the esim program's infrastructure and approach was critical in a pandemic situation, as the information and learnings from the sis were used to iteratively make improvements and help teams across the organization anticipate and plan for issue mitigation and process improvement. the timely analysis of large volumes of data that was being collated and themed in real time by the esim response team proactively informed and enabled scaling up of quality improvement activities across sites, departments, and zones. our organizational learning included broad sharing of weekly dashboard updates of key outcomes, webinars (local and international webinars shared across the entire ahs organization and beyond resulting in over unique views; recording shared with > , email addresses) [ , ] , and key covid- resources developed for simulation. highest impact and highest frequency outcomes the provincial esim covid- simulation response team facilitated simulation session requests by leading the intake, design, development, planning, and facilitation of over acute care simulation sessions across all sectors of our provincial health program. in under a -week period, an estimated , learners participated in simulation in both rural ( %) and urban ( %) centers across the province (fig. ) . there was a wide variance in the number of sessions/ learners per request ranging from - days of simulation training and - people requiring training per request. well over systems issues, including lsts, have been proactively identified and mitigated through > simulation sessions. systems issues across all sessions were categorized into processes ( %), tools and technology ( %), persons and tasks ( %), environment ( %), and organization ( %). table highlights the highest priority themes discussed in the debriefings (impact) and the highest reported outcomes (frequency) that emerged from all covid- simulations. in analyzing the nine themes, it is clear that the rapid knowledge translation of best practices, new guidelines, and processes following system simulation events can potentially serve other organizations that may seek to learn from our centralized, coordinated approach to using system integration simulation for pandemic planning and preparedness. in synthesizing the learnings from the highest impact and highest frequency outcomes of the themes reported in table , there are several reasons on why these salient themes came together based on our unique context and organizational level approach to sis. each of these themes informed our organization as to what was working well at one site, department, and zone and what needed to be improved and scaled up across the organization. for example, although we had an ipac team, and multiple related resources and cognitive aids designed to support ipac processes; it became clear, as identified by the frontline through simulation, that more needed to be done to address the nuances and unique clinical practices of ipac specific to the pandemic. while hundreds of learners continued to struggle with safe doffing, simulation was able to inform the development of emerging best practices surrounding : doffing, what questions were repeatedly being discussed; why breaches were happening; and ensuring one person guided and supported individuals during doffing. observing the trending of process-related systems issues enabled our team to share this finding broadly and focus our simulation tools and approaches to further address systems issues that impacted not just one unit, site or department enabling the learnings identified through simulation to be scaffolded and shared across the entire province. this led to further development of a systemsbased process walk through approach, with debriefing, to ensure a systematic identification of process issues. repeated sis debriefings where frontline team members asked about personal items such as watches, earrings, and identification badges in covid rooms allowed us to share rapidly evolving strategies to address proper maintenance of isolation environments and the prevention of contamination. for teams who were struggling with effective ways to communicate outside of covid rooms, we were able to rapidly share innovations on a large scale to any other teams who were in the same position in preparing their unit and staff to respond to the evolving nature of the global pandemic. this involved designing, through simulation, innovative approaches necessary to keep staff and patients safe by communicating using dry erase markers on glass between rooms, as one example. as protected covid- intubations were identified as a high anxiety and high-risk time for healthcare workers, as shown by repeated simulation requests from healthcare staff targeting these objectives, having the ability to test these processes in simulation and refine a critical care medicine cognitive aid for pre-intubation and then share these findings on such a large scale was essential to successful preparation and safety of staff. as a result of multiple simulations on intubation, a covid- cognitive aid was developed, which was then contextualized for rural sites and then broadly shared across the province using our coordinated system. our use of simulation for systems integration involved taking a project approach to the initiation, planning, execution, and reporting [ ] (e.g., shared learnings) to enable proactive improvement work for safer, more efficient, and reliable care processes for patients and healthcare teams [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . this paper adds to the emerging literature on using simulation for pandemic planning and preparedness [ , ] as it describes a highly coordinated covid- pandemic simulation response using a centralized team, robust valid curriculum, and data outcomes team to analyze and rapidly share an unprecedented volume of simulation data for a large-scale sis project across the largest single health authority in canada. unfortunately, the speed at which the covid- pandemic has emerged in canada may prevent every acute care center in both urban and rural settings in having healthcare teams participate in "just-in-time" in situ simulation-based learning and systems/process. the ability to test new pandemic processes, and share organizational learnings to be disseminated on a mass scale has been pivotal in preparing our healthcare system to respond to the emergent threat of covid- . the importance of using simulation as a "first choice" strategy for ensuring individual, team, and system readiness in times of crisis is supported by multiple publications in the literature [ , [ ] [ ] [ ] , and highlights that a sustained investment in simulation programs will have immeasurable impacts across healthcare systems following the pandemic. many of these papers [ , [ ] [ ] [ ] [ ] ] indicate a single site or unit approach to pandemic preparation, although do not specifically highlight using a coordinated and centralized simulation team, development of robust valid curriculum, and real time data analysis of emerging themes from hundreds of simulations. although "more" may not necessarily always be better, we advocate that during times of pandemic where time sensitivity and reliable information are of utmost importance, a coordinated organizational-wide simulation table highest impact and highest frequency outcomes response approach allows for broader and faster sharing, scalability, and generalizability of the findings. the validation of these themes from simulations across multiple sites and teams outweighs the findings at only one. one of the emerging findings that differed our project from other covid- system simulations experiences both nationally and globally in using simulation as both a learning and evaluation tool to prepare [ , [ ] [ ] [ ] [ ] , was recognizing the critical importance of embedding simulation as a central part of the organizational learning, and the overall pandemic preparedness strategy. similar to an operational "emergency command center," simulation programs (regardless of the size) need to situate themselves to be members "at the table" with key programs informing decision-making, and influencing organizational planning and pandemic use of trigger scripts on pagers to signal a priority response. scripts like "covid airway" or "covid transport" to alert a team and get the right people and the right equipment to the right place. preparedness from the beginning. many factors influence the ability of simulation programs to "take this seat" including how the program is established prior to pandemic and how well it may be recognized by hospital administration staff in informing the organization of the needs and challenges coming directly from the frontline care providers. we situated ourselves as key informants to leaders and the organization's administration, through planning and executing a large-scale simulation for systems integration project. our outcomes, which identified over systems issues, including lsts, had meaning to the organization because they were widespread and converged data from several sites including both urban and rural centers and across the continuum of care. in addition, we could equally share and reach all sites within our organizational structure for the new emerging themes we were uncovering in real time. we informed our organization on multiple levels through our webinars, dashboards, and relationships built across a large health authority. queueing ipac team members of ongoing concerns with best practices for safe doffing to enable targeted approaches; sharing weekly questions still arising from the frontline to the ipac team; and then supporting the development of a "doffing buddy" program are a few examples. this example highlights that while the emerging literature on covid- simulations [ , [ ] [ ] [ ] [ ] differ in their approach and scale of sis, there is overlapping outcomes and triangulation of findings specific to ipac across the different systems, countries, and jurisdictions. essentially, this underlines the validity and robustness of the use of simulation for systems integration methodology for organizational learning. we realized that process-related systems issues were widespread and the requests for environmental scans with debriefing prompted hundreds of teams to start redesigning their covid care spaces after one of our "shared learnings" webinars. seeing the rapid uptake of teams developing checklists and cognitive aids in isolation of each other, and with limited human factors experience, led us to establish collaborative human factors tools on how to develop an effective cognitive aid and principles of safe use. we believe all of these developments were the result of a swift and purposeful largescale centralized approach. recognizing that not all health authorities have opportunity to coordinate or operationally support a centralized team and curriculum across sites; we recommend the explicit effort of simulation programs to align with other programs in meaningful ways to analyze and share emerging data in real-time to support validation for broader sharing and scalability when possible. the simulation methods and outcomes used in the covid- response have had a profound impact on our teams, processes, and system functioning. our experience offers other organizations' learnings to glean and consider the importance of establishing a centralized simulation response team for scale, spread and speed of knowledge translation, implementation, and change management effectiveness. with on-going use of sis sessions informing cycles of improvement, the simulation will continue to be a key organizational tool we will use to further manage this evolving crisis, as well as future needs of our healthcare organization. our pandemic preparedness highlighted the essential use of simulation as both an evaluation tool capable of testing systems and processes, and identifying and mitigating lsts, as well as an education tool capable of rapidly preparing frontline teams in terms of the changes identified above. this project has identified how the dissemination and broadcasting of curriculum and lessons learned (e.g., emerging themes, innovations, systems-based approaches) from simulation can rapidly help a large organization over a large geographic area be adequately prepared for an evolving situation like the covid- pandemic of . supporting the health care workforce during the covid- global epidemic critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response preparing for a covid- pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore covid simulation shared learning and resource review preparing and responding to novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in china the use of simulation to prepare and improve responses to infectious disease outbreaks like covid- : practical tips and resources from norway, denmark, and the uk covid- airway management: better care through simulation • litfl [internet]. life in the fast lane • litfl • medical blog translational simulation for rapid transformation of health services, using the example of the covid- pandemic preparation lessons learned in preparing for and responding to the early stages of the covid- pandemic: one simulation's program experience adapting to the new normal our story: building the largest geographical provincial simulation program in canada. accepted article in medical training magazine,. medical training magazine goals, recommendations, and the how-to strategies for developing and facilitating patient safety and system integration simulations a multiphase disaster training exercise for emergency medicine residents: opportunity knocks precepting at the time of a natural disaster impact of repeated simulation on learning curve characteristics of residents exposed to rare life threatening situations simulation as a critical resource in the response to ebola virus disease use of simulation to gauge preparedness for ebola at a free-standing children's hospital an active shooter in your hospital: a novel method to develop a response policy using in situ simulation and video framework analysis see one, do one, teach one: is it enough? no: trainee focus the value proposition of simulation-based education collaborative practice in action: building interprofessional competencies through simulation based education and novel approaches to team training promoting excellence and reflective learning in simulation (pearls): development and rationale for a blended approach to health care simulation debriefing in situ simulation: detection of safety threats and teamwork training in a high risk emergency department in situ simulation in continuing education for the health care professions: a systematic review simulation in the clinical setting: towards a standard lexicon connecting simulation and quality improvement: how can healthcare simulation really improve patient care? adapting form to function: can simulation serve our healthcare system and educational needs? crash testing the dummy: a review of in situ trauma simulation at a canadian tertiary centre translational simulation: not 'where?' but 'why?' a functional view of in situ simulation reducing door-to-needle times in stroke thrombolysis to min through protocol revision and simulation training: a quality improvement project in a norwegian stroke centre priorities related to improving healthcare safety through simulation pearls for systems integration: a modified pearls framework for debriefing systemsfocused simulations commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety agency for healthcare research and quality seips . : a human factors framework for studying and improving the work of healthcare professionals and patients covid- : protecting worker health. ann work expo health what factors might have led to the emergence of ebola in west africa? beyond the clinical team: evaluating the human factors-oriented training of non-clinical professionals working in healthcare contexts basics of quality improvement in health care systematic review of the application of the plan-do-study-act method to improve quality in healthcare pediatric resident resuscitation skills improve after "rapid cycle deliberate practice covid simulations simulation canada variation and adaptation: learning from success in patient safety-oriented simulation training systems integration, human factors, and simulation comprehensive healthcare simulation simulation to assess the safety of new healthcare teams and new facilities use of simulation to test systems and prepare staff for a new hospital transition using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit the use of in situ simulation to detect latent safety threats in paediatrics: a cross-sectional survey work system design for patient safety: the seips model using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward using briefing, simulation and debriefing to improve human and system performance rapid cycle deliberate practice in medical education -a systematic review considerations for psychological safety with system-focused debriefings springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to recognize the many partnerships and people that enabled an impressive simulation response to the covid- pandemic. this project, considering its scope and scale, would not have been possible without the efforts of many team members from the alberta health services' esim provincial simulation program, kidsim pediatric simulation program, and covenant health authority. the authors would like to acknowledge the following people for their contributions to the project curriculum design, delivery, data entry, manuscript review, and input throughout the covid- supplementary information accompanies this paper at https://doi.org/ . /s - - -w. authors' information md is a masters certified critical care registered respiratory therapist with years of experience in healthcare. she has over thirteen years' experience in simulation and debriefing; training hundreds of interprofessional teams, faculty development, simulation for systems integration and debriefing, undergraduate education, global health, human factors, design thinking, research, project and change management, former provincial director of quality and patient safety education, and leading provincial simulation and quality improvement projects. she is passionate about patient safety, improving healthcare systems, and has multiple peer-reviewed publications on interprofessional collaboration, team training, and using simulation and debriefing for systems improvement. during the covid- pandemic of , md was the esim provincial simulation response team lead for the province of alberta, canada. no funding was required for the development of this manuscript. data sharing is not applicable to this article as no datasets were generated or analyzed.ethics approval and consent to participate no ethics approval or consent was needed for this manuscript. the authors declare that they have no competing interests.author details esim provincial simulation program, alberta health services, alberta health services, th street nw, calgary, alberta t n t , canada. key: cord- -zp oddrt authors: mccoy, liam g; smith, jonathan; anchuri, kavya; berry, isha; pineda, joanna; harish, vinyas; lam, andrew t; yi, seung eun; hu, sophie; fine, benjamin title: can-npi: a curated open dataset of canadian non-pharmaceutical interventions in response to the global covid- pandemic date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: zp oddrt non-pharmaceutical interventions (npis) have been the primary tool used by governments and organizations to mitigate the spread of the ongoing pandemic of covid- . natural experiments are currently being conducted on the impact of these interventions, but most of these occur at the subnational level - data not available in early global datasets. we describe the rapid development of the first comprehensive, labelled dataset of npis implemented at federal, provincial/territorial and municipal levels in canada to guide covid- research. for each intervention, we provide: a) information on timing to aid in longitudinal evaluation, b) location to allow for robust spatial analyses, and c) classification based on intervention type and target population, including classification aligned with a previously developed measure of government response stringency. this initial dataset release (v . ) spans january st, and march st, ; bi-weekly data updates to continue for the duration of the pandemic. this novel dataset enables robust, inter-jurisdictional comparisons of pandemic response, can serve as a model for other jurisdictions and can be linked with other information about case counts, transmission dynamics, health care utilization, mobility data and economic indicators to derive important insights regarding npi impact. since the first case of covid- was reported in canada in january , there have been a total of , reported cases and , reported deaths as of april , . in the absence of population immunity or an effective medical treatment, traditional public health interventions (e.g. physical distancing, testing, contact-tracing, and hand hygiene) are critical to protect population health , . these non-pharmaceutical interventions (npis) have been the primary tool employed by governments and organizations to reduce the spread of the virus, and avoid the possibility that peak case numbers overwhelm healthcare capacity , , . in canada, npis have included the closure of borders and bans on non-essential travel, as well as the imposition of voluntary or mandatory physical distancing measures. while some npi policies have been implemented at a national scale, much of the authority and responsibility to oversee rollout of these policies falls on provincial, territorial, and municipal governments . as such, there has been substantial variability in what, when, and how npis have been implemented across canada -highlighting the importance of a subnational lens of data gathering and analysis. we present the first comprehensive, open dataset containing detailed information about all publicly available npis that have been implemented by governments and major private organizations in canada in response to covid- . to ensure a comprehensive review that captures jurisdictional differences, we collect npis at the canadian federal level, in all ten provinces and three territories, as well as in the twenty largest census metropolitan areas (cmas). each intervention is labelled based on timing, location, intervention type, target population, and a previously developed measure of government response stringency. the ultimate value of this dataset is to help researchers and policy-makers make sense of the first phase of npis, which are essentially a set of natural experiments occurring across the globe. the first of its kind in canada, this dataset enables research characterizing the nature of canada's covid- response at a regional level. regional npi data can now be linked with other information about case counts, transmission dynamics, health care utilization, mobility data and economic indicators to derive important insights regarding npi impact. moreover, each canadian region can be compared to other candian or international jurisdiction to facilitate comparative analyses. we hope this dataset can also serve as a model for subnational npi data collection from other jurisdictions. in this dataset, we define a non-pharmaceutical intervention (npi) as any publicly-announced program, statement, enforceable order, initiative, or operational change originating from any public or private organization in response to covid- -whether to curtail its transmission or mitigate its social and economic ramifications. this includes distancing measures (including closures), infection control measures (excluding vaccination or medical treatment), testing strategies, public announcements, media campaigns, and social and fiscal measures, among others. broadly, these are all parameters that influence the behaviour of individuals in an effort to limit the spread and economic impact of covid- . primary review was performed by the covid- canada open data working group: non-pharmaceutical interventions, a -member team primarily composed of medical students and graduate students from the university of toronto. this team was recruited one of the authors via a standardized onboarding process. we identified npis implemented at all different levels of government, including the canadian federal level, provincial and territorial level, and the municipal level for the largest cmas in canada (see supplementary material, table s ). we also included npis implemented by private organizations at these regional levels. for the first version of the dataset, we conducted a comprehensive scan of all covid- -related npis and changes to testing requirements or case definitions between january st and march st, . future versions will be updated every weeks until the pandemic ends. interventions were recorded only for the administrative level responsible for them, such that an intervention recorded at the provincial level was not repeated at the municipal level. articles were selected through a comprehensive online environmental scan, which is appropriate for the rapidly evolving nature of the ongoing pandemic and the variety of avenues through which information is announced (figure ) . a hierarchy of preferred sources was used to identify and code interventions (supplementary material table s ). first, official government sources were reviewed in full and any covid- -related announcements were identified as the gold standard for data inclusion. government sources include press releases on the official websites of provincial and territorial governments, ministries of health, or provincial public health commissions. second, additional information was identified using purposive search methods for covid- -related articles and online reports from accredited news agencies. finally, we include updates provided by the official social media accounts of governmental or public health institutions -such as provincial chief medical officers of health. for each source, after an initial verification check for redundancy with a previous announcement of the same npi was completed, information was systematically extracted using a consistent format (supplementary material table s ). each npi was labelled with a free-text summary and categorical classifiers describing the nature of the intervention and its target population. given the shifting nature of the pandemic response, our list of categories was iteratively expanded and adjusted as novel classes of npis were identified. if a reviewer was uncertain regarding the appropriate classifier to select, the item was flagged and discussed collectively until consensus was obtained by at least authors. our consensus labelling schema contained classes. additional to these, the interventions could be assigned one of labels aligned with the methodology of the oxford covid- government response tracker (oxcgrt) . the oxford group defines interventions in broad categories: decisions related to public gatherings (distancing), financial indicators, and testing and tracing categories. (the oxcgrt group also defines an oxford stringency index using simple scoring of the distancing measures, details of which are provided in supplementary material table s .) to ensure data was recorded in a consistent format by each reviewer, we established a streamlined onboarding protocol and a step-wise data-entry process. standardized data entry forms and skip patterns were also used to minimize data input errors. the data was audited for consistency by evaluating the relative proportions of specific intervention categories between regions. a focused second review of the dataset was also performed by a subset of authors to identify discrepancies and further standardize for consistency and accuracy across reviewers and jurisdictions. we identified information on , interventions from unique source urls and unique source organizations across the federal government, all provinces and territories, and the largest cmas in canada. this version of the dataset covers interventions starting between january st ( days before the first case was reported in canada ) and march st inclusive, with time being recorded on a daily basis and the median intervention date falling between march and march at a provincial level. the distribution of interventions by daily count over time is shown in figure a . there are categories of intervention in this schema in addition to the oxcgrt interventions. interventions are also classified based on categories of target populations. the top intervention categories are enumerated in table with a single example provided for each category. the classes are imbalanced, and most ( %) are classified under the oxford classification in addition to our categories. the top intervention categories without a corresponding oxford response category are public announcements, general case announcements, and healthcare facility restrictions. not all intervention categories are recorded in each jurisdiction. figure b shows the variation in the number of unique intervention categories recorded in each region covered by the dataset. two of the categories were not assigned to an intervention in the first dataset release. we provide a few examples highlighting the utility of this dataset which uniquely contains longitudinal, geographic, and stringency data on npis from across canada: . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . combining the longitudinal, geographic and strincency features of the dataset, we illustrate the evolution of oxford stringency index for each province over time, which highlights differences in subnational decision-making ( figure ). for this figure, intervention records that fall into one of the seven categories that qualify for computing the oxford stringency index were used ( out of , interventions records). the index was established and tracked daily at the provincial and territorial level. the who announcement declaring a global pandemic on march th was selected as a reference date. the jurisdictional and temporal granularity of this dataset allows comparison across provinces and territories of each region's latency of response to covid- . as an example, we show the time-to-intervention for two major npis that were instituted in all provinces and territories: declaration of state of emergency (including public health emergency) and school closure. we plot these npis on a timeline relative to the first case of and first death due to covid- in each province or territory to visually estimate a time-to-intervention ( figure ). we have created the first comprehensive dataset of npis in response to covid- across canada that is being made openly available to researchers. our dataset allows for the comparison of different regions in space and time with regard to their use of npis, through both descriptive characterization of the npis themselves as well as through time-series based linkage with other data sources (e.g. case and mortality counts, testing, mobility) to enable further analyses of the epidemic's trajectory in canada. the bulk of existing work done on npis has been limited to groups simulating the effect of npis in mathematical models or creating region-based collections of npis to answer a specific question , , . to our knowledge, little work has been done to systematically compile and update npis subnationally. while there have been efforts to capture npis in the united states at the county level, the data needs to be requested from the user which presents a barrier to access as compared to an open-access download link . the use of npis to combat covid- spread is fundamentally a local issue, in which decisionmakers are best guided by data specific to their own locale. while the scope and scale of initiatives such as oxcgrt or the assessment capacities project (acaps) 'government measures' dataset is commendable, these datasets lack uniform granularity in subnational coverage (neither dataset includes subnational entries for canada at the time of writing). thus, the emphasis of our work is predominantly its applicability to the canadian context, while also ensuring compatibility with existing work at the international level. this dataset has the capacity to enable a wide range of research -both urgently as decisionmakers are tasked with understanding and managing canada's immediate pandemic response, and in the long-term as retrospective work seeks to understand the nature of this response and . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . how it may be improved for the next pandemic. given that these public health measures are fundamentally based on the non-occurrence of outcomes (in this case, covid- infections and deaths), such analyses are critical in evaluating the value and appropriateness of various components of the public health response and answering questions about what "should" have been done and when. linkages with external sources of high-resolution epidemiologic data , healthcare capacity data, economic impact data, and other subnational npi datasets (as they become available) will be critical in enabling further research. our future work involves making these linkages, and providing researchers with streamlined and comprehensive access to high-quality, multi-modal data on the covid- pandemic. we are also seeking to align our data into the global work being done by groups such as oxcrt to allow for robust global analyses. we will continue to update this dataset and others, as well as to offer these analyses, for the duration of the pandemic. due to our reliance on public information and releases in creating this dataset, it is possible that interventions that were not publicly announced may have been omitted from the dataset. for example, nunavut is offering up to $ in support for businesses in the territory, but they give no indication of the number of eligible businesses , and thus we could not compute and report a total fiscal value. similarly, testing policy changes that were not communicated directly to the public through online announcements, such as substantial shifts in practice occurring within public health units and hospitals (e.g. whether or not a testing referral is accepted), may not have been captured in this dataset. there is inherent variability in how different jurisdictions choose to report and describe their npis, as well as the range of information that they choose to include or not include. this may have introduced a degree of variability in our labelling. we have sought to minimize inconsistencies across jurisdictions and reviewers through the aforementioned standardized onboarding process, step-wise data-entry, and a secondary, focused review by a smaller group of reviewers prior to data release. moreover, as residual variation is likely due to subjective differences rather than error, the open nature of our data allows for end users to suggest future improvements to our dataset or download it to make modifications to suit their specific research needs. in just over a month since the declaration of the covid- global pandemic, we have assembled a comprehensive dataset of non-pharmaceutical interventions at the national and subnational level in canada (which we will continue to update at two-week intervals throughout the pandemic). by capturing data about npis at a fine spatio-temporal resolution and presenting it publicly, we have provided researchers, analysts, and the public a means of evaluating policy responses while the course of the pandemic can still be altered. researchers can now link npi data to outcome datasets such as case and mortality counts, healthcare resource use, and . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . testing to help determine the most effective and efficient distancing and re-opening strategies. this will be critical if further pandemic waves are to come. perhaps most importantly, this dataset enables analysis at the provincial, territorial, and municipal levels, where the most impactful decisions will likely be made in canada. we hope this dataset can act to inform rapid evidence-based policymaking to help flatten the curve, as well as to support retrospective analyses in understanding the spread of covid- in canada. the dataset will be distributed via the website howsmyflattening.ca, as well as on kaggle (https://www.kaggle.com/howsmyflattening/covid -challenges) and github (https://github.com/jajsmith/covid nonpharmaceuticalinterventions). howsmyflattening is a team of physicians, medical students, computational health researchers, designers, engineers and epidemiologists across academia and industry who rapidly gather, integrate, and display data to inform ontario's decision-making around the management of covid- . this collective will systematically centralize open source data and tackle priority problems while producing data visualizations of challenges related to capacity planning, testing and tracing, regional nuances, and intervention planning. guided by a team of experts with connections to the covid- decision-making tables, this collaborative will enhance ontario's response through cutting-edge data visualizations and triangulation of multiple data sources. this dataset is shared under the creative commons cc by . license (https://creativecommons.org/licenses/by/ . /) allowing for sharing and adaptation with credit given. this paper must be cited whenever this dataset is used. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . figure . overview of data collection and validation process for the can-npi dataset. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . non-essential workplace closure state of emergency declared: all regulated health services providers will cease operations unless the services to be provided are to address essential health care or an emergency health-care situation. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . table s )), n= . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : variation in time-to-intervention by canadian province / territory for two major npis-declaration of state of emergency and school closure-shown relative to two descriptors of the local covid- outbreak, dates of first case and first death in each region. supplementary material: . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . calculation of the oxford stringency index the oxford stringency index (osi) is a simple score calculated using a sum of the first of classes (s to s ). for s , a score of or is given, and for the other six types, a score between and is given depending on the strictness of the government measure. each score is then scaled to take a value between and and the seven scores are averaged to get the composite stringency index. for instance, a generalized, recommended school closing announcement would correspond to a score of out of , resulting in the final score of . this index is indicative of the number and the strictness of different government interventions, but should not be interpreted as effectiveness. our dataset allows us to compute this index for each province and territory to better understand the evolution of government response across canada over time. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint open access epidemiologic data and an interactive dashboard to monitor the covid- outbreak in canada impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand non-pharmaceutical interventions for pandemic influenza, national and community measures interventions to mitigate early spread of sars-cov- in singapore: a modelling study. the lancet infectious diseases evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease in wuhan, china. medrxiv canadian pandemic influenza preparedness: public health measures strategy variation in government responses to covid- the utility of the environmental scan for public health practice: lessons from an urban program to increase cancer screening diagnosis and management of first case of covid- in canada: lessons applied from sars government measures dataset -humanitarian data exchange effect of non-pharmaceutical interventions for containing the covid- outbreak: an observational and modelling study key: cord- -jkzxjk authors: papineau, amber; berhane, yohannes; wylie, todd n.; wylie, kristine m.; sharpe, samuel; lung, oliver title: genome organization of canada goose coronavirus, a novel species identified in a mass die-off of canada geese date: - - journal: sci rep doi: . /s - - -y sha: doc_id: cord_uid: jkzxjk the complete genome of a novel coronavirus was sequenced directly from the cloacal swab of a canada goose that perished in a die-off of canada and snow geese in cambridge bay, nunavut, canada. comparative genomics and phylogenetic analysis indicate it is a new species of gammacoronavirus, as it falls below the threshold of % amino acid similarity in the protein domains used to demarcate coronaviridae. additional features that distinguish the genome of canada goose coronavirus include novel orfs, a partial duplication of the gene and a presumptive change in the proteolytic processing of polyproteins a and ab. due to the remote location of the die off, samples from the dead birds were not collected immediately and sent to a diagnostic laboratory until severe predation and decomposition had occurred. the poor sample quality, in addition to the difficulty of coronavirus isolation, led to the failure to isolate infectious virus using standard methods. however, the complete genome of a novel gammacoronavirus was assembled from high throughput sequencing reads derived from the cloacal swab of a single canada goose. the assembled genome of the novel canada goose coronavirus (cgcov) is , nts in length (excluding the poly(a) tail) and has . % gc-content. the genome of cgcov is approximately nts longer than the reference genomes for acov available in genbank. the genome organization of cgcov is presented in fig. . the ′ utr of cgcov is nt in length and contains a higher gc content ( . %) relative to the genome as a whole. the ′ utr of cgcov shares only % pairwise identity with that of duck coronavirus (dcov) and . % pairwise identity to that of sw . like all coronavirus genomes reported to date, cgcov's genome is dominated by the coding regions for the large polyproteins a and ab, followed by the structural and accessory genes. the heptanucleotide slippery sequence uuuaaac, associated with the ribosomal slippage that produces polyprotein ab, was present at nt positon , . cgcov's genome contains genes for all four structural proteins common to coronaviruses; spike (s), envelope (e), membrane (m) and nucleocapsid (n). in addition, cgcov contains open reading frames (orfs) predicted to encode accessory proteins. the order of the structural and accessory protein-coding orfs in cgcov resembles that of acov, but there are notable differences. the general genome organization of acov is ab-s- a- b-e-m- b- c- a- b-n- b . however, there is some variance in the genome organization within the acov species. for example, australian ibv strains lack orfs a, b and b . overall, cgcov contains a larger number (n = ) of orfs coding for predicted accessory and structural proteins downstream of the polyprotein ab coding region. two additional orfs ( a and b) are found between the cgcov m and n orfs. there are also two additional orfs ( and ) following the n gene. while some acovs do have orfs following the n gene, orfs and in cgcov do not share obvious homology to those of ibv and tcov. the ′ utr of cgcov is nucleotides in length and contains the stem loop-like motif bp upstream from the poly(a) tail. this stem loop-like motif was first identified in astroviruses but is also present in acovs and sars-cov . further downstream in the ′ utr, the octanucleotide motif (ggaagagc) is found bp upstream of the poly(a) tail. the ′ utr of cgcov shares % pairwise identity to the partially sequenced gcov and % pairwise identity to ibv. a trait suggesting common ancestry between cgcov and acov is the canonical acov transcription regulatory sequence (trs) found at the end of the leader sequence in cgcov. the trs of cgcov is identical to that identified by cao et al. ( ) as the trs of tcov (cttaacaaa). body trs's regulate viral gene expression by forming a complex with the leader trs, causing discontinuous transcription of mrna . ten putative body trss were found in the ′ end of the cgcov genome (fig. ) . four of the ten putative trss ( , , , ) were exact matches to the canonical leader trs. three trss ( , , ) contained one mismatch and the remaining three trss ( , , ) contained two mismatches to the leader trs. the functionality of these trss would need to be experimentally determined; however, previous studies have shown that trss of acovs are subject to some variation , . cgcov contains twice the number of trs's as acovs and a similar number compared to the nine contained in sw . table demonstrates the nucleotide distances between the trs and the start codon of orfs found in cgcov's, which are comparable to those of tcov . the start codon of cgcov's polyprotein ab is located nucleotides downstream of the leader trs. the coronavirus polyprotein ab is cleaved into - non-structural proteins (nsps) by two viral proteases . putative cleavage sites for these proteases are present in cgcov's a and ab polyproteins, with the exception of the nsp / (polyprotein a) and nsp / (polyprotein ab) cleavage sites. the missing cleavage site would be located near the end of polyprotein a, producing the nsps and , and also in the alternatively transcribed polyprotein ab, producing nsps and . the absence of the nsp / and / protease recognition site was confirmed with sanger sequencing. with the exception of the missing cleavage sites, the putative cleavage sites would produce nsps of sizes congruent with other gammacoronavirus species (table ) . no gammacoronavirus species to date, including cgcov, have a papain-like protease cleavage site between nsp - . while the genome structure of cgcov resembles that of acov, there are some notable differences. for example, there are no homologues to acov's a or b accessory proteins in cgcov, a trait shared with sw . furthermore, cgcov has a number of orfs that do not appear to have homologues in other sequenced gammacoronavirus species, such as the orfs for putative proteins and a (fig. ) . these two orfs are found in cgcov in the corresponding location of acov's a and b orfs (between the s and e orfs) and are also similar in size to acov's a and b proteins. however, they share no obvious sequence similarity with any a or b gene, or any other entry in ncbi (table ) . acov's a and b proteins have been shown to be unnecessary for replication , however knock-out mutants for these accessory genes are attenuated . the ibv's gene is functionally tricistronic, meaning the a, b and e proteins are under the control of a single trs , . this is not the case www.nature.com/scientificreports www.nature.com/scientificreports/ in cgcov, as the e orf of cgcov shares a trs with only the a orf in cgcov and orf is preceded by a separate trs (fig. ). an additional trs is also found in between cgcov's m and n orfs, preceding the proteins a and b (fig. ) . commonly acov's have two orfs between the m and genes, coding for the b and c accessory proteins. cgcov contains orfs between the m and gene (acov gene homologue). two of these orfs ( b and a) are acov b homologues, likely the result of gene duplication. this area in ibv has been identified as a hotspot for recombination . the region between the acov m and gene was formally called the intergenic region because of the lack of a trs. however, it was later shown that gene is expressed using an alternative trs in ibv . notably, one of the b homologs (i.e. b) in cgcov does have a trs (fig. ) . the use of template switching at trss is thought to lend to recombination in coronaviruses . the two cgcov b homologs are not identical to each other (table ) . amino acid sequence identity to other b proteins is low for both cgcov b homologues, % to ibv and % to dcov respectively. the gene duplication was also confirmed by sanger sequencing of the genomic region between the m orf to the gene. the acov a and b accessory proteins ( a and b in cgcov) appear to be the only accessory proteins conserved in all gammacoronavirus species, although gene order differs. orfs encoding putitive proteins a and b belong to the bicistronic gene of acovs and are also unnecessary for replication . to date, all publically available sequence information suggest that gammacoronavirus species have lost the nsp cleavage site. the function of nsp in alphacoronaviruses and betacoronaviruses is the inhibition of host protein production. accessory protein a is shown to have adopted this function in place of nsp in ibv . the majority of structural proteins of cgcov also share low amino acid sequence identity ( - %) with ibv and dcov. phylogenetic analysis of the spike gene show that the cgcov spike gene clusters with the ibv spike gene, separate from the tcov cluster (fig. a) . figure b also demonstrates the nucleocapsid gene of cgcov is distantly related to those of acovs. however the cgcov nucleocapid protein does share % amino acid sequence identity with the nucleocapsid protein encoded in the partially sequenced graylag gcov genome . in addition, orfs and , which are preceded by the nucleocapsid gene, also share high amino acid identity with graylag gcov proteins, % and % respectively. it should be noted that, among full and partial genomes of gammacoronaviruses sequenced to date, orfs and seem to be unique to cgcov and gcov and are both preceded by a trs, suggesting that these orfs are very likely expressed. the fact that some cgcov proteins share higher amino acid sequence similarity with the partial gcov sequences available suggest these two viruses are more closely related to each other than to other gammacoronaviruses known to date. the phylogenetic tree built using the coding regions for the conserved replicase and helicase domains demonstrates that cgcov clusters with gammacoronaviruses and shares a more recent common ancestor with acov than with the cetacean gammacoronaviruses (fig. ) . further comparisons suggest that cgcov is a separate species from acov. current taxonomy of coronaviridae is determined using pairwise comparisons of the amino acid sequence of seven conserved domains in the ab polyprotein. members of the same species share over % amino acid identity in these seven conserved domains . percent identity of cgcov falls well below the % threshold set by ictv with acov and sw , suggesting cgcov is a separate species (table ) . within coronaviridae, cgcov shares the highest homology ( %) in the conserved domains to the gammacoronaviruses tcov and dcov. as the full genome was sequenced from only the cloacal swab of a single canada goose, a screening pcr was designed based on the b duplication region unique to cgcov and performed on all samples. the sanger sequencing primers of the region between the m and gene were used, as this area of the genome is specific to cgcov. all samples were found to be positive, with the exception of the pharyngeal swab of the snow goose and the lung tissue of the second canada goose which could not be tested as the sample was exhausted. amplicons were sanger sequenced and confirmed to match the cgcov genome. high throughput sequencing conducted on rna extracted from cloacal swabs from the second canada goose and the snow goose also resulted in partial ( and %) genomes of the cgcov. while this does not confirm the virus's presence in all animals that perished in the die off, this shows cgcov was present in all birds that were available for testing. further studies will require the availability of an infectious virus to determine the pathogenicity of cgcov and its ability to cause mortality in canada geese and snow geese. to summarize, the complete genome of cgcov, a novel gammacoronavirus species was sequenced directly from the cloacal swab of a canada goose associated with a mass die-off. the cgcov genome was also detected in samples derived from a second canada goose and a snow goose that perished in the die-off, using pcr, sanger and high throughput sequencing. comparative genomics and phylogenetic analysis indicate cgcov clusters with acov but is a distinct gammacoronavirus species. interesting features of this new species include the cloacal and pharygenal swabs were collected from all three birds, lung tissue was collected from one canada goose. other organs were not present or were in extremely poor condition. detection of both common avian pathogens, such as avian influenza and avian paramyxovirus by the national reference laboratory, by routine laboratory testing gave negative results. virus isolation was performed by two serial passages in spf chicken eggs using protocols prescribed by the world organization for animal health (oie) for the most closely related gammacoronavirus, infectious bronchitis virus (ibv). samples were then subjected to targeted sequence enrichment and next-generation sequencing on an illumina miseq platform. sample pre-treatment. tissues were homogenized using a precellys evolution homogenizer (bertin instruments) according to the manufacturer's instructions. following a clarification by centrifugation at rpm for minutes, nucleic acids were extracted using the magmax pathogen rna/dna kit (ambion) according to the manufacturer's instructions. cdna synthesis was then performed using superscript ™ iv first-strand synthesis system (ssiv) (thermofisher) according to the manufacturer's recommendation. a total of ul of extracted total nucleic acid was mixed with dntps ( mm) and a tagged random nonamer primer ( um) (gtt tcc cag tca cga tan nnn nnn nn). samples were incubated at °c for minutes, and then placed on ice for minute. a reagent mixture of x ssiv buffer, ribonuclease inhibitor ( u/μl), dtt ( mm) and superscript ™ iv reverse transcriptase was then added. the samples were incubated for minutes at °c, minutes at °c and minutes at °c. second strand synthesis was performed using sequenase version . dna polymerase (thermofisher) according to the manufacturer's recommendation. the first strand synthesis product was incubated with ul of sequenase version . dna polymerase diluted in x reaction buffer and nuclease free water. samples were then heated to °c over five minutes and incubated at °c for minutes, followed by minutes at °c. samples were then cooled to °c and . ul of sequenase dna polymerase in dilution buffer was added. samples were again ramped to °c over five minutes and incubated at °c for minutes, followed by minutes at °c. a total of ul of the second strand synthesis product was then used as template for amplification. accuprime ™ taq dna polymerase (thermofisher) was mixed with x accuprime ™ pcr buffer i, nuclease free water and a primer for the nonomer's tag ( um). cycles of pcr were then performed with the following parameters: seconds at °c, seconds at °c, seconds at °c and minute at °c. cdna/dna mixtures were then cleaned with genomic dna clean & concentrator columns (zymo research) and eluted in mm tris (thermofisher). library preparation and sequencing. sequence libraries were prepared with the kapa hyperplus library kit (roche). sequence library construction and capture were carried out according to nimblegen's seqcap ez hypercap workflow user's guide v . samples were pooled in equal amounts by weight prior to capture. sequencing was performed on an illumina miseq instrument in the national centre for foreign animal disease biocontainment level sequencing facility. a v flow cell was used with a cycle reagent cartridge (illumina). ′ race and sanger sequencing. ′ race was used to obtain the missing leader sequence ( bp). the smarter ′ race and ′ race kit (takarabio) was used according to the kit instructions. the gene specific primer used for ′ race was tcagctacagtagagggagatgtcataggtgc. for sanger sequencing, amplicons was performed using kapa hifi hotstart readymixpcr kit (kapabiosystems). the primers ctaaagagaaggtggacactggt and ctaagaatgcgaacttcacagagc were used to amplify the gene b homologue region. the primers gttgttgtgttacaaggcaaggg and ggattatgatcaaaccatgaacctgg were used to amplify the nsp / region. cycling conditions table . comparison of the amino acid pairwise identity of conserved coronavirus domains in the poly ab protein of canada goose coronavirus to other gammacoronaviruses. a cluster of cases of severe acute respiratory syndrome in hong kong an apparently new syndrome of porcine epidemic diarrhoea discovery of seven novel mammalian and avian coronaviruses in the genus deltacoronavirus supports bat coronaviruses as the gene source of alphacoronavirus and betacoronavirus and avian coronaviruses as the gene source of gammacoronavirus and deltacoronavirus comparative analysis of complete genome sequences of three avian coronaviruses reveals a novel group c coronavirus revision of the family coronaviridae. taxonomic proposal to the ictv executive committee the early history of infectious bronchitis global distributions and strain diversity of avian infectious bronchitis virus: a review characterization of turkey coronavirus from turkey poults with acute enteritis identification of a novel coronavirus from a beluga whale by using a panviral microarray discovery of a novel bottlenose dolphin coronavirus reveals a distinct species of marine mammal coronavirus in gammacoronavirus viral respiratory diseases (ilt, ampv infections, ib): are they ever under control? molecular identification and characterization of novel coronaviruses infecting graylag geese (anser anser), feral pigeons (columbia livia) and mallards (anas platyrhynchos) complete nucleotide sequence of polyprotein gene and genome organization of turkey coronavirus infectious bronchitis viruses with a novel genomic organization a common rna motif in the ′ end of the genomes of astroviruses, avian infectious bronchitis virus and an equine rhinovirus structure and functional relevance of a transcription-regulating sequence involved in coronavirus discontinuous rna synthesis identification of a noncanonically transcribed subgenomic mrna of infectious bronchitis virus and other gammacoronaviruses virus-encoded proteinases and proteolytic processing in the nidovirales infectious bronchitis coronavirus limits interferon production by inducing a host shutoff that requires accessory protein b neither the rna nor the proteins of open reading frames a and b of the coronavirus infectious bronchitis virus are essential for replication deletion of accessory genes a, b, a or b from avian coronavirus infectious bronchitis virus induces an attenuated phenotype both in vitro and in vivo a polycistronic mrna specified by the coronavirus infectious bronchitis virus comparisons of envelope through b sequences of infectious bronchitis coronaviruses indicates recombination occurs in the envelope and membrane genes infectious bronchitis viruses with naturally occurring genomic rearrangement and gene deletion why do rna viruses recombine? enhanced virome sequencing using targeted sequence capture trimmomatic: a flexible trimmer for illumina sequence data rapid and sensitive removal of background sequences from next generation sequencing data spades: a new genome assembly algorithm and its applications to single-cell sequencing the pfam protein families database in clustal w and clustal x version . molecular evolutionary genetics analysis across computing platforms the authors acknowledge funding from canadian food inspection agency (cfia) project win-a- and canadian safety and security program project ti- for the student stipend of a.p. the authors would also like to acknowledge michelle nebroski and mathew fisher for review of the manuscript and technical assistance. a.p. and o.l. designed the experiment and wrote the main manuscript text. y.b. and s.s. performed sample collection and routine testing. t.w. and k.w. designed the targeted sequence capture method used for enrichment of viral sequences. a.p. performed the experimental work and performed the analysis. all authors reviewed and approved the manuscript. competing interests: the authors declare no competing interests.publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/licenses/by/ . /. key: cord- -f k authors: walsh, geraldine m.; shih, andrew w.; solh, ziad; golder, mia; schubert, peter; fearon, margaret; sheffield, william p. title: blood-borne pathogens: a canadian blood services centre for innovation symposium date: - - journal: transfus med rev doi: . /j.tmrv. . . sha: doc_id: cord_uid: f k testing donations for pathogens and deferring selected blood donors have reduced the risk of transmission of known pathogens by transfusion to extremely low levels in most developed countries. protecting the blood supply from emerging infectious threats remains a serious concern in the transfusion medicine community. transfusion services can employ indirect measures such as surveillance, hemovigilance, and donor questioning (defense), protein-, or nucleic acid based direct testing (detection), or pathogen inactivation of blood products (destruction) as strategies to mitigate the risk of transmission-transmitted infection. in the north american context, emerging threats currently include dengue, chikungunya, and hepatitis e viruses, and babesia protozoan parasites. the sars and ebola outbreaks illustrate the potential of epidemics unlikely to be transmitted by blood transfusion but disruptive to blood systems. donor-free blood products such as ex vivo generated red blood cells offer a theoretical way to avoid transmission-transmitted infection risk, although biological, engineering, and manufacturing challenges must be overcome before this approach becomes practical. similarly, next generation sequencing of all nucleic acid in a blood sample is currently possible but impractical for generalized screening. pathogen inactivation systems are in use in different jurisdictions around the world, and are starting to gain regulatory approval in north america. cost concerns make it likely that pathogen inactivation will be contemplated by blood operators through the lens of health economics and risk-based decision making, rather than in zero-risk paradigms previously embraced for transfusable products. defense of the blood supply from infectious disease risk will continue to require innovative combinations of surveillance, detection, and pathogen avoidance or inactivation. • through improvements in screening, testing, and real time surveillance, the residual risk of transmissible diseases in the canadian blood supply remains very low. • we continue to deal with infectious diseases which emerge or reemerge, such as chikungunya, babesiosis, and hepatitis e, as well as infectious diseases such as influenza, that threaten the security of the blood supply despite not being transfusion-transmissible. • new paradigms for transmissible disease prevention must become more cost effective in their scope, using targeted surveillance, donor screening, and risk-based decision making. dr margaret fearon, cbs medical director, medical microbiology, and assistant professor, university of toronto, discussed the current prevalence of classical transfusion-transmissible infections (ttis) in cbs blood donors, new and emerging infectious diseases, how cbs prepares for and manages new risks, and also addressed new paradigms for risk management. dr fearon began by emphasizing that several layers of protection in the canadian blood supply have likely reduced the risk of the classical ttis, (hepatitis b virus [hbv] , hepatitis c virus [hcv] , human immunodeficiency viruses [hiv] and , human t-lymphotropic viruses [htlv] i and ii, and syphilis). the success can be largely attributed to intensive donor testing for ttis, supplemented by donor education and deferral of donors with risk factors. the two latter approaches have reduced the number of donors with window-period infections and contributed to a decrease in confirmed transmissible disease-positive allogeneic donors over the last decade in canada, most notably for hbv and hcv [ ] . thus, the residual risk of ttis is low by any standard. the estimated residual risk in canada calculated in , using incidence rates from observed donor seroconversions to , is per million donations for hiv, per . million donations for hcv, and is per . million donations for hbv [ ] . dr fearon noted that updated residual risks are currently being calculated, but that compared to the report, the risks are not expected to change dramatically. dr fearon next turned her attention to newer and emerging infectious diseases that threaten the blood supply. some of these diseases have led to the introduction of new tti testing paradigms at cbs (ie, seasonal and selective testing for west nile virus [wnv] and chagas disease). other emerging infections are being monitored (eg, babesiosis, hepatitis e, chikv) while others such as influenza feature in contingency planning, in spite of not being transfusion-transmitted, due to their potential to disrupt blood donation and the health care system. she emphasized her opinion that transmissible disease testing must be context-specific, and account for local disease prevalence, environmental factors, and resource allocation. wnv is a mosquito-borne zoonotic arbovirus that emerged in north america in and was found to be transfusion-transmissible in [ ] . in humans, febrile illness occurs in % to % of wnv cases and % of patients have serious neurologic symptoms. since most cases are asymptomatic, tti testing is the primary means of preventing transmission [ ] . universal donor testing was adopted in using nucleic acid testing (nat). however, given the seasonal nature of wnv outbreaks, a more nuanced testing methodology was introduced by cbs in june that recognizes the lack of local transmission during the winter months. now, all donors are tested from june to november and only donors who travel outside of canada are tested during the rest of the calendar year. selective testing is also conducted for chagas disease. chagas is caused by the protozoan parasite trypanosoma cruzi and is endemic to central and south america and mexico, where it is estimated that - million people have been infected [ ] . with increasing northward immigration of people from these regions, it is estimated that n , people are infected in the united states, and most american blood services have implemented universal donor testing [ , ] . the rates of immigration from endemic countries are lower in canada and thus cbs tests donors who are identified to be at risk based on the donor questionnaire. those considered at high risk include those who were born or lived in an endemic country, or had a mother or maternal grandmother that was born or lived in an endemic country. the safety of this approach was demonstrated in a recent study that identified no evidence of infection amongst donors without risk factors identified on the questionnaire (with the exception of one very unusual transfusion transmissionvertical transmission case) [ ] . interestingly, the selective testing approaches used for wnv and chagas disease at cbs represent a change from the universal testing approach of the last three decades, which can be summed up as "test everyone for everything". the newer approach to certain ttis takes into account geographic location, seasonal effects, and other risk factors in setting the optimal testing strategy. dr fearon called attention to other infectious outbreaks that can impact the security of the blood supply despite not being transfusiontransmissible, and cited severe acute respiratory syndrome (sars) and pandemic influenza as examples. outbreaks of these diseases can lead to shortages of staff and donors due to illness and shortages of critical supplies. contingency planning is necessary to guard against these risks. staff and donor education, infection control procedures in the clinic, and reassessment of donor deferral criteria are key steps that must be taken to protect the blood supply in this context. other transfusion-transmissible diseases are currently being monitored as potential emerging threats to the safety of the blood supply, including babesiosis, hepatitis e, chikv, and dengue virus. babesiosis is caused by the protozoan parasites b microti, b duncani, and others in this genus, and spread by infected ticks. most infections are asymptomatic or unrecognized, but the spectrum of clinical severity also includes flu-like symptoms, ranging to more severe illness and death in the immunocompromised [ ] . babesia microti is the most frequently transfusion-transmitted microbial pathogen in the united states, especially in the northeast and upper midwest states [ ] . there were transfusion-transmitted cases reported from to in the united states with one case reported in canada [ ] . hepatitis e is clinically similar to hepatitis a and it causes water-borne outbreaks in developing countries. in canada, where it was previously thought to be primarily a disease of travelers, the actual prevalence of endemic hepatitis e is unknown. no cases of transmission by transfusion have been reported in north america, but transfusion transmission has been reported in endemic countries and recently in the united kingdom [ ] . chikv and dengue are two viruses common in the tropics that are spread by mosquitos. both lead to similar acute illnesses with fever, rash, and muscle/joint pain. transfusion-transmitted cases of dengue have been reported. chikv arrived in the caribbean in and was thus identified as a threat to north america [ ] . however, no transfusion transmitted cases of chikv have been reported to date. current malaria travel deferral provides some protection with respect to many but not all of the affected areas, particularly in the caribbean. how can blood operators best prepare for emerging threats? surveillance is conducted by multiple health agencies, including the world health organization (who), centers for disease control and prevention, and the international society for infectious diseases, which operates the promed (program for monitoring emerging diseases). available to any subscriber, promed is an internet-based reporting system dedicated to rapid global dissemination of information on transmissible diseases. the public health agency of canada is the federal agency responsible for transmissible disease surveillance in canada. public health agency of canada encompasses the national microbiology laboratory and in collaboration with the provincial public health laboratories, provides diagnostic testing and surveillance data that is useful in guiding cbs decision-making. testing data provided by the national microbiology laboratory on travel-acquired chikungunya was used by cbs to calculate an estimated risk of a case of transfusion transmitted chikv in canada of less than in million. collaboration with veterinarians, etymologists, and ornithologists may provide additional information to inform preparative and reactive strategies for emerging agents. for example, active tick surveillance reports provide risk data for lyme disease, but are also relevant to other tick-borne, transfusion-transmissible diseases such as babesiosis [ ] . a recent babesia seroprevalence study for b microti in canadian blood donors demonstrated that donor testing is not warranted in canada at this time [ ] . dr fearon presented as-yet-unpublished data on a collaborative cbs and héma-quebec (the transfusion service for quebec province) hepatitis e seroprevalence study that indicated that age is the only significant factor for increasing seroprevalence of hepatitis e. the absence of polymerase chain reaction (pcr)-positive results suggests that the risk of transfusion-transmission of hepatitis e in canada is extremely low; however, further prevalence data needs to be collected. a cbs donor travel survey from also provided data that is used to inform risk assessment. while the united states remains the most popular travel destination for cbs blood donors, nearly % of respondents reported travel to the caribbean. such donor travel survey data allows cbs to estimate potential donor loss when assessing the risk/benefit of deferring donors who have travelled to countries with outbreaks. the challenge facing all blood operators is to synthesize all of the available information on existing and emerging threats in order to rapidly make decisions that balance risks, costs, and safety. to meet this challenge, dr fearon suggested utilization of the alliance of blood operators' risk-based decision making framework for blood safety (fig : risk-based decision making framework) [ ] [ ] [ ] . this framework has a health sector focus, can aid evidence-based decisions using risk assessment tools, and accounts for multiple sectors included in the decision making process [ , ] . the use of this approach also represents a paradigm shift for blood operators, away from "zero-risk" to one that uses a decision-making process that integrates evidence, ethics, social values, economics, public expectations, and historical context with broader health care priorities [ ] . • the emergence of infectious diseases is unpredictable. • emerging infectious diseases (eids) is a global issue that demands international surveillance efforts. horizon scanning is important. • the eid tool-kit provides a useful framework for managing infectious threats to the blood supply. dr roger dodd, secretary general of the international society of blood transfusion, presented his perspectives on past and current pathogens affecting the safety of the blood supply. the objectives of his presentation were -fold: ( ) to define what eids are and why they occur; ( ) to discuss why some eids impact blood safety; ( ) to review how the impact on the blood supply is managed; and ) to examine some current examples of emerging infections and how they are being managed. dr dodd began with the institute of medicine's definition of an emerging infectious disease as one "whose incidence in humans has increased within the past two decades or threatens to increase in the near future". the institute of medicine further elaborates that "emergence may be due to the spread of a new agent, to the recognition of an infection that has been present in the population but has gone undetected, or to the realization that an established disease has an infectious origin. emergence may also be used to describe the reappearance (or reemergence) of a known infection after a decline in incidence" [ ] . eids often originate from animal-human interactions. a prime example is variant creutzfeldt-jakob disease (vcjd) which probably results from human consumption of meat from animals infected with bovine spongiform encephalopathy (also called mad cow disease) [ ] . it is estimated that approximately % to % of current eids are zoonoses, and they can be caused by any class of pathogenic agent (viruses, bacteria, parasites, and prions) and spread through several modes of transmission (fecal-oral, sexual contact, etc). infections emerge for a variety of reasons. pathogens may undergo a "species jump" as was the case in hiv [ ] and sars [ ] . environmental change, such as global warming, may increase the incidence and range of eids such as dengue, malaria, and babesiosis. drug resistance and mutations may lead to challenges in controlling malaria and hbv and subsequent spread. human migration and travel contributes to the dissemination of t cruzi (the chagas disease pathogen) and chikv. the migration patterns of birds, reservoirs for wnv, are also associated with the spread of this disease. certain parts of the world are considered to be "hot spots" for the emergence of infectious disease for a variety of reasons. for example, china is considered a prime site for the emergence of new strains of viruses (influenza and sars) due to the close proximity of human-human interactions and human-animal interactions, which can lead to the evolution of animal viral strains into novel strains that can infect humans. in a general sense, this evolution can be potentiated by the consumption of wild meat (meat from non-domesticated mammals, reptiles, amphibians, and birds). through careful phylogenetic analysis of simian and human viruses, africa has been recognized as the "hot spot" for hiv emergence, probably due to consumption of primate bush-meat by humans, [ ] . urbanization, poor sanitation, and crowding in the developing world have also been linked to hepatitis e emergence [ ] . although our understanding of the factors contributing to specific eid transmission has improved, these transmissions are likely multifactorial in nature. dr dodd emphasized that eids are both a local and a global issue. some infections may emerge explosively in new areas if appropriate conditions (eg, the vector or environment) are met, as is the case with wnv, dengue, and chikv. other eids, such as chagas disease, may expand slowly as a result of population movements, but can become constrained in their new environment. tick-borne infections, such as those caused by babesia in the united states, may be constrained regionally. infections that are characterized by direct human to human transmission may spread worldwide but at differing rates, depending on the mode of transmission such as the rapid respiratory spread of influenza and sars and slower sexual transmission of hiv. despite our understanding of infectious disease transmission, the emergence of these diseases remains largely unpredictable. understanding that eids may be spread by human travel and through animal contact allows us to understand the probability of acquiring an infection if specific conditions are met, but it does not allow us to predict which infectious disease will emerge and when. such unpredictability requires regular surveillance and hemovigilance efforts to be in place around the world. disease surveillance has many challenges, but warning signals may help focus efforts to better monitor disease spread. these warning signals may include disease outbreaks in particularly susceptible populations (such as the immunocompromised), and/or the blood-borne nature of a disease. why do some emerging infections impact blood safety? dr dodd noted that when an epidemic occurs, only a minute proportion is attributable to transfusion. for example, only % of hiv cases were transfusion-transmitted during the hiv epidemic [ ] . similarly, only of , wnv cases ( . %) were established as ttis [ ] . in other words, outbreaks are not likely to start from a transfusion, and transfused patients are not necessarily more likely to acquire an infection than the general population. for an infectious disease to be considered a transfusion-transmissible disease, certain pathogen-related and recipient-related characteristics have to be present. first, the pathogen must have an asymptomatic blood-borne phase (such as hepatitis b), which may either be acute or chronic. second, the pathogen must be able to survive the donated blood processing and storage procedures, including temperature changes, leukoreduction, and centrifugation. third, the disease must be transmissible by the intravenous route. fourth, the recipient has to be susceptible to infection. fifth, the disease must be a recognizable entity in the recipient once symptoms appear. next, dr dodd turned his attention to how the impact of eids on the blood supply is managed. in , the aabb published a list of eids of interest. each eid was categorized based on the threat it poses to transfusion safety, the level of regulatory concern, the lack of effective intervention, and the amount of public concern. the top priority was assigned to pathogens towards which intellectual and future resources should be focused: dengue viruses; babesia species; and prions causing human vcjd [ ] . the list also included chikv, plasmodium species, t cruzi, human parvovirus b , hiv, and hepatitis e. an eid tool-kit (fig ) was subsequently developed as a framework to guide health professionals and public health officials in triaging and managing infectious threats to the blood supply [ ] . the eid tool-kit presents: a variety of methods for eid surveillance; key questions to be asked when a threat is suspected; and potential courses of action based on the situation. the risk-based decision-making framework. the risk-based decision-making framework was designed by the alliance of blood operator to help blood operators identify, assess, act on, and communicate risk in decisions related to blood safety. it is a flexible tool, and its objectives are to optimize the safety of the blood supply while recognizing that elimination of all risk is not possible; allocate resources in proportion to the magnitude and seriousness of the risk and the effectiveness of the interventions to reduce risk; and assess and incorporate the social, economic, and ethical factors that may affect decisions about risk [ ] [ ] [ ] . included among the pathogens identified in the aabb report, several agents are being actively monitored both on a regional and global level. due to increasing reports of transfusion-transmitted cases, their poor prognosis in immunocompromised transfusion recipients, and the lack of effective prevention strategies, babesia species have been classified as a top priority for future blood supply safety efforts in the united states. prions such as vcjd are being monitored closely and donor screening has been successful in preventing their spread into the donor pool [ ] . prions are currently being investigated for their potential relationship with other protein-folding diseases such as alzheimer's disease [ ] . although respiratory infections (eg, middle east respiratory syndrome coronavirus) are not transfusiontransmissible, they do disrupt donor availability and organizational aspects of the blood collection and donation system. dr dodd expanded upon wnv, adding american insights into those earlier provided in the canadian context by dr fearon. west nile fever is caused by a flavivirus transmitted by culicine mosquitoes. the virus spread from southern europe, africa, and the middle east to india, and arrived in the united states in . by wnv was endemic in most of the continental us and canada [ ] . the experience of wnv in the us demonstrated that imported infections can be overwhelming and unpredictable. while wnv was considered a stable disease elsewhere in the world, in north america it was experienced as an explosive outbreak in and infecting over , individuals. public concern was high as wnv, previously unknown in north america, spread rapidly across the continent via infected birds, and then to humans via mosquitoes. although human to human transmission is not possible, there is potential for transfusion-associated transmission if the donation occurs during periods of pre-symptomatic viremia. nat of pooled donor samples offered a rapid route to testing. like other north american blood operators, cbs tests donors in pools. if a pool tests positive, individual donor testing is initiated. after nat was initiated in the us in , cases of transfusion-transmitted wnv have only rarely been encountered [ ] . horizon scanning efforts are actively monitoring other potential eids. dr dodd described several emerging agents for which there is some evidence that that have or an assumption that they may be transfusion-transmitted including severe fever with thrombocytopenia syndrome virus (no reported transfusion transmission [tt]), q fever (one report of tt, but no definitive evidence), hepatitis e virus (good evidence of occasional tt), vcjd, and other prions (evidence for tt) [ ] . dr dodd focused on two viruses that are current causes for concern. dengue virus is an important arbovirus. like wnv, it is a flavivirus and is spread by mosquitos (aedes genus). humans are the amplifying host, and while a vaccine is under investigation there is currently no vaccine or specific treatment. vector control is the only effective intervention. there are an estimated million infections per annum worldwide [ ] . in % to % of cases infection is asymptomatic. dengue viruses have been found to be transfusion-transmitted in separate geographic clusters in hong kong, singapore, puerto rico, and brazil. currently, there is no fda-licensed test for dengue rna [ , ] . chikv, which has caused recent massive outbreaks in the caribbean and co-exists with dengue virus, is a potential threat to the north american blood supply due to its geographic proximity and donor travel emerging infectious disease toolkit. the emerging infectious disease toolkit is a framework developed by the aabb transfusion-transmitted diseases, emerging infectious diseases subgroup to guide health professionals and public health officials in triaging and managing infectious threats to the blood supply. the eid tool-kit presents: a variety of methods for eid surveillance; key questions to be asked when a threat is suspected; and potential courses of action based on the situation [ ] . patterns [ ] . chikv recently appeared in the caribbean. should it arrive in north america, donors could be deferred for exposure or symptoms, nat testing for chikv rna could be initiated, and red cell and plasma collections could even be stopped. dr dodd stated that pathogen inactivation will likely become increasingly important in preventing transfusion-transmission of emerging agents. the american red cross in puerto rico is currently involved in a trial to investigate and monitor the safety of intercept pathogen inactivation technology (cerus corporation). intercept was recently approved by the fda for use with apheresis platelets. use of intercept to make available pathogenreduced apheresis platelets could prevent interruptions in the local platelet supply in areas where viruses like chikv emerge [ ] . • the ebola outbreak in west africa was the largest in history. • the difficulties in identifying the virus in west africa and in containing its spread were related to poverty, growing populations and deforestation, lack of healthcare infrastructure and resources. these fundamental issues must be addressed in order to prevent and/or contain future outbreaks. dr allison mcgeer, director of infection control at toronto's mount sinai hospital, used the recent ebola outbreak in west africa to provide a thought-provoking global perspective regarding pathogens and their spread. as a consultant on a who-initiated mission to liberia, dr mcgeer obtained first-hand information and impressions of the situation on the ground in west africa, where she navigated issues related to policy and healthcare set-up. ebola virus is difficult to study because of its high mortality rates, and because it often occurs in areas that are difficult to access due to poor infrastructure or because of conflict or political turmoil. ebola infections seem to emerge due to the interconnection of enzootic and epizootic cycles [ ] . the first sequence involves bats as the most likely reservoir host for the virus, which is spread by enzootic transmission within the bat population. from this pool of virus carriers, transmission to other non-human species is thought to happen in an epizootic cycle. initial transmission to humans involves contact with infected bats or other species through hunting or accidental contact with ill wild animals. humanto-human spread via direct close contact is then very efficient. once humans are infected, the ebola virus first appears to target the immune system and subsequently destroys the vascular system, leading to blood leakage. initial attacks on dendritic cells lead to decreased interferon production and macrophage and endothelial cell degradation [ ] . this pattern results in clinical presentations of hemorrhage, hypotension, drop in blood pressure, followed by shock and death [ ] . the ebola outbreak, which primarily affected guinea, sierra leone, and liberia in west africa, is the most recent in the history of ebola epidemics [ ] . since , more than outbreaks have been recorded in sub-saharan africa leading to hundreds of cases and deaths [ ] . historically, infection has been controlled by local communities with the isolation of any patient showing symptoms. however, in in west africa, the outbreak was on an unprecedented scale. dr mcgeer provided an eye-opening overview of health infrastructure in the affected west african countries. guinea, liberia, and sierra leone have populations of . , . , and million, respectively (vs million in canada). spending on health (total expenditure per capita) is us$ , us$ , us$ , and us$ in guinea, liberia, sierra leone, and canada, respectively [ ] . this imbalance is mirrored in the number of doctors per , population: , . , . for guinea, liberia, sierra leone, respectively, compared to . in the united states of america [ ] . under-resourcing of public health and healthcare delivery was an important contributor to the unprecedented scale of the epidemic. the first step in this epidemic was the spread of the virus from a reservoir in west africa, but the outbreak was aided by many economic, political, and geographic factors. being now relatively stable after periods of civil war, these countries have increasing birth rates and increasing populations. the median age in guinea, liberia, and sierra leone is . , . , and , respectively (vs in canada). the ever-growing population and deforestation is believed to have accelerated the frequency of the epizootic cycle. once rich in forests, west africa has been intensively logged over the last decade. guinea's rainforests have been reduced by %, while liberia has sold logging rights to over half its forests. some analysts have predicted the complete deforestation of sierra leone within the next few years [ ] . the forests are the habitat for fruit bats, ebola's probable reservoir host. with the loss of their habitat, the bats escape to urban environments to hunt for food, coming in contact with humans and triggering more frequent transmissions of the virus. dr mcgeer personally witnessed the huge barriers to effective control of the epidemic in hospitals in liberia. she pointed to the rudimentary nature of facilities and equipment, poor hygiene, and a lack of infrastructure for disposing of hospital waste. dr mcgeer commented that due to the lack not only of resources but also of any form of emergency plan, the base from which to fight the epidemic was completely lacking. the lack of resources for infection control and personal protective equipment are the main reasons for nosocomial transmission [ ] , and affected healthcare workers can act as amplifiers spreading the virus into the community. in the epidemic, in healthcare workers were infected, and of those, in are believed to have died [ ] . this devastated the ability of front-line healthcare workers to control the epidemic, and led to hospital closures. poor general infrastructure hindered transportation of medical supplies and expertise, isolating rural areas and limiting access. dr mcgeer highlighted the absence of public health and health care infrastructure as a fundamental issue in being able to fight this disease, not just on the ground in west africa, but globally. this issue is illustrated by a fragmented global health system is which the institutions, laws, and strategies are not interconnected. experience of this outbreak has led to calls to reform the worldwide health systems architecture and the who [ ] . some media reports led to widespread misunderstanding of the ebola outbreak as an "african problem," and unhelpfully perpetuated prejudicial colonial-era stereotypes. dr mcgeer took the audience through the evolution of the epidemic in liberia which peaked in august/september . during july and august the number of confirmed cases per day increased from about to about , and ebola treatment units and burial systems were overwhelmed. in monrovia, the liberian capital city, about % of patients with ebola virus disease were being managed at home. despite this, hospitals were overwhelmed with ebola patients, filling to % of its capacity. many health care workers were infected, which ultimately led to the decision to close hospitals. at the peak of the outbreak, the president of liberia quarantined west point, a township particularly badly affected. this decision led to riots in that area. similar actions took place in other parts of liberia [ ] . as a consequence of the deteriorating situation in west africa, international responses were initiated [ ] . by september , more than non-governmental organizations were on the ground in liberia to contribute to the fight against ebola. their work spanned a wide range of activities including: setting up medical care; contact tracing; opening orphanages; providing food for people in quarantine; building roads for improved access to cemeteries; identifying how to de-sludge septic tanks from ebola treatment units; and sourcing and supplying personal protection equipment for ebola treatment units. the crisis response also involved a coordinated international response of unprecedented scale to accelerate vaccine development. no vaccine had ever been tested in humans prior to , but several were fast-tracked through phases i and ii, and in june of , an international group of scientists published the interim results of an open-label, cluster-randomized ring vaccination trial of an engineered vesicular stomatitis virus-based ebola vaccine developed at canada's national microbiology laboratory [ ] . ring vaccination seeks to create a buffer of protection around each case, so that the virus cannot continue to spread. this initial trial found that % of recipients were protected from the virus; further study of this vaccine and trials of other vaccines are on-going. with improvements in the coordination of the overall emergency response, more than a year later, the outbreak is under control. occasional cases were still appearing in liberia in november , but on november , , who declared the end of ebola virus transmission in sierra leone, as days had passed since the second negative test of the last confirmed patient with ebola in the country [ ] . control of the outbreak was only achieved through the institution of effective control and quarantine measures and an understanding of local practices and challenges that impacted the spread of the virus. dr mcgeer added her voice to the chorus of experts recommending coordinated national and international efforts to prevent future outbreaks. early warning systems should be developed in connection with local communities in high-risk areas, and provision of clearly defined response recommendations specific to the needs of each community [ ] . recent advances in diagnostics, risk mapping, mathematical modeling, and pathogen genome sequencing have the potential to improve substantially the quantity and quality of information available to guide the public health response to outbreaks [ ] . however, prevention remains extremely difficult [ ] . the world bank estimated that an~$ m investment in public health in west africa would have prevented more than % of cases in west africa. this missed opportunity eventually led to a costly emergency response estimated by the un mission for ebola emergency response at about $ . billion. future epidemic control measures in poverty-stricken areas, including worldwide response teams and pre-approved emergency funds may improve outbreak response, but addressing the fundamental issues of poverty, infrastructure, education, healthcare, workforce development, and communications will be needed if outbreaks are to be prevented [ ] . • several approaches for the production of red blood cells (rbcs) ex vivo exist and have demonstrated feasibility; however, none can yet be conducted on a scale that would allow replacement of donor-derived rbcs • to improve the chances of success in bringing ex vivo rbcs to the clinic, a multidisciplinary approach and an integrated plan are required to navigate the long path from concept to commercial product. an alternative means to keep the blood system safe from pathogens is to move away from the current paradigm of donor-derived products. this topic was addressed by dr marc turner, medical director at the scottish national blood transfusion service and professor of cellular therapy at the university of edinburgh. dr turner began by mentioning some milestones in the history of blood transfusion, highlighting a number of events that took place in his adopted home city of edinburgh, scotland. for example, in the first systematic experiments in intra-species transfusion were carried out by john henry leacock, who was studying in edinburgh at the time. james blundell, a university of edinburgh medical school graduate, is credited with conducting the first successful human transfusions several years later. since early in the last century, transfusion has become a mainstay of clinical practice with around million rbc transfusions conducted annually worldwide [ ] . for the most part, and particularly in developed countries, blood transfusion is safe. however, limitations remain, including sufficiency of supply, immunological compatibility of the donor and recipient, the risk of ttis, and the risk of other complications such as iron overload. many of these limitations could potentially be overcome by the production of rbcs for transfusion in the laboratory. dr turner's talk focused on human stem cells and their potential use for the ex vivo generation of rbcs for transfusion. dr turner discussed the biological and engineering limitations that must be overcome in order for ex vivo generated cells to become viable alternatives to donor-derived rbcs. the first conclusive observation of stem cells was in by mcculloch and till in the host city of this symposium -toronto [ ] . stem cells have the capability for self-renewal and can differentiate into multiple lineages, ultimately resulting in the generation of differentiated cells or tissues. there are various types of stem cells, including those derived from embryos (eg, human embryonic stem cells [hescs]) and from adults. not all stem cells are the same. for example, hescs are pluripotent and have unlimited ability to replicate, whereas adultderived hematopoietic stem and progenitor cells (hspcs) can differentiate into cells of the hematopoietic and immune systems and have limited ability to replicate. found in the bone marrow, hspcs are morphologically indistinct from other bone marrow cells, and are distinguished as cd + cells using flow cytometry. in vivo, hspcs are found in a hypoxic environment at the edges of the bone marrow. as they differentiate, they move more centrally in the marrow into an environment with a higher o tension. it has long been known that when placed into agar/semisolid medium and provided with the right cytokine support, hspcs can differentiate along different hematopoietic lineages, forming granulocyte/monocyte, and erythroid colonies with to days [ ] . culturing hspcs in suspension using a two-phase culture system has several advantages over solid-phase culture [ ] , the in vitro environment can be more precisely controlled and can be separated more easily [ , ] . dr turner provided an overview of a two stage culture system which uses combinations of cytokines to control cell differentiation and proliferation and can be used to produce erythroid cells from cd + adult peripheral blood cells. during the enucleation process, which moves the cells into the early reticulocyte stage, the nucleus is extruded from the cell, and engulfed by macrophages. by days to of the two-stage culture, the population consists of approximately % normoblasts and % early (r ) reticulocytes. other -stage systems have had demonstrated success expanding cd + hspc from peripheral blood, bone marrow, or cord blood into functional rbcs [ ] . these proofs-of-principle demonstrated that rbc generation ex vivo is possible, but processes described to date have limited scalability and do not yet constitute a workable approach to generate rbcs for transfusion. dr turner spent the remainder of his talk discussing the two major types of challenges facing the ex vivo generation of rbcs for transfusion: biological challenges and engineering/logistical challenges. from the biological point of view, one major challenge is to determine the best source from which to derive the cells. adult hematopoietic stem cells (hscs), one potential source of ex vivo rbcs, have a limited replication capacity; they could generate a small number of units of rbc but the reliance on donors remains. unlike hscs, hescs have indefinite expansion capabilities and can self-renew, and were a source of much excitement when their derivation was first described [ ] . hescs are pluripotentthey can be cultured indefinitely as cell lines and are able to differentiate into all the cells of the body including hematopoietic cells [ ] . in , a considerably less ethically-controversial source of pluripotent stem cells was discovered-induced pluripotent stem cells (ipscs) [ , ] earning the discoverer the nobel prize for medicine in . initially generated by takahashi and yamanaka from human somatic skin fibroblasts by the use of four genes (oct /sox /klf /myc), ipscs are very similar to hescs, can be differentiated into all three germ layers and have huge potential for regenerative medicine applications and disease modeling. like hescs, human ipscs can be differentiated into hematopoietic cells in vitro [ ] [ ] [ ] [ ] , and this is an area of intensive research [ ] . dr turner provided an overview of a system by which rbcs can be derived from human pluripotent stem cells (hpsc) in vitro using a feeder/serum free approach and cytokine mixes that drive the hpsc to hspcs, then erythroblasts, normoblasts, and eventually reticulocytes over an approximately -day time frame. the differentiation process is complex and uses mixes of multiple cytokines and small molecules. several issues remain including the long differentiation time, and the fact that while hpsc-derived rbcs can enucleate, the resulting cells are fragile and difficult to maintain in culture. the hpsc-derived rbcs express α/γ globin chains, the same combination of hemoglobin polypeptides expressed in fetal rbcs (as opposed to α/β globin chains in adult rbcs); however, the oxygen-delivering characteristics of the hpscderived rbcs are acceptable and therefore this would not preclude their use. efforts are underway to optimize erythrocyte differentiation and enucleation and modify the hemoglobin to a more adult form [ , ] . another approach that holds promise is to immortalize multipotent stem cells using well-understood and established methods. conditional immortalization from hpscs or adult hspc can be achieved using human papilloma virus e /e or combinations of transcription factors. this approach can establish immortalized human erythroid progenitor cell lines [ ] . switching off the immortalization allows the production of enucleate rbcs ex vivo. this approach has several benefits over psc-as a starting material: the process is less complex and the differentiation time is shorter; there are reduced costs related to cytokines, growth factors, and media; and the final rbc phenotype is closer to an adult phenotype. the feasibility of this approach to produce enucleated rbcs has been shown [ ] . potential drawbacks of this approach include concerns regarding: the introduction of oncogenes into the cells; cell line stability; and the likelihood of being able to meet good manufacturing practice standards and produce clinical grade products. notwithstanding the difficulties involved, the potential now clearly exists to allow culturing of rbc with rare phenotypes or modification of the rbcs [ ] to help meet the needs of hard-to-match transfusion recipients. the first proof-of-principle human transfusion with ex vivo generated rbcs cultured from peripheral cd + hsc was conducted in , and showed that post-transfusion survival of ex vivo generated rbcs in a single, healthy subject was comparable to that of donorderived rbcs [ ] . dr turner then turned his attention to the engineering technology needed to make ex vivo generated rbcs a viable alternative to donorderived products. the key issues here are scale-up, process control, and intensification. dr turner described the use of the ambr bioreactor technology (from tap biosystems, part of the sartorius stedim biotech group) as an approach to optimising the in vitro culture environment. stirred tank bioreactors are a mature technology that is scalable and well-established for production of biotherapeutics. they allow for precise control of several physico-chemical parameters and economic/ rapid development screening at a variety of scales ( ml, ml, multi-liter). there are two gross limits to system efficiency. the first is the absolute density limit, which is calculated from specific oxygen uptake rate of cells and the mass transfer coefficient of the system. in this regard, the bioreactor system performs well; high density can be achieved, and the potential is certainly there to succeed in scaling it up to the needs of producing erythroid cells. the second limit is media volumetric productivity (liters of media/units of blood). volumetric productivity is precisely determined by cell growth rate and specific support capacity of the media-consumption and supplementation. specific rates are unstable and supplementation with glucose and glutamine does not improve growth, suggesting these are not limiting factors. in order for potential scale-up of this system, the limiting factors need to be identified. currently, dr turner estimates that the costs of ex vivo-derived rbcs stand at many times the cost of donor-derived rbcs. at this stage this technology is therefore only likely to be considered for "boutique" applications in patients for whom a donor-derived matched product is difficult or impossible to source. for more generalized application, many challenges remain, including control over the genetic and epigenetic stability of cell lines; optimization of the differentiation pathway to allow stable enucleation; efficiency of the differentiation pathway; process control over multiple physical and biochemical factors; scale up and intensification to control the cost of goods; detailed characterization of the product; demonstration of preclinical safety and efficacy; quality control and regulatory compliance; and the design and execution of pivotal clinical trials [ ] . many of the challenges dr turner mentioned are common to all cellbased therapeutics. regarding quality control and product characterization, one advantage in this field is that there is more than years of rbc product characteristic information, knowledge, and experience on which to draw. dr turner ended by noting that a sea change in the level of process control would be required to make the production of the ex vivo rbcs a reality. dr turner outlined the environment, resources, and approaches he believes are necessary in order for this type of innovation to take place and achieve commercial success [ ] . this includes multidisciplinarity, integrated planning, and lengthy time lines and in these regards dr turner acknowledged the commitment of the research teams and funders working in this space. • pathogen testing in canada is centralized, automated, and closely regulated by the federal government. ms. nancy angus, director of testing at cbs, provided an overview of the current state of testing at this organization, with an emphasis on donor testing. focusing on tests in use in canada, ms. angus described laboratory tests for the detection of blood-borne pathogens and summarized the differences in sensitivity among the tests currently in use. cbs testing sites include donor testing, diagnostic services, the national testing laboratory, national reference laboratories, quality control product laboratories, and the human leukocyte antigen laboratory. donor testing, which includes transmissible disease testing, is performed at two sites: calgary, alberta, where all blood collected west of ontario is tested; and toronto, where all blood collected in ontario and east of ontario is tested. each site is a mirror-image of the other in terms of equipment, and can act as a back-up for the other site for business continuity reasons should the need arise. all blood collected by cbs is tested for a number of blood-borne pathogens: syphilis; hiv- and − ; hbv; hcv; and htlv i and ii (table ). since implementation in , wnv testing has been performed on all collected blood; however, as of , that testing is now performed seasonally. in addition to mandatory testing performed on all collected blood, there are tests that are performed based on risk. approximately % of collected blood is tested for cytomegalovirus (cmv) in order to supply hospital demand and based on an algorithm identifying which donors are most likely to be cmvfree. testing for chagas is performed selectively, based on risk; donations from donors indicating on their questionnaires that they or their mothers or maternal grandmothers originate in a chagasendemic country or that they have had extended stays in endemic areas for greater than six months. chemiluminescent assays are performed using the abbott prism platform to detect the surface antigen of the hepatitis b virus (hbsag), total antibody to hepatitis b core antigen, antibodies to hepatitis c virus, antibodies to hiv- groups m and o and/or antibodies to hiv- , antibodies to human t-lymphotropic virus type i and/or human tlymphotropic virus type ii, and antibodies to t cruzi. agglutination assays are performed on the beckman coulter pk platform: syphilis infection is identified using a micro-hemagglutination assay to detect treponema pallidum antibodies, and cmv infection is detected using a passive particle agglutination assay to detect total cytomegalovirus antibodies. nat is performed using the roche cobas platform to detect hiv- rna (groups m and o), hiv- rna, hcv rna, hbv dna, and wnv rna. samples are screened in pools of , and single unit testing is performed on selected donations from the same geographic region when a positive donation for wnv is identified. in canada, all testing platforms require approval by health canada. other platforms currently available include the immucor neo platform, which is a solid phase system that allows for the serological detection of syphilis and cmv, and the grifols tigris platform, in use at hema-quebec, which performs nat to detect hiv rna, hcv rna, hbv dna, and wnv rna. if a blood donation is found to be serologically reactive, confirmatory testing is performed to determine if the donor is a "true" positive. confirmatory testing is either performed at cbs or at an external agency. within cbs, confirmatory tests include hbsag neutralization assay, immunoblots for hiv- , htlv i, htlv ii, and hcv, and enzyme immunoassay to detect hiv- . syphilis confirmatory testing is performed at either the alberta public health laboratory or the ontario public health laboratory and chagas confirmatory testing is performed at the national reference centre for parasitology in montreal. the medical services and innovation division at cbs performs surveillance to identify blood-borne pathogens that may pose a threat to the blood supply. if it is decided that a new test needs to be implemented to identify a new pathogen or new equipment is required to replace equipment at the end of its life, health canada licensure is required, unless there is an emerging threat. currently on the horizon, cbs is considering the possibility of introducing hepatitis e virus nat, and testing for babesia next generation sequencing: the future of pathogen testing? • next generation sequencing (ngs) is an advanced technology approach that involves sequencing all dna found in a clinical sample. • innovative bioinformatic approaches are required to minimize the computational time required to find pathogen dna in the sample and to maximize accuracy. • ngs is being increasingly used for otherwise indeterminate clinical diagnoses, for tracking of infectious disease outbreaks, and to detect novel pathogens. • ngs is unlikely to play a role in screening the blood supply for infectious disease markers in the near to medium term. dr samia naccache, associate specialist, department of laboratory medicine, university of california san francisco (ucsf) school of medicine, introduced attendees to the use of next generation sequencing, metagenomics, and bioinformatics for the detection and identification of infectious agents. dr naccache first pointed out that she was a member of the laboratory of dr charles chiu, which is home to the ucsf/abbott viral diagnostics and discovery center (ucsf/avddc), and that the center works closely with the ucsf clinical microbiology laboratory to provide advanced technology assistance with the most challenging problems in infectious disease diagnosis and tracking. dr naccache commenced her presentation by contrasting "classical" dna sequencing methods with next generation sequencing (ngs). anti-hiv and , antibodies to hiv- groups m and o and antibodies to hiv- ; nat, nucleic acid testing; anti-hbc, total antibodies to hepatitis b core antigen; anti-hcv, antibodies to hepatitis c virus; anti-htlv i/ii, antibodies to human t-lymphotropic virus i and human t-lymphotropic virus type ii. ⁎ only selected units are tested. § single unit limit of detection; theoretical sensitivity is calculated by multiplying single unit limit of detection by . frederick sanger and colleagues invented a method of dna sequence determination in the s [ ] that was intensively used by scientists for the next years [ ] . sanger sequencing was based on the selective and partial incorporation of chain-terminating dideoxyribonucleotides into copies of the dna strand being sequenced, and their separation by denaturing electrophoresis into a readable sequence "ladder". dr naccache stressed that sanger sequencing, even in later, high throughput versions, was employed on one limited piece of dna (typically a small dna sector amplified using pcr) at a time to yield a single output sequence. although this method was sufficiently advanced to be used to sequence first the human mitochondrial genome [ ] and then the entire human genome [ , ] , its robustness pales in comparison to ngs approaches. ngs yields huge amounts of dna sequence in parallel; in other words, many sequences in a sample can be analyzed simultaneously [ ] . for this reason, ngs is also called deep or massively parallel or high throughput sequencing. its information output is such that thousands or millions of sequences can be provided concurrently, in a matter of hours. ngs has made possible metagenomic approaches, in which all dna sequences from all genomes present in a clinical sample can be identified. this approach can now be used to determine if a blood sample contains only human dna, or human dna plus the dna of an infectious pathogen, as well as to identify that pathogen if its sequence is known. a brief technical overview of ngs methodology was provided by dr naccache. all dna/rna present in a sample is first rapidly extracted (or copied using pcr) and fragmented into pieces of uniform length, providing a library. short artificial dna sequences are then bonded onto either end of all library dna fragments. these adaptors allow hybridization of one strand of the modified dna to complementary, tethered pieces of dna in a flow cell. they are then "sequenced by synthesis" using fluorescent deoxyribonucleotide triphosphate building blocks. as each base is added to the growing chain, its position is noted via imaging and the positional information is captured in parallel. ngs can therefore provide to gigabytes of data-much of it "redundant" in that the same sequence has been detected and read multiple times-to ensure sufficient coverage of all dna sequence present in a sample. this huge amount of data is first processed using algorithms that detect and remove low quality reads, and then the "host" or human genome sequence information is subtracted. the remaining dna is assembled into contiguous arrays by alignment of overlapping sequences, and compared to reference genomes of known pathogens. if an identified pathogen differs slightly from reference genomes, taxonomic classification can then be done to determine how recently the variant has diverged from known sequences. dr naccache stressed that this approach will work on bacterial, viral, fungal, and parasitic pathogens, all encoded by rna-or dna-based genomes, but not on prions, which are protein-based pathogens that infect by causing host proteins to take on pathological conformations. ngs is an advanced technology approach fully dependent on the characteristics of the instrumentation employed. dr naccache surveyed the rapid development of commercial deep sequencing machines [ ] . first to market in was roche, with its sequencer, capable of reads of to bp. illumina and ion torent produced instruments that generated millions to billions of reads of slightly shorter sizes of to bp, with similar overall run times, between and . these products all worked on the paradigm of sequencing by synthesis. the most recent entries into this instrumentation field work on a different principle, called nanopore sequencing: pac bio's rs apparatus ( ); and oxford nanopore technology's minion ( ). both instruments are capable of a smaller number of reads than earlier machines (up to , ) but the reads are much longer, up to , bp. the technology works on the principle of detecting a growing dna chain electrically when the chain is extruded through an engineered protein pore of nanometer diameter. the minion instrument is amazingly small to essentially the size of a large memory stick [ ] . effective exploitation of the "mountain" of dna information produced by ngs from a clinical or blood bank sample requires minimizing computation time and maximizing the accuracy of the diagnostic output. dr naccache and co-workers developed a bioinformatics platform for these tasks called surpi, sequence-based ultra-rapid pathogen identification [ ] . such platforms are necessary given the size of the ngs output dna sequence, the size of pathogen reference sequence databases, and the fact that pathogen sequences typically constitute no more than . % to % of reads in the ngs output. this presents a needle in a haystack-type problem. to achieve rapid and robust detection, surpi employs two analyzer programs that work on both dna and translated protein alignments, using bacterial and viral databases. the platform can be employed in either fast or comprehensive mode; in fast mode pathogenic sequences can be identified in a clinical sample in minutes to hours, while comprehensive mode is more appropriate for detection of a novel pathogen's entire genome or to rule out infection in a clinically complex case. dr naccache noted that % to % of clinically significant respiratory infections are currently of unknown etiology. dr naccache presented data comparing the time of completion of analysis of ngs data using either surpi mode on a variety of clinical sample types. serum took less time to analyze than biological materials open to the environment (eg, stool samples); hiv spiked into plasma could be detected in minutes in either mode, down to viral copies per milliliter, with successful identification of strain specificity. surpi was extensively tested and optimized using such clinical samples prior to its employment in a prospective clinical case series carried out at the ucsf between april and december . this was a single-site study with respect to analysis, but included cases referred from across the united states and also from europe. the study included acutely or chronically ill, hospitalized patients with clinical features suggestive of an infectious disease but who tested negative for all candidate agents. dr naccache highlighted two of the diagnoses achieved by ngs in the clinical series. the first involved an adolescent boy whose fever and headaches evolved over the course of four months to hydroencephalopathy that forced his physicians to induce a coma to stabilize him [ ] . following over a hundred inconclusive laboratory tests, ngs revealed the presence of leptospira santarosai, a pathogenic bacterium, in cerebrospinal fluid samples. in view of the patient's poor status and the safety of the specific treatment for leptospira had the ngs-based diagnosis been incorrect, intravenous penicillin treatment was commenced before confirmation of leptospira infection was received from the center for disease control. following weeks' treatment followed by rehabilitation, the patient made a full recovery. in the second case highlighted by the speaker, a -year-old man underwent a bone marrow transplant, with immunosuppression, for treatment of chronic lymphocytic leukemia [ ] . a month later he developed tinnitus and partial deafness, which progressed rapidly and was accompanied by increasing mental deterioration. brain biopsy tissue was assessed by ngs, which detected neuroinvasive astrovirus infection, for which there is no known efficacious therapy; the patient died months post-ngs diagnosis and . months after the onset of symptoms. ngs sample to answer turnaround times were reported to be hours in the first case [ ] and hours in the second [ ] . a substantial list of the different pathogens detected by the ucsf/ avddc group using ngs in different biological fluids such as csf, respiratory secretions, and blood, was next presented by the speaker. in the latter category, the agents included pathogens familiar to the transfusion medicine-oriented audience such as the viruses epstein-barr virus, cytomegalovirus, hiv- and - , west nile virus, hepatitis viruses a through e, and chikv virus (chikv), the bacterium pseudomonas aeruginosa (which can be transferred from donor skin into blood products by venipuncture) and the parasite plasmodium falciparum (one of the causative agents of malaria). also included on the ngs detection list were less familiar agents, such as rna viruses enterovirus d , hantavirus, pegivirus, and rhinovirus c, double-stranded dna viruses such as four variants of human herpesviruses, and the bk and jc viruses, and various single-stranded dna viruses of the cycloviridae and anelloviridae families, the bacterium salmonella typhi, and the parasite leishmania infantum. the sensitivity of ngs is underlined by the detection of viruses that are not usually associated with disease (anelloviridae) or are only associated with disease in immunosuppressed individuals (the bk and jc viruses) that may be part of the "background flora and fauna" in humans that must be discounted in arriving at a bona fide ngs diagnosis. dr naccache continued with a consideration of recent results from the ucsf/avddc group employing nanopore sequencing. the ucsf/ avddc participated in a research program sponsored by oxford nanopore technologies designed to probe and optimize the capabilities of the minion instrument. dr naccache reported that, using minion and a surpi-like bioinformatics platform called metapore, plasma samples from individuals separately infected with chikv, ebola virus, and hepatitis c were rapidly identified in real time [ ] . for chikv and ebola virus, samples contained to copies/ml and were detected within to minutes of data acquisition; lower-titer hepatitis c virus ( copies/ml) was detected within minutes. the analyzer algorithms successfully identified these viruses despite the relatively error-prone nature of the sequence data. the total sample to answer time was less than hours, a feat apparently unprecedented in the ngs area. dr naccache then provided a cautionary tale illustrating the extreme sensitivity of ngs which involved parvovirus-like hybrid virus, a previously undescribed novel virus related to both circoviridae and parvoviridae families, initially detected in chinese patients with chronic seronegative hepatitis of unknown etiology [ ] . the ucsf/avddc group also found parvovirus-like hybrid virus by ngs in their hepatitis cohorts, but eventually realized that the virus was present in commercial silica-type spin columns used for dna purification/concentration, but not in any original patient sample [ ] . the silicates are typically sourced from cell walls of diatoms and a % concordant pvh sequence was found in environmental metagenomics databases of samples taken from north american coastal waters. this instance of laboratory contamination illustrates the extreme sensitivity of ngs and the methodological stringency that must be brought to its application. in wrapping up her presentation, dr naccache discussed the likelihood that ngs would contribute directly to blood donation screening. she assessed this outcome as somewhat improbable over the near term, in part because blood donation screening is currently highly effective. ngs is currently quite expensive in its most accurate form, leading dr naccache to estimate the cost of a well-covered ngs study of around samples using a total of million sequences on the hiseq platform at us$ , and a more shallow study, of the kind described above for rapid detection of ebola and chikv, of around samples using a total of million sequences on the miseq platform, at us$ . however, these estimates do not truly take into account the substantial infrastructure in place at ucsf/avvdc, which comprises specialized equipment for sample extraction, library generation, and validation, ngs sequencing, and extensive computational analysis, not to mention the skills of medical technologists, researchers, and bioinformatics specialists. the relevance of ngs with respect to keeping the blood system safe from emerging pathogens will more likely lie in determining patterns of disease transmission and providing the confidence necessary to re-qualify a previously deferred blood donor. suspected transmission by transfusion can be identified rapidly with great sensitivity and specificity using ngs of all implicated donors and recipients. it can also be used in a general, epidemiological sense, to trace patterns of infection and adaptation and speciation of infectious agents. while the contributions of ngs to clinical diagnosis of intractable cases and to public health, with respect to tracking and understanding disease outbreaks are already substantial, and will likely continue to accumulate exponentially, the prospects of using ngs for routine blood donation screening remain remote due to cost and throughput considerations. the biological impact of pathogen inactivation on blood product quality • pathogen inactivation (pi) of blood products may be advantageous as they overcome some of the limitations of current strategies (eg, assay sensitivity and threats of emerging pathogens). • pi techniques bring two sides of a coin into blood banking: improved safety versus a negative effect on blood component quality (damage to~ %- % of platelets). • in order to improve the quality of pathogen-inactivated blood products, molecular mechanisms triggered by these technologies need to be identified. • pi-treatment of whole blood might be the emerging method of choice in this field. dr peter schubert, research associate at the canadian blood services' centre for innovation and a clinical associate professor in the department of pathology and laboratory medicine at the university of british columbia, focused his talk on the need for pi to ensure the safety of the blood supply. he compared the currently available pi technologies and their mechanisms of action, and discussed the potential impact of this technology on product quality. dr schubert noted that blood safety has historically been achieved by mitigating known risks with interventions such as donor screening and universal donor testing for specific pathogens. however, risks remain, as all tests have a detection limit and current testing does not account for unknown or unexpected pathogens. thus, pi has the potential to improve the safety of blood products by preventing ttis, especially in platelet products, where bacterial contamination is a particular risk [ ] . in the united states, the intercept blood system from cerus corporation is currently licensed for platelet products, and both intercept and the octaplas product from octapharma are licensed for plasma (table , [ ] ). in canada, the only currently licensed pi product is octaplas plasma. three different pi systems for platelet concentrates are currently on the market ( table ) . these exploit the fact that pathogen proliferation occurs by replicating dna or rna, a mandatory step for all pathogens except prions. all use uv light, with or without a photosensitizer, to damage nucleic acids and subsequently prevent proliferation of pathogens. many of these systems are in routine use, mostly in europe and the middle east [ ] , and in many other jurisdictions regulatory approval is initiated and under investigation. worldwide, the cerus intercept blood system is the most adopted system, and has been in routine use for over years. hemovigilance data from jurisdictions that use these products are highly favorable and support their safety and efficacy [ ] . several clinical trials of pi technologies have taken place or are underway, including eurosprite (looking at intercept-treated platelet concentrates [ ] ), sprint (looking at intercept-treated apheresis platelets [ ] ), and miracle (looking at mirasol-treated apheresis platelets [ ] ). although safety and levels of adverse transfusion reactions were favorable with pi-treated platelets, one observation was that approximately % to % of the platelets appear to be damaged by the pi treatment. the sprint and miracle trials demonstrated a lower mean -hour post-transfusion count increment, increased number of platelet transfusions, and lower -hour corrected count increment, respectively, for patients treated with pi platelets [ , ] . the prepares (pathogen reduction evaluation and predictive analytical rating score) trial is a recently completed prospective, randomized, single-blinded, multicenter non-inferiority trial comparing mirasol-treated and standard of care pooled platelet products in hemato-oncological patients [ ] . initiated in the netherlands in november , prepares is sponsored by the sanquin blood supply foundation, the national blood operator in the netherlands, and financially supported by terumobct. the canadian arm of the trial involved cbs producing mirasol-treated pooled platelets at its ottawa manufacturing site and several hospitals in ontario. to account for the observed damage seen in pi techniques in other trials and to be consistent with the preparation of platelet pools in the netherlands, mirasoltreated platelets contain the donation of five donors, rather than four, which is the standard buffy coat platelet product prepared by cbs. although simply increasing the platelet dose in this setting is a straightforward solution to the issue of platelet damage seen with pi, dr schubert noted that the mechanisms of this pi-associated damage are unknown. currently in the literature, there is debate regarding the clinical efficacy of pi platelets. a meta-analysis of bleeding complications in randomized controlled trials using the intercept system suggests an increased risk of clinically significant bleeding [ ] while a meta-analysis from the cochrane collaboration suggests no difference in bleeding with pi platelets, although this conclusion is limited by significant heterogeneity between studies [ ] . thus, elucidating potential mechanisms is important to further finetune these systems and dr schubert provided an overview of the effect on quality parameters of platelet products by the three different pi systems. the common trend is a negative impact on routine quality measures as well as newer tools introduced to further characterize platelet quality and functionality; however, the magnitude of the effect can be different dependent on the pi technology. amongst other effects, pi treatment increases metabolism, apoptosis development, and platelet activation. these features lead to decreased platelet responsiveness and in vitro clot formation [ ] . furthermore, the effect of pi treatment on novel aspects of platelet function has also been extensively investigated. these studies show pi-dependent effects on cytokine [ ] , mitochondrial dna and microparticle release [ ] [ ] [ ] , generation of reactive oxygen species and initiation of signaling cascades [ ] , and expression profiles of mrna and mirna [ , ] . these "novel" platelet features might assist with explaining pi-effects associated with increased inflammation, cell damage, and apoptosis, transfusion-related acute lung injury, and modulation of endothelial cell functions. in addition, studies of the effects of pi on the proteome of platelets could provide further insights into mechanisms, although the overall impact on the protein expression profile is relatively small [ ] , suggesting pi-triggered modulations of protein activities. finally, some of dr schubert's own work on elucidating signaling cascades in mirasoltreated platelets revealed a central role of p mapk in regulating platelet activation and apoptosis development [ , ] . besides platelet concentrates, pi-treatment of plasma is used routinely in some jurisdictions [ ] ; however, pi of rbc concentrates has been challenging due to their high optical density, requiring a large amount of uv light, accordingly leading to significant rbc damage. the cerus s- system for pi of rbcs demonstrated similar -hour recovery to standard rbcs, but these products would not meet canadian standards due to their decreased shelf life [ ] . dr schubert then discussed how pi of whole blood may be a more efficient approach compared to pi of individual components. potential benefits of whole blood pi include early removal of pathogens, protection against transfusionassociated graft versus host disease due to wbc inactivation, and increased safety of all blood product components. the application of the mirasol technology on whole blood has demonstrated efficacy against hiv [ ] , trypansoma cruzi [ ] , and b microti [ ] . most recently, a study using mirasol for malaria inactivation in whole blood has been performed in ghana [ ] . however, reduction of ttis must be balanced against the effect that whole blood pi has on blood component quality. a study of in vivo viability of stored rbcs derived from mirasol-treated whole blood suggests decreased viability that correlates with quality variables such as hemolysis and atp concentration [ ] . this approach was complemented by a study by schubert and colleagues further demonstrating that platelet product quality seems to be less affected when produced from whole blood illumination compared to platelet component treatment [ ] . dr schubert concluded by acknowledging that there are two sides to the pi coin, and that a balance must be achieved between safety and quality. further research is needed to understand molecular mechanisms that lead to changes in quality with pi and to balance potential reductions in component effectiveness against reduction in ttis. ultimately, clinical trials are essential when it comes to making decisions regarding the implementation of pathogen inactivation into blood banking. economic and health outcome implications of introducing new pathogen testing and inactivation technologies • in order to be cost-effective, implementation of broad spectrum interventions such as pi are likely to require discontinuation of some current interventions. • the risk-based decision-making framework is a useful set of guiding principles for health economic assessments of blood safety interventions. to end the day, dr brian custer, a senior investigator with blood systems research institute in san francisco and an adjunct professor at the department of laboratory medicine at ucsf, gave an informative lecture on the economic and health outcome implications of introducing new blood safety interventions with a focus on pathogen testing and inactivation technologies. dr custer began his presentation by introducing the audience to the three main concepts that are the basis of economics in general, and of health economics in particular. the first concept, scarcity, stresses the current reality of limited resources and budgets, which may restrict the scope of services health care systems and practitioners are able to provide. the second concept, choice, has to do with choosing how to allocate the limited resources available. the third basic economic concept is opportunity cost, which relates to the next best alternative use of resources. in other words, opportunity cost is the benefit willingly forgone when we do not choose the next best alternative. these three notions summarize the challenge of the decision making process when it comes to economic information. in most jurisdictions, system-level health care decisions are made using a different decision-making framework. district health authorities resolve problems based on the determinants of health priorities such as: national and regional targets; clinical and research data; health experts' opinions and views; and the public's participation. for example, the fda annually tracks data on fatalities related to blood collection, transfusion reactions, and transmissible diseases (http://www.fda.gov). microbial fatalities from transfusion are tracked using variables that experts deem important for focusing future pathogen testing and inactivation efforts such as by the type organism and blood product. these fatality reports help determine the relative burden of fatalities from different causes. as a result, it was shown that in the united states, plateletrelated deaths are mainly caused by bacteria and red cell-related deaths are mainly attributable to babesia. data sources, such as the fda fatality data, help health authorities to understand the most important infection risks blood recipients face. with respect to health economics of the blood supply, dr custer suggested that the blood supply aims to serve the public good. achieving this aim necessitates that scarce resources be allocated in ways that maximize social welfare. the objective enumeration of costs, benefits, and consequences of alternate health programs must be weighed in comparison to society's ethical beliefs and expectations. if resource allocation does not align well with the values that society allocates to certain health outcomes, this may lead to friction between the determinants of health priorities, and ultimately to difficulties in decision making [ ] . the risk-based decision-making framework developed by the alliance of blood operators is intended as a guide for the assessment of blood safety interventions. as an integral part of any blood system's risk-management program, the risk-based decision-making framework has two components as shown in figure : policy foundations; and the decision making process. adherence to the framework increases consistency in methods and results, and it integrates contextual issues (social concern, legal considerations) into the decision making process. the concept of quality adjusted life years (qaly) has been developed to facilitate decision making by establishing a balance between public good (subjective qualitative outcome) and resource allocation (objective quantitative outcome). qaly is a tool that measures disease burden, including both the quality and the quantity of years lived. it is a measure of a medical intervention's "value for money". scientists may make various assumptions when measuring health resource outcomes, from choosing the wrong outcome to choosing an inappropriate test to measure it. these limitations, as well as an incomplete knowledge base, lead to uncertainty in data used for health economic analyses. when measuring health costs, one assumes that some expenditures are more important than others for the health care system; when measuring consequences from an intervention, one assumes that there is a sufficient understanding of the risks and benefits associated with that intervention. cost per qaly provides a common denominator for comparing interventions, but cannot reduce uncertainty introduced by unavoidable assumptions. established thresholds for what is considered "cost-effective" in health care interventions are in the range of $ , to $ , / qaly (all values in us dollars). blood safety interventions, however, consistently fall well above these thresholds. good examples are nat for hiv, hcv, and hbv ($ , , - , , /qaly; broad range reflects uncertainty and testing strategy used) serology and pcr for babesia species ($ , - , , /qaly) and wnv nat testing ($ , - , /qaly), and t cruzi antibody testing for chagas disease ($ , - , , /qaly). when it comes to considering pathogen testing and pi, some outcomes of interest may not be available to aid in decision making. for example, qaly data on the utility of testing for chikv, dengue viruses, and hepatitis e virus in the blood safety context are not available to inform an economic analysis. hence, understanding the budget impact of such tests becomes difficult. on the other hand, data regarding babesia testing are available. babesia screening in endemic american states was compared to universal screening using qaly and taking into account the number of deaths prevented and the testing methodology used [ ] . there are also qaly data available to support the practice of bacterial testing of platelets, and pathogen inactivation of plasma [ ] . the data estimate that platelet bacterial testing is more cost-effective ($ , /qaly) than pathogen inactivation ($ , /qaly) [ ] . when implementation of a cost-effective blood donor test is needed, qaly has been applied to several patient populations and several interventions. bell et al compared platelet pi using intercept in leukemia, lymphoma, orthopedic, and cardiac patients [ ] . the authors found that the new method's cost effectiveness ($/qaly) is similar to other accepted blood safety interventions. this means the method can be considered cost-effective in the blood safety context while preserving patient quality of life. dr custer and colleagues have modeled the costeffectiveness of pi as an addition to current pathogen testing based on canadian data. comparing mirasol treatment of whole blood, and of platelet and plasma, costs per qaly of $ , , and $ , , , respectively (cdn, in this instance), were shown [ ] . a more recent cost-utility analysis of implementing pi in poland suggest high costs, but better cost-effectiveness than found in previous analyses of pi and nucleic acid testing in north america [ ] . pi may replace other interventions that currently incur large costs to the health care system such as blood irradiation, bacterial culture, and maintenance of cmv negative inventory [ ] . if pi is implemented, removing costs associated with bacterial culture and irradiation could result in a reduction in the cost/qaly of pi by about % [ , ] . other operational gains may further offset investment costs, including reduction in product wastage [ ] . these analyses are based on assumptions, and while there is a high degree of uncertainty in the results, their potential usefulness, as blood operators move into the era of pi, is substantial. health economic analysis allows quantification of alternatives and comparison of interventions in different areas of medicine. broad implementation of pi for blood safety may thus prove unpalatable to funders without compensatory cost reductions in other aspect of component production. either a more focused application of pi or lack of implementation until lowercost alternatives are developed may ensue. decision making based on health economics and on risk assessments is likely to become the new norm in blood transfusion. this would comprise a strikingly different approach to blood safety implementation and decision making than in the past, when novel interventions were added to older ones, sequentially increasing costs and overall blood safety budgets. this shift represents a move towards effectively and transparently managing process change, rather than the traditional approach of reactive change in response to an emerging situation or disaster. defending the blood supply from the threat of transfusiontransmissible infections remains a high priority for transfusion services in canada and around the world. the residual risk from established pathogens is exceptionally small. the emerging agents of greatest concern in the north american setting are arboviruses and babesia. the west african ebola virus epidemic reinforced concerns about environmental change fueling the rapid emergence of pathogens not previously thought to have potential global significance. pathogen inactivation of blood products may further reduce residual risk from established agents and provide protection from new agents in the medium term; however, the most likely driver for a paradigm shift to the use of pathogen inactivation is to reduce the ever-present risk of bacterial contamination of platelet products. longer term, the possibility of donor-free cellular products and rapid next generation sequencing could drive down transfusion-transmission rates even further than the impressive safety margins now in place in canada and other developed countries. health economic analysis and risk-based decision making will be required to determine if anticipated benefits outweigh the considerable costs of these potential steps. the th annual international symposium received funding from the canadian blood services centre for innovation. among the authors of this report, dr geraldine walsh, dr mia golder, dr margaret fearon (author and speaker), and dr william sheffield have no actual or potential conflict of interest in the context of the subject of this program over the past five years. dr peter schubert, author and speaker, discloses grant/research support from terumobct and macopharma. among the speakers, dr allison mcgeer, nancy angus, and dr samia naccache have no actual or potential conflict of interest in the context of the subject of this program over the past five years. the following relationships that could be perceived as a related or apparent conflict of interest in the context of the subject of this program over the past five years are disclosed by dr roger dodd: grant/research support grifols and cerus; consultant with mosaiq and roche; dr marc turner: grant/research support from the wellcome trust; dr brian custer: grant/research support from grifols (formerly novartis), hologic (formerly gen-probe) and macopharma, and member of the speakers' bureau with terumobct. among members of the planning committee who were not speakers at the event, dr kathryn webert, dr robert skeate, dr sophie chargé, ahmed coovadia, and sue gregoire have no actual or potential conflict of interest in relation to this program over the past five years. dr ed pryzdial discloses grant/research support from biogen. blood group antigens and normal red blood cell physiology: a canadian blood services research and development symposium red blood cell storage 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whole blood whole blood treated with riboflavin and ultraviolet light: quality assessment of all blood components produced by the buffy coat method alliance of blood operators risk-based decision-making i. health economics and outcomes methods in risk-based decision-making for blood safety costs, consequences, and costeffectiveness of strategies for babesia microti donor screening of the us blood supply costs and benefits of bacterial culturing and pathogen reduction in the netherlands costeffectiveness of transfusion of platelet components prepared with pathogen inactivation treatment in the united states the cost-effectiveness of pathogen reduction technology as assessed using a multiple risk reduction model introducing pathogen reduction technology in poland: a cost-utility analysis pathogen reduction: state of reflection in ireland model calculations to quantify clinical and economic effects of pathogen inactivation in platelet concentrates reducing the financial impact of pathogen inactivation technology for platelet components: our experience variation of platelet production and discard rates in blood centers representing european countries from cerus corporation. the intercept blood system: one system -two components, cerus corporation mirasol pathogen reduction technology system. terumobct main properties of the theraflex mb-plasma system for pathogen reduction macopharma. the theraflex mb-plasma system is able to efficiently remove bacteria and bacterial spores from plasma canadian agency for drugs and technologies in health. cadth optimal use reports. use of solvent/detergent-treated human plasma (octaplas): pilot project. ottawa (on): canadian agency for drugs and technologies in health characteristics of the theraflex uv-platelets pathogen inactivation system -an update we would like to acknowledge the key: cord- - l ok o authors: elbeddini, ali; prabaharan, thulasika; amasalkhi, sarah; tran, cindy; zhou, yueyang title: barriers to conducting deprescribing in the elderly population amid the covid- pandemic date: - - journal: res social adm pharm doi: . /j.sapharm. . . sha: doc_id: cord_uid: l ok o deprescribing aims to reduce polypharmacy, especially in the elderly population, in order to maintain or improve quality of life, reduce harm from medications, and limit healthcare expenditure. coronavirus disease (covid- ) is an infectious disease that has led to a pandemic and has changed the lives many throughout the world. the mode of transmission of this virus is from person to person through the transfer of respiratory droplets. therefore, non-essential healthcare services involving direct patient interactions, including deprescribing, has been on hiatus to reduce spread. barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. some of these barriers can be mitigated by using the following interventions:patient education, prioritization of non-pharmacological therapy, incorporation of electronic health record (ehr), continuous prescriber education, and development of research studies on deprescribing. currently, deprescribing cannot be delivered through in person interactions, so virtual care is a reasonable alternative format. the full incorporation of ehr throughout canada can add to the success of this strategy. however, there are several challenges of conducting deprescribing virtually in the elderly population. these challenges include, but are not limited, to their inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. virtual care is the future of healthcare and in order to retain the benefits of deprescribing, additional initiatives should be in place to address the challenges that elderly patients may experience in accessing deprescribing virtually. these initiatives should involve teaching elderly patients how to use technology to access health services and with technical support in place to address any concerns. one of the definitions of polypharmacy is when an individual uses five or more medications (prescription and over-the-counter products) concomitantly creating a situation where the risks outweigh the benefits of the medications. , medication use in the elderly is complex due to a variety of factors: frailty, limited research representation, and physiological changes. frailty refers to elderly people who have reduced physiologic reserve and greater stressor sensitivity. both of these key characteristics contribute to the vulnerability of this population to medications. trials of medications have restrictions on age and usually limit the percentage of elderly patients enrolled. consequently, the results of the study are not representative of the elderly population and when inferred to the elderly population can lead to severe harm or lack of efficacy. aging causes several consequences in the body, such as alteration inbody composition, organfunction and protein synthesis. body fat increases, while muscle mass decreases leading to greater distribution and consequent increase in the exposure of some drugs. drug clearance is impaired because of reduction in kidney and liver size as well as blood flow, which increase the half-life of medications that are eliminated by these organs. because of the impaired liver function, the synthesis of proteins decreases including receptors, which are drug targets leading to the increase in the free drug concentration in the serum. elderly patients have a greater sensitivity to medications due to the combination of changes resulting from aging. therefore, medications require careful assessment and alterations as patients reach late adulthood. deprescribing is a method ofreducing drug dosage, changing a drug to a safer alternative, or discontinuing a drug without a specific indication or added benefit, under the supervision of a healthcare practitioner, and can be used to resolve inappropriate medication use in the elderly population. , , coronavirus disease (covid- ) is a recent infectious disease that attacks the human respiratory system leading to symptoms, such as fever, cough, and fatigue. , , the mode of transmission of this virus is person-to-person through the transfer of respiratory droplets. therefore, social distancing and isolation of infected people protocols were implemented globally to reduce spread. , the severity of the infection can be divided in five categories: asymptomatic, mild, moderate, severe, and critical. data from many countries support thatthe elderly population has the greatest risk of mortalityfrom covid- , but all ages have been infected. as a result of covid- , non-essential services that involve direct patient interactions including deprescribing has been on hold in canada in an effort to contain the outbreak. there are several benefits to deprescribing: maintains or improves the quality of life of patients,reduces harm from medications in patients, and reduces healthcare expenditure. , delirium, syncope and falls are some examples of medication related harm which can lead to hospitalization of elderly patients. canadian health care system spends roughly $ million on inappropriate medication use and $ . billion on negating the harm incurred from inappropriate medicationuse. according to canadian institute for health information, about one third of the elderly population of canada were taking five or more different classes of medications chronically in , which is a significant portion of the population that could benefit from deprescribing. a recent study that evaluated the financial impact of different deprescribing scenarios on a typical patient case across different provinces in canada showed that deprescribing cansave money for the patient( . % to . %) and government ( . % to . %). there are several deprescribing initiatives in place in different provinces in canada, such as ubc pharmacists clinic in british columbia, prairie mountain health sedative describing initiative in manitoba, medication therapy services clinic in newfoundland and labrador, winchester district memorial hospital describing program in ontario, and agir pour mieux dormir program in quebec. thepartnership between patients, caregivers, and healthcare practitioners is instrumental to the success of deprescribing and due to covid- , these interactions have been interrupted. covid- can lead to severe complications in the elderly population and individuals with existing comorbidities. therefore, reducing the medication burden and having an uptodate medication list is very important in the case that these patients get infected with the virus and require hospitalization. there were several barriers to conducting deprescribing prior to covid- , but the pandemic has led to additional challenges that further impede the momentum of deprescribing initiatives. barriers to deprescribing in the elderly population before covid- can be divided into two categories: patientand system. patient-related barriers include resistance to change (due to concerns about experiencing withdrawal effects or symptoms of disease), knowledge deficit about deprescribing, and lack of alternatives for treatment of disease . , , all of these barriers can be addressed by educating the patient on the purpose and process of deprescribing. the patient needs to be aware that there is no reason to continue a medication that is not beneficial and/or may be contributing to side effects. a study conducted elderly canadians living in the community on their attitude on deprescribing demonstrated approximately % of participants would like to lessen their medication load. on the other hand other, research evaluating the willingness of residents of senior homes for deprescribing has shown that . % of them were prepared to make changes to their medications with positive reinforcement from their doctor. consequently, setting some time to address the patient's concerns before beginning the process of deprescribing and checking up on how the patient is feeling throughout the process can help ensure that this intervention remains successful.in terms of the lack of alternatives, non-pharmacological interventions, which do not have side effects, can be prioritized in specific conditions, such as insomnia. for example, a study conducted on patient engagement during deprescribing showed that when resources are combined with nonpharmacological advice, deprescribing initiatives were more successful. system-related factors include uncoordinated delivery of health services,prescribers'attitudes and/or experience, limited availability of guidelines for deprescribing,lack of evidence on preventative therapy. , , , healthcare in canada is delivered provincially, and each province has their own procedures in place. however, a commonality within the provinces is that care is given in isolation depending on levels of care(primary care, secondary care, tertiary care, and quaternary care) and communication gaps exist between healthcare practitioners. this discrepancy is because of the absence of an electronic health record (ehr), which would consist of a complete record of a patient's health history. all healthcare practitioners and patientswould have access to her, leading to more collaborationand consequently better medication choices and deprescribing efforts. many provinces arein transition to ehr under canada health infoway (chi) within the last couple of years, which can help overcome these challenges. moreover, healthcare practitioners must continuously learn about new practices, such as deprescribing to be able to provide optimal evidence-based medicine. , therefore, it is important to teach deprescribing in the curriculum of healthcare practitioners as well as offer it as a topic of importance in continuing education for practising healthcare practitionners. , prescribing guidelines exist, but for a number of reasons, there is difficulyt with healthcare practitioners implementing them in practice. , the applicability of the available guidelines for deprescribing was tested by a recent study. the results showed that . % of discharged elderly patients from a hospital used medications within deprescribing guidelines and % of patients fit the requirements for deprescribing. another study evaluating the deprescribing self-efficacy of health care practitioners (physicians, nurse practitioners, and pharmacists) before and after being given different algorithms has shown that significant increases in self-efficacy scores across classes of medications studied in in the development and implementation of a deprescribing plan. canada has been slowly increasing access to evidence-based deprescribing guidelines through the deprescribing network and more guideline are expected to be available in the near future to ease the application of deprescribing. as deprescribing becomes more prevalentdue to the incorporation of ehr, researchers would have more opportunities to evaluate the benefits of deprescribing. thus, we can infer that more healthcare practitioners would be willing to incorporate deprescribing into their daily practices when there is abundance of evidence supporting the effectiveness of deprescribing. covid- has led additional barriers to deprescribing. because non-essential in-person interactions have been on hold, healthcare has adapted to providing these services electronically through video conferencing and telephone. video conferencing can better mimic the in-person experience allowing healthcare practitioners to conduct some of their visual assessments. as mentioned previously, the ehr is important in order to overcome barriers in deprescribing, but in the currentsituation the importance has been amplified. in response to the current situation the transition to ehr has been accelerated as chi andhealth canada have joined forces to provide faster and greater access to virtual care to canadians. the virtual delivery of deprescribing has challenges in the elderly for a variety of reasons: inability to use technology, lack of resources (e.g. video camera, smartphone), lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and greater risk for hospitalization (refer to figure ). most elderly patientsare not able to navigate technology as efficiently asthe younger population, so delivering deprescribing servicesin this manner can be difficult.moreover, elderly patients with psychological conditions, such as alzheimer's disease and dementia or physical conditions, such as arthritis or parkinson'sdisease will be further disadvantaged due to their mental and/or physical limitations. another factor is literacy, as some elderly patients have reduced literacy relative to younger patients. using technology to delivery healthcare services requires patients to be able to read or write as well as speak and those without sufficient literacy cannot communicate their thoughts. elderly patients that live with family members could seek assistance on how to use technology. nonetheless, according to statistics canada approximately % of seniors lived alone in , which is substantial number of elderly patients. due to social distancing and isolation protocol, they would not be receiving help from family members in navigating these services, which further exacerbates the challenges. income is also an important factor, because elderly patients would need access to a smartphone or computer with a webcam that allows them to connect to these services.ifelderly patients do not have an electronic device already, then having to purchase oneand the associated data/internet plans area significant cost during this crucial time. moreover, the environment should be quiet for elderly patients to have uninterrupted assessments during the virtual interaction. connection problems are also an issue with technology, so repetition is important to verify that the content of the discussion has been interpreted carefully. elderly patients' lives have already been drastically altered by the pandemic, so they may be less receptive to making more changes in their lives. therefore, healthcare practitioners may have difficult time initiating a conversation about making changes to medication that they have been taking for many years.another issue is that during the pandemic, elderly patients' lives have been changed and initiating a conversation aboutmaking changes to medication that they have been using for many years might be difficult. due to isolation, their conditions could be exacerbated, such as insomnia and anxiety. therefore, instructing these patients to discontinue certain medication -like benzodiazepines and antipsychotics -can cause them to experience withdrawal symptoms. furthermore, if they do experience severe withdrawal symptoms,admitting them to a hospital would put them at greater risk of acquiring covid- andnegatively impacting their health. although the pandemic may be a temporary situation, virtual care is the future of health care. consequently, steps need to be taken to make sure that the elderly population is wellequipped for the future (refer to figure ) . libraries and community centres should have the required technology and private room in place to allow for seniors to access health services electronically. these locations should have classes to teach elderly patientson how to navigateelectronic health serviceswith technical support available to help troubleshoot any difficulties. one example of an initiative that aims to help seniorsis through a non-profit association in ottawa called connected canadians. this organization helps the elderly population use technology in order to connect with their families during the pandemic. these types of initiatives aimed atincreasing connectivity to healthcare practitionersshould be encouraged all over canada. deprescribing is a valuable service that will help the elderly population better manage their medications as well as benefit the canadian healthcare system financially. barriers to deprescribing before covid- , such as resistance to change, knowledge deficit about deprescribing, and lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescribers' attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy need to be managed through different interventions. some examples of these interventionsinclude patient education, prioritization of non-pharmacological therapy, incorporation of the ehr continuous prescriber education, and development of research studies. barriers due to covid- from the lack of direct patient interaction can collectively be addressed through increased access to the ehr and virtual care, which has been expeditated by health canada and canada health infoway. nonetheless, there is a necessity to manage some of the challenges that elderly patients have with using virtual care, such as inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk after hospitalization. some of these issues can be resolved by encouraging policy makers to allow technological access to the elderly through community centres and libraries. virtual care is the future of health care and we should take the necessary steps to make sure that seniors are not left behind as we renovate healthcare. deprescribing: managing medications to reduce polypharmacy what is deprescribing? -do i still need this medication? is deprescribing for you? deprescribing in older people financial advantage or barrier when deprescribing for seniors: a case based analysis. res social adm pharm q&a on coronaviruses the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak epidemiology of covid- ottawa: canadian institute for health information deprescribing as a clinical improvement focus deprescribing initiatives in canada [internet]. deprescribingnetwork.ca barriers and facilitators to the deprescribing of nonbenzodiazepine sedative medications among older adults barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from switzerland deprescribing medications for older adults in the primary care context: a mixed studies review community-dwelling older people's attitudes towards deprescribing in canada are residents of aged care facilities willing to have their medications deprescribed? a collaborative intervention for deprescribing: the role of stakeholder and patient engagement views of medical practitioners about deprescribing in older adults: findings from an italian qualitative study how confident are physicians in deprescribing for the elderly and what barriers prevent deprescribing infoway-inforoute.ca implementing deprescribing guidelines into frontline practice: barriers and facilitators deprescribing recommendations: an essential consideration for clinical guidelines developers deprescribing opportunities for elderly inpatients in an academic, safety-net health system self-efficacy for deprescribing: a survey for health care professionals using evidence-based deprescribing guidelines rapid response to covid- . infoway-inforoute.ca living arrangements of seniors. .statcan.gc.ca ottawa non-profit organization helps seniors connect during covid pandemic key: cord- -w scpc authors: amariei, raluca; willms, allan r; bauch, chris t title: the united states and canada as a coupled epidemiological system: an example from hepatitis a date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: w scpc background: hepatitis a (ha) is a low-incidence, non-endemic disease in canada and the united states (us). however, a large difference in ha incidence between canada and ha-endemic countries has made travel an important contributor to hepatitis a prevalence in canada. there is also a (smaller) incidence differential between canada and the us. although the us has only moderately higher ha incidence, the volume of travel by canadians to the us is many times higher than travel volume to endemic countries. hence, travel to the us may constitute a source of low to moderate risk for canadian travelers. to our knowledge, travel to the us has never been included as a potential risk factor for ha infection in canadian epidemiologic analyses. the objective of this study was to use dynamic models to investigate the possible effects on hepatitis a incidence in canada due to ( ) implementing vaccination in the us, and ( ) varying the volume of travel by canadians to the us. methods: we developed and analyzed age-structured compartmental models for the transmission and vaccination of hepatitis a, for both canada and the us. models were parameterized using data on seroprevalence, case reporting, and travel patterns. the potential effect of hepatitis a prevalence in the us on hepatitis a prevalence in canada was captured through a term representing infection of canadians due to travel in the us. results: the model suggests that approximately % of ha cases in canada in the mid s may have been attributable to travel to the us. a universal vaccination programme that attained % coverage in young children in the us in the mid s could have reduced canadian incidence by % within years. conclusion: since not all necessary data were available to parameterize the model, the results should be considered exploratory. however, the analysis shows that, under plausible assumptions, the us may be more important for determining ha prevalence in canada than is currently supposed. as international travel continues to grow, making vaccination policies ever more relevant to populations beyond a country's borders, such multi-country models will most likely come into wider use as predictive aids for policy development. wealth varies dramatically across countries, and with it, the disease burden for many infectious diseases [ ] . one example is hiv, where prevalence is % in sub-saharan africa but only . % in western europe [ ] . a less striking but still significant example is hepatitis a (ha). ha is a non-endemic, low-incidence disease in the us and canada, but is highly endemic in many other countries [ ] [ ] [ ] [ ] . the average reported ha incidence in canada was . per , per year from to [ ] , and the average reported ha incidence in the us was . per , per year from to [ ] . by comparison, in , reported incidence ranged from to per , per year in africa and the middle east (depending on the country), to in asia, and to in central and south america [ ] . moreover, reported incidence significantly underestimates actual incidence due to underreporting and subclinical infection [ , , ] . because subclinical infection is more common in children, who are infected more frequently in developing countries than developed countries, the global differential in true infection levels is much higher than for reported incidence. this incidence differential between canada and haendemic countries, combined with increasing air travel, makes travel by canadian residents to ha-endemic countries a significant source of ha infection in canada [ , ] . travel to endemic countries is also a source of infection in the us, with % of reported infections attributable to travel in ha-endemic countries in [ ] . hepatitis a vaccine has been available in canada and the us since [ ] . in canada, the average reported incidence from to , while a targeted vaccination programme was in place, declined to . per , per year [ ] . the vaccination policy in canada is still targeted and includes high-risk groups, such as men who have sex with men, intravenous drug users, members of first nations communities, and travelers to endemic countries, among others. in the us, after vaccination was implemented (with universal vaccination in the states with highest incidence), the reported incidence had declined to . per , per year by [ , ] . the true incidence of infection (including both clinical and subclinical infection) has been underestimated by approximately fold in canada and -fold in the us [ , ] . there also exists an incidence differential between canada and the us, with the us having somewhat higher incidence ( figure ). hepatitis a incidence tends to rise and fall at the same time in the us and canada. in fact, the reported incidence in the two countries is positively correlated with a correlation coefficient + . ( figure ) [ , ] . interestingly, outbreaks of hepatitis a in men who have sex with men (msm) in montreal often follow outbreaks in msm in new york by or months (vladimir gilca, institut national de santé publique du québec, pers. comm.). the two countries are also bound together by very high travel volume. for instance, in , the number of person-trips by canadian residents returning to canada from the us was times the number to all other countries combined, and times the number made to all ha-endemic countries combined [ ] . similarly, on average from - , outbound travel from canada to the us was times that to all other countries combined [ ] . given these observations, it is worth posing the question: how does ha epidemiology in the us influence ha epidemiology in canada? this issue has implications for policy, since it implies that health interventions in one country may potentially influence health outcomes in other countries. this question also has implications not only for hepatitis a but for many diseases such as sars, as burgeoning air travel turns local problems into global problems. in this paper, we develop mathematical (agestructured compartmental) models of hepatitis a transmission and vaccination in canada and the us. we use travel data to couple the two countries epidemiologically through travel. we focus on these two countries (rather than attempting a global model) because of the relatively good availability of data for the us and canada and the close relationship of canada to the us. the coupled model allows us to analyze how transmission and vaccination in the us may be affecting ha incidence in canada. we begin with a description of hepatitis a epidemiology, which will motivate our choice of mathematical model. in canada and the us, unlike most developing countries, hepatitis a is transmitted mostly by person-to-person contact, by the fecal-oral route [ ] . unlike in many countries, foodborne outbreaks are very infrequent in canada [ ] . children play an important role in transmission due to their higher rates of subclinical infection and poor hygiene [ ] . clinical illness typically lasts four weeks, there is no chronic state of infection [ ] , and natural immunity is lifelong. although % of infected post-adolescents develop jaundice, many do not seek medical attention [ , ] . individuals with symptomatic ha infection experience nausea, loss of appetite, fatigue, fever, abdominal pain and jaundice [ ] . hepatitis a infection is more severe in older individuals or those with co-morbidities such as chronic liver disease [ , ] . the most serious possible complication of hepatitis a infection is fulminant hepatic failure. the rate of mortality attributable to ha varies from . % in symptomatic young adults to . % in symptomatic individuals years and older [ ] . given the predominance of person-to-person contact, lifelong immunity, and the importance of children in transmission, a suitable mathematical model is an agestructured compartmental model. this widely-used class of models has been shown to be particularly useful in assessing the effects of universal vaccination programmes against diseases with acquired immunity transmitted horizontally through person-to-person contact, and has been shown to provide good agreement with pre-and post-vaccination age stratified case reports and seroprevalence surveys for infectious diseases such as measles [ , ] . our age-structured seirv compartmental model stratifies individuals according to epidemiologic status (susceptible-exposed-infectious-recovered-vaccinated) and age class (ages - , - , - , - , - , - maternal immunity is short-lived and affects relatively few individuals in a non-endemic country such as canada, so we do not include it [ ] . since ha in canada and the us is spread primarily person-to-person, we do not model foodborne or waterborne outbreaks [ ] . the model equations appear in appendix a and the parameterization is described in appendix b. a diagram of the model appears in figure . the united states and canada are both large countries and one may consider that a model by states would be more appropriate. however, despite their close proximity, there is more travel within canada than between canada and the us: from to , there were . times as many person-trips made within canada (across provinces) as between canada and the us [ ]. table gives the parameter values used for the us model and their data sources [ , , , [ ] [ ] [ ] [ ] . demographic and epidemiologic parameter values are from the pre-vaccine era, - . demographic parameters such as birth rates and age-specific death rates were taken from demographic data. clinical and epidemiologic literature on hepatitis a were used to determine the durations of latent and infectious periods, vaccine efficacy, and duration of vaccine-derived immunity. the rate at which a susceptible person is infected due to travel in endemic countries ( ), and the rate at which a susceptible person is infected by infectious persons due to domestic us transmission ( ) were computed simultaneously using: ( ) published data on the true incidence of hepatitis a in the us, adjusted for under-reporting and the probability of jaundice [ ] , ( ) data on the age-specific proportion of cases attributable to travel in endemic countries [ ] , and ( ) an assumed form for a "who acquires infection from whom" matrix consisting of the parameters [ ] . this method of computation, which uses the model equations and does not require explicit knowledge of the force of infection or seroprevalence data (although those were necessary to estimate the true incidence in this particular case), is described in appendix b. hepatitis a is not endemic in the us, and the us incidence of ha is only modestly higher than that of canada. however, there is such a greater volume of travel to the us than to ha-endemic countries that it makes sense to make allowance for infection due to travel to the us in the where y us (resp. y end , y c ) is the incidence in the us (resp. endemic countries, canada) where (resp. ) is the annual volume of travel by individuals in age class i to the us (resp. endemic countries), and where (resp. ) is the average duration of stay by travelers in the us (resp. endemic countries). these parameters can be obtained from published data [ ] or from travel data available on government agency websites [ ] . the difference between canadian incidence and us/endemic incidence is used since that is proportional to the marginal increase in infection risk to canadian residents traveling in other countries. for instance, if canadian incidence were per , per year, and us incidence changed from per , per year to per , per year (due to more foodborne outbreaks in that country, for example), then the additional risk of infection per year that canadian residents assume upon themselves due to travel to the us would double. we note that equation does not take all possible factors into account. for instance, individual behaviour may vary, since canadian residents are perhaps more risk-averse when traveling in an endemic country than when traveling in the us. the canadian parameters and are estimated using the same method as for the corresponding us parameters and , except that the force of infection due to travel to the us is first subtracted from the total force of infection, and canadian seroprevalence, case reporting, table . the age-structured model for canada has identical structure to the us model except for the additional term representing infection attributable to travel in the us (see appendix a). we wish to make the force of infection attributable to travel to the us a function of the number of infectious individuals at any given time in the us, in order to study the effects of differing vaccine coverage in the us and differing travel volume to the us. hence, the function therefore couples the two countries and reflects our assumption that when the number of infected individuals in the us increases (resp. decreases), the number of canadian individuals becoming infected due to travel in the us also increases (resp. decreases). the demographic and epidemiological parameter values for canada are listed in table . parameter values relating to disease progression in infected individuals are the same as those for the us and so are not listed. some parameters (such as the birth rate) are very similar in the two countries. the number of residents of the us who become infected while traveling in canada is likely very small due to the relative population sizes of the two countries, and ( ) rate at which an individual in age class i dies , , , , , . , . per year [ ] rate at which a susceptible individual in age class i becomes exposed due to travel in endemic countries us so a similar term was not introduced in the us equations. however, we note that this assumption could become invalid under certain situations. for instance, if us vaccination coverage is high and canadian vaccination coverage is low, then travel to canada could, in principle, be a risk factor for us residents (particularly those living close to the border). however, figure suggests that this is unlikely in practice, as canadian incidence has remained below us incidence before and after the vaccine was licensed in both countries in the mid s. here we describe the predicted incidence of hepatitis a in canada under various vaccination scenarios in the us, and for various volumes of travel to the us. the adjusted incidence values reported here are the predicted incidence of reported cases adjusted for subclinical infection and under-reporting. hence, the adjusted incidence represents the true incidence of all ha infections. if reported incidence were plotted instead, the qualitative results would be the same and the quantitative results would be similar except for a scaling due to the adjustment for underreporting and subclinical infection. figure shows the adjusted incidence in canada at the equilibrium state of the dynamic model as a function of vaccination coverage in the - age class in the us. as the vaccine coverage in the us increases, the adjusted ha incidence in canada decreases significantly. for instance, universal vaccination in the us at % coverage in the - age class causes a % decline in the adjusted canadian incidence, across all age classes. hence, this allows us to infer that approximately % of canadian incidence was attributable to travel in the united states, in the years for which the model was parameterized ( to ). implementing a universal vaccination programme in the us soon shows its effects in canadian incidence. figure shows the adjusted incidence in the us and canada when, initially, there is no vaccination in either country, but in , a strategy of vaccinating % of children in the us in the - age class begins. within a few years of the start of the us vaccination programme, adjusted incidence has also declined in canada significantly. the choice of as the year that vaccination begins is motivated by the fact that was the last year before ha vaccine became widely available in the us and canada. we also note that the model was parameterized using data from (the earliest year of availability for certain data) to inclu- figure shows the adjusted us and canadian incidence, stratified by age class, before and after implementing universal vaccination in at % coverage in the - age class in the us. in the us, incidence declines rapidly not only in the - age class, but also in the other unvaccinated age classes due to the indirect protective effects of herd immunity. likewise, incidence declines in all age classes in canada upon initiation of universal vaccination in the us. similarly, the effect of an instantaneous % increase in the us adjusted incidence in is soon reflected in a % increase in canadian incidence ( figure ). although this scenario of such a rapid increase in incidence is only hypothetical, the example serves to illustrate how closely coupled the countries are. the time difference between the us peak and the canadian peak in figure is about days. as noted already, the observed time delay between outbreaks of hepatitis a in gay men in new york with outbreaks in gay men in montreal is - months (vladimir gilca, inspq, pers. comm.). other scenarios where the effects of fluctuating us incidence on canadian incidence are studied, such as sinusoidal variation in the us, give rise to lags between us and canadian incidence peaks of approximately months. as the annual volume of travel by canadian residents to the us increases, the adjusted incidence in canada also adjusted incidence by age classes in the us (top) and canada (bottom) upon initiation of a universal vaccination pro-gramme in the us at % coverage in all age classes in adjusted incidence in canada versus us vaccination coverage (in the - age class), at the equilibrium state of the model dynamics figure adjusted incidence in canada versus us vaccination coverage (in the - age class), at the equilibrium state of the model dynamics. the adjusted incidence is the reported incidence adjusted for asymptomatic infection and under-reporting. the effect of implementing universal vaccination in the united states on the incidence in canada figure the effect of implementing universal vaccination in the united states on the incidence in canada. universal vaccination is implemented in in the united states by vaccinating % of individuals in the - age class. the adjusted incidence is the reported incidence adjusted for asymptomatic infection and under-reporting. increases in almost direct proportion (figure ) . the adjusted incidence in canada when there is no travel to the us is % less than the adjusted incidence in canada at the actual volume of travel in (indicated in figure ). hence, approximately % of infected individuals in canada in may have acquired the disease through travel to the us, insofar as equation is correct. i.e., the combination of parameters and such that the incidence can be reduced most quickly. although ha incidence is much lower in the us than in ha-endemic countries, it is still somewhat higher than in canada. this, coupled with the enormous annual volume of canadian travel to the us compared to endemic countries, means that the us could be a more significant source of travel-related infection (particularly for hepatitis a) than previously recognized. indeed, the results in the previous section illustrate the potential impact of hepatitis a transmission and vaccination in the us on ha prevalence in canada. simulation results based on the assumptions in equation show that a significant proportion ( %) of ha incidence in the mid 's, before vaccination was introduced, may have been attributable to travel in the us. hence, some of the declines in ha incidence observed after in canada ( figure ) may partly be due to the start of universal vaccination in the higher-incidence regions of the us in the mid- s. we speculate that detecting travel to the us as a risk factor is difficult because ( ) the incidence is only moderately higher in the us than in canada (hence the risk to an individual is only modestly increased when traveling to the us), and ( ) due to high travel volume, travel to the us becomes a commonplace and under-reported event in the lives of many canadians. however, this modelling study suggests that future epidemiological studies of risk factors for ha infection should include travel to the us as a variable in risk factor analysis. adjusted incidence in canada at the equilibrium state of the model dynamics, as a function of the total annual volume of canadian travel (number of trips per year) to the united states figure adjusted incidence in canada at the equilibrium state of the model dynamics, as a function of the total annual volume of canadian travel (number of trips per year) to the united states. the "x" denotes the actual volume of travel to the us in . adjusted incidence in the us and canada after a sudden increase in us incidence figure adjusted incidence in the us and canada after a sudden increase in us incidence. in , the number of infected individuals in the united states is instantaneously increased by %. there are several limitations to the methodologies used in this paper. firstly, these results assume the contribution due to travel in the us is similar to the contribution due to travel to endemic countries, adjusted for the total passenger-days in those respective destinations as well as the difference in incidence between canada and the respective destination (equation ). moreover, here we have neglected cohort effects for the sake of simplicity [ ] . in reality, the age-structured seroprevalence profile for hepatitis a exhibits a cohort effect, whereby the seroprevalence in older age classes is higher than can be explained by the current force of infection (thus implying that the force of infection was higher in the past). the existence of a cohort effect influences how the disease can be modeled. in particular, if the cohort effect is neglected and it is assumed that transmission rates have always been constant, then the dynamic model will overpredict the average population incidence both before and after vaccination, and will also overpredict the percentage reduction in incidence due to vaccination [ ] . finally, there is social heterogeneity within countries in risk factors and transmission patterns for hepatitis a that may be important for modelling certain aspects of disease transmission. geographical heterogeneity in travel destinations of canadian traveling to the us may also be important. the actual ha incidence in the us and canada appeared to oscillate on a non-seasonal seven-year cycle before the vaccine era ( figure ) . however, our model solutions do not oscillate. non-seasonal oscillations in models are often associated with endemic diseases, and the period of oscillation (time between peaks) can even be predicted successfully from models [ ] . in the case of these models, setting the travel transmission rates to zero for both the us and canada caused the infection to die out, suggesting that hepatitis a was not endemic in these two countries for the period - , the time for which the model was parameterized. the fact that ha incidence surface plot of adjusted incidence in canada, versus vaccination rate and travel-related transmission rate figure surface this would allow the model to capture, for instance, us residents who return from endemic countries and travel to canada shortly thereafter. however, the data requirements for such a model would be significantly greater. there have been at least eight hepatitis a transmission models in recent years that have assessed hepatitis a transmission and/or vaccination in various populations and have included herd immunity effects [ , , , [ ] [ ] [ ] [ ] [ ] . like the present model, these models have mostly been deterministic, age-structured compartmental models. some have structured the population along social [ ] or, like the present study, geographic lines [ , ] . those models predicting or estimating the effects of universal vaccination report declines in incidence due to universal vaccination that are similar in magnitude to those found by the present model [ , , , ] . several of the models also included a cost-effectiveness or cost-utility analysis [ , ] . van effelterre and colleagues included transmission across regions in the united states in a preliminary way, as part of the sensitivity analysis of their model of us hepatitis a transmission and vaccination [ ] . they found that the benefits of universal vaccination across the entire us, compared to the benefits of region-specific strategies according to regional hav incidence, were less important with transmission among regions than without. however, there were still benefits in terms of the number of cases averted by universal vaccination across the entire us with transmission among regions. they did not incorporate travel data into their model. to our knowledge, the present model is the first to incorporate transmission of hepatitis a between countries due to international travel by residents. the worldwide sars coronavirus outbreaks exemplified how a public health problem in one population can quickly become a problem in others, due to strong travel connections between countries. the example of hepatitis a transmission in canada and the us represents the (significantly less spectacular) flipside to that of sars: the decline of hepatitis a in canada may partly be attributable to universal vaccination in the us. other modelling work illustrates how nonvaccinators in a population can "freeride" by taking advantage of the herd immunity provided by vaccinators [ ] [ ] [ ] [ ] . this has been compared to a prisoner's dilemma (wherein vaccinators are "cooperators" and nonvaccinators are "defectors") and analyzed using game theory [ ] [ ] [ ] . in the same way, entire countries can also "free-ride" by benefiting from vaccination programmes carried out in and funded by other countries. as international air travel continues to increase, vaccination policies and public health policies in one country will become increasingly important to other countries. in the future, multi-country or multi-regional models may come into more common usage. this study illustrates that changes in hepatitis a vaccination or incidence in the us, or changes in the volume of travel by canadians to the us, may all have significant and rapidly-realized impacts on the prevalence of hepatitis a in canada. the possibility of such a connection is also supported by other evidence, such as the positive correlation in hepatitis a incidence in the us and canada from to ( figure ). hence, declines in reported incidence since the mid- s observed in canada may be partially attributable to vaccination in the us. future epidemiological studies of risk factors for ha infection should include travel to the us as a variable in risk factor analysis. should travel to the us be found as a significant risk factor, then it should be included as such in vaccine recommendations. ha: hepatitis a us: united states seirv: susceptible-exposed-infectious-recovered-vaccinated the author(s) declare that they have no competing interests. all authors contributed to the modelling, parameterization, analysis and/or the writing of the manuscript. ra programmed and simulated the dynamic model and wrote early drafts of the manuscript. aw conceived of the method of parameterization for transmission rates described in appendix b and wrote early drafts of the manuscript. ctb conceived the study, contributed background material, and finalized the manuscript. all authors read and approved the final manuscript. this study is based on ra's msc thesis in mathematics, university of guelph, . the model equations for the us are: the definitions of the variables and parameters are given in table . note that a s = bn to represent recruitment into the youngest age class through birth, and a = . the simulations took as initial conditions s = e = r = v = and i > , however, equilibrium solutions are analyzed throughout the results section and hence the initial values are not relevant to the analysis. the canadian equations are identical except for the susceptible and exposed compartmental equations: the model was simulated in matlab, and the fourth-order runge-kutta method was used to numerically integrate the equations. the model is parameterized using incidence and demographic data from to , since seroprevalence data is readily available for years after , and since vaccination introduced in altered outbreak patterns and hence transmission probabilities. the size of each age class from the us census data [ ] is approximately n = n = , , , n = n = n = n = , , , n = , , . the number of births in the us in was approximately , , [ ] . the ageing parameter, a i , is simply the inverse of the time spent in each age class, hence a = a = / = . year - , a = a = a = / = . year - , a = / = . year - , a = year - . the death rates are obtained by requiring the size of each age class to remain constant over time (by balancing the inflow and outflow for each age class). this is expressed by the equations solving these equations using the above values for b us , , and a i yields . we note that, in principle, it would be possible to include demographic parameters that change over time according to real-world patterns. for instance, the changing sizes of age classes might be incorporated. however, because the primary purpose of the model is to illustrate the effects of travel coupling between the us and canada rather than to exactly predict future incidence, the introduction of extraneous processes corresponding to the additional parameters may make the model output more difficult to interpret. clinical and epidemiological literature on hepatitis a was used to estimate the durations of the latent and infectious periods. the mean duration of the latent period, /δ, is approximately weeks [ , ] . the mean duration of the infectious period for the different age groups is /γ = . weeks, /γ = . weeks, /γ = /γ = /γ = /γ = /γ = . weeks [ , , ] . the longer durations in younger age classes reflect the fact that virus is shed for longer in children than adults. let be the total force of infection (the probability per year that a susceptible person in age class i becomes infected, or approximately, the number of infected individuals in a given year in age class i divided by the susceptibles in that age class at the start of that year). in , . % of infected ha cases in the us acquired the disease through international travel [ ] . here it is assumed that, when the disease was acquired through international travel, it was acquired by traveling to endemic countries. to obtain age-specific values of the proportion of cases attributable to travel in endemic countries for (the values to be used in the model), the available age-specific number of cases for [ ] were adjusted for the population sizes of age classes [ ] and the resulting incidence values by age for were multiplied by the ratio of the overall proportion of cases attributable to travel in compared to , yielding . to estimate the number infectious at any given time dur- ing the year, , we adjust the reported incidence per year per , in age class i, , for subclinical infection and under-reporting, yielding the adjusted incidence . this is then modified using the typical duration of infectiousness to obtain . the reported incidence per year per , for the years - is, by age class, [ ] . the incidence in each age class is then divided by the probability of jaundice by age class p i : p = . , p = . , p = . , p = p = p = p = . [ ] and multiplied by the under-reporting factor of . [ ] to obtain the adjusted incidence values ( = . × observed incidence/p i ). finally, we must modify once again since it represents the number of cases per , per year, not the total number of cases at a given time during the year. for this, following formula is used, . in other words, the number of infectious individuals at any given time during the year is the annual incidence adjusted for the size of the age group divided by the average number of intervals of infectiousness that can occur within a year. therefore thus the system of linear equations (system b ) can be solved to obtain the values for us transmission rate attributable to travel to endemic countries (see table for values). next, is found from equation b . since there are more unknowns ( × = ) than knowns ( ), we make additional assumptions about the values: , etc. similar assumptions have been made for other diseases modeled with age-structured compartmental models [ ] . expressed as a matrix, this becomes a "who acquires infection from whom" matrix. the values obtained by solving the linear system of equations (b ) are found in table . the rate of waning vaccine-derived immunity was obtained by fitting an exponential curve to the estimated proportion of vaccinated individuals retaining immunity after , , , and years ( %, %, %, %, and % respectively), obtained using the delphi method [ ] , yielding f = . year - . in our simulations, only individuals in the first age class were vaccinated, hence . to determine such that % of individuals are vaccinated at a given age each year in the - age class, we set f = , , applied the condition to system a and solved it analytically to obtain = / year - . the average size of the age classes from - in canada were approximately [ ] . the average number of births per year during this time was approximately , [ ] . the death rates, ageing parameters, and duration of the latent infectious periods are the same as in the us model. the canadian rate of infection due to travel to endemic countries ( ) was computed using the same method as for the us, except that there is an additional contribu-tion to the travel transmission rate, , from travel to the us. hence, the total force of infection in canada is again using the fact that , we have that is found following the same method as for the us case, but using canadian incidence and travel data. the values appear in table . the parameter is obtained from equation . the volume of travel (annual number of trips) by canadian residents using any mode of transport in to the us and endemic countries is available from published data [ ] . estimates of age-specific travel volumes to the us ( ) and endemic countries ( ) are obtained from these data by assuming travel volume to be distributed across the age classes according to the sizes of the age classes [ ] , yielding the results in table . the average duration of travel to the us and to endemic regions are = . nights and = . nights respectively [ ] . the incidence per , per year in the us, canada and endemic countries, adjusted for under-reporting and subclinical infection, are estimated as y us = . , y c = . , y end = . [ , , ] . all these values are substituted into equation to obtain the values appearing in table . the parameter is found using the same methods as for the us model, yielding values for (see table ). the rate of loss of vaccine derived immunity is the same as for the us model, f = . year - [ ] . the vaccination policy in canada is currently targeted vaccination toward high-risk groups. a previous study estimates that, to date, about % of the canadian population has been vaccinated under this programme (which also vaccinates travelers to endemic countries) (bauch et al, unpublished data). hence, we assume in this paper a % coverage rate for each age class. although the actual coverage rates across age classes under the current targeted policy may be dissimilar, the available data do not allow us to stratify the vaccine coverage rates by age. hence, we have assumed the same vaccination rate applies to each age class. we note that there are also other heterogeneities in vaccine coverage (e.g., social) that the present model was not designed to address. the values of g i are obtained from imposing f = , as for the us case, as well as the constraints on system a , and solving system a to yield g c = . year - . .. the global burden of disease, - unaids: aids epidemic update the effects of socioeconomic development on worldwide hepatitis a seroprevalence patterns hepatitis a: old and new epidemiological patterns of hepatitis a in different parts of the world hepatitis a in latin america: a changing epidemiologic pattern public health agency of canada (phac): notifiable diseases online hepatitis a virus infections in the united states: model-based estimates and implications for childhood immunization global impact of hepatitis a virus infection changing patterns hepatitis a vaccines: the growing case for universal immunisation of children ineffectiveness of the current strategy to prevent hepatitis a in travelers hepatitis a virus in urban children -are preventative opportunities being missed? hepatitis surveillance report quantifying the impact of hepatitis a immunization in the united states a dynamic model for assesssing universal hepatitis a vaccination in canada touriscope: international travel; travel between canada and other countries . historical supplement statistics canada: cansim table - public health agency of canada (phac): canadian immunization guide centers for disease control and prevention: prevention of hepatitis a through active or passive immunization kelley pw: frequency of illness associated with epidemic hepatitis a virus infection in adults relapsing hepatitis a. review of cases and literature survey hav infection in chronic liver disease: a rationale for vaccination clinical spectrum and natural history of viral hepatitis a in a shanghai epidemic the cost-effectiveness of adolescent hepatitis a vaccination in states with the highest disease rates predicting the impact of measles vaccination in england and wales: model validation and analysis of policy options effects of long-term retinoic acid treatment on epidermal differentiation in vivo: specific modifications in the programme of terminal differentiation hepatitis a in the united states prevention of hepatitis a with the hepatitis a vaccine another vaccine preventable disease continues to emerge annual population estimates by sex, race and hispanic origin, selected years from infectious diseases of humans: dynamics and control oxford statistics canada: international travel. travel between canada and other countries cohort effects in epidemic models: an example from hepatitis a the spread and persistence of disease in structured populations cost-effectiveness of hepatitis a immunization of children and adolescents in germany a mathematical model of hepatitis a transmission in the united states indicates value of universal childhood immunization cost-utility of universal hepatitis a vaccination in canada individual versus public priorities in the determination of optimal vaccination policies imitation dynamics predict vaccinating behaviour vaccination and the theory of games group-interest versus selfinterest in smallpox vaccination policy trends in characteristics of births by state: united states controle de l'hépatite a par l'immunisation au quebec. (final report results from the national sentinel health unit surveillance system, - aw and ctb were supported by discovery grants from the natural sciences and engineering research council of canada (nserc). the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /prepub key: cord- -mvo k jt authors: mcintyre, roger s.; lee, yena title: projected increases in suicide in canada as a consequence of covid- date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: mvo k jt macroeconomic indicators, notably unemployment, are significant moderators of suicide. we projected the number of excess suicides in canada as a consequence of the impact of covid- on unemployment. annual suicide mortality ( - ) and unemployment ( - ) data were derived from statistics canada. time-trend regression models were used to evaluate and predict the number of excess suicides in and for two possible projection scenarios following the covid- pandemic: ) an increase in unemployment of . % in , . % in , or ) an increase in unemployment of . % in , . % in . a percentage point increase in unemployment was associated with a . % increase in suicide between - . in the first scenario, the rise in unemployment rates resulted in a projected total of excess suicides in - (suicide rate per , : . in ). in the second scenario, the projected suicide rates per , increased to . in and . in , resulting in , excess suicides in - . these results indicate that suicide prevention in the context of covid- -related unemployment is a critical priority. furthermore, timely access to mental healthcare, financial provisions and social/labour support programs, as well as optimal treatment for mental disorders is urgently needed. as a consequence of the covid- pandemic, approximately one-third of the global population currently resides under some form of lockdown or quarantine. the impact of the containment measures on the global economy is projected to dwarf the macroeconomic impact of the - financial crisis in both magnitude and scope (oecd economics department, ) . unprecedented proportions of the employment sectors in the usa and canada have filed for unemployment benefits. statistics canada reported, on april , , that one-in-ten working-age individuals (i.e., fifteen years of age and over) in canada lost their jobs or worked less than half their usual hours as a result of the widespread restrictions imposed in march (government of canada, statistics canada, ). suicide rates, at a population-level, are highly sensitive to macroeconomic indicators, particularly unemployment (chang et al., ; reeves et al., ; stuckler et al., ) . we recently reported that the rapid rise in unemployment as a result of the covid- pandemic is predicted to result in , excess suicides between and , representing a . - . % increase in suicides per year from the rate of , suicides in the usa (mcintyre and lee, ). during the great recession, an increase in the number of suicides was also reported in canada (reeves et al., ) . herein, we replicate and extend our previous findings and project the number of excess suicides in canada as a consequence of the impact of covid- on unemployment. annual, national-level suicide mortality ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and unemployment ( - ) data were acquired from statistics canada (government of canada, statistics canada, , . the vital statistics -death database records the number of deaths due to suicide among canadian residents and non-residents in canada. suicide rate per , was codified using international statistical classification of diseases and related health problems, th revision (icd- ) codes for intentional self-harm (i.e., x -x , y . ). the labour force survey collects cross-sectional unemployment data with stratified multi-stage sampling and a rotating panel sample design (i.e. rotation groups of six consecutive months). this research was based on publicly available data and therefore did not require ethics approval. time-trend regression models were used to evaluate and predict the number of excess suicides attributable to the projected rise in unemployment rate following the covid- pandemic. first, we modelled the number of suicide detahs annually between and and the association between suicide and unemployment rates. second, we estimated the number of suicide deaths in using the time-trend model and the published unemployment rate of . % for . third, we predicted the number of suicide deaths in and for the three following scenarios: ) minimal change in unemployment (i.e., average annual unemployment rate of . % in , . % in ; derived from the federal budget); ) moderate increase in projected unemployment rate (i.e., average annual unemployment rate of . % in , . % in ), as forecasted by the international monetary fund based on the assumption that the pandemic will fade in the second half of that there will not be a second outbreak in ; and ) extreme increase in projected unemployment rate (i.e., average annual unemployment rate of . % in , . % in ), approximating the peak unemployment rate of % during the great depression (government of canada, department of finance, ; "world economic outlook, april --chapter : the great lockdown," ). we quantified the number of excess suicide deaths associated with a moderate increase in unemployment by subtracting the number of suicide deaths estimated in the first scenario from the number of suicide deaths in the second scenario. similarly, we quantified the number of excess suicide deaths associated with an extreme increase in unemployment by subtracting the number of suicide deaths estimated in the first scenario from the number of suicide deaths in the third scenario. the suicide rate per , and the unemployment rate were ln-transformed. the analyses were conducted using the functions ts from the package stats and auto.arima and forecast from the package forecast on r statistical software version . . (hyndman et al., ; hyndman and khandakar, ; r core team, ) . the historical suicide rates for - and the projected suicide rates for - are visualized in in the first scenario, wherein unemployment rates change minimally between and , the predicted suicide rates are . per , in and (table ) . the foregoing suicide rates would result in , suicides in and , in (assuming population size of , , ). in the second scenario, wherein the pandemic is contained and lockdown measures are lifted during the latter half of , moderate increases in projected unemployment rates to . % in and . % in will increase the forecasted suicide rates per , from . in to . in and . in . this second scenario would result in a total of excess suicides over the - period, representing a . % increase in suicides per year (when compared to the rate of , ). in the third scenario (i.e., extreme increase in projected unemployment rate), suicide rates per , are projected to increase to . in and . in . this rise in suicide rate would result in , excess suicides over the two-year period, representing a . % increase in suicides per year (relative to the suicide rate). the results of our projection analysis are in accordance with what we previously discovered in a similar analysis in the usa that the abrupt increase in unemployment in canada is associated with an increase in deaths due to suicide. the projection estimates we have observed are also similarly aligned with what was observed in canada during the great recession (reeves et al., ) . we recognize that no single variable accounts for completed suicide within individuals or populations. we additionally recognize that no single macroeconomic indicator is sufficiently predictive of suicide. notwithstanding, it was observed during the great recession in the usa, canada, and various economies of europe, as well as asia, that the change in unemployment rate was highly associated with increase in suicide rates (chang et al., ; reeves et al., reeves et al., , stuckler et al., ) . moreover, the association between economic distress and adverse mental health outcomes, notably suicide, is a highly replicated observation (alicandro et al., ; collins et al., ) . the covid- pandemic introduces other aspects that are detrimental to mental health not seen during the great recession and other economic downturns, notably the risk of viral infection, as well as social distancing and quarantine measures. a separate body of literature indicates that quarantine alone is an independent contributor to adverse mental health outcomes (e.g., post-traumatic stress symptoms), as observed during the sars epidemic in toronto in (brooks et al., ) . it was reported in several countries in europe after the great recession (e.g., denmark) that social spending on emergency healthcare/mental healthcare, wage subsidies, supplemental income, and work retraining mitigated risk of suicide (peeples, ) . it was also reported in japan, as well, during the great depression, that increased social spending significantly mitigated suicide completion (matsubayashi et al., ) . the results of our analysis underscore the urgency of prioritizing access to mental healthcare and the provision of psychological first aid. the covid- pandemic has accelerated the implementation of telemedicine/telehealth; clinicians are encouraged to incorporate the assessment of mental health amongst all patients including, but not limited to, those previously diagnosed with mental illness. social isolation measures are critical to reduce the spread of the coronavirus and a recently conducted analysis also indicates that during the great depression those cities in the usa that had the most rapid and robust social isolation measures also witnessed the greatest economic rebound (stuckler et al., ) . a policy approach to managing the covid- pandemic needs to be informed by the projection of possible suicides to prevent excess suicides in the context of the covid- pandemic. we see a role for primary, secondary, and tertiary prevention. for example, wage subsidies, forbearance on financial obligation, government support of small business, work retraining programs, and access to community-based support programs can all serve as primary prevention. we also believe that the creation of virtual, as well as conventional, services that provide timely access to high quality mental health assessment and, where appropriate, specific treatment for persons at risk of mental illness are urgently needed. finally, we assert that specialized services with an emphasis on psychiatric first aid available in communities and co-localized with other medical services will be especially relevant as a mechanism to reduce suicide at this time. suicide mortality in and were projected for three scenarios of change in unemployment rates: no change (i.e., . % in and . % in as published in the federal budget), moderate increase (i.e., . % in , . % in ), and extreme increase (i.e., . % in , . % in ). worldwide trends in suicide mortality from to with a focus on the global recession time frame the psychological impact of quarantine and how to reduce it: rapid review of the evidence was the economic crisis - responsible for rising suicide rates in east/southeast asia? a time-trend analysis for japan suicide, sentiment and crisis labour force characteristics by sex and detailed age group, annual [www document]. government of canada deaths and age-specific mortality rates, by selected grouped causes forecast: forecasting functions for time series and linear models automatic time series forecasting: the forecast package for r government spending, recession, and suicide: evidence from japan preventing suicide in the context of the covid- pandemic evaluating the initial impact of covid- containment measures on economic activity how the next recession could save lives r: a language and environment for statistical computing economic suicides in the great recession in europe and north america increase in state suicide rates in the usa during economic recession the public health effect of economic crises and alternative policy responses in europe: an empirical analysis the great lockdown abbreviations: ci = confidence interval, ur = unemployment rate. key: cord- -v mde l authors: vaid, shashank; cakan, caglar; bhandari, mohit title: using machine learning to estimate unobserved covid- infections in north america date: - - journal: j bone joint surg am doi: . /jbjs. . sha: doc_id: cord_uid: v mde l the detection of coronavirus disease (covid- ) cases remains a huge challenge. as of april , , the covid- pandemic continues to take its toll, with > . million confirmed infections and > , deaths. dire projections are surfacing almost every day, and policymakers worldwide are using projections for critical decisions. given this background, we modeled unobserved infections to examine the extent to which we might be grossly underestimating covid- infections in north america. methods: we developed a machine-learning model to uncover hidden patterns based on reported cases and to predict potential infections. first, our model relied on dimensionality reduction to identify parameters that were key to uncovering hidden patterns. next, our predictive analysis used an unbiased hierarchical bayesian estimator approach to infer past infections from current fatalities. results: our analysis indicates that, when we assumed a -day lag time from infection to death, the united states, as of april , , likely had at least . million undetected infections. with a longer lag time—for example, days—there could have been at least . million undetected infections. given these assumptions, the number of undetected infections in canada could have ranged from , to , . duarte’s elegant unbiased estimator approach suggested that, as of april , , the united states had up to > . million undetected infections and canada had at least , to , undetected infections. however, the johns hopkins university center for systems science and engineering data feed on april , , reported only , and , confirmed cases for the united states and canada, respectively. conclusions: we have identified key findings: ( ) as of april , , the united states may have had . to . times the number of reported infections and canada may have had . to . times the number of reported infections and ( ) even if we assume that the fatality and growth rates in the unobservable population (undetected infections) are similar to those in the observable population (confirmed infections), the number of undetected infections may be within ranges similar to those described above. in summary, different approaches indicated similar ranges of undetected infections in north america. level of evidence: prognostic level v. see instructions for authors for a complete description of levels of evidence. we have identified key findings: ( ) as of april , , the united states may have had . to . times the number of reported infections and canada may have had . to . times the number of reported infections and ( ) even if we assume that the fatality and growth rates in the unobservable population (undetected infections) are similar to those in the observable population (confirmed infections), the number of undetected infections may be within ranges similar to those described above. in summary, different approaches indicated similar ranges of undetected infections in north america. level of evidence: prognostic level v. see instructions for authors for a complete description of levels of evidence. t he detection of coronavirus disease (covid- ) cases remains a huge challenge . as of april , , the covid- pandemic continues to take its toll, with close to . million confirmed infections and > , deaths . dire projections are surfacing almost every day, and policymakers worldwide are using projections for critical decisions. while social distancing now appears to be globally accepted, approaches vary substantially. whereas hong kong and singapore are experimenting with "suppress and lift" measures , india has been estimated to be at the top of the lockdown stringency index . intelligence on the number of infections and projected courses has never been more urgent as the world economy heads toward a contraction of % in and the world faces the worst recession since the great depression . while organizations such as the world health organization (who) are establishing covid- -detection protocols , leading scientific opinion and commentaries appear to be highlighting the possibility of detection bias . there also appears to be a grudging acceptance that identifying and quantifying such bias may depend largely on the number of reported cases. the challenge with reported cases is that they are dependent on the extent of testing. as of april , the numbers of tests per million population varied greatly across some of the key jurisdictions most impacted by the pandemic, including the u.s. ( , ), u.k. ( , ) , italy ( , ), france ( , ), spain ( , ), canada ( , ), and india ( ) . however, the extent of testing is not just a policy matter but also is dependent on the availability of scarce public and private resources. under such circumstances, it may not be prudent for policymakers to rely only on "observable" data (i.e., confirmed covid- cases) as such measures are likely to under-report the extent of the problem. for example, by publicly reporting , deaths against only , cases, the united states may not be accounting for the influence of lower levels of testing ( , tests per million) relative to other countries. by not proactively acknowledging data that are unobservable-i.e., expected infections that have not been captured by whoestablished covid- -detection protocols-policymakers could be grossly underestimating the true number of infections in the population. furthermore, if case fatality rates (that is, the ratio of deaths to reported cases; e.g., ; . % for the u.s.) do not factor in unobservable infections, models may overestimate the risk of death . given this background, we modeled unobserved infections to examine the extent to which we might be grossly underestimating covid- infections in north america. w e developed a machine-learning model to uncover hidden patterns based on reported cases and to predict potential infections. first, our model relied on dimensionality reduction to identify parameters that were key to uncovering fig. -b) ; the x axis is in days. covid- data are also normalized for better visualization. a visual inspection indicates the temporal delay between the waves. , hidden patterns. next, our predictive analysis used an unbiased estimator approach to infer past infections from current fatalities. we referenced the initial rapid research and contributions by pueyo, duarte, and others [ ] [ ] [ ] [ ] [ ] . broadly speaking, our analysis compared the numbers of confirmed cases, deaths, and estimated infections across north america (u.s. and canada). our data were made available thanks to the generosity of the johns hopkins university center for systems science and engineering (jhu csse), the esri living atlas team, and the johns hopkins university applied physics laboratory (jhu apl). the data were pulled from the covid- data repository by the jhu csse every hour. we started with exploratory data analysis. we aggregated the u.s. and canada since they were split by states and provinces. while we focused on north america, we also included countries with a minimum of cases. the columns in our timeseries dataset initially included country, state, and number of deaths and confirmed cases. first, we filtered data to include at least cases. as the "deaths" and "confirmed cases" data were separate in the jhu csse database, we concatenated both time series. after dropping duplicated columns, we created new columns for ( ) dirty ratio = confirmed cases/(deaths ) and ( ) fatality = deaths/confirmed cases. we also created new columns for new deaths and new confirmed cases. next, we created a smaller dataset with at least cumulative cases. we also grouped data for states (u.s.) and provinces (canada). our final dataset included the following columns: index, country, date, confirmed cases, deaths, dirty ratio, fatality, new deaths, new confirmed cases, and days since case . we assumed that the average time from infection to death could be days (to account for older patients), days, or days (to account for younger patients); however, we based our results on days . the time from infection to death was taken as being equal to the incubation period plus the time from symptoms to death. this assumption was used to estimate the timing of the infections that led to the observed deaths. we used the fatality rate per country (total deaths/total cases) to estimate the number of infections that were responsible for the observed deaths. next, we extrapolated available information with use of duarte's elegant unbiased hierarchical bayesian estimator approach , . we inferred past infections from current daily deaths as the average fatality rate was approximated from confirmed cases , , . in doing so, we assumed that ( ) the case fatality rate (that is, the fatality rate among patients with confirmed cases) may be a good proxy for the fatality rate of the infected population, ( ) the growth rate of the infected population may serve as an unbiased estimate of confirmed cases, and ( ) on average, the interval between the initial symptoms and death is to days. o ur analysis indicated that, with a -day lag time from infection to death, the u.s. likely had at least . million undetected infections as of april , (represented by dashed bars in figs. -a and -b; covid- data are also normalized for better visualization). under a longer lag time of days, there could have been at least . million undetected infections. given these same assumptions, the number of undetected infections in canada could have ranged from , to , . we used duarte's elegant unbiased hierarchical bayesian estimator approach (which uses the case fatality rate to infer the fatality rate of the unobservable population) as a robustness check on these results. using that approach, we found that, as of april , , the united states had up to > . million undetected infections and canada had at least , to , undetected infections (figs. -a and -b) . however, the jhu csse data feed on april , , reported only , and , confirmed cases for the united states and canada, respectively. o ur research explored the role of unobservable infections in covid- detection bias. we identified key findings: ( ) as of april , , the united states may have had . to . times the number of reported infections and canada may have had . to . times the number of reported infections and ( ) even if we assume that the fatality and growth rates in the unobservable population (undetected infections) are similar to those in the observable population (confirmed infections), the number of undetected infections may be within ranges similar to those described above. in summary, different approaches indicated similar ranges of undetected infections in north america. our analysis has unique strengths. our multidimensional analysis of unobservable infections in the context of the covid- pandemic has helped us to uncover trends that are likely to have an impact on scientific research in respects. first, we estimated the distribution of successive waves of infections (dashed bars), detections (black bars), and deaths (red bars) for both the u.s. and canada (figs. -a and -b) . with the time from infection to death being defined as the incubation period plus the time from symptoms to death, we estimated the timing of the infections that led to the observed deaths. our results indicated that, as of april , , the u.s. may have had at least . million undetected infections and canada may have had at least , undetected infections. next, we supported these results through a robustness check that used the case fatality rate to infer the fatality rate of the infected population. assuming that the growth rate of the infected population could be an unbiased estimate of confirmed cases, we found that the numbers of undetected infections may be quite high in the u.s. (> . million) and canada ( , to , ) (figs. -a and -b) . we also extended the mandate of this research to understand why a set of western countries accounted for a large number of fatalities despite high testing. as of april , , the following countries had relatively higher testing per million population: u.s. ( , ), u.k. ( , ) , italy ( , ), france ( , ), spain ( , ), and canada ( , ). yet, together they accounted for close to % of all fatalities. one reason for this finding could be that testing was late as it followed cumulative deaths and new deaths. nevertheless, this research is not without shortcomings. to some extent, our method is limited in that asymptomatic carriers (who are believed to account for % to % of all cases , ) cannot be observed without antibody tests and thus are not factored into the derived fatality rate. this means that the number of actual infections (dashed bars) is limited to the estimation from observed deaths and cases only and serves as a lower boundary estimate (figs. -a and -b) . furthermore, we relied on the extant literature, some of which may still not be peer-reviewed, to arrive at a novel framework that may point to the extent of unobservable infections across north america, specifically, the u.s. and canada. however, we hope that readers will appreciate the rapid rate at which the pandemic scenario has evolved over the past weeks and understand the limitations of this research while also acknowledging that unusual times call for unusual solutions. our goal is to contribute to the ongoing debate on detection bias and to present an alternative mechanism that can help to improve the robustness of covid- data being made available to the scientific community. in summary, our research adds another perspective to the ongoing debate on the e ( ) pandemic. however, we highlight the need for more robust data. as the covid- pandemic progresses, it is crucial for policymakers to begin to focus on the potential for detection bias. we must be aware of the extent to which unobservable data-infections that have still not been captured by the system-can damage efforts to "flatten" the pandemic's curve. n world faces worst recession since great depression data on covid- coronavirus pandemic ( ). . accessed suppress and lift': hong kong and singapore say they have a coronavirus strategy that works. science magazine oxford covid- government response tracker. blavatnik school of government world health organization. national capacities review tool for a novel coronavirus estimating case fatality rates of covid- lancet infect dis full spectrum of covid- severity still being depicted coronavirus: why you must act now report : estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak science the next generation of the penn world table covid- and italy: what next? lancet up to % of coronavirus cases asymptomatic estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship key: cord- -plcdwazu authors: gore, dana; kothari, anita title: social determinants of health in canada: are healthy living initiatives there yet? a policy analysis date: - - journal: int j equity health doi: . / - - - sha: doc_id: cord_uid: plcdwazu introduction: preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in british columbia and ontario for combating chronic diseases. what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health. methods: initiatives active between january , and september , were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs). results: initiatives were identified in ontario and were identified in british columbia. in british columbia, . % of initiatives were structure-based. in ontario, of provincial initiatives identified, % were structure-based. ontario had a higher proportion of direct interventions than british columbia for all intervention types. however, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened. conclusions: the paucity of initiatives in british columbia and ontario that address healthy eating and active living through action on the social determinants of health is problematic. in the context of canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. if public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. it is necessary that health be seen for what it is: a political matter. as such, the health sector needs to take a more political approach in finding solutions for health inequities. preventative strategies focusing on healthy eating and physical activity, collectively known as healthy living, have become an important strategy in canada for combating chronic diseases. chronic diseases are rising to epidemic proportions in the canadian population and costs associated with treating them pose a serious threat to the sustainability of the health care system [ ] . addressing the underlying causes of chronic diseases and their inequitable distribution through a preventative health promotion strategy has been acknowledged as an effective way to reverse these trends in both ontario (on) and british columbia (bc). these provinces have recently reformulated their chronic disease prevention strategies as part of canada's renewal of public health systems, initiated in as a response to severe acute respiratory syndrome (sars). a common strategy that both provinces pursue is to address chronic disease prevention through healthy living initiatives -initiatives that work to promote healthy eating and physical activity as well as address other risk factors such as unhealthy alcohol consumption and tobacco use. while healthy eating and physical activity were traditionally considered individual lifestyle choices, public health has shifted its perspective in the past several decades to encompass the broader context in which these choices are made. this includes daily living and working conditions that are not conducive to healthy lifestyles as well as broader structural determinants that create inequities between population groups, which together form the social determinants of health [ ] . the world health organization (who) has defined the social determinants of health in the following way: "the poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples livestheir access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or citiesand their chances of leading a flourishing life. together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries" [ , p. ] . within a canadian context, some examples of social determinants of health that have been identified are: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, aboriginal status, gender, race and disability [ ] . the social determinants of health have been consistently linked in the literature to chronic diseases such as cardiovascular disease, respiratory diseases, diabetes and cancer in canada and worldwide; for example, it has been found that low socioeconomic status (ses), often measured by income and education levels, is associated with higher rates of cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus and asthma [ ] [ ] [ ] [ ] [ ] [ ] . research on canadian cities has shown that people living in low income neighbourhoods experience significantly higher rates of chronic diseases such as diabetes and die several years earlier than their wealthier counterparts [ ] . job insecurity, characterized by unemployment, part-time employment and temporary employment, has been found to result in elevated blood pressure and higher risk of death from cardiovascular disease [ , ] . even in a financially secure job, poor working conditions that place high demands on the worker, combined with low support and low job control have been correlated with elevated stress and increased rates of coronary heart diseases as well as higher risk of cardiovascular-specific mortality [ ] [ ] [ ] . nor are these trends colour-blind; racialized groups such as aboriginal people, new immigrants and minorities of colour consistently earn lower incomes and experience higher rates of chronic disease than north americans of european descent [ ] [ ] [ ] [ ] . canadian policy documents outlining priorities for public health have stressed the importance of an approach that addresses the social determinants of health [ ] [ ] [ ] . in a recent high-level united nations meeting on chronic diseases, the role that the social determinants of health play in chronic disease was recognized, as was the importance of addressing them in disease prevention strategies [ ] . a delegation from canada participated in this meeting, and canada endorsed the resulting declaration [ ] . an approach that effectively engages with the determinants has been suggested in mikkonen and raphael's the social determinants of health: the canadian facts, and includes policies that offer a higher minimum wage, higher assistance levels for those unable to work, a more progressive taxation structure that redistributes income more fairly, increased unionization, better funding of public education, government regulation of post-secondary institution tuition, stronger legislation on anti-discrimination policies and equal opportunity hiring, a national childcare strategy, strategies to increase the affordability of nutritious food, increased spending on a housing strategy, policies that reduce barriers for refugees and immigrants to practice their professions, and recognizing aboriginal government authority over a wider range of aboriginal affairs [ ] . provincial health policy on chronic disease prevention for bc and on corresponds to federal priorities. on has stated in policy documents that the causes of chronic diseases are complex and rooted in broad determinants of health, which encompass lifestyle, socioeconomic, cultural and environmental factors [ , ] . in order to tackle these upstream causes, the province has decided on a comprehensive, integrated population health approach that is evidence-based [ , ] . for example, in a policy document on combating obesity, on committed to a population health approach, which explores health disparities and interactions among the social determinants of health in order to improve the well-being of populations [ ] . this approach can also be seen in the ontario action plan for healthy eating and active living [ ] . on has made efforts to integrate a social determinants of health perspective into the province's public health practice through data and information use guidelines for boards of health of public health units. in the healthy eating, physical activity and healthy weights guidance document, the board of health is instructed to use information on health inequities and the social determinants in order to assess population needs and identify groups at highest risk [ ] . bc shares fundamental similarities with on in its agreement on the importance of the social determinants of health and the need for an evidence-based, population health approach to chronic disease prevention. in the model core program paper on chronic disease prevention in bc, the paper's working group identified key principles for successful disease prevention, which includes a focus on social, environmental and economic determinants of health, a "whole of society" approach to population health, and an equity lens to examine health disparities between different groups [ , p. iv] . the determinants of health are understood to interact with each other in a variety of ways, to compound vulnerabilities for certain sections of the population, and to be modifiable through health public policy and changing social norms. like on, bc also takes health disparities between different parts of the population into account, such as between men and women, different ethnic groups, those who identify as aboriginal, or between people of varying socioeconomic status [ ] . in order to effectively address the social determinants of health, on and bc have committed to multi-sectoral action that targets the population on a variety of levels. both bc and on have stressed the importance of partnerships in the public health model to achieve prevention goals with other levels and sectors of government, ngos, private industry, service providers, researchers, and communities to name a few [ , , [ ] [ ] [ ] . these partnerships are considered crucial for real change, given the upstream, wide-ranging impact of the social determinants of health. both provinces advocate for comprehensive strategies that target the population in diverse environments and at multiple levels [ , ] . these strategies suggest a socio-ecological approach to healthy eating and active living, a model of health that recognizes the interaction between individuals and their greater environment and its impact on health. in a socio-ecological model, the health behaviours that individuals engage in are impacted by individual factors (such as knowledge, lifestyle choices, and attitudes towards health behaviours), as well as interpersonal, community, organizational and society-level factors [ , ] . interventions that follow this model aim to target the population at all these levels and address downstream as well as upstream barriers to healthy living [ ] . it is important to note that although the socio-ecological model is different from the social determinants of health approach, it does not preclude attention to the social determinants of health. the social determinants of health can in theory be addressed at multiple levels within the socio-ecological framework, especially those that are more upstream such as at the societal level. based on the priorities that are listed above for healthy eating and active living in on and bc, it would be expected that initiatives in both provinces target the population in diverse settings and at multiple levels, with a majority of initiatives focusing on improving population health through a social determinants of health framework. however, what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health. this study seeks to evaluate healthy living initiatives in bc and on that focus on healthy eating and physical activity based on their approach to the social determinants of health and health inequities. the authors draw on a political economy of health perspective in order to evaluate the initiatives within their broader social, political and economic context [ ] . this implies that the findings related to the data are discussed in relation to the larger discourse around the socioeconomic environment and acknowledge the effect of structures and processes external to the health sector. recommendations that emerge from the discussion are approached in a similar way. publically-available provincial policy documents written between and in bc and on that focused on chronic disease prevention were used as a starting point to identify relevant initiatives. the focus was on chronic diseases that are most affected by nutrition and physical activity -namely cardiovascular diseases, some cancers, diabetes, hypertension, stroke and chronic respiratory disease. once initiatives were identified, a web-based search was conducted to obtain a detailed description of the program as well as its timeline and current status (in-planning, ongoing, discontinued) etc. provincial organizations that had the potential to conduct initiatives were also researched online to find initiatives that may not have been mentioned in the original policy documents and database. the search was not restricted to initiatives led by provincial ministries related to health; they could be initiatives of other ministries, arms-length government agencies or independent nonprofit organizations that worked to improve healthy eating and physical activity. in order to ensure the list of healthy living initiatives was comprehensive, it was compared against recent documents and public databases that provide listings of healthy living initiatives at municipal, regional and provincial levels in bc and on [ , , ] . lastly, two policy-makers in bc and on reviewed the list of initiatives to fill any gaps. a) initiatives focused on healthy eating and physical activity as a preventative strategy to reduce chronic diseases or improve general health. the initiatives were not limited to government interventions -the initiatives could be funded and developed by various organizations including actors in the government, non-profit and private sectors. b) initiatives were implemented in bc and on between january , and september , . c) initiatives were provincial rather than regionally or nationally-based. initiatives that focused on select sites in the province were also permitted provided they weren't restricted to a particular region or area. for example, an intervention targeting remote communities in on would be acceptable for analysis, whereas an intervention led by a particular health authority and applied only to that health authority's region would not be included. the findings are limited to the provincial scope of initiatives selected. it is difficult to determine if analysis of regional, municipal or community level initiatives would reveal convergent findings, and represents an area for future study. each of the identified initiatives was reviewed, analyzed and grouped using descriptive labels. codes were developed directly from the data by asking the following questions of each initiative: a) what section of the population does the initiative target? (ex. general public, vulnerable populations, health service providers, community actors, etc.) b) what factor is the initiative trying to change that will lead to healthy eating and active living? (e.g. knowledge, skills, attitudes, built environment, access, social/economic/political factors, etc.) c) does the initiative directly acknowledge and attempt to act on the social determinants of health? if so, in what way? (e.g. education, advocacy, public policy change, etc.) d) what is the mechanism that the initiative uses to promote healthy living? (e.g. direct program for population, resources, toolkits, consultation services, grants, etc.) the predominant themes that emerged from questions b. and c. reflected three types of initiatives: lifestylebased, environment-based, and structure-based, which were defined for this paper in the following ways: lifestyle-based: these initiatives aim to improve healthy living through lifestyle change of individuals. examples include raising awareness of the issues (e.g. obesity) in the general population, increasing knowledge around nutrition and physical activity, changing attitudes towards healthy living by appealing to social norms (e.g. social marketing campaigns) or directly encouraging the adoption of new behaviours through programs (ex. eating foods with lower salt content, exercising for minutes each day). the target audience could be the general public or specific groups (e.g. low income individuals, children, or aboriginal people) environment-based: these initiatives are meant to improve healthy living by influencing the immediate environment in which people spend their time, such as schools, workplaces and community spaces. examples of these initiatives range from encouraging employers to initiate healthy workplace programs to banning the sale of unhealthy foods in schools or working towards a built environment that encourages physical activity. these initiatives were frequently settings-based and address the role that immediate environmental factors play in health. structure-based: these initiatives directly acknowledge the impact of various structures (e.g. social, political, economic) that create inequities leading to chronic diseases and attempt to address the social determinants of health directly in order to improve healthy eating and active living. these types of interventions are most frequently centered around education and advocacy on the social determinants of health and worked specifically to correct health inequities caused by these structural conditions. examples include a survey tool that assesses the cost of basic healthy eating in different geographic areas in order to monitor accessibility and affordability of a nutritious diet, the creation of community forums to discuss the social determinants of health and explore structural barriers to healthy living, or consultation services that provide gender equity audits to sport and recreation organizations. of the three categories, this one is the only one that directly acts on the social determinants of health. for each initiative type, it was also found using questions a. and d. that there was a broad variety of mechanisms by which the initiative was supported and delivered. consequently, in each category, initiatives were classified according to the mechanism by which they were administered. mechanisms were categorized as direct programs, blueprints, and building blocks, and were defined as the following: direct program: initiatives that are developed and implemented to directly influence the health of the population. initiatives could be implemented through organization staff, contracting of other staff, working with community partners, or enforcing mandatory policy. examples include direct services from health professionals such as phone lines staffed by dieticians and specialists in physical activity, bills to prohibit certain foods, and programs that provide healthy snacks to schoolchildren. this category also applies to programs that reward organizations (communities, schools) for programs they have already implemented. blueprint: initiatives that are developed but require implementation and tailoring by a third party such as a school, public health unit, or community organization. these initiatives are categorized as blueprints because while they offer a "plan" for a healthy eating and active living intervention (heal), they do not directly act on the population and their implementation is optional. examples include toolkits for healthy school policies, materials for teachers to encourage student physical activity, and frameworks for how to build healthy communities. these initiatives require more action at the local level than direct programs because although the initiative is planned, local actors are needed to carry it through. building blocks: initiatives that are meant to act as resources for third parties to develop their own projects, within certain guidelines. examples include grants for communities to build their own heal project, consultation and training services on program planning, and directories of heal initiatives to act as a resource for ideas in developing an initiative. these initiatives require the most action at the local level; their planning and implementation fall to local actors and they provide the least support from the organization that is offering the initiative. from the systematic scan of the policy documents, database and website search, initiatives were identified in on and were identified in bc. (please see additional file and additional file for a full list of initiatives). programs were headed by various actors in both provinces, including ministries of health, other government sectors such as the ministry of education, non profit organizations, and professional associations. often initiatives were structured as a partnership among multiple actors across different sectors. while many different organizations led and implemented healthy living initiatives, the majority were linked to provincial government in some way -either through direct funding, funding through an arms-length government agency (e.g. cancer care ontario or public health ontario), funding through a non-profit organization that has received sizeable grants for healthy living initiatives (e.g. bc healthy living alliance), or partnership with a government agency. government involvement in on programming or financing included the province of ontario, the ministry of health and long-term care, the ministry of child and youth services, the ministry of community and social services, the ministry of education, the (former) ministry of health promotion and sport, and the ministry of agriculture, food and rural affairs. government involvement in bc programming or financing included all ministries, since all participated in act-now bc. some key ministries involved in healthy living initiatives were the ministry of health, the ministry of community, sport and cultural development, the ministry of education, the ministry of agriculture and lands, the ministry of children and family development, and the ministry of transportation and infrastructure. many initiatives involved multiple ministries and most included a health-related ministry. in on, of the initiatives were not linked to the provincial government, and were organized and/or financed by parks and recreation ontario, the ontario heart and stroke foundation, dairy farmers of canada, and a partnership between the university of guelph and the city of guelph. in bc, of the initiatives were not linked to government, and were organized and/or financed by the bc parks and recreation association, the heart and stroke foundation of bc & yukon, the bc dairy foundation, the greater vancouver food bank and breakfast for learning bc. for examples of initiatives classified into the three intervention types, please see table . for examples of initiatives classified into the three delivery types, please see table . in bc, interventions were lifestyle-based, were environment-based and seven were structure-based. nine interventions had multiple components that targeted a combination of lifestyle, environmental and structural factors, and so were classified into more than one category. in terms of method of delivery, direct interventions were more prevalent in lifestyle-based initiatives: initiatives used direct programming while initiatives were blueprints and were building blocks. in the environment-based category, there was more of a balance between mechanisms of delivery: a roughly equal number of environment-based initiatives worked through direct, blueprint and building block mechanisms ( , eight and nine, respectively). structure-based interventions were those that received the least direct support: only one was enacted through direct programming, one used the blueprint format, and six were building blocks-type initiatives. on yielded similar results in terms of distributionthe preponderance of initiatives were lifestyle-based, followed by environment-based, with very few aimed at structural change. of provincial initiatives identified, were lifestyle-based, were environment-based and nine were structure-based. six interventions had multiple components that targeted a combination of lifestyle, environmental and structural factors, and so were classified into more than one category. most lifestylebased interventions were direct ( ), while were blueprint initiatives and four were building blocks. environment-based initiatives were also more likely to a six week cooking program that is administered to 'at-risk' target populations. the program is administered by community facilitators, who have been trained by the bchla (the organization that offers this initiative). offers ontarians free dietitian services on healthy eating and nutrition through a website, email, and toll-free number. a set of written resources with activity ideas to help parents, caregivers and early learning practitioners encourage healthy eating and physical activity in young children. a set of programs, written resources and workshops to help early childhood, elementary, and middle school teachers teach their students about nutrition and healthy eating. a program offering grants for start-up of community and school-based snack programs directed at children and youth and bc that include an educational component. an organization that provides services to community organizations that aim to develop health promotion programs. services include consultations, workshops and resources related to program planning, implementation, and evaluation. a free telephone resource for british columbians to receive information and advice from exercise physiologists on physical activity and healthy living. screening of children up to the age of as well as parenting support, referrals and information on healthy practices such as breastfeeding, infant care and infant nutrition. farm to school salad bar bill : healthy food for healthy schools act a program that connects schools with local farms in order to increase students' access to healthier food (e.g. fresh produce). an amendment to on's education act limiting the amount of transfats that can be sold on school property through means such as vending machines, special events and cafeterias. a grants program for communities to begin a dialogue on how to address barriers to physical activity. it also provides resources on how social determinants of health such as poverty and social exclusion affect access to physical activity. a survey tool that municipal boards of health are required to use in order to calculate the cost of nutritious food. this can be used to monitor how affordable and accessible foods are by comparing them to income levels of on households be direct ( ) while nine were blueprints and four were building blocks. of initiatives that acted at a structural level, two acted through direct mechanisms, three were blueprints and four were building blocks. in summary, bc and on had similar distributions of intervention types, with the majority falling into lifestyle-based initiatives, followed by environment-based initiatives, and a small proportion falling into the structure-based category. while many initiatives focused on changing lifestyle and the immediate environment to improve healthy eating and physical activity, very few were directed towards changing more upstream social determinants of health, such as the economic and social conditions that create inequities between genders, income groups and ethnic groups. only . % of initiatives in bc and . % of initiatives in on had structural components that directly spoke to the social determinants of health. in terms of the mechanism by which the intervention was implemented, on had a higher proportion of direct interventions than bc for all intervention types ( . % vs. . % for lifestyle-based interventions, . % vs. . % for environment-based interventions, and . % vs. . % for structure-based interventions). however, the same trend can be observed for both provinces: as the intervention becomes more upstream and attempts to target the social determinants of health more directly, the level of direct support for the intervention lessens. in bc direct programming drops from . % for lifestyle-based initiatives to . % for environment-based initiatives to % for structure-based initiatives. in on direct programming drops from . % for lifestyle-based initiatives to . % for environment-based initiatives to . % for structure-based initiatives. for a visual representation of this trend, please see figure . the dominance of lifestyle-based and environmentbased initiatives is troubling considering that initiatives were expected (and directed) to focus on the social determinants of health. although individual behaviour change theories were popular early in the health promotion movement, the field of public health has matured to embrace a more multi-level approach. this change of focus was in recognition of the fact that individual behaviour change strategies are not enough for lasting health improvements, given structural conditions which predispose people to illness [ ] [ ] [ ] . they may actually be counterproductive; they tend to place responsibility to change directly on individuals and can lead to victimblaming should barriers prove too great for them to be successful [ ] [ ] [ ] . the individual change strategy can be particularly problematic when it comes to addressing the impact of inequities on vulnerable populations, considering that such interventions often focus on increasing knowledge, changing attitudes and/or encouraging adoption of healthy behaviours. this approach in a marginalized group runs the risk of implying that the group is to blame for their higher rates of chronic disease, purportedly due to their own ignorance of healthy living or lifestyle choices. environment-based interventions, while more sensitive to the context in which people live and work, still do not tackle the structural determinants which create these conditions in the first place. programs aiming to increase access to nutritious food and physical activity in particular settings such as schools, workplaces, government buildings and communities do not alter the factors which create inequities and unfavourable living conditions [ ] . environment-based initiatives can also have potentially negative implications for health equity when applied at a population level with no consideration for differential access. programs that "treat everyone the same" and fail to acknowledge different positions vis-àvis the social determinants of health may in fact benefit those who already have access while excluding those who are more vulnerable. this effect was succinctly illustrated in frohlich and potvin's critique of geoffrey rose's population strategy [ ] . what is needed are structural interventions that are inherently redistributive in nature; interventions that broaden the distribution of power, income, goods and services across the population. research has demonstrated limited effectiveness of downstream interventions (such as programs that focus on behaviour change) when structural barriers are not addressed [ ] [ ] [ ] [ ] . this is not surprising, considering that structural determinants have been found to influence the distribution of risk factors for chronic diseases such as smoking behaviour, overweight and obesity, and physical inactivity [ , , ] . therefore, attempting to prevent chronic disease by targeting risk factors at the individual or environmental level may not be effective without also addressing the broader determinants that shape those risk factors. as can be seen from the paucity of structural interventions, this approach to healthy living is lacking in on and bc despite provincial policy direction. another discouraging trend found in the data is the decrease in direct initiatives (direct programs) and increase in more indirect ones (at the blueprint and building blocks levels) as the initiatives become more upstream. the amount of indirect initiatives could be interpreted as a move towards increasing community capacity, inclusion, local responsiveness and decision-making in healthy living initiatives. however, the more upstream and broadscale an intervention is (i.e. an environment or structure-based program), the more it would benefit from coordinated action at a higher, more structural level [ ] . initiatives that address the social determinants of health in order to impact the population at a broad level can extend beyond the scope of a particular community organization, whose on-going population reach and resource availability are limited. health equity interventions can also require more direct action from government -for example, an initiative that would help to balance the distribution of wealth in canada is a more progressive taxation structure or an increase in minimum wage to account for inflation and provide a higher standard of living. these are initiatives which cannot be undertaken by individuals and communities. as the word 'structural' implies, they need to be acting directly on the structures (economic, social, political, etc.) which create and maintain health inequities. instead, communities that do not have that capacity are more likely to receive this responsibility -in the form of grants, training workshops for program planning, or mechanisms of initiative implemented included direct programs, blueprints, and building blocks and were calculated for a total of initiatives in bc and in ontario. please note that percentages may not add to % because some initiatives operated by more than one mechanism and so were placed in multiple categories. resource directories. these initiatives are framed as supporting communities in building their own initiative that addresses the social determinants of health. however, the pressure that it places on communities is enormous, and allows the public health system to abdicate its responsibility to address the social determinants of health directly and in a concrete manner. instead it can point to these initiatives and claim that they are focussing on the social determinants of health -this is essentially the provinces of on and bc "passing the buck". given the fact that policy documents on chronic disease prevention and healthy living at the provincial level in both bc and on acknowledge the importance of the social determinants of health, why is the health sector not acting on them? an explanation can be found in the context of canada's political and economic policy over the past several decades. a neoliberal approach to the economy that favours freedom of the market has resulted in the retraction of government intervention in the areas that are crucial to the health and well-being of canadians. research has found that canadians are experiencing increasing levels of poverty and income inequality, as absolute levels of poverty increase and the gap between the poorest % and richest % widens [ ] . research based in toronto has demonstrated this trend of polarization starting from the s [ ] . urban poverty is also becoming more concentrated in peripheral areas -areas that have the highest rates of new immigrants and visible minorities. not surprisingly, child poverty in canada has also deepened in the s [ ] . other determinants of health have also been affected by government policy. the public education system has suffered cutbacks and labour conflicts that reduce its ability to provide quality education [ ] . stricter immigration policy that went into effect as of december will increase social exclusion of immigrants and refugees, while cutbacks to legal aid aggravate the situation [ ] . job insecurity is rising, with the percentage of people in full-time jobs decreasing and the number of people working part-time, in shift work, temporary contracts or self employed increasing [ ] . unionization rates have also dropped across the country [ ] . disproportionate spending on necessities such as housing comes hand in hand with increasing poverty and job insecurity. canada is experiencing a national housing and homelessness crisis. as of , over % of people renting in major urban areas such as toronto, montreal and vancouver were spending more than % of their income on housing (the cut-off for affordable housing). around % are spending more than % of their income on rent, which puts them at risk of homelessness [ ] . when such a high amount of income is being devoted to shelter, not enough is left over for nutritious food, leading to food insecurity [ ] . the effects are felt as a result of inadequate policy and public expenditures on social programs, which are key characteristics of the neoliberal model. public spending on family-related benefits has been scaled back since the s, and taxation policy between and has increased the tax burden on the bottom % of income earners and relieved it from the top % [ ] . minimum wage, although it has increased in absolute terms, has fallen behind the inflation rate and made living above the poverty line more difficult to achieve. the fall of unionization in bc and on can be attributed to policies put into place by conservative governments that made unionization more difficult [ ] . with respect to housing policy, it has been argued that a budgetary increase of % in canadian government spending at the federal, provincial, territorial and municipal levels has the potential to end the homelessness crisis, but they have demonstrated their unwillingness to make that commitment [ ] . within the context of a national and provincial neoliberal climate, it is not surprising that the health sectors of bc and on have not attempted to implement widespread structural change to improve healthy living [ ] [ ] [ ] . even though well aware of the necessity to address the social determinants of health, they may feel powerless to do so in the face of conservative policies initiated by other sectors. as alvaro et al. emphasized using a critical theory lens, government departments linked to economics and ensuring the dominance of the free market have more power than departments such as the ministry of health in a neoliberal model [ ] . those in the health sector face barriers to encouraging other sectors to effect policy change to improve the social determinants of health, and may resort to individual or intermediate behaviour change because they are able to effect that change either through their own department or allied with other de-prioritized departments such as the ministry of education or the ministry of environment. for example, partnering with schools to increase the amount of healthy foods sold in vending machines may be significantly easier than convincing the department of finance to raise the province's minimum wage. we would argue that the ultimate goal of healthy living programs should be to improve the social determinants of health and eliminate health inequities. it is recognized that it is out of the scope of the health care sector to effect those changes on its own, and it faces barriers in partnering with sectors for collaborative, cross-sectoral action. however, public health should be constantly attempting to move towards those goals. it should not settle for programs that bring about changes in lifestyle and the immediate environment while only addressing the social determinants model at a conceptual level. if programs cannot directly affect lasting, broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health -advocacy at the level of the population, service providers, health organizations, and government in order to build political will to address them. the structural interventions listed in additional file and additional file are already taking the initiative to do this and more should be added. one barrier for public health professionals to address the social determinants of health is a lack of understanding of how to do so; although there is a wealth of theoretical understanding of how these determinants affect health, there have been few examples to date that illustrate how to effectively change them [ , ] . in an environmental scan of the integration of the social determinants of health with public health practice, the national collaborating centre for determinants of health noted that implementation of programs that dealt with the social determinants of health in canada was relatively scarce and, when extant, in early phases [ ] . some of the barriers noted to mounting programs that focused on social determinants included gaps in the existing evidence base on the social determinants of health and on interventions that were effective in addressing them, difficulties public health professionals faced in conceptually differentiating individual-level and population-level approaches, a lack of clarity on where in the path from determinants to outcomes public health is expected to act, and limitations in current public health practice methods, which rely mostly on quantitative data. even in a conservative political climate, it is clear that there are improvements that can be made within public health to foster a greater understanding of how to focus programming on the social determinants of health. the who commission on the social determinants of health notes that a comprehensive health equity surveillance system would capture the most upstream structural drivers of health inequities (the unequal distribution of power, money, goods and services) as well as more intermediate ones that encompass the daily conditions in which people live and work. such a system could monitor health equity by stratifying morbidity and mortality data by indicators such as income, occupation, gender, region, ethnicity and immigration status [ ] . some such initiatives already exist, for example the eu health monitoring programme, which could be used as a model for canada [ ] . solid data on health inequities and the social determinants of health serve a dual purpose: not only do they allow public health professionals and provincial health care systems to understand inequities and design effective initiatives that address structural determinants, they can also be used as tools to advocate for change at a broader level, which may be outside the scope of the public health system. for example, data on the health effects of social exclusion faced by new immigrants and refugees could be used to advocate for progressive immigration policies. it is equally important that health organizations and professionals know how to use evidence on inequities and the social determinants of health to create meaningful initiatives. to do this, there must be a comprehensive understanding among the healthcare force of the social determinants of health and how they affect populations. this includes awareness of the social, political and historical context of how these inequities are generated and continue to be maintained. the provincial health services authority in bc has a program modeling this principle called the indigenous cultural competency online training program [ ] . this program consists of a series of online modules and discussions designed to educate health professionals across the province on the context surrounding aboriginal health issues, including the history of colonization in bc, indian residential schools and hospitals, structural and interpersonal racism, and their impacts on aboriginal peoples and their health. it would be extremely useful to have such programs implemented in all provinces, ideally with specific sections that focus on chronic disease, as rates of chronic diseases such as diabetes and cardiovascular disease are much higher in aboriginal populations. with solid evidence and a comprehensive understanding of inequities, there are many ways that public health can begin to address the social determinants of health in programming. one possibility is using public health planning models that integrate the social determinants of health into the planning process. the region of waterloo public health in on developed a planning model that does this, based on the ontario public health standards (ophs) [ ] . the model is called evidence and practice-based planning framework: with a focus on health inequities. in the first two steps of program planning ( . define issue, . situational assessment), planners are encouraged to consider the following: community health needs, the ophs mandate on the social determinants of health, and the association between health status and the determinants of health. further, they are asked to engage stakeholder perspectives [ ] . another model developed by the national public health partnership in australia makes the determinants of health even more central to the planning process [ ] . this framework bases the intervention on the determinant that is causing the health problem, rather than the health problem itself. public health teams are to identify the determinants of the health problem and their context, assess how determinants may be detrimental or protective, appraise different intervention options, decide on an option -taking into consideration its impact on health equity, then implement and review it [ ] . when consistently implemented province-wide these types of planning models will help public health teams incorporate the equity and the social determinants of health into practice in a systematic manner. information and programs generated within the public health sector can be used to advocate for structural change to improve healthy living. an exemplary initiative in ontario is the nutritious food basket, described in table . the nutritious food basket is a program mandated by ontario public health standards (ophs) for boards of health to implement in municipalities across the province. boards of health are required to survey local supermarkets and grocery stores in order to calculate the cost of basic healthy eating for individuals and families. this program is ideal for a number of reasons. it links what is normally considered a behaviour (healthy eating) to greater structural determinants such as income and regional differences in food accessibility. because the survey is taken annually, it can keep pace with larger economic trends such as inflation and food cost patterns, and because it is performed systematically using a detailed protocol it presents reliable data. the data, as mentioned in the nutritious food basket protocol, can be used for program planning, policy decisions, and advocating for accessible, affordable foods. the nutritious food basket can be used as powerful evidence for the necessity of income redistribution policies ensuring that families make enough money to maintain a healthy diet [ ] . certain boards of health, for example in the cities of hamilton and sudbury, have used this tool for this purpose [ ] [ ] [ ] . a current leader in championing health inequities is the sudbury & district health unit, whose team has launched public awareness campaigns linking the social determinants to health outcomes, created health planning and mapping tools that focus on equity, established in conjunction with the city of sudbury a food charter that recognizes food as a basic human right, and developed a primer for municipal leaders explaining the connections of social determinants to public health and how they could address them effectively [ ] . although individual public health units are to be commended for their leadership, coordinated action at the provincial level would be much more influential. external evidence from other countries can also be used as leverage -for example healthy living and chronic disease policy in northern european countries such as sweden and norway. sweden initiated a public health policy in which stressed improving employment conditions and decreasing poverty as primary goals for improving health [ ] . sweden has significantly lower obesity rates than canada and research has shown obesity trends levelling off between / and / [ ] . elizabeth fosse has pointed out that norway focuses on structural measures that function to redistribute resources within society, which is characteristic of a social democratic welfare state [ ] . in a health policy document, the norwegian government outlined a number of strategies to combat health inequities, including reducing inequalities that contribute to poor health [ ] . the government pledged to work to provide safe childhood conditions, fair income distribution, and equal opportunities in work and education. it was also recognized by the norwegian government that individual behavioural choices which impact healthy living are influenced by broader structural determinants, and therefore the government must work to address those determinants by influencing cost and availability of resources to healthy living [ ] . lastly, a strategy employed to reduce inequities was to develop all initiatives to maximize social inclusion of all citizens. these types of policies could be used as models for health inequity reduction strategies advocated by the health sector in bc and on. this study is not without limitations. for example, the focus on provincial-level initiatives excluded initiatives happening at regional, municipal and community levels. this selection was strategic in that it attempted to maximize the likelihood of finding initiatives which addressed the social determinants of health -conditions that require multi-sector, systemic change. it was assumed that this type of change more likely to happen at the provincial level as opposed to in a city or region, but it is possible that initiatives that address the social determinants of health at a more local level were overlooked. secondly, our search strategy was limited to initiatives that focused explicitly on healthy eating and active living and did not seek to identify social programs in other sectors (for example housing) that may address the social determinants of health and impact healthy eating and active living indirectly. we would like to emphasize, however, that our focus was on what is occurring within public health at a provincial level to improve healthy eating and active living. the presence of social programs in other sectors does not reduce public health's obligation or commitment to addressing the social determinants of health. finally, our analysis did not attempt to document whether desired outcomes related to the social determinants of health were achieved by the searched investing in prevention: improving health and creating sustainability: the provincial officer' s special report. british columbia: office of the provincial health officer commission on social determinants of health: closing the gap in a generation: health equity through action on the social determinants of health. final report of the commission on social determinants of health. geneva: world health organization social determinants of health: the canadian facts. toronto: york university school of health policy and management distribution of cardiovascular disease risk factors by socioeconomic status among canadian adults a % higher prevalence of life-shortening chronic conditions among 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equity into canadian public health practice: environmental scan decision no / /ec of the european parliament and of the council of june adopting a programme of community action on health monitoring within the framework for action in the field of public health bc: core icc health training region of waterloo public health: evidence and practice-based planning framework: with a focus on health inequities. waterloo: region of waterloo public health national public health partnership: a planning framework for public health practice. melbourne: national public health partnership ministry of health and long-term care: nutritious food basket protocol. minister of health and long-term care hamilton: public health services healthy living division overview of the health equity mapping project: a report on process, results, and recommendations for practice. sudbury: sudbury & district health unit sudbury: sudbury & district health unit find out about the actions taken by the health unit to reduce social inequities in health national committee for public health: national goals for public health levelling off of prevalence of obesity in the adult population of sweden between / and / norwegian public health policy: revitalization of the social democratic welfare state? submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution we thank the renewal of public health systems research team (website) and in particular dr. marjorie macdonald for allowing us access to their dataset in order to initially identify policy initiatives. we also thank drs. nicole berry and lorraine halinka malcoe who provided important insights into the subject matter and suggestions for the manuscript. ak is partially supported through a new investigator award from the canadian institutes of health research. initiatives; such outcomes require many years to manifest themselves. addressing the social determinants of health necessarily means moving away from depoliticized frameworks that emphasize biomedical factors in disease. attention to the social determinants and inequities has been growing, as health promotion movements evolve -movements that were initially led by canada. however it is necessary that health be seen for what it is: a political matter. as such, the health sector needs to diversify to a more political approach in finding solutions for health inequities. until this occurs, it is debatable how much progress can occur on improving the social determinants of health. additional file : bc healthy eating and active living initiatives analyzed ( ) .additional file : on healthy eating and active living initiatives analyzed ( ). the authors declare that they have no competing interests.authors' contributions dg conceived of the study, lead the analysis and drafted the manuscript. ak participated in refining the study's design, acted as a critical discussant of analytical findings and helped to draft the manuscript. both dg and ak read and approved the final manuscript. key: cord- -dkm y authors: tam, theresa w. s. title: preparing for uncertainty during public health emergencies: what canadian health leaders can do now to optimize future emergency response date: - - journal: healthc manage forum doi: . / sha: doc_id: cord_uid: dkm y it is clear that the risk for epidemics with high health and socio-economic impacts remains but there will be many unknowns at the start of future responses to these events. this article highlights principles and practices to assist health leaders in preparing for uncertainty, including integrating scalability to ensure response activities can be more easily adapted to suit evolving needs; assessing risk and capabilities to inform planning for appropriate response measures; and considering overall flexibility and adaptability of plans, systems, and resources. ultimately, being prepared for “disease x” is about applying the approaches that we have learned from previous events, using evidence-based practices to develop and strengthen foundational capacities, so that we are able to respond to the unanticipated in proportionate and appropriate ways. lessons from emerging health events, past and present, remind us that threats to human health are always present and will continue to be influenced by factors such as climate change, the human-animal interface, and international travel. however, emerging diseases come with many unknowns and even known diseases can behave in unexpected ways. during the initial preparation of this article, a novel coronavirus causing disease in humans was emerging at the humananimal interface in china. the covid- is a harsh reminder that uncertainty is part of the emergence equation and we will always be challenged to rapidly confirm the knowns and to respond as best we can, despite the unknowns. it helps to prepare with this in mind. severe acute respiratory syndrome (sars) was our first "disease x" of the st century. the world health organization recently coined this term to represent uncertainty as a critical planning element in preparedness for a serious international epidemic and specifically to encourage preparedness activities that account for uncertainty. there are many sources of uncertainty that are essentially the "who, what, when, where, why, and how" characteristics of a public health emergency. the "who" might be unexpected at-risk groups, such as persons with obesity who developed severe illness during the h n influenza pandemic. the "what" could be unexpected outcomes such as microcephaly in infants born to mothers with zika virus infection during pregnancy. the "where" could be an unexpected location for disease emergence, such as the h n pandemic influenza that began in north america, rather than asia, as had been anticipated and planned for. finally, in the event of an unknown pathogen such as sars in and now with covid- , the outbreak response must run parallel with a rapid gathering of international evidence (clinical, laboratory, epidemiological, etc), meaning that the level of uncertainty is dynamic and the response will need to be adjusted as and when we know more. the purpose of this article is to identify some basic principles for dealing with uncertainty in the context of a public health emergency, to provide some examples of how these principles in combination with past experience have advanced preparedness within the health sector in canada, and to stimulate thinking regarding what health leaders can do to further improve preparedness across the health sector in the immediate as the covid- situation unfolds and going forward in the longer term. in terms of preparedness planning, assumptions help establish a "starting point"-a direction to quickly proceed (eg, using specific established/routine practices) until a need to adjust the course is identified. they give responders an indication of what real-time data to collect, or what to watch for, to either validate the planning assumptions or signal that a change in approach is needed. for example, an assumption used in influenza pandemic planning posits that the novel influenza virus will be transmitted from person to person in the same way seasonal influenza is transmitted. healthcare providers will thus know what infection prevention and control (ipc) precautions to utilize, which builds confidence in responders when dealing with unknowns. this starting point also helps to inform how ipc measures can be scaled up or down if reality proves to be different from the planning assumption. therefore, assumptions are a foundational component for the development of preparedness and response plans and essential for incorporating flexibility. in the emergency preparedness and response context, scalability is used to convey the need for response activities to be dynamic. to manage demands and risks by scaling up (eg, adding more resources, enhancing active surveillance activities) or scaling down when there is evidence to indicate that specific response actions are no longer needed to achieve response objectives. a key lesson learned from past responses is that uncertainty and/or risk aversion can lead to overcompensation during a response (eg, inappropriate use of limited resources, responder burnout, or angst when trying to de-escalate). overcompensation can be avoided by ensuring there is sufficient content in guidance, plans, and emergency exercises to demonstrate how and when the response will be scaled up or down based on risk assessments and specific data analyses that build confidence and reduce risk aversion. another key principle involves taking a risk management approach to preparedness and response by conducting risk and capability assessments, to inform planning and response measures, and to identify gaps or enhancements that need to be addressed. specifically, this involves making an assessment of current resources available to mitigate and respond to the risk. assumptions can be used as a starting point to create scenarios against which risks and capabilities can be identified and assessed. for example, a planning scenario might include a person who presents to the emergency department complaining of nausea, weakness, and fever. to prepare for uncertainty, planners must consider variables in the scenario. for example, if this person had recently returned from a country with an ongoing ebola outbreak, would the existing triage system be sufficient to identify, assess, and rapidly contain a possible ebola case? this type of assessment helps identify specific risks, such as not including ebola in the intake differential diagnosis for ill travellers returning from an affected area. likewise, scenarios can facilitate a discussion regarding what capabilities are currently in place to mitigate this risk. however, it is also important to identify what might change the risk profile in the scenario. for example, the toronto sars case that triggered the first hospital-based outbreak was initially missed because they had no travel history. it was only learned later that the patient had been exposed to the true index case, who did have a significant travel history but was not seen in a healthcare setting. , this flagged a gap in our risk mitigation-that the capability to rapidly identify, and therefore contain, a sars case that had no travel history was lacking. to close this gap, triage questions also needed to include questions about close contact with an ill traveller. unfortunately, not all risks can be accounted for so it is important to consider what unknowns might significantly impact a risk and what planning can be done to account for them. emergency planners with expertise in risk and capability assessment need to work with healthcare leaders to determine how changes to risk levels will be addressed in real time, when to change course, and whether the capabilities are in place to deal with the requirements of the "new course." public health preparedness efforts have been largely based on previous infectious disease outbreaks, models, and scenarios. it is important to consider the flexibility and adaptability of current plans, systems, and resources when preparing for any health emergency; this is a key principle in "all-hazard" emergency preparedness. the preparedness efforts and response resources that have been developed and used for infectious disease outbreaks are now being utilized for other public health threats. borne out of the sars and h n experience, new federal/provincial/territorial governance structures were established to oversee the overall public health response. these governance structures have in turn been leveraged to respond to non-infectious disease national response, including most recently for the national epidemic of opioid-related deaths in canada. adaptable response systems are agile enough to incorporate learnings in real time and make adjustments to response activities through feedback loops. such systems can quickly establish new inter-sectoral connections to meet immediate specific response needs while increasing general response capabilities. specifically, the urgency of the opioid crisis led to the mobilization of new and pooled resources that ultimately established a timely surveillance and reporting network with coroners and medical examiners. built on an infectious disease outbreak response model, this network can potentially be leveraged for rapid mortality surveillance for emerging health events beyond opioids. there are also international efforts underway to invest in platform technologies for vaccines and therapeutics that can be adapted to target new pathogens once they are identified. utilizing sustainable, flexible governance structures and resources ensures the response system is well exercised and able to adapt to uncertainties, while supporting readiness for other health threats and emergencies. the idea of identifying "lessons learned" after the conclusion of an emergency response is also a key principle of preparedness for future events. the challenge for health leaders is to ensure that the lessons identified actually translate to better understanding and ultimately an improved ability to respond. importantly, this process has to ensure that learnings are not forgotten during peacetime or lost over time with staff turnover. the importance of risk communication, building and maintaining public trust and confidence, and cross health sector engagement are just a few of the key lessons that have been identified from past emergency responses. the covid- response is now showing us in real time the growing role of the internet and social media in risk communication. early, frequent communication of uncertainties is vital to building and maintaining public trust and confidence. we have learned that perception is reality and that being transparent in risk communication is essential. this means it is vital for health leaders to be forthcoming from the outset, clearly stating what we know and what we do not know, while reassuring the public that we will provide new information as and when we know it. despite the relatively limited spread of sars in canada, it served to highlight the importance of supporting and maintaining cross health sector preparedness for a seamless and comprehensive health response. this starts with increasing the number of astute frontline practitioners who are sensitized and equipped to practice "think, tell, test." this means the first line of defence is primed to think about the possibility of an emerging pathogen, promptly tell local public health authorities, and efficiently work with clinical colleagues, hospital administrators, public health, and laboratory partners to ensure early detection and rapid containment through appropriate and timely testing. continuing to build and maintain a skilled and engaged workforce is essential to a robust and flexible response system. health leaders can ensure that the lessons learned from past experiences are passed on through regular training and exercises to those entering or taking on new roles within the workforce. engaging across the health sector on a regular basis, in order to re-confirm roles and responsibilities, conduct joint risk and capability assessments, foster research, and provide updates on the status of preparedness activities, is also key to ensuring health sector preparedness and maintaining an ongoing state of readiness. there are operational (eg, medical evacuation and domestic transportation) and logistical (eg, supply chain and stockpiling issues) aspects of a response that require crosssectoral engagement to address, ideally in advance of an emergency. we have seen the benefit of having contracts in place, for example, for influenza pandemic vaccine supply during the h n pandemic and more recently for international medical evacuation capacity during the ebola outbreak in west africa. we have also witnessed the need for advanced preparedness to engage in real-time research to ensure the response is as evidence based as possible. this has translated into advanced planning by organizations such as the canadian institutes of health research, for example, to foster rapid ethics reviews during an emergency response and supporting the canadian immunization research network to conduct vaccine clinical trials in real time. extending the health sector preparedness to include other sectors/disciplines (eg, social services, critical infrastructure, regulatory authorities, public safety, justice) is critical to a seamless response. engaging communities and considering their contexts, culture, and perspectives in the preparedness for public health events is essential to the building of trust and public cooperation with health authorities during a response. post-sars, emergency management practices have been adopted more widely by the health system in canada. there is also a greater recognition of the significant social and economic impacts of public health emergencies and the importance of mitigating these impacts through mechanisms that enhance capabilities. health leaders would be wise to ensure that emergency management, multi-sectoral coordination, and mutual aid capabilities are well integrated and exercised within their institutional response planning. health facilities must also develop and practice their business continuity plan as a complement to their pandemic plan, given that the health of the workforce may be significantly impacted while workload demand is high. the public health agency of canada, established following sars as the national coordinating body for health emergencies, has made significant investments in order to increase emergency preparedness and response capacity in canada, build on the lessons learned from past experiences, and facilitate cross-sector preparedness and resiliency. this work has been multi-focal, ranging from the production and updating of plans, protocols, and technical guidance to conducting training, stockpiling vaccines, and therapeutics, to running exercises to test current knowledge and capabilities. many of these efforts are intended to increase the level of preparedness across the breadth of the healthcare sector, not just public health, and not just for emergencies originating in canada. examples include enhancing public health laboratory and border screening capacity; establishing mutual aid and information sharing agreements ; and clarifying roles, responsibilities, and procedures (eg, how to request and receive aid and emergency provisions) during emergencies. canada has met the international health regulations core capacity requirements and was ranked th in the world in the global health security index, assessing global health security and capabilities. although there is a strong existing system in place, ongoing work is still needed to achieve a state of flexible and scalable readiness for the next public health emergency. as we begin a new decade, we must maintain constant vigilance as epidemics are predicted to become more frequent, more complex, and harder to prevent and contain. health leaders need to prepare for uncertainty during an emergency response by developing, enhancing, and exercising resources-whether it be plans, people, or other resources-that can be flexible, scalable, and that are built on lessons learned and evidence-based practices. health leaders are well poised to see gaps and reflect on persistent challenges and recurring themes, while looking beyond their scope of influence to find creative solutions. working from the ground up, health leaders should train staff in emergency management principles, share corporate memory, incorporate lessons learned, and build confidence through regular exercises. exercises and training should consider the response to complex health emergencies, including pandemics, which are rapidly evolving and may last many months. health leaders should also consider engaging with health professional regulatory bodies to explore whether and how regulatory requirements might be adapted, streamlined, or otherwise expedited during an emergency. finally, staff must be encouraged to contribute to contingency planning by identifying concerns and repositioning them as uncertainties to be addressed. although it can be difficult to convince decision-makers to invest upstream in non-specific emergency preparedness resources, it is important to present the downstream benefits including risk reduction, medium-to long-term cost savings, and operational resilience. one means of fostering support is to build the understanding that investment of time, energy, and resources can pay off during normal operations, not just during large-scale health emergencies. emergency planning can help ensure business continuity whenever there is an unexpected surge in resource demands against the backdrop of everlimited, finite supplies. finally, recognize that the opportunity to address critical gaps is never more urgent than during an emergency. every event is an opportunity, given heightened political attention and investment in health capacity during a crisis. we need to build on these gains to both improve routine practice and better prepare us for future response. throughout this call to action to strengthen health security, i would urge health leaders to integrate a health equity lens and seek meaningful engagement from the communities they serve in order to build trust and enable a collaborative and effective response during times of uncertainty. the covid- is the latest "disease x" but it will not be the last. health leaders, now more than ever, need to gather new knowledge, adapt response activities, and meaningfully engage with all partners across government, research, and the public at large to respond, as flexibly and effectively as possible, to this new health threat in canada and around the world. available at: https:// www.who.int/activities/prioritizing-diseases-for-research-anddevelopment-in-emergency-contexts risk factors for severe outcomes following influenza a (h n ) infection: a global pooled analysis world health organization. zika epidemiology update lessons learned review: public health agency of canada and health canada response to the h n pandemic sars: lessons learned from toronto severe acute respiratory syndrome (sars): a year in review canadian pandemic influenza preparedness: planning guidance for the health sector fifteen years post-sars: key milestones in canada's public health emergency response covid public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap multi-lateral information sharing agreement (mlisa) joint external evaluation of ihr core capacities of canada mission report global health security index: building collective action and accountability the author would like to thank jill sciberras, jeannette macey, and teresa leung for their assistance in preparing this manuscript. theresa w. s. tam, bmbs (uk), frcpc https://orcid.org/ - - - key: cord- - rnvawfa authors: cousineau, j; girard, n; monardes, c; leroux, t; jean, m stanton title: genomics and public health research: can the state allow access to genomic databases? date: - - journal: iran j public health doi: nan sha: doc_id: cord_uid: rnvawfa because many diseases are multifactorial disorders, the scientific progress in genomics and genetics should be taken into consideration in public health research. in this context, genomic databases will constitute an important source of information. consequently, it is important to identify and characterize the state’s role and authority on matters related to public health, in order to verify whether it has access to such databases while engaging in public health genomic research. we first consider the evolution of the concept of public health, as well as its core functions, using a comparative approach (e.g. who, paho, cdc and the canadian province of quebec). following an analysis of relevant quebec legislation, the precautionary principle is examined as a possible avenue to justify state access to and use of genomic databases for research purposes. finally, we consider the influenza pandemic plans developed by who, canada, and quebec, as examples of key tools framing public health decision-making process. we observed that state powers in public health, are not, in quebec, well adapted to the expansion of genomics research. we propose that the scope of the concept of research in public health should be clear and include the following characteristics: a commitment to the health and well-being of the population and to their determinants; the inclusion of both applied research and basic research; and, an appropriate model of governance (authorization, follow-up, consent, etc.). we also suggest that the strategic approach version of the precautionary principle could guide collective choices in these matters. "during the past century, achievements in public health have led to enormous improvements and benefits in the health and life expectancy of people around the world" ( ). however, even now, at the dawn of the xxi st century, public health still faces important challenges. new zoonoses such as bovine spongiform encephalopathy (bse) ( ) or west nile virus (wnv) ( ) as well as new infectious diseases such as acquired immune deficiency syndrome (aids) ( ) or severe acute respiratory syndrome (sars) ( ) come easily to mind and provide good examples. moreover, the continuing and growing prevalence of chronic diseases such as cancer and diabetes also merits considerable attention. because many of these diseases are multifactorial disorders, the scientific progress in genomics and genetics must be taken into consideration in public health research ( , ) this approach, integration of genomics into public health, requires that we: "assess […] the impact of genes and their interaction with behaviour, diet, and the environment on the population's health. the promise of public health genomics is to have practitioners and researchers accumulating data on the relationships between genetic traits and diseases across populations, to use this information to develop strategies to promote health and prevent disease in populations, and to more precisely target and evaluate population-based interventions" ( ) . in short, "public health genomics uses population based data on genetic variation and geneenvironment interactions to develop evidencebased tools for improving health and preventing disease" ( ) . thus, genomic databases will constitute an important source of information, on the one hand, in order to pursue research aiming to understand better the genetic susceptibility to a disease regarding certain individuals within a population, and on the other, to implement eventually public health interventions. consequently, from this viewpoint, it is important to identify and characterize the state's role and authority on matters related to public health, in order to verify whether it has access to such databases while engaging in public health genomic ( ) research. then, is the mandate of our public health authorities adapted to the actual expansion of the genomic research domain? to answer this question, we first examine the evolution of the concept of public health, as well as its core functions, using a comparative approach (e.g. who, paho, cdc, and the canadian province of quebec) . following an overview of the essential roles of public health and an analysis of relevant quebec legislation, the precautionary principle is examined as another possible avenue to justify state access to and use of genomic databases for research purposes or, for the management of a pandemic. finally, we consider the influenza pandemic plans developed by who, canada, and quebec, which are key tools framing public health decision-making. they public health genomics is defined as : "the responsible and effective translation of genome-based and technologies into public policies, programs and services for the benefit of population". quebec is one of the ten canadian provinces. canada is a federal state where health is a shared jurisdiction. in public health matters, both the federal and provincial levels have some competencies. could illustrate the first steps in the evolutionary inclusion of genomics into public health. we think that this paper could help countries to examine their own definitions and legislations of public health to see if they contain provision that could form the foundation of the state powers to access genomic databases. the world health organisation (who) defines public health as "the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number" ( ). despite the fact that who is the lead agency in health, up to now, no definition of public health has yet produced a general consensus ( ) . the notion is heterogeneous, depending on whether public health is defined in terms of objectives, methods, actors, or values. this can result in difficulties in assessing health in its collective dimension such as the contribution of various disciplines, of determinants of health and of various practices that are used in the development of health knowledge ( ) . the current trend for western countries is to adopt a broad definition ( ) . for example, the canadian institutes of health research define it as "the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions" ( ) . this definition illustrates the importance of the collective dimension of public health measures and puts forward the idea that the concept of public health is constantly evolving. the american institute of medicine's committee for the study of the future of public health reminded us that the very substance of public health has expanded with the passage of time. indeed: "early public health focused on sanitary measures and the control of communicable disease. with the discovery of bacteria and immunologic advances, disease prevention was added to the subject matter of public health. in recent decades, health promotion has become an increasingly im-portant theme, as the interrelationship among the physical, mental, and social dimensions of wellbeing has been clarified" ( ) . for example, until quite recently, the vision of the quebec legislator concerning public health meant health protection and protection of the population's well-being. this observation is based in part on the evolving title of quebec legislation, which was changed from public health protection act (r.s.q., c. p- ; act abrogated april ) to public health act ( ). in adopting the public health act, the quebec legislator chose to implement a proactive rather than a defensive approach in order to respond to society's evolution and to knowledge about health determinants and therefore to encompass prevention, promotion and surveillance in the expression "public health" . along these same lines, article states: "[t]he object of this act is the protection of the health of the population and the establishment of conditions favorable to the maintenance and enhancement of the health and well-being of the general population". in this context, well-being is to the social sphere what health is to the medical sphere. it is a positive concept that goes beyond the absence of social problems and resembles the concept of quality of life. in fact, health and wellbeing are often linked ( ) . the who stresses that a growing understanding of various health determinants is transforming the assessment of public health ( ) . thus, in order for a public health system to adequately fulfill its function and keep up with advances in the discovery of health determinants, it must adopt a global approach to public health and define its components. indeed, "[s]uch an approach will when examining the bill in november , minister rémy trudel specified that more than just to ensure health protection in case of threat, the new law would also deal with prevention and promotions. help to ensure that the public health infrastructure covers all appropriate public health activities adequately and that it can function well in an increasingly complex and changing environment" ( ) according to the canadian institutes of health research, "[t]here is a critical need to reach consensus on the core essential functions of the public health system. it will not be possible to assess and develop a system infrastructure if these are not defined" ( ) . the study of essential functions of public health is helpful in understanding public health legislation, its functioning and the scope of its application; essential functions are "the set of actions that should be carried out specifically to achieve the central objective of public health: improving the health of populations" ( , ) . in effect, "in january , the who executive board recommended that work proceed on the concept as a tool for implementing the renewed [health for all] policy in the st century" ( ) . the regional office for the western pacific of who specifies that it is the responsibility of governments to define the fundamental missions of public health more precisely and systematically and to articulate them, without having the obligation to execute them and finance them ( ) . definitions of the main functions of public health, unlike broader definitions, address the need for the clarification of roles and responsibilities in the public health domain ( ) . in fact, a univocal definition of the field of public health is impossible; rather, referring to the missions and roles of the field would illustrate the actionbased character, the knowledge, and the areas of intervention in public health ( ) . although many categories and definitions of essential functions have been suggested, these categories and definitions are constantly evolving ( ) and are specific to each organization. interestingly, quebec's approach to public health, proposed in and still in force, refers to measures relating to the determinants of health and well-being at the population level and the systems, which govern them ( ) . these measures are delimited by the essential and the supporting functions of public health ( ) . in order to better understand the fundamental concept of public health, we drew up a table of the categories used by the québec public health program and compared them to those of the who, the pan american health organization and the national public health. a similar analytical approach has been proposed in quebec ( ) . according to lévesque and bergeron such a comparative analysis constitute an interesting basis for reviewing the roles of public health. the authors specify that the selected organizations seem to equate elements related to roles of public health (health promotion, prevention, etc.) with elements related to the type of intervention used (information, education, empowerment) as well as to the strategies used (social participation, partnership mobilization, legislation). furthermore, in terms of healthcare, they limit themselves to evaluating its quality and to the defense of access equality ( ) . similarly, other authors indicate that various functions defined by the american program, the who and paho have much in common, even though they demonstrate some specificities. studying quebec legislation, we retain the public health functions adopted by the provincial government. these are listed and defined in the québec national public health program program - . the program distinguishes core functions from support functions. thus, core functions include ongoing surveillance of the population's state of health; promoting health and well-being, prevention of disease, psychosocial problems, and trauma; health protection. as for supporting functions, they refer to the regulation, legislation, and public policies that can have an impact on health; to research and innovation; to the development and the maintaining of professional competencies. a more in-depth understanding of the functions of public health is susceptible to this echoes the population-centered approach that must guide public health according to provision of the public health act, r.s.q. c. s- . . provide a legal basis for public health legislation to allow access, by the state, to genomic databases for research purposes. the next section is therefore devoted to their definition. the ongoing surveillance function has two main objectives: to follow closely the evolution of the population's health status and of its determinants and to inform the public and those responsible for the planning, organization and evaluation of services, within and outside of the healthcare network of this evolution ( ) . included in this function are measures that delimit access to information, as well as those needed for the description and analysis of the population's health status and then for the distribution of this information to each targeted public ( ) . the ongoing surveillance function also encompasses vigilance, producing snapshots of health and well-being (sociomedical statistics), analysis of determinants, and finally, identification of vulnerable groups and of efficient interventions ( ) . it accounts for observed variations and tendencies, detects emerging problems, and elaborates prospective scenarios of health status and well-being, taking into account the natural evolution of problems, interventions and the change of determinants. it also implies communicating information on the state of public health and well-being to the population itself ( ) . ongoing surveillance thus differs from public health research. surveillance aims to support decision-making concerning the health and wellbeing status of a given population. research, as a source of new scientific knowledge is better characterized as a support function of public health (table ) . public health legislation and regulations. strengthening of public health regulation and enforcement capacity. enforce laws and regulations that protect health and ensure safety. **regulation, legislation and public policies that have an impact on health. public health management. development of policies and institutional capacity for health planning and management. develop policies and plans that support individual and community health efforts. human resources development and training in public health. assure competent public and personal health care workforce. **skills development and maintenance. quality assurance in personal and populationbased health services. evaluate effectiveness, accessibility, and quality of personal and population-based health services. personal health care for vulnerable and high risk populations. evaluation and promotion of equitable access to necessary health services. link people to needed personal health services and assure the provisions of health care when otherwise unavailable. research in public health. research for new insights and innovative solutions to health problems. **research and innovation. social participation in health. mobilize community partnerships and action to identify and solve health problems. occupational health protecting the environment * core functions ** support functions prevention specifically targets chronic diseases, trauma, and social problems having an impact on the health of the population (suicide, violence, drug addiction, etc.) this includes reducing risk factors, vulnerability, and early screening ( ) . prevention thus has a double objective: reducing risk factors for disease, psychosocial problems and trauma and detecting these problems before they become exacerbated ( ) . prevention can be carried out among individuals and at-risk groups by bolstering existing aptitudes, developing the acquisition of new skills, and practicing preventive care, including screening ( ) . protection refers to the collection, by public health officials, of information deemed necessary in preventing or responding to a dangerous situation; this information is to be collected from individuals, groups, and populations in the case of a real or anticipated threats to public health ( ) . a threat to public health occurs as stated by article , when there is the "presence within the population of a biological, chemical, or physical agent that may cause an epidemic if it is not controlled" ( ). in the case of a real or apprehended health threat, health authorities will act at the scale of either the entire population, groups, or individuals ( ) . health protection measures apply to harmful situations and particularly to biological, physical, and chemical aggressors, including the battle against sexually transmitted diseases and aids, workplace health, and environmental health ( ) . the compilation of information for epidemiological studies, in order to better determine the threat and implement measures to counter or assess the situation is authorized. medical observation by public health teams, established by article of the quebec public health act ( ) allows the discovery of threats to population health in real time ( ) . for the québec national public health program - ( ) , health promotion refers to actions supporting individuals and communities in their effort to exert better control over essential factors of health and well-being. these actions, while encouraging individual progress, emphasize social and political dimensions: supporting community action, developing public policies, and creating a (physical, cultural, social, economical, and political) environment that is favorable to health ( , ) . this is in line with article of the quebec public health act ( ), in virtue of which measures provided by the act are geared towards "exerting a positive influence on major health determinants, in particular through trans-sectoral coordination". thus, its aim is, from an ecological perspective, to facilitate the development of conditions favorable to health in the social and economic environment as well as in individual and collective behaviors ( ) . this includes interventions not only on lifestyle but also on the totality of health determinants and the development of conditions and environments that are favorable to health and well-being ( ). according to the québec national public health program - ( ) , this function involves identifying the problems and situations which call for a regulatory, legislative or policy-based solution in order to enhance or maintain the health of the population. it consists also in assessing the consequences of public policies for the population's health and recommending measures to reduce their negative effects on health; finally, it includes carrying out mandates related to the application of regulations, laws, or policies, which come under spheres other than public health in order to prevent certain health problems ( ) . overall, this function illustrates the support needed for the elaboration and application of laws and regulations, which have an effect on the health, and well-being of citizens ( ) . this support function demands the development and the maintenance of professional resources, expertise, and skills ( ) . of course, it includes the importance of evaluating the program's training needs in order to offer continuing education ( ) . as expected, "the research and innovation function includes all activities focused on the production, dissemination, and application of scientific knowledge as well as on innovation" ( ) . in short, this element refers to research needed to maintain and develop expertise for the implementation and evaluation of public health programs ( ) . if genomics research is a new tool in public health action, should not the research and innovation function be integrated into the core functions of public health as an important activity, thus enabling the state to achieve its public health objectives? in this respect, should state powers in public health allow access to databases for the purposes of genomic research? in this section of the paper, in order to understand the legislative powers and the possibility of research in genomics, the public health act ( ) is firstly examined and, secondly, the act respecting institut national de santé publique du québec ( ), which allows powers for public health research. an overview of the public health act is helpful to identify the powers of the state in the protection of public health. the act does not contain any specific provision regarding access to genomic databases for research purposes. it is nevertheless important to examine the different options laid out by the legislation. in fact, be it in the context of common practices related to public health, in an alert or in an emergency, the act establishes certain powers related to the collection or transmission of information necessary for exercising public health powers. within the framework of current practices related to public health, the public health act stipulates that public health authorities may collect information by means of registries or information and data collection systems. registries, which are established for the purpose of clinical preventive care or for protecting the health of the population, contain personal information on certain health services or health care received by the population ( ). the best example is the vaccination registry described at article ( ). data and information collection systems administered by public health authorities are divided into two categories. the first category refers to the system established by the minister of health and social services for the compilation of sociological and health-related personal or non-personal information on births, stillbirths, and deaths ( ). this system is not intended for genetic information. the second category refers to systems for the collection of data and personal and non-personal information on the prevalence, incidence, and distribution of health problems and in particular on problems having a significant impact on premature mortality and on morbidity and disability ( ). these systems could be used to investigate the prevalence of infectious diseases. these collection systems have been implemented within the framework of the ongoing surveillance entrusted exclusively to the minister and to public health directors (art. , par. ). ongoing surveillance is carried out in order to: ) "obtain an overall picture of the health status of the population; ) monitor trends and temporal and spatial variations; ) detect emerging problems; ) identify major problems; ) develop prospective scenarios of the health status of the population; a copy of the opinion of the ethics committee must then be forwarded to the commission. public health act, r.s.q. c. s- . , art. , par. . ) monitor the development within the population of certain specific health problems and of their determinants" (art. ). undoubtedly, points , and could be perceived by some as legislative basis for the creation of a data collection system of genomic information; nevertheless, ongoing surveillance, as prescribed by the act, is surveillance of the "health status of the general population and of health determinants so as to measure their evolution and be able to offer appropriate services to the population" (art. , par. ). ongoing surveillance does not apply "to research and knowledge development activities carried out in the sector of health or social services in particular, by the institut national de santé publique du québec" (art. , par. ). in addition, although the act stipulates that "[p]eriodic surveys on health and social issues shall be conducted to gather the recurrent information necessary for ongoing surveillance of the health status of the population" (art. ), the nature of such surveys leads us to believe that they cannot be used in the context of genomic databases. indeed, the act specifies that "[t]he carrying out of national surveys shall be entrusted to the institut de la statistique du québec created under the act respecting the institut de la statistique du québec (chapter i- . ), which shall comply with the objectives determined by the minister" (art. , par. ). conducting genetic susceptibility research is not equivalent to conducting statistical surveys. having established the lack of a legislative basis for genomic research by the state in the course of the normal practice of public health, and more specifically, in ongoing surveillance, would it be possible for other previously collected data to be used by the state for other purposes, such as genomic research? the public health act provides measures for monitoring public health and for ensuring proper transmission of information. four areas are outlined: reporting of unusual clinical manifestations associated with a vaccination (art. ); mandatory reporting of intoxications, infections and diseases (art. - ); notification of the public health director in the case where a person who is likely suffering from a disease or infection, subject to mandatory reporting, is refusing or neglecting to submit to an examination (art. ); alerting public authorities to health threats (other than those arising from a sexually transmitted biological agent) (art. - ). two areas outlined by the act are particularly relevant to our study: mandatory reporting of intoxication, infections, and diseases, and the alerting of public authorities to health threats. first, we ask ourselves if genetic susceptibilities should be included in the category of reportable intoxications, infections, and diseases pursuant to section. it is important to specify that "the list may include only intoxications, infections or diseases that are medically recognized as capable of constituting a threat to the health of a population and as requiring vigilance on the part of public health authorities or an epidemiological investigation" (art. ) . thereby: "with respect to the list drawn up pursuant to section of the act, the intoxications, infections and diseases that may be included for reporting to public health authorities must satisfy the following criteria : ( ) they either present a risk for the occurrence of new cases in the population, because the disease or infection is contagious, or because the origin of the intoxication, infection, or disease may lie in a source of contamination or exposure in the environment of the person affected; ( ) they are medically recognized as a threat to the health of the population, as defined in section of the act, which may result in serious health problems in the persons affected; ( ) they require vigilance on the part of public health authorities or an epidemiological investigation; and ( ) public health or other authorities have the power to take action in their respect to prevent new cases, to control an outbreak or to limit the magnitude of an epidemic, through the use of medical or other means" ( ) . genetic susceptibility does not satisfy these criteria; the above list enumerates diseases, rather than methods for the detection of disease akin to the detection of susceptible genes. secondly, government departments and bodies, local municipalities, health care professionals, directors of institutions must report threats, other than those that arise from a sexually transmitted infection, to the public health director (art. - ). given the current legislative framework, reporting "does not authorize the person making the report to disclose personal or confidential information unless, after evaluating the situation, the public health authority concerned requires such information in the exercise of the powers provided for" in the case of threat to the public health (art. ). a threat to public health occurs when there is the "presence within the population of a biological, chemical, or physical agent that may cause an epidemic if it is not controlled" (art. , par. ). therefore, in any situation where the public health director believes on reasonable grounds that the health of the population is or could be threatened, he may conduct an epidemiological investigation (art. ). where required within the scope of an epidemiological investigation, the public health director may: ) "require that every substance, plant, animal or other thing in a person's possession be presented for examination; […] ) take or require a person to take samples of air or of any substance, plant, animal or other thing; ) require that samples in a person's possession be transmitted for analysis to the institut national de santé publique du québec or to another laboratory; ) require any director of a laboratory or of a private or public medical biology department to transmit any sample or culture the public health director considers necessary for the purposes of an investigation to the institut national de santé publique du québec or to another laboratory; ) order any person, any government department, or any body to immediately communicate to the public health director or give the public health director immediate access to any document or any information in their possession; even if the information is personal information or the document or information is confidential; ) require a person to submit to a medical examination or to furnish a blood sample or a sample of any other bodily substance, if the public health director believes on reasonable grounds that the person is infected with a communicable biological agent"(art. , ). if certain authorities have powers to sanction the collection and transfer of biological samples or of personal information (held by a third party or by the individual concerned), is it conceivable that these powers could be used to sanction genomic research, for example research into genetic susceptibility to an infectious disease endangering the health of the population? in declaring a public health emergency, the government has extraordinary powers at its disposal. the declaration of a public health emergency in all or part of the territory of quebec will occur "where a serious threat to the health of the population, whether real or imminent, requires the immediate application of certain measures to protect the health of the population" (art. ). the government or the minister (if he or she has been so empowered) may, notwithstanding any contrary provisions, order any person, government department or body to communicate or provide immediate access to any document or information held, even personal or confidential information or a confidential document, in order to protect the health of the population (art. , par. ( )). the state of emergency is considered so paramount that "[t]he government, the minister or another person may not be prosecuted by reason of an act performed in good faith" (art. , par. ). unless such "emergency" information is available and workable, genomic research will not be possible due to time constraints; the research would take too long before results could determine which measures to adopt. if the government has extraordinary powers at its disposal, we consider that they are inappropriate in this research con-text. in fact, such information should already be accessible under these powers. not only does the public health act not expressly permit research in public health, but also, our analysis leads us to conclude that these provisions do not give appropriate powers to the state to access genomic databases for research purposes. on the other hand, because the act respecting institut national de santé publique du québec ( ) already gives certain powers for research into public health, it seems appropriate to examine whether this act presents a new avenue to explore. the institut national de santé publique du québec (inspq) was established to contribute to the development, consolidation, dissemination and application of knowledge in the field of public health (art. , par. ( )) and also to develop and promote research in the field of public health in collaboration with the various research organizations and funding bodies (art. , par. ( ), ). a review published by the inspq also notes that research into the health and well-being of the population and its determinants seeking to produce, integrate, disseminate and apply scientific knowledge to the exercise of public health functions, belong to the field of public health research ( ). knowing this, could the inspq initiate fundamental research in genomics? this would present a challenge since the government of quebec prioritizes applied research over fundamental research in public health ( ) . on this matter, the inspq states that basic research, the results and applications of which are not expected in the short or medium term have been excluded from for example, are considered as public health research activities research related to the surveillance of a population's health status and well-being; on the relationship between a population's health status and wellbeing and its determinants; on intervention and on promotional, preventive and protective programs aimed at maintaining and improving the health and well-being of a population; on public policies related to a population's health and well-being the field of research in public health, while applied research was included ( ) . if all legislative texts examined here do not create an explicit power to access and use genomic databases for research purposes, we can ask ourselves if it is possible to invoke the precautionary principle to legitimate a state power allowing this type of intervention. is there a clear definition of the precautionary principle? the framework for the application of precaution in science-based decision making about risk ( ) outlines guiding principles for the application of precaution to science-based decision making in areas of federal regulatory activity regarding the protection of health, the environment, and the conservation of natural resources. the concept of precaution is presented as resting on the notion that the absence of full scientific certainty shall not be used as a reason for postponing decisions where there is a risk of serious or irreversible harm ( ) . formalized in international environmental law, the precautionary principle was incrementally introduced into the domain of public health . spe- the precautionary principle has not been explicitly integrated in the provincial (quebec) and international public health legislations. see: loi sur la santé publique, l.r.q., c. s- . ; international health regulations ( ), art. ( )d) and c). however, both the programme national de santé publique ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , which identifies public action that provincial (quebec) authorities must put into place until year , and the report of the review committee of the functioning of the international health regulation ( ) cifically, we can emphasize its use in food safety. its direct applicability was explicitly recognized by the european court of justice, notably in the case of the embargo on british beef during the mad cow crisis ( ) . the principle has also been recognized as an important risk management tool in the context of pandemics. in france, as in canada, it was prominent in the reports of commissioners appointed to inquire into the tainted blood scandal and the sars crisis ( ) ( ) ( ) . three fundamental components of the precautionary principle are outlined: the lack of full scientific certainty, the risk of serious or irreversible harm and the need for a decision ( ) . the first two elements are criteria for the application of the principle, whereas the third determines its normative scope. however, these application parameters establish standards that cannot be determined objectively, and are therefore subject to different interpretations. for example, concerning scientific uncertainty, the level, and threshold of scientific knowledge on potential risk, required to apply the principle, is unclear . in the same line of thought, the severity or the irreversibility of the potential harm cannot always be evaluated solely by objective scientific criteria ( ) . furthermore, the conceptual "the response of who and many countries to the pandemic was a reflection of this mindset. this was affirmed in the sentiments expressed by many member states to the review committee: in the face of uncertainty and potentially serious harm, it is better to err on the side of safety. public-health officials believe and act on this conviction. it is incumbent upon political leaders and policy-makers to understand this core value of public health and how it pervades thinking in the field". to this effect, we cite the krever's report on contaminated blood as well as judge campbell's report on sars in canada, in addition to commissioner legal's report in france. this question constitutes one of the most important problems faced by the doctrine with regards to the application of the principle. one can wonder whether theoretical knowledge is enough or if it is necessary to support the hypothesis of risk by empirical data. it is also important to question the degree of consensus needed within the scientific community, so that a scientific hypothesis is regarded plausible. framework of the third element, the need for a decision, does not anticipate the nature or the scope of the precautionary measures, leaving the authorities with a margin of discretion. different interpretations of the precautionary principle resulting from the articulation of these three key elements have been developed and reviewed in the literature ( ) . indeed, the precautionary principle is a concept of "variable geometry" ( ) . it has a malleable character; the definition and its impact on the decision making process vary according to the context of application. there is no strict consensus on this issue. a typology of the precautionary principle permits an examination of interpretations in line with our primary objective, which is to legitimate a state power allowing access and use by the authorities of genomic databases for research purposes and to see if, for this end, it is possible to invoke the precautionary principle. the first two versions, "the institutional model" and "the cautious approach", can be qualified as antagonistic . they are based on the proportionality and the severity of the precautionary measures adopted. the institutional model promotes early action that is proportionate to the potential risks. the cautious approach, instead, calls for the implementation of more demanding precautionary measures and favors eradicating risk. in its extreme form, the cautious approach constitutes the rule of abstention or prohibition. the institutional model was recognized by justice krever in the tainted blood report ( ) . he stated that additional precautionary measures, such as heating blood products and screening of blood donors to reduce the risk of hiv transmission via blood products should have been taken at an earlier point in the crisis. the cautious approach, which favours eradication of risks, can be associ- the articulation of these three elements leads to differences regarding the measures adopted, the precocity of the application of the principle, etc., as well as its normative character (ethical principal or legal etc.). with the exception of antagonistic versions, it is possible for precautionary measures adopted by authorities to stem from different interpretations of the principle. ated with the implementation of quarantine measures once fatalities occurred (e.g. efforts to counter the threat of sars). the third and fourth versions of the precautionary principle, the "tactic approach", and the "strategic approach" deal with the timeframe of the enactment of precautionary measures. according to the tactic approach, precaution is a temporary and flexible instrument; uncertainty is thought to dissipate with knowledge. the tactic approach operates in the short and medium term. thus, measures are provisional and revisable, subject to change in response to increased knowledge. the tactic approach, used in the area of food safety, is associated with moratoriums, embargos, and all other reversible measures ( ) . in the specific context of pandemics, quarantine measures could also serve as an example of this particular interpretation. the strategic approach relates to the vorsorgeprinzip, a legal concept developed in germany, which inspired the creation of the precautionary principle. the strategic approach is premised on the notion that obtaining scientific certainties cannot always be done in time to allow for guidance of collective choices. its proponents argue that a policy of prevention based on medium and longterm objectives should be adopted. thus, attention should be shifted from advances in the understanding of risks, to understanding the evolution of the technological and economic resources available for risk prevention (i.e. the invention of new and substitute treatments, etc.) ( ) . among the different versions discussed above, this final version, the strategic approach, could legitimate power authorities to use genetic databanks for research purposes and to utilize their findings in the context of public health interventions. the implementation of surveillance systems and pre-authorized procedures illustrate measures corresponding to this approach. recently, the possibility of a pandemic caused by the avian influenza mobilized the forces of many international and national public health bodies. various surveillance mechanisms were recommended. it would be particularly interesting to verify whether these governing bodies, in the elaboration of their intervention plan, intend to take advantage of the field of genomics, and if so, in which manner they plan to do it. our analysis of the pandemic influenza recommendations proposed by the world health organization, canada and quebec, all of which are important planning instruments, centers on the four principal functions of public health: monitoring, promotion, prevention and protection. the emergency issue is dealt with separately to accentuate the characteristics of this specific context. canada's and quebec's plans emphasize the responsibility of governments in the risk management of pandemic influenza. the world health organization's influenza preparedness plan ( ) has had a significant impact on the design and on the implementation strategies of the canadian and quebec plans. the canadian pandemic influenza plan ( ) can be studied in parallel with the new quarantine act ( ) . the purpose of the act is to prevent the introduction and spread of communicable diseases (art. ). it specifically addresses the screening of travelers or conveyances leaving and entering canada (art. ). by definition, a pandemic affects several countries. public health measures at the borders will therefore be crucial in preventing and controlling outbreaks. precise details concerning various types of data to be collected and the roles and responsibilities of individuals at the local, provincial, territorial and federal levels can be found in the canadian plan, and specifically in the pandemic influenza surveil-lance guidelines ( ) . the document also outlines the responsibility of canadian officials towards the world health organization. a number of factors are likely to influence the nature of surveillance measures. in addition to the various phases and periods of a pandemic, which shape the surveillance objectives and officials roles, the guidelines recommend considering changes in circumstances and new information ensued. this approach requires attentiveness to any development or variation in multiple areas. in particular, all aspects of a disease or of the epidemiology of the infection will require special attention: clinical manifestation (case definition and pathogenesis of influenza), virulence, mode of transmission, incubation period, period of transmissibility, and its effect on the population (distribution and frequency of the disease). could this latter aspect possibly include the need for population genomic data on gene-environment relationships? in addition to the recommendations of the pandemic influenza surveillance guidelines ( ) , annex c of the canadian plan sets out recommendations concerning the virological monitoring and laboratory tests and procedures ( ) . the annex c is not as explicit as the surveillance guidelines on the subject of research studies. nonetheless, annex c institutes a context of investigation and information updates for laboratories by addressing certain test protocols as well as communication between stakeholders. apart from citizens and health professionals, communication and health promotion tools are also intended for a third category of persons: politicians. any information regarding the influenza pandemic would certainly be valuable in guiding different public health authorities (public health directors, ministers, governments). the annex on communication in the canadian plan describes national objectives of communication in detail and according to pandemic periods ( ) . the plan favors transparency and stakeholder responsibility in risk communication. the canadian plan thus strives to ensure that up-to-date information about a situation and risks for society are transmitted to the political authorities concerned ( ) . a large portion of the canadian plan deals with functions linked to prevention and protection. for instance, guidelines on public health measures set out recommendations on education and communication of information to the population, community measures, such as school closures and public assembly limitations, and the care and services to be offered to persons infected by the new influenza virus and to their contacts ( ) . our analysis of the annexes of the canadian plan concerning prevention and protection demonstrates two guiding ideas in the elaboration of recommendations: updating the information to be used for public health interventions, but also, in parallel, maximum use of existing expertise in devising scenarios and hypotheses of an influenza pandemic in canada. annex l of the canadian plan, entitled federal emergency preparedness and response system, outlines the federal government's responsibilities in the area of public health, particularly the powers conferred to the public health agency of canada and health canada. this annex does not include a definition of "emergency" per se, but the concept is elucidated by the examples provided. from these examples, we can infer that emergencies share the following characteristics: severity, need for immediate action, and a large number of people affected. the examples listed include sars, the ice storm of , nuclear emergencies, pandemic influenza and "events or catastrophes of natural origin or deliberately caused". similarly, to its federal counterpart, the québec pandemic influenza plan -health mission ( ) serves as a reference document in preparing for an influenza pandemic. its implementation will take into account new epidemiological knowledge of pan-demics and the overall evolution of the situation ( ) . the québec plan proposes participation methods for all susceptible individuals in the event of a pandemic influenza, including decision-makers, citizens, informal caregivers, and workers. with respect to this participation, "three rules of governance" are provided as guiding principles: protection, solidarity, responsibility, and sound management. as the authors point out, the three rules of governance "are interdependent and have the common condition that everyone be vigilant as to their own state and the state of others and act accordingly" ( ) . the government of quebec, in partnership with political and health authorities, has a responsibility to protect the lives and health of the population, and more generally, its well-being ( ) . the québec plan reflects this complex objective in distinguishing five broad facets of state intervention: "protecting the health of the population (public health); providing medical care (physical health); ensuring people's psychosocial well-being (psychosocial response); providing clear, relevant and mobilizing information (communication) […] [, and] keeping the network working (continuity of services)" ( ) . our analysis of the québec plan continues in light of the public health ethics committee's study of this document. the public health ethics committee was created by the public health act. as mentioned, "scientific activity" plays a significant role in controlling pandemic influenza ( ) . yet, although the need to obtain the best knowledge possible and to adopt the most effective measures is evident, other documents fail to mention scientific activity. this acuteness with regards to knowing about ones own health status is now coupled with a traveller's duty to disclose their suspicion that they have or might have a communicable disease listed in the schedule or are infested with vectors as provided by law: quarantine act, s.c. , c. , art. . this disclosure shall be done to a screening or quarantine officer while crossing the country's border and this without waiting to be questioned by the officer. we must point out; however, that "scientific activity" is an area that can have significant demands. these demands lead us to question whether the collection and analysis of genetic or genomic information can be pursued as a means of obtaining the best public health intervention strategies . influenza control plans only refer to genetics under the label of "scientific information". for example, though the canadian plan mentions the impact of "information from the viral genome" ( ) , no direct or indirect mention is made of genomic information as it relates to information concerning individuals or group of people. the same observation is true for the québec plan ( ) , and that of the world health organization ( ) . nevertheless, the obligation to protect the population in the event of a pandemic places an incumbent responsibility on different levels of government to implement measures to attain this objective. could genomic research programs be a part of these measures? after having examined different definitions and legislations regarding public health particularly in the canadian province of québec to see if they provide the basis to allow the state to access genomic databases, we offer the following conclusion. we must admit that genomics, or more specifically, genomic susceptibility to disease, offers interesting avenues for action in public health. in a not too distant future, genomics may well become a health determinant ( ) . in fact, in quebec, biological and genetic predispositions, lifestyles and other health-related behaviours, living conditions and social settings; physical environment and finally, organisation of health and social we note that the public health ethics committee opinion does not mention genetic nor genomic information. the consideration of its inclusion among scientific activities is ours. services as well as access to resources ( , ) are considered health determinants. nonetheless, we have observed in the paper that state powers in public health, are not, in québec, well adapted to the expansion of genomics research. currently in canada, in the absence of emergencies, states powers to access genomics databases for research purposes are not explicitly and clearly established. however, to the extent that it can be shown that the genomic can be a very useful tool to respond more efficiently to a crisis in public health, should the state not take into account this new field of knowledge? the influenza control plans by highlighting the important responsibilities incumbent upon states to implement effective interventions in a pandemic, and by recognizing the contribution of knowledge and research, promote an open approach toward public health genomics. this leads us to make an important recommendation. in the future, the scope of the concept of research in public health should be clear and include the following characteristics: a commitment to the health and well-being of the population and to their determinants; the inclusion of both applied research and basic research; and, an appropriate model of governance (authorization, follow-up, consent, etc.). medium and long-term objectives should be adopted in relation to the possible future use of research results for public health interventions (public health promotion, prevention, and planning). therefore, we propose that the strategic approach version of the precautionary principle, based on premise that scientific certainties cannot always be obtained in a timely manner, could guide collective choices in these matters. as an autonomous discipline, public health deals with the global health of populations in all its curative, preventive, and social aspects; its objective is to develop systems and initiatives of health promotion, prevention, and treatment of illnesses, and rehabilitation of handicaps ( , ) . as mentioned, the concept of public health is far from being static; it demonstrates a flexibility that guarantees a perpetual adaptation to new forms of risks attributable to the determinants of health. on the one hand, this flexi-bility is a consequence of the evolution of the notions of health, well-being, and illness, which are recognized as multifactorial phenomena. on the other hand, it is the result of developments in informational and biomedical technologies ( ) . as such, the flexibility of public health may allow it to embrace new research tools, such as genomics. however, how can this innovative tool be utilized to reach the public health objectives of protection, prevention, promotion, and surveillance? in order to insure its appropriate use, it is essential to take into account the state's powers and responsibilities and to decide on the most suitable model of governance for this new biomedical research asset. interestingly enough, world health report no health without research ( ) will discuss the impact of research in the elaboration of effective and efficient policy options, recognizing that, unfortunately, health policies are often not well-informed by research evidence. as stated, "the theme was selected in part to meet who's core function of stimulating the generation, translation and dissemination of valuable knowledge" ( ) . keeping in mind that, in april , the who department of research policy and cooperation established the who initiative on genomics & public health ( ), it will be fascinating to find out the importance given to genomics. ethical issues (including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors. getting ready for the future: integration of genomics into public health research, policy and practice in europe and globally understanding the bse threat mad cow update: risk now limited Étude d'impact stratégique du plan d'intervention gouvernemental de protection de la santé publique contre le virus du nil occidental west nile virus: don't underestimate its persistence learning from sras -renewal of public health chemokine (c-c motif) receptor - genotype in patients receiving highly active antiretroviral therapy: race-specific influence on virologic success committee on genomics and the public's health in the st century -board on health promotion and disease prevention -institute of medicine of the national academies years of public health genomics at cdc - the path from genomebased research to population health: development of an international public health genomics network le risque comme problème politique: sur les obstacles de nature politique au développement de la santé publique. revue française des affaires sociales de l'individuel au collectif: une vision décloisonnée de la santé publique et des soins. ruptures, revue transdisciplinaire en santé la santé publique au québec à l'aube du xxi e siècle. santé publique the future of public health in canada: developing a public health system for the st century committee for the study of the future of public health -division of health care services regional office for the west pacific, provisional agenda item (document wpr/rc / ): essential public health functions: the role of ministries of health, regional committee, fifty-third session, kyoto (japan) public health in the americas: conceptual renewal, performance assessment, and bases for action redefining the scope of public health beyond the year essential public health functions: results of the international delphi study les fonctions essentielles de santé publique : histoire, définition et applications possibles. santé publique québec public health program québec, institut national de santé publique du québec et ministère de la santé et des services sociaux pan american health organization national public health performance standards program -the essential public health services programme national de santé publique - , version abrégée. québec, direction des communications du ministère de la santé et des services sociaux Éthique et santé publique : enjeux, valeurs et normativité. les presses de l'université laval framework for the application of precaution in science-based decision making about risk uk/commission krever commission report, ottawa, public works and government services canada the sars commission -spring of fear: final report. government of ontario le développement durable contre le principe de précaution le principe de précaution comme norme de l'action publique, ou la proportionnalité en question. revue économique le principe de précaution dans le contexte du commerce international : une intégration difficile pandemic influenza preparedness and response: a who guidance document her majesty the queen in right of canada, canadian pandemic influenza plan for the health sector pandemic influenza surveillance guidelines in her majesty the queen in right of canada, supra, note , annex n (date of latest version pandemic influenza laboratory guidelines in her majesty the queen in right of canada, supra, note , annex c (date of latest version canadian pandemic influenza plan for the health sector: communications annex in her majesty the queen in right of canada, annex k (date of latest version quebec pandemic influenza plan -health mission volet santé publique du plan québécois de lutte à une pandémie d'influenza -mission santé, avis adopté à la e séance du comité d'éthique de santé publique, le juin les défis de la santé au xxi e siècle: approche législative des déterminants de la santé santé publique : santé de la communauté population health in canada : a systematic review. canadian policy research networks secrétariat du comité d'éthique de la santé publique -ministère de la santé et des services sociaux world health report the initiative on genomics & public health the authors want to thank genome canada, genome québec and the social sciences and con humanities research council of canada for their financial support. the authors declare that there is no conflict of interests. key: cord- -nzvon hc authors: whitley, jess; hollweck, trista title: inclusion and equity in education: current policy reform in nova scotia, canada date: - - journal: prospects (paris) doi: . /s - - -z sha: doc_id: cord_uid: nzvon hc this article aims to explore the context of inclusive education policy in canada, and to highlight the particular case of inclusive education policy reform in the province of nova scotia. as with most other provinces and territories, inclusive education policy in nova scotia has broadened to include a lens of equity, with a focus on not only students with special education needs, but all students – particularly those most often marginalized by and within canadian school systems. the article reflects on the first phase of the developmental evaluation process which took place prior to full implementation of the policy. four interconnected key themes emerge: ) the shifting roles and identities for educators and specialized staff; ) the changing roles of classroom teachers; ) the importance of support to ensure effective universal and differentiated classroom practices; and ) the professional learning of school staff. although situated within the nova scotian and the national canadian context, the discussion and implications can readily be applied to international systems engaged in developing and implementing broad inclusive education policy. across canada, where education is provincially, rather than federally organized, all provinces and territories have demonstrated a commitment to the ideals of inclusion and equity (hutchinson and specht ) . several provincial and territorial policies related to inclusive education have been re-imagined over the past decade to include a broader perspective on equity as it relates to providing equal access and opportunity to all students, particularly those who have historically been marginalized or viewed as unsuccessful in canada's education systems (government of alberta ; ontario ministry of education ; the social planning council of winnipeg ). this focus is in contrast to previous and in some provinces, current policies where inclusive education refers primarily to students with special education needs (province of british columbia ). the importance of valuing and reflecting the diversity of student identity, including ancestry, ethnicity, gender identity, intellectual ability, and socio-economic status in schools, as well as identifying and dismantling systemic barriers is often highlighted. this type of equity and inclusion policy is reflective of international efforts by organizations like the un with sustainable development goals that include a need to "ensure inclusive and equitable quality education and promote lifelong learning opportunities for all" (united nations , p. ). the persistence of educational inequities (among others) for certain populations has been noted across canada by those within and beyond the country borders (george et al. ; gordon and white ; united nations ) . as an example, black students, those who self-identify as indigenous and those with disabilities are significantly less likely to experience the opportunities and successes of their peers within provincial education systems (canadian human rights commission ; james and turner ; province of nova scotia a). recognition of continued disparities among student experiences and outcomes has propelled recent efforts in provinces including nova scotia to collect and share achievement and wellbeing-related data that is disaggregated in a number of ways (ontario ministry of education ; unicef canada ). this approach will in theory allow for greater attention to the gaps that exist and guide policies and programming to improve outcomes for students marginalized by and within education systems, suggesting both an educational and social justification (campbell ). while many necessary efforts related to equity and inclusion emerge within and across provinces and territories, approaches differ with respect to the positioning of these alongside deeply entrenched special education policies. it has been noted by ainscow ( ) that a focus on including students with disabilities "should be seen as an essential part of an overall strategy for promoting inclusion and equity, not as a separate policy strand" (p. ). across jurisdictions, separate special education policies, some of which have been developed or updated within the past years, continue to exist in parallel with the equity efforts (bc ministry of education ; ontario ministry of education ; province of manitoba ; province of nova scotia ). in terms of class placement, which is how we historically have defined inclusive education, most students with special educational needs in canada are educated in regular classrooms, with varying levels of "pull out" service provision; segregated classes and a small number of segregated schools also exist in most provinces and territories (specht et al. ) . certain groups of students, in particular those with intellectual and developmental disabilities, are over-represented in segregated settings in canadian school systems (reid et al. ) . within the range of placements available, students with disabilities may be included socially and/or may be supported in engaging with the regular curriculum with same-age peers. however, as in an analysis of inclusive education in ontario by parekh ( ) , "it is critical to actively explore into what are we including students. how do we ensure the environment, curriculum, and climate are ones which students can experience a sense of belonging, a sense of membership and shared power?" (para. ). physical placement is not synonymous with inclusion. in implementing inclusive education, provincial and territorial ministries of education all include some mention of universal design for learning (udl) and differentiated instruction (di) as pedagogical and assessment practices that can facilitate teaching and learning in diverse, inclusive settings (whitley et al. ) . udl principles can align with practices of different levels or "tiers" of intervention and support -typically three (katz ) . in canada, multi-tiered systems have been in varying stages of adoption for many years, in the form of response to intervention (rti) (mcintosh et al. ) . rti in many provinces is intended to shift from a traditional approach where funding and programming are based on a testing, identification, and placement process to a focus on identifying individual student strengths and needs and to providing interventions where needed. while considering the needs of all learners is possible within a tiered system, the language surrounding udl, mtss and rti in canada tends to reflect a focus on students with special education needs (robinson and hutchinson ) . thus, while policies have shifted in some provinces to adopt a more multidimensional inclusive lens, there continues to be evidence of parallel equity and inclusion conversations. our current work in the province of nova scotia is an opportunity to examine the ways in which a new policy of inclusive education is understood and implemented in light of the broader canadian and international discussions of equity and inclusion. since the spring of , our research team based at the university of ottawa (led by professors jess whitley and andy hargreaves) has been engaged in a developmental evaluation of the implementation of a new inclusive education policy in nova scotia. this implementation is in its early phases, with fall set as the official start date of the policy. nova scotia is the largest maritime province in eastern canada with a population of approximately , ; halifax is the capital city with almost half of the residents of the province. the province has a large rural population of over per cent (statistics canada ). according to the canadian income survey of , . per cent of nova scotians live below the poverty line which is the highest share in canada where the average is . per cent (province of nova scotia b); per cent of nova scotian children live in poverty which is the third highest rate in the country (frank and fisher ) . within nova scotia, approximately . per cent of the population self-identify as indigenous, the majority of whom are from the mi'kmaq nation and are recognized as the founding people of nova scotia (province of nova scotia ). approximately . per cent of nova scotians identify as african nova scotian, most of whom have lived in the province for three generations or more (province of nova scotia a). there is also a strong acadian and francophone presence (province of nova scotia c). with respect to the organization of schools across the province, a major shift occurred in with the adoption of recommendations arising from a review of the education system (glaze ). glaze made several controversial recommendations including the elimination of elected school boards and the removal of school administrators from the nova scotia teachers union (nstu). many of the suggested changes were heavily criticized (laroche ; ritchie ) and a few were subsequently rejected in response to imminent job action by the nstu (nova scotia teachers' union ). the system was reconfigured to contain seven regional centres of education (rces), with executive directors who report directly to the eecd -the francophone school board (csap) structure remained unchanged. most of the newly formed rces contain broad geographic swaths of the province with many including extensive rural areas. the halifax rce is the most urban region and also the most populated (in all of atlantic canada), with schools and approximately , students; the tri-county region is among the most rural and has approximately , students in schools and encompasses over , square kilometers. in terms of broad achievement and equity, students in english-language schools in nova scotia scored similarly to the canadian average on reading in the programme for international student assessment (pisa) test; students in french-language schools scored below the canadian average (o'grady et al. ) . provincial assessment results in nova scotia are regularly disaggregated by student self-identification as either mi'kmaq or other indigenous ancestry ( per cent of enrollment), or of african descent ( per cent of enrollment). the most recent results demonstrate discrepancies in the scores, with indigenous and african nova scotian students scoring lower than non-identified peers in all instances (province of nova scotia a). while we view equity in terms of achievement as central to inclusion, we know it to be integrally related to wellbeing. exclusion, isolation, stigmatization and lack of belonging give rise to problems of emotional, mental and physical health -and most certainly impact achievement. students across nova scotia in grades through were surveyed on topics related to wellbeing and school experiences for the first time in . many positives were noted in the findings, including high rates of reports of having a close friend or adult to talk to, and generally high academic expectations of self and teachers. overall, per cent of students reported feeling like they belong at their school, with per cent of students of african descent and per cent of mi'kmaq/indigenous students in agreement. notably, only per cent of those with disabilities and per cent of students identifying as lgbtq + felt like they belonged at school. the same four subgroups of students reported feeling less respected than other students and less safe at school than the provincial average. over several decades, a number of reviews, reports, and position papers have documented the strengths and needs of the nova scotia education system, including the educational disadvantages related to indigenous and african nova scotian students (aylward et al. ; glaze ; njie et al. ; nova scotia teachers' union ; nunn ). in addition, in parallel with other provinces in canada, the concept of inclusive education has expanded beyond students with identified disabilities, to encompass other needs and populations at risk of exclusion and under-achievement such as immigrant and refugee populations, african nova scotians, students growing up in poverty, mi'kmaq communities, and gender-related minorities (ns department of education and early childhood development ). a focus on the unique experiences, needs and barriers typifying communities with strong cultural identities and historical presence is not a recent shift in nova scotia. with respect to african nova scotian students, the black learners advisory committee (blac) report on education was released over years ago ( ) and describes a series of inequities and systemic barriers within the education system, and society broadly. following the blac report many policies, reports and frameworks have continued efforts and shed a critical lens in order to guide improved outcomes for african nova scotian students through curriculum, instruction, assessment, leadership and partnerships with families and communities (enidlee consultants inc. ; province of nova scotia ; sparks ). concerns regarding equity were also noted in the report produced by the commission on inclusive education which took place in - (njie et al. ). this report, entitled "students first", serves as the foundation of the new inclusive education policy and describes obstacles to progress in inclusive education, including inconsistent operationalization and implementation of various policies and procedures. as the commission noted, this lack of shared agreement regarding the basic underpinnings and practices that comprise inclusive education in nova scotia limits the potential of collaborative learning communities that are key to ongoing development of pedagogical practice within a culture of inquiry. the commission and its recommendations were strongly supported by the nstu although concerns regarding a lack of collaboration and transparency continue to be raised in terms of the speed and nature of implementation efforts (nova scotia teachers' union ). the current inclusive education policy (province of nova scotia b), furthermore referred to as the policy, emerged from the findings and recommendations within the students first report (njie et al. ) , as well as the broader history and context of nova scotia education. the policy was developed by the eecd in consultation with multiple groups and was released to the public in august . implementation of the policy is slated to take effect in september . the policy includes a broad focus on ensuring equity, opening with the statement: "inclusive education is a commitment to ensuring a high-quality, culturally and linguistically responsive and equitable education to support the well-being and achievement of every student. all students should feel that they belong in an inclusive school-accepted, safe, and valued-so they can best learn and succeed" (province of nova scotia b, p. ). the eight guiding principles of the policy are listed in figure . the policy also includes a number of directives which include classroom teachers taking on responsibility for all students, most often in a common learning environment, with support and collaboration. the development of specific school-based teams to support teachers and students are described, along with the directive that "every school will support student well-being and achievement through a multi-tiered system of supports (mtss)" (province of nova scotia b, p. ). finally, a series of roles and responsibilities for each group of education stakeholders (e.g., students, families, teachers, administrators) is detailed. following the release and recommendations of the students first report (njie et al. ) , the government of nova scotia announced initiatives and funding that were situated within the umbrella of inclusive education implementation. in the fall of , new positions were added to the education system. these new hires included a mix of positions that were new to the system, as well as additional hiring of existing positions; examples include child and youth care practitioners, autism and behaviour specialists, parent navigators, african nova scotian and mi'kmaq student support workers. in , a second wave of hires ( positions) were added. in late , in order to guide and support the implementation of the policy, and to provide greater accountability as recommended in the students first report, the government sought proposals for a developmental evaluation. our research team bid successfully and, every student can learn with enough time, practice and equitable and responsive teaching. every student, including those with special needs, should receive full-day instruction every day, with flexibility based on the student's individual strengths and challenges. every student should be taught within a common learning environment (e.g., a classroom) with students of similar age within the community school, with flexibility that is based on, and responsive to, the student's individual strengths and challenges. inclusive education values, draws upon, and includes student voices and choices to assist students in achieving their goals. every student deserves to belong (affirmed, validated, and nurtured), be safe, and feel welcomed in all aspects of their daily experience. inclusive education is a commitment to honour and respect each student's cultural and linguistic identities and knowledge systems inclusive education practices use evidence of students' strengths and challenges to determine a system of supports and monitor the effectiveness of those supports. all partners are committed and empowered to work collectively to identify and eliminate barriers that interfere with students' well-being and achievement. nova scotia inclusive education policy: guiding principles in the spring of , as the policy was being finalized, our research team embarked upon a developmental evaluation of its implementation. the next section details our approach and initial findings. the innovation in inclusive education currently underway in nova scotia offers an ideal opportunity to interweave a developmental evaluation. the evaluation is an iterative process, whereby our team works with eecd staff and a broader design team to conceptualize implementation of broad system change for inclusive education. as a collective, we are engaged in collaboratively generating the specific questions to guide the developmental evaluation, establishing priorities, identifying what data is required and how it will be collected, interpreting findings, and tracking development to inform next steps whilst considering changing conditions and new information gathered throughout the process. in our application of developmental evaluation, we situate ourselves within the eight essential principles outlined by patton ( ) which include evaluation rigor, utilizationfocused, systems thinking, co-creation and timely feedback. our first few months engaging with the developmental evaluation have been focused on: a) developing relationships with those knowledgeable about, and likely to be affected by the policy; b) developing a greater understanding of the many moving pieces that comprise the inclusive education policy implementation; c) working closely with a design team to guide the ongoing evaluation planning; d) collecting and analyzing data provided by key informants; and e) providing initial feedback to the eecd based on our findings to date. our first step was to develop an evaluation design team in consultation with eecd which comprises a teacher, principal, regional executive director, eecd executive directors of early learning and student success and the eecd director of research and partnerships. as researchers "from away", we also began the process of developing relationships with key individuals and groups to support and inform our shared work. a project manager, based in nova scotia, was hired to assist with planning and to maintain a consistent local presence in the eecd. beginning in the summer of , we also engaged in early data collection, which will inform the analysis in the next section. we travelled to nova scotia four times in the first eight months of the evaluation, twice to halifax, and twice to other regions. given the pre-implementation phase within which these visits took place, the focus of our evaluation efforts was on: a) developing a deeper sense of the context in which the policy and its implementation was embedded and b) exploring the perceptions of key stakeholders regarding the policy. to the first goal, we engaged in information-gathering discussions with individuals within and outside of the eecd. some of these individuals preferred not to be interviewed and to have their perspective captured on a recording and all provided helpful contextual information that informed our ongoing efforts. our project manager met with key individuals with the eecd on a weekly basis, to stay abreast of ongoing developments and to take part in the everyday conversations of those engaged in the implementation. we also took part in six advisory group or internal leadership meetings, reflecting participation by teachers from across the province, directors of programs and student services from each region and csap, regional executive directors and the eecd leadership team. in addition to our efforts to learn and engage, formal interviews were conducted with key informants, including regional senior staff, school leadership and resource teachers, representatives of unions and professional associations, as well as post-secondary institutions that offer bachelor of education (teacher preparation) and graduate education programmes. interviews focused on the roles and contexts of the participants, their knowledge and perceptions of the policy, and hopes and concerns for the policy implementation. the interviews were audio-recorded and were on average minutes in length. verbatim transcripts of each interview were developed and analyzed thematically. four main themes emerged from our analysis of this preliminary series of interviews. these include: ) shifting of roles and identities: who am i and what do you do? ) the changing roles of classroom teachers: islands no longer? ) inclusion = mtss and success hinges on tier , and ) professional learning: if we teach a teacher to fish. when discussing the inclusion policy, the majority of participants described the state of flux, either present or anticipated, of the roles and responsibilities of a range of school staff. much of the discussion within these themes focused on new positions within the education system that were added prior to the release of the policy. in general, participants were positive about the addition of the positions and the ways in which these individuals and their skill sets could and in some cases already were benefitting staff, students, parents and community partners. however, confusion was regularly expressed by participants, both those in the new positions and working alongside, regarding job descriptions, overlap of tasks with those of existing staff, boundaries of responsibilities and a lack of clarity and communication related to the new hires. efforts were described where regions were mapping the roles and responsibilities of the new positions alongside others with the multi-tiered system structure; these efforts were seen as very beneficial. some of the concerns expressed by participants related to perceived threats to expertise and identity. one school guidance counsellor stated: we need the support, but i'm always going to be like, "but what's our role?" because in some ways i've felt like our role has been chipped away at through all of the new supports that have been put in. i know a more positive way to look at it would be there are supports and we got to join with them, but it's hard when in some of these cases, some of these roles, we don't really understand what the role is. the lack of clarity and alignment was also raised as a barrier to effective supports for students -not knowing who was responsible for what in which type of situation could lead to student needs not being addressed or overlap of services. shifting roles were also discussed by the majority of the participants in response to the perceived emphasis of the inclusion policy on the increased responsibility of classroom teachers to meet student needs. the new inclusive education policy states that "classroom teachers are responsible for teaching all students. teaching and interventions are expected to happen most often in a common learning environment, such as the classroom. classroom teachers cannot do this alone" (province of nova scotia b, p. ). participants described the significant shift in mindset and practice that this would necessitate for some teachers who were at an earlier point along an inclusive continuum and who were used to what was described by one participant as the " s pull out model" which was still in evidence in many schools. one regional consultant stated, "…we've got to support those classroom teachers, if we're saying they're the folks that are responsible with support, we got to do more support for them. way more support". as is evident in the policy statement above, the shift towards greater responsibility for classroom teachers is intended to be accompanied by greater collaboration. although many teachers were already working in partnership with other teachers, specialists, families and community, the sense of ownership for planning and programming for students with special education needs in particular was seen in some instances as sitting with a resource or learning centre teacher. the shift in the policy noted by many participants who were providing specialist supports at the school or regional level (e.g., resource teacher, psychologists, student services consultant) was described as changes in their roles from supporting students to supporting teachers. the policy described how a range of support teachers (currently resource or learning centre teachers) "would provide direct, collaborative support to classroom teachers and students" (province of nova scotia b, p. ). this is in contrast to the current role of some support teachers which strictly involves working directly with students in a pull-out model or of some psychologists who engage primarily in individual student assessment and intervention. one specialist wondered, "can we do more in class consultative types of services with our slps so that teachers are building their skillsets and understanding what they can do at the classroom level before they are asking for direct therapy whether small group or individual?" having greater collaboration within a regular classroom requires an openness that was seen as challenging for some teachers. one regional consultant believed, "the big issue, i think, for teachers is that they're not really used to having people in their classroom… and they feel like they're being judged all the time. and it's not about judging them. it's about supporting them. and with a multi-tiered system of support and inclusive education, you've got to get used to having many people in your room. although described sequentially, this third theme is tightly interwoven with some aspects of the first two, specifically the shifting roles and responsibilities for regular classroom teachers. there was a very strong and shared belief evident among participants of the importance of tier described as the need to bring supports to the classroom and the need to ensure effective universal and differentiated classroom practices. one regional leader described how "there's no question that there's an increased focus on excellence in teaching at tier one, which i am a very strong proponent of" and a school psychologist shared her belief that "the tier has a ton of potential to really improve overall student learning if we are looking at increasing some of the more evidence-based interventions". one guidance counsellor described her desire to work more often alongside classroom teachers rather than spending most of her time supporting individual students but also described the overwhelming mental health needs of students in her school and the existing : ratio of counsellor to students: "and you want to get into the classrooms and do the proactive piece. you do, because you're hitting kids when you're getting in there and doing cyber stuff, when you're doing positive mental health". in describing ways in which she could meet the needs of a large group of students however, one resource teacher described that supporting individual teachers at the tier level, in the general classroom, was just not feasible. the long-term view adopted by system leaders and supports was less palatable to those working on a daily basis with large caseloads of students: well, i usually group my students according to their needs. so ideally, i get into classes, which i do. but a lot of the time, because of the needs in this building, i find that it turns out being a pull-out model…just for the amount of students that i need to see, like i could have upward of students during first intake and another during second intake. so, the needs are high, and it's much more efficient for me to take them all at the same time. a need for professional learning emerged from the discussions of the first three themes, where the increasing focus on regular classroom practices at the tier level and the shifting roles of educators and staff in a number of different positions generally led to the same recommendations from participants: more professional learning. discussions of professional learning typically centred around capacity-building among classroom teachers and the role of skill development in building confidence and a willingness to take ownership for students experiencing difficulties. one regional consultant described how she noticed in her work, "…a lot of people don't feel that they have the skill set to be able to deal with students that have diverse learning needs, that they really don't feel that they've had the training… because if they've been in the school system a long time, differentiation may be not really a concept that's… or udl, that really is something that they can pull out of their back pocket". the framing of the multi-tiered system was also applied to teacher professional learning as it was recognized by participants that different teachers working in different roles within different regions would have varying professional learning needs. as with the example provided by the resource teacher describing the necessity of a pull-out approach, a shift to a capacity-building versus a child-fixing mindset is a long-term view likely to be challenging for many teachers overwhelmed by day-to-day challenges. one regional consultant described this view: but you really have to look at the staff that you have and the expertise and how can we make this work if we do things in a different fashion. because it's about building capacities, the other thing, and that's what a lot of the time people aren't seeing. they just want the immediate fix or the immediate, like, "come and help me right now", not realizing that if we teach them how to fish it's going to be something that they can use for a long time and the skill set that they develop this year is going to… it is about building their own repertoire as far as i'm concerned, in terms of skill set. a number of challenges were described in considering the professional learning required. a lack of substitute teachers often resulted in in-service opportunities being scheduled after school hours which was not seen as ideal and often precluded the involvement of staff whose workdays were scheduled in different ways (e.g., education assistants). opportunities to collaborate with other schools for professional learning was seen as very valuable but again challenges were noted in terms of the amount of travel required in the often geographically large, rural areas typical of many regions in nova scotia and the costs of releasing teachers should substitutes become available. some participants did share examples of committees, advisory groups or informal networks that they were part of that allowed them to discuss and share plans for implementing the inclusive policy. those most senior in the system mentioned the upcoming opportunities to apply for network school projects, an initiative funded by eecd as part of the implementation of the inclusive education policy. these projects were again seen as opportunities to build collective efficacy among school-based educators and administrators to support students more effectively at the tier level. the majority of the participants had not yet been made aware of this initiative. in contrast to the wide-ranging scope of the policy, the bulk of the discussion with participants, which was prompted by very open questions, centred around student services and special education needs. this is likely in part to be a reflection of the participant pool, which was heavily weighted with those who traditionally held roles in these areas and who were suggested to us as knowledgeable key informants. it is further reflective of many of those charged with leading the work of implementing inclusive education. a few participants spoke specifically about students who were african nova scotian or mi'kmaq and raised issues of equity and of making connections with families and communities. this broader issue was noted by one regional equity consultant, "in order for this to be effective, it cannot sit with student services… and certainly, the optics will be that it is still a policy that is targeting a very specific population. so, there has to be collaboration at the provincial and at the regional level in order for this to be truly realized…if you're going to bring in a team to talk about the implementation of this, it shouldn't be students service coordinators". feedback of our initial findings, which includes data shared here, as well as recommendations specific to the activities of eecd and the regional contexts was shared with the design team, and then the system at large in the fall of . as is typical of a developmental evaluation, this feedback was intended to be accessible and immediately useful. a subsequent visit in the winter of began to reveal some of the ways in which these results could and were informing implementation planning. the school closures and shift in priorities resulting from the covid- pandemic have prompted us to re-imagine our activities and the ways in which the policy may be implemented. ongoing discussions with the eecd have interestingly raised issues of equity that have been revealed by distance and emergency learning efforts -the work of inclusive education remains critical. this paper has described the current context of inclusive education policy in canada, with the specific example of our developmental evaluation of the implementation of inclusive education reform in nova scotia. situated within the national canadian context, the example of nova scotia is both typical and unique. as with most other provinces and territories, inclusive education policy in nova scotia has broadened to include a lens of equity, and to include a focus on not only students with special education needs, but all students -particularly those most often marginalized by and within canadian school systems. the inclusion policy currently sits alongside special education policies and procedures -which is also typical of most provinces and territories. recent inclusion policies reflect both a social and educational justification for inclusive education -a need for a just and equitable society where all students have opportunities to succeed, as well as a belief that in universally designing education, we can ensure the needs of some with the benefits for all. according to ainscow ( , p. ) , progress in relation to inclusion and equity…requires new thinking which focuses attention on the barriers experienced by some children that lead them to become marginalized as a result of contextual factors. the implication is that overcoming such barriers is the most important means of development forms of education that are effective for all children. in this way, inclusion becomes a way of achieving the overall improvement of education systems. in assessing and informing equity and inclusion efforts, many systems are beginning to collect and examine achievement and wellbeing data. nova scotia students performed similar to the canadian average on most of the elements of the most recent pisa despite unique challenges associated with poverty. canada's performance is often lauded as reflective of equity alongside excellence. a deeper exploration at a provincial level, however, reveals that academic success and wellbeing are experienced differentially according to self-identification as african nova scotian, mi'kmaq, lgbtq + or with a disability. the success for all approach espoused in many of canada's equity and inclusion policies, including that of nova scotia, needs to also reflect that "all" students do not have the same opportunities and possibilities provided to them within schools and societies. the disaggregation of data that has become commonplace within nova scotia education can facilitate ongoing attention on equity issues. most provinces are not yet engaging with this type of data analysis and public sharing of results (campbell ) . however, while the availability of data can inform discussions and planning, it is the action -the interventions and subsequent shifts in beliefs and local and systemic practices that can lead to change in student opportunities. a focus on local application is key in exploring, and in our case evaluating, the implementation of policy (datnow et al. ) . the mere act of inviting and funding a -year developmental evaluation reflects a recognition on the part of the nova scotia government that drawing on evidence and a reflexive process throughout the implementation of this type of policy is a high priority. our presence in the province, including regular discussions with leaders within the eecd and regions, as well as teachers, principals and other school staff, serves as one thread of the implementation. we provoke sharing of understandings, beliefs and practices related to inclusive education which can be personally impactful for participants but can also lead to subsequent shifts in policy implementation as findings are shared with the eecd. in nova scotia, as in many other jurisdictions, regional differences need to be reflected in policy implementation in the same way that student diversity is increasingly being considered in classrooms and schools (smit ) . our initial data reveals consistency and disparities with and across regions with regards to understandings of the policy and its implementation; this is in part related to the role of the participant -whether system leader or classroom teacher -and expected due to the emergent nature of the policy at this point. it also reflects the varied readiness of each region with respect to the policy and the sensemaking engaged in by participants (snodgrass rangel et al. ; spillane et al. ) . the shift in roles and identities of educators and specialized staff as key to the implementation of this policy, and the need for responsive and collaborative supports encircling the tier "common learning environment" emerged as powerful themes in our initial findings. concerns regarding these changes were related to confusion regarding process but also to identity questioning -reflecting the emotional dimension of educational change (datnow ; hargreaves ) . the professional learning that so often accompanies any discussion of inclusive education reform (cumming et al. ; turnbull and turnbull ) was also highlighted time and time again by participants -a greater and more varied skill set, and one that is shared with and across educators was seen as essential to policy implementation. existing research is replete with examples of the power of collaborative structures and communities that support educators in shifting in response to required reforms, particularly when leaders champion and model such work (ainscow ; butler and schnellert ; datnow ; hargreaves and o'connor ; schnellert et al. ). the participants we engaged with reflected more senior positions in the system and spoke of individual learning they perceived as required on the part of teachers -the need for collective learning and development was also evident in our analysis (fullan and hargreaves ) . examining the potential power of teachers as leaders with a voice in change (hargreaves and shirley ) will be important in our ongoing work in nova scotia; facilitated in part by the greater inclusion of the voices of teachers as participants and hopefully those of students and families as well. our work in nova scotia continues over the next two years and the policy is slated to be implemented province-wide in the fall of . however, schools in nova scotia are planning for the school year ahead within similar constraints to those faced by education systems worldwide -school closures and social distancing requirements that may be in place for some time due to the covid- pandemic. the developmental evaluation 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publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. whitley is an associate professor of inclusive education at the university of ottawa. her research and teaching are driven by a dedication to improving the school experiences of all students and teachers. her research focuses on mental health literacy, inclusive education policy, teacher preparation for inclusive education and the wellbeing of children and youth with mental health issues. she conducts research in partnership with colleagues at universities across canada and engages collaboratively with community organizations including crossroads children's mental health centre. jess is part of the canadian research centre on inclusive education and an associate of inclusive education canada, as well as the centre for research on educational and community services. in her teaching, she aims to best prepare future teachers of inclusive classrooms and further develop the skills and knowledge of graduate-level learners.trista hollweck is a part-time professor and a project director for the international arc education project, faculty of education, university of ottawa. she is a pracademic who straddles the worlds of research, policy and practice. trista is a former teacher, vice-principal and school district consultant at the western quebec school board. her doctoral dissertation examines a school board teacher induction, mentoring and coaching program and its systemic change implications. trista teaches, researches and publishes about restorative justice, professional learning and development, teacher evaluation, systemic change, mentoring and coaching, teacher induction, as well as pandemic pedagogies and professionalism. trista received her bachelor of arts from mcgill university, her post graduate certificate of education (pgce) from moray house at the university of edinburgh, her master of education from the ontario institute for studies in education (oise) of the university of toronto, and her doctorate from the university of ottawa. key: cord- -wjsyun i authors: draper, jon; murray, cate title: stem cell network date: - - journal: stem cell res doi: . /j.scr. . sha: doc_id: cord_uid: wjsyun i nan in just under two decades the stem cell network (scn) has transformed stem cell research in canada and established an outstanding international reputation. as canada's only national network and leader for stem cell research and regenerative medicine, scn has led the way in building a vibrant sector that is yielding scientific advancements, fuelling clinical trials and enabling company creation. scn's mandate has remained the same since its inception: to act as a catalyst for enabling the translation of stem cell research into clinical applications, commercial products and public policy. today, scn is driven by a new vision to capitalize upon canada's competitive advantage in stem cell research for the benefit of canadians. those within the network are guided by a core set of values that permeate day to day activities and overall direction. scn is a not-for-profit organization funded by the government of canada. scn has invested $ m into stem cell research taking place across canada. these funds have benefitted world-class research teams. a significant number of women make up the ranks of scn's investigator community, with percent of projects funded by scn in the period to april led or co-led by women. scn's community is comprised of canada's best and brightest stem cell and researchers (e.g. biologists, chemists, bio-engineers, clinicians, policy and legal experts) and their trainees. the network also benefits from partnerships with industry, research institutes, universities and the charitable sector. these partners are key to building on scn research investments and to date they have invested more than $ m of in-kind and cash support directly into scn projects.  require research excellence, integrity and a commitment to ethical practice;  fostering collaboration;  fostering equity, diversity and inclusion;  driving innovation; and  supporting continual learning and development when scn was first launched in , the stem cell research community was scattered and siloed across the country. the network started with a small group of approximately investigators. canada's stem cell science enterprise was in its infancy and knowledge just starting to build. scn's leaders knew that to be successful, partnerships and strong networks would be critical. over the years, scn has worked tirelessly to build a robust national network through programs that stressed collaboration and a multidisciplinary approach for moving stem cell science forward. such collaborations led to numerous discoveries by canadian investigators (see appendix ). as the field matured, scn helped to spinout enabling organizations such as ccrm to support investigators who were generating intellectual property and needed assistance with commercialization strategies and cell manufacturing. in - , scn was part of the formation of cellcan, a knowledge mobilization centre designed to support the development of cell therapies and enable best practices among canada's cell manufacturing facilities. today, organizations such as the ontario institute of regenerative medicine and biocanrx are based on the stem cell network model. scn is proud to work with each of these organizations to enable high-quality research, training, outreach and innovation. scn is proud to be an on-the-ground network able to adjust as the science develops. in its current phase of activity scn is focused on supporting translational research and clinical trials. scn research is peer reviewed by international experts and the network's research management committee. funding decisions are confirmed by scn's -member independent board of directors. for the - period scn is providing research support ($ m+) through a strategic set of research programs described below:  advancing clinicals trials: focusing on novel cellular or stem cell related therapeutic approaches to tissue repair and regeneration for specific diseases.  accelerating clinical translation: supports multidisciplinary research projects that are moving toward the clinic within five years.  fuelling biotechnology partnerships: supports academic partnerships with emerging canadian regenerative medicine biotechnology companies working to drive an innovative stem cell-based technology or therapy into the clinic/market.  translation & society team awards: supports elsi-led (ethical, legal and social implications) research address issues that impede the translation of innovative stem cell research scn has led the way in building multidisciplinary networks, generating industry partnerships, training the next generation of scientific talent and enabling knowledge mobilization. as a result, canada's stem cell research community is second to none. dr in early , canada, like all countries around the world, faced the impacts of the sars-cov virus. in response, the stem cell network quickly launched a rapid response research initiative to support projects that would seek to address covid- using a stem cell-based approach. scn funds were allocated for one clinical trial and two innovative research projects. the clinical trial is evaluating the safety of a cell therapy to reduce the impacts and severity of acute respiratory distress syndrome (ards) associated with covid- , and the two research projects are generating knowledge about how cells in the airway and brain are affected by the virus. since its inception scn has invested in over research projects, including early stage clinical trials. this support has helped numerous canadian researchers, who rank among the highest impact in the world. in , principal investigators of the stem cell network were among the one hundred most highly cited researchers in the field, globally. the stem cell network has hosted an annual scientific meeting for many years. over time, these meetings have expanded and now bring together up to experts from across canada and around the world. they have also been re-named the till and mcculloch meetings (tmm), after drs. james till and ernest mcculloch, the two canadians who demonstrated the existence of stem cells in the early s. these meetings are an annual highlight for canada's stem cell research community and provide a key training opportunity for the next generation of stem cell researchers. the meetings include interactive workshops for trainees (masters students, phd students and postdoctoral fellows) on subjects such as scientific communication, commercialization and grant writing). the meetings also give trainees an opportunity to present their work through oral presentations and poster sessions. as scn works to respond to the needs of its community, small meetings and training workshops are designed and offered on annual basis according to need. each year, scn strives to provide up to a dozen training workshops that cover everything from lab-based technical skills, to understanding commercialization and how to take a discovery to the clinic. these events are highly popular, and scn is able to provide - training support opportunities annually. of particular interest was a new training activity offered in january entitled, navigating the regulatory steps in biotherapeutic translation. this unique offering brought lab teams (a senior investigator and two trainees) together for . days to learn from experts about the necessary steps for translating research discoveries into a clinical trial. participants learned about canada's regulatory landscape, challenges of reproducibility, and requirements for cell and virus manufacturing. overall, participants found this workshop to be extremely valuable for moving their specific research projects forward and also for creating 'lab memory.' more information about the impact of scn training and the career trajectories of trainees can be found in a / study conducted by scn, available at stemcellnetwork.ca/about-us/reports/. scn also provides support to bring groups of researchers together to discuss issues of particular interest or importance. for example, scn has provided support for relevant investigators to meet and discuss how best to use stem cells in the fight against type diabetes. in , scn convened a series of policy workshops focused on genetic reproductive technologies relevant to canada's assisted human reproduction act (ahra). in late , scn will convene canada's policy community to consider the notion of 'serious' disease, a concept that carries with it significant ethical, legal and financial implications. everywhere we look today -in online, traditional and social media, and among patient groups, families and health care providers -stem cells are a hot topic of discussion. they have become synonymous with the promise of better health. scn believes in this promise! however, we know that it will take time, effort and greater knowledge before innovative new treatments will be widely available. in the meantime, unscrupulous providers offering unproven stem cell treatments are taking advantage of vulnerable people. scn receives inquiries on a weekly basis from members of the public who are looking for a stem cell treatment that will cure their loved one. as such, over the years scn and its partners have produced plain language videos about stem cell research, launched an interactive traveling museum exhibit (experienced by over a million people), and developed online content providing lay-friendly information about stem cells. in recent years, scn has held events for stem cell researchers to present to legislators and science policy experts about the state of stem cell science and the risks associated with unproven treatments. it is clear that the stem cell network voice can't do it alone, so the network collaborates with isscr and researchers from around the world in sharing information and calling for ethical practices. thanks in part to the work of members of canada's stem cell network, in health canada started to take decisive action against those individuals and businesses who offer unregulated therapies and treatments. scn is also committed to encouraging young canadians to take up a career in health research. scn has been a partner of let's talk science for the past decade in offering stemcelltalks, an interactive program for high school students that takes place in major centres across canada. it connects scn researchers and senior high school students in day-long symposia to discuss the ethics, advancements and opportunities and challenges in the field of stem cells. canada's growing knowledge economy is dependent on a robust science and technology enterprise, one where highly-skilled workers are able to generate the knowledge, discoveries, technologies and other types of innovation that will spur productivity. scn has the track record, expertise and ability to continue to deliver on the promise and power of stem cells. the network will continue to provide leadership and work with like-minded organizations, industry partners and governments to develop a path forward that will see regenerative medicine flourish. in the years to come a focus on training talent, accelerating clinical trials, collaborating globally, building manufacturing capacity, and working with receptors and patients on the delivery of effective and affordable therapies will be at the heart of all that we do. this will be achieved through a culture that embraces equity, diversity and inclusion, and above all supports research excellence. in vitro analyses of suspected arrhythmogenic thin filament variants as a cause of sudden cardiac death in infants proneurogenic ligands defined by modeling developing cortex growth factor communication networks hematopoietic stem cell transplantation using single um -expanded cord blood: a single-arm, phase - safety and feasibility study reversal of diabetes with insulin-producing cells derived in vitro from human pluripotent stem cells appendix : reference list of recent high impact papers supported by scn key: cord- -jtj authors: yassi, annalee; gilbert, mark; cvitkovich, yuri title: trends in injuries, illnesses, and policies in canadian healthcare workplaces date: - - journal: canadian journal of public health doi: . /bf sha: doc_id: cord_uid: jtj background: analysis of workers’ compensation data and occupational health and safety trends in healthcare across canada was conducted to provide insight concerning workplace injuries and prevention measures undertaken in the healthcare sector. methods: timeloss claims data were collected for – from the association of workers’ compensation boards of canada. labour force data from statistics canada were used to calculate injury rates. the occupational health and safety agency for healthcare in british columbia coordinated with provincial occupational health and safety agencies in ontario, quebec and nova scotia to analyze injury data and collate prevention measures in their regions. results: the national timeloss injury rate declined from . to . injuries per personyears since . musculoskeletal injuries consistently comprised the majority of timeloss claims. needlestick injuries, infectious diseases and stress-related claims infrequently resulted in timeloss claims although they are known to cause great concern in the workplace. prevention measures taken in the various provinces related to safer equipment (lifts and electric beds), return-to-work programs, and violence prevention initiatives. different eligibility criteria as well as adjudication policies confounded the comparison of injury rates across provinces. discussion: since , all provinces experienced healthcare restructuring and increased workload in an aging workforce. despite these increased risks, injury rates have decreased. attribution for these trends is complex, but there is reason to believe that focus on prevention can further decrease injuries. while occupational health is a provincial jurisdiction, harmonizing data in addition to sharing data on successful prevention measures and best practices may improve workplace conditions and thereby further reduce injury rates for higher risk healthcare sector occupations. h ealthcare workers (hcws) have greater risk of workplace injuries and mental health problems than many occupational groups in canada; nursing personnel also have considerably more sick time than personnel in most other occupations. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in , the timeloss injury rate for all hcws was . injuries per person-years compared to . for all bc industries. similar to other jurisdictions, disaggregating the long-term care (ltc) occupations from all hcw occupations revealed that nursing aides had very high injury rates ( . per person-years), with registered nurses also having higher than average rates ( . per person-years). this article provides an overview of trends in workplace injuries and prevention measures in the healthcare sector across canada. reviews note that hcws face substantial occupational risks from exposure to poor ergonomics associated with patient care; patient violence; and exposure to allergens and infectious agents. for example, it is well established that musculoskeletal injuries (msi) occur due to equipment and environmental inadequacies, high work demands, inadequate staffing, poor work morale and low social support. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] nursing personnel report msi prevalence as high as % for upper-body and % for lower-body symptoms. [ ] [ ] [ ] [ ] [ ] [ ] [ ] psychological distress has been linked to patient violence/aggression, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] high workload [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and stress. skin and respiratory disorders are concerns due to exposure to irritants as well as a large variety of substances known to cause skin or respiratory sensitization. [ ] [ ] [ ] [ ] [ ] [ ] infectious diseases including tuberculosis, influenza, severe acute respiratory syndrome (sars), hiv and hepatitis are also of concern. - creating "healthy workplaces" to support worker well-being, retain personnel, and ultimately ensure high-quality patient care is therefore increasingly being promoted. [ ] [ ] [ ] [ ] [ ] [ ] health canada commissioned this study to obtain an overview of trends in workers' compensation claims and provincial-level prevention initiatives in order to gain insight into successful strategies for improving working conditions in healthcare. the occupational health and safety agency for healthcare (ohsah) in bc coordinated all data collection and analysis with partner occupational health and safety provincial associations in each respective region (see acknowledgement section). timeloss injury and occupational disease data for - were collected from the national work injuries statistics program (nwisp) compiled by the association of workers' compensation boards of canada (awcbc). labour force data from statistics canada were used to determine workforce size for each province and to calculate provincial injury rates expressed per person-years. healthcare labour force data from statistics canada's socio-economic database were only available by two occupational groupings. injury rate determinations were limited to: "healthcare professionals" and "technical, assisting and other related occupations". where applicable, injury 'frequency' analyses were provided from nwisp data for the three occupational groupings defined by the standard occupation code (soc ), "nurse supervisors and registered nurses", "other technical occupations in healthcare", and "assisting occupations in support of healthcare". collaborating agencies in the provinces provided a chronology of regulatory changes and prevention measures implemented in each province in their region. during - , injury rates in healthcare across provinces ranged from . (table i) . injury rate reductions may indeed be attributable to prevention programs, whether initiated from government or from within the sector itself, but injury rates are also influenced by socio-economic factors including labour relations issues and adjudicative policy trends. ontario's time-loss injury rate trends may suggest the impact of prevention measures ( figure ) . similarly, bc's positive results seem to be at least partially attributable to the formation of ohsah, a bi-partite health and safety agency ( figure ) . while comparison of rates across provinces is problematic due to substantial provincial differences in coding, reporting, and adjudication criteria for timeloss claims, there are major injury rate differences across occupational groups in all provinces (see figure for definitions). the "healthcare professionals" injury rate is almost half that of the "technical, assisting and others". injury frequency patterns for these "assisting occupations" show that ontario, bc and quebec all saw steady declines in injuries from to , with injuries for ontario and bc levelling off, but injuries for quebec beginning to rise again each year after . all other provinces recorded relatively stable injuries per year from to . each province experienced modest yearly fluctuations in rates, but alberta saw a dramatic increase from almost no injuries in and for rns, to more than reported injuries per year thereafter. musculoskeletal injuries (msi) consistently comprised the majority of timeloss claims in each province. from to , saskatchewan, prince edward island (pei) and bc had average msi rates above . injuries per person-years; manitoba, newfoundland/labrador, quebec and nova scotia had msi rates from . to just above . ; and alberta, ontario and new brunswick had msi rates at . or below. the multiplicity of different msi codes confounds the comparison of msi rates across provinces, making detailed comparisons very difficult. for example, bc and alberta disaggregate msis according to connective tissue diseases (noi code ) and traumatic injuries to muscles, tendons, ligaments and joints (noi code ), carpal tunnel syndrome (code ) and back pain (code ). in quebec, back pain is underestimated with awcbc data because many * the labour force survey (lfs) data for this project were a -month average of the total number of hours usually worked by all employed persons in the lfs reference weeks. in order to annualize the size of the workforce, the total weekly hours was multiplied by (weeks in the year). this report used , hours as the yearly equivalent of productive hours. ** injury rate is reported as injuries per person-years. provincial injury rates ( ) ( ) ( ) ( ) ( ) ( ) ( ) source: awcbc and cansim cases are coded as 'sprains' without indicating the part of body affected. violence-related injury is an emerging concern (as much as . incidents per person-years) although most of these injuries do not result in timeloss (less than . claims per person-years). the most prevalent injury in this category consists of 'surface wounds' such as abrasions and bruises. the majority of provinces, with the exception of pei, bc and manitoba, experienced minimal changes in the rate of violence-related injuries (timeloss and non-timeloss) from to . access to "no timeloss" claims data in every province is necessary to provide a better indication of the overall severity of this issue. pei went from having the lowest reported provincial violence frequency rate in and to the highest from through . there is wide inconsistency among provincial wcbs in categorizing infectious disease claims, and this category comprises only a small proportion of all timeloss claims. provincial rates ranged from . to . timeloss claims per personyears. infectious diseases claims are rarely filed although they are associated with stress, especially within the context of sars and hiv. puncture wounds as a proxy for needlestick injuries ranged from less than . to . claims per person-years across provinces for - . research on this subject indicates that needlestick incidents are largely under-reported, yet are an ongoing concern for healthcare workers. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the low rate reflects the fact that needlestick injuries do not generally result in accepted timeloss claims; in addition, coding may be problematic. with regard to accepted stress, anxiety, and other mental disorder timeloss claims, only bc, ontario, quebec and alberta had sufficient data to comment on trends. most wcbs only recognize mental health claims that occur following a traumatic event (i.e., post-traumatic stress). quebec and bc reported a substantially higher claim rate than the other two provinces. in ontario, % of all stress-related claims were related to violence, with a steady increase in post-traumatic stress from to . quebec saw a steady reduction in stress, anxiety and mental disorder claims from . to less than . claims per person-years during the same time period. the most common prevention measures implemented across provinces were related to safer equipment (such as lifts and electric beds), msi prevention programs, return-to-work programs, and violence year prevention programs. with the implementation of these programs, many provinces reported an initial drop in injury frequency, for example in ontario around - with a gradual increase thereafter (see figure ). collaborating agencies in all regions reported that since , each province has experienced an increased prevalence of factors that are known to contribute to risk of injury, including healthcare restructuring and increased workload in an aging workforce. , , [ ] [ ] [ ] [ ] , , , this suggests that while there has been an increased focus on prevention and safety programs, the impact of these efforts may have been undermined by increased risks within the healthcare sector. it is likely that injury rates would have increased substantially rather than decreasing marginally, as was the case from to , had it not been for the emphasis on prevention. however, we do not have data to substantiate this hypothesis. there are different eligibility criteria, adjudication policies and practices across the country that affect the likelihood of a claim being accepted or even reported. for example, acceptance of repetitive strain injuries (rsi) is inconsistent. there are also different rules concerning when an injury "counts" as a timeloss injury. for example, the waiting period before compensation may vary from: days in new brunswick; an average of days in nova scotia; and the following day in newfoundland/labrador, quebec and ontario. levels of compensation payments also differ across provinces, which may influence the incentive to submit claims. these factors preclude the reliability of any conclusions comparing rates across provinces. available data were not disaggregated to the level of specific occupations and inter-provincial comparisons of occupational groups proved problematic since the occupational mix within the broad categories varies among provinces. msis comprise the majority of healthcare sector timeloss claims in every province, primarily occurring during direct patient care activities. while many strategies have been implemented to specifically target patient/resident care issues, msi risks are still prevalent and still require attention. needlestick injuries and infectious diseases make up only a small proportion of timeloss claims. however, studies have shown that even before the sars outbreak, exposure to infectious agents, including bloodborne pathogens, was associated with anxiety from fear of contracting a fatal disease. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the very serious risks of infectious diseases must not be disregarded because of the scarcity of timeloss claims due to these conditions. mental stress also accounts for very few timeloss claims, even though numerous national surveys and studies suggest that burnout and mental stress are increasing problems in healthcare. the paucity of mental health timeloss claims undoubtedly relates to criteria governing acceptance of such claims. injury and illness rates vary considerably within the healthcare sector by province, occupational group, and injury/illness type. cross-provincial comparisons are confounded not only by different adjudicative policies but by different coding practices. the harmonization of workers' compensation data would facilitate the evaluation of prevention measures for reducing workplace injuries and improving working conditions. labour force data disaggregated by occupational category is especially important to facilitate injury analyses since risks differ for occupations within large groupings (e.g., rns and physicians are in the same group yet their risks differ widely). injury tracking would be more feasible if wcb data included: time of incident (enabling analysis by staffing level); type and size of healthcare workplaces (facilitating comparisons); and demographics (enabling the analysis of the impact of an aging work force). sharing data across provinces should be encouraged regarding the effectiveness of programs, policies and interventions that impact positively on reducing injury, illness and disability. there are several successful programs to track injuries (including data collection tools for needlestick, msi and other types of injuries). it is recognized that occupational health and safety is within provincial jurisdiction and each wcb will always have provincial criteria concerning adjudication. cross-sectional surveys (e.g., those proposed by health canada, statistics canada and the canadian institutes for health year information for nursing personnel) would be useful adjuncts, especially in areas such as mental health. ideally, longitudinal studies linking survey data with comprehensive healthcare utilization data and other linked data, would provide the best monitoring tool for the analyses of trends and the effectiveness of interventions. there is growing recognition that the health and safety of hcws needs attention. improved integration of occupational health and safety programs into the orientation and job description of hcws may result in improved work conditions and quality patient care. further research in this area is warranted. résultats : depuis , on a noté un déclin dans le taux de lésions professionnelles (pour travailleurs par année) au niveau national de , a , . les troubles musculosquelettiques constituaient la majorité des réclamations pour jours de travail perdus dans chaque province. les réclamations liées au stress, à des piqûres accidentelles avec des aiguilles et à des maladies infectieuses donnaient peu fréquemment lieu à des jours de travail perdus, bien qu'il s'agisse d'incidents reconnus pour causer d'importantes préoccupations en milieu de travail. les mesures préventives prises par les diverses provinces avaient trait à de l'équipement plus sécuritaire (lèvepersonne et lits électriques), des programmes de retour au travail et des initiatives de prévention de la violence. la différence dans les critères d'admissibilité et la politique d'indemnisation rendait difficile la comparaison des taux de lésions professionnelles entre les provinces. discussion : depuis l'an , toutes les provinces ont connu une restructuration du secteur de la santé et une charge de travail accrue, dans un milieu où la main-d'oeuvre est vieillissante. or, malgré des risques accrus, le taux de lésions professionnelles a diminué. les motifs à l'appui de ces tendances sont complexes, mais tout porte à croire que mettre l'accent sur la prévention peut réduire le taux de lésions professionnelles. bien que les questions de santé au travail relèvent des provinces, l'harmonisation des données de même que le partage de données sur les mesures préventives fructueuses et les meilleures pratiques pourraient sans doute améliorer les conditions en milieu de travail et, partant, réduire davantage le taux de lésions professionnelles dans les professions à risque élevé du secteur de la santé. work organization and patient care staff injuries: the impact of different care models for "alternate level care" patients occupational health and safety agency for healthcare (ohsah), workers' compensation board of british columbia. reducing injuries in intermediate care. risk factors for musculoskeletal and violence-related injuries among care aides and licensed practical nurses in intermediate care facilities. final report -community alliance for health research (cahr) project # factors associated with staff 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arthritis and associated joint disorders in an employed population and the associated healthcare, sick leave, disability, and workers' compensation benefits costs and productivity loss for employers national work injury statistics program: association of workers compensation boards of canada patterns and risk factors for sprains and strains in ontario, canada : an analysis of the workplace health and safety agency database the prevalence and cause of occupational back pain in hong kong registered nurses work-related factors of low back pain among nursing aides in nursing homes for the elderly an ergonomic evaluation of nursing assistants' job in a nursing home epidemiological aspects of back pain: the incidence and prevalence of back pain in nurses compared to the general population manual handling activities and risk of low back pain in nurses evaluation of physiological work demands and low back neuromuscular fatigue on nurses working in geriatric wards back injury among healthcare 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surveillance of healthcare workers exposed to blood/body fluids and bloodborne pathogens annual number of occupational percutaneous injuries and mucocutaneous exposures to blood or potentially infective biological substances. international health care worker safety center risky procedures, risky devices, risky job epidemiology and prevention of occupational transmission of bloodborne pathogens through percutaneous injuries occupational transmission of hepatitis c virus hepatitis c virus infection in healthcare workers: risk of exposure and infection exposure rates to patients' blood for surgical personnel references . alter da, eny k. the relationship between the supply of fast-food chains and cardiovascular outcomes systolic and diastolic blood pressures and urinary sodium excretion in mainland china dietary patterns in groups and the relationship with blood pressure. collaborative study group for cardiovascular diseases and their risk factors cardiovascular disease in china the current state of cardiology in china to the editor: i read with interest the recent report that inter-regional cardiac outcome disparities throughout ontario were partially explained by fast-food service intensity. such an association has also been demonstrated in china, especially with regard to hypertension. , zhou et al. showed a close relation between daily urinary sodium excretion and blood pressure in mainland china ( figure ). in general, blood pressure and urinary sodium excretion as a measure of sodium intake tended to be higher in northern china, e.g., beijing (formerly called peking), and shijiazhuang than in southern china, e.g., guangzhou (formerly called canton). of note was the observation that, in guangzhou, a study showed a gradual rise of blood pressure as compared with a study, associated with a corresponding increase in urinary sodium excretion. the increase in sodium intake between these two surveys coincided with the rise in the number of american fast food restaurants, such as mcdonald's and kentucky fried chicken, that had opened in guangzhou during that period. key: cord- -lwr rcap authors: chen, innie; bougie, olga title: women's issues in pandemic times: how covid- has exacerbated gender inequities for women in canada and around the world date: - - journal: j obstet gynaecol can doi: . /j.jogc. . . sha: doc_id: cord_uid: lwr rcap nan d espite progress in women's issues in recent decades, there is concern that the covid- pandemic has accentuated existing disparities, causing a reversion to traditional gender roles and adversely affecting the health of many women in canada, with possible long-lasting physical, psychological, social, and economic effects. from february to april , statistics canada reported that employment decreased by . % for women compared with . % for men. even more disparate is the employment recovery statistic from april to may: the rate of unemployment fell by . % for men and only . % for women. even before the pandemic, women were more likely to work part-time, were more likely to work in support and retail positions, and were subsequently more likely to become unemployed due to closures. furthermore, women were earning less for similar jobs, were saving less, and were more likely to provide unpaid care work compared with men; they were thus more likely to give up their jobs to fulfill household duties. such examples of worsening gender inequities since the arrival of the pandemic may be partly compounded by the lack of supportive services that had previously enabled women to work. with the suspension of many care services, such as childcare, senior care, and assistance with domestic duties and meal preparation, the additional household demands have disproportionately fallen to women. for women who have retained their jobs, additional stress is to be expected as they attempt to balance work and household, potentially resulting in decreased work productivity. one report, for example, found a dramatic decrease in publications submitted to academic journals by female authors compared with their male counterparts. in addition to bearing the brunt of social and economic losses from the pandemic, women appear to be disproportionately negatively affected in terms of physical health and well-being. although men are at higher risk of severe disease and death when infected with covid- , a higher proportion of women in canada are becoming infected and are dying as a result. as of june , , public health agency of canada weekly updates report that % of covid- infections and % of deaths are among women. although this may in part be due to the higher proportion of women in long-term care homes, it also points to the larger proportion of women in health care professions and service-oriented jobs, with associated exposure to covid- . there is global alarm as countries around the world are seeing reports of gender-based violence increase by % to %. in canada, there has been an uptake in use of women's emergency shelters, and in the united kingdom, a twofold increase in deaths from domestic violence was reported within a -week period. it is likely that the unprecedented scale of the stay-at-home advisories have resulted in increased tensions in household relationships and social isolation from friends, family, and support networks. as such, there is a greater need than ever for women's health care providers to recognize and provide support to the women affected by gender-based violence whom they may encounter in clinical practice. the various economic, social, and physical stressors that women face during the pandemic are undoubtedly having an adverse impact on mental health as well. one study found a much larger decline in women's subjective mood during the pandemic compared with men. although a gender gap existed in mental health before the pandemic, it increased by % from late march to mid-april. given these multiple contributors to gender disparity, our specialty needs to be especially concerned about safe and timely access to women's health services. because women have been more adversely economically affected by the pandemic, they may be reluctant to seek medical attention owing to an inability to take time off work. women may also not be able to afford some appointment-related costs, such as transportation fees, the cost of the digital technologies required for virtual visits, or the costs of medication or other treatments. with schools and daycares being closed, the limited availability of childcare options may be another barrier to women attending health care visits, as social distancing measures often prevent women from bringing children to appointments. moreover, because of the increased social isolation and decreased mobility and household privacy resulting from large-scale stay-at-home orders, women's autonomous decision-making over reproductive choices may be further compromised. thus, women affected by gender-related violence may face restricted choice and access regarding their reproductive health. within the health care system, a number of services for women's reproductive health have faced closures or restrictions. services provided by many primary and specialist clinics have remained significantly reduced, which may result in inadequate assessment and treatment for a variety of conditions that necessitate in-person visits, such as testing and treatment of sexually transmitted infections, cervical cancer screening, treatment of cervical neoplasia, endometrial biopsy, and other important laboratory or imaging tests. in some jurisdictions, pharmacies have restricted medication dispensing to monthly intervals, resulting in increased dispensing fees and more potential for interruption of medication use. there is also concern for drug shortages of certain reproductive care medications, such as the mifepristone−misoprostol combination for medical termination of pregnancy. even before the pandemic, scarce attention was paid to women's menstrual and pain disorders. the provision of care for chronic, noncancerous gynaecologic conditions in pandemic times may be further deprioritized as resources are reallocated to the pandemic response, resulting in additional deterioration of women's health, productivity, and quality of life. as a woman-oriented specialty with good representation of women in its governance, the society of obstetricians and gynaecologists of canada is well positioned to advocate for gender equity in canada and around the world. to this end, our society has issued a number of statements and guidance documents to help mitigate the impact of covid- on women's health services. the federal government has also moved to protect women's reproductive rights by deeming abortion an essential service, even as jurisdictions elsewhere have restricted access, and has allocated funding to support women at risk of gender-based violence. although these measures acknowledge the extra burden that women bear during the pandemic, they are not enough to correct the deep-rooted issues of gender disparity within our societies. as a community of dedicated and caring health care providers for women, the obstetriciangynaecologists of canada must continue to advocate for the long-lasting systemic changes that are needed at all levels of society to ensure gender equity for women, especially during pandemic times. statistics canada. covid- and the labour market in may. available at women's research plummets during lockdown -but articles from men increase. the guardian public health agency of canada. covid- in canada-coronavirus disease weekly epidemiology update-update policy brief: the impact of covid- on women the impact of the coronavirus lockdown on mental health: evidence from the us. human capital and economic opportunity working group contraception consensus: updated guidance during pandemics and periods of social disruption key: cord- -e itktq authors: adisesh, anil; durand-moreau, quentin; patry, louis; straube, sebastian title: covid- in canada and the use of personal protective equipment date: - - journal: occup med (lond) doi: . /occmed/kqaa sha: doc_id: cord_uid: e itktq nan on january , the world health organization (who) declared the coronavirus disease (covid- ) outbreak a public health emergency of international concern and on march it was declared a pandemic by the who director-general, dr tedros ghebreyesus. in his speeches dr ghebreyesus first called on countries to, 'review preparedness plans, identify gaps and evaluate the resources needed to identify, isolate and care for cases, and prevent transmission' [ ] . when declaring the pandemic, he urged countries to, 'communicate with your people about the risks and how they can protect themselves -this is everybody's business; find, isolate, test and treat every case and trace every contact; ready your hospitals; protect and train your health workers. and let's all look out for each other, because we need each other' [ ] . the protection of healthcare workers (hcws), readiness of hospitals and protection of the public were clearly emphasized early by the who. canada's experience with the severe acute respiratory syndrome (sars) outbreak in led to the creation of the public health agency of canada (phac) [ ] . this organization monitors and responds to disease outbreaks that could endanger the health of canadians. the canadian government has contributed to international efforts to combat the covid- pandemic, supporting who efforts as well as implementing travel restrictions and issuing guidance to the canadian provinces and territories [ ] . since phac has produced a federal guideline entitled, 'routine practices and additional precautions for preventing the transmission of infection in healthcare settings' which provides a framework for organizations in developing policies and procedures [ ] . this document details the circumstances in which contact, droplet or airborne transmission precautions should be used. it lists specific micro-organisms including the virus responsible for sars, severe acute respiratory syndrome coronavirus (sars-cov), for which contact and droplet precautions are advised, except during aerosol-generating medical procedures, when airborne precautions are to be instituted. when respirators are used for airborne precautions (in the context of a full ensemble of appropriate personal protective equipment (ppe)), amongst instructions are, the importance of hcw being clean-shaven in the area of the face seal and that, in cohort settings, respirators may be used for successive patients. upon discharge of the patient or discontinuation of airborne precautions, the recommendation is that sufficient time should be allowed for the air to be free of aerosolized droplet nuclei before housekeeping staff perform terminal cleaning, or else the housekeepers should wear a respirator, again together with other appropriate ppe. there is also guidance on modification for long-term care, ambulatory care, home care and pre-hospital care settings. the routine practices and additional precautions lay out in some detail the ppe to be used together with descriptions of the different types of medical grade gloves, masks and respirators, and eye protection. contact precautions direct that in addition to the use of ppe as for 'routine practices', gloves should be used and long-sleeved gowns, where it is anticipated that clothing or forearms will be in direct contact with the patient or with potentially contaminated environmental surfaces or objects. these gowns should be cuffed and cover the front and back of the hcw from the neck to mid-thigh. the type of gown worn is based on the degree of contact with infectious material, potential for blood and body fluid penetration and the requirement for sterility. in the instructions for gown use it is mentioned that the cuffs of the gown should be covered by gloves. droplet precautions additionally specify facial protection (i.e. masks and eye protection, or face shields, or masks with visor attachment) should be worn: for the care of patients with symptoms of acute respiratory viral infection, or when within m of a patient who is coughing at the time of interaction, or if performing procedures that may result in coughing. airborne precautions are additional to the routine practices, contact and droplet precautions. as well as federal guidance, there is national guidance in the form of technical standards issued by the canadian standards association (csa) who in september provided an update to the document csa z . 'selection, use and care of respirators' [ ] . the standard covers the choice of respiratory protection for bioaerosols and adopts a control banding approach. it is noteworthy that if this approach were followed for exposure to sars-cov- , a biosafety risk group organism [ ], the choice of respiratory protection for any patient encounter for suspected or known covid- disease would be at least a filtering face-piece respirator. in north america, this would typically be an n respirator, european equivalent ffp . during the covid- pandemic, to assist in the response, the csa group have made their standards available at no cost. phac guidance has been in keeping with who recommendations [ ] with the consistent application of routine practices, and to follow contact and droplet precautions. when performing aerosol-generating medical procedures on a person under investigation (pui) for covid- , the use of an n respirator is recommended. canada usually tends to align closely with us practices, but it is notable that the guidance from the us centers for disease control and prevention (cdc) is different in recommending an n respirator in all situations for a patient suspected or known to have covid- [ ] . cdc only suggests use of a facemask if a respirator is not available. the availability of ppe has been a concern in canada, with notable differences across canadian jurisdictions. for example, alberta has been able to send supplies to others. in common with other countries, items stockpiled in canada have often been found to be many years past expiry, causing uncertainty about usability. consequently, a number of provincial efforts have been started to determine the functional performance of such ppe, including respirators. in tandem, efforts to explore the potential for reprocessing respirators and other ppe are also being undertaken. hcws have expressed concerns about the level of respiratory protection recommended when caring for pui and have used occupational health and safety legislation to challenge provincial standards [ ] . it seems that, in common with other countries, the long-term care homes have not been as well provided for as the hospital system although their residents were tragically vulnerable. compensation for the health effects and any deaths from covid- adjudicated to be acquired at work will be available from the provincial and territorial workers' compensation boards. the canadian workers' compensation system is a no-fault system which precludes any litigation against the employer where for instance it may be alleged that there was inadequate provision of ppe. the ministry of labour inspectors of each province or territory would address any such failings based on complaints or evidence presented. it is also these inspectors who would judge whether a worker's right to refuse what was perceived as unsafe work was justified or not. whilst the provision and use of ppe has certainly been, and remains, an issue during the covid- pandemic, canada has been well-served by having comprehensive guidance describing not only the minimum ppe provisions but that states, 'although the use of ppe controls are the most visible in the hierarchy of controls, ppe controls are the weakest tier in the hierarchy of controls, and should not be relied on as a stand-alone primary prevention program' [ ] . -ncov) director-general's opening remarks at the media briefing on covid- government of canada takes action on covid- canada's role in strengthening global health security during the covid- pandemic routine practices and additional precautions for preventing the transmission of infection in healthcare settings. public health agency of canada use, and care of respirators (can/csa-z . - ) sars-cov- (severe acute respiratory syndrome-related coronavirus ) infection-prevention-and-controlduring-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected- using personal protective equipment (ppe) canadian nurses treating covid- patients cite unsafe-work laws to demand n masks key: cord- -x gn wqv authors: oostlander, samantha a.; bournival, vanessa; o’sullivan, tracey l. title: the roles of emergency managers and emergency social services directors to support disaster risk reduction in canada date: - - journal: int j disaster risk reduct doi: . /j.ijdrr. . sha: doc_id: cord_uid: x gn wqv emergency managers (ems) and emergency social services directors (essds) are essential service providers who fulfill critical roles in disaster risk reduction. despite being positioned throughout all levels of government, and in the private sector, ems and essds fulfill roles which occur largely behind the scenes. the purpose of this phenomenological study was to explore the roles of ems and essds from different regions across canada. specifically, we wanted to understand their perceptions of barriers, vulnerabilities and capabilities within the context of their roles. ems (n= ) and essds (n= ) from six canadian provinces participated in semi-structured telephone interviews. through content analysis, five themes and one model were generated from the data: ) emergency management is not synonymous with first response, ) unrealistic expectations for a “side-of-desk” role, ) minding the gap between academia and practice with a ‘whole-society’ approach, ) personal preparedness tends to be weak, ) behind the scenes roles can have mental health implications. we present a model, based on these themes, which makes explicit the occupational risks that ems and essds may encounter in carrying out the skills, tasks, and roles of their jobs. identification of occupational risks is a first step towards reducing vulnerabilities and supporting capability. this is particularly relevant in our current society as increased demands placed on these professionals coincides with the increasing frequency and severity of natural disasters due to climate change and the emergence of the world wide covid- pandemic. in , the united nations released the sendai framework for disaster risk reduction reduction - , an international, action-oriented approach to achieving a reduction in disaster risks across economic, physical, social, cultural, and environmental domains (undrr, ) . canada, along with other countries, adopted the sendai framework, and the federal government has since released the emergency management strategy for canada: toward a resilient (public safety canada, ) . this complimentary strategy takes aim at canadian specific priority areas including: ) enhance whole-ofsociety collaboration and governance to strengthen resilience, ) improve understanding of disaster risks in all sectors of society, ) increase focus on whole-of-society disaster prevention and mitigation activities, ) enhance disaster response capacity and coordination and foster the development of new capabilities, and ) strengthen recovery efforts by building back better to minimize the impacts of future disasters (public safety canada, ). recommendations for achieving these priorities, and strengthening disaster risk reduction (drr), emphasize the need for investment in multi-hazard and multi-sectoral approaches, as well as increased resources and support for the public service workers who implement these approaches (undrr, ) . emergency managers (ems) and emergency social services directors (essds) are essential service providers who fulfill critical roles in drr. they carry out important tasks in positions throughout all levels of government and in the private sector, and their roles span all phases of the disaster management cycle: mitigation/prevention, preparedness, response and recovery (waugh, ; waugh & streib, ) . broadly, ems are responsible for reducing community vulnerabilities to hazards and planning for, and coping with disasters (public safety canada, ; iaem, n.d.-a). whereas, essds put in place supports that meet the essential needs of communities affected by emergencies/disasters (alberta government, ; jibc, n.d.) . despite the vital jobs of these professionals, emergency j o u r n a l p r e -p r o o f management departments are chronically underfunded and understaffed (howes et al., ; canadian red cross, ) . as more frequent and severe disasters occur due to climate change, the demands placed on ems and essds are growing. climate change poses a serious threat to human health and sustainable development (un, ) . the national capital region of canada (ottawa, gatineau and surrounding areas) alone has experienced substantial natural disasters in two years ( and ) due to flooding and tornadoes. many areas in canada cope with the aftermath of severe flooding and extreme forest fires in the warmer months, and snow storms and blizzards in the cooler seasons. this experience is not unique to canada. it is widely acknowledged that more frequent and severe disasters have become the new reality of the changing climate across the globe (ipcc, ) . the united nations have incorporated action against climate change within the agenda for sustainable development goals, with an emphasis on improving human and institutional capacity to reduce its negative impacts (un, ) . how the capacity of ems and essds is currently being supported amidst the increasing pressures due to climate change is not well understood. increasing demands on ems and essds comes with an increased risk of occupational stress that can impact both mental and physical health. it is well known that individuals involved in disaster-related work are at a higher risk of experiencing negative psychosocial impacts due to: exposure to traumatic events, high work demands, working with disrupted communities, and separation from loved ones at times of uncertainty (benedek et al., ) . these occupational stressors are more commonly associated with the roles of first responders, such as fire fighters, police officers, and emergency medical services (benedek et al., ) . however, less is known about how these stressors impact ems and essds in their day-to-day roles and what vulnerabilities they experience. our research seeks to add to the growing body of literature exploring disaster and emergency management practices in canada. this paper is part of a larger research program exploring the social construction of resilience in the context of disaster mitigation/prevention, preparedness, response and recovery. here we present findings from a qualitative phenomenological study where we explored the role of ems and essds from different regions across canada. specifically, we wanted to understand their perceptions of barriers, vulnerabilities and capabilities within the context of their roles. initial approval for this study was received in april and modified in march from the university of ottawa research ethics committee (#h - - ). data collection began in september of and was completed by april ; purposive and snowball sampling were used to recruit ems and essds from across canada. our sampling strategy was to recruit approximately people. participants were initially contacted by email and this information was obtained through publicly available websites. the inclusion criteria for participation was: ) hold an emergency management or emergency social services director-level title, which may or may not be held in conjunction with other titles; ) the emergency management or emergency social services title could be held for any length of time; ) reside in canada; ) work at any level of government (municipal, provincial, federal) or in the private sector; ) able to participate in an interview in either official language (french or english). data were collected in the form of -minute semi-structured telephone interviews, conducted by the first two authors (so and vb). participants provided informed consent to complete the interview and had the option to consent to being audio-recorded and quoted. when participants chose not to be audio-recorded, notes were taken to document the interview. the semi-structured interview guide consisted of open-ended questions developed in an iterative and collaborative process to facilitate a discussion of the role of em or essd, and specifically inquire about their perceptions of capability and j o u r n a l p r e -p r o o f vulnerability within the context of these roles. probes and prompts were used to clarify information provided by participants and the interview guide was modified as needed after interviews to improve clarity in question asked (tong, sainsbury, & craig, ) . data was generated until no new relevant insights emerged and saturation was achieved. the interviews were transcribed verbatim by one team member and checked for accuracy by a different team member. the transcripts were analyzed using line-by-line in vivo coding which was initially performed independently, and then concurrently by the first two authors using nvivo software. the coding grid was developed inductively, codes were mutually agreed upon and grouped in an iterative process by all authors (braun et al., ; braun & clarke, ) . inductive reasoning was used to develop themes from the coded transcripts (terry et al., ) . the emergent themes presented below represent the subjective experiences of the participants. in this study we sought to answer the following questions: what are the roles of emergency managers (ems) and emergency social services directors (essds) in canada? what are their perceptions of capabilities, vulnerabilities and barriers that exist within the context of these roles? the final narrative data set was generated with n= ems and n= essds, for a total of n= participants. these participants held a variety of titles; some examples include: emergency manager, emergency social services director, program manager for the emergency management office, emergency management using content analysis, five themes were identified and a model was created to highlight the reality of the day-to-day roles carried out by ems and essds: theme : emergency management is not synonymous with first response theme : unrealistic expectations for a "side-of-desk" role theme : minding the gap between academia and practice with a 'whole-society' approach theme : personal preparedness tends to be weak theme : behind the scenes roles can have mental health implications the day-to-day tasks that underpin em roles were highlighted in three different ways by participants: ) tasks were categorized as administrative or operational; ) tasks were determined by the location and level of the position (federal, provincial or municipal government, or private sector); and ) roles are distinct from those of first responders. the most recent years were described as a period of growth for the field of emergency management, particularly in terms of professional development. the tasks of ems can be understood as either administrative or operational. table consists of examples of administrative and operational tasks described by participants. both administrative and operational tasks could be carried out in any of the four phases of disaster management (mitigation/prevention, preparedness, response, and recovery), with a greater emphasis on operational tasks during the response and recovery phases. the descriptions of tasks that make up the em role varied by the location and level of the position within government or the private sector. at the federal level, surveillance-focused tasks were emphasized such as monitoring, collecting and sharing information. at the provincial level, providing guidance, direction and resources to the municipalities was highlighted. at the municipal level, action tasks were emphasized, and included the provision of services such as public education. in the private sector, providing guidance to government departments or other clients was the main focus. finally, ems compared and contrasted their roles with those of first responders. they described how first responders have well-known roles and high public visibility, while ems have lower profiles and receive less recognition in comparison. this is notably true when there is no obvious activation occurring in the community, and a greater period of time is spent completing administrative rather than j o u r n a l p r e -p r o o f operational tasks. the following quotations highlight some of the ways in which the profession of emergency management is different from first response. "police and fire are very much command and control, whereas emergency management is consult, facilitate and coordinate" (em) "first responders are used to getting in and getting out, they make sure life safety is good and then depart from the scene, and that is where emergency management really comes in" (em) participants highlighted a clear distinction between em and first responder roles but noted that many individuals who hold, or have held, first responder roles have the ability to transition into an em position. this was seen as both a benefit, in the experience and knowledge that these individuals bring to the role, and a limiting factor, as "the training that first responders receive often does not translate to the emergency management role" (em) . engagement in administrative tasks, such as prevention and planning activities, business continuity planning and stakeholder engagement were particular areas noted to require a different skillset when compared with operational duties. to reduce the number of individuals obtaining an em position without appropriate training, most, if not all, em positions in canada now require candidates to have an academic background in disaster and emergency management from a post-secondary institution. participants noted that requiring an academic background to enter the field of emergency management is one of the distinct ways the profession has evolved in the last years. they described having an academic background as an asset which allows for profession-specific training and awareness of relevant tools, such as frameworks and documents for use in the field. ems fulfill dynamic roles -which continue to evolve -as an influx of individuals trained in postsecondary disaster and emergency management programs enters the field. suggested by one participant, emergency management is a "broader umbrella term" (em) that includes many programs where both administrative and operational tasks are required that extend into all four phases of disaster management. ems engage in essential roles that are distinct from those of first responders when disasters and emergencies arise. the essential roles of essds are distinct yet complimentary to those of ems. the tasks carried out by essds can also be categorized as administrative or operational, and specific to the level of the position within government. essds have concerns related to sustainability of service provision, particularly during long-term recovery periods. compounding this concern are high public expectations for support, and an over-reliance of the public on the government to provide those supports. the administrative tasks described by essds were similar to those of ems, but greater emphasis was placed on connecting with stakeholders, such as non-profit organizations, community partners and other governmental departments. essds provide social programming, regardless of whether there is an activation in the community, and rely on their network of stakeholders for assistance with carrying out these operations. examples of programs within the portfolio of essds include, community housing, financial assistance, and disability supports. in the event of an activation, essds not only continue to j o u r n a l p r e -p r o o f provide these programs, but they are also responsible for facilitating the provision of six emergency social services ) food ) clothing ) shelter ) registration ) inquiry and ) personal services. importantly, "when an emergency arises, all the other tasks on our plate do not get alleviated" (essd), but rather the workload accumulates because people who may not have needed social services in the past now require assistance as the result of an emergency/disaster. lack of professional hours allocated to the prevention/mitigation and planning phases, and lack of resources, training, and funding were all voiced concerns with respect to feeling capable of supporting citizens post-disaster. this lack of investment in human resources was of particular concern when discussing disasters that would require support for longer recovery periods. compounding this concern is an observed over-reliance of the public on government to meet their needs post-disaster, as expressed by one participant: "there has always been this culture that i have a problem and i need the government to help solve that problem. i think that people need to appreciate that the more they can do to prepare themselves in their own communities will help to ensure that people who really need support will get the resources that they need in a timely manner" (essd) public expectations on professionals such as essds are high, and many of the participants expressed doubt about the capacity of government departments to respond adequately in the event of a large-scale disaster. one participant noted that in their jurisdiction they "rely on the fact that major disasters with long-terms consequences don't happen here" (essd), which represents a fallacy in the midst of a changing climate and widespread pandemic. participants described how they work around scarce resources and high demands by focusing on assisting those affected to reach a 'new normal'. this can be achieved by creating partnerships with stakeholders -such as ngos -to share and coordinate resources. while community partnerships help to cover a gap in resources, another gap exists between community-based approaches described by academia and those occurring in practice. a 'whole-society' or 'all-of-society' approach, as described by the federal emergency management agency (fema, ), j o u r n a l p r e -p r o o f is one of the guiding frameworks for best practice in emergency management. while many participants had heard of this approach, the extent to which it was recognized as an important process and implemented in practice varied between participants. a gap between academia and practice was the most commonly cited barrier to implementation. participants expressed a need for action items that describe how to go about this process. participants described a 'whole-society' approach as meaning that everyone in society is responsible and has a role to play in all phases of disaster management. however, engagement of citizens in this process is not necessarily reflected in practice. a 'whole-of-government' approach was cited as more common in practice, and refers to the process by which multiple sectors and levels of government collaborate, particularly in the response and recovery phases. progression from 'whole-of- while some participants noted the importance of engaging citizens in the community to promote a 'whole-society' approach, not everyone saw it as a viable option. in addition to a general lack of time and resources to promote citizen engagement, some participants endorsed a lack of understanding of how to go about carrying out this type of approach. "it is not an approach that i find our organization has really already embraced and i think part of the challenge is that there is no sort of model out there to tell you how to do a 'wholesociety' or 'whole-of-community' approach" (em) a gap between academia and practice was identified as a reason for the disconnect between the concept of a 'whole-society' approach and the process for carrying it out in the field. one participant suggested that there still exists an underlying sentiment that "academia and theory are no good for practice" (em). a continued influx of individuals entering the field of emergency management with degrees from post secondary institutions may alter this underlying sentiment by fostering awareness of j o u r n a l p r e -p r o o f frameworks and resources available for reference in practice. however, bridging the gap between academics and practitioners will require continued collaboration and acknowledgement that every jurisdiction has its own unique needs. provision of public education related to preparedness for emergencies and disasters was a commonly cited task for both ems and essds; examples included, emergency preparedness week and the promotion of -hour readiness kits. although many participants highlighted the importance of personal preparedness, they also admitted they did not feel prepared themselves. this has profound implications for continuity of critical operations within em and essd departments. using -hour kits as an example, emphasis is often placed on the importance of citizens having kits prepared for themselves and others who may depend on them during a disaster, however many participants disclosed that they do not have kits of their own. the underlying sentiment was one of amusement and lack of urgency, with many participants noting the irony of the lack of uptake. exploring this issue further revealed that many participants do not feel well supported in terms of their own personal preparedness, which impacts their ability to support the preparedness of others. although preparedness is one of the most prominent phases of emergency management, with much time and funds invested in public campaigns, there is a lack of emphasis on preparedness at the level of ems and essds. this represents a barrier to their professional response capacity and their ability to support the public. participants noted that a greater emphasis on personal preparedness is warranted, yet "everything gets trumped by emergencies" (em). this quotation represented an underlying belief of some of the participants that their personal preparedness remains secondary to the requirements of their job. at the broader level, this has the potential to create vulnerabilities in the emergency management system, as it leaves professionals open to increased stress and burn out; it may further lead to gaps in the system if they are unable to continue working. recommendations put forward by participants to increase their own preparedness and therefore capacity, were related to raising awareness of the issue within the em and essd professions. participants also suggested that increased training opportunities, and increased supports provided by management (i.e. time and resources allocated to preparedness) would go a long way to improving personal preparedness. in the eyes of the public, ems and essds carry out largely unknown roles. lack of visibility and recognition have contributed to reduced awareness of the secondary stressors these professionals face when carrying out their day-to-day tasks. in contrast with the services provided by first responders, the contributions of ems and essds were thought to go unnoticed. as highlighted by participants in this study, first responders are out in the public so citizens are aware of the roles that they carry out, as well as the vulnerabilities they may experience. in contrast, ems and essds are not highly visible and therefore the roles they carry out and the vulnerabilities that they experience may not be well understood. there is a very poor understanding of the types of secondary stressors we encounter. in my day- due to the demands of their response occupations, ems and essds should be considered at 'high-risk' of experiencing mental illness. in an effort to reduce this risk, participants provided recommendations they believe would support their mental health. in the prevention/mitigation and planning phases it is imperative that multiple individuals be trained to perform the em or essd roles, to enable the work-load to be distributed between multiple people during the response and recovery phases -and to allow for adequate breaks when sustained response is required. increased opportunities for training in areas such as stress management were also suggested. during the response and recovery periods many participants suggested that having a disaster social services volunteer, counsellor or a therapist available to act as a support for staff would be an asset as "it is crucial to have someone there to look out for you while you are looking out for others" (em). some participants noted that these suggestions are already starting to be integrated into protocols in the workplace, while others expressed that they would like to see these suggestions implemented. finally, bringing increased awareness to the importance of self-care was highlighted as important in order to promote increased coping capacity. from the five themes identified we created a model to highlight the skills, tasks, and roles that make-up the em and essd occupations, as described by participants. in this model we make explicit the occupational risks that these professionals may experience. through the identification of themes from this study, it is apparent that ems and essds are at an increased risk of experiencing stressors and burnout due to the nature of their work. supporting awareness and bringing visibility to the important skills, tasks and roles these professionals engage in, as well as the occupational risks they may encounter, is a first step towards reducing vulnerabilities and supporting capability. the following model was developed from the data to provide a visual representation of the roles, tasks, skills that ems and essds carry out, and occupational risks that they are exposed to. the skills are located at the center of the model as they are required to carry out greater tasks and roles, which are represented in the outer rings, respectively. the six occupational risks identified can impede the ability of ems and essds to carry out their roles, which are represented in the column with an arrow pointing towards the rings. the participants mentioned skills required to carry out tasks and roles; they are located in the center ring in figure . for example, one essential skill is the ability to be decisive, which is particularly important in the response and recovery phases, when other professionals are dependent upon receiving direction. the ability to be reflexive is another important skill, for instance, in the prevention/mitigation phase in order to acknowledge what worked well -and what could be improved -for future responses. these skills give ems and essds the ability to carry out administrative and operational tasks as described in themes and respectively; tasks are highlighted in the center ring in figure . the skills and tasks carried out by ems and essds build into greater overarching roles. there were seven dynamic roles identified which are represented in the outer ring of figure and include: lead, collaborate, j o u r n a l p r e -p r o o f educate, facilitate, advocate, consult and coordinate. for example, for ems and essds at the municipal level, educate and advocate were roles often emphasized to meet the needs of the citizens in their particular jurisdictions. in contrast -at the provincial level -coordination was a focus for managing an intersectoral approach to disaster management. finally, six main occupational risks were identified that impact the ability of ems and essds to carry out the skills, tasks and roles required in the context of these positions. these occupational risks are areas where ems and essds are vulnerable to experiencing an increased risk of mental health issues. occupational risks identified included: lack of role awareness, recognition and secondary stressors, lack of upstream investment, lack of practical supports, and a gap between academia and practice. importantly in today's society, ems and essds engage in a range of roles and tasks that span all four phases of the disaster management cycle, prevention/mitigation, preparedness, response and recovery (waugh, ) . the purpose of this study was to explore the current roles of ems and essds in a canadian context; we specifically wanted to learn about barriers, vulnerabilities and capabilities experienced by these professionals. the evolution of emergency management as a profession in canada, in the most recent decade, was highlighted by participants as an increasing number of individuals have entered into the field with relevant degrees from post-secondary institutions. the professionalization of emergency management has been well documented, particularly in the united states where education and certification programs have existed since the early 's (waugh, ; waugh & sadiq, ; iaem, n.d.-b) . oyola-yemaiel and wilson ( ) note that beyond certification programs, accreditation and hierarchical structure contributes to the professionalization process. in canada, disaster and emergency management educational opportunities are growing, with colleges offering diploma and certificate options, and universities offering both bachelor and graduate degrees in the field (crhnet, n.d). each province and territory have their own emergency management organization and many have provincial/territorial professional associations to foster continued professional development, advocacy, mentorship and networking opportunities (government of canada, ; oaem, n.d.) . although a national professional association no longer exists, canada is j o u r n a l p r e -p r o o f engaged with the international association of emergency managers, which offers a certification process, promotes profession specific principles and is bound by a code of ethics (iaem, n.d.-b) . in terms of hierarchical structure, ems and essds are positioned throughout all levels of government and in the private sector, however the formalization of a rank/order (i.e. junior vs senior em/essd, or assistant vs associate em/essd) does not currently exist; this is similar to the united states. oyola-yemaiel and wilson ( ) argue that moving from a loose to a formal structure is the next step in the professionalization process. whether or not this will manifest in the future remains to be seen, but the concept is reminiscent of the command and control style of the profession's origins, which it has moved away from to give way to more collaborative approaches to administration (waugh & streib, ) . waugh and streib ( ) argue that a lack of understanding of emergency management is one of the reasons why people think that a command and control style would strengthen emergency managements response to disasters, when in practice it interferes with a collaborative approach necessary to manage disaster operations. the public has come to expect that emergency management professionals will carry out their roles effectively and efficiently to respond to their needs before, during, and after a disaster (kapucu et al., ) . this requires skill in the ability to facilitate both vertical and horizontal coordination between numerous ngos, government departments and private companies, as well as a plethora of skills including the ability to adapt, and make hard and fast decisions (kapucu et al., individuals and communities to an acceptable new normal post-disaster. these findings are consistent with the calls for emergency management to take on a network governance style approach whereby collaborative practices, rather than hierarchical command and control tactics, are fostered in order to meet the demands of the job, despite economic and financial constraints (bosomworth et al., ; howes et al., ) . however, maintaining networks is difficult, particularly when there is no activation ongoing. this speaks to the need for continued upstream investment to promote adequate preparedness. the lack of upstream investment in disaster mitigation/prevention and preparedness is concerning, given the increased frequency and severity of disasters as a result of climate change j o u r n a l p r e -p r o o f (o'sullivan et al., ) . the impact of climate change on emergency management professions is not fully understood, however there has been a shift from focusing on acute hazards to chronic conditions, leaving ems and essds to support longer recovery periods with minimal support and resources (labadie, ; mccreight & harrop, ) . increased demands, coupled with high public expectations, makes ems and essds a high-risk group for experiencing mental illness. however, the mental health of these professionals is often overlooked, with the focus remaining on the vulnerabilities of first responders and the greater community (goldmann & galea, ; haugen et al., ) . the ems and essds in this study made it clear that unrealistic expectations that come with their "side-of-desk" role, accompanied by invisibility of their roles, and lack of support for personal preparedness is leaving them vulnerable to burnout and stress. of particular concern is what will happen if these individuals need to take leave as a result of occupational stressors -resulting in a gap in the system that relies on them to carry out an increasing work load. this concern is particularly relevant with the emergence of the worldwide covid- pandemic where plans are changing every day; the impact will be an extensive recovery period. this study explores the occupational roles and risks of ems and essds from six canadian provinces. gaining perspectives from different regions in canada is a strength of this study because it incorporates the perceptions of professionals who have different climate-related concerns. however, perspectives from the territories could not be gathered due to ethics approval restrictions. this study also took place before the covid- pandemic; therefore, it was not possible to understand how these findings might be understood in this context. with the climate crisis, and changes to the landscape of emergency management, additional investment in support and resources are essential to enable ems and essds to support the greater community. drabek ( ) defined a successful em as one who could interact effectively with government officials and with the broader disaster relief community. this definition has not been revised over several decades. here we suggest an updated definition to reflect the current state of j o u r n a l p r e -p r o o f emergency management: an effective individual working in emergency management is one whose personal and professional capacity is well supported, such that it allows them to support individuals and communities throughout all phases of the disaster management cycle, to build back better after an adverse community event. throughout all phases of disaster management, ems and essds carry out essential roles and tasks to support individuals, citizens, and communities. the increasing demands and high expectations for these professionals are not conducive to the "side-of-desk" nature of these roles. this has implications for continuity of critical operations during an activation if ems and essds need to leave their work due to occupational stressors and burn out. this has particular relevance in our current society with the increasing frequency and severity of natural disasters due to climate change and the emergence of the world wide covid- pandemic. future studies should explore how the covid- pandemic will impact the ability of ems and essds to carry out their roles. studies should also look at interventions to support the mental health of ems and essds to promote capacity building in the midst of increasing demands due to climate change and increased frequency and severity of other types of disasters, including pandemics. provincial emergency social services framework first responders: mental health consequences of natural and human-made disasters for public health and public safety workers addressing challenges for future strategic-level emergency management: reframing, networking, and capacity-building using thematic analysis in psychology thematic analysis integrating emergency management and high-risk populations: survey this study was funded by the social sciences and humanities research council of canada. the authors would like to acknowledge the participants who took part in the interviews and the co- key: cord- - m ch ls authors: ford, james d.; berrang-ford, lea; king, malcolm; furgal, chris title: vulnerability of aboriginal health systems in canada to climate change date: - - journal: glob environ change doi: . /j.gloenvcha. . . sha: doc_id: cord_uid: m ch ls climate change has been identified as potentially the biggest health threat of the st century. canada in general has a well developed public health system and low burden of health which will moderate vulnerability. however, there is significant heterogeneity in health outcomes, and health inequality is particularly pronounced among aboriginal canadians. intervention is needed to prevent, prepare for, and manage climate change effects on aboriginal health but is constrained by a limited understanding of vulnerability and its determinants. despite limited research on climate change and aboriginal health, however, there is a well established literature on aboriginal health outcomes, determinants, and trends in canada; characteristics that will determine vulnerability to climate change. in this paper we systematically review this literature, using a vulnerability framework to identify the broad level factors constraining adaptive capacity and increasing sensitivity to climate change. determinants identified include: poverty, technological capacity constraints, socio-political values and inequality, institutional capacity challenges, and information deficit. the magnitude and nature of these determinants will be distributed unevenly within and between aboriginal populations necessitating place-based and regional level studies to examine how these broad factors will affect vulnerability at lower levels. the study also supports the need for collaboration across all sectors and levels of government, open and meaningful dialogue between policy makers, scientists, health professionals, and aboriginal communities, and capacity building at a local level, to plan for climate change. ultimately, however, efforts to reduce the vulnerability of aboriginal canadians to climate change and intervene to prevent, reduce, and manage climate-sensitive health outcomes, will fail unless the broader determinants of socio-economic and health inequality are addressed. climate change has been identified as potentially the biggest health threat of the st century (costello et al., ) . addressing the challenge will be a defining question for public policy (campbell-lendrum et al., ; costello et al., ; lim et al., ; parry et al., ) . while reducing greenhouse gas emissions responsible for climate change is essential (i.e. mitigation), health systems will have to adapt to climate change through interventions to manage climate-sensitive health outcomes, many of which are now unavoidable ebi and semenza, ; frumkin et al., ; furgal and prowse, ). without such intervention, the burden of climate-sensitive health outcomes will increase confalonierei et al., ) . international assessments have highlighted that developed nations have a high capacity to adapt to the health effects of climate change (confalonierei et al., ; costello et al., ). on the whole, this is true: individuals, communities, and governments have access to significant resources and engage in a range of actions to manage and control climate-sensitive health outcomes (ebi, ; ebi et al., ; watson et al., ) . this assumption, however, does not adequately consider the persistence of withincountry economic and health inequities and their implications for vulnerable populations. this is particularly pertinent for developed nations with indigenous populations living in what has been referred to as the 'fourth world' (o'neill, ) . indigenous peoples in canada, new zealand, united states, and australia all experience a disproportionate burden of morbidity and mortality, with many social, economic, and health indicators similar to those in middleincome nations (cooke et al., ; green et al., ; stephens et al., ) . the existing burden of ill-health increases the sensitivity of indigenous peoples to the adverse impacts of climate change, which combined with a proportionally higher dependence of many indigenous climate change health adaptation vulnerability aboriginal inuit mé tis first nations canada social determinants of health inequality indigenous a b s t r a c t climate change has been identified as potentially the biggest health threat of the st century. canada in general has a well developed public health system and low burden of health which will moderate vulnerability. however, there is significant heterogeneity in health outcomes, and health inequality is particularly pronounced among aboriginal canadians. intervention is needed to prevent, prepare for, and manage climate change effects on aboriginal health but is constrained by a limited understanding of vulnerability and its determinants. despite limited research on climate change and aboriginal health, however, there is a well established literature on aboriginal health outcomes, determinants, and trends in canada; characteristics that will determine vulnerability to climate change. in this paper we systematically review this literature, using a vulnerability framework to identify the broad level factors constraining adaptive capacity and increasing sensitivity to climate change. determinants identified include: poverty, technological capacity constraints, socio-political values and inequality, institutional capacity challenges, and information deficit. the magnitude and nature of these determinants will be distributed unevenly within and between aboriginal populations necessitating place-based and regional level studies to examine how these broad factors will affect vulnerability at lower levels. the study also supports the need for collaboration across all sectors and levels of government, open and meaningful dialogue between policy makers, scientists, health professionals, and aboriginal communities, and capacity building at a local level, to plan for climate change. ultimately, however, efforts to reduce the vulnerability of aboriginal canadians to climate change and intervene to prevent, reduce, and manage climate-sensitive health outcomes, will fail unless the broader determinants of socio-economic and health inequality are addressed. ß elsevier ltd. all rights reserved. livelihoods on the environment, spiritual and cultural ties to the land, demographic trends, and experience of marginalization, makes indigenous peoples particularly vulnerable (furgal, ; furgal and seguin, ; green et al., ) . public health interventions focused on indigenous peoples are needed to prevent, prepare for, and manage climate change risks (i.e. adaptation). assessing vulnerability is essential to this end, locating at-risk populations, identifying vulnerability determinants that need to be addressed, and directing attention to the most appropriate level for intervention (ipcc, b) . canada has been a leader in vulnerability assessment in public health (berrang-ford, ; berrang-ford and noble, ; berrang ford et al., ; charron, charron, , charron et al., ; doyon et al., ; health canada, a,c; ogden et al., ; thomas et al., ) . natural resources canada's from impacts to adaptation: canada in a changing climate , for example, assesses the current state of knowledge on climate change for six regions of canada, and health canada's human health in a changing climate (seguin, ) specifically focuses on climate change and health. however, there remains a significant deficit in information required to inform and guide adaptation among aboriginal peoples-part of what we broadly term an indigenous peoples 'vulnerability deficit.' major canadian assessments of climate change, for example, identify research on aboriginal health a priority for action , and while furgal and prowse ( ) focus on the health of mostly inuit inhabitants in the north, other aboriginal populations have been less studied (healey and meadows, ; wilson and young, ) . this lack of information leaves aboriginal health systems insufficiently prepared to identify the risks of climate change and develop adaptations (seguin, ) . the vulnerability deficit is further evident in the peer-reviewed literature. a review of pubmed ( pubmed ( - , for example, reveals only articles referring to a combination of ''indigenous or aboriginal'' and ''health'' and ''climate change'' and ''canada.'' of this literature, only article formally assesses vulnerability with a focus on the north (furgal and seguin, ) , and only are explicitly concerned with aspects of health in a changing climate. for comparison, articles match the search criteria for canada if ''indigenous or aboriginal'' are excluded. addressing the vulnerability deficit should be a priority for aboriginal health research and planning on climate change (furgal, ; green et al., ; seguin, ) . a common approach to examining health vulnerability begins with the question, 'given projected climate changes, how will this affect health systems?' the long range future is the focus of interest here (often or ), with assessment starting by modeling how health exposures will be affected by climate projections. an alternative approach starts with the question 'what predisposes health systems to be negatively affected by climate change.' the first step here is to characterize the current structure and functioning of health systems, and identify the processes and conditions which affect how health risks are experienced and managed: these characteristics in turn will determine sensitivity and adaptive capacity to climate change (smit and wandel, ) . given that the second approach focuses on current capacity and vulnerability of the health system, we can use existing literature to characterize sensitivity and adaptive capacity to climate changes. this is important given the volume of research on all aspects of aboriginal health: articles using search terms ''indigenous or aboriginal'' and ''health'' and ''canada'' in pubmed ( - ) . in this paper we systematically review the literature on aboriginal health in canada to identify health outcomes, determinants, and trends, and use a vulnerability framework to synthesize how these factors will affect the vulnerability (and resilience) of aboriginal health systems to climate change. on this basis we identify strategic priorities for policy intervention and research needs. aboriginal peoples in canada are constitutionally defined as north american indian (commonly referred to as first nations), mé tis, and inuit (table ). in , aboriginal peoples accounted for % of canada's population, numbering approximately . million, and are the fastest growing segment of the population (table ). in many instances, indicators of economic, social and health well-being among aboriginal canadians compare unfavourably with the canadian population in general (table ) (adelson, ; cooke et al., ; phac, ; stephens et al., ) . aboriginal peoples experience lower life expectancy, higher incidence of chronic diseases (e.g. diabetes), higher rates of infectious diseases (in particular tuberculosis and childhood rsv bronchiolitis), and higher rates of substance abuse, suicide, and addiction, than canadians in general (table ) (adelson, ; banerji et al., ; clark and cameron, ; frohlich et al., ; macdonald et al., ; macmillan et al., ; mcdonald and trenholm, ) . canada's aboriginal population is diverse, including people living on reserves, in the territories, and in rural communitiesthese groups account for approximately half the aboriginal population. we collectively refer to this segment of the population as the 'remote aboriginal population': they are generally remote and rural in character, maintain a close and intimate relationship with the environment, with many still practicing aspects of traditional lifestyles (table and fig. ) (furgal and seguin, ; richmond and ross, ). this remoteness, combined with close links to environmental conditions for livelihoods, creates particular sensitivity to climate change. the remainder of the aboriginal population lives in urban areas, and this population is growing rapidly with migration from remote communities, particularly among young people seeking education and employment (siggner and costa, ; statistics canada, a) . urban aboriginal peoples, in many respects, are engaged in livelihood activities similar to non-aboriginal people and are often disconnected from land based activities. nevertheless, many retain connections with their traditional home (inac, ) . we recognize that focusing on all aboriginal subpopulations risks overgeneralization as there is significant heterogeneity in health outcomes and determinants of health between urban and remote and rural aboriginal populations, and also between and within first nations, inuit, and mé tis. table characteristics of aboriginal habitation. reserves are tracts of land, the legal title to which is held by the crown, set apart for the use and benefit of first nations with constitutional responsibility resting with the federal government. there are approximately reserves in canada. the territories are administrative subdivisions of canada which, unlike provinces, derive their mandate and powers from the federal government. a significant proportion of the population of territories is aboriginal, residing in approximately communities. over half of the aboriginal population lives in urban centres. winnipeg, edmonton, saskatoon, and regina are major urban areas where aboriginal people make up > of the population. aboriginal people also reside in rural settlements outside of the territories and not on reserves, data on this segment of the aboriginal population is lacking. there are, however, shared experiences of health inequalities which result in a unique vulnerability to climate change. the focus in this paper on canada's aboriginal population reflects the serious risks posed by climate change to aboriginal health. canada has already experienced disproportionate warming with climate change, with average temperatures in some northern regions increasing beyond c (acia, ; barber et al., ; ford, a; ipcc, a; prowse et al., b,c) . implications for aboriginal health have already documented, particularly in the arctic (ford, b; ford et al., a; furgal, ; furgal and prowse, ; furgal and seguin, ) . projections of relevance to aboriginal health include: changing temperature and precipitation regimes will increase the probability and severity of extreme events including heatwaves, storms, floods, drought, and wildfire with implications for asthma, chronic respiratory disease, water quality, cardiovascular disease, and the health effects of dislocation and displacement ( fig. ) (charron et al., ; doyon et al., ; hess et al., ; thomas et al., ) . sea level rise and associated coastal erosion are already threatening the viability of some aboriginal settlements . remote aboriginal settlements are particularly sensitive to these impacts, with many dependent on water delivery and sewage collection by truck, basic water treatment facilities, and some settlements located on marginal and hazardous locations, a consequence of government relocation in the s and s (furgal and prowse, ; lemmen et al., ) . warmer, wetter summers have the potential to increase the incidence of water and insect borne disease (e.g. entamoeba histolytica, giardia lamblia, cryptosporidium parvum) (hennessy et al., ; martin et al., ) , while rising temperatures are expected to increase the incidence of temperature-dependant food-borne diseases, including salmonella as well as toxins produced by staphylococcus aureus and clostridium botulinm (hess et al., ; parkinson et al., ) . these are important in an aboriginal context given traditional food cultures, which includes the consumption of raw meats, in which small changes in storage and transport temperatures can significantly increase the risk of food-borne diseases. there will be a number of indirect pathways through which climate change will affect health involving second, third, or even fourth order indirect impacts. these are generally less researched and understood but could be more extensive and disruptive (hess et al., ; mcmichael, ) changing temperatures, for example, are likely to impact the distribution and availability of animal populations important in aboriginal subsistence hunting with implications for community health, nutrition, and well-being ( fig. ) (ford, b; furgal and seguin, ) . climate change could result in increased migration to urban centres as traditional activities and livelihoods are compromised, with implications for disease transmission and diagnosis (parkinson et al., ) . changes to the incidence and prevalence of some infectious diseases will also be indirect, stemming for example from climate impacts in other countries from which diseases may be introduced into canada, or changes in the distribution and densities of vector habitat or animal hosts of zoonotic and vectorborne diseases (berrang-ford, ; berrang ford et al., ). there might also be positive health implications associated with increased economic opportunity with improved transportation in areas currently inaccessible (e.g. by melting sea ice). we structure the literature review using the concept of vulnerability-a concept that underpins much of the research in the human dimensions of climate change (hdcc) field. vulnerability is a measure of the susceptibility to harm in a system in response to a stimulus or stimuli, and can essentially be thought of as the 'capacity to be wounded,' (smit and wandel, ) . in this paper we are interested in aboriginal health systems, defined collectively as organizations, institutions (formal and informal) and resources whose primary purpose is aboriginal health. this includes frontline health personnel, community and territorial health authorities, federal agencies, aboriginal organizations, research bodies, and also individuals and households who are an important informal component of health care provision and advice in many aboriginal communities. the stimulus or stimuli are health risks linked directly or indirectly to climate change. a general model of vulnerability has emerged in climate change scholarship that conceptualizes vulnerability as a function of exposure and sensitivity to climate change and adaptive capacity (ebi et al., ; ipcc, b; smit and wandel, ) . in a health context, exposure refers to the nature of climate-related (direct or indirect) health outcomes. sensitivity concerns the organization and structure of health systems relative to the climate-related health outcomes and determines the pathways through which exposure is manifest. adaptive capacity reflects the ability of health systems to address, plan for, or adapt to adverse climate-related health outcomes and take advantage of new opportunities (ebi and burton, ; ebi et al., ; ebi and semenza, ; ford and smit, ) . exposure, sensitivity, and adaptive capacity are not mutually exclusive, with interaction between these components potentially moderating or exacerbating vulnerability. the recognition of the role of adaptive capacity and sensitivity is important, directing attention to health systems themselves and the nonclimatic factors operating at multiple spatial-temporal scales that determine how climate change will be experienced and responded to (ebi and burton, ; ebi et al., ; ford and smit, ; ford et al., b ). this general model of vulnerability has been applied essentially in two main ways in vulnerability research (burton et al., ; o'brien et al., ; ford et al., b) . firstly, 'end point' approaches begin by projecting climate change impacts and then estimate potential vulnerabilities to future conditions, and have historically dominated the hdcc literature in general. the first step towards tackling the vulnerability deficit for aboriginal health using this approach would be to develop climate scenarios to model changing exposure. this is a time consuming and intensive process, however, and is particularly problematic in a canadian aboriginal context where baseline data that is needed for health modelling is lacking . more generally, 'end point' assessments have been criticized for neglecting the complex dynamics that shape how climate change is experienced and responded to, focus on future conditions and risks as opposed to current stresses that are relevant to the people being affected, neglect of indirect health risks that cannot easily be modeled, and failure to capture the dynamic nature of vulnerability (brooks et al., ; ford and smit, ; o'brien et al., o'brien et al., , smit and wandel, ) . conversely, 'starting point' approaches begin with the system of interest, examining the factors that determine sensitivity and adaptive capacity to climate related risks and change (burton et al., ; o'brien et al., ) . common in the hdcc literature in general (adger, ; burton et al., ; o'brien et al., ; smit and wandel, ) and increasingly in a health context (ebi and burton, ; ebi et al., ; ebi and semenza, ; furgal and seguin, ) , vulnerability here is viewed as a state or condition, not an outcome, continually evolving and changing. the 'starting point' approach seeks, therefore, not to identify vulnerability independently attributable to climate change, but to understand the conditions and processes that predispose a system to negative effects. in the context of the vulnerability deficit this approach directs attention to aboriginal health systems themselves, a topic which has been the focus of significant research. recurring themes in this literature concern the social, economic, political conditions that affect aboriginal health outcomes. this work has renewed importance for understanding climate change vulnerability, and we use a 'staring point' approach to identify and examine the broad characteristics of aboriginal health systems that influence their sensitivity and adaptive capacity. we used keyword combinations to search for peer reviewed articles on aboriginal health published from to july using pubmed database. keywords used included: ''aboriginal '' or ''indigenous'' or ''first nations'' or ''inuit'' or ''health problems,'' and ''social determinants of health.'' information was also obtained from other sources, including aboriginal organization websites, government reports about the status and health of aboriginal peoples and health of canadians in general. our search was limited to publications in english. once all relevant sources were identified and retrieved, pertinent information on aboriginal health outcomes, determinants, and trends, was extracted, categorized, and analyzed using the vulnerability framework described above. in this section we examine the broad characteristics of aboriginal health systems that will determine vulnerability to climate change. these determinants do not exist in isolation and fig. captures important interactions and highlights how these broad scale or underlying factors provide the context within which local to regional health systems will experience and respond to [ ( f i g . _ ) t d $ f i g ] table provides an overview of the determinants of vulnerability. canada is a wealthy nation consistently placed near the top of the united nations develop programs human development index, and as such is expected to be less vulnerable to climate change (cooke et al., ; o'brien et al., ) . national level indicators, however, hide significant disparities, with aboriginal peoples at substantively higher risk of living in poverty and experiencing housing and food insecurity (adelson, ; mcdonald and trenholm, ; phac, ; raphael et al., ) . these gaps continue to grow despite policy intervention, and are particularly pronounced among the remote aboriginal population (table ) . a complex interplay of factors has been identified to contribute towards high rates of poverty including low labour force participation, lack of employment opportunities, low educational attainment, loss of land and sovereignty, high cost of living in remote areas, job market discrimination, and the burden of illhealth (rcap, ; adelson, ; phac, ) . poverty influences climate vulnerability at two main levels: individual/household level and institutional level. firstly, at an individual and household level, poverty translates to negative health outcomes through material conditions and associated behavioural factors (frohlich et al., ; woolf, ) increasing the sensitivity of aboriginal canadians to climate risks. poverty forces many to live in suboptimal conditions, engage in dangerous livelihood activities, live in areas at high risk, and increases the risk of engaging in unhealthy behaviours (e.g smoking, drinking). overcrowding in inadequate housing and food and water insecurity, for example, are chronic poverty-related problems facing aboriginal people across canada (boult, ; dunn et al., ; egeland et al., ; ford and berrang-ford, ; hamelin et al., hamelin et al., , harvey, , ; shaw, ) . those who are nutritionally challenged will be particularly vulnerable to changing access, availability, and quality of traditional foods with climate change, and susceptible to increasing incidence of climate-sensitive infectious diseases (ford, b; furgal and seguin, ) . similarly, house overcrowding and high rates of tobacco use increase the risk of person-to-person spread of infectious diseases, favor transmission of respiratory and gastrointestinal diseases, and increase susceptibly to heat stress; health outcomes with a strong link to climate and expected to increase in prevalence with warming temperatures and changing precipitation regimes (furgal and seguin, ; orr et al., ; parkinson et al., ) . the sensitivity of aboriginal canadians will result in health impacts of climate change occurring faster, sooner, and of a greater magnitude than for non-aboriginal people. this will challenge the ability of health systems to adequately invest time and resources in prevention, preparedness, and response seguin, ) . adaptive capacity at an individual and household level is also negatively affected by poverty, with many adaptations exceeding financial means. poverty has already been noted as a major constraint to adaptation to climate change related disruptions to subsistence hunting and fishing in arctic regions with implications for food security (furgal, ; furgal and seguin, ; turner and clifton, ; wolfe et al., ) . a number of behavioral and psychological conditions associated with poverty including substance abuse, addiction, stress, family disruption, alienation, and compromised education are also strongly associated with limited capacity to identify and respond to risks phac, ; tanner and mithcell, ) . research has identified how social networks which increase uptake of adaptive measures and are essential to well-being and managing climate change can be undermined by addictive behaviour (chan et al., ; beaumier and ford, in press; ford et al., a; pearce et al., ). notwithstanding, a critical factor in moderating the effects of climate change on aboriginal health lies in the adaptability and the resilience of aboriginal peoples (ford, a; ford and furgal, ; furgal, ; furgal and seguin, ) . aboriginal peoples have a deep attachment to their lands and their cultures, and this forms part of identity, which is a determinant of health . however, aboriginal cultures and identity are not static or fixed in time. aboriginal peoples are adaptable if they are allowed to, and current rates of poverty, and associated health impacts challenge this capacity. secondly, poverty is a major constraint on institutional capacity to respond to climate change. institutions with jurisdiction over reserve and territory-based aboriginal populations are challenged by human and financial resources, and exacerbated by the challenge of poverty (adelson, ; . substantial shortfalls remain in meeting basic needs, and planning for future health problems frequently ranks behind other existing challenges (mathias et al., ) . even in nunavut, which is globally believed to be a climate change 'hot spot' and where awareness of climate change is high, health systems at a local and territorial level have not had the financial or human resources to assess or plan for climate change health impacts; poverty related issues are more pressing (boyle and dowlatabadi, in press; ford et al., ) . to compound these difficulties, it has also been argued by some policy makers that resources and attention directed to climate change should be invested in poverty alleviation, with climate change perceived as a distant, diffuse, and uncertain threat (mathias et al., ) . this is ill-advised on a number of levels yet is challenging institutional response to climate change. firstly, climate change has the potential to exacerbate poverty, further increasing health vulnerability to climate change. secondly, climate change projections for canada in the ipcc (ipcc, c) and lemmen et al. ( ) are now widely believed to be conservative, with significantly greater impacts projected (barber et al., ; schellnhuber, ) . finally, addressing climate change and poverty need not be a zero sum game: climate policy has significant potential for co-benefits and can be mainstreamed into ongoing health activities and planning (campbell-ledrum and woodruff, ; ebi and burton, ; ebi and semenza, ; patz et al., ) . ameliorating poverty is a key challenge to improving aboriginal health, reducing vulnerability to the health effects of climate change, and creating an enabling environment for adaptation. as long as aboriginal people experience a higher prevalence of poverty than canadians in general they will bear a disproportionate vulnerability to climate change. reversing the current state of poverty is a significant undertaking requiring long term strategic investments in sustainable economic development, education, infrastructure, health care, the settlement of outstanding land claims, and greater involvement of aboriginal communities and organizations in decision making (rcap, ) . there is evidence that the cycle of poverty is being broken in some communities and regions, offering hope for the future. the assembly of first nations, for example, has recently launched a strategic plan to decrease poverty through creating opportunities, building on community assets and structural change for management of resources (assembly of first nations (afn), ) while the northern territories are trying to harness resource development to provide a basis for creating new and lasting economic opportunities. technological capacity refers to the ability of health systems to identify, respond to, and manage health risks, including those associated with climate change, through the application of appropriate technical strategies or interventions in the areas of diagnosis, treatment, surveillance, early warning, and planning. the canadian health system generally has a high technological capacity: geographical information systems are widely utilized to project future health burden and optimize planning, advanced treatments and preventive care are universally available, a strong educational and scientific base underpins a vigorous health research sector, and effective surveillance and early warning systems are in development or operation (davidson, ; gosselin et al., ) . this capacity reduces vulnerability to climate change and provides a strong basis for adaptive planning ipcc, b; phac, ) . aboriginal canadians enjoy many of the health benefits of the technologically sophisticated canadian health system. diagnosis and treatments, for example, are provided to aboriginal peoples through canada's universal and comprehensive health care system (madore, ) . however, technological capacity to address health outcomes for aboriginal peoples and plan for future risks is constrained by the accessibility of health services and availability of technology to health systems, contributing to unequal health burden (romanow, ) . this increases the sensitivity of aboriginal health systems to climate-related health outcomes and compromises adaptive capacity. firstly, canada's remote aboriginal population frequently note barriers to accessing health services, ranging from wait times, a shortage of doctors/nurses in the area, limited access to specialty and emergency services, the cost of transportation to health centres, to complaints that services provided are inadequate or not culturally sensitive (mackinnon, ; minore et al., b; muttitt et al., ; nti, ; wardman et al., ) . this is partly a function of geography. servicing small communities located in remote regions, many only accessible by air, is difficult and poses significant strain on health budgets. frontline health care in communities therefore often only involves basic diagnostic and treatment services, with other services provided in regional centres which may require significant travel and associated family disruption and financial stress (anderson et al., ; muttitt et al., ; wardman et al., ) . challenges of geography are compounded by the cross-cultural context of health provision. in particular, high turn-over of frontline health personnel, lack of training on working in aboriginal contexts for health professionals, language, and history of oppression through the medical system, have been noted to create reluctance among aboriginal people to seek health advice (adelson, ; bird et al., ; minore et al., b; tester and irniq, ) . urban aboriginal populations generally face fewer problems with health care services widely available. physical availability of services however, does not ensure health services are accessed or considered accessible; in many ways challenges associated with cultural sensitivity are more pronounced among urban aboriginal populations as they leave community health networks to the anonymity of urban health systems (adelson, ) . improving access and reducing inequalities to health services is a major challenge and has significant importance for climate change vulnerability. preventing, reducing, and managing the health burden of climate change requires individuals having access to timely and effective information, diagnosis, and treatment (berrang-ford, ; kovats and haines, ) . while some barriers to health service access reflect the reality of living in remote areas and others will only be overcome over time (e.g. trust in health system), some of the more egregious determinants can be addressed. entry points suggested in the literature include: collaboration between aboriginal stakeholders, policy makers, and frontline health workers to improve cultural sensitivity, training of health practitioners in both traditional and western health systems, and improved use of multi-media technology to communicate health messages (abonyi and jeffery, ; minore et al., b; muttitt et al., ; . secondly, effective surveillance and early warning systems are critical components of efforts to anticipate and respond to the effects of climate change and other risks on health (ebi and semenza, ; harrell and baker, ; parkinson et al., ) . surveillance involves the systematic collection of information on health determinants and outcomes necessary to determine the occurrence and spread of health risks, identify the emergence of new risks, and disseminate information to relevant actors. early warning systems provide timely information to populations and frontline health personnel when a threat is expected. current surveillance and early warning capacity for canada's remote aboriginal population, is underdeveloped (furgal, ; furgal and prowse, ; parkinson et al., ) . the fundamental challenge, as note, is the inadequacy of health data for planning: data sources that do exist are often inconsistent, sometimes based on faulty calculation methods, and are of limited coverage, baseline data do not exist for some health conditions and universally accepted measures, collection methods and techniques vary over time limiting the possibility for longitudinal analyses, surveillance among small populations limits analytical capacity for identifying significant changes and thresholds, and culturally and locally specific indicators have not been developed. these problems are compounded by challenges to institutional memory and high staff turnover in aboriginal health systems noted in sections . and . . early warning and surveillance capacity in canada's urban centres is generally more advanced, and information on a range of emerging health risks is available to urban aboriginal populations as part of broader health initiatives. nevertheless, problems surrounding culturally specific communication, surveillance of aboriginal-specific health sensitivities, and lack of baseline data on health outcomes, have also been noted in urban contexts (health canada, b; tudiver et al., ) . for remote aboriginal populations, existing surveillance is insufficient to detect the occurrence and spread of climate change related health risks, and early warning systems are insufficient to deliver projections in a timely and effective manner (kondro, ; , increasing sensitivity and reducing adaptive capacity to climate-related risks negative health outcomes. investments are needed to increase surveillance and early warning capacity, including the identification and monitoring of culturally specific and locally relevant health indicators in a systematic manner, examination of the potential to use sentinal health events as indicators, identification of indicators to monitor emerging climate change impacts and vulnerabilities, and development of infrastructure to link indicators to early warning (eyles and furgal, ; furgal and gosselin, ) . several aboriginal groups have initiated projects to develop indicators for surveillance, including climate change indicators, and offer insights for the development of national level systems (abonyi and jeffrey, ) . researchers have also started to work with communities to develop innovative surveillance approaches (martin et al., ; tremblay et al., ) . continuation and expansion of these initiatives requires addi-tional financial and human resource commitments at all levels of government. climate change will result in the emergence of health risks which cross borders, extend over multiple spatial-temporal scales, and span jurisdictions of government departments (campbell-lendrum and woodruff, ) . addressing these risks will require new governance structures, including increased participation of vulnerable peoples in decision making, increased accountability, and financial commitments (costello et al., ) . aboriginal canadians, however, face unique political challenges to achieving a range of social, economic, environmental, and health goals, with implications for sensitivity and adaptive capacity to climate change effects on health. as damman et al. ( ) note, government policies and actions often do not sufficiently address aboriginal interests, culture and lifestyle, specifically socioeconomic and spiritual connections to the land. inequality is evident in the neglect of aboriginal rights which are -in theoryprotected by the canadian constitution and international human rights obligations of the canadian state (damman et al., ; nilsson, ; raphael et al., ) . overcrowded living conditions, food and water insecurity, discrimination, and outstanding land claims are a few examples of this neglect, earning canada rebukes from the united nations (inac, ; statistics canada, b; united nations human rights council, ). marginalization of aboriginal peoples has been compounded by refusal of the canadian government to ratify international treaties which establish obligations for states towards indigenous peoples including the un declaration on the rights of indigenous peoples (un, ) , and domestic initiatives including the kelowna accord which aimed to substantively invest in programs to address aboriginal inequality (government of canada, november - , ; patterson, ) . political inequality links to climate change vulnerability in a number of ways. firstly, political inequality has been linked to a range of negative social, economic and health outcomes which increase sensitivity to climate-related health outcomes (adelson, ; richmond and ross, ). secondly, concerning adaptive capacity, inequality reduces the political power of aboriginal peoples to draw attention to pressing issues and develop interventions to manage emerging threats including climate change. this is evident in the reluctance of successive federal governments to advocate aboriginal rights on an international stage and develop effective policy domestically, for example with regards food and water security, and health inequality (budreau and mcbean, ) . this is also evident with climate policy. canada has made limited progress towards meeting its ratified commitments under the un framework convention on climate change (fccc), specifically its mitigation commitments to ''stabili [ze] greenhouse gas concentrations in the atmosphere at a level that would prevent dangerous anthropogenic interference with the climate system,'' (fccc, ) ; indeed emissions have rapidly increased since the signing of kyoto (weaver, ) . the fact that this commitment is unmet has particular relevance for aboriginal canadians who's livelihoods are sensitive to climate change, particularly in arctic regions where a strong climate change signal has already been detected (cbc, ; prowse and furgal, ; prowse et al., a) . the canadian state nevertheless has obligations to aboriginal peoples through the constitution and human rights treaties. while these obligations have often been overlooked, increasing public sympathy with aboriginal issues, visibility of inequality, and increasing political power of aboriginal peoples as reflected in self government for some regions, provides a basis for renewed political lobbying. the recent apology by the federal government to aboriginal canadians for past abuses of the state also potentially signals willingness for a new era of cooperation. this will be important with climate change which has the potential to compromise the basic human rights of many aboriginal peoples in absence of intervention, particularly in remote and northern regions (crump, ; ford, a; lukovich and mcbean, ). open and meaningful dialogue will be essential to ensure that policies respect, protect and fulfill the rights of aboriginal peoples. federal departments (e.g. health canada, indian and northern affairs canada, public health agency) are also working with aboriginal communities in vulnerable, mostly arctic, regions to develop programs and measures to facilitate adaptation. aboriginal canadians are also uniquely sensitive to climate change deriving from the cultural and spiritual relationship to ''the land.'' the ability to engage in traditional activities (e.g. hunting and fishing) and environmental stewardship remain central to aboriginal identify and culture and are closely linked to health, even for many urban aboriginal populations who no longer live on traditional lands or regularly engage in traditional activities. climate change threatens this: changing ice regimes are limiting access and availability of culturally and nutritionally important animal species, warming temperatures are increasing incidence of abnormalities and certain diseases in animals with implication for meat consumption, coastal erosion is threatening important cultural sites, and changing weather and wind patterns are challenging traditional environmental knowledge lemmen et al., ) . policy intervention can help manage some of these changes but some predicted impacts will result in irreplaceable cultural loss. in arctic regions, for example, climate change will make some communities uninhabitable and necessitate relocation, in other instances changing access to traditional areas and loss of livelihood may precipitate increased migration away from aboriginal communities (parkinson and berner, ). relocation could lead to an exacerbation of loss of culture and disconnection from the land, with implications for depression, anxiety, and substance abuse (berry et al., ; hess et al., ; kvernmo and heyerdahl, ) . these socio-cultural impacts present limits to adaptive capacity, where a limit implies an absolute barrier to adapting (adger et al., ) and indicates the continued importance of mitigation. health systems are composed of multiple institutions, including government health departments at municipal to federal levels, frontline health provision, research institutions, international donors, and informal community wellness groups. high income countries including canada are generally believed to have well developed institutional capacity underpinning the ability to identify, recognize, evaluate, anticipate and respond to health risks and learn from past mistakes. recent experiences in canada and developed nations more generally, however, including severe acute respiratory syndrome (sars), h n , and hurricane katrina, have challenged this complacency (ebi, ; ebi and semenza, ) . the institutional capacity of aboriginal health systems in remote areas is a particular concern, and is constrained by two key challenges: jurisdictional conflict over health care provision and human and financial resource limits. firstly, health care provision in canada for first nations and inuit falls under two jurisdictions, federal and provincial. all canadians are entitled to comprehensive, accessible, portable and universal health care as stated in the canada health act, , with provinces responsible for providing and financing the majority of health care services. however, provincial jurisdiction on health care in most instances does not extend to reserves which, along with the territories, fall directly under the jurisdiction of the federal government. through the first nations and inuit health branch, the federal government is mandated to provide a range of services to aboriginal people not covered by provincial jurisdiction, including primary health care and mental health (madore, ) . more recently, health transfer initiatives have sought to empower aboriginal communities and regions directly to manage their own health care with varying degrees of success. many services remain federally directed however. while in theory this model should cover aboriginal health needs, the reality is often much different. as documented in the literature, jurisdictional responsibility is not always clear and in some instances is shared, the status of health as a treaty right has not been settled with implications for local level health provision, decision making is often fragmented, and disputes within and between federal and provincial agencies regarding a range of health services for which there are pressing needs impedes health care access (adelson, ; mackinnon, ; minore et al., b) . urban aboriginal populations receive health care through provincial health care systems and do not generally face the same jurisdictional challenges. the consequences of this jurisdictional predicament are fragmented delivery of health care for aboriginal peoples on reserves and in the territories, uncoordinated management, constrained and short-term policy development, and a bureaucratic maze that constrains health provision and compromises health kirby, ; romanow, ) . these problems have implications for climate change vulnerability. indirectly, institutional constraints increase sensitivity and reduce adaptive capacity to climate change and act as a barrier to adaptation by limiting access to health services, constraining technology transfer and development, and posing barriers to developing baseline information on health vulnerabilities. directly, institutions characterized by jurisdictional conflicts, limited accountability, and complex bureaucracy are less likely to be able to identify, prepare for, and manage emerging risks like climate change, and learn from past mistakes (adger, ; berkes et al., ; gunderson and holling, ; keskitalo and kulyasova, ) . secondly, institutional capacity, particularly in remote areas, is constrained by human and financial resources. this has direct implications for sensitivity and adaptive capacity to climate change because local capacity is important for identifying and managing risks: evidence from multiple contexts has shown that well developed local health capacity increases the likelihood that policies and actions will be appropriate, effective and acceptable (blas et al., ; ford et al., ) . difficulty in recruiting and retaining human health resources has been widely noted (bird, ; boyle and dowlatabadi, in press; marrone, ; minore et al., a) . high staff turnover presents barriers to developing relationships with community members and stakeholders and creates problems for basic service delivery with employees often overworked and fatigued, key positions vacant, and inexperienced personnel undertaking responsibilities for which they do not have the necessary training or expertise. in this context, action on climate change is often undermined by other priorities, dependant on personnel, and subject to sudden change. if the health of aboriginal peoples is to be improved, sensitivity to climate change reduced and adaptive capacity enhanced, there is a need to build health systems that work well, provide universal care, ensure enough staff, and provide adequate health education (adelson, ) . policy discussion has focused on numerous ways to address institutional problems including resolving aboriginal land claims, consolidating fragmented funding, adapting health programs to local priorities, giving aboriginal people a direct voice in health planning, making aboriginal health the responsibility of provincial and territorial governments, and increasing self reliance (mackinnon, ; phac, ; richards, ; romanow, ) . as romanow ( ) reports, this will require a new structured approach that cuts across jurisdictional barriers and develops a new ethos of coordination and cooperation among government levels. the inadequacy of attempts to address the institutional determinants of poor health that have been widely recognized since the s is discouraging. however, increased self government, self determination, community level health initiatives, and the recent apology to aboriginal peoples by the federal government provide a strong basis from which to build. as fankhuaser and tol ( ) argue, ''successful adaptation requires a recognition of the necessity to adapt, knowledge about available options, the capacity to assess them, and the ability to implement most suitable ones.'' without this information, health systems are less likely to develop anticipatory adaptation interventions, leaving them sensitive to climate change risks and constraining adaptive capacity. vulnerability assessment is an important first step for providing the necessary information for adaptation. as noted in the introduction, however, information on aboriginal health system vulnerability is limited. this paper goes some way towards addressing this deficit, developing an understanding of the broad level or underlying determinants of vulnerability (fig. ) . this needs to be complimented by in-depth vulnerability assessments at local to regional scales to examine how broader determinants interact and shape local level factors, and specifically identify high risk regions and groups, characterize sensitivity to important health outcomes, evaluate current health planning in light of current impacts and future projections, and assess and prioritize response options (fig. ) . such initiatives require close collaboration with aboriginal communities, organizations, and policy makers, integrating local expertise, knowledge, and understanding of health determinants (adelson, ; green et al., ; pearce et al., pearce et al., , raphael et al., ; richmond and ross, ) . there is also need for a comprehensive assessment of the various pathways through which climate change will affect the incidence and prevalence of various outcomes affecting aboriginal health systems, many of which will be unique influenced by livelihoods, living conditions, and traditional food cultures. uncertainly about climate change impacts on aboriginal health characterises much current scientific understanding, and is magnified at regional and local levels where risks are largely unknown among policy makers and communities. this constrains effective risk assessment and planning. improved scientific understanding needs to be complimented by more effective partnerships with aboriginal communities and organizations and culturally relevant knowledge translation. the significant body of literature on aboriginal health provides considerable insights on the broad level determinants of vulnerability which will shape the extent to which aboriginal health systems are able to prevent, prepare for, and manage the effects of climate change. a number of key trends are highlighted in the review: material conditions and behaviours associated with poverty will increase sensitivity and constrain adaptive capacity to climate change. surveillance and early warning capacity for those living in remote regions is underdeveloped for identifying emerging risks and vulnerable populations. comprehensive, reliable, and culturally specific health assessment measures from which to assess climate change impacts are absent. access to health information, diagnosis, and treatment is insufficient for timely and effective intervention to manage climate-sensitive health outcomes. the special rights and needs of aboriginal peoples have often been neglected, resulting in continued and persistent inequality which exacerbates climate change health vulnerability. institutions responsible for aboriginal health are challenged by jurisdictional conflict and resource constraints, limiting the ability to identify and prepare for future risks and address inequalities. these underlying determinants provide the context within which health system vulnerability at regional to local levels will be influenced. how they influence vulnerability at lower scales, however, will not be uniform. inuit will probably experience the greatest vulnerability to climate change on account of the sensitivity of arctic environments to climate change, magnitude of projected changes, remoteness of communities, dependence on the environment, burden of poor health, and limited institutional capacity (furgal and prowse, ; furgal and prowse, ). however, the settlement of outstanding land claims with inuit could provide the basis for progress in addressing inequalities that lie at the heart of many health problems (tester and irniq, ) . the challenges facing first nations and mé tis will be similarly diverse, reflecting colonial history, extent of environmental dispossession, existence of outstanding land claims, and local institutional capacity and accountability. geography also matters. aboriginal peoples living in remote areas generally face more challenges and enhanced climate vulnerability than urban populations on account of their remoteness, close links to the land, and more pronounced socio-economic-political marginalization. access to informal health networks (e.g. through family, community wellness initiatives), however, remain strong in remote settlements and more is known about the burden of ill health among remote aboriginal populations than urban-based populations (adelson, ; wilson and young, ) . the factors that are identified here as creating aboriginal health system vulnerability in canada are also evident among indigenous populations in other 'fourth world' contexts. similarly, many adaptation challenges noted here are comparable to those documented by other studies in mostly middle-and some lowincome nations, challenging the generalization that developed nations have a high capacity to adapt to climate change. yet despite this, there are few examples of systematic attempts to assess the vulnerability of indigenous peoples, identify adaptation needs, or initiate adaptation action. as has been argued in the general climate change and health literature, a new public health movement is required to promote adaptation to the health effects of climate change (costello et al., ) . for indigenous peoples in developed nations this movement needs: interdisciplinary scientific research to characterize climate vulnerabilities specifically at local and regional levels and identify and prioritize opportunities for adaptation. health sector leadership to integrate climate change into health planning and provide guidance on the risks of climate change and importance of adaptation. effective communication from 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physical science basis. contribution of working group i to the fourth assessment report of the intergovernmental panel on climate change the role of governance in community adaptation to climate change indigenous health part : the underlying causes of the health gap reforming health protection and promotion in canada: time to act. ottawa, report of the standing senate committee on social affairs inadequate surveillance global climate change and health: recent findings and future steps acculturation strategies and ethnic identity as predictors of behavior problems in arctic minority adolescents nutrition and food security in kugaaruk, nunavut: baseline survey for the food mail pilot project. department of indian and northern affairs nutrition and food security in fort severn, ontario: baseline survey for the food mail pilot project from impacts to adaptation: canada in a changing climate . government of canada politicians must heed health effects of climate change addressing human security in the arctic in the context of climate change through science and technology. mitigation and adaptation strategies for urban aboriginal understandings and experiences of tuberculosis in montreal a first nations voice in the present creates healing in the future aboriginal health the canada health act: overview and options: parliamentary research publication # - e. government of canada understanding barriers to healthcare: a review of disparities in health care services among indigenous populations drinking water and potential threats to human health in nunavik: adaptation strategies under climate change conditions arctic change and coastal communities: overview of the coastal zone canada conference cancer-related health behaviours and health service use among inuit and other residents of canada's north population health as the 'bottom line' of sustainability: a contemporary challenge for public health researchers addressing the realities of health care in northern aboriginal communities through participatory action research addressing the realties of health care in northern aboriginal communities through participatory action research integrating telehealth into aboriginal healthcare: the canadian experience climate change from an indigenous perspective nunavut's health system: annual report on the state of inuit culture and society mapping vulnerability to multiple stressors: climate change and globalization in india questioning complacency: climate change impacts, vulnerability, and adaptation in norway why different interpretations of vulnerability matter in climate change discourses climate change and the potential for range expansion of the lyme disease vector ixodes scapularis in canada the politics of health in the fourth world: a northern canadian example an outbreak of diarrhea due to verotoxin-producing escherichia coli in the canadian northwest-territories climate change and impacts on human health in the arctic: an international workshop on emerging threats and the response of arctic communities to climate change international circumpolar international surveillance, an arctic network for surveillance of infectious diseases overshoot, adapt and recover aboriginal roundtable to kelowna accord: aboriginal policy negotiations health impact assessment of global climate change: expanding on comparative risk assessment approaches for policy making community collaboration and climate change research in the canadian arctic inuit vulnerability and adaptive capacity to climate change in ulukhaktok the chief public health officer's report on the state of public health in canada northern canada in a changing climate: major findings and conclusions climatic conditions in northern canada: past and future implications of climate change for economic development in northern canada: energy, resource, and transportation sectors implications of climate change for northern canada: the physical environment barriers to addressing the social determinants of health: insights from the canadian experience department of indian and northern affairs indian/non-indian life expectancy: why the gap? social support, material circumstance and health behaviour: influences on health in first nation and inuit communities of canada the determinants of first nation and inuit health: a critical population health approach building on values: the future of health care in canada. commision on the future of public health care in canada global warming: stop worrying, start panicking? proceedings of the national academy of sciences of the united states of human health in a changing climate. health canada aboriginal conditions in census metropolitan areas adaptation, adaptive capacity, and vulnerability understanding the health of indigenous peoples in canada: key methodological and conceptual challenges indigenous health performance measurement systems in canada aboriginal peoples in canada in : inuit, mé tis and first nations canada in : inuit, mé tis and first nations indigenous health. . disappearing, displaced, and undervalued: a call to action for indigenous health worldwide entrenchment or enhancement: could climate change adaptation help to reduce chronic poverty? inuit qaujimajatuqangit: social history, politics and the practice of resistance a role of high impact weather events in waterborne disease outbreaks in canada the health of off-reserve aboriginal population. supplements to climate change in northern quebec: adaptation strategies from community-based research women's health surveillance: implications for policy it's so different today'': climate change and indigenous lifeways in british columbia report of the working group on the universal periodic review* canada access and utilization of health services by british columbia's rural aboriginal population environmental health implications of global climate change keeping our cool: canada in a warming world. penguin group (canada) an overview of aboriginal health research in the social sciences: current trends and future directions from isotopes to tk interviews: towards interdisciplinary research in fort resolution and the slave river delta, northwest territories future health consequences of the current decline in us household income this project was supported by the social sciences and humanities research council of canada, the canadian institutes of health research, arcticnet, and the international polar year caviar project. two anonymous reviewers provided detailed and constrcutive feedback. thanks to adam bonnycastle for figures and . key: cord- -tpqsjjet authors: nan title: section ii: poster sessions date: - - journal: j urban health doi: . /jurban/jti sha: doc_id: cord_uid: tpqsjjet nan food and nutrition programs in large urban areas have not traditionally followed a systems approach towards mitigating food related health issues, and instead have relied upon specific issue interventions char deal with downstream indicators of illness and disease. in june of , the san francisco food alliance, a group of city agencies, community based organizations and residents, initiated a collahorarive indicator project called rhe san francisco food and agriculture assessment. in order to attend to root causes of food related illnesses and diseases, the purpose of the assessment is to provide a holistic, systemic view of san francisco\'s food system with a focus on three main areas that have a profound affect on urban public health: food assistance, urban agriculture, and food retailing. using participatory, consensus methods, the san francisco food alliance jointly developed a sec of indicators to assess the state of the local food system and co set benchmarks for future analysis. members collected data from various city and stare departments as well as community based organizations. through the use of geographic information systems software, a series of maps were created to illustrate the assets and limitations within the food system in different neighborhoods and throughout the city as a whole. this participatory assessment process illustrates how to more effectively attend to structural food systems issues in large urban areas by ( t) focusing on prevention rather than crisis management, ( ) emphasizing collaboration to ensure institutional and structural changes, and ( ) aptly translating data into meaningful community driven prevention activities. to ~xplore the strategies to overcome barriers to population sample, we examined the data from three rapid surveys conducted at los angeles county (lac). the surveys were community-based partic· patory surveys utilizing a modified two-stage cluster survey method. the field modifications of the method resulted in better design effect than conventional cluster sample survey (design effect dose to that if the survey was done as simple random sample survey of the same size). the surveys were con· ducte~ among parents of hispanic and african american children in lac. geographic area was selected and d .v ded int.o small c~usters. in the first stage, clusters were selected with probability proportionate to estimated size of children from the census data. these clusters were enumerated to identify and develop a list of households with eligible children from where a random sample was withdrawn. data collectmn for consented respondents involved - minutes in-home interview and abstraction of infor· ma~ion from vaccine record card. the survey staff had implemented community outreach activities designed to fost~r an~ maintain community trust and cooperation. the successful strategies included: developing re.lat on .w. th local community organizations; recruitment of community personnel and pro· vide them with training to conduct the enumeration and interview; teaming the trained community introduction: though much research has been done on the health and social benefits of pet ownership for many groups, there have been no explorations of what pet ownership can mean to adults who are marginalized, living on fixed incomes or on the street in canada. we are a community group of researchers from downtown toronto. made up of front line staff and community members, we believe that community research is important so that our concerns, visions, views and values are presented by us. we also believe that research can and should lead to social change. method: using qualitative and exploratory methods, we have investigated how pet ownership enriched and challenged the lives of homeless and transitionally housed people. our research team photographed and conducted one-on-one interviews with pet owners who have experienced home· lessncss and live on fixed incomes. we had community participation in the research through a partnership with the fred vicror centre camera club. many of the fred victor centre camera club members have experienced homelessness and being marginalized because of poverty. the members of the dub took the photos and assisted in developing the photos. they also participated in the presenta· tion of our project. results: we found that pet ownership brings important health and social benefits to our partici· pants. in one of the most poignant statements, one participant said that pet ownership " ... stops you from being invisible." another commented that "well, he taught me to slow down, cut down the heavy drugs .. " we also found that pet ownership brings challenges that can at times be difficult when one is liv· ing on a fixed income. we found that the most difficult thing for most of the pet owners was finding affordable vet care for their animals. conclusion: as a group, we decided that research should only be done if we try to make some cha.nges about what we have learned. we continue the project through exploring means of affecting social change--for example, ~eti.tions and informing others about the result of our project. we would like to present our ~mdmgs and experience with community-based participatory action resea.rch m an oral. presentarton at yo~r conference in october. our presentation will include com· mumty representation ~f. both front-hne staff and people with lived experience of marginalization and homdessness. if this is not accepted as an oral presentation, we are willing to present the project m poster format. introduction the concept of a healthy city was adopted by the world health organization some time ago and it includes strong support for local involvement in problem solving and implementation of solutions. while aimed at improving social, economic or environmental conditions in a given community, more significantly the process is considered to be a building block for poliq reform and larger scale 'hange, i.e. "acting locally while thinking globally." neighbourhood planning can he the entry point for citizens to hegin engaging with neighbours on issues of the greater common good. methods: this presentation will outline how two community driven projects have unfolded to address air pollution. the first was an uphill push to create bike lanes where car lanes previously existed and the second is an ongoing, multi-sectoral round table focused on pollution and planning. both dt•monstrate the importance of having support with the process and a health focus. borrowing from traditions of "technical aid"• and community development the health promoter /planner has incorporated a range of "determinants of health" into neighbourhood planning discussions. as in most urban conditions the physical environment is linked to a range of health stressors such as social isolation, crowding, noise, lack of open space /recreation, mobility and safety. however typical planning processes do not hring in a health perspective. health as a focus for neighbourhood planning is a powerful starti_ng point when discussing transportation planning or changing land-uses. by raising awareness on determmants of health, citizens can begin to better understand how to engage in a process and affect change. often local level politics are involved and citizens witness policy change in action. the environmental liaison committee and the dundas east hike lanes project resulted from local level initiatives aimed at finding solutions to air pollution -a priority identified hy the community. srchc supported the process with facilitation and technical aid. _the processs had tangible results that ultimately improve living conditions and health. •tn the united kmgdom plannm in the 's established "technical aid" offices much like our present day legal aid system to provide professional support and advocacy for communities undergoing change. p - (c) integrating community based research: the experience of street health, a community service agency i.aura cowan and jacqueline wood street health began offering services to homeless men and women in east downtown ~oronto in . nursing stations at drop-in centres and shelters were fo~lowed by hiv/aids prevent ~, harm reduction and mental health outreach, hepatitis c support, sleeping bag exchange, and personal tdennfication replacement and storage programs. as street health's progi;ams expanded, so to~ did the agency:s recognition that more nee~ed t~ be done to. address the underl~ing causes of, th~ soct~l and economic exclusion experienced by its clients. knowing t.h~t. a~voca~y ts. helped by . evtd~nce , street he.alt~ embarked on a community-based research (cbr) initiative to dent fy commumty-dnven research priorities within the homeless and underhoused population. methods: five focus groups were conducted with homeless people, asking participants to identify positive and negative forces in their lives, and which topics were important to take action on and learn more about. findings were validated through a validation meeting with participants. results: participants identified several important positive and negative forces in their lives. key positive forces included caring and respectful service delivery, hopefulness and peer networks. key negative forces included lack of access to adequate housing and income security, poor service delivery and negative perceptions of homeless people. five topics for future research emerged from the process, focusing on funding to address homelessness and housing; use of community services for homeless people; the daily survival needs of homeless people and barriers to transitioning out of homelessness; new approaches to service delivery that foster empowerment; and policy makers' understanding of poverty and homelessness. conclusions: although participants expressed numerous issues and provided much valuable insight, definitive research ideas and action areas were not clearly identified by participants. however, engagement in a cbr process led to some important lessons and benefits for street health. we learned that the community involvement of homeless people and front-line staff is critical to ensuring relevance and validity for a research project; that existing strong relationships with community parmers are essential to the successful implementation of a project involving marginalized groups; and that an action approach focusing on positive change can make research relevant to directly affected people and community agency staff. street health benefited from using a cbr approach, as the research process facilitated capacity building among staff and within the organization as a whole. p - (c) a collaborative process to achieve access to primary health care for black women and women of colour: a model of community based participartory research notisha massaquoi, charmaine williams, amoaba gooden, and tulika agerwal in the current healthcare environment, a significant number of black women and women of color face barriers to accessing effective, high quality services. research has identified several issues that contribute to decreased access to primary health care for this population however racism has emerged as an overarching determinant of health and healthcare access. this is further amplified by simultaneous membership in multiple groups that experience discrimination and barriers to healthcare for example those affected by sexism, homelessness, poverty, homophobia and heterosexism, disability and hiv infection. the collaborative process to achieve access to primary health care for black women and women of colour project was developed with the university of toronto faculty of social work and five community partners using a collaborative methodology to address a pressing need within the community ro increase access to primary health care for black women and women of colour. women's health in women's hands community health centre, sistering, parkdale community health centre, rexdale community health centre and planed parenthood of toronto developed this community-based participatory-action research project to collaboratively barriers affecting these women, and to develop a model of care that will increase their access to health services. this framework was developed using a process which ensured that community members from the target population and service providers working in multiculrural clinical settings, were a part of the research process. they were given the opportunity to shape the course of action, from the design of the project to the evaluation and dissemination phase. empowerment is a goal of the participatory action process, therefore, the research process has deliberately prioritized _ro enabling women to increase control over their health and well-being. in this session, the presenters will explore community-based participatory research and how such a model can be useful for understanding and contextualizing the experiences of black women and women of colour. they will address. the development and use of community parmerships, design and implementation of the research prorect, challenges encountered, lessons learnt and action outcomes. they will examine how the results from a collaborative community-based research project can be used as an action strategy to poster sessions v address che social determinants of women health. finally the session will provide tools for service providers and researchers to explore ways to increase partnerships and to integrate strategies to meet the needs of che target population who face multiple barriers to accessing services. lynn scruby and rachel rapaport beck the purpose of this project was ro bring traditionally disenfranchised winnipeg and surrounding area women into decision-making roles. the researchers have built upon the relationships and information gachered from a pilot project and enhanced the role of input from participants on their policy prioriries. the project is guided by an advisory committee consisting of program providers and community representatives, as well as the researchers. participants included program users at four family resource cencres, two in winnipeg and two located rurally, where they participated in focus groups. the participants answered a series of questions relating to their contact with government services and then provided inpuc as to their perceptions for needed changes within government policy. following data analysis, the researchers will return to the four centres to share the information and continue che discussion on methods for advocating for change. recommendations for program planning and policy development and implementation will be discussed and have relevance to all participants in the research program. women's health vera lefranc, louise hara, denise darrell, sonya boyce, and colleen reid women's experiences with paid and unpaid work, and with the formal and informal economies, have shifted over the last years. in british columbia, women's employability is affected by government legislation, federal and provincial policy changes, and local practices. two years ago we formed the coalition ior women's economic advancement to explore ways of dealing with women's worsening economic situations. since the formation of the coalition we have discussed the need for research into women's employabilicy and how women were coping and surviving. we also identified how the need to document the nature of women's employability and reliance on the informal economy bore significanc mechodological and ethical challenges. inherent in our approach is a social model of women's health that recognizes health as containing social, economic, and environmental determinants. we aim to examine the social contexc of women's healch by exploring and legitimizing women's own experiences, challenging medical dominance in understandings of health, and explaining women's health in terms of their subordination and marginalizacion. through using a feminist action research (far) methodology we will explore the relationship between women's employability and health in communities that represent bricish columbia's social, economic, cultural/ethnic, and geographic diversities: skidegate, fort st . .john, lumhy, and surrey. over the course of our year project, in each community we will establish and work with advisory committees, hire and train local researchers, conduct far (including a range of qualitative methods), and support action and advocacy. since the selected communities are diverse, the ways that the research unfolds will ·ary between communities. expected outcomes, such as the provision of a written report and resources, the establishment of a website for networking among the communities, and a video do.:umentary, are aimed at supporting the research participants, coalition members, and advisory conuniuces in their action efforts. p t (c) health & housing: assessing the impact of transitional housing for people living with hiv i aids currently, there is a dearth of available literature which examines supporrive housing for phas in the canadian context. using qualitative, one-on-one interviews we investigace the impact of transitional housing for phaswho have lived in the up to nine month long hastings program. our post<'r pr<·senta-t on will highlight research findings, as well as an examination of transitional housing and th<· imp;kt it has on the everyday lives of phas in canada. this research is one of two ground breaking undertakings within the province of ontario in which fife house is involved. p - (c) eating our way to justice: widening grassroots approaches to food security, the stop community food centre as a working model charles l.evkoe food hanks in north america have come co play a central role as the widespread response to growing rates of hunger. originally thought to be a short term-solution, over the last years, they have v poster sessions be · · · · d wi'thi'n society by filling the gaps in the social safety net while relieving govemcome mst tut ona ze . . . t f the ir responsibilities. dependent on corporate donations and sngmauzmg to users, food banks men so th' . · i i . are incapable of addressing the structural cause~ of ~u~ger. s pres~ntation w e~~ ore a ternanve approaches to addressing urban food security while bmldmg more sustamabl.e c~mmumt es. i:nrough the f t h st p community food centre, a toronto-based grassroots orgamzanon, a model is presented case e h'l k' b 'id · b that both responds to the emergency food needs of communities w e wor mg to. u ~ sustama le and just food system. termed, the community food centre model. (cfc), ~he s~op is worki?g to widen its approach to issues of food insecurity by combining respectful ~ rect service wit~ com~~mty ~evelop ment, social justice and environmental sustainability. through this approach, various critical discourses around hunger converge with different strategic and varied implications for a~ion. as a plac~-based organization, the stop is rooted within a geographical space and connected directly to a neighbourhood. through working to increase access to healthy food, it is active in maintaining people's dignity, building a strong and democratic community and educating for social change. connected to coalitions and alliances, the stop is also active in organizing across scales in connection with the global food justice movement. inner city shelter vicky stergiopoulos, carolyn dewa, katherine rouleau, shawn yoder, and lorne tugg introduction: in the city of toronto there are more than , hostel users each year, many with mental health and addiction issues. although shelters have responded in various ways to the health needs of their clients, evidence on the effectiveness of programs delivering mental health services to the home· less in canada has been scant. the objective of this community based research was to provide a forma· tive evaluation of a multi-agency collaborative care team providing comprehensive care for high needs clients at toronto's largest shelter for homeless men. methods: a logic model provided the framework for analysis. a chart review of clients referred over a nine month period was completed. demographic data were collected, and process and outcome indicators were identified for which data was obtained and analyzed. the two main outcome measures were mental status and housing status months after referral to the program. improvement or lack of improvement in mental status was established by chart review and team consensus. housing outcomes were determined by chart review and the hostel databases. results: of the clients referred % were single and % were unemployed. forty four percent had a psychiatric hospitalization within the previous two years. the prevalence of severe and persistent men· tal illness, alcohol and substance use disorders were %, % and % respectively. six months after referral to the program % of clients had improved mental status and % were housed. logistic regression controlling for the number of general practitioner and psychiatrist visits, presence of person· ality or substance use disorder and treatment non adherence identified two variables significantly associ· ated mental status improvement: the number of psychiatric visits (or, . ; % ci, . - . ) and treatment non adherence (or, . ; % ci, . - . ). the same two variables were associated with housing outcomes. history of forensic involvement, the presence of a personality or substance use disorder and the number of visits with a family physician were not significantly associated with either outcome. conclusions: despite the limitations in sample sire and study design, this study can yield useful informa· tion to program planners. our results suggest that strategies to improve treatment adherence and access to mental health specialists can improve outcomes for this population. although within primary care teams the appropriate collaborative care model for this population remains to be established, access to psychiatric follow up, in addition to psychiatric assessment services, may be an important component of a successful program. mount sinai hospital (msh) has become one of the pre-eminent hospitals in the world by contributing to the development of innovative approaches to effective health care and disease prevention. recently, the hospital has dedicated resources towards the development of a strategy aimed at enhancing the hospital's integration with its community partners. this approach will better serve the hospital in the current health care environment where local health integration networks have been struck to enhance and support local capacity to plan, coordinate and integrate service delivery. msh has had early success with developing partnerships. these alliances have been linked to programs serving key target populations with _estabhshe~. points of access to msh. recognizing the need to build upon these achievements to remain compe~mve, the hospital has developed a community integration strategy. at the forefront of this strategy is c.a.r.e (community advisory reference engine): the hospital's compendium of poster sessions v community partners. as a single point of access to community partner information, c.a.r.e. is more than a database. c.a.r.e. serves as the foundation for community-focused forecasting and a vehicle for inter and intra-organizational knowledge transfer. information gleaned from the catalog of community parmers can be used to prepare strategic, long-term partnership plans aimed at ensuring that a comprehensive array of services can be provided to the hospital community. c.a.r.e. also houses a permanent record of the hospital's alliances. this prevents administrative duplication and facilitates the formation of new alliances that best serve both the patient and the hospital. c.a.r.e. is not a stand-alone tool and is most powerful when combined with other aspects of the hospital's community integration strategy. it iscxpected that data from the hospital's community advisory committees and performance measurement department will also be stored alongside stakeholder details. this information can then be used to drive discussions at senior management and the board, ensuring congruence between stakeholder, patient and hospital objectives. the patient stands to benefit from this strategy. the unique, distinct point of reference to a wide array of community services provides case managers and discharge planners with the information they need to connect patients with appropriate community services. creating these linkages enhances the patient's capacity to convalesce in their homes or places of residence and fosters long-term connections to neighborhood supports. these connections can be used to assist with identifying patients' ongoing health care needs and potentially prevent readmission to hospital. introduction: recruiting high-risk drug users and sex workers for hiv-prevention research has often been hampered by limited access to hard to reach, socially stigmatized individuals. our recruitment effom have deployed ethnographic methodology to identify and target risk pockets. in particular, ethnographers have modeled their research on a street-outreach model, walking around with hiv-prevention materials and engaging in informal and structured conversations with local residents, and service providers, as well as self-identified drug users and sex workers. while such a methodology identifies people who feel comfortable engaging with outreach workers, it risks missing key connections with those who occupy the margins of even this marginal culture. methods: ethnographers formed a women's laundry group at a laundromat that had a central role as community switchboard and had previously functioned as a party location for the target population. the new manager helped the ethnographers invite women at high risk for hiv back into the space, this time as customers. during weekly laundry sessions, women initiated discussions about hiv-prevention, sexual health, and eventually, the vaccine research for which the center would be recruiting women. ra.its: the benefits of the group included reintroducing women to a familiar locale, this time as customers rather than unwelcome intruders; creating a span of time (wash and dry) to discuss issues important to me women and to gather data for future recruitment efforts; creating a location to meet women encountered during more traditional outreach research; establishing the site as a place for potential retention efforts; and supporting a local business. women who participated in the group completed a necessary household task while learning information that they could then bring back to the community, empowering them to be experts on hiv-prevention and vaccine research. some of these women now assist recruitment efforts. the challenges included keeping the group women-only, especially after lunch was provided, keeping the membership of the group focused on women at risk for hiv, and keeping the women in the group while they did their laundry. conclusion: public health educators and researchers can benefit from identifying alternate congregation sites within risk pockets to provide a comfortable space to discuss hiv prevention issues with high-risk community members. in our presentation, we will describe the context necessary for similar research, document the method's pitfalls and successes, and argue that the laundry group constitutes an ethical, respectful, community-based method for recruitment in an hiv-prevention vaccine trial. p - t (c) upgrading inner city infrastructure and services for improved environmental hygiene and health: a case of mirzapur in u.p. india madhusree mazumdar in urgency for agricultural and industrial progress to promote economic d.evelopment follo_wing independence, the government of india had neglected health promotion and given less emphasis on infrastructure to promote public health for enhanced human pro uct v_ity. ong wit r~p m astrucrure development, which has become essential if citie~ are to. act ~s harbmger.s of econ~nuc ~owth, especially after the adoption of the economic liberalization policy, importance _is a_lso ~emg g ve.n to foster environmental hygiene for preventive healthcare. the world health orga~ sat ~ is also trj:' ! g to help the government to build a lobby at the local level for the purpose by off~rmg to mrroduce_ its heal.thy city concept to improve public health conditions, so as to reduce th_e disease burden. this pape~ s a report of the efforts being made towards such a goal: the paper descr~bes ~ c~se study ?f ~ small city of india called mirzapur, located on the banks of the nver ganga, a ma or lifeline of india, m the eastern part of the state of uttar pradesh, where action for improvement began by building better sanitation and environmental infrastructure as per the ganga action plan, but continued with an effort to promote pre· ventive healthcare for overall social development through community participation in and around the city. asthma physician visits in toronto, canada tara burra, rahim moineddin, mohammad agha, and richard glazier introduction: air pollution and socio-economic status are both known to be associated with asthma in concentrated urban settings but little is known about the relationship between these factors. this study investigates socio-economic variation in ambulatory physician consultations for asthma and assesses possible effect modification of socio-economic status on the association between physician visits and ambient air pollution levels for children aged to and adults aged to in toronto, canada between and . methods: generalized additive models were used to estimate the adjusted relative risk of asthma physician visits associated with an interquartile range increase in sulphur dioxide, nitrogen dioxide, pm . , and ozone, respectively. results: a consistent socio-economic gradient in the number of physician visits was observed among children and adults and both sexes. positive associations between ambient concentrations of sul· phur dioxide, nitrogen dioxide and pm . and physician visits were observed across age and sex strata, whereas the associations with ozone were negative. the relative risk estimates for the low socio-«onomic group were not significantly greater than those for the high socio-economic group. conclusions: these findings suggest that increased ambulatory physician visits represent another component of the public health impact of exposure to urban air pollution. further, these results did not identify an age, sex, or socio-economic subgroup in which the association between physician visits and air pollution was significantly stronger than in any other population subgroup. eco-life-center (ela) in albania supports a holistic approach to justice, recognizing the environ· mental justice, social justice and economic justice depend upon and support each other. low income cit· izens and minorities suffer disproportionately from environmental hazards in the workplace, at home, and in their communities. inadequate laws, lax enforcement of existing environmental regulations, and ~ea.k penalties for infractions undermine environmental protection. in the last decade, the environmental ust ce m~ve~ent in tirana metropolis has provided a framework for identifying and exposing the links ~tween irrational development practices, disproportionate siting of toxic facilities, economic depres· s on, and a diminished quality of life in low-income communities and communities of color. the envi· ~onmental justice agenda has always been rooted in economic, racial, and social justice. tirana and the issues su.rroun~ing brow~fields redevelopment are crucial points of advocacy and activism for creating ~ubstantia~ social chan~~ m low-income communities and communities of color. we engaging intensively m prevcnnng co'.' mumnes, especially low income or minority communities, from being coerced by gov· ernmenta~ age_nc es or companies into siting hazardous materials, or accepting environmentally hazard· ous_ practices m order to create jobs. although environmental regulations do now exist to address the environmental, health, and social impacts of undesirable land uses, these regulations are difficult to poster sessions v enforce because many of these sites have been toxic-ridden for many years and investigation and cleanup of these sites can be expensive. removing health risks must be the main priority of all brown fields action plans. environmental health hazards are disproportionately concentrated in low-income communities of color. policy requirements and enforcement mechanisms to safeguard environmental health should be strengthened for all brownfields projects located in these communities. if sites are potentially endangering the health of the community, all efforts should be made for site remediation to be carried out to the highest cleanup standards possible towards the removal of this risk. the assurance of the health of the community should take precedence over any other benefits, economic or otherwise, expected to result from brownfields redevelopment. it's important to require from companies to observe a "good neighbor" policy that includes on-site visitations by a community watchdog committee, and the appointment of a neighborhood environmentalist to their board of directors in accordance with the environmental principles. vancouver - michael buzzelli, jason su, and nhu le this is the second paper of research programme concerned with the geographical patterning of environmental and population health at the urban neighbourhood scale. based on the vancouver metropolitan region, the aim is to better understand the role of neighbourhoods as epidemiological spaces where environmental and social characteristics combine as health processes and outcomes at the community and individual levels. this paper builds a cohort of commensurate neighbourhoods across all six censuses periods from to , assembles neighbourhood air pollution data (several criterion/health effects pollutants), and providing an analysis to demonstrate how air pollution systematically and consistently maps onto neighbourhood socioeconomic markers, in this case low education and lone-parent families. we conclude with a discussion of how the neighbourhood cohort can be further developed to address emergent priorities in the population and environmental health literatures, namely the need for temporally matched data, a lifecourse approach, and analyses that control for spatial scale effects. solid waste management and environment in mumbai (india) by uttam jakoji sonkamble and bairam paswan abstract: mumbi is the individual financial capital of india. the population of greater mumbai is , , and sq. km. area. the density of population , per sq. km. the dayto-day administration and rendering of public services within gr. mumbai is provided by the brihan mumbai mahanagar palika (mumbai corporation of gr. mumbai) that is a body of elected councilors on a -year team. mumcial corporation provides varies conservancy services such as street sweeping, collection of solid waste, removal and transportation, disposal of solid waste, disposal of dead bodies of animals, construction, maintance and cleaning of urinals and public sanitary conveniences. the solid waste becoming complicated due to increase in unplanned urbanization and industrialization, the environment has deteriorated significantly due to inter, intra and international migration stream to mumbai. the volume of inter state migration to mumbai is considerably high i.e. . lakh and international migrant . lakh have migrated to mumbai. present paper gives the view on solid waste management and its implications to environment and health. pollution from a wide varity of emission, such as from automobiles and industrial activities, has reached critical level in mumbai, causing respiratory, ocular, water born diseases and other health problems. sources of generation of waste are -household waste, commercial waste, institutional waste, street sweeping, silt removed from drain/nallah/cleanings. disposal of solid waste in gr. mumbai done under incineration . processing to produce organic manure. . vermi-composting . landfill the study shows that the quantity of waste disposal of through processing and conversion to organic ~anure is about - m.t. per day. the processing is done by a private agency m/s excel industries ltd. who had set up a plant at the chincholi dumping ground in western mumbai for this purpose. the corporation is also disposal a plant of its waste mainly market waste through the environment friendly, natural pro-ces~ known as vermi-composing about m.t. of market waste is disposed of in this manner at the various sites. there are four land fill sites are available and percent of the waste matter generated m mumbai is disposed of through landfill. continuous flow of migrant and increa~e in slum population is a complex barrier in the solid waste management whenever community pamc pat on work strongly than only we can achieved eco-friendly environment in mumbai. persons exposed to residential craffic have elevated races of respiratory morbidity an~ ~ortality. since poverty is an important determinant of ill-health, some h~ve argued that t~es~ assoc at ons may relate to che lower socioeconomic status of those living along ma or roads. our ob ect ve was to evaluate the association between traffic intensity at home and hospital admissions for respiratory diagnoses among montreal residents older than years. morning peak traffic estimates from the emmej montreal traffic model (motrem ) were used as an indicator of exposure to road traffic outside the homes of those hospitalised. the influence of socioeconomic status on the relationship between traffic intensity and hospital admissions for respiratory diagnoses was explored through assessment of confounding by lodging value, expressed as the dollar average over road segments. this indicator of socioeconomic status, as calculated from the montreal property assessment database, is available at a finer geographic scale than socioeconomic information accessible from the canadian census. there was an inverse relationship between traffic intensity estimates and lodging values for those hospitalised (rho - . , p vehicles during che hour morning peak), even after adjustment for lodging value (crude or . , cl % . - . ; adjusted or . , cl % . - . ). in montreal, elderly persons living along major roads are at higher risk of being hospitalised for respiratory illnesses, which appears not simply to reflect the fact that those living along major roads are at relative economic disadvantage. the paper argues that human beings ought to be at the centre of the concern for sustainable development. while acknowledging the importance of protecting natural resources and the ecosystem in order to secure long term global sustainability, the paper maintain that the proper starting point in the quest for urban sustainability in africa is the 'brown agenda' to improve che living and working environment of che people, especially che urban poor who face a more immediate environmental threat to their health and well-being. as the un-habitat has rightly observed, it is absolutely essential "to ensure that all people have a sufficient stake in the present to motivate them to take part in the struggle to secure the future for humanity.~ the human development approach calls for rethinking and broadening the narrow technical focus of conventional town planning and urban management in order to incorporate the emerging new ideas and principles of urban health and sustainability. i will examine how cities in sub-saharan africa have developed over the last fifty years; the extent to which government policies and programmes have facilitated or constrained urban growth, and the strategies needed to achieve better functioning, safer and more inclusive cities. in this regard i will explore insights from the united nations conferences of the s, especially local agenda of the rio summit, and the istanbul declaration/habitat agenda, paying particular attention to the principles of enablement, decentralization and partnership canvassed by these movements. also, i will consider the contributions of the various global initiatives especially the cities alliance for cities without slums sponsored by the world bank and other partners; che sustainable cities programme, the global campaigns for good governance and for secure tenure canvassed by unhabit at, the healthy cities programme promoted by who, and so on. the concluding section will reflect on the future of the african city; what form it will take, and how to bring about the changes needed to make the cities healthier, more productive and equitable, and better able to meet people's needs. heather jones-otazo, john clarke, donald cole, and miriam diamond urban areas, as centers of population and resource consumption, have elevated emissions and concentrations of a wide range of chemical contaminants. we have developed a modeling framework in which we first ~stimate the emissions and transport of contaminants in a city and second, use these estimates along with measured contaminant concentrations in food, to estimate the potential health risk posed by these che.micals. the latter is accomplished using risk assessment. we applied our modeling framework to consider two groups of chemical contaminants, polycyclic aromatic hydrocarbons (pah) a.nd the flame re~ardants polybrominated diphenyl ethers (pbde). pah originate from vehicles and stationary combustion sources. ~veral pah are potent carcinogens and some compounds also cause noncancer effects. pbdes are additive flame retardants used in polyurethane foams (e.g., car seats, furniture) fer sessions v and cl~ equipm~nt (e.g., compute~~· televisio~s). two out of three pbdes formulations are being voluntarily phased by mdustry due to rmng levels m human tissues and their world-wide distribution. pbdes have been .related to adv.erse neurological, developmental and reproductive effects in laboratory ijlimals. we apphed our modelmg framework to the city of toronto where we considered the southcattral area of by km that has a population of . million. for pah, local vehicle traffic and area sources contribute at least half of total pah in toronto. local contributions to pbdes range from - %, depending on the assumptions made. air concentrations of both compounds are about times higher downtown than km north of toronto. although measured pah concentrations in food date to the s, we estimate that the greatest exposure and contribution to lifetime cancer risk comes from ingestion of infant formula, which is consistent with toxicological evidence. the next greatest exposure and cancer risk are attributable to eating animal products (e.g. milk, eggs, fish). breathing downtown air contributes an additional percent to one's lifetime cancer risk. eating vegetables from a home garden localed downtown contributes negligibly to exposure and risk. for pbdes, the greatest lifetime exposure comes through breast milk (we did not have data for infant formula), followed by ingestion of dust by the toddler and infant. these results suggest strategies to mitigate exposure and health risk. p - (a) immigration and socioeconomic inequalities in cervical cancer screening in toronto, canada aisha lofters, rahim moineddin, maria creatore, mohammad agha, and richard glazier llltroduction: pap smears are recommended for cervical cancer screening from the onset of sexual activity to age . socioeconomic and ethnoracial gradients in self-reported cervical cancer screening have been documented in north america but there have been few direct measures of pap smear use among immigrants or other socially disadvantaged groups. our purpose was to investigate whether immigration and socioeconomic factors are related to cervical cancer screening in toronto, canada. methods: pap smears were identified using fee codes and laboratory codes in ontario physician service claims (ohip) for three years starting in for women age - and - . all women with any health system contact during the three years were used as the denominator. social and economic factors were derived from the canadian census for census tracts and divided into quintiles of roughly equal population. recent registrants, over % of whom are expected to be recent immigrants to canada, were identified as women who first registered for health coverage in ontario after january , . results: among , women age - and , women age - , . % and . %, rtspcctively, had pap smears within three years. low income, low education, recent immigration, visible minority and non-english language were all associated with lower rates (least advantaged quintile:most advantaged quintile rate ratios were . , . , . , . , . , respectively, p < . for all). similar gradients were found in both age groups. recent registrants comprised . % of women and had mm;h lower pap smear rates than non-recent registrants ( . % versus . % for women age - and . % versus . % for women age - ). conclnsions: pap smear rates in toronto fall well below those dictated by evidence-based practice. at the area level, immigration, visible minority, language and socioeconomic characteristics are associated with pap smear rates. recent registrants, representing a largely immigrant group, have particularly low rates. efforts to improve coverage of cervical cancer screening need to be directed to all ~omen, their providers and the health system but with special emphasis on women who recently arrived m ontario and those with social and economic disadvantage. challeges faced: a) most of the resources are now being ~pent in ~reventing the sprea.d of hiv/ aids and maintaining the lives of those already affected. b) skilled medical ~rs~nal are dymg under· mining the capacity to provide the required health care services. ~) th.e comphcat o~s of hiv/aids has complicated the treatment of other diseases e.g. tbs d) the ep dem c has led. to mcrease number of h n requiring care and support. this has further stretched the resources available for health care. orp a s d db . . i methods used on our research: . a simple community survey con ucte y our orgamzat on vo · unteers in three urban centres members of the community, workers and health care prov~ders were interviewed ... . meeting/discussions were organized in hospitals, commun.ity centre a~d with government officials ... . written questionnaires to health workers, doctors and pohcy makers m th.e health sectors. lessors learning: • the biggest-health bigger-go towards hiv/aids prevention • aids are spreading faster in those families which are poor and without education. •women are the most affected. •all health facilities are usually overcrowded with hiv/aids patients. actions needed:• community education oh how to prevent the spread of hiv/aids • hiv/aids testing need to be encouraged to detect early infections for proper medical cover. • people to eat healthy • people should avoid drugs. implications of our research: community members and civic society-introduction of home based care programs to take care of the sick who cannot get a space in the overcrowded public hospitals. prl-v a te sector private sector has established programs to support and care for the staff already affected. government provision of support to care-givers, in terms of resources and finances. training more health workers. introduction: australian prisons contain in excess of , prisoners. as in most other western countries, reliance on 'deprivation of liberty' is increasing. prisoner numbers are increasing at % per annum; incarceration of women has doubled in the last ten years. the impacts on the community are great - % of children have a parent in custody before their th birthday. for aboriginal communities, the harm is greater -aboriginal and/or torres strait islanders are incarcerated at a rate ten times higher than other australians. % of their children have a parent in custody before their th birthday. australian prisons operate under state and territory jurisdictions, there being no federal prison system. eight independent health systems, supporting the eight custodial systems, have evolved. this variability provides an unique opportunity to assess the capacity of these health providers in addressing the very high service needs of prisoners. results: five models of health service provision are identified -four of which operate in one form or another in australia: • provided by the custodial authority (queensland and western australia)• pro· vided by the health ministry through a secondary agent (south australia, the australian capital territory and tasmania) • provided through tendered contract by a private organization (victoria and northern territory) • provided by an independent health authority (new south wales) • (provided by medics as an integral component of the custodial enterprise) since the model of the independent health authority has developed in new south wales. the health needs of the prisoner population have been quantified, and attempts are being made to quantify specific health risks /benefits of incarceration. specific enquiry has been conducted into prisoner attitudes to their health care, including issues such as client information confidentiality and access to health services. specific reference will be made to: • two inmate health surveys • two inmate access surveys, and • two service demand studies. conclusions: the model of care provision, with legislative, ethical, funding and operational independence would seem provide the best opportunity to define and then respond to the health needs of prisoners. this model is being adopted in the united kingdom. better health outcomes in this high-risk group, could translate into healthier families and their communities. p - (a) lnregrated ethnic-specific health care systems: their development and role in increasing access to and quality of care for marginalized ethnic minorities joshua yang introduction: changing demographics in urban areas globally have resulted in urban health systems that are racially and ethnically homogenous relative to the patient populations they aim to serve. the resultant disparities in access to and quality of health care experienced by ethnic minority groups have been addressed by short-term, instirutional level strategies. noticeably absent, however, have been structural approaches to reducing culturally-rooted disparities in health care. the development of ethnic-specific h~alth car~ systems i~ a structural, long-term approach to reducing barriers to quality health care for eth· me mmonty populations. methods: this work is based on a qualitative study on the health care experiences of san francisco chinatown in the united states, an ethnic community with a model ethnic-specific health care infrastrucrure. using snowball sampling, interviews were conducted with key stakeholders and archival research was conducted to trace and model the developmental process that led to the current ethnic-specific health care system available to the chinese in san francisco. grounded theory was the methodology ijltd to analysis of qualitative data. the result of the study is four-stage developmental model of ethnic-specific health infrastrueture development that emerged from the data. the first stage of development is the creation of the human capital resources needed for an ethnic-specific health infrastructure, with emphasis on a bilingual and bicultural health care workforce. the second stage is the effective organization of health care resources for maximal access by constituents. the third is the strengthening and stability of those institutional forms through increased organizational capacity. integration of the ethnic-specific health care system into the mainstream health care infrastructure is the final stage of development for an ethnic-specific infrastructure. conclusion: integrated ethnic-specific health care systems are an effective, long-term strategy to address the linguistic and cultural barriers that are being faced by the spectrum of ethnic populations in urban areas, acting as culturally appropriate points of access to the mainstream health care system. the model presented is a roadmap to empower ethnic communities to act on the constraints of their health and political environments to improve their health care experiences. at a policy level, ethnic-specific health care organizations are an effective long-term strategy to increase access to care and improve qualiiy of care for marginalized ethnic groups. each stage of the model serves as a target area for policy interventions to address the access and care issues faced by culturally and linguistically diverse populations. users in baltimore md: - noya galai, gregory lucas, peter o'driscoll, david celentano, david vlahov, gregory kirk, and shruti mehta introduction: frequent use of emergency rooms (er) and hospitalizations among injection drug users (idus) has been reported and has often been attributed to lack of access to primary health care. however, there is little longitudinal data which examine health care utilization over individual drug use careers. we examined factors associated with hospitalizations, er and outpatient (op) visits among idus over years of follow-up. methods: idus were recruited through community outreach into the aids link to lntravenous experience (alive) study and followed semi-annually. , who had at least follow-up visits were included in this analysis. outcomes were self-reported episodes of hospitalizations and er/op visits in the prior six months. poisson regression was used accounting for intra-person correlation with generalized estimation equations. hits: at enrollment, % were male, % were african-american, % were hiv positive, median age was years, and median duration of drug use was years. over a total of , visits, mean individual rates of utilization were per person years (py) for hospitalizations and per py for er/op visits. adjusting for age and duration of drug use, factors significantly associated with higher rates of hospitalization included hiv infection (relative incidence [ri(, . ), female gender (ri, . ), homelessness (ri, . ), as well as not being employed, injecting at least daily, snorting heroin, havmg a regular source of health care, having health insurance and being in methadone mainte.nance treatment (mmt). similar associations were observed for er/op visits except for mmt which was not associated with er/op visits. additional factors associated with lower er/op visits were use of alcohol, crack, injecting at least daily and trading sex for drugs. % of the cohort accounted for % of total er/op visits, while % of the cohort never reported an op visit during follow-up. . . . lgbt) populations. we hypothesized that prov dmg .appomtments .for p~t ~nts w thm hours would ensure timely care, increase patient satisfaction, and improve practice eff c ency. further, we anticipated that the greatest change would occur amongst our homeless patients.. . methods: we tested an experimental introduction of advanced access scheduling (usmg a hour rule) in the primary care medical clinic. we tracked variables inclu~ing waiting ti~e fo~ next available appointment; number of patients seen; and no-show rates, for an eight week penod pnor to and post introduction of the new scheduling system. both patient and provider satisfaction were assessed using a brief survey ( questions rated on a -pt scale). results and conclusion: preliminary analyses demonstrated shorter waiting times for appointments across the clinic, decreased no-show rates, and increased clinic capacity. introduction of the advanced access scheduling also increased both patient and provider satisfaction. the new scheduling was initiated in july . quantitative analyses to measure initial and sustained changes, and to look at differential responses across populations within our clinic, are currently underway. introduction: there are three recognized approaches to linking socio-economic factors and health: use of census data, gis-based measures of accessibility/availability, and resident self-reported opinion on neighborhood conditions. this research project is primarily concerned with residents' views about their neighborhoods, identifying problems, and proposing policy changes to address them. the other two techniques will be used in future research to build a more comprehensive image of neighborhood depri· vation and health. methods: a telephone survey of london, ontario residents is currently being conducted to assess: a) community resource availability, quality, access and use, b) participation in neighborhood activities, c) perceived quality of neighborhood, d) neighborhood problems, and e) neighborhood cohesion. the survey instrument is composed of indices and scales previously validated and adapted to reflect london specifically. thirty city planning districts are used to define neighborhoods. the sample size for each neighborhood reflects the size of the planning district. responses will be compared within and across neighborhoods. data will be linked with census information to study variation across socio-eco· nomic and demographic groups. linear and gis-based methods will be used for analysis. preliminary results: the survey follows a qualitative study providing a first look at how experts involved in community resource planning and administration and city residents perceive the availability, accessibility, and quality of community resources linked to neighborhood health and wellbeing, and what are the most immediate needs that should be addressed. key-informant interviews and focus groups were used. the survey was pre-tested to ensure that the language and content reflects real experiences of city residents. the qualitative research confirmed our hypothesis that planning districts are an acceptable surrogate for neighborhood, and that the language and content of the survey is appropriate for imple· mentation in london. scales and indices showed good to excellent reliability and validity during the pre· test (cronbach's alpha from . - . ). preliminary results of the survey will be detailed at the conference. conclusions: this study will help assess where community resources are lacking or need improve· ment, thus contributing to a more effective allocation of public funds. it is also hypothesized that engaged neighborhoods with a well-developed sense of community are more likely to respond to health programs and interventions. it is hoped that this study will allow london residents to better understand the needs and problems of their neighborhoods and provide a research foundation to support local understandmg of community improvement with the goal of promoting healthy neighborhoods. p - (a) hiv positive in new york city and no outpatient care: who and why? hannah wolfe and victoria sharp introduction: there are approximately million hiv positive individuals living in the united sta!es. about. % of these know their hiy status and are enrolled in outpatient care. of the remaining yo, approx~mately half do not know their status; the other group frequently know their status but are not enrolled m any .sys~em of outpatient care. this group primarily accesses care through emergency departments. when md cated, they are admitted to hospitals, receive acute care services and then, upon poster sessions v di 'harge, disappear from the health care system until a new crisis occurs, when they return to the emergency department. as a large urban hiv center, caring for over individuals with hiv we have an active inpatient service ".'ith appr~xi~.ately discharges annually. we decided to survey our inpatients to better charactenze those md v duals who were not enrolled in any system of outpatient care. results: % of inpatients were not enrolled in regular outpatient care: % at roosevelt hospital and % at st.luke\'s hospital. substance abuse and homelessness were highly prevalent in the cohort of patients not enrolled in regular outpatient care. % of patients not in care (vs. % of those in care) were deemed in need of substance use treatment by the inpatient social worker. % of those not in care were homeless (vs. % of those in care.) patients not in care did not differ significantly from those in me in terms of age, race, or gender. patients not in care were asked "why not:" the two most frequent responses were: "i haven't really been sick before" and "i'd rather not think about my health. conclusions: this study suggests that there is an opportunity to engage these patients during their stay on the inpatient units and attempt to enroll them in outpatient care. simple referral to an hiv clinic is insufficient, particularly given the burden of homelessness and substance use in this population. efforts are currently underway to design an intervention to focus efforts on this group of patients. p .q (a) healthcare availability and accessibility in an urban area: the case of ibadan city, nigeria in oder to cater for the healthcare need of the populace, for many years after nigeria's politicl independence, empphasis was laid on the construction of teaching, general, and specialist hospital all of which were located in the urban centres. the realisation of the inadequacies of this approach in adequately meeting the healthcare needs of the people made the country to change and adopt the primary health care (phc) system in . the primary health care system which is in line with the alma ata declaration of of , wsa aimed at making health care available to as many people as possible on the basis of of equity and social justice. thus, close to two decades, nigeria has operated primary health care system as a strategy for providing health care for rural and urban dwellers. this study focusing on urban area, examimes the availabilty and accessibility of health care in one of nigeria's urban centre, ibadan city to be specific. this is done within the contest of the country's national heath policy of which pimary health care is the main thrust. the study also offers necessary suggestion for policy consideration. in spite of the accessibility to services provided by educated and trained midwifes in many parts of fars province (iran) there are still some deliveries conducted by untrained traditional birth attendants in rural parts of the province. as a result, a considerable proportion of deliveries are conducted under a higher risk due to unauthorised and uneducated attendants. this study has conducted to reveal the pro· portion of deliveries with un-authorized attendants and some spatial and social factors affecting the selection of delivery attendants. method: this study using a case control design compared some potentially effective parameters indud· ing: spatial, social and educational factors of mothers with deliveries attended by traditional midwifes (n= ) with those assisted by educated and trained midwifes (n= ). the mothers interviewed in our study were selected from rural areas using a cluster sampling method considering each village as a cluster. results: more than % of deliveries in the rural area were assisted by traditional midwifes. there are significant direct relationship between asking a traditional birth attendant for delivery and mother age, the number of previous deliveries and distance to a health facility provided for delivery. significant inverse relationships were found between mother's education and ability to use a vehicle to get to the facilities. conclusion: despite the accessibility of mothers to educated birth attendants and health facilities (according to the government health standards), some mothers still tend to ask traditional birth attendants for help. this is partly because of unrealistic definition of accessibility. the other considerable point is the preference of the traditional attendants for older and less educated mothers showing the necessity of changing theirs knowledge and attitude to understand the risks of deliveries attended by traditional and un-educated midwifes. p - (a) identification and optimization of service patterns provided by assertive community treatment teams in a major urban setting: preliminary findings &om toronto, canada jonathan weyman, peter gozdyra, margaret gehrs, daniela sota, and richard glazier objective: assertive community treatment (act) teams are financed by the ontario ministry of health and long-term care (mohltc) and are mandated to provide treatment, rehabilitation and support services in the community to people with severe and persistent mental illness. there are such teams located in various regions across the city of toronto conducting home visits - times per week to each of their approximately respective clients. each team consists of multidisciplinary health professionals who assist clients to identify their needs, establish goals and work toward them. due to complex referral patterns, the need for service continuity and the locations of supportive housing, clients of any one team are often found scattered across the city which increases home visit travel times and decreases efficiency of service provision. this project examines the locations of clients in relation to the home bases of all act teams and identifies options for overcoming the geographical challenges which arise in a large urban setting. methods: using geographic information systems (gis) we geocoded all client and act agency addresses and depicted them on location maps. at a later stage using spatial methods of network analysis we plan to calculate average travel rimes for each act team, propose optimization of catchment areas and assess potential travel time savings. resnlts: initial results show a substantial scattering of clients from several act teams and substan· rial overlap of visit travel routes for most teams. conclusions: reallocation of catchment areas and optimization of act teams' travel patterns should lead to substantial savings in travel times, increased service efficiency and better utilization of resourc_~· ~e l'<!tenri~i modifications to catchment areas must be conducted with appropriate attention to specific clients servtce needs, service continuity and applicable regulations by the mohl tc. venice lido is a popular island within and outside italy because it hosts the international cinema festival yearly. only few people remember the island for its hospital, which, in the fifties, was one of the most important hospitals in italy and in europe, being a modern center for wind-, sun-and thermal-therapy. since the sixties, its fame became to drop away, since its structure was no longer adequate for the evolving medicine science. at the end of the seventies all the wards were moved into a new big building in the same area. at present the hospital is made up by about forty 'pavilions' (mostly partially used or empty) and a big building, disseminated in a hectares area, on the sea front, on the m long beach. the aim of my research is to suggest a realistic solution, sustainable on the functional use of the area according to basic local needs and economically realizable. i used a philological and multi-disciplinary method, more in detail: -from historical documents, i found what was the very first call of the property and how it adapted to the needs of the demographic development and the sanitary supply over time; -by contacting some operators from different fields, i realized which functions were suitable to the buildings in existence, to the population's needs and to the present sanitary supply. moreover the planning idea considers: -the debate going on between local people who strongly want to preserve the property, and die ones who want to renew it by different new opportunities; and -the regional sanitary politics, aiming at rationalizing the regional hospitals dislocation, and the budget needs. this plan analyzes and proposes some new alternative solutions to satisfy different needs. the different activities will be dealt out and the environmental fall will be limited as much as possible. after having analyzed its basic call, considered its environmental peculiarities and its position, verified the emerging needs of the local population, the plan proposes different activities: the hospital; the social-rehabilitation center; the elderly house; the thermal center; the residential center; and other activities. such a plan wants to share in the solution of a basic problem by giving architectonic and functional dignity to an historical completely degraded area and by starting again a social-economical broken off process, by bringing in venice lido some fresh necessary elements for its so wished new throw. p - (c) dilemma of free health care in spokane, wa david bunting introduction: the paper reports on the activities of project access spokane [pas], a physician sponsored initiative to provide uncompensated health care to low income, uninsured residents of spokane county wa. program providers included all county hospitals, over physicians, other medical professionals, and specialized clinics. each prescription requires only a $ co-payment. sponsored and administered by the county medical society, pas is funded by local and national foundations, private corporations, municipalities, civic organizations and individuals. method: the paper is based on a first year assessment report funded by pas, using hcfa [health care financing administration] insurance claim data documenting utilization rates, disease categories and donated charge information and patient cares [centralized applications, referrals and enrollment status) data. results: while essentially free for enrollees, the program involved real costs. an administrative organization to refer over patients to any of over providers had to be developed and staffed, using both paid and unpaid personnel. methods to identify potential patients and veri.fy eligibility. had to ~devised. patient appointments and transportation had to be scheduled and monitored. pu~hc relanons, provider solicitations and fundraising activities were continuous. information requirements regarding program operation were also significant. data reporting the volume. ~nd value of dona~ed medical services were necessary to demonstrate accomplishments and attr~ct addmon~l support. providers required assurances their contributions were both significant and eqmtable. funding sources sought evidence that their support had important consequences. however, generating this ~~ta proved difficult. many providers failed to submit appropriate insurance claims forms because .of a~dmonal donated effort and administrative cost, thereby not only reducing their own apparent conmbut ons but also the overall significance of the program. conclusions: during its initial year, the estimated cost to deliver free health care was ~bout per enrollee. the lesson is that without an elaborate administrative structure and record keeping s.yst~~· efforts to provide free health care probably will fail. eligible enrollees c~n not be ~parated from in~hgi ble ones, care will not be accessed or delivered in an efficient manner, neither fundmg nor ~upport "". be offered without evidence of tangible benefits, and providers will withdraw if they perceive mequ table tteannent. v p - s (c) mobility in prostitution and the impact of health therese van der helm and henk sulman poster sessions introduction: many of the estimated . commer~ial ~ex wor~ers (c~w)in a'.' ~terdam ~~me from developing countries and eastern europe. to gain ins~ght mto their workmg and_ hvmg condinons the intermediary project (ip) at the municipal health serv ~e _contacts these women via ?utreach work on regular basis. since the new brothel law in october s ~troduc~d, ~sw ~rom outside the eu and who have no dutch residence permit are not allowed to work m prost tut n. smee then, many of these csw therefore have gone "underground." the consequences of the new law in the netherlands will be discussed with regard to the accessibility of csw and their risk for stl/hiv acquisition and unplanned pregnancies. methods: topics during outreach work are the interventions to increase the knowledge of safe sex and birth control for csw. written information is handed out in relevant languages and with addresses of health and social services. in conversations with the women, it appeared that many are not aware of these services. to provide easier access to health care for women, staff of the ip carries out free sti control csw working places, in windows brothels and sex houses. also, women are offered vaccination against hepatitis b (hbv). results: from january till july we approached csw for first contact. one third was dutch; others were from developing countries, other eu countries and eastern europe. sti consul· rations were done among non-iv drug using sex workers, of whom % was dutch. of these, % was diagnosed with syphilis, % with gonorrhea, and % with chlamydia. of women tested for hiv, none were infected. due to the high turnover of csw in .brothels, most wnmen were tested only once. among csw tested for hbv -of whom one third is dutch - % had antibodies for hbv, were carrier of hbv, most of whom came from hbv endemic areas. conclusions: sti control and hbv vaccination in brothels is an important support in health care. our findings suggest that csw do not play an important role in the transmission of sti. many csw are highly mobile and often not aware of the existing health and social services. continuous outreach is important to remain in contact with this mobile population. regulations in the new brothel law should not hamper contacts with (illegal) csw. heart disease (cho) is projected to become the leading cause of death. studies conducted in europe and the united states have proven a higher rate of cho in south asians who have migrated from south asia, most notably india, pakistan and bangladesh. approximately % of all heart attacks among south asian men occur under the age of ; % of them occur under the age of -unheard of in any other population. associated risk factors such as diabetes, high blood pressure and cholesterol are also com· mon in this group. the population of south asians residing in nyc has more than doubled over the past decade to over , , the majority being young, working-class and with limited health care access. many south asian men are employed as taxi drivers ( out of nyc taxi drivers are from south asial, working daily hour plus shifts. methods: acknowledging that this vulnerable, at-risk group was unavailable for outreach through conventional venues, three of the hospitals of the new york city health and hospital corporation, (elmhurst, queens and bellevue) conducted a one day outreach effort at nyc's jfk international air· ~rt's taxi holdin~ ar~a, ~here over one thousand taxis regularly assemble. bringing an outreach event directly to the taxi dnvers workplace, a tent was set up where cardiovascular-related health screenings, in~luding bl~ pressure, sugar, cholesterol, body mass index (bmi), were provided. results were shared with and explamed to the drivers and each participant received a south asian health education brochure. a total of taxi drivers who identified as south asian were involved. rau/ts: participants were all male, ranging from to years; mean age, . . screenings revealed % hypertensive; % had cholesterols over ; % blood glucose over ; % had a bmi greater than . conc~on: a unique outreach activity, adapting to logistical, occupational limitations, is pre· se~ted. on-site f~back and explanation of results, reiterating and reinforcing the concern that south asia~. men are at mcreased danger for early coronary heart disease, and the dissemination of a culturally sensmve and r~levant brochure, may heighten awareness of prevailing cardiac risk factors in this immi· grant community. p - (c) the community-hospital integration program framework: community-hospital panoenhips to improve the population's health john stevenson, richard blickstead, ann-marie marcolin, and sandi kendal v introduction: st. josephs health centre is a catholic community teaching hospital located in the heart of southwest toronto. st. joseph\'s was founded from a community-expressed need for hospital services, and since then has stayed committed to fostering a healthy community through collaboration and parmership. st. joseph's has developed an innovative model, the community-hospital integration program (chip), to strengthen st. joseph's partnerships with community stakeholders, and facilitates the building of links between community needs, service provision, and public policy outcomes to improve the health and wellness of the diverse neighbourhoods they together serve. methods: development of the chip framework st. joseph's health centre developed the chip framework through a multidisciplinary approach that included extensive international literature reviews, consultations, and key informant interviews with community service agencies and academics. to ensure active community voice, st. joseph's has hosted a number of community consultations including a community outreach forum attended by over ninety representatives from community partners. results: the chip framework the chip framework aims to improve the health and wellness of the urban communities served by st. josephs health centre through four intersecting pillars: • raising community voices provides an infrastructure and process that supports community stakeholder input into health care service planning, decision-making, and delivery by the hospital and across the continuum of care; • sharing reciprocal capacity promotes healthy communities through the sharing of our intellectual and physical capacity with our community partners; • cultivating integration initiatives facilitates vertical, horizontal, and intersectoral integration initiatives in support of community-identified needs and gaps; and • facilitating healthy exchange develops best practices in community integration through community-based research, and facilitates community voice in informing public policy. the chip framework drives the complex inter-relationships between community-hospital engagement, reciprocal capacity-building, integration initiatives, and community-based research and evaluation, to create an interconnected network of health care services. the fluidity and simplicity of this framework, and its dedication to balancing community needs and hospital mandate, posits the st. josephs health centre's chip model as an integral component in building healthy and thriving communities. p - (c) home based care promotion: improving acess to quality services and livelihood in the face of aids home based care is a service provided to persons affected/living with hiv/aids, a menu of care/support services at home/community. it is a prominent alternative approach. in uganda, hospital bed ocupacny is high, patient health care worker ratio deteriorating. empowering communities offers solutions to the problems; adressing cost, effectiveness of care. hiv/aids demands changes in attitudes, behaviour, approaches which is enhanced in home/community settings. for example art requires high levels of adherecnce, which medical workers have vety little opportunity to enforce. it also demands other support mechanisims in terms of nutrition, personal displine, etc which work best in stigma free environments. hence the relevance of home based care. this paper highlights the gaps that call for increased action in terms of home based care, examples of whre it has worked key challenges and recommendations for the future. p - (c) health care for one ... health care for alli katharina kovacs burns introduction: at the surface, it appears that every person in canada _has. ~ccess to a publicly funded health care system. those living in urban centers should have the best ava l~b hty, chmce, and access to a variety of health care services because of the distribution of health care services, fac lmes, and health professionals in concentrated in urban centers. this is not true for everyone -people with low income or who are homeless experience the challenges of social exclusion and being marginalized: there are many factors at play making it difficult for the latter group of people to access health care. service they need,.when they need them. health care is not as accessible or inclusive as intended. the quesuon to be explore.cl ~: if health care is available and accessible to one person, what makes it not available to all people? the ~ gmfic~nce of having marginalized people accessing health care and other services includes e~hanced quality of hfe and decreased risks associated with being homeless, and cost savings in ion~ ter~ w rh acute health care. methodology: community-based participatory research is applied m a case study on health care access and challenges experienced by low income and homeless people in one urban centre, edmonton, edmonton, and their challenges. the data is being gathered and ana_lyzed usmg basic m x~d methods. results: the results will focus on how services can be more mtegrated and accessible to all people with low income and who are homeless. there will also be discussion about specific perceptions of not only the service providers but also of people with low income an~ who are homeless~ and vario~s decision makers. the results will be compared to the literature regardmg health care services access mother urban centers in canada and elsewhere. conclusions: recommendations will need to address social exclusion and other factors which can make health care and other services more available to all people in the community. the implications for health care will also be discussed. additional information will be gathered in the next phases of the study to develop a community services access model. p - (c) availability and access exemplified: a case study beth hayhoe and ruth ewert introduction: access to health care in canada requires either the correct documentation or money. street youth have neither. in addition, health services in canada are designed by adults for adults. youth in general are often wary of having trust in adults with respect to their health concerns and frequently feel misunderstood. street youth are even more mistrustful of adults and public organizations, making their contact with health care professionals minimal. this combined with their risky behaviours and dangerous environment creates a population at risk for numerous health issues but with no place to have them investi· gated. at our non-government, not for profit health service designed specifically to provide a broad range of health care to street youth, professional services are provided almost entirely by volunteers. methods: using a retrospective analysis of the years of data gathered from this organization and reviewing the initial reasons gathered from youth about their needs, the success of the health centre was examined. results: all the things youth had listed as being important in a health centre have been implemented, and even more things have been added to improve the breadth and quality of services offered. the use of the health centre has increased by more than six times since its opening in . in addition, tens of thousands of visits have been paid to the health centre, costing the government and taxpayers nothing. as far as we know there is nothing else in canada that offers so many diverse and innovative services to youth in need. conclusion: it is clear from this case, that health care targeted at the needs of specific disadvan· taged populations can successfully provide them with appropriate health care. a model of accessible health care for marginalized populations can easily be developed for high impact and low cost from this successful case. toronto is one of the most ethno-racially diverse cities in the world of the estimated , , toronto residents, % ( , ) live in scarborough population growth in scarborough is faster than toronto. scarborough's population increased by % from to while toronto increased only by %. toronto's population is projected to increase by % ( ) in while scarbor· ough's will increase by %. (census canada ) low income, pove;ty, seniors, hidden homeless, new~omers to canada, the uninsured, are just a few of the issues concerning health care in our community. health care needs in scarborough are greatly impacted by diversity of ethnic and racial groups, poverty and settlement issues. this paper will share how the scarborough hospital (tsh) an urb~n communir_y hospital cares f~~ it~ community. tsh recognizes: •the changing community• b_arriers t~ accessing care • lnequalmes m health care the hospital in caring for its community pro· v ~es services that '!'e~e cu~turally, racially, and linguistically sensitive to our community. the paper will share the hospitals unique program on access and equity. the paper will share the needs in scar· borough and tsh's response to these needs: working in partnership with the local health committee, i:ne scarborough homeless co.mminee, the scarborough network of immigrant services organiza· nons a~d others. :' e paper will also share the many initiatives this urban community hospital has taken viz. community and home programs in service areas such as mental health, haemodialysis day care, t~~ home oxyg~n program, the palliative at-home program, and above all support for the volunteer clinic for the uninsured. j"'" tllu:lion: in canada's universal health care system it is generally assumed that everyone has equal access to health care. however, some immigrant groups in canada have historically been uninswed. these groups include failed refugee claimants, those overstaying their visas, and new immigrants in transition who are waiting to become eligible for health insurance. some estimates have suggested that at the present time there may be as many as one hundred thousand undocumented and thus uninsured immigrants in toronto alone. understandably, information on the characteristics of this marginalized population is very limited, since undocumented immigrants tend to have little contact with formal institutions. knowledge of the demographic characteristics of this population may aid in the development of health and social programs to better identify and meet the needs of undocumented immigrants in toronto. we conducted a review of all undocumented, uninsured patients, years of age or older at access alliance multicultural community health centre (aamchc) between and . demographic information such as age, gender, preferred language, length of time living in canada, selfreported education level and household income were recorded. rmdts: % of all adult patients at access alliance were undocumented and uninsured. % were under years of age (with a median age of years), % were women and only % spoke english. this group lived in canada for an average period of . years before they were first seen at aamchc. % of undocumented clients reported having completed at least a secondary or post-secondary education. % had self-reported household incomes of less than , $/year, while % of households reported earning less than $ , /year. the mean income per person in an average household was $/month. conchuions: uninsured individuals at aamchc were predominantly young females with limited knowledge of the english language. despite having attained a high level of education most were living well below the poverty line. recognition of these characteristics may assist in the development of health and social programs that are better adapted to meet the needs of undocumented immigrants. p - (c) sharing expertise: a role for the hospital lactation consultant in the community. badrgrmuul: st. michael's hospital is a tertiary care hospital that serves a large inner city population in downtown toronto. in order to provide care to this population, the hospital has developed a number of unique outreach roles. one such role was developed to work with pregnant and breastfeeding women living in regent park, a social housing complex located near the hospital. the population of regent park includes new immigrants, refugees and the socially disadvantaged. approach: the outreach lactation consultant provides care, as part of the canada prenatal nutrition program, in the community prenatally, in the hospital during their inpatient stay and postnatally when they return to the community. the continuity of care enhances the probability of long term successful breastfeeding. aside from the health benefits of breastmilk, breastfeeding is especially important for women who are financially needy and must depend on food banks for formula. . . lason learned: aher two years of partnership, the relationship between the an-hospital ~stpar tum experience for breastfeeding mothers and the community postpartum support, the breastfeeding rate ~thin this community is high. the professional support and visibility of the : ctation consultant, both m the hospital and in the community, contributes to the support of breastfee~m~.. . in light of ongoing funding constraints, this ha son between hospital and community could be at risk and discontinued. in light of the benefits to the mother/baby dyad, the lactation consultant as a community partner in the canada prenatal nutrition program should be safeguarded. . lldpodiu:tion: although the importance of adequate health care in pregna~cy is well recognised, ethnic disparities in utilization of prenatal care still exist in many western coun~~es. a fun~amental factor in these disparities may be language proficiency, as it influences women's ab hty. to ob~m and understand health information, to find the way in the health care system and to communicate with health care v poster sessions providers. we investigated the role of language proficiency in use and knowledge of folic acid as aspect of prenatal care in an urban multi-ethnic pregnancy c?hort. . . design: prospective cohort study. setting and parnc pants: amsterdam ~regnant women attending obstetric care providers for their first antenatal visit (n= ). country of birth defined ethnicity: the netherlands, surinam, antilles, turkey, morocco, ghana, other non-~est~m (nw) and other western (w) country. main outcome measures: knowledge about and use of.fohc a~d (fa) supplements in pregnancy, and determinants of these in diffe~~t ethnic ~~ups. deterrrunants mcl~ded age, ed~ tion, parity, pregnancy intention and dutch prof c ency. stansncs: ~ to co~p~re e~c groups, stranfied logistic regression (forward stepwise method) to explore determmants "'.'thm ethmc groups .. use of fa supplements was significantly lower among ghanaian, moroccan, turkish and other nw women ( %to %) than among dutch ( %) or other w women ( %). use amongsurinames and antillean women was intermediate ( %and %). ethnic differences in fa knowledge were similar. knowledge was the strongest determinant of use in all ethnic groups, with odds ratios (ors) ranging from . to . . language proficiency was the strongest determi~a~t of kno~ledge in ethnic groups with a mother tongue different from dutch (ors good vs. low proficiency ranging from . ro . ). educational level had a modifying role, as shown by an interaction effect between education and language proficiency in the nw group. here, the odds of having fa knowledge given a high education and good dutch proficiency was times the odds given a good proficiency but low education. conclusions: appropriate periconceptional use of folic acid supplements in non-western ethnic groups is low, reflecting an absence of knowledge that is largely determined by the inability to speak and understand the language of the habitual country. tailored interventions using communication channels most likely to address (pregnant) women from ethnic minority groups are necessary. apan from specific interventions, our results are in support of strong incentives on language education despite current political debate. introduction: recent research suggests living in an economically disadvantaged neighborhood is asso· ciated with decreased likelihood of undergoing mammography and increased risk of late-stage breast can· cer diagnosis. long distances and travel times to facilities offering low-or no-cost mammography may be imponant barriers to adherence to mammography screening recommendations for residents of economically disadvantaged neighborhoods. the purpose of this study was to examine whether facilities providing low-and no-cost screening mammography were less spatially accessible in low-income neighborhoods in chicago, and the extent to which the relationship between neighborhood income and the spatial accessibility of facilities varied by the proponion of african-american residents in the neighborhood. methods: the sample consisted of chicago neighborhoods. for each neighborhood, we con· structed three measures of the spatial accessibility of facilities: street network distance to the nearest facility, public transportation travel time to the nearest facility, and shortest automobile travel time to a facility. using decennial census data, we characterized the neighborhoods according to proportion of residents with incomes below the poverty line, proportion of residents in each of four raciavethnic groups (african-american, latino, white, and other), and population density. we used ordinary least squares (ols) and spatial exogenous lag regression to examine relationships. model estimated the relationship between neighborhood poverty and the spatial accessibility of facilities, adjusting for raciaveth· nic composition and population density. model added a multiplicative interaction term between neighborhood poverty and african-american. restllts: we identified deven facilities that provided low-or no-cost screening mammography to chicago residents in . we found that the distance and travel times via automobile and public trans· portation to facilities generally decreased as neighborhood poveny increased. however, we also found that the ~egative associations between neighborhood poverty and two of the spatial accessibility mea· sures -distance and public transportation travel time -were less strong in neighborhoods with the highest proponions of african-american residents. among neighborhoods in the highest tertile for poveny, th~ mean distance and mean public transportation travel time to facilities were over twice as long in neighborhoods in the highest tertile than in those in the lowest tenile of african-american residents. . ~ persistent socioeconomic and racial/ethnic disparities in breast cancer stage at diagno-s ~nd su~ val suggest that ensuring an equitable distribution of affordable mammography is a worth-w~e policy .goal. the ~~dy sugges~ that ~ture investigations should consider both neighborhood soc oecono d c charactensbes and rac avethmc composition when examining the spatial distribution of health resources. , ) . epidemiological data suggest tha~ hiv prevalence among msm is over % in some metropolitan cities, such .as beijing (ibid.). due to widespread homophobia in chinese society, however, this population remains invisible within current health/social services. lack of research on sexuality, specifically homosexuality, has impaired our understanding of health and health practices of chinese msm. focusing on the illness experiences of chinese msm with hiv/aids, this paper explores the socio-cultural impacts of hiv/ aids on this group. the data used for this paper were collected through semi-constructed in-depth face-toiace interviews with adult plwhas (including msm) in beijing, china. with the permission of the participants, the interviews were audio-taped or recorded in notes. the transcribed interviews and interview notes were analyzed by using n-vivo, a software program for qualitative data analysis. this phenomenological study aimed to understand the experiences chinese plwhas (including msm) from their own perspectives. results: it is found that the illness experiences of chinese msm with hiv/aids are profoundly shaped by the socio-cultural meanings of homosexuality, which are further complicated by the dominant discourses on hiv/aids in china. at a macro level, homophobia in the larger society has decreased the capability of this group to respond to this epidemic in a more efficient way. at a meso level, aids-phobia within the chinese msm circuits has prevented this group from openly confronting this disease and offering support to those who are already affected by it. at a micro level, however, these hiv-infected/ affected msm have tried their best to locate spaces to live and to construct hope for their future lives despite various barriers within family, community, and the larger society. this study suggests that facilitating chinese msm's response to the aids crisis urgently requires bridging awareness, commitment, knowledge and resources both within and without this group. it also illustrates the importance of understanding homosexuality in the local context of hiv i aids, which will be helpful for developing culturally sensitive hiv/aids programs for this population on the community, national and international levels. introduction: having a regular family doctor (rfd) is known to be positively correlated with a good medical follow up, including access to preventive and/or chronic care. inversely, a lack of primary care may lead to high rates of avoidable hospitalizations, especially among poor people and/or in underserved neighbourhoods. in such a matter, a recent comparative study showed that paris was better ranged than other cities, such as nyc, tokyo or london. nevertheless, despite a quasi universal health insurance and a high density of general practitioners, a noticeable fraction of the paris population does not have any regular physician and we aimed to understand who they are and for what reasons rhey don't have any rfd. mdbods: cross sectional population survey among a random sample of households in ~nderpriv ileged neighbourhoods in paris inner city, performed in , using a face-to-face quest nna re collecr- ng more than social and health characteristics. ruults: a quarter ( . %) of rhe study popularion did not have any rfd. this proporrion was iignificantly higher among male (or= . , %ci = [ . - . ), younger (e.g. or - /> .s l _= ._oo, " .ci = ( . - . )), and/or unemployed (or = . , %ci = ij . - . _ people. in multtvanate analysis, after a full adjustment on gender, age, health status, health insura~ce, income, occupat n and tducation level, we observed significant associations between having no rfd and: ~arrtal and_ pare~t hood status (e.g. or single no kids/in couple+kids = . , %ci = ( . - . ()~ quality of relattonsh ps with neighbours (or bad/good= . , %ci = [ . - . )), and length of residence m the neighbourhood (with a dose/effect statistical relationship). . co clusion: gender, age, employment status, mariral and parenthood stat~s as well as ~e gh bourhood anchorage seem to be major predictors of having a rfd, even when um.versa! health i~sur ance has reduced most of financial barriers. in urban contexts, where residential migrattons and single lift (or family ruptures) are frequent, specific information may be conducted to encourage people to ket rfd. :tu~y tries to assess the health effects and costs and also analyse the availability and accessibility to health care for poor. . methods: data for this study was collected by a survey on households of the local community living near the factories and households where radiation hazard w~s n?~ present. ~~art from mor· bidity status and health expenditure, data was collected ~n access, a~ail~b .hty and eff c ency of healrh care. a discriminant analysis was done to identify the vanables that d scnmmate between the study and control group households in terms of health care pattern. a contingent valuation survey was also undertaken among the study group to find out the factors affecting their willingness to pay for health insurance and was analysed using logit model. results: the health costs and indebtedness in families of the study group was high as compared to control group households and this was mainly due to high health expenditure. the discriminant analysis showed that expenditure incurred by private hospital inpatient and outpatient expenditure were significant variables, which discriminated between the two types of households. the logit analysis showed !hat variables like indebtedness of households, better health care and presence of radiation induced illnesses were significant factors influencing willingness to pay for health insurance. the study showed that study group households were dependent on private sector to get better health care and there were problems with access and availability at the public sector. conclusion: the study found out that the quality of life of the local community is poor due to health effects of radiation and the burden of radiation induced illnesses are so high for them. there is an urgent need for government intervention in this matter. there is also a need for the public sector to be efficient to cater to the needs of the poor. a health insurance or other forms of support to these households will improve the quality for health care services, better and fast access to health care facilities and reduces the financial burden of the local fishing community. the prevalence of substance abuse is an increasing problem among low-income urban women in puerto rico. latina access to treatment may play an important role in remission from substance abuse. little is known, however, about latinas' access to drug treatment. further, the role of social capital in substance abuse treatment utilization is unknown. this study examines the relative roles of social capital and other factors in obtaining substance abuse treatment, in a three-wave longitudinal study of women ages - living in high-risk urban areas of puerto rico, the inner city latina drug using study (icldus). social capital is measured at the individual level and includes variables from social support and networks, familism, physical environment, and religion instruments of the icdus. the study also elucidates the role of treatment received during the study in bringing about changes in social capital. the theoretical framework used in exploring the utilization of substance abuse treatment is the social support approach to social capital. the research addresses three main questions: ( t) does social capital predict parti~ipating in treatment programs? ( ) does participation in drug treatment programs increase social capital?, and ( ) is there a significant difference among treatment modalities in affecting change in ~ial capital? the findings revealed no significant association between levels of social capital and gettmg treatment. also, women who received drug treatment did not increase their levels of social capital. the findings, however, revealed a number of significant predictors of social capital and receiving drug ~buse treatment. predictors of social capital at wave iii include employment status, total monthly mcoi:rie, and baseline social capital. predictors of receiving drug abuse treatment include perception of physical health and total amount of money spent on drugs. other different variables were associated to treatment receipt prior to the icldus study. no significant difference in changes of social capital was found among users of different treatment modalities. this research represents an initial attempt to elucidate the two-way relationship between social capital and substance abuse treatment. more work is necessary to unden~nd. ~e role of political forces that promote social inequalities in creating drug abuse problems and ava lab hty of treatment; the relationship between the benefits provided by current treatment poster sessions v sctrings and treatment-seeking behaviors; the paths of recovery; and the efficacy and effectiveness of the trtaanent. and alejandro jadad health professionals in urban centres must meet the challenge of providing equitable care to a population with diverse needs and abilities to access and use available services. within the canadian health care system, providers are time-pressured and ill-equipped to deal with patients who face barriers of poverty, literacy, language, culture and social isolation. directing patients to needed supportive care services is even more difficult than providing them with appropriate technical care. a large proportion of the population do not have equitable access to services and face major problems navigating complex systems. new approaches are needed to bridge across diverse populations and reach out to underserved patients most in need. the objective of this project was to develop an innovative program to help underserved cancer patients access, understand and use needed health and social services. it implemented and evaluated, a pilot intervention employing trained 'personal health coaches' to assist underserved patients from a variety of ethno-linguistic, socio economic and educational backgrounds to meet their supportive cancer care needs. the intervention was tested with a group of underserved cancer patients at the princess margaret hospital, toronto. personal coaches helped patients identify needs, access information, and use supportive care services. triangulation was used to compare and contrast multiple sources of quantitative and qualitative evaluation data provided by patients, personal health coaches, and health care providers to assess needs, barriers and the effectiveness of the coach program. many patients faced multiple barriers and had complex unmet needs. barriers of poverty and language were the easiest to detect. a formal, systematic method to identify and meet supportive care needs was not in place at the hospital. however, when patients were referred to the program, an overwhelming majority of participants were highly satisfied with the intervention. the service also appeared to have important implications for improved technical health care by ensuring attendance at appointments, arranging transportation and translation services, encouraging adherence to therapy and mitigating financial hardship -using existing community services. this intervention identified a new approach that was effective in helping very needy patients navigate health and social services systems. such programs hold potential to improve both emotional and physical health out· comes. since assistance from a coach at the right time can prevent crises, it can create efficiencies in the health system. the successful use of individuals who were not licensed health professionals for this purpose has implications for health manpower planning. needle exchange programs (neps) have been distributing harm reduction materials in toronto since . counterfit harm reduction program is a small project operated out of a community health centre in south-east toronto. the project is operated by a single full-time coordinator, one pan-rime mobile outreach worker and two peers who work a few hours each week. all of counterfit's staff, peers, and volunteers identify themselves as active illicit drug users. yet the program dis~rib utes more needles and safer crack using kits and serves more illicit drug u~rs t~an the comb ~e~ number of all neps in toronto. this presentation will discuss the reasons behind this success, .s~ f cally the extended hours of operation, delivery models, and the inclusion of an. extremely marg ~ahzed community in all aspects of program design, implementation and eva.luat ?n. ~ounterfit was recently evaluated by drs. peggy milson and carol strike, two leading ep dem olog st and researchers in the hiv and nep fields in toronto and below are some of their findings: "the program has experienced considerable success in delivering a high quality, accessible and well-used program .... the pro· gram has allowed (service users) to become active participants in providing. services to others and has resulted in true community development in the best sense. " ... counterf t has ~~n verr succe~sful attracting and retaining clients, developing an effective peer-based model an.d assisting chen~s ~ th a vast range of issues .... the program has become a model for harm red~ctmn progr~ms withm the province of ontario and beyond." in june , the association of ?ntano co~mumty heal~~ <:en· ires recognized counterfit's acheivements with the excellence m community health initiatives award. in kenya, health outcomes and the performance of government health service~ have det~riorated since the late s, trends which coincide with a period of severe resource constramts necessitated by macro-economic stabilization measures after the extreme neo-liberalism of the s. when the govern· ment withdrew from direct service provision as reform trends and donor advocacy suggested, how does it perform its new indirect role of managing relations with new direct health services providers in terms of regulating, enabling, and managing relations with these health services providers? in this paper therefore, we seek to investigate how healthcare access and availability in the slums of nairobi has been impacted upon by the government's withdrawal from direct health care provision. the methodology involved col· leering primary data by conducting field visits to health institutions located in the slum areas of kibera and korogocho in nairobi. purposive random sampling was utilized in this study because this sampling technique allowed the researcher(s) to select those health care seekers and providers who had the required information with respect to the objectives of the study. in-depth interviews using a semi-structured ques· tionnaire were administered ro key informants in health care institutions. this sought to explore ways in which the government and the private sector had responded and addressed in practical terms to new demands of health care provision following the structural adjustment programmes of the s. this was complemented by secondary literature review of publications and records of key governmental, bilateral and multilateral development partners in nairobi. the study notes a number of weaknesses especially of kenya's ministry of health to perform its expected roles such as managing user fee revenue and financial sustainability of health insurance systems. this changing face of health services provision in kenya there· fore creates a complex situation, which demands greater understanding of the roles of competition and choice, regulatory structures and models of financing in shaving the evolution of health services. we rec· ommend that the introduction of user fees, decentralization of service provision and contracting-out of non-clinical to private and voluntary agencies require a new management culture, and new and clear insri· tutional relationships. experience with private sector involvement in health projects underlines the need not only for innovative financial structures to deal with a multitude of contractual, political, market and risks, but also building credible structures to ensure that health services projects are environmentally responsive, socially sensitive, economically viable, and politically feasible. purpose: the purpose of this study is to examine the status of mammography screening utilization and its predictors among muslim women living in southern california. methods: we conducted a cross-sectional study that included women aged ::!: years. we col· leered data using a questionnaire in the primary language of the subjects. the questionnaire included questions on demography; practices of breast self-examination (bse) and clinical breast examination (cbe); utilization of mammography; and family history of breast cancer. bivariate and multiple logistic regression analyses were performed to estimate the odds ratios of mammography use as a function of demographic and other predictor variables. . results: among the women, % were married, % were - years old, and % had family h story of breast cancer. thirty-two percent of the participating women never practiced bse and % had not undergone cbe during the past two years. the data indicated that % of the women did not have mammography in the last two years. logistic regression analysis showed that age ( r= . , % confi· dcnc~ interval (cl)=l. - . ), having clinical breast examination ( r= . , % cl= . - . ), and practtce of self-breast examination ( r= . , % cl= . - . ), were strong predictors of mammography use . . conclusions: the data point to the need for intervention targeting muslim women to inform and motivate th.cm a~ut practices for early detection of breast cancer and screening. further studies are needed to investigate the factors associated with low utilization of mammography among muslim women population in california. we conducted a review of the scientific literature and° government documents to describe ditnational health care program "barrio adentro" (inside the neighborhood). we also conducted qualiurivt interviews with members of the local health committees in urban settings to descrihe the comm unity participation component of the program. rtsmlts: until recently, the venezuelan public health system was characterized by a lack or limited access w health care ( % of the population) and long waiting lists that amounted to denial of service. moit than half of the mds worked in the five wealthiest metropolitan areas of the country. jn the spring oi , a pilot program hired cuban mds to live in the slums of caracas to provide health care to piople who had previously been marginalized from social programs. the program underwent a massive expansion and in only two years , cuban and , venezuelan health care providers were working acmss the country. they provide a daily average of - medical consultations and home visits, c lly out neighborhood rounds, and deliver health prevention initiatives, including immunization programs. they also provide generic medicines at no cost to patients, which treat % of presenting ill-ij!m, barrio adentro aims to build , clinics (primary care), , diagnostic and rehabilitation ctnrres (secondary care), and upgrade the current hospital infrastructure (tertiary care). local health committees survey the community to identify needs and organize a variety of lobby groups to improve dit material conditions of the community. last year, barrio adentro conducted . times the medical visits conducted by the ministry of health. the philosophy of care follows an integrated approach where btalrh is related to housing, education, employment, sports, environment, and food security. conclusions: barrio adentro is a unique collaboration between low-middle income countries to provide health care to people who have been traditionally excluded from social programs. this program shows that it is possible to develop an effective international collaboration based on participatory democracy. low-income americans are at the greatest risk of being uninsured and often face multiple health concerns. this evaluation of the neighborhood health initiative (nh!), an organization which uses multiple programmatic approaches to meet the multiple health needs of clients, reflected the program's many activities and the clients' many service needs. nh! serves low-income, underserved, and hard-to-reach residents in the des moines enterprise community. multiple approaches (fourth-generation evaluation, grounded theory, strengths-and needs-based) and methods (staff and client interviews, concept mapping, observations, qualitative and quantitative analysis) were used to achieve that reflection. results indicate good targeting of residents in the zip code and positive findings in the way of health insurance coverage and reported unmet health needs of clients. program activities were found to match client nttds, validating the organization\'s assessment of clients. important components of nhi were the staff composition and that the organization had become part of both the formal and informal networks. nhi positioned as a link between the target population and local health and social sc:rvice agencies, working to connect residents with services and information as well as aid local agencies in reaching this underserved population. p - (c) welfare: definition by new york city maribeth gregory for an individual who resides in new york city, to obtain health insurance under the medicaid policy one must fall under certain criteria .. (new york city's welfare programs ) if the individual _is on ssi or earns equal to or less than $ per month, he is entitled to receive no more than $ , m resources. a family the size of two would need to earn less than $ per month to qualify for no greater than ss, worth of medicaid benefits. a family of three would qualify for $ , is they earned less than $ per month and so on. introduction: the vancouver gay communiry has a significant number of asian descendan!l. because of their double minority status of being gay and asian, many asian men who have sex with men (msm) are struggling with unique issues. dealing with racism in both mainstream society and the gay communiry, cultural differences, traditional family relations, and language challenges can be some of their everyday srruggles. however, culturally, sexually, and linguistically specific services for asian msm are very limited. a lack of availability and accessibiliry of culturally appropriate sexual health services isolates asian msm from mainstream society, the gay community, and their own cultural communities, deprives them of self-esteem, and endangers their sexual well-being. this research focuses on the qualita· tive narrative voices of asian msm who express their issues related to their sexualiry and the challenges of asking for help. by listening to their voices, practitioners can get ideas of what we are missing and how we need to intervene in order to reach asian msm and ensure their sexual health. methods: since many asian msm are very discreet, it is crucial to build up trust relationships between the researcher and asian msm in order to collect qualitative data. for this reason, a community based participatory research model was adopted by forming a six week discussion group for asian msm. in each group session, the researcher tape recorded the discussion, observed interactions among the participants, and analyzed the data by focusing on participants' personal thoughts, experiences, and emotions for given discussion topics. ra lts: many asian msm share challenges such as coping with a language barrier, cultural differ· ences for interpreting issues and problems, and westerncentrism when they approach existing sexual health services. moreover, because of their fear of being disclosed in their small ethnic communities, a lot of asian msm feel insecure about seeking sexual health services when their issues are related to their sexual orientation. conclflsion: sexual health services should contain multilingual and multicultural capacities to meet minority clients' needs. for asian msm, outreach may be a more effective way to provide them with accessible sexual health services since many asian msm are closeted and are therefore reluctant to approach the services. building a communiry for asian msm is also a significant step toward including them in healthcare services. a communiry-based panicipatory approach can help to build a community for asian msm since it creates a rrust relationship between a worker and clients. p - (c) identifying key techniques to sustain interpretation services for assisting newcomers isolated by linguistic and cultural barriers from accessing health services s. gopi krishna lntrodaetion: the greater toronto area (gta) is home to many newcomer immigrants and other vulnerable groups who can't access health resources due to linguistic, cultural and systemic barriers. linguistic and cultural issues are of special concern to suburbs like scarborough, which is home to thousands of newcomer immigrants and refugees lacking fluency in english. multilingual community ~nterpreter. service~ (mcis) is a non-profit social service organization mandated to provide high quality mterpretanon services. to help newcomers access health services, mcis partnered with the scarborough network of immigrant serving organizations (sniso) to recruit and train volunteer interpreters to accompany clienrs lacking fluency in english and interpret for them to access health services at various locati?ns, incl~~ing communiry ~c:-lth centres/social service agencies and hospitals. the model envisioned agencies recruin~ and mcis ~.mm.g and creating an online database of pooled interpreter resources. this da.tabase, acces& bl~ to all pama~~g ?rganization is to be maintained through administrative/member · ship fees to. be ~ d by each parnapanng organization. this paper analyzes the results of the project, defines and identifies suc:cases before providing a detailed analysis for the reasons for the success . . methods:. this ~per~ q~ntitative (i.e. client numben) and qualitative analysis (i.e. results of key •~ormant m~rv ews with semce ~sers and interpreters) to analyze the project development, training and mplementanon phases of the project. it then identifies the successes and failures through the afore· mentioned analysis. poster sessions vss resljts: the results of the analysis can be summarized as: • the program saw modest success both ia l?lllls of numbers of clients served as well as sustainability at various locations, except in the hospital iririog. o the success of the program rests strongly on the commitment of not just the volunteer interprmr, but on service users acknowledgments through providing transponation allowance, small honororia, letter of reference etc. • the hospital sustained the program better at the hospital due to the iolume and nature of the need, as well as innate capacity for managing and acknowledging volunceers. collc/llsion: it is possible to facilitate and sustain vulnerable newcomer immigrants access to health !ul'ices through the training and commitment of an interpreter volunteer core. acknowledging volunteer commitment is key to the sustenance of the project. this finding is important to immigration and health policy given the significant numbers of newcomer immigrants arriving in canada's urban communities. nity program was established in to provide support to people dying at home, especially those who were waiting for admission to the resi<lential hospice. with the advent of haart and corresponding challenges for people living with hiv/aids in the community, the community program has developed a unique case management approach. this model features an interdisciplinary team providing a clientdrivcn service. the case manager provides continuity of care to clients in a variety of settings both within and outside of the health care system. a case study is used to demonstrate how formal and informal networks of support facilitate efficient and appropriate resource utilization to promote client health. this case study demonstrates the value of consistent coordination with a client who has complex physical, spiritual, substance use and mental health needs. the authors will show how they liaised with the housing authority, police, social services as well as the family physician, clinic staff and a hospital emergtncy room to ensure this client did not fall between the cracks. tarek hussain recognition of the importance of community involvement and sectoral cooperation in health and !ocial services, formalized in alma-ata declaration in , was reinforced at riga meeting held at the mid·point between alma-ata and the year . then at the th anniversary of alma-ata declaration, ir was declared that 'primary health care is everybody's business'. health does not exist in isolation. health cannot be defined only as an outcome of 'medical care' but also as one of 'social action'; the responsibility of disease prevention and health promotion rests not only on governments, but also with don·govemmentorgan izations, the community, and individuals. the major accomplishment to date may be that rhere is growing realization in the health sector that community involvement is more than a political right-it is absolute necessary. lessons have learned during the implementation of disease-specific l'cltical programmes, such as cdd, ari, and epi; first, integrated and holistic approaches to childcare art needed, and second, the need for community involvement has become evident. imc! is a broad inte-gra ed strategy with an overall objective contributing to reducing child morbidity and mortality in developing countries. and one of the imci components, 'community !mci', which is now broadening ~s an entry point for child-focused community development initiatives. community jmcl/c~ ld health is ~n mtcgrated approach to the promotion of key family and community practices that have impact on: child growth and development, disease prevention, home care for sick, malnourished child~en, a.nd care-seekmg behavior and compliance with advice and treatment. the presentation addres~es, m brief, the ~evel opinent of community !mci, operational aspect of community/im cl, key strategies and tools ava la~le for implementation of c/imci. the paper draws some successful programme examples on working logether for imc! with the community in various countries which had substantial benefns on programme outcomes. p - t (c) healthy child screening: an innovative service initiative ann-marie marcolin and joyce allen . introduction: with mounting attention for creative and integrated models of c~re .that are populallon and community focused, the healthy child screening initiative achiev.es t~ese pnncipl~s and more! . • parkdale high park rotary (sponsorship) the heal~h ~h ld scree? ?g is a ~opl~-centred model of care. agency and professional sector-specific silos are ehmmated, ~rov dmg f~~ hes wit~ one-sto~ access to primary prevention services in a local school gym! children at nsk are rece vmg early mtervent n and appropriate referrals to the right care provider, at the right time a~d in t~e right place. further, with a complimentary focus on prevention, the program serves to keep at nsk children healthy. healthy child screening results: the service model is developed around four distinct phases: ) planned outreach; ) coordinated intake and registration; ) interdisciplinary screening; and ) targeted referral. since the fall and through six collaborative healthy child screenings children ranging in age from to have benefited from this unique service model of care. conclusion: the presentation will provide practical information on the development and implementation of the model. there will also be a focus on lessons learned in building community service provider-hospital relationships. according to statistics canada ( ) % of the toronto population was born outside of canada and % were new immigrants. immigrants often arrive in canada in superior health compared to the canadian born population, but they lose this health advantage over time. changes in immigrant health status over time may be attributed to a variety of factors including barriers to accessing and receiving care as well as limitations in the mainstream health service organizations and their approaches to health care delivery (hyman, ) . for example, immigrant women are less likely to receive pap tests, which places them at a greater risk for developing cervical cancer. similarly, immigrant women receive less mammography screening than their canadian counterparts. the immigrant women's health centre mobile health unit (mhu) was created as an alternative care delivery model to address the need for increased accessibility as well as culturally and linguistically appropriate reproductive health care. toronto western hospital and the immigrant women's health centre have formed a collaborative partnership which incorporates a primary care nurse practitioner and lay ethnocultural counselors providing care on the mhu. currently, a qualitative ethnonursing study is underway to understand the unique experiences of women using the mhu for their reproductive health care as well as the perspectives of the mhu health care providers. based on a literature review and preliminary findings from provider and participant interviews, the proposed presentation will address the themes of health status for immigrant and refugee women, accessibility issues as well strategies to improve their reproductive health care. we will discuss benefits as well as limitations to health care provision using this alternative service delivery model. michael carden, brian edlin, andrew talal, elizabeth getter, and marla shu lntrod.ction: to date most active drug users have not had access to treatment for hepatitis c virus (hcv) infection and substantial barriers continue to exist that interfere with treatment availability for this population. methods: active illicit drug users interested in pursuing hcv care and treatment were recruited in partnership w~th co~munity-based organizations (cbo's) in new york city. baseline data were collected on quahty of hfe, substance use patterns, depression, health care utilization, hcv health beliefs and other relev.ant variables. medical evaluations were conducted, including liver biopsy when indicated, an~ treatment ts ~ffered when no contraindications are present. participants also receive psychiatric evaluahons to determme the appropriateness of interferon treatment. renlts: fifteen individuals have been recruited to date and received an initial medical evaluation. the mean age was years and _the average age of initial heroin or cocaine use was . . eight ( %) ha~ been homeless at least once m the last months and s ( %) were homeless for most or all of this penod. fourteen ( %) had a history of injection drug use with the mean age at first injection being s frsewons v ,an. elrven persc.!ns ( %) reported inje~~ng .heroin or cocaine within the last days while the .wing four ( l'o) reported regular non-m ect on use of cocaine and street-obtained benzodiazepines. sijiy seven percent of the sample (n= ) reported ever being referred to hcv treatment while ( t % ) ftponeddiattreann~nt had been offered by~ ~e.dical provider. none had ever received a liver biopsy or araanent. most believed that hcv was a s gmf cant threat to their health ( %) and that there was a pm)dchance they would eventually die if their hepatitis c was not treated ( %). though individuals % believed that there was no cure for hcv, ( %) reported that they would initiate treatment if i was recommended by their doctor. thirteen ( %) had a current psychiatric diagnosis including «pmsion, anxiety disorder, schizophrenia, schizoaffective disorder, and borderline and antisocial persooaliry disorders. among eight individuals who had the beck depression inventory administered, the mean score was . . attendance rates were % ( / ) at scheduled medical and psychiatric ppointments and % ( / ) at liver biopsy. <andtuions: active drug users, despite experiencing multiple psycho-social problems, can be mgaged in hcv care using a multidisciplinary approach, but require intensive follow-up support. hcv aunnent of active drug users should not be dismissed. n- (c) antiretroviral therapy in mv infected infants: when to initiate therapy an african experience kingsley okonkwo, ademola adeyemo, israel sokeye, and nwaife umeike /""°""ction: as technology for early diagnosis of human immunodeficiency virus [hiv] improves, m to commence highly active antiretroviral therapy [haarn is yet to be fully evaluated. this prospective study describes our initial experience with early haart in hiv infected nigerian infants and rqions the outcome. we also analyzed the socioeconomic implications of early haart therapy in infants in the african setting. method: hiv infected infants were started on haart before months and followed up at mkly intervals.we monitored baseline and monthly cd . conclusion: initial results suggest early haart before months resulted. in improv~d out~ome in african children. treatment appears to be as effective as in developed counmes. in. a~nca as. m most developing countries with limited resources it is possible and effective to use haart m ~~ants if p~oper llloniroring facilities are available. however the occurrence of long-term drug related tox c ty and mk of emergence of resistant viral strains create need for further evaluation of haart in infants. background: most risk factors for cardiovascular disease (cvd) can be mitigated through ~th clinical interventions and lifestyle change. we used data from a telephone survey of new york city (nyc) adults to characterize health care access and healthy behavior among those with three or more cvd risk factors. methods: the study population included respondents to the nyc community health survey (n= , ) self-reporting~ of the following: smoking, diabetes, high cholesterol level, high blood pres· sure, body mass index > , and age > (males) or > (females) (n= , ). results: based on self-report, an estimated . , ( %) of nyc adults have~ or more cvd risk factors. this population is % male, % white, % black, and % with s years of education. most report good access to health care, indicated by having health insurance ( %), regular doctor ( %), their blood pressure checked within last months ( %), and their choles· terol checked within the past year ( % ). only % reported getting at least minutes of exercise ~ times per week and only % eating ~ servings of fruits and vegetables the previous day. among current smokers, % attempted to quit in past months, but only % used medication or counseling. implications: these data suggest that most nyc adults known to be at high risk for cvd have access to regular health care, but most do not engage in healthy lifestyle or, if they smoke, attempt effective quit strategies. more clinic-based and population-level interventions are needed to support lifestyle change among those at high risk of cvd. introduction: recently, much interest has been directed at "obesogenic" (obesity-promoting) (swinburn, egger & raza, ) built environments, and at geographic information systems (gis) as a tool for their exploration. a major geographical concept is accessibility, or the ease of moving from an origin to a destination point, which has been recently explored in several health promotion-related stud· ies. there are several methods of calculating accessibility to an urban feature, each with its own strengths, drawbacks and level of precision that can be applied to various health promotion research issues. the purpose of this paper is to describe, compare and contrast four common methods of calculating accessibility to urban amenities in terms of their utility to obesity-related health promotion research. practical and conceptual issues surrounding these methods are introduced and discussed with the intent of providing health promotion researchers with information useful for selecting the most appropria e accessibility method for their research goal~ ~ethod: this paper describes methodological insights from two studies, both of which assessed the neighbourhood-level accessibility of fast-food establishments in edmonton, canada -one which used a relatively simple coverage method and one which used a more complex minimum cos method. res.its: both methods of calculating accessibility revealed similar patterns of high and low access to fast-food outlets. however, a major drawback of both methods is that they assume the characteristics of the a~e~ities and of the populations using them are all the same, and are static. the gravity potential method is introduced as an alternative, since it is ·capable of factoring in measures of quality and choice. a n~mber of conceptual and pr~ctical iss~es, illustrated by the example of situational influences on food choice, make the use of the gravity potential model unwieldy for health promotion research into sociallydetermined conditions such as obesity. co.nclusions: i~ ~ommended that geographical approaches be used in partnership with, or as a foun~ation for, ~admonal exploratory methodologies such as group interviews or other forms of commumty consultation that are more inclusive and representative of the populations of interest. qilhl in los angeles county ,,..ia shaheen, richard casey, fernando cardenas, holman arthurs, and richard baker ~the retinomax autorefractor has been used for vision screening of preschool age childien. ir bas been suggested to be used and test school age children but not been validated in this age poup. ob;taiw: to compare the results of retinomax autorefractor with findings from a comprehensive i!' examination using wet retinoscopy for refractive error. mllhods: children - years old recruited from elementary schools at los angeles county were iaml with snellen's chart and the retinomax autorefractor and bad comprehensive eye examination with dilation. the proportion of children with abnormal eye examination as well as diesensitiviry and specificity of the screening tools using retinomax autorefractor alone and in combinalion wirh snellen's chart. results of the children enrolled in the study (average age= . ± . years; age range, - years), ?% had abnormal eye examination using retinoscopy with dilation. for the lerinomax, the sensitivity was % ( % confidence interval [ci] %- %), and the specificity was % ( % ci, %- o/o). simultaneous testing using snellen's chart and retinomax resulted in gain in sitiviry ( %, % cl= , ), and loss in specificity ( %, % cl= %- %). the study showed that screening school age children with retinomax autorefractor could identify most cases with abnormal vision but would be associated with many false-positive results. simuhaneous resting using snellen's chart and retinomax maximize the case finding but with very low specificiry. mdhotjs: a language-stratified, random sample of members of the college of family physicians of canada received a confidential survey. the questionnaire collected data on socio-demographic characteristics, medical training, practice type, setting and hcv-related care practices. the self-adminisratd questionnaire was also made available to participants for completion on the internet. batdti: response proportion was %. median age was years ( % female) and the proporlionoffrench questionnaires was %. approximately % had completed family medicine residency lllining in canada; median year of training completion was . sixty-seven percent, % and % work in private offices/clinics, community hospitals and emergency departments, respectively. regarding ~practices, % had ever requested a hcv test and % of physicians had screened for hcv iafrction in rhe past months· median number of tests was . while % reported having no hcv-uaed patients in their practic~, % had - hcv-infected patients. regarding the level of hcv care provided, . % provide ongoing advanced hcv care including treatment and dose monitoring for ctmduions: in this sample of canadian family physicians, most had pro~ided hcv screening. to •least one patient in the past year. less than half had - hcv-infected patients and % provide ~:relared care the role of socio-demographic factors, medical training as wel_i as hcv ca~e percep-lldas rhe provision of appropriate hcv screening will be examined and described at the time of the canference. ' - (c) healthcare services: the context of nepal meen poudyal chhetri """ tl.ction healthcare service is related with the human rights and fundamental righ~ of the ci~ ciaaiuntry. however, the growing demand foi health care services, quality heal~care service, accessib b~ id die mass population and paucity of funds are the different but interrelated issues to .be ~ddressed. m nepat. n view of this context, public health sector in nepal is among other sectors, which is struggling -.i for scarce resources. . . . nepal, the problems in the field of healthcare servic~s do not bnut ~o the. paucity of faads and resources only, but there are other problems like: rural -urban imbalance, regional unbalance, poster sessio~ f the ll ·m ·ted resources poor healthcare services, inequity and inaccessibility of the poor management o , . poor people of the rural, remote and hilly areas for the healthcare services and so on.. . . . · . i f ct the best resource allocation is the one that max m zes t e sum o m ivi ua s u · ea t services. n a , · h d' ·b · · · h . ·t effi.ciency and efficient management are correlated. it might be t e re istn utmn of mes. ence, equi y, . . . . . income or redistribution of services. moreover, maximizanon of available resources, qua tty healthcare services and efficient management of them are the very important and necessary tools and techmques to meet the growing demand and quality healthcare services in nepal. p - (a) an jn-depth analysis of medical detox clients to assist in evidence based decision making xin li, huiying sun, ajay puri, david marsh, and aslam anis introduction: problematic substance use represents an ever-increasing public health challenge. in the vancouver coastal health (vch) region, there are more than , individuals having some probability of drug or alcohol dependence. to accommodate this potential demand for addiction related services, vch provides various services and treatment, including four levels of withdrawal management services (wms). clients seeking wms are screened and referred to appropriate services through a central telephone intake service (access i). the present study seeks to rigorously evaluate one of the services, vancouver detox, a medically monitored -bed residential detox facility, and its clients. doing so will allow decision makers to utilize evidence based decision-making in order to improve the accessibility and efficiency of wms, and therefore, the health of these clients. methods: we extract one-year data (october , -september , from an efficient and comprehensive database. the occupancy rate of the detox centre along with the clients' wait time for service and length of stay (los) are calculated. in addition, the effect of seasonality on these variables and the impact of the once per month welfare check issuance on the occupancy rate are also evaluated. results: among the clients (median age , % male) who were referred by access! to vancouver detox over the one-year period, were admitted. the majority ( %) of those who are not admitted are either lost to follow up (i.e., clients not having a fixed address or telephone) or declined service at time of callback. the median wait time was day [q -ql: - ], the median los was days iq -qt: - ], and the average bed occupancy rate was %. however, during the threeday welfare check issue period the occupancy rate was lower compared to the other days of the year % vs. %, p conclusion: our analysis indicates that there was a relatively short wait time at vancouver detox, however % of the potential clients were not served. in addition, the occupancy rate declined during the welfare check issuance period and during the summer. this suggests that accessibility and efficiency at vancouver detox could be improved by specifically addressing these factors. background: intimate partner violence (ipv) is associated with acute and chronic physical and men· tal health outcomes for women resulting in greater use of health services. yet, a vast literature attests to cultural variations in perceptions of health and help-seeking behaviour. fewer studies have examined differences in perceptions of ipv among women from ethnocultural communities. the recognition, definition, and understanding of ipv, as well as the language used to describe these experiences, may be different in these communities. as such, a woman's response, including whether or not to disclose or seek help, may vary according to her understanding of the problem. methods: this pilot study explores the influence of cultural factors on perceptions of and responses to ipv among canadian born and immigrant young women. in-depth focus group interviews were con· ducted with women, aged to years, living in toronto. open-ended and semi-structured interview questions were designed to elicit information regarding how young women socially construct jpv and where they would go to receive help. interviews were transcribed, then read and independently coded by the research team. codes were compared and disagreements resolved. qualitative software qsr n was used to assist with data management. . ruu~ts_: res~nses_abo~t what constitutes ipv were similar across the study groups. when considering specific ab.us ve ~ tuanons and types of relationships, participants held fairly relativistic views about ipv, especially with regard to help-seeking behaviour. cultural differences in beliefs about normaive m;ile/femal~ relations. familial.roles, and customs governing acceptable behaviours influenced partictpants perceptions about what n ght be helpful to abused women. interview data highlight the social l ter srnfons v suucrural _impact these factors ha:e on you?g women and provide details regarding the dynamics of cibnocultur~ m~uences on help-~eekmg behav ur: t~e ro~e of such factors such as gender inequality within rtlaoo?sh ps and t_he ~erce ved degree of ~oc al solat on and support nerworks are highlighted. collc~ the~ findmgs unde~score the _ mporta_nc_e of understanding cultural variations in percrprions of ipv ~ relanon to ~elp-seekmg beha~ ':'ur. th s_mformation is critical for health professionals iodiey may connnue developmg culturally sensmve practices, including screening guidelines and protorol s. ln addition, _this study demonstr~tes that focus group interviews are valuable for engaging young romen in discussions about ipv, helpmg them to 'name' their experiences, and consider sources of help when warranted. p -s (a) health problems and health care use of young drug users in amsterdam .wieke krol, evelien van geffen, angela buchholz, esther welp, erik van ameijden, and maria prins / trod ction: recent advances in health care and drug treatment have improved the health of populations with special social and health care needs, such as drug users. however, still a substantial number dots not have access to the type of services required to improve their health status. in the netherlands, tspccially young adult drug users (yad) whose primary drug is cocaine might have limited access to drugrreatment services. in this study we examined the history and current use of (drug associated) treatmmt services, the determinants for loss of contact, and the current health care needs in the young drug mm amsterdam study (yodam). methods: yodam started in and is embedded in the amsterdam cohort study among drug mm. data were derived from y ad aged < years who had used cocaine, heroin, ampheramines and i or methadone at least days a week during the months prior to enrolment. res lts:of yao, median age was years (range: - years), % was male and % had dutch nationality at enrolment. nearly all participants ( %) reported a history of contact with drug llt.lnnent services (methadone maintenance, rehabilitation clinics and judicial treatment), mental health car? (ambulant mental care and psychiatric hospital) or general treatment services (day-care, night-care, hdp for living arrangements, work and finance). however, only % reported contact in the past six l!xlllths. this figure was similar in the first and second follow-up visit. among y ad who reported no current contact with the health care system, % would like to have contact with general treatment serl' icts. among participants who have never had contact with drug treatment services, % used primarily cocaine compared with % and % among those who reported past or current contact, respectively. saied on the addiction severity index, % reported at least one mental health problem in the past days, but only % had current contact with mental health services. concl sion: results from this study among young adult drug users show that despite a high contact rm with health care providers, the health care system seems to lose contact with yao. since % indicatt the need of general treatment services, especially for arranging house and living conditions, health m services that effectively integrate general health care with drug treatment services and mental health care might be more successful to keep contact with young cocaine users. mtthods: respondents included adults aged and over who met dsm-iv diagn?snc criteria for an anxiety or depressive disorder in the past months. we performed two sets of logisnc regressmns. thtdichotomous dependent variables for each of the regressions indicated whether rhe respondenr_vis-ud a psychiatrist, psychologist, family physician or social worker in the _past_ months. no relationship for income. there was no significant interaction between educatmn an mco~:· r: ::or respondents with at least a high school education to seek help ~rom any of the four servic p were almost twice that for respondents who had not completed high school. th . d ec of analyses found che associacion becween educacion and use of md-provided care e secon s · · be d · · ·f· ly ·n che low income group for non-md care, the assoc anon cween e ucatlon and was s gm icant on -· . . . . use of social workers was significant in both income groups, but significant only for use of psychologists in che high-income group. . . . conclusion: we found differences in healch service use by education level. ind v duals who have nor compleced high school appeared co use less mental he~lt~ servi~es provided ~y psyc~iatrists, psycholo· gists, family physicians and social workers. we found limited e.v dence _suggesting the influence of educa· tion on service use varies according to income and type of service provider. results suggesc there may be a need to develop and evaluate progr~ms.designe~ to deliver targeted services to consumers who have noc completed high school. further quahtanve studies about the expen· ence of individuals with low education are needed to clarify whether education's relationship with ser· vice use is provider or consumer driven, and to disentangle the interrelated influences of income and education. system for homeless, hiv-infected patients in nyc? nancy sahler, chinazo cunningham, and kathryn anastos introduction: racial/ethnic disparities in access to health care have been consistently documented. one potential reason for disparities is that the cultural distance between minority patients and their providers discourage chese patients from seeking and continuing care. many institucions have incorporated cultural compecency craining and culturally sensicive models of health care delivery, hoping co encourage better relacionships becween patients and providers, more posicive views about the health care system, and, ulcimacely, improved health outcomes for minority patients. the current scudy tests whether cultural distance between physicians and patients, measured by racial discordance, predicts poorer patient attitudes about their providers and the health care system in a severely disadvantaged hiv-infected population in new york city that typically reports inconsistent patterns of health care. methods: we collected data from unscably housed black and latino/a people with hiv who reported having a regular health care provider. we asked them to report on their attitudes about their provider and the health care system using validated instruments. subjects were categorized as being racially "concordant" or "discordant" with their providers, and attitudes of these two groups were compared. results: the sample consisted of ( %) black and ( %) latino/a people, who reported having ( %) black physicians, ( %) latino/a physicians, ( %) white physicians, and ( %) physicians of another/unknown race/ethnicity. overall, ( %) subjects had physicians of a different race/ethnicity than their own. racial discordance did not predict negative attitudes about rela· tionship with providers: the mean rating of a i-item trust in provider scale (lo=high and o=low) was . for both concordant and discordant groups, and the mean score in -icem relationship with provider scale ( =high and !=low) was . for both groups. however discordance was significantly associated with distrust in che health care syscem: che mean score on a -icem scale ( =high discrust and l=low distrust) was . for discordant group and . for che concordant group (t= . , p= . ). we further explored these patterns separacely in black and lacino/a subgroups, and using different strategies ro conceptualize racial/ethic discordance. conclusions: in this sample of unscably housed black and latino/a people who receive hiv care in new york city, having a physician from the same racial/ethnic background may be less important for developing a positive doctor-patient relationship than for helping the patients to dispel fear and distrust about the health care system as a whole. we discuss the policy implications of these findings. ilene hyman and samuel noh . .abstract objectiw: this study examines patterns of mental healthcare utilization among ethiopian mm grants living in toronto. methods: a probability sample of ethiopian adults ( years and older) completed structured face-to-face interviews. variables ... define, especially who are non-health care providers. plan of analysis. results: approximately % of respondents received memal health services from mainstream healthcare providers and % consulted non-healthcare professionals. of those who sought mental health services from mainstream healthcare providers, . % saw family physicians, . % visited a psychiatrist. and . % consulted other healthcare providers. compared with males, a significantly higher proportion gsfer sessions v ri ftlnales consulted non-healthcare_ professionals for emotional or mental health problems (p< . ). tlbile ethiopian's overall use of mamstream healthcare services for emotional problems ( %) did not prlydiffer from the rate ( %) of the general population of ontario, only a small proportion ( . %) rjerhiopians with mental health needs used services from mainstream healthcare providers. of these, !oj% received family physicians' services, . % visited a psychiatrist, and . % consulted other healthll/c providers. our data also suggested that ethiopian immigrants were more likely to consult tradioooal healers than health professionals for emotional or mental health problems ( . % vs. . % ). our bivariate analyses found the number of somatic symptoms and stressful life events to be associated with an increased use of medical services and the presence of a mental disorder to be associated with a dfcreased use of medical services for emotional problems. however, using multivariate methods, only die number of somatic symptoms remained significantly associated with use of medical services for emooonal problems. diu#ssion: study findings suggest that there is a need for ethnic-specific and culturally-appropriate mrcrvention programs to help ethiopian immigrants and refugees with mental health needs. since there ~a strong association between somatic symptoms and the use family physicians' services, there appears robe a critical role for community-based family physicians to detect potential mental health problems among their ethiopian patients, and to provide appropriate treatment and/or referral. the authors acknowledge the centre of excellence for research in immigration and settlement (ceris) in toronto and canadian heritage who provided funding for the study. we also acknowledge linn clark whose editorial work has improved significantly the quality of this manuscript. we want to thank all the participants of the study, and the ethiopian community leaders without whose honest contributions the present study would have not been possible. this paper addresses the impact of the rationalization of health-care services on the clinical decision-making of emergency physicians in two urban hospital emergency departments in atlantic canada. using the combined strategies of observational analysis and in-depth interviewing, this study provides a qualitative understanding of how physicians and, by extension, patients are impacred by the increasing ancmpts to make health-care both more efficient and cost-effective. such attempts have resulted in significantly compromised access to primary care within the community. as a consequence, patients are, out of necessity, inappropriately relying upon emergency departments for primary care services as well as access to specialty services. within the hospital, rationalization has resulted in bed closures and severely rmricted access to in-patient services. emergency physicians and their patients are in a tenuous position having many needs but few resources. furthermore, in response to demands for greater accountability, physicians have also adopted rationality in the form of evidence-based medicine. ultimately, ho~ever, rationality whether imposed upon, or adopted by, the profession significantly undermines physu.: ans' ability to make decisions in the best interests of their patients. johnjasek, gretchen van wye, and bonnie kerker introduction: hispanics comprise an increasing proportion of th.e new york city (nyc) populanon !currently about %). like males in the general population, h spamc males (hm) have a lower prrval,nce of healthcare utilization than females. however, they face additional access barriers such as bnguage differences and high rates of uninsurance. they also bear a heavy burden of health problems lllehasobesity and hiv/aids. this paper examines patterns of healthcare access and ut hzat on by hm compared to other nyc adults and identifies key areas for intervention. . . . and older are significantly lower than the nhm popu anon . v. . , p<. ), though hi\' screening and immunizations are comparable between the two groups. conclusion: findings suggest that hm have less access t? healthcare than hf or nhm. hown r, hm ble to obtain certain discrete medical services as easily as other groups, perhapsdueto!rtor are a hm. i i . subsidized programs. for other services, utilization among s ower. mprovmg acc~tocareinthis group will help ensure routine, quality care, which can lead to a greater use of prevennve services iii! thus bener health outcomes. introduction: cancer registry is considered as one of the most important issues in cancer epidemiology and prevention. bias or under-reporting of cancer cases can affect the accuracy of the results of epidemiological studies and control programs. the aim of this study was to assess the reliability of the regional cancer report in a relatively small province (yasuj) with almost all facilities needed for c llcll diagnosis and treatment. methods: finding the total number of cancer cases we reviewed records of all patients diagnoicd with cancer (icd - ) and registered in any hospital or pathology centre from until i n yasuj and all ( ) surrounding provinces. results: of patients who were originally residents of yasui province, . % wereaccoulll!d for yasuj province. the proportion varies according to the type of cancer, for exarnplecancetsofdiglstive system, skin and breast were more frequently reported by yasuj's health facilities whereas cancmoi blood, brain and bone were mostly reported by neighbouring provinces. the remaining cases ( . % were diagnosed, treated and recorded by neighbouring provinces as their incident cases. this is partly because of the fact that patients seek medical services from other provinces as they believed that the facil. ities are offered by more experienced and higher quality stuffs and their relative's or temporary acooiii' modation addresses were reported as their place of residence. conclusion: measuring the spatial incidence of cancer according to the location of report ortht current address affected the spatial statistics of cancer. to correct this problem recording the permanm! address of diagnosed cases is important. p - (c). providing primary healthcare to a disadvantaged population at a university-run commumty healthcare facility tracey rickards the. c:ommuni~y .h~alth ~linic (chc) is a university sponsored nurse-managed primary bealthwt (p~c:l clime. the clm c is an innovative model of healthcare delivery in canada that has integrated tht principles of phc ser · · h' . vices wit ma community development framework. it serves to provide access to phc services for members of th · · illi · dru is ii be . . e community, particularly the poor and those who use or gs, we mg a service-learning facil'ty f d · · · · · · d rionll h . . .,m.:. · t · . meet c ient nee s. chmc nursing and social work staff and srudents r·--· ipa em various phc activities and h .l.hont" less i . f . outreac services in the local shelters and on the streels to'"" popu auon o fredericton as well th chc · model iii fosterin an on oi : . • e promotes and supports a harm reduction . · local d!or an~ h ng ~art:ersh p with aids new brunswick and their needle exchange program, w tha ing condoms and :xu:t h:~~~e e~aint~nance therapy clients, and with the clie~ts themselves ~_r; benefits of receiving health f ucation, a place to shower, and a small clothing and food oai~· care rom a nurse p · · d d · --""~'i"· are evidenced in th r research that involved needsaans mvo ves clients, staff, and students. to date the chc has unacn- · sessment/enviro i . d ; •• '"""" ll eva uanon. the clinic has also e . d nmenta scan, cost-benefit analysis, an on-go...,, "".'i'~ facility and compassionate lea x~mme the model of care delivery' focusing on nursing roles wi~ cj rmng among students. finally, the clinic strives to share the resu•p v . -arch with the community in which it provides service by distributing a bi-monthly newsletter, and plllicipating in in-services and educational sessions in a variety of situations. the plan for the future is coolinued research and the use of evidence-based practice in order to guide the staff in choosing how much n~ primary healthcare services to marginalized populations will be provided. n- (c) tuming up the volume: marginalized women's health concerns tckla hendrickson and betty jane richmond bdrotbu:tion: the marginalization of urban women due to socio-economic status and other determinants negatively affects their health and that of their families. this undermines the overall vitaliry of urban communities. for example, regarding access to primary health care, women of lower economic surus and education levels are less likely to be screened for breast and cervical cancer. what is not as widely reported is how marginalized urban women in ontario understand and articulate their lack of access to health care, how they attribute this, and the solutions that they offer. this paper reports on the rnults of the ontario women's health network (owhn) focus group project highlighting urban women's concerns and suggestions regarding access to health care. it also raises larger issues about urban health, dual-purpose focus group design, community-based research and health planning processes. mdhods: focus group methodology was used to facilitate a total of discussions with urban and rural women across ontario from to . the women were invited to participate by local women's and health agencies and represented a range of ages, incomes, and access issues. discussions focussed on women's current health concerns, access to health care, and information needs. results were analyzed using grounded theory. the focus groups departed from traditional focus group research goals and had two purposes: ) data collection and dissemination (representation of women's voices), and ) fostering closer social ties between women, local agencies, and owhn. the paper provides a discussion and rationale for a dual approach. rax/ts: the results confirm current research on women's health access in women's own voices: urban women report difficulty finding responsive doctors, accessing helpful information such as visual aids in doctors' offices, and prohibitive prescription costs, in contrast with rural women's key concern of finding a family doctor. the research suggests that women's health focus groups can address access issues by helping women to network and initiate collective solutions. the study shows that marginalized urban women are articulate about their health conctrns and those of their families, often understanding them in larger socio-economic frameworks; howtver, women need greater access to primary care and women-friendly information in more languages and in places that they go for other purposes. it is crucial that urban health planning processes consult directly with women as key health care managers, and turn up the volume on marginalized women's voices. women: an evaluation of awareness, attitudes and beliefs introduction: nigeria has one of the highest rates of human immunodeficiency virus ihivi seroprrvalence in the world. as in most developing countries vertical transmission from mother to child account for most hiv infection in nigerian children. the purpose of this study was ro. determine the awareness, attitudes and beliefs of pregnant nigerian women towards voluntary counseling and testing ivct! for hiv. mnbod: a pre-tested questionnaire was used to survey a cross section '.>f. pregnant women ~t (lrlleral antenatal clinics in awka, nigeria. data was reviewed based on willingness to ~c~ept or re ect vct and the reasons for disapproval. knowledge of hiv infection, routes of hiv transm ssmn and ant rnroviral therapy iart) was evaluated. hsults: % of the women had good knowledge of hiv, i % had fair knowledge while . % had poor knowledge of hiv infection. % of the women were not aware of the association of hreast milk feeding and transmission of hiv to their babies. majority of the women % approved v~t while % disapproved vct, % of those who approved said it was because vct could ~educe risk of rransmission of hiv to their babies. all respondents, % who accepted vc.i ~ere willing to be tnted if results are kept confidential only % accepted to be tested if vc.t results w. be s~ared w .th pinner and relatives % attributed their refusal to the effect it may have on their marriage whale '-gave the social 'and cultural stigmatization associated with hiv infection for their r~fusal.s % wall accept vct if they will be tested at the same time with their partners. ~ of ~omen wall pref~r to breast feed even if they tested positive to hiv. women with a higher education diploma were times v more likely to accept vct. knowledge of art for hiv infected pregnant women as a means of pre. vention of maternal to child transmission [pmtct) was generally poor, % of respondents wm aware of art in pregnancy. conclusion: the acceptance of vct by pregnant women seems to depend on their understanding that vct has proven benefits for their unborn child. socio-cultur al factors such as stigmatizationof hiv positive individuals appears to be the maj_or impedi~ent towards widespread acceptanee of ycr in nigeria. involvemen t of male partners may mpro~e attitudes t~wa~ds vct:the developmentofm novative health education strategies is essential to provide women with mformanon as regards the benefits of vct and other means of pmtct. p - (c) ethnic health care advisors in information centers on health care and welfare in four districts of amsterdam arlette hesselink, karien stronks, and arnoud verhoeff introduction : in amsterdam, migrants report a "worse actual health and a lower use of health care services than the native dutch population. this difference might be partly caused by problems migrants have with the dutch language and health care and welfare system. to support migrants finding their way through this system, in four districts in amsterdam information centers on health care and welfare were developed in which ethnic health care advisors were employed. their main task is to provide infor· mation to individuals or groups in order to bridge the gap between migrants and health care providers. methods: the implementat ion of the centers is evaluated using a process evaluation in order to give inside in the factors hampering and promoting the implementat ion. information is gathered using reports, attending meetings of local steering groups, and by semi-structu red interviews with persons (in)directly involved in the implementat ion of the centers. in addition, all individual and groupcontaets of the health care advisors are registered extensively. results: since four information centers, employing ethnic health care advisors, are implemented. the ethnicity of the health care advisors corresponds to the main migrant groups in the different districts (e.g. moroccan, turkeys, surinamese and african). depending on the local steering groups, the focus of the activities of the health care advisors in the centers varies. in total, around individual and group educational sessions have been registered since the start. most participants were positive about the individual and group sessions. the number of clients and type of questions asked depend highly on the location of the centers (e.g. as part of a welfare centre or as part of a housing corporation). in all districts implementa tion was hampered by lack of ongoing commitment of parties involved (e.g. health care providers, migrant organization s) and lack of integration with existing health care and welfare facilities. discussion: the migrant health advisors seem to have an important role in providing information on health and welfare to migrant clients, and therefore contribute in bridging the gap between migrants and professionals in health care and welfare. however, the lack of integration of the centers with the existing health care and welfare facilities in the different districts hampers further implementation . therefore, in most districts the information centres will be closed down as independent facilicities in the near future, and efforts are made to better connect the position of migrant health advisor in existing facilities. the who report ranks the philippines as ninth among countries with a high tb prevalence. about a fourth of the country's population is infected, with majority of cases coming from the lower socioeconomic segments of the community. metro manila is not only the economic and political capital of the philippines but also the site of major universities and educational institutions. initial interviews with the school's clinicians have established the need to come up with treatment guidelines and protocols for students and personnel when tb is diagnosed. these cases are often identified during annual physical examinations as part of the school's requirements. in many instances, students and personnel diagnosed with tb are referred to private physicians where they are often lost to follow-up and may have failure of treatment due to un monitored self-administered therapy. this practice ignores the school clinic's great potential as a tb treatment partner. through its single practice network (spn) initiative, the philippine tuberculosis initiatives for the private sector (philippine tips), has established a model wherein school clinics serve as satellite treatment partners of larger clinics in the delivery of the directly observed treatment, short course (dots) protocol. this "treatment at the source" allows school-based patients to get their free government-suppl ied tb medicines from the clinic each day. it also cancels out the difficulty in accessing medicines through the old model where the patient has to go to the larger clinic outside his/her school to get treatment. the model also enables the clinic to monitor the treatment progress of the student and assumes more responsibility over their health. this experience illustrates how social justice in health could be achieved from means other than fund generation. the harnessing of existing health service providers in urban communities through standardized models of treatment delivery increases the probability of treatment success, not only for tb but for other conditions as well. p - (c) voices for vulnerable populations: communalities across cbpr using qualitative methods martha ann carey, aja lesh, jo-ellen asbury, and mickey smith introduction: providing an opportunity to include, in all stages of health studies, the perspectives and experiences of vulnerable and marginalized populations is increasingly being recognized as a necessary component in uncovering new solutions to issues in health care. qualitative methods, especially focus groups, have been used to understand the perspectives and needs of community members and clinical staff in the development of program theory, process evaluation and refinement of interventions, and for understanding and interpreting results. however, little guidance is available for the optimal use of such information. methods: this presentation will draw on diverse experiences with children and their families in an asthma program in california, a preschool latino population in southern california, a small city afterschool prevention program for children in ohio, hiv/aids military personnel across all branches of the service in the united states, and methadone clinic clients in the south bronx in new york city. focus groups were used to elicit information from community members who would not usually have input into problem definitions and solutions. using a fairly common approach, thematic analysis as adapted from grounded theory, was used to identify concerns in each study. next we looked across these studies, in a meta-synthesis approach, to examine communalities in what was learned and in how information was used in program development and refinement. results: while the purposes and populations were diverse, and the type of concerns and the reporting of results varied, the conceptual framework that guided the planning and implementation of each study was similar, which led to a similar data analysis approach. we will briefly present the results of each study, and in more depth we will describe the communalities and how they were generated. conclusions: while some useful guidance for planning future studies of community based research was gained by looking across these diverse studies, it would be useful to pursue a broader examination of the range of populations and purposes to more fully develop guidance. background: the majority of studies examining the relationship between residential environments and cardiovascular disease have used census derived measures of neighborhood ses. there is a need to identify specific features of neighborhoods relevant to cardiovascular disease risk. we aim to ) develop methods· data on neighborhood conditions were collected from a telephone survey of s, fesi· dents in balth:.ore, md; forsyth county, nc; and new york, ny. a sample of of the i.ni~~l l'elpondents was re-interviewed - weeks after the initial interview t~ measure the tes~-~etest rebab ~ ty of ~e neighborhood scales. information was collected across seven ~e ghborho~ cond ~ons (aesth~~ ~uah~, walking environment, availability of healthy foods, safety, violence, social cohesion, and acnvmes with neighbors). neighborhoods were defined as census tracts or homogen~us census tra~ clusters. ~sycho metric properties.of the neighborhood scales were accessed by ca~cu~~.ng chronba~h s alpha~ (mtemal consistency) and intraclass correlation coefficients (test-r~test reliabilmes) .. pear~n s .corre~anons were calculated to test for associations between indicators of neighborhood ses (tncludmg d mens ons of race/ ethnic composition, family structure, housing, area crowding, residential stability, education, employment, occupation, and income/wealth) and our seven neighborhood scales. . chronbach's alphas ranged from . (walking environment) to . (violence). intraclass correlations ranged from . (waling environment) to . (safety) and wer~ high~~~ . ~ for ~urout of the seven neighborhood dimensions. our neighborhood scales (excluding achv hes with neighbors) were consistently correlated with commonly used census derived indicators of neighborhood ses. the results suggest that neighborhood attributes can be reliably measured. further development of such scales will improve our understanding of neighborhood conditions and their importance to health. childhood to young adulthood in a national u.s. sample jen jen chang lntrodfldion: prior studies indicate higher risk of substance use in children of depressed mothers, but no prior studies have followed up the offspring from childhood into adulthood to obtain more precise estimates of risk. this study aimed to examine the association between early exposure to maternal depl'elsive symptoms (mds) and offspring substance use across time in childhood, adolescence, and young adulthood. methods: data were obtained from the national longitudinal survey of youth. the study sample includes , mother-child/young adult dyads interviewed biennially between and with children aged to years old at baseline. data were gathered using a computer-assisted personal interview method. mds were measured in using the center for epidemiologic studies depression scale. offspring substance use was assessed biennially between and . logistic and passion regression models with generalized estimation equation approach was used for parameter estimates to account for possible correlations among repeated measures in a longitudinal study. rnlllta: most mothers in the study sample were whites ( %), urban residents ( %), had a mean age of years with at least a high school degree ( %). the mean child age at baseline was years old. offspring cigarette and alcohol use increased monotonically across childhood, adolescence, and young adulthood. differential risk of substance use by gender was observed. early exposure to mds was associated with increased risk of cigarette (adjusted odds ratio (aor) = . , % confidence interval ( ): . , . ) and marijuana use (aor = . , % ci: . , . ), but not with alcohol use across childhood, adolescence, and young adulthood, controlling for a child's characteristics, socioeconomic status, ~ligiosity, maternal drug use, and father's involvement. among the covariates, higher levels of father's mvolvement condluion: results from this study confirm previous suggestions that maternal depressive symptoms are associated with adverse child development. findings from the present study on early life experi-e~ce have the potential to inform valuable prevention programs for problem substance use before disturbances become severe and therefore, typically, much more difficult to ameliorate effectively. the ~act (~r-city men~ health study predicting filv/aids, club and other drug transi-b~) study a multi-level study aimed at determining the association between features of the urban enyjronment mental health, drug use, and risky sexual behaviors. the study is randomly sampling foster sessions v neighborhood residents and assessing the relations between characteristics of ethnographically defined urban neighborhoods and the health outcomes of interest. a limitation of existing systematic methods for evaluating the physical and social environments of urban neighborhoods is that they are expensive and time-consuming, therefore limiting the number of times such assessments can be conducted. this is particularly problematic for multi-year studies, where neighborhoods may change as a result of seasonality, gentrification, municipal projects, immigration and the like. therefore, we developed a simpler neighborhood assessment scale that systematically assessed the physical and social environment of urban neighborhoods. the impact neighborhood evaluation scale was developed based on existing and validated instruments, including the new york city housing and vacancy survey which is performed by the u.s. census bureau, and the nyc mayor's office of operations scorecard cleanliness program, and modified through pilot testing and cognitive testing with neighborhood residents. aspects of the physical environment assessed in the scale included physical decay, vacancy and construction, municipal investment and green space. aspects of the social environment measured include social disorder, social trust, affluence and formal and informal street economy. the scale assesses features of the neighborhood environment that are determined by personal (e.g., presence of dog feces), community (e.g., presence of a community garden), and municipal (e.g., street cleanliness) factors. the scale is administered systematically block-by-block in a neighborhood. trained research staff start at the northeast corner of an intersection and walk around the blocks in a clockwise direction. staff complete the scale for each street of the block, only evaluating the right side of the street. thus for each block, three or more assessments are completed. we are in the process of assessing psychometric properties of the instrument, including inter-rater reliability and internal consistency, and determining the minimum number of blocks or street segments that need to be assessed in order to provide an accurate estimate of the neighborhood environment. these data will be presented at the conference. obj«tive: to describe and analyze the perceptions of longterm injection drug users (idus) about their initiation into injecting. toronto. purposive sampling was used to seek out an ethnoculturally diverse sample of idus of both genders and from all areas of the city, through recruitment from harm reduction services and from referral by other study participants. interviews asked about drug use history including first use and first injecting, as well as questions about health issues, service utilization and needs. thematic analysis was used to examine initiation of drug use and of injection. results: two conditions appeared necessary for initiation of injection. one was a developed conception of drugs and their (desirable) effects, as suggested by the work of becker for marijuana. thus virtually all panicipants had used drugs by other routes prior to injecting, and had developed expectations about effects they considered pleasureable or beneficial. the second condition was a group and social context in which such use arose. no participants perceived their initiation to injecting as involving peer pressure. rather they suggested that they sought out peers with a similar social situation and interest in using drugs. observing injection by others often served as a means to initiate injection. injection served symbolic purposes for some participants, enhancing their status in their group and marking a transition to a different social world. concl ion: better understanding of social and contextual factors motivating drug users who initiate injection can assist in prevention efforts. ma!onty of them had higher educational level ( %-highschool or higher).about . yo adffiltted to have history of alcohol & another . % had history of smoking. only . % people were on hrt & . % were receiving steroid. majority of them ( . ) did not have history of osteoporosis. . % have difficulty in ambulating. only . % had family history of osteoporosis. bmd measurements as me~sured by dual xray absorptiometry (dexa) were used for the analysis. bmd results were compare~ w ~ rbc folate & serum vitamin b levels. no statistical significance found between bmd & serum v taffiln b level but high levels of folate level is associated with normal bmd in bivariate and multivariate analysis. conclusion: in the studied elderly population, there was no relationship between bmd and vitamin b ; but there was a significant association between folate levels & bmd. introduction: adolescence is a critical period for identity formation. western studies have investigated the relationship of identity to adolescent well-being. special emphasis has been placed on the influence of ethnic identity on health, especially among forced migrants in different foreign countries. methodology: this study asses by the means of an open ended question identity categorization among youth in three economically disadvantaged urban communities in beirut, the capital of lebanon. these three communities have different histories of displacement and different socio-demographic makeup. however, they share a history of displacement due to war. results and conclusion: the results indicated that nationality was the major category of identification in all three communities followed by origin and religion. however, the percentages that self-identify by particular identity categories were significantly different among youth in the three communities, perhaps reflecting different context in which they have grown up. mechanical heart valve replacement amanda hu, chi-ming chow, diem dao, lee errett, and mary keith introduction: patients with mechanical heart valves must follow lifelong warfarin therapy. war· farin, however, is a difficult drug to take because it has a narrow therapeutic window with potential seri· ous side effects. successful anticoagulation therapy is dependent upon the patient's knowledge of this drug; however, little is known regarding the determinants of such knowledge. the purpose of this study was to determine the influence of socioeconomic status on patients' knowledge of warfarin therapy. methods: a telephone survey was conducted among patients to months following mechan· ical heart valve replacement. a previously validated -item questionnaire was used to measure the patient's knowledge of warfarin, its side effects, and vitamin k food sources. demographic information, socioeconomic status data, and medical education information were also collected. results: sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score :s; %). age was negatively related to warfarin knowledge scores (r= . , p = . ). in univariate analysis, patients with family incomes greater than $ , , who had greater. than a grade education and who were employed or self employed had significantly higher warfarm knowledge scores (p= . , p= . and p= . respectively). gender, ethnicity, and warfar~n therapy prior to surgery were not related to warfarin knowledge scores. furthermore, none of t~e. m-hospital tea~hing practices significantly influenced warfarin knowledge scores. however, panic ~ants who _rece v~d post discharge co~unity counseling had significantly higher knowledge scores tn comp~r son with those who did not (p= . ). multivariate regression analysis revealed that und~r~tandmg the ~oncept of ?ternational normalized ratio (inr), knowing the acronym, age and receiving ~ommum !' counseling after discharge were the strongest predictors of warfarin kn~wledge. s~ oeconom c status was not an important predictor of knowledge scores on the multivanate analysis. poster sessions v ~the majority of patients at our institution have insufficient knowledge of warfarin therapy.post-discharge counseling, not socioeconomic status, was found to be an important predictor of warfarin knowledge. since improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive post-discharge education program or, at least, to ensure that patients have access to a community counselor to compliment the in-hospital educatiop program. brenda stade, tony barozzino, lorna bartholomew, and michael sgro lnttotl#ction: due to the paucity of prospective studies conducted and the inconsistency of results, the effects of prenatal cocaine exposure on functional abilities during childhood remain unclear. unlike the diagnosis of fetal alcohol spectrum disorder, a presentation of prenatal cocaine exposure and developmental and cognitive disabilities does not meet the criteria for specialized services. implications for public policy and services are substantial. objective: to describe the characteristics of children exposed to cocaine during gestation who present to an inner city specialty clinic. mnbods: prospective cohort research design. sample and setting: children ages to years old, referred to an inner city prenatal substance exposure clinic since november, . data collection: data on consecutive children seen in the clinic were collected over an month period. instrument: a thirteen ( ) page intake and diagnostic form, and a detailed physical examination were used to collect data on prenatal substance history, school history, behavioral problems, neuro-psychological profile, growth and physical health of each of the participants. data analysis: content analysis of the data obtained was conducted. results: twenty children aged to years (mean= . years) participated in the study. all participants had a significant history of cocaine exposure and none had maternal history or laboratory (urine, meconium or hair) exposure to alcohol or other substances. none met the criteria of fetal alcohol spectrum disorder. all were greater than the tenth percentile on height, weight, and head circumference, and were physically healthy. twelve of the children had iqs at the th percentile or less. for all of the children, keeping up with age appropriate peers was an ongoing challenge because of problems in attention, motivation, motor control, sensory integration and expressive language. seventy-four percent of participants had significant behavioral and/or psychological problems including aggressiveness, hyperactivity, lying, poor peer relationships, extreme anxiety, phobias, and poor self-esteem. conclusion: pilot study results demonstrated that children prenatally exposed to cocaine have significant learning, behavioural, and social problems. further research focusing on the characteristics of children prenatally exposed to cocaine has the potential for changing policy and improving services for this population. methods: trained interviewers conducted anonymous quantitative surveys with a random sample (n= ) of female detainees upon providing informed consent. the survey focused on: sociodemographic background; health status; housing and neighborhood stability and social resource availability upon release. results: participants were % african-american, % white, % mixed race and % native american. participants' median age was , the reported median income was <s , year, and % reported receiving a high school diploma or equivalent. women reported a number of health conditions rypical of underserved populations, including asthma ( %), sexually transmitted infections ( %), high blood pressure ( %), hcv ( %), diabetes ( %) and hiv ( %). nearly half ( %) did not anticipate having a place to stay for at least days upon release. factors significantly associated housing stability upon release were: high family support score (adjusted odds ratio [aor) . ; % confidence interval ( % cl) . , . ), high neighborhood stability score (aor . ; % cl . , . ), wanting a commercial sex worker (csw) support group (aor . ; % cl . , . ); and identifying as bisexual (aor . ; % cl . , . ). women desired employment ( %), housing ( %), education ( %), drug treattnent ( %), help with custody of children ( %), childcare ( %), and domestic violence suppon ( %) services. conclusions: female detainees represent one of urban centers' most marginalized pcjpwatioos. short periods of detention represent a unique opportunity for _interven?~ns bri~ co~s and public health institutions. service providers should collaborate ~ th local ~ails to .p~de a con uwnof care for female detainees upon release that includes transportation , housing, residential drug treallllcnt, employment, education, family reunification, childcare and domestic viol~nce su~rt. ~pecial attenlion is warranted to lesbian and bisexual women and csws, who may be especially margmalized &om family and service-based support networks. introduction: "health care and ethnic minority immigrants" examines how health care policy dil· ferences between canada and the united states impact the health-related hardships, access and use of preventative care, and health outcomes of urban ethnic minority immigrants in both countries. methods: the findings of this paper build on the results of my qualitative comparative study of hotel workers in vancouver, bc and seattle, wa that revealed greater health related hardships for similarly matched employees in seattle compared to vancouver. in this paper, i examine the generalizability of these findings at the cross-national level for similar ethnic minority immigrant groups. i compare the impact of health care policy differences on specific groups that have emigrated to cities in both canada and the united states. these include immigrants from china, viemam, philippines, west indies, africa, sri lanka, pakistan, and latin america. comparative statistical analysis -utilizing rel· evant data from statistics canada and the u.s. census -reveal the extent to which health policy differ· ences help explain how current health policy in the united states disadvantages urban ethnic minority immigrants. results: many ethnic minority immigrants are a part of the working poor, a group which disproportionately lacks health insurance coverage in the united states. their position in the labour market makes them most vulnerable to exclusion from health care services. the data reveals how current u.s. health policy creates barriers for recently arrived ethnic minority immigrants to access health insurance and care. it remains difficult to ascribe health outcome differences directly to policy differences because of the challenge in disentangling the complex interacting interventing variables, including income inequality, that determine health outcomes. yer suggestive evidence suggests that health policy in the united states is harming the health of urban ethnic minority immigrants. the current health policy regime in the united states harms the health access, care, and outcomes of urban ethnic minority immigrants. comparing the fortunes of similar immigrants in cana· dian and u.s. cities reveals these patterns of disadvantage and some of their consequences. these barriers are an understudied factor in the sociological literature on "segmented assimilation" and social exclu· sion. the paper ends with policy recommendatio ns to improve access to health care among ethnic minor· ity immigrants in both countries, with the goal of reducing health related hardships, and improving health outcomes. mass index deyu pan, richard baker, and keith norris badtgrou~ over the past decades, there has been dramatic increase in prevalence of obesity in the us population. however, the relationship between obesity and the prevalence of cardiovascular dis· ease (cv~) risk factors in different race/ethnic groups over time is not well known. . ik~rgn: _we use cross-sectional , nationally representative surveys: national health and nutri· t nal examination survey (nhanes iii - (n= ) and nhanes nhanes - , including white, black, and hispa~ic races who were no~preg~ant, aged to years. res lt : the preval~nce of high cholesterol level (~ mg/dl), untreated high blood pressure ( : l / mm hg) an~ diabetes were calculated according to bmi group (lean, < ; overweight, - ; and obese, : ) for different race/ethnicity groups. over the approximately years period (from l ~ ~o [ ] [ ] [ ] [ ] , reducrion in cvd risk factors in non-hispanic white has been observed. for mmonty race/~hnicity groups, black and hispanic, there had been increases in prevalence in high blood fa pressure and diabetes. the lean group experienced larger increase in prevalence of those cvd risk ctors. . fo~~ the prevalence in cvd risk factors over time had reduced in most of the bmi ca egoes r t e w ~~e population. however, for black and hispanic, prevalence of of cvd risk factors ave generauy uncreased, especially in overweight and obese groups. methods: strategies identified to achieve these goals include: developing meaningful neighbourhood and district boundaries for comparing health information, providing free access to neighbourhood health profiles (including relevant data at the smallest level for which valid rates could be calculated); mapping relationships of inequality at a variety of nested levels; providing a range of formats (maps, tables) to meet the needs of users; providing technical support; seeking user input to advance and improve the site; and conducting workshops to foster access and use of data for decision-making , advocacy and collaboration. an evaluation strategy is being developed to assess the efforts and impact of these strategies. a preliminary assessment of the results of the first six months of activity will be completed in october . results: significant differences in health are shown at all the geographic levels indicating success in developing the boundaries. results tabulated for the first six months use of the site include: site visits; media use; reference/acknow ledgement of the site in other documents; number of contacts through presentations and workshops; feedback from users identifying strengths and limitations; and, response from health decision makers. members of the partnership are identifying additional tools and services to further support actions that reduce health inequalities. the assessment will be used to develop more specific goals, targets and monitoring mechanisms. conclusions: our experience with paper-based health profiles indicates that they have been used extensively for program planning and advocacy. the greater availability of information in a publiclyavailable web-based format is expected to translate into even greater usefulness and wider application. the web site has had considerable usage to date, extensive media coverage. site users and workshop participants have provided positive feedback and suggestions for next steps. the six month review will be available in october . in india, more than and a half people are hiv-positive and half a million have aids. india currently has the largest number of positive people in the world, oumumbering south africa and accounting for nearly one tenth of the global hiv/aids prevalence. the world bank predicts that by , there will be million hiv/aids cases in india. the central challenge facing hiv prevention efforts in south asia today is learning how to respond to the societal determinants of vulnerability to hiv. hiv/aids is an issue largely engulfed by social stigma. stigma and discrimination are often considered the foremost barriers to effective poster sess ns v prevention and care initiatives. stigma can make a person afraid of disclosing their status~ ~yone el se, and may make them feel depressed or alone. stigma can .also le~d to poor adherence to medicanon, ~ likelihood to access health and social services, and less desire to hve. hiv+ men and women may beafraidtotd! their co-workers that they have hiv for fear of their reactions or for fear of losing their jobs. in a study conducted of people living with hiv/aids in delhi, india ov~r. -~, many respo~ts shared their experiences of discrimination in their families, in their communmes, an~ m health ~e settmgs. these findings will be shared in the workshop, and will be compa~ed to m~ ex~nences workmg as an ~ co~l~ at the center for aids prevention studies in san francisco, cahforma and congreso de lannos unidos m philadelphia, pennsylvania. the workshop will include an overview of hiv/aids in urban contexts in tht united states (los angeles, san francisco, new york, philadelphia) and south asia (delhi, hyderabad, chennai). differences in methods for outreach, prevention and treatment efforts between devdoped world and developing world contexts will be discussed. a large portion of the workshop will be centered on discussion. participants will engage in an exercise to categorize their ideas of stigma. the workshop will also include a powerpoint presentation on the quantitative data gathered from the survey. the number of homeless and runaway youth is increasing in toronto, which is currently home to out of youth in the gt a who live alone, and it is the preferred locale for the street-involved and homeless youth. the city's youth population is expected to grow by nearly % by , the school dropout rate is rising, and there are is a paucity of empirical data on what works with these at-risk youth. over a two-year period, ( ) ( ) ( ) , youthlink-inner city, conducted an evaluation of the impact of a harm reduction program aimed at reducing street youth's risk of contracting/infecting others with the hep c virus, which has both short-term and long-term deleterious effects. demographic data from street-youth, along with resources/services used, employment methods, type and frequency of drug use, health status, police contacts, and their views of program impact were analyzed using a standardized sur· vey. additionally, focus groups with youth, agency staff and community key informants were conducted, as well as in-depth interviews with three youth, over a sixth-month period. this paper details study results, which both inform both practice and future study about what works, why it works, and how best to work with these vulnerable youth. sho~ed .that the wasteland in this area was contaminated by as cd zn pb cu simultaneously. the con-ta~matton of as ~d was quit significant. the contamination problems and environmental issues in this region are very. serious. the awareness on environmental and health issues was investigated by spot survey and analysis. overall awareness among the residents in the region is very poor. the measures must be taken to assu~e t~e .sustainable economy development by local and central gorvernments. keywords nandan guangx ; mmmg area; environmental awareness. concern like, epileptic fits, vision problems, earache, cough of more than weeks and urinary problems. ninety-five subjects did not take bath regularly and were exposed to sex. the health problems identified are only of a particular point of time and it may be difficult to interpret the depth of "iceberg" of the street children's world also draw the health-illness continuum. periodic interaction and follow-up is very difficult as they generally disappear from the research setting due to their frequent mobility for survival measures. as per the prediction of the iceberg theory, only some problems may have been identified, larger problems in respect to their health may not have been identified. in spite of various limitations, this attempt had proven that, it is possible to enter the street children world, explore the iceberg of illnesses, and establish data of health-illness continuum through an effective nursing agency. it is recommended to deworm these children, provide nutritional education, establish "condom corners" and "street children help line" in the city and urban slum areas and undertake action research on their health. malnutrition is a serious problem in developing countries like bangladesh. malnutrition causes a great deal of child suffering. malnutrition is one of the major causes of morbidity and mortality among the child. the aim of present study was to investigate the nutritional status and its relation to socioeconomic conditions of urban disadvantaged child of under five years age. nutritional status was determined by anthropoemetric measurement(heig ht, weight, mid-arm circumference etc.). determination of total protein and serum albumin were done for biochemical examination. haematological examination was done by blood haemoglobin profile estimation by cynmethhaemoglob in method and determination of haematocrit value or packed cell volume (pcv). stool examination for ova of hook worm, round worm, trichuris species and other species were also done. relevant information on socioeconomic characteristics was recorded by interviewing the house hold head using pretested questionnaire. our study demonstrated that nutritional status of the children are positively correlated with family income, parents level of formal education and negatively related to the family size. the effect of family income on the nutritional status, haematological and biochemical indices of urban disadvantaged child under five will be discussed in detail which will help us to determine proper way of utilization of health care facilities exists in developing countries. introduction: with the increase in morbidity and reduction in mortality and with the introduction of highly active antiretroviral therapy (haart), there is increasing focus on the determinants of healthrelated quality of life (hrqol) in hiv-infection. the focus on the present study is to examine the relationship between social support, depression, and hiv disease severity, and the extent to which these variables impact on hrqol in adult men with hiv-infection. methods: as part of a larger ongoing natural history study focusing on the neurobehavioural complications of hiv and aids, we administered questionnaires to assess depression (beck depression inventory), social support, and hrqol (mos-hiv) to adult men with hiv-infection. a structured interview was used to collect health information and data on hiv disease severity. physical and mental health summary scores (phs and mhs) were derived through principal components analysis. participants were grouped according to level of social support: "well supported" (n= ), "moderately supported" (n= ), "little or ineffective support" (n= ). analysis of variance was conducted to assess the effects of three levels of perceived social support, depression status (present vs absent), and hiv disease severity (aids vs non-aids) on mental and physical health dimensions of hrqol. potential interaction effects were also evaluated. results: social support was found to have a significant effect on both mhs and phs. presence of depression was found to have a significant effect on mhs but not phs. hiv disease severity (presence of aids diagnosis) was found to have a significant effect on phs but not mhs. manov a analyses revealed no significant interactions effects. conclusions and implications: level of social support, presence of depression and hiv disease severity were shown to have independent effects on hrqol. feeling "well supported" appears to have significant benefits for mental and physical health. biological indicators of hiv disease appear to have a selective impact on physical health while presence of depression is related to significant reductions in mental health. the development and evaluation of behavioural interventions to improve perceived social support network and depression will likely result in significant improvements in health outcomes of adults with hiv and aids. introduction: ongoing medical advances have greatly enhanced the longevity of penons living with aids (plwa). however, for certain subgroups living with hiv/aids, including, members of minority groups, women and the economically underprivilege d, aids outcomes have not changed so favorably. one obvious factor to consider when explaining disparities in aids outcomes is the environ· ment within which an individual resides. few studies of aids outcomes have focused on how commu· nity setting influences the effectiveness of care delivery. the principle research questions were: ) what is the relationship between the locations of areas with concentrations of pl wa and the distribution of both primary and ancillary service providers? ) how has the widespread availability of haart (after ) impacted aids outcomes at the community level? ) how do aids mortality and fatality rates vary when related community characteristics, such as household income, ethnic mix, and geographic access to primary and ancillary hiv/aids services are considered? we examine this issue across residential communities in the los angeles area. methods: los angeles county's comprehensive aids service providers database (compiled and maintained by aids project los angeles) was geo-referenced and distances between weighted mean population centers and the nearest hiv/aids service providers were calculated to provide a measure of access which was then merged with aids diagnosis and mortality data along with relevant socioeconomic and population indicators and for analysis using bivariate and multivariate statistics at the zip code level. results: there is a growing disparity in hiv/aids outcomes between low-income minority areas and affluent non-minority areas in the post-haart era (p = . ). ancillary aids services such as case management and counseling and testing are located near the places where low income hiv/aids service consumers are likely to live (p =. ). in spite of having more access to ancillary services low income areas continue to be associated with smaller decreases post-haart aids mortality rates (p= . ). conclusions: given the increasing disparities in aids outcomes between lower and upper income communities in the post -haart era, more specific research into the capacities of aids services providers and the efficiency of their interventions is required. although it is clear that ancillary services are operating in the areas of greatest need, their effectiveness remains limited. understanding the reasons for t~is, be they lack of adequate resources for inner city service providers, failure to reach target popula· tmns or other causes, requires additional research. in ? , y.out~ who were able to speak either french or english and had been absent from their parent's/ c~regivers ~es. dence for at least three consecutive nights took part in the survey which consisted of inter· viewer-adm ms tered question~aires. p.arti~i~an~s were recruited from drop in centres in cities across <?-nada.y~uth self-report as either using in ect on or non-injection drugs. statistical analyses were car· r ed out using sas version . the 'home' is a contested site for many women living in urban areas. women living in poverty and using illicit drugs are largely excluded from participation in dominant 'home-base' gender roles of wife and mother because of economic disadvantage. they thus 'make home' in ways that are specific to their everyday experiences. while research has established links between housing, health and drug use, this literature does not tend to consider the meanings that home may have within the lives of women who lack access to adequate tenured living spaces. this presentation reports the findings of my master's thesis work. using grounded theory methodology within a poststructuralist feminist conceptual framework, i conducted in-depth, open-ended interviews with women living in the toronto area. the women were recruited from within the community through posters at different social service agencies (e.g., drop-in centres, community health centres). they were asked to describe their housing experiences and what home meant to them over the course of their lives. through the data analysis process, a substantive theory of 'making home' for women living in poverty and using illicit drugs emerged. the central concept of making home is a continual process of learning about and interacting with the environment. the process of making home entails different subprocesses: finding home (knowing what is available and accessible, and accessing home), adaptation, and leaving home. the different meanings of home that women developed from their experiences and knowledge emerged as critical components for the process of making home. the women i interviewed were very mobile and experienced constant change with regards to home. home was not considered only in relation to physical living space. home could be made within a relationship or with regards to a possession. while dominant meanings of home relation to tenured living spaces are generally positive, my research indicated that home could also be a negative context. the presentation will describe my research process and findings as well as the theoretical and policy implications of my results. in the western democracies, social citizenship bundles the right to social provision (defined as a share of the social good, not necessarily proportionate to the market value of a citizen's contribution) with participation in the paid labour force. for this reason, social citizenship rights, which usually involve some kind of redistributive measures, are a key mechanism by which states ensure economic equality, or at least, economic equality of opportunity, but are also a mechanism of social exclusion. social rights are inscribed around a single kind of relationship, that which exists between a male family breadwinner and the paid labor market; those who make economic contributions that fall outside this relationship -such as unpaid care-work, or, work that occurs in shadow or underground economiesare to a greater or lesser degree barred from accessing citizen-based social provisions. furthermore, social provision that occurs outside of the breadwinner/market-eco nomy dyad is very often meanstested and is accompanied by regulatory state apparatuses (this includes a range of social services, from welfare payments, to child-care subsidies, to disability pensions). social citizenship is thus stratified; the legal relationship that is at the heart of social citizenship acts as a form of social closure against claims for a share of the social good made by those who are 'lesser' citizens than others. of particular interest in this paper is how citizenship inequalities translate into inequalities in the social provisions that emerge from economic participation: the right to safety on the job, protection from employer harassment, protection from the vagaries of the market as well the right to adequate, comprehensive, and appropriate health services. drawing on mixed methods, longitudinal data from adult sex workers (n= ) located in two research sites with different social welfare regimes -one in canada and one in the u.s. -we examine the consequences of working in a "shadow" or "underground" economy on various facets of health and access to health services, taking into consideration the mediating role that citizenship constructs and social welfare regimes play in accessing other key social and economic determinants of health. methods: the study population included methadone patients (re)admitted at the mhs in the period from / / to / / , born in the netherlands, morocco, surinam, dutch antilles or turkye, and officially registered in the population register of amsterdam. the population register was used to ascer· rain the vital status. causes of death were provided by the central bureau of statistics. mortality was categorised as hiv related, directly drug related (overdose) and other.mortality. results: the methadone patients had the following characteristics: years of age at entry; % male; % ethnic minority; % ever injected. in total, personyear (py) of observation time and deaths ( % hiv related, % overdose; % other) were observed. hence, the crude mortality rate was / py ( % ci - / py). the percentage of (ever) injectors was higher among the native dutch than among the ethnic minorities, % and % respectively. higher rates were observed among native dutch drug users compared to those belonging to an ethnic minority (age adjusted hazard ratio (hr) . ( % ci . - . ). the age adjusted hr of (ever) injecting drug users versus non injecting users was . ( % cl . - . ). after additional adjustment for route of administration a non significant difference between the dutch and ethnic minorities remained (hr . , % cl . - . , p-value . . conclusion: the mortality rate among the heroin users in amsterdam is strongly affected by the high prevalence of non-injecting drug use. moreover, this study confirms that differences in mortality between the native dutch and the ethnic minorities is related to differences in route of administration. the ongoing reduction of injecting drug use (due tot selctieve mortality, and switching route ofadministration and popularity of crack cocaine) may lead to a further reduction of mortality rates among heroin users in amsterdam. interventions preventing the initiation of injecting should be encouraged. . introduction: food insecurity is an inequality that is central in the lives of many low-income cana· d ans. people lack food security when regular access to nutritious food is limited or variable due to high prices'. low income, lack of transportation or inadequate food distribution, or they become disadvan· taged m other w~ys through the acquisition of food. a group comprising academics, health profession· als, and commumty workers who have experience in food insecurity, developed a pilot study in ottawa that sought to und~rstand the lived experience of food insecurity. the study also used the united states department of agriculture (usda) community food security module. methods: a series of group meetings determined the best research approaches; questionnaires and consent forms were developed by a working group. twenty-three self-identified food insecure respon· dents were interviewed. the data were analysed using frequency distributions· the food security module was coded according to the usda coding guide, and open-ended responses w~re coded using a grounded approach. renlts: preliminary results from our pilot study have given the research team cause for considerable concern. out of households without children, experienced food insecurity with hunger; ~ere at the severe l~vel. out of households with children, experienced food insecurity with hunger. ~•rst person reflecnons commonly featured feelings of depression low self-esteem and despair. participants' account tha d . an cu ty gettmg to the store, severely limited putting knowledge and skills mto practice. l'oster sessions v conclusion: based on these early findings, our research team is looking to challenge what appear to be assumptions about poverty and food insecurity and for best ways to use this information. some policy approaches and interventions that encourage people to eat better and exercise more, may be missing the mark for low-income individuals, and may serve to maintain food insecurity. future research will build on this pilot. with methods augmentation, and a comprehensive knowledge dissemination plan, we hope co contribute to research and policy frameworks at all levels. ps- (a) mental health and the corrections system: population-based analyses in urban, semi-urban, and rural settings julian somers, robert watts, and michelle patterson introduction: according to recent epidemiological research, rates of mental disorders vary considerably across countries and across regions within countries. nevertheless, rates of mental disorders (including substance use disorders) are consistently higher in populations involved in the corrections sys- em. courts have long recognized the heavy burden of mental illness within their purview, and have developed innovative programs to better manage the needs of such individuals. the majority of these innovations (e.g., specialized courts) exist in urban settings. however, few studies have examined the degree of variability in rates of different mental disorders between courts in urban and other settings (e.g., semi-urban, rural). variability between courts in different settings, if present, holds implications for needs-based resource planning. the present study was conducted as part of a long-term inter-ministerial collaboration in british columbia (bc). analyses were conducted on linked administrative data regarding population health and correctional services. a database was constructed including all individuals sentenced in bc in a single year (n= , ). corrections records were matched to records of health services utilization (hospital and outpatient services) for mental disorders and substance use disorders in the years preceding sentencing. services for mental health and substance-related problems were aggregated into three groups: severe mental illness (smi); less-severe mental illness (lsmi); alcohol/other drug (ad). courts were grouped, based on their annual volumes, inro three categories: "urban"; "semi-urban" and "rural." rates of service use for mental disorders were compared between groups for -year and -years preceding sentencing. results: there were significant differences in the rates of mental disorders in courts of different size (urban, semi-urban, rural) . however, differences between the rates of disorders within each of these groups exceeded the discrepancies between groups. comparatively high and low rates of disorders were observed in courts of each size. moreover, the courts with the highest rates of certain disorders (e.g., ad) did not have the highest rates of other types of mental disorders (e.g., smi). conclusions: rates of mental disorders differed significantly among the annual populations sentenced across courts in bc. urban courts (which process comparatively large numbers of people) have implemented services to address the needs of the mentally ill. the present analyses strongly suggest that program development should be closely linked to the demonstration of need. the results caution that a uniform approach to court programs for the mentally ill is likely to be inefficient, over-supplying services in some settings and underestimating need in others. results: public settings used for injection are characterized by highly unhygienic conditions, the presence of unsafely disposed syringes, limited availability of sterile syringes and a lack of sterile water for injecting. a number of unsafe injection practices observed were common among public injectors. the presence of police officers nearby and the potential of assault by street predators fostered rushed injecting among those consuming drugs in public spaces. the ecological features of these environments encourage unhygienic and unsafe injecting practices, heighten risk for overdose and the transmission of blood borne viruses. introduction: approximately % of women experience depression in the first weeks or months after giving birth. although it has been argued that postpartum depression (ppd) is a culture-bound p~ nomenon, experienced only in western, industrialized countries, recent international research studies have confirmed that the prevalence of ppd is similar around the world. however, little is known about variables that may influence the experience of ppd in women from diverse cultures and immigrant women. research is needed to identify the role culture may play in the presentation of ppd (i.e., types of symptoms most commonly reported), how women from various racial, ethnic and cultural backgrounds perceive and attribute their symptoms of ppd, and finally, how culture can be appropriately addressed in ppd treatment programs. method: to examine the role of culture in ppd, semi-structured interviews and self-report question· naires were administered to clients of the women's health centre of st. joseph's health centre, tor· onto. participants were identified as either first generation canadians (relative newcomen) (n= ) or second generation canadian (parents were immigrants to canada) (n= ). data were collected qd these two groups of women based on: severity of depression, symptom presentation, perceived role of social supports and culturally-specific traditions, and barriers and responses to treatment. the interview data were analyzed using qualitative methods (thematic content analysis), and the following themes were identified: ) stress about passing on their culture to their children, ) lack of social support and feelings of isolation, ) perceived importance or lack of importance of cultural based tra· ditions, ) conflicts with family members. about cultural traditions and beliefs, ) mental health stigma within ethnic communities and beyond, ) race-and sex-based discrimination, and ) language barriers. conclrllion: identifying the role culture plays in the presentation of ppd, and how women from diverse backgrounds perceive and attribute their symptoms of ppd, is critical in order to establishcultur· ally appropriate guidelines for treatment options. furthermore, information gathered from this study can be used to develop policies and resources for delivering culturally competent care for newcomer wo~ who are dealing with ppd as well as the issues around acculturation (i.e., language barriers, racism). llus is of particular importance for urban health centers which provide postpartum care to diverse groups of women, and particularly recent immigrants or newcomers. ps-~ (al. contaminated 'therapeutic landscape': perceptions of the aamjiwnaang fint nation keyln smith and isaac luginaah . in~: this. paper pres;ents the findings of an ongoing study among the aamjiwnaang f!rst nanon. aam wnaang is located m the heart of samia's 'chemical valley', surrounded by cherrucal ~(ants such as esso, imperial oil, shell, suncor energy, and canada's largest hazardous waste disposal sate. safety kleen. this fint nation community is located within the st. clair river •area of concem'. as destgna~ by health canada for the population of samia and the surrounding region. although this comm_umty, by way of. its proximity to the numerous chemical plants is already exposed to high levels pollu~on, recent che?ucal dumping in ~mjiwnaang, as well as a failed proposal for another ethanol plant m the community, only helped to mtensify community concerns about potential health impacts of exposure. research on the cultural beliefs and traditions of first nation communities has established that th~ ~isting rel~tionship between first nations people and 'mother earth' is not only physical, but also_ spmtual. in this study we explore how the complex relationship between the aamjiwnaang first naaon and 'mother earth' be ha · · · i .. may c ngmg a contammated 'therapeutic' landscape. the study a so ~lores h?w aam wnaang residents are coping with these changes and with the probable conramina· boa of their community. ra!jts: aamjiwnaang residents acknowledge that they are living in a contaminated environment and are being impacted by emissions from the surrounding 'chemical valley' especially for future generations, and have expressed concerns that members of the community and mother earth are 'sick' as a result of this exposure. while moving from that 'place' has been discussed, residents have strong personal and generational connections to the land and insist however, that aamjiwnaang is their 'home' and will remain that way despite growing community concerns about the impact from industry. the contribution of this study lies in the direct involvement of community leadership in designing and conducting this research and distributing the results to further local policy development regarding community concerns on the reserve. background: truck driver are at very high risk for drug abuse because the factor contributing to drug abuse among driver are multiple. it is important to gain an understanding of the key factors that contributing to drug abuse among truck drivers. methods: seventy-truck driver aged - years were conveniently selected from the population. all the participants were male. an interview schedule was developed in the light of literature data and data were collected by personal interview with informed consent in selected urban area of eastern part of nepal. results: a considerable percentage of truck driver have less knowledge about drug abuse, its effect on body and their complication. majority of the participants ( %) explained that lack of education, financial crisis were leading factors of drug abuse. the average numbers of respondents were believed that lack of meaning in life, marital disharmony. friendship with drug abuser, stress, tiredness, modernization of life pattern and freedom from the home pressure were the influencing risk factors to drug abuse. conchuion: this study reveals those truck drivers are at risk in urban area for developing drugs abuse, mostly influenced by social and environmental factors. hence, these groups should undergo certain educational programme to prevent not only drug abuse, but also prevent transmission of infectious disease among these groups. introduction: food insecurity is an inequality that is central in the lives of many low-income canadians. our group of university researchers, health professionals, and community developers conducted a study in ottawa with community workers who work with people identified as food insecure. the purpose of the study was to understand the nature of their work, and their perspectives, perceptions and experiences of the causes and consequences of food insecurity. (a parallel study was conducted with food insecure participants). methods: sampling was through local knowledge of organizations involved in the provision of food to community members. written permission for the researchers to contact workers in confidence was obtained from each organization. thirteen in-depth interviews were conducted. the interviews consisted of a number of open-ended questions. the data were collated, and analysed using a grounded approach. results: workers interviewed represented organizations that offered diverse programming and methods of food distribution intended to address the needs of the community. the provision of food was seen as a necessary response to address hunger that arose for the majority from poverty caused by low income, or levels of government income support and safety nets that were insufficient to support food requirements. workers reported that food requirements varied according to different. ethnic backgrounds, ages of recipients and family configurations, and with food preferences, and d'.etary (health) requirements. workers' observations of the effects of insufficient food on adults and children such as depression, low energy and non-participation or social disengagement matched those of food insecure respondents. food insecurity was cited as "another srressor among the mountain of problems." overall, workers presented a picture of a silent, stigmatized, poor population including children, and a lack of advocacy to address the issues. be tha th · ·ty the results suggest that workers and organizations, like the commuruty mem rs t ey msecun • · · · · f ilab'l' f food · t d ·n thei·r ab 'l 'ty to address food insecurity. l m tanons m terms o ava ty o , serve, are restnc e . . funding, and donations appeared to set the para? eters of pr~g:am r.espon~ to commuruty food msecurity. workers were concerned with program des g": and a~m mstranon that m general addr~d hunger on an emergency short-term basis, although food msecunty was long-ter_m for ~any. sustainable solutions that include knowledge translation strategies, and health and social pohcy responses were suggested and will be explored in future research that hopes to build on this pilot. background: socioeconomic deprivation as well as low levels of soc!al s.uppoi:r have .been associated with poor outcomes following cardiac surgery. pre-operative depression m ~anents with coron~ry artery disease awaiting cabg ranges from - % and is an independent predictor of post-operanve mortality. since st. michael's hospital has a large inner city population, this study was designed to determine the both the prevalence of depressive symptomatology (ds) in patients awaiting cabg as well as its relationship with socioeconomic status (ses) and social support. methods: consecutive patients referred for isolated cabg were invited to complete the centre for epidemiological studies depression scale (ces-d) as well as a social support scale and a life stressors inventory. a ces-d score of : represents mild ds and a score of : represents moderate to severe ds. participants also recorded information on functional status, perceived progression of heart failure, demographic and ses variables. all participants with ces-d scores : were considered to have ds. results: of the patients ( %) who returned the survey, ( . %) of participants had a ces-d score : with ( . %) of those having scores suggestive of severe depression. females and those with ongoing medical concerns tended to have more ds (p= . and p= . respectively). age was not related to ds. perceived worsening of symptoms and increased ccs angina class were significantly related to the presence of ds (p= . and p= . respectively) but not the number of diseased heart vessels. satisfaction with personal relationships including having someone to confide in (p= . ), feeling lonely (p= . ) and not having a partner (p= . ) were significantly related to ds. being very upset by a recent breakup in the immediate family was also significantly related to ds (p= . ). having greater than a grade education was the only ses variable related to ds (p= . ). multivariate logistic regression suggested that not being partnered and having low education were the most significant predictors of ds. conclnsion: pre-operative depression is present in at least one quarter of patients referred for cabg. since ds is related to poor outcomes following cabg, single patients with few social supports and low education should be considered at high risk for ds. these findings support the need for the development of supportive interventions in patients at risk in order to decrease post-operative morbidity. this study examines the relationship between childhood sexual abuse, sexual assault during adolescence, and hiv-risk-related behaviours in a sample of homeless youths. over the past decade, there has been increasing research devoted to the impact of childhood sexual abuse. some studies have suggested that the experience of childhood sexual abuse is associated with substance use and abuse, at· risk sexual behaviour and subsequent higher rates of hiv infection (ompad et al., ; cinq-mars et al., ; brown et al., ) . other studies have found that childhood abuse, especially sexual abuse, is c_o~n among stree~ youth (noell et al. ). this study compares sexually abused males and females livtng on the street ~th non-sexually abused street youth, with regards to unsafe sexual behaviours and e~ures to potmnal t:dv sources (e.g., tattooing, body piercing and injection drug use). the hypothe-sis oft~ ~nt study is that the prevalence of hn-risk-related behaviours will be higher among street youth vtctuns of sexual abuse than those who have not been sexually abused. the sample includes youths aged to who met specific criteria's for itinerancy ( male and female, with a mean ~of . y· and a standard deviation of . ). they were recruited through five organisations working ~th~ you~ and were~ of an ongoing cohort study. all youth completed a to minute ques· ~onnaue on their sexual behaviours, use of drugs and alcohol and other hiv risk behaviours. oral spec· unens for hiv testing were. also collected. a total of ( . %) youth reported at least one incident of ~i •~use/assault ( ~ girls ( . % of all the girls) and boys ( . % of all the boys]). preliminary descnpnve analyses pomt to sexually abused/assaulted youth showing the highest prevalence of sexual poster sessions v at-risk behaviours. for example, . % of sexual abuse/assault victims have engaged in prostitution in their lives compared with . % in the non-sexually abused/assaulted group. in addition, . % of sexual abuse/assault victims reported having injected drugs, compared with . % in the non-sexually abused/assaulted group. more statistical analyses will bring other significant factors to light, especially when we analyze separately those victim of childhood sexual abuse as compare to those victim of sexual assault after childhood. elucidating the risk factors for getting involved in hiv-risk-related behaviours is important for the development of comprehensive and appropriate prevention and treatment intervention strategies. introduction: new immigrants and refugees to canada frequently emigrate from regions of the world where intestinal parasitic infections with worms are endemic. of note, some of these parasites area capable of surviving for years to decades within a given host and can have life threatening consequences many years after initial infection. thus, early diagnosis and treatment of intestinal parasitic worms is considered important in high risk immigrant populations, however there remains a lack of consensus regarding the best method of accomplishing this. diagnosing worm infections through stool examinations is costly and has limited sensitivity, while presumptive treatment of all immigrants, although advocated by some, is expensive and results in healthy individuals being unnecessarily treated. herein, we examine the utility of a hematologic marker (i.e. peripheral blood eosinophilia) as a screening instrument to identify parasitic worm infections in new immigrants to toronto. we identified adults, years of age or older, who were screened for intestinal parasitic infections by stool examination as part of a recently developed screening protocol at a downtown toronto community health centre. we examined the prevalence of infections with worms and subsequently evaluated the impact of several demographic factors on the presence of worm infections. we also determined the sensitivity and specificity of peripheral blood eosinophilia (defined as greater than eosinophils per ml) as a marker for intestinal parasitic worm infections. results: overall, % of the immigrants tested had evidence of at least one worm infection on a single stool examination, while % of such individuals bad infections with multiple worms concurrently. age did not appear to be associated with the presence of worms, however % of males had evidence of worm infections compared with % of females (p= . ). immigrants from asia, sub-saharan africa, and central america had the highest burden of overall infection. the sensitivity and specificity of peripheral blood eosinophilia for worm infections was % and % respectively. conclusions: one in five recent immigrants presenting to a community health centre in downtown toronto had evidence of at least one intestinal parasitic worm infection. the highest burden of illness was in men and in those emigrating from less developed regions of the world. peripheral blood eosinophilia is a poor screening test for worm infections however its presence is highly suggestive of the existence of worms in new immigrants. more than a decade ago, the journal of american college health recommended that a national study be conducted to measure the health status of african american college students, 'both health disparities and [their] positive healthful behaviors' (fennell, ) . it was later decided that when exploring the level of health risk behaviors for african american students, gender is an important variable and should be included in the research (fennell, ) . at historically black college and universities (hbcus) college health researchers must tackle gender disparities through highly-effective health promotion and disease prevention programs. the purpose of this review is to examine the literature that addresses the overarching health behaviors (i.e. risky sexual behavior, poor diet, smoking, physical inactivity, etc.) of african american men who attend hbcus. despite the various social, cultural, and academic benefits of african american students who attend hbcus, the number of research studies that adequately address their health and health behaviors is limited. studies indicate that african american men who attend hbcus are actively engaged in poor health behaviors. compared to females at hbcus, african american men are more likely to behave in ways that could result in injuries and the use tobacco, alcohol, and ~ther dru~. the city of toronto has recently proposed to conduct a street count of the homeless. like proposals that have come before, this most recent proposal is controversial among many homeless advocates and service providers because it is perceived as intrusive, likely to undercount the target population, and unnecessary for addressing the problem. advocates of the count view it as necessary to gauge the scope of the problem and advise city leaders about how to most effectively direct resources ro.the various homeless services. this paper first reviews the history of efforts to count homeless populat ns m toronto, describing the motivations and arguments of people on both sides of the issue. second, the paper reviews the methodological complexities of counting homeless populations, describing approaches that use shelter-counts, administrative data and street observations. those interested in counts for toronto and elsewhere can benefit from this review of approaches that have been proposed and carried out in other municipalities. third, the paper proposes a new community-base d strategy that joins the skills of methodologists, local experts, and service providers to ensure a fair and accurate count. the method of systematic social observation avoids some of the problems of early counts by utilizing a repeated identification approach to minimize undercount bias. the method also has the advantage of involving and compensating homeless individuals for assisting with the street count estimates. the estimation approach can be implemented on a rolling basis throughout the year. drug transitions) is a multi-level study aimed at examining the associations between features of the urban environment and mental health, drug use, and risky sexual behaviors. research participants are being recruited in new york city (nyc) neighborhoods. an essential first step in the implementation of this study was to delineate boundaries for each target neighborhood that could then be used to establish sampling frames and as key units of analytic interest. although many neighborhood studies rely on pre-established definitions (e.g. those used for the census or administrative purposes), such definitions do not always reflect contemporary settlement patterns. we felt that street level observations were a neces· sary component of the definition process. methods: the procedures used to delineate neighborhoods were: ( ) development of census block maps of targeted areas; ( ) review of land use maps and census tract data to ensure, prior to going into the field, tha.t particular blocks are residential and likely to have sufficient population for recruitment purposes; and ( ) field vislts and observation in each of the targeted areas. field observations focused on: housing characteristics, including housing type and condition; characteristics of commercial areas, such as likely customer base (e.g. local or no~, socio-economic status and ethnicity of customers); pedestrian volume (including con· gregauons of people m parks and outside stores or residences); obstructions to pedestrian traffic (e.g. ma or thoroughfares, multi-block industry or institutions); and maintenance and use of open spaces. results: in making the final decisions regarding neighborhood boundaries and the inclusion or exclusion of particular. blocks, we considered a broad range of factors including evidence of homogeneity an~ heterogeneity (socmeconomic, ethnic, housing type, environmental) across blocks within and blocks ad acent to a nei.ghborhood, and across the sample neighborhoods; the potential for efficient recruit· ment of appropriate particip.ants (i.e. sufficient local pedestrian traffic); and boundaries used in reporting census data (s? that population data can be used in our analysis). . altho~gh utilization of field observations for neighborhood definitions is relatively time consuming (ap~~ox mately hours for a block area, with more diverse neighborhoods taking even longer), we annc p~t~ that it will substantially improve the quality and consistency of our data gath· ~rmg ~nd analyse~. spec f c e?'amples from neighborhoods defined through this process will be given dur· m~ this presentatmn. we will also discuss the merits and limitations of characterizing neighborhoods usmg street level observations. has been no consideration for how social networks are associated with sse. the objective of this study was to identify personal and social network characteristics associated with being a recipient of sse. in this cross-sectional study, idus who injected in the past months were recruited from syringe exchange programs in montreal, canada, between april and january . information on each participant and on the persons with whom contact had occurred in the past month were elicited using a structured, interviewer-administe red questionnaire. participants provided detailed demographic and drug use information on up to idu members with whom drugs or injecting materials were shared. using logistic regression, personal and network characteristics were examined in relation to receipt of sterile syringes. res.its: of idus, % reported receiving sterile syringes in the past month from another idu. the sample mean age was years (range - ), % male, % caucasian, and % cocaine injectors. in multivariate analyses adjusted for age and gender, recipients of sterile syringes were more likely than non-recipients to share drugs after preparation ( r= . ( . - . )), to require help or to have helped inject another idu (or= . ( . - . )), to have asked someone to get sterile syringes from a syringe exchange program (or= . [ . - . )), to lend syringes (or= . [ . - . ) ) and to use drug preparation water that was previously used by another iou ( r= . ( . - . ) ) during the past months. recipients also had a higher rate of change (p= . ) of idus in their drug injecting network during the past month. with respect to social networks, % ( / ) of idu network members were providers of sterile syringes and were more likely than non-providers to inject everyday (or= . ( . - . )). when stratified by their role as a sexual partner or as someone who provides support (e.g. friend, family member), further risk behaviours were observed in relation to sharing injecting materials with the participant. conclusion: recipients of sterile syringes and their idu network members had several high-risk behaviours for infection with bloodborne diseases. sse may afford an opportunity for the dissemination of other salutary behaviours such as information sharing on safe injecting practices between recipients and distributors. furthermore, drug injecting networks may be an avenue to reach idus who may not otherwise be exposed to preventive measures. there are numerous sources of stigma and labelling of mental and physical illness. first, the sociocultural dimension to stigma and labelling clearly influences patients, families, health care professionals and society's perception and treatment of illness. this creates multiple challenges related to illness identification and recovery, particularly in culturally diverse societies. second, the media is a major source of stigma and stereotyping with regard to a variety of mental and physical illnesses. despite increased public knowledge of many illnesses, studies have shown that stigma has intensified over the years in certain cases. a third element of stigma and labels appears with the use of diagnosis as a solution to human problems with the result that difficult to treat patients are repudiated and social issues are unaddressed. this presentation will serve to outline the development of stigma, various expressions of stigma, and consequences of stigma. it will provide some practical recommendations for the reduction of stigma related to mental and physical illness. purpose: to assess the knowledge, attitude, and practice about immunization for parent of - years old hispanic and african american children in los angeles county (lac). methods: we conducted two cluster surveys in lac. the sample was selected with probability proportionate to estimated size at the first stage and simple random sample of children at the second stage. data were collected through interview. we absuacted vaccine coverage data from immunization record card (irc) at home or from clinic records. the participation was % in hispanics and % in african americans populations. irc was not available at home for % of african american and % of hispanic children. results: all parents perceived their children got all necessary vaccine~. fa~orable attitudes to.w~rd immunization were reported by % of african american and % of h s?amc parents. '.he m~ ority of the parents ( % african american and % hispanic) agreed that vaccines prevent senous d se~ses among children. regarding vaccine safety, significantly more hispanic parents ( %) than african american parents ( %) mentioned that vaccines are safe. introduction: cervical cancer has been shown to be preventable by papanicolau tests in heterosexual women; however, the utility of papanicolau test in lesbians is controversial. cervical cancer is caused by the human papillomavirus (hpv) which is transmitted by sexual _intercourse; howev_er, its' transmission by homosexual intercourse is also controversial. the goal of this study was to review the evidence for papanicolau tests in lesbians. methods: a pub med, ovid ( ovid ( to , and cochrane library search was performed using the mesh headings "homosexuality , female," "vaginal smears," and "papillomavirus, human." in pub med, the clinical queries feature was used with "diagnosis" and "broad, sensitive" filters. a google advanced search of the internet was conducted with the terms "lesbian," "cervical cancer," and "pap rest." the url was limited to ".ca," ".edu," or ".gov." results: the search yielded original articles and reviews, but no cochrane reviews. none of the publications were canadian. website hits were found and selected websites were reviewed. studies showed that lesbians have fewer papanicolau tests than heterosexual women; however, many reported risk factors for cervical cancer, including multiple past or current sexual partners (male and female), early age of first coitus, history of sexually transmitted diseases, and cigarette smoking. hpv has been detected in - % of lesbians and - % of lesbians who have never had sex with men. case studies of abnormal papanicolau tests in lesbians who have never had sex with men have also been reponed. sexual transmission of hpv among lesbians can be explained by several factors: ) - % of lesbians have had sex with men and - % of lesbians continue to have sex with men. ) hpv may be transmitted by sexual behaviours among women, like digital-vaginal sex, digital-anal sex, oral sex, and the use of insertive sex toys. ) hpv transmission requires only skin-to-skin contact. genital hpv has been identified on human fingers. some professional organizations, like the society of obstetricians and gynecologists of canada and the american cancer society, recognize the need for papanicolau tests in lesbians. other organizations, like the canadian cancer society, do not have official policy statements. the current ontario cervical screening program does not specifically address lesbians. conclusion: although the data was limited, most studies recommended that lesbians should receive papanicolau tests. the frequency of these tests was controversial. policy makers and professional organizations should address the needs of this special population and make specific recommendations . monique chaaya, ahia sibai, hiam chemaitelly, and zana el roueiheb . literature concerning the mental and physical effect of work at an old age is contradictory. in addinon, urban environments are physically and socially harsh with reduced potential for income generation and employment and increased potential for depression. the present paper is an attempt to study how do work, or lack of work, link to the experience of depression among older adults in underprivileged lebanese urban communities. the data comes from a cross-sectional survey, where elderly residing in underprivileged communities in beirut, including a palestinian refugee camp, were successfully inter-v ewed through face-to-face interviews. logistic regression was performed to assess the effect of work on depression ad_justing for many other covariates. data showed that . % of people aged years and more were still workmg. there was a highly protective effect of work on depression in elderly males (or= . , % cl= . - . ). the current study is the first of its kind in the arab region and more work shou_ld be _don_e in this area. it is important for the lebanese government to consider elderly rights for social mclus n m terms of employment opportunities. amam nuru-jeter, nancy adler, and burton singer . l~u~on:_ the socioeconomic gradient is perhaps the most persistent and significant finding in social epidem ological research. the insistent nature of the ses effect is evidenced by its significance after acc?untmg for ~umerous confounds. the significance and magnitude of the effect, however, varies by ::•al group. evidence_ o_f the relative effect of race and ses is inconclusive. further, less attention has f ~ ptid to the specific interactions of race and ses than to examinations of which is a better predictor d ~ th. ~sues are further complicated by the explanatory complexity of the various measures of ses anl . owht ey relate to the health of various social groups. understanding the specific nature of these re a ons ips s necessary for guiding he ith d · i · · h a an soc a po mes and programs aimed at improving t e poster sessions v health of our most disadvantaged groups, and therefore population health, overall. this study examines the synergistic effects of ses with both race and gender in predicting group differences in mortality. methods: analyses use data from the national longitudinal mortality survey (n= , ) for the years , , and - ; and were linked to the national death index for deaths occurring through . results were confirmed using data from the national mortality followback survey for people who died in (n= , ) and the national health interview survey (denominator). we used correlation analysis and the standardized mortality ratio to examine ses (education and income), race, and gender as predictors of group differences in changes in mortality. results: for the total population, analyses support the income gradient showing significant declines in mortality ratios from low to high income along the income strata. education shows a significant drop in mortality with completion of high school and completion of college, exhibiting a threshold rather than a gradient effect. compared to whites, blacks receive diminishing health returns for each subsequent level of income and education; with whites closely mirroring the total population in ses thresholds. similarly, compared to men, women do not experience the same health gains at comparable ses levels. for education, black men and women only show significant mortality declines upon completion of high school. the ses gradient operates differently among race and gender subgroups. threshold effects suggest resource gains in life opportunities at particular milestones along the ses gradient. further, ses matters less for blacks and women compared to whites and men suggesting differing implications for health and social policy aimed at reducing disparities. objective: we assessed the impact of diabetes in a large puerto rican community of chicago by measuring the prevalence of diagnosed diabetes and calculating the diabetes mortality rate. methods: we analyzed data from a comprehensive health survey conducted in randomly selected households in community areas. questions on diagnosed diabetes and selected risk factors were asked. in addition, mortality data were analyzed in order to calculate the age-adjusted diabetes mortality rate. when possible, rates were compared to those found in other studies. results: the diabetes prevalence located in this community ( . %: % cl= . %- . %) is one of the highest ever reported for puerto ricans. for instance, it is more than three times higher than the prevalence for the us ( . %) and twice the prevalence for puerto ricans in new york ( . %) and puerto rico ( . %- . %). diagnosed diabetes was found to be significantly associated with obesity (p= . ). the prevalence was particularly high among older people, females, those horn in the us, and those with a family history. the diabetes mortality rate ( . per , population) was more than twice the rate for all of chicago ( . ) and the us ( . ). conclusions: understanding why the diabetes and mortality rates for puerto ricans in this commu· nity are so much higher than those of other communities is imperative. collaboration between researchers, service providers and community members can help address the issues of diabetes education, early screening and diagnosis and effective treatment needed in this community. introduction: sars is a respiratory illness that is spread from person to person through dose contact. this infectious disease outbreak was unusual due to the high rate of infection among health care workers. the aim of the study is to explore the demographic and attitudinal determinants of psychological distress due to sars among health care workers of a toronto hospital. methods: a total of adult participants completed questionnaires co assess psychological distress (impact of event scale -jes) and attitudes to sars. of these, participants completed the questionnaire during the sars i outbreak, and participants completed the questionnaire during the sars ii outbreak. participants also provided information on demographic variables, including occupation and exposure to sars. principal components analysis was used to derive eight attitudinal scales: fear: system, protection, prevention, job stress, stigma, instrumental coping, and psychological copm~. l ear regression analyses were applied to evaluate the associations of the demographic and amtudmal variables, as well as time, with psychological distress. . . regression analyses showed that time and higher scores on fear, ob stress, stigma'. and instrumental coping were associated with a higher total ies score: (r =. ). contrary to expectations, none of the demographic variables was associated with total ies score. conclusion: the presence of psychological distress in health care workers is indicative of intrusive or avoidant responses to thoughts, feelings, and memories associated with the sars outbreak. this study shows that ( ) fear for one's health and the he~lth of.others, ( ) ex~erien~in~ job stress, ( )_tbe per· ception of stigma, ( ) usage of instrumental copmg skills, ~n~ ( ) t m_e s grufi~an~ly c~nmb~te to increased psychological distress in health care workers. potential mterventmns during mfecttous diseaie outbreaks in health care settings should be targeted to minimize the impact of these factors. purpose: the purpose of this study was to expand knowledge regarding feeding practices, know!· edge and nutritional beliefs of mothers currently residing in the dominican republic (dr). the rising incidence of obesity in children is a major national health concern and obesity in first and second-generation immigrant children also continues to rise. we know that parents (particularly mothers) shape children's early diet patterns and that immigrant mothers experience additional challenges related to acculturation and assimilation into a new culture, however there is a paucity of literature concerning the effect of immigrant adaptation to american culture on the nutrition of children. in addition, new immigrant knowledge about the causes of obesity and the resulting health implications for childhood obesity has not been assessed and reported. this qualitative study used focus group methodology to discuss views and practices related to the introduction of food for infants and feeding practices for young children, along with a discussion on knowledge and beliefs related to the causes and health implications of child· hood obesity. ten dominican mothers' of young children (birth to years old) who reside in a small town in the western frontier area of the dr were participants in the focus group. results from this srudy will be compared to results from an identical study that will be conducted in fall with new immi· grant mothers from the dr to the boston area. we will compare feeding practices, beliefs and knowledge about nutrition for young children between these two groups. methods: using participatory principles, a focus group design was used to interview a group of mothers in the dr. the investigator along with a bilingual translator conducted the focus group. the session was tape recorded and is currently in the process of being transcribed and translated. transcribed data will be systematically analyzed themes will be identified. a qualitative data analysis software will be used to organize and code the data according to the specific aims of the study. supporting quotations will be selected to substrate each theme. lmpli~tions for urban health practice: an ultimate goal of this study is to lay a foundation for understanding the process of acculturation on feeding practices of mothers when they immigrate to the us. understanding beliefs, knowledge and feeding practices that mothers use with young children will help m ~he ~evelopment of culturally and linguistically appropriate educational strategies and materials for use m primary prevention of pediatric obesity. in canada more than seventy-five percent of immigrants choose to stay in three major urban centers of toronto, montreal and vancouver. approximately fifty percent of the immigrants eventually set· tie m ~~e greater tor<_>nto area. there is mounting evidence that the increasing immigrant population has a_ sigmfic~nt health disadvantage over canadian-born residents. this health disadvantage manifests particularly m the ma "ority of "mm "gr t h h d be · · h . . . . an s w o a en m canada for longer than ten years. this group as ~n associ~te~ with higher risk of chronic disease such as cardiovascular diseases. this disparity twccb n ma onty of the immigrant population and the canadian-born population is of great importance to ur an health providers d" · i i · b as isproporttonate y arge immigrant population has settled in the ma or ur an centers. generally the health stat f · · · · · · h h been . us most mm grants s dynamic. recent mm grants w o av_e ant •;ffca~ada _for less ~han ~en years are known to have a health advantage known as 'healthy imm • ~ants r::r · ~:s eff~ ~ defined by the observed superior health of both male and female recent immi- immigrant participation in canadian society particularly the labour market. a new explanation of the loss of 'healthy immigrant effect' is given with the help of additional factors. lt appears that the effects of social exclusion from the labour market leading to social inequalities first experienced by recent immigrant has been responsible for the loss of healthy immigrant effect. this loss results in the subsequent health disadvantage observed in the older immigrant population. a study on patients perspectives regarding tuberculosis treatment by s.j.chander, community health cell, bangalore, india. introduction: the national tuberculosis control programme was in place over three decades; still tuberculosis control remains a challenge unmet. every day about people die of tuberculosis in india. tuberculosis affects the poor more and the poor seek help from more than one place due to various reasons. this adversely affects the treatment outcome and the patient's pocket. many tuberculosis patients become non-adherence to treatment due to many reasons. the goal of the study was to understand the patient's perspective regarding tuberculois treatment provided by the bangalore city corporation. (bmc) under the rntcp (revised national tuberculosis control programme) using dots (directly observed treatment, short course) approach. bmc were identified. the information was collected using an in-depth interview technique. they were both male and female aged between - years suffering from pulmonary and extra pulmonary tuberculosis. all patients were from the poor socio economic background. results: most patients who first sought help from private practitioners were not diagnosed and treated correctly. they sought help form them as they were easily accessible and available but they. most patients sought help later than four weeks as they lacked awareness. a few of patients sought help from traditional healers and magicians, as it did not help they turned to allopathic practitioners. the patients interviewed were inadequately informed about various aspect of the disease due to fear of stigma. the patient's family members were generally supportive during the treatment period there was no report of negative attitude of neighbours who were aware of tuberculosis patients instead sympathetic attitude was reported. there exists many myth and misconception associated with marriage and sexual relationship while one suffers from tuberculosis. patients who visited referral hospitals reported that money was demanded for providing services. most patients had to borrow money for treatment. patients want health centres to be clean and be opened on time. they don't like the staff shouting at them to cover their mouth while coughing. conclusion: community education would lead to seek help early and to take preventive measures. adequate patient education would remove all myth and conception and help the patients adhere to treatment. since tb thrives among the poor, poverty eradiation measures need to be given more emphasis. mere treatment approach would not help control tuberculosis. lntrod#ction: the main causative factor in cervical cancer is the presence of oncogenic human papillomavitus (hpv). several factors have been identified in the acquisition of hpv infection and cervical cancer and include early coitarche, large number of lifetime sexual partners, tobacco smoking, poor diet, and concomitant sexually transmitted diseases. it is known that street youth are at much higher risk for these factors and are therefore at higher risk of acquiring hpv infection and cervical cancer. thus, we endeavoured to determine the prevalence of oncogenic hpv infection, and pap test abnormalities, in street youth. ~tbods: this quantitative study uses data collected from a non governmental, not for profit dropin centre for street youth in canada. over one hundred females between the ages of sixteen and twentyfour were enrolled in the study. of these females, all underwent pap testing about those with a previous history of an abnormal pap test, or an abnormal-appearing cervix on clinical examination, underwent hpv-deoxyribonucleic (dna) testing with the digene hybrid capture ii. results: data analysis is underway. the following results will be presented: ) number of positive hpv-dna results, ) pap test results in this group, ) recommended follow-up. . the results of this study will provide information about the prevalence of oncogemc hpv-dna infection and pap test abnormalities in a population of street youth. the practice implic~ tions related to our research include the potential for improved gynecologic care of street youth. in addition, our recommendations on the usefulness of hpv testing in this population will be addressed. methods: a health promotion and disease prevention tool was developed over a period of several years to meet the health needs of recent immigrants and refugees seen at access alliance multicultural community health centre (aamchc), an inner city community health centre in downtown toronto. this instrument was derived from the anecdotal experience of health care providers, a review of medical literature, and con· sultations with experts in migration health. herein we present the individual components of this instrument, aimed at promoting health and preventing disease in new immigrants and refugees to toronto. results: the health promotion and disease prevention tool for immigrants focuses on three primary health related areas: ) globally important infectious diseases including tuberculosis (tb), hiv/aids, syphilis, viral hepatitis, intestinal parasites, and vaccine preventable diseases (vpd), ) cancers caused by infectious diseases or those endemic to developing regions of the world, and ) mental illnesses includiog those developing among survivors of torture. the health needs of new immigrants and refugees are complex, heterogeneous, and ohen reflect conditions found in the immigrant's country of origin. ideally, the management of all new immigrants should be adapted to their experiences prior to migration, however the scale and complexity of this strategy prohibits its general use by healthcare providers in industrialized countries. an immigrant specific disease prevention instrument could help quickly identify and potentially prevent the spread of dangerous infectious diseases, detect cancers at earlier stages of development, and inform health care providers and decision makers about the most effective and efficient strategies to prevent serious illness in new immigrants and refugees. lntrodmction: as poverty continues to grip pakistan, the number of urban street children grows and has now reached alarming proportions, demanding far greater action than presently offered. urbanization, natural catastrophe, drought, disease, war and internal conflict, economic breakdown causing unemployment, and homelessness have forced families and children in search of a "better life," often putting children at risk of abuse and exploitation. objectives: to reduce drug use on the streets in particular injectable drug use and to prevent the transmission of stds/hiv/aids among vulnerable youth. methodology: baseline study and situation assessment of health problems particularly hiv and stds among street children of quetta, pakistan. the program launched a peer education program, including: awareness o_f self and body protection focusing on child sexual abuse, stds/hiv/aids , life skills, gender and sexual rights awareness, preventive health measures, and care at work. it also opened care and counseling center for these working and street children ar.d handed these centers over to local communities. relationships among aids-related knowledge and bt:liefs and sexual behavior of young adults were determined. rea.sons for unsafe sex included: misconception about disease etiology, conflicting cultural values, risk demal, partner pressur~, trust and partner significance, accusation of promiscuity, lack of community endorsement of protecnve measures, and barriers to condom access. in addition socio-economic pressure, physiological issues, poor community participation and anitudes and low ~ducation level limited the effectiveness of existing aids prevention education. according to 'the baseline study the male children are ex~ to ~owledge of safe sex through peers, hakims, and blue films. working children found sexual mfor~anon through older children and their teachers (ustad). recommendation s: it was found that working children are highly vulnerable to stds/hiv/aids, as they lack protective meas":res in sexual abuse and are unaware of safe sexual practices. conclusion: non-fatal overdose was a common occurrence for idu in vancouver, and was associated with several factors considered including crystal methamphetamine use. these findings indicate a need for structural interventions that seek to modify the social and contextual risks for overdose, increased access to treatment programs, and trials of novel interventions such as take-home naloxone programs. background: injection drug users (idus) are at elevated risk for involvement in the criminal justice system due to possession of illicit drugs and participation in drug sales or markets. the criminalization of drug use may produce significant social, economic and health consequences for urban poor drug users. injection-related risks have also been associated with criminal justice involvement or risk of such involvement. previous research has identified racial differences in drug-related arrests and incarceration in the general population. we assess whether criminal justice system involvement differs by race/ethnicity among a community sample of idus. we analyzed data collected from idus (n = , ) who were recruited in san francisco, and interviewed and tested for hiv. criminal justice system involvement was measured by arrest, incarceration, drug felony, and loss/denial of social services associated with the possession of a drug felony. multivariate analyses compared measures of criminal justice involvement and race/ethnicity after adjusting for socio-demographic and drug-use behaviors including drug preference, years of injection drug use, injection frequency, age, housing status, and gender. the six-month prevalence of arrest was highest for whites ( %), compared to african americans ( %) and latinos ( % ), in addition to the mean number of weeks spent in jail in the past months ( . vs. . and . weeks). these differences did not remain statistically significant in multivariate analyses. latinos reported the highest prevalence of a lifetime drug felony conviction ( %) and mean years of lifetime incarceration in prison ( . years), compared to african americans ( %, . years) and whites ( %, . years). being african american was independently associated with having a felony conviction and years of incarceration in prison as compared to whites. the history of involvement in the criminal justice system is widespread in this sample. when looking at racial/ethnic differences over a lifetime including total years of incarceration and drug felony conviction, the involvement of african americans in the criminal justice system is higher as compared to whites. more rigorous examination of these data and others on how criminal justice involvement varies by race, as well as the implications for the health and well-being of idus, is warranted. homelessness is a major social concern that has great im~act on th~se living.in urban commu?ities. metro manila, the capital of the philippines is a highly urbanized ar~ w. t~ the h gh~st concentration of urban poor population-an estimated , families or , , md v duals. this exploratory study v is the first definitive study done in manila that explores the needs and concerns of street dwdlent\omc. less. it aims to establish the demographic profile, lifestyle patterns and needs of the streetdwdlersindit six districts city of manila to establish a database for planning health and other related interventions. based on protocol-guid ed field interviews of street dwellers, the data is useful as a template for ref!!. ence in analyzing urban homelessness in asian developing country contexts. results of the study show that generally, the state of homelessness reflects a feeling of discontent, disenfranchisem ent and pow!!· lessness that contribute to their difficulty in getting out of the streets. the perceived problems andlar dangers in living on the streets are generally associated with their exposure to extreme weather condirioll! and their status of being vagrants making them prone to harassment by the police. the health needs of the street dweller respondents established in this study indicate that the existing health related servias for the homeless poor is ineffective. the street dweller respondents have little or no access to social and health services, if any. some respondents claimed that although they were able to get service from heallh centers or government hospitals, the medicines required for treatment are not usually free and are beyond their means. this group of homeless people needs well-planned interventions to hdp them improve their current situations and support their daily living. the expressed social needs of the sucet dweller respondents were significantly concentrated on the economic aspect, which is, having a perma· nent source of income to afford food, shelter, clothing and education. these reflect the street dweller' s need for personal upliftment and safety. in short, most of their expressed need is a combination of socioeconomic resources that would provide long-term options that are better than the choice of living on the streets. the suggested interventions based on the findings will be discussed. . methods: idu~ aged i and older who injected drugs within the prior month were recruited in usmg rds which relies on referral networks to generate unbiased prevalence estimates. a diverse and mon· vated g~o~p of idu "seeds." were given three uniquely coded coupons and encouraged to refer up to three other ehgibl~ idu~, for which they received $ usd per recruit. all subjects provided informed consent, an anonymous ~t erv ew and a venous blood sample for serologic testing of hiv, hcv and syphilis anti~!· results. a total of idus were recruited in tijuana and in juarez, of whom the maion!)' were .male < .l. % and . %) and median age was . melhotls: using the data from a multi-site survey on health and well being of a random sample of older chinese in seven canadian cities, this paper examined the effects of size of the chinese community and the health status of the aging chinese. the sample (n= , ) consisted of aging chinese aged years and older. physical and mental status of the participants was measured by a chinese version medical outcome study short form sf- . one-way analysis of variance and post-hoc scheffe test were used to test the differences in health status between the participants residing in cities representing three different sizes of the chinese community. regression analysis was also used to examine the contribution of size of the chinese community to physical and mental health status. rmdts: in general, aging chinese who resided in cities with a smaller chinese population were healthier than those who resided in cities with a larger chinese population. the size of the chinese community was significant in predicting both physical and mental health status of the participants. the findings also indicated the potential underlying effects of the variations in country of origin, access barriers, and socio-economic status of the aging chinese in communities with different chinese population size. the study concluded that size of an ethnic community affected the health status of the aging population from the same ethnic community. the intra-group diversity within the aging chinese identified in this study helped to demonstrate the different socio-cultural and structural challenges facing the aging population in different urban settings. urban health and demographic surveillance system, which is implemented by the african population & health research center (aphrc) in two slum settlements of nairobi city. this study focuses on common child illnesses including diarrhea, fever, cough, common cold and malaria, as well as on curative health care service utilization. measures of ses were created using information collected at the household level. other variables of interest included are maternal demographic and cultural factors, and child characteristics. statistical methods appropriate for clustered data were used to identify correlates of child morbidity. preliminary ratdts: morbidity was reported for , ( . %) out of , children accounting for a total of , illness episodes. cough, diarrhoea, runny nose/common cold, abdominal pains, malaria and fever made up the top six forms of morbidity. the only factors that had a significant associ· ation with morbidity were the child's age, ethnicity and type of toilet facility. however, all measures of socioeconomic status (mother's education, socioeconomic status, and mother's work status) had a significant effect on seeking outside care. age of child, severity of illness, type of illness and survival of father and mother were also significantly associated with seeking health care outside home. the results of this study have highlighted the need to address environmental conditions, basic amenities, and livelihood circumstances to improve child health in poor communities. the fact that socioeconomic indicators did not have a significant effect on prevalence of morbidity but were significant for health seeking behavior, indicate that while economic resources may have limited effect in preventing child illnesses when children are living in poor environmental conditions, being enlightened and having greater economic resources would mitigate the impact of the poor environmental conditions and reduce child mortality through better treatment of sick children. inequality in human life chances is about the most visible character of the third world urban space. f.conomic variability and social efficiency have often been fingered to justify such inequalities. within this separation households exist that share similar characteristics and are found to inhabit a given spatial unit of the 'city. the residential geography of cities in the third world is thus characterized by native areas whose core is made up of deteriorated slum property, poor living conditions and a decayed environment; features which personify deprivation in its unimaginable ma~t~de. there are .eviden~es that these conditions are manifested through disturbingly high levels of morbidity and mortality. ban · h h d-and a host of other factors (corrupt n, msens t ve leaders p, poor ur ty on t e one an , . · f · · · th t ) that suggest cracks in the levels and adherence to the prmc p es o socta usnce. ese governance, e c . . . . . ps £factors combine to reinforce the impacts of depnvat n and perpetuate these unpacts. by den· grou o . · "id . . bothh tifying health problems that are caused or driven by either matena _or soc a e~nvanon or , t e paper concludes that deprivation need not be accepted as a way. of hfe a~d a deliberate effon must be made to stem the tide of the on going levels of abject poverty m the third world. to the extent that income related poverty is about the most important of all ramifications of po~erty, efforts n_iu_st include fiscal empowerment of the poor in deprived areas like the inner c~ty. this will ~p~ove ~he willingness of such people to use facilities of care because they are able to effectively demand t, smce m real sense there is no such thing as free medical services. ). there were men with hiv-infection included in the present study (mean age and education of . (sd= . ) and . (sd= . ), respectively). a series of multiple regressions were used to examine the unique contributions of symptom burden (depression, cognitive, pain, fatigue), neuropsychologic al impairment (psychomotor efficiency), demographics (age and education) and hiv disease (cdc- staging) on iirs total score and jirs subscores: ( ) activities of daily living (work, recreation, diet, health, finances); ( ) psychosocial functioning (e.g., self-expression, community involvement); and ( ) intimacy (sex life and relationship with partner). resnlts: total iirs score (r " . ) was associated with aids diagnosis (ii= . , p < . ) and symptoms of pain (ii= - . , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (p = . , p < . ). for the three dimensions of the iirs, multiple regression results revealed: ( ) activities of daily living (r = . ) were associated with aids diagnosis (ii = . , p < . ) and symptoms of pain <p =- j , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (ji = . , p < . ); ( ) psychosocial functioning (r = . ) was associated with was associated with symptoms of fatigue (ii= - . , p < . ) and cognitive difficulties <ii = . , p < . ); and ( ) intimacy (r = . ) was related to was associated with symptoms of fatigue (ij = - . , p < . ) and cognitive difficulties (ii= . , p < . ). methods: the sif evaluation methodology involves a comprehensive database located at the sif, a randomly selected p~o.spective coh~rt of sif users, and two pre-existing external control cohorts. . . ~ts: in addmon to reporting process data and descriptions of the sif users, we report on data indicating that the establishment of the sif has been independently associated with reductions in public ~':°g ~ (p <?. ), and syringe sharing (aor = . [ %ci: . _ . ); p = . ) and other unsafe m ecnon pract _ces_ (p ~ . ), and increased uptake of detox services (log-rank p = . ). as well, we report on da~ md cat ng that the sif has not prompted adverse changes in community drug use patterns. the vancouver sif has been well accepted by the target population, and while adve~ events s~c~ as overdoses have occurred, these events have been successfully managed. externally compiled data indicate that the sif has been associated with substantial declines in public disorder !'oster sessions v associated with injection drug use, syringe sharing, and increased uptake of detox services. as well, the establishment of the sif has not exacerbated community drug use patterns. ongoing evaluation activities wiu involve assessing the impact of the sif on a variety of outcomes, including infectious disease transmission, fatal overdose, and utilization of health and social services. city, brazil, - maria cristina almeida, waleska caiaffa, renato assum;iio, and fernando proietti dengue cases were described according to time, space, intensity, age, gender, onset of symptoms, residence address and census tract. spatial distribution of two groups (children and women over years old and men aged - ) were compared, under assumption that they have distinct behaviors regarding their displacement around the city. analysis included local moran index, ripley\\'s k function and recurrence of census areas over time. about , cases were identified in seven epidemic waves. concentration of cases in small areas, followed by a spread either in space or time suggested endemic patterns. regarding age-gender groups, distinct patterns suggested that residence might not be a good proxy in determining the local of infection for men aged - . dengue is shifting to endemic pattern in this city and transmission may not be sole related to home environment, suggesting that additional spatial information must be couected aiming efficient control measures. murukan kandamuthan and subodh kandamuthan lnl uduction: illness or disablement of a child may affect the economic functioning of a family as it alters the employment pattern and earnings of parents this paper tries to assess the health status and the quality of life of disabled children, and how generally, severe disablement in a child affected their fami-lies\' finances, and to quantify any such effects the problems faced by children in their home and to provide information relevant to the formation of criteria for new or increased cash support. methods: a case-control study was done in the thiruvananthapuram district, capital city of kerala by selecting a random sample of families with severely disabled children below years and a random sample of normal children matched for age and occupation of the parents. comparative and subjective data were collected. money spent on children\'s medical care, loss of earnings of the parents, and other economic burden to the family due to the disability of the child in the family. a discriminant analysis along with univariate analysis was done to assess the factors that mostly differentiate the disabled and normal children. the mean expenditure of the families with a disabled child was rs. /-per month, which is significantly higher than the corresponding expenditure of rs. /-per month of families with normal child, (t= . , p <. ). of the disabled children, % were not getting any social security payments and % had no special concessions for medical and other educational purposes. the analysis of income and expenditure pattern indicated that financial impact of disablement in a child on the family is significant. the discriminant model results revealed that medical expenditure was a significant variable that differentiated the disabled and normal child. the study found that the health status and quality of life of the disabled children were far from satisfactory. this in fact affected the economic status of the disabled children. in addition to reduced earnings, there are extra costs for disabled children for travel, domestic help, medical care, and health care expenditures (hospital care, physician services, dentistry, drugs and others) for disabled individuals. a strong case can be made for their long-term care by improving the financial support to such families possibly through the introduction of an allowance specially to compensate for the earnings lost by parents due to the disability of their children. widows in india are considered disadvantage group of population. because they are characterized by pangs of separation from spouse, and consequently they go through mental agony, social ~s?lation, and economic dislocation. in addition to these, poverty, landlessness, homelessness, malnutr non etc. endure serious deterioration of their health. according to census , there are million women are widowed and one fourth live in urban areas. there is a noticeable increase of urban widows from the previous census (almost half). the paper examines the type of disability and chronic ailment borne among elderly widows ( years and above). fifty second round of national sample survey aske~ the individuals three sets of questions regarding their health: their status of health, whether they are physically poster sessions v immobile, and whether or not they have had any specific chronic illnesses. although health infrastruc- · ble ·n urban setting in india as compared to rural counterpart, prevalence of tures are arge y ava a . . . . . h · · · h h"gher "n urban areas analysis shows omt problems m old age qmte common c romc ness is muc • . . and nearly percent elderly widows are suffering from this ail'. ent in urban areas. one-fifth of widows are suffering from high/low bp. heart disease, diabetes and urinary problems are much ~ore pre~alent in urban areas though disabilities is comparatively lower in urban areas. however, the d~fference is not statistically significant. disability with respect to vision is more pronounced and one third_ of the total respondents have problems regarding eyesight. one fifths ofdderly widows are _ha.rd of hearing. though disability increases with age, similar trend is not observed with respect to chr~mc illness. the percepnon of self-health among elderly becomes poorer as their age increases. the perceived health status need not be always corrected to objective indicators of health. it is noted that around per~en~ of those perceived their health as "excellenr" or "very good" are found to be suffering from chrome disease of omts and percent have visual disability. to conclude an elderly widow living in urban areas have similar health problems as she jives in rural areas. this can be easily explained, as they were not made aware to seek treatment from health facility. in addition, the study shows that the economic conditions are deterrent factors for their illness. it is essential that intervention should be taken up improving their economic conditions so that wellbeing of this most vulnerable group of the society can be taken care of. heart failure is a disease that affects nearly million people world wide. the united states alone accounts for one third of this population. blacks are stricken with heart failure twice as often as whites. men are more likely to develop chf than women, however since the majority of the chf population are seniors, there are actually more women than men. congestive heart failure (chf) has become a pandemic. as the baby boomer generation ages, the number of chf cases will rise dramatically. (young, j. & mills, r., ). after the age of , each proceeding decade doubles the incidence level of chf. the average person has a in chance of developing heart failure within their lifespan according to the framingham study (nih.gov). individuals aging or older compose over half of the entire documented heart failure population. in this age group, chf is the leading cause of hospitalization. many patients are continuously readmitted. it is estimated that the chf population will increase by one million within the next years. mortality was at % for a two year period and % for five years (young, j. & mills, r., ). data from: aha as technology evolves, the understanding of the nature of heart failure has become clearer. in the beginning of the th century heart failure was diagnosed as a condition that presented with edema (swelling) in the extremities caused by water retention. treatment in the beginning of the past cenrury was limited to abdominal drainage and diuretics. the discovery of the heart's insufficient pumping ability in heart failure patients lead to new surgeries and devices such as heart transplants and ventricular assist devices (bridge until transplant is available). ventricular hypertrophy often occurs before the development of heart failure. hypertrophy is the term given for cardiac remodeling. cardiac remodeling also includes chamber dilation (young, j. & mills, r., ) . chf financial burden the us healthcare financing administration has ranked chf as the highest cost illness in the diagnose-related area. direct costs related to chf in the us for were nearly $ billion. these costs included hospital admissions, physician fees, home health aids and medications. indirect costs were over $ billion in . loss of jobs or death due to chf was the criteria for this category (young, j. & mills, r., ). . introduction: the injection drug user quality of life scale (iduqol) is a relatively new scale ~es gned to capture the unique and individual circumstances that determine quality of life among injection drug users (idus). the life areas comprising the instrument were based on the research literature an~ ~ocus group discussions with idus. the purpose of the present study was to evaluate the content validity of t.h~ iduqol using judgmental methods based on subject matter experts' (smes) ratings. content vah~ ty refers to the de~ee to which elements of an assessment tool are representative of the construct of interest and appropnate for a given population. methods: data were obtained from six smes, from the field of idu research and practice, who ~ere. asked t.o evaluate various aspects of the iduqol, including the title of the instrument, administraon instruchons, clarity of the names and descriptions of each life area, response format, scoring instruc-no~s and examples, record form and whether each life area should be included in the instrument. sme ratings were made using either or point scales. sm es were also given the opportunity to comment on poster sessions v each section and to suggest whether important life areas had been overlooked, were redundant, not relevant, or in need of revision. (cvi) and the ~v.erage ~eviation index (ad) were used to evaluate smes' agreement on ratings of the content vahd ty vanables. both measures provided support for the content validity of various aspects of the iduqol, although results from the stricter ad index noted some areas of disagreement, including the description of particular life areas (e.g., being useful, drugs, sex), the inclusion of some life areas (e.g., drug treatment, education, independence and free choice), and the ease of the scoring instructions. the findings from this study provide (a) content validity evidence to support the use of the iduqol as well as (b) recommendations to suengthen both the instrument (e.g., improved descriptions for some items) and the accompanying administration and scoring manual (e.g., an easier scoring template). changes made to the instrument and its manual make the iduqol even easier for researchers, practitioners, and program evaluators to use as a way of assessing, and tracking changes over time or as a result of interventions in, quality of life in injection drug users. introduction: strict adherence to prescribed regimens is required to derive maximal benefit from highly active antireuoviral therapy (haart) in persons living with hiv/aids (phas). adherence is a key determinant of the degree and durability of viral suppression. adherence is also essential in reducing the spread of hiv and ensuring that today's treatments remain effective for as long as possible. the objective of this study is to conduct a systematic review of the research literature on the effectiveness of education and patient support strategies for improving adherence to haart. methods: a systematic search of the core databases was performed from january until may . randomized controlled trials examining the effectiveness of education and patient support interventions to improve the adherence to haart were considered for inclusion. only those studies that measured adherence at a minimum of six weeks were included. study selection, quality assessments, and data abstraction were performed independently by two reviewers. results: study heterogeneity with respect to differing populations, interventions, outcomes, and length of follow-up did not allow for meta-analysis. we included studies involving , ph as. sample sizes ranged from to . study duration ranged from a single session to a variable number of sessions delivered over one year. many of the interventions involved the provision of an educational component to improve adherence and often addressed strategies to overcome barriers to adherence and the development of problem-solving skills. they ranged from simple interventions (e.g., the provision of reminder devices) to complex interventions (e.g., cognitive-behavioural therapy delivered by licensed psychologists). eleven of the studies demonstrated a statistically significant advantage associated with the described adherence intervention. the advantage associated with adherence outcomes does not seem to translate into the more clinically relevant outcome of viral suppression. only out of studies that reported virological or immunological results found a significant effect associated with the intervention. the studies had several methodological shortcomings. conclusions: there is a need for standardization and methodological rigour in the conduct of adherence trials. some interventions may have a significant impact on improving adherence. further research is required before any specific adherence improving strategy can confidently be incorporated into standard clinical practice. focus groups were used to collect data from a purposive sample of treatmentexperienced participants. focus group data were analyzed using a grou~ded t~eory appr~ach. i:ne themes identified from the interviews were used to identify the effects of ant rerrov rals on quality of hfe. the content of the mos-hiv was appraised against the themes identified from our analysis. participants also completed the mos-hiv survey and were asked whether the survey covered all important aspects of quality of life on antiretroviral medications. results: five key informant interviews and five focus groups with participants were used to identify effects on quality of life that are not directly ~aptu~ed by_ the mos-hiv health survey. our~~ showed that our participants described quality of hfe as mvol~mg_ a set of ~rsonal trad~ffs ~stay alive. in most cases, worsened quality of life was traded-off for gams ~ longevlty from ~~canon use. these eff~'ts or tradeoffs included: ( ) downstream consequences of side effects and toxlanes; ( ) loss of lrufe. pende~t decision-making privileges, ( ) having to choose drugs over ~areer; (~)burden of medication-taking responsibilities; and ( ) living life under a pretense and havmg to hide-the net effect of the tradeoffs, or "prices" to pay led to what was described as "longevity with hn without hope and future~. conclusion: our study highlights five major themes summarizing the impact of haart on quality on life, and suggests that currently used scales for measuring quality of life do not a~atd~ cap~e these findings and the associated consequences. the conceptual framework for measuring quality of bfe in hiv should be reconsidered in order to better capture the important effects of the medications on quality of life. this may involve widening the boundaries of the definition of health-related quality oflife to include aspects such as finances, employment, and housing. we should further consider the development of a haart adverse effect specific instrument, using a broad definition of adverse effect in order to capture all types of adverse impacts of hiv treatments on quality of life. introduction: measles (rubeola) is the most contagious vaccine preventable disease of humans. while cases of measles are uncommon in canada today, the disease continues to be a leading cause of morbidity and death in the developing world. as a result of human migration, measles cases still occur in canada, primari~ among immigrants, returning travelers, and other susceptible groups. canada's national advisory council on immunizations (naci) recommends that immigrants without records of measles immunization be considered for vac:cination since these individuals may not have been appropriately vaccinated in their native country. on rhe other hand, natural immunity to measles in immigrants is likely to be high given the high incidence of disease in developing parts of rhe world. thus it remains unclear if the most efficient strategy to achieve high levels of measles immunity in immigrants should entail initial serologic screening followed by vaccination of susceptible individuals or preemptive vaccination of all persons lacking immunization records. understanding the epidemiology of measles immunity in immigrant populations could help guide such decisions. . methods: we identified adults, years of age or older, who were screened for serologtc immunity to measles as part of a recently developed screening protocol at a downtown toronto community health centre. we subsequently determined if these individuals had any immunization records from their native country or from within canada. we then examined the relationship between several demographic factors and immunity to measles. results: % of immigrants had no prior immunization records. overall, % of the immigrants rested for immunity to measles were found to be immune; % of those under the age of , % of those between and years of age, % of those between and years of age, and % of those years of age or older. gender, education status, household income, and immigration status were nor ~ssoc ated wirh immunity to measles. immunity to measles was lowest among immigrants from eastern europe ( ~%), whil~ immigrants from other regions of the globe had greater than % immunity. c~lusrons: immigrants and refugees appear to have reasonably high levels of immunity to mea· sics, possibly related to natural infection wirh the measles virus. immigrants from eastern europe appear to have slightly. lower l~vel~ of immunity to the measles virus. universal screening for immunity to meales or preemptive vac:cmauon may both be inefficient public health strategies, however further research is needed to corroborate these findings. nancy r~ss, stephane tremblay, saeeda khan, daniel crouse, mark tremblay, and jean-marie berrhelor o~ve: the speed of the rise in obesity in places like canada suggests that rather than a shift in the gcncnc_ com~sirion of the population, the root of the obesity pandemic is an environment that suprrs ~besity. this paper examines the influence of neighbourhood and metropolitan characteristics. bour~lts:. while accounting. for individual socio-demographics and behaviours, residents of neighs with a large proportmn of poorly educated individuals had higher bmis than those living in poster sessions v neighbourhoods with more highly educated individuals (p <. ). residing in a neighbourhood with a high proportion of recent immigrants was associated with lower bmi for men (p<. ), but not women. neighbourhood dwelling density, a proxy for walkability, was not associated with bm! for either sex. metropolitan sprawl was associated with higher male bmi (p=. ) but the effect was negligible for women (p=. ). bmi was significantly lower for women (p<. ) living in a city in the province of quebec, even after accounting for the influence of individual and neighbourhood covariates. conclusions: bm! was strongly patterned by individual-level social position in urban canada. the incremental influence on bmi of neighbourhood related to the neighbourhood's social conditions and not to their physical form. metropolitan sprawl was associated with higher bm! for men, a group with longer car-dependent commutes than women. the findings suggest that both individuals and their environments (both social and physical) influence the distribution of bmi in urban populations. introduction: urban environments have been linked to a range of human health issues. in singapore, prevalence of end stage renal disease (esrd) is predicted to rise ( in to in , kidney international, vol. , . the clinical and economic burden of esrd has promoted development of strategies aimed at preventing the development and progression of chronic kidney disease. these include population based screening programs such as the national kidney foundation, sin-gapore\'s (nkfs) "partnership for prevention."the program, aims to reduce incidence of esrd through comprehensive intervention and screening for early detection of urinary abnormalities, blood pressure (bp), and random blood glucose (rbg). objective of this study is to examine gender, race and age wise prevalence of elevated bp, rbg and proteinuria. methodology: this current analysis includes , subjects, age to years, who underwent screening during september and december . participants were asked to give demographic information and the history of diseases. tests were given to get clinical information such as proteinuria, blood glucose, sbp, and dbp. blood pressure abnormalities were defined according to ]nc vi criteria. proteinuria was defined as the presence of plus or greater protein (equivalent to> mg/di) on dipstick analysis. results: there were , ( . %) males. racial distribution was chinese ( . % ), malay ( . % ), indians ( . %) and others ( . % ).among participants, who were apparently "healthy" (asymptomatic and without history of dm, ht, or kd), gender and race wise % prevalence of elevated (bp> / ), rbg (> mg/di) and positive urine dipstick for protein was as follows male: ( . ; . ; . ) female:( . ; . ; . ) chinese:( . ; . ; ) malay: ( . ; . ; . ) indian:( . ; . ; . ) others: ( . ; . ; . ) total:(l . , . , . ). percentage of participants with more than one abnormality were as follows. those with bp> / mmhg, % also had rbg> mg/dl and . % had proteinuria> i. those with rbg> mgldl, % also had proteinuria> and % had bp> / mmhg. those with proteinuria> , % also had rbg> mg/dl, and % had bp> / mmhg. conclusion: we conclude that sub clinical abnormalities in urinalysis, bp and rbg readings are prevalent across all genders and racial groups in the adult population. the overlap of abnormalities, point towards the high risk for esrd as well as cardiovascular disease. this indicates the urgent need for population based programs aimed at creating awareness, and initiatives to control and retard progression of disease. introduction: various theories have been proposed that link differential psychological vulnerability to health outcomes, including developmental theories about attachment, separation, and the formation of psychopathology. research in the area of psychosomatic medicine suggests an association between attachment style and physical illness, with stress as a mediator. there are two main hypotheses explored in the present study: ( t) that individuals living with hiv who were upsychologically vulne~able" at study entry would be more likely to experience symptoms of depression, anxiety and phys ca! illness over. the course of the -month study period; and ( ) life stressors and social support would mediate the relat nship between psychological vulnerability and the psychological ~nd physical outcomes. . (rsles), state-trait anxiety inventory (stai), beck depr~ssi~n lnvento~ (bdi), and~ _ -item pbys~i symptoms inventory. we characterized participants as havmg psychological vulnerability and low resilience" as scoring above on the raas (insecure attachment) or above on the das (negative expectations about oneself). . . . . . " . . ,, . results: at baseline, % of parnc pants were classified as havmg low resilience. focusmg on anxiety, the average cumulative stai score of the low-resilience group was significandy hi~e~ than that of the high-resilience group ( . sd= . versus . sd= . ; f(l, )= . , p <. ). similar results were obtained for bdi and physical symptoms (f( , )= . , p<. and f( , )= . , p<. , respec· tively). after controlling for resilience, the effects of variance in life stres".°rs averaged over time wa~ a_sig· nificant predictor of depressive and physical symptoms, but not of anxiety. ho~e_ver, these assooan~s became non-significant when four participants with high values were removed. s id larly, after controlling for resilience, the effects of variance in social support averaged over time became insignificant. conclusion: not only did "low resilience" predict poor psychological and physical outcomes, it was also predictive of life events and social support; that is, individuals who were low in resilience were more likely to experience more life events and poorer social support than individuals who were resilient. for individuals with vulnerability to physical, psychological, and social outcomes, there is need to develop and test interventions to improve health outcomes in this group. rajat kapoor, ruby gupta, and jugal kishore introduction: young people in india represent almost one-fourth of the total population. they face significant risks related to sexual and reproductive health. many lack the information and skills neces· sary to make informed sexual and reproductive health choices. objective: to study the level of awareness about contraceptives among youth residing in urban and rural areas of delhi. method: a sample of youths was selected from barwala (rural; n= ) and balmiki basti (urban slums; n= ) the field practice areas of the department of community medicine, maulana azad medical college, in delhi. a pre-tested questionnaire was used to collect the information. when/(calen· dar time), by , fisher exact and t were appliedxwhom (authors?). statistical tests such as as appropriate. result: nearly out of ( . %) youth had heard of at least one type of contraceptive and majority ( . %) had heard about condoms. however, awareness regarding usage of contraceptives was as low as . % for terminal methods to . % for condom. condom was the best technique before and after marriage and also after childbirth. the difference in rural and urban groups was statistically signif· icant (p=. , give confidence interval too, if you provide the exact p value). youth knew that contra· ceptives were easily available ( %), mainly at dispensary ( . %) and chemist shops ( . %). only . % knew about emergency contraception. only advantage of contraceptives cited was population con· trol ( . %); however, . % believed that they could also control hiv transmission. awareness of side effects was poor among both the groups but the differences were statistically significant for pills (p= . ). media was the main source of information ( %). majority of youth was willing to discuss a~ut contraceptive with their spouse ( . %), but not with others. . % youth believed that people in their age group use contraceptives. % of youth accepted that they had used contraceptives at least once. % felt children in family is appropriate, but only . % believed in year spacing. . conclusion: awareness about contraceptives is vital for youth to protect their sexual and reproduc· tive health .. knowledge about terminal methods, emergency contraception, and side effects of various contraceptives need to be strengthened in mass media and contraceptive awareness campaigns. mdbot:ls: elderly aged + were interviewed in poor communities in beirut the capital of f:ebanon, ~e of which is a palestinia~. refugee camp. depression was assessed using the i -item geriat· nc depressi~n score (~l?s- ). specific q~estions relating to the aspects of religiosity were asked as well as questions perta rung to demographic, psychosocial and health-related variables. results: depression was prevalent in % of the interviewed elderly with the highest proportion being in the palestinian refugee camp ( %). mosque attendance significantly reduced the odds of being depressed only for the palestinian respondents. depression was further associated, in particular communities, with low satisfaction with income, functional disability, and illness during last year. condiuion: religious practice, which was only related to depression among the refugee population, is discussed as more of an indicator of social cohesion, solidarity than an aspect of religiosity. furthermore, it has been suggested that minority groups rely on religious stratagems to cope with their pain more than other groups. implications of findings are discussed with particular relevance to the populations studied. nearly thirty percent of india's population lives in urban areas. the outcome of urbanization has resulted in rapid growth of urban slums. in a mega-city chennai, the slum populations ( . percent) face greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. amongst the slum population the health of women and children are most neglected, resulting in burden of both communicable and non-communicable diseases. the focus of the paper is to present the epidemiology profile of children (below years) in slums of chennai, their health status, hygiene and nutritional factors, the social response to health, the trends in child health and urbanization over a decade, the health accessibility factors, the role of gender in health care and assessment impact of health education to children. the available data prove that child health in slums is worse than rural areas. though the slum population is decreasing there is a need to explore the program intervention and carry out surveys for collecting data on some specific health implications of the slum children. objective: during the summer of there was a heat wave in central europe, producing an excess number of deaths in many countries including spain. the city of barcelona was one of the places in spain where temperatures often surpassed the excess heat threshold related with an increase in mortality. the objective of the study was to determine whether the excess of mortality which occurred in barcelona was dependent on age, gender or educational level, important but often neglected dimensions of heat wave-related studies. methods: barcelona, the second largest city in spain ( , , inhabitants in ) , is located on the north eastern coast. we included all deaths of residents of barcelona older than years that occurred in the city during the months of june, july and august of and also during the same months during the preceding years. all the analyses were performed for each sex separately. the daily number of deaths in the year was compared with the mean daily number of deaths for the period - for each educational level. poisson regression models were fitted to obtain the rr of death in with respect to the period - for each educational level and age group. results: the excess of mortality during that summer was more important for women than for men and among older ages. although the increase was observed in all educational groups, in some age-groups the increase was larger for people with less than primary education. for example, for women in the group aged - , the rr of dying for compared to - for women with no education was . ( %ci: . - - ) and for women with primary education or higher was . ( %ci: . - . ). when we consider the number of excess deaths, for total mortality (>= years) the excess numbers were higher for those with no education ( . for women and . for men) and those with less than primary education ( . for women and - for men) than those with more than primary edm:ation ( . for women and - . for men). conclusion: age, gender and educational level were important in the barcelona heat wave. it is necessary to implement response plans to reduce heat morbidity and mortality. policies should he addressed to all population but also focusing particularly to the oldest population of low educational level. introduction: recently there has been much public discourse on homelessness and its imp~ct on health. measures have intensified to get people off the street into permanent housing. for maximum v poster sessions success it is important to first determine the needs of those to be housed. their views on housing and support requirements have to be considered, as th~y ar~ the ones affected. as few res.earch studies mclude the perspectives of homeless people themselves, httle is known on ho~ they e~penence the mpacrs on their health and what kinds of supports they believe they need to obtain housing and stay housed. the purpose of this study was to add the perspectives of homeless people to the discourse, based in the assumption that they are the experts on their own situations and needs. housing is seen as a major deter· minant of health. the research questions were: what are the effects of homelessness on health? what kind of supports are needed for homeless people to get off the street? both questions sought the views of homeless individuals on these issues. methods: this study is qualitative, descriptive, exploratory. semi-structured interviews were conducted with homeless persons on street corners, in parks and drop-ins. subsequently a thematic analysis was carried out on the data. results: the findings show that individuals' experiences of homelessness deeply affect their health. apart from physical impacts all talked about how their emotional health and self-esteem are affected. the system itself, rather than being useful, was often perceived as disabling and dehumanizing, resulting in hopelessness and resignation to life on the street. neither welfare nor minimum wage jobs are sufficient to live and pay rent. educational upgrading and job training, rather than enforced idleness, are desired by most initially. in general, the longer persons were homeless, the more they fell into patterned cycles of shelter /street life, temporary employment /unemployment, sometimes addictions and often unsuccessful housing episodes. conclusions: participants believe that resources should be put into training and education for acquisition of job skills and confidence to avoid homelessness or minimize its duration. to afford housing low-income people and welfare recipients need subsidies. early interventions, 'housing first', more humane and efficient processes for negotiating the welfare system, respectful treatment by service providers and some extra financial support in crisis initially, were suggested as helpful for avoiding homelessness altogether or helping most homeless people to leave the street. this study is a national homelessness initiative funded analysis examining the experiences and perceptions of street youth vis-a-vis their health/wellness status. through in-depth interviews with street youth in halifax, montreal, toronto, calgary, ottawa and vancouver, this paper explores healthy and not-so healthy practices of young people living on the street. qualitative interviews with health/ social service providers complement the analysis. more specifically, the investigation uncovers how street youth understand health and wellness; how they define good and bad health; and their experiences in accessing diverse health services. findings suggest that living on the street impacts physical, emotional and spiritual well·being, leading to cycles of despair, anger and helplessness. the majority of street youth services act as "brokers" for young people who desire health care services yet refuse to approach formal heal~h care organizational structures. as such, this study also provides case examples of promising youth services across canada who are emerging as critical spaces for street youth to heal from the ravages of ~treet cultur~. as young people increasingly make up a substantial proportion of the homeless population in canada, it becomes urgent to explore the multiple ways in which we can support them to regain a sense of wellbeing and "citizenship." p - (c) health and livelihood implications of marginalization of slum dwellers in provision of water and sanitation services in nairobi city elizabeth kimani, eliya zulu, and chi-chi undie . ~ntrodfldion: un-habitat estimates that % of urban residents in kenya live in slums; yet due to their illegal status, they are not provided with basic services such as water sanitation and health care. ~nseque~tly, the services are provided by vendors who typically provide' poor services at exorbitant prices .. this paper investigates how the inequality in provision of basic services affects health and livelihood circumstances of the poor residents of nairobi slums . . methods: this study uses qualitative and quantitative data collected through the ongoing longitudmal .health and demographic study conducted by the african population and health research center m slum communities in n ·rob" w d · · · · ai . e use escnpnve analytical and qualitative techmques to assess h~w concerns relating to water supply and environmental sanitation services rank among the c~mmumty's general and health needs/concerns, and how this context affect their health and livelihood circumstances. results: water ( %) and sanitation ( %) were the most commonly reported health needs and also key among general needs (after unemployment) among slum dwellers. water and sanitation services are mainly provided by exploitative vendors who operate without any regulatory mechanism and charge exorbitantly for their poor services. for instance slum residents pay about times more for water than non-slum households. water supply is irregular and residents often go for a week without water; prices are hiked and hygiene is compromised during such shortages. most houses do not have toilets and residents have to use commercial toilets or adopt unorthodox means such as disposing of their excreta in the nearby bushes or plastic bags that they throw in the open. as a direct result of the poor environmental conditions and inaccessible health services, slum residents are not only sicker, they are also less likely to utilise health services and consequently, more likely to die than non-slum residents. for instance, the prevalence of diarrhoea among children in the slums was % compared to % in nairobi as a whole and % in rural areas, while under-five mortality rates were / , / and / respectively. the results demonstrate the need for change in governments' policies that deprive the rapidly expanding urban poor population of basic services and regulatory mechanisms that would protect them from exploitation. the poor environmental sanitation and lack of basic services compound slum residents' poverty since they pay much more for the relatively poor services than their non-slum counterparts, and also increase their vulnerability to infectious diseases and mortality. since iepas've been working in harm reduction becoming the pioneer in latin america that brought this methodology for brazil. nowadays the main goal is to expand this strategy in the region and strive to change the drug policy in brazil. in this way harm reduction: health and citizenship program work in two areas to promote the citizenship of !du and for people living with hiv/aids offering law assistance for this population and outreach work for needle exchange to reduce damages and dissemination of hiv/aids/hepatit is. the methodology used in outreach work is peer education, needle exchange, condoms and folders distribution to reduce damages and the dissemination of diseases like hiv/aids/hepatitis besides counseling to search for basic health and rights are activities in this program. law attendance for the target population at iepas headquarters every week in order to provide law assistance that includes only supply people with correct law information or file a lawsuit. presentations in harm reduction and drug policy to expand these subjects for police chiefs and governmental in the last year attended !du and nidu reached and . needles and syringes exchanged. in law assistance ( people living with aids, drug users, inject drug users, were not in profile) people attended. lawsuits filed lawsuits in current activity. broadcasting of the harm reduction strategies by the press helps to move the public opinion, gather supporters and diminish controversies regarding such actions. a majority number of police officer doesn't know the existence of this policy. it's still polemic discuss this subject in this part of population. women remain one of the most under seviced segments of the nigerian populationand a focus on their health and other needs is of special importance.the singular focus of the nigerian family welfare program is mostly on demographic targets by seeking to increase contraceptive prevalence.this has meant the neglect of many areas of of women's reproductive health. reproductive health is affected by a variety of socio-cultural and biological factors on on e hand and the quality of the service delivery system and its responsiveness on the other.a woman's based approach is one which responds to the needs of the adult woman and adolescent girls in a culturally sensitive manner.women's unequal access to resources including health care is well known in nigeria in which stark gender disparities are a reality .maternal health activities are unbalanced,focusi ng on immunisation and provision of iron and folic acid,rather than on sustained care of women or on the detection and referral of high risk cases. a cross-sectional study of a municipal government -owned hospitalfrom each of the geo-political regions in igeria was carried out (atotal of ce~ters) .. as _part ~f t~e re.search, the h~spital records were uesd as a background in addition to a -week mtens ve mvesuganon m the obstemc and gynecology departments. . . . : little is known for example of the extent of gynecological morbtdtty among women; the little known suggest that teh majority suffer from one or more reproductive tr~ct infect~ons. although abortion is widespread, it continues to be performed under ilegal and unsafe condmons. with the growing v poster sessions hiv pandemic, while high riskgroups such ascomn;iercial sex workers and their clients have been studied, little has been accomplished in the large populat ns, and particularly among women, regardmgstd an hiv education. . . conclusions: programs of various governmentalor non-governmental agen,c es to mvolve strategies to broaden the narrow focus of services, and more importan~, to put wo~en s reproducnve health services and information needs in the forefront are urgently required. there is a n~d to reonent commuication and education activities to incorprate a wider interpretation of reproducnve health, to focus on the varying information needs of women, men, and youth and to the media most suitable to convey information to these diverse groups on reproductive health. introduction: it is estimated that there are - youths living on the streets, on their own with the assistance of social services or in poverty with a parent in ottawa. this population is under-serviced in many areas including health care. many of these adolescents are uncomfortable or unable to access the health care system through conventional methods and have been treated in walk-in clinics and emergency rooms without ongoing follow up. in march , the ontario government provided the ct lamont institute with a grant to open an interdisciplinary and teaching medical/dental clinic for street youth in a drop-in center in downtown ottawa. bringing community organizations together to provide primary medical care and dental hygiene to the streetyouths of ottawa ages - , it is staffed by a family physician, family medicine residents, a nurse practitioner, public health nurses, a dental hygienist, dental hygiene students and a chiropodist who link to social services already provided at the centre including housing, life skills programs and counselling. project objectives: . to improve the health of high risk youth by providing accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. . to model and teach interdisciplinary adolescent care to undergraduate medical students, family medicine residents and dental hygiene students. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative:a) semi-structured interviews b) focus groups with youth quantitative:a) electronic medical records for months b) records (budget, photos, project information). results: in progress-results from first months available in august . early results suggest that locating the clinic in a safe and familiar environment is a key factor in attracting the over youths the clinic has seen to date. other findings include the prevalence of preventative interventions including vaccinations, std testing and prenatal care. the poster presentation will present these and other impacts that the clinic has had on the health of the youth in the first year of the study. conclusions: ) the clinic has improved the health of ottawa streetyouth and will continue beyond the initial pilot project phase. ) this project demonstrates that with strong community partnerships, it is possible meet make healthcare more accessible for urban youth. right to health care campaign by s.j.chander, community health cell, bangalore, india. introduction: the people's health movement in india launched a campaign known as 'right to health care' during the silver jubilee year of the alma ata declaration of 'health for all' by ad in collahoration with the national human rights commission (nhrc). the aim of the campaign was to establish the 'right to health care' as a basic human right and to address structural deficiencies in the pubic health care system and unregulated private sector . . methods: as part of the campaign a public hearing was organized in a slum in bangalore. former chairman of the nhrc chaired the hearing panel, consisting of a senior health official and other eminent people in the city. detailed documentation of individual case studies on 'denial of access to health care' in different parts of the city was carried out using a specific format. the focus was on cases where denial of health services has led to loss of life, physical damage or severe financial losses to the patient. results: _fourte_en people, except one who had accessed a private clinic, presented their testimonies of their experiences m accessing the public health care services in government health centres. all the people, e_xcept_ one person who spontaneously shared her testimony, were identified by the organizations worki_ng with the slum dwellers. corruption and ill treatment were the main issues of concern to the people. five of the fourteen testimonies presented resulted in death due to negligence. the public health cen· n:s not only demand money for the supposedly free services but also ill-treats them with verbal abuse. five of these fourteen case studies were presented before the national human right commission. the poster sessions v nhrc has asked the government health officials to look into the cases that were presented and to rectify the anomalies in the system. as a result of the public hearing held in the slum, the nhrc identified urban health as one of key areas for focus during the national public hearing. cond#sion: a campaign is necessary to check the corrupted public health care system and a covetous private health care system. it helps people to understand the structure and functioning of public health care system and to assert their right to assess heath care. the public hearings or people's tribunals held during the campaign are an instrument in making the public health system accountable. ps- (a) violence among women who inject drugs nadia fairbairn, jo-anne stoltz, evan wood, kathy li, julio montaner, and thomas kerr background/object ives: violence is a major cause of morbidity and mortality among women living in urban settings. though it is widely recognized that violence is endemic to inner-city illicit drug markets, little is known about violence experienced by women injection drug users (!du). therefore, the present analyses were conducted to evaluate the prevalence of, and characteristics associated with, experiencing violence among a cohort of female idu in vancouver. methods: we evaluated factors associated with violence among female participants enrolled in the vancouver injection drug user study (vidus) using univariate analyses. we also examined self-reported relationships with the perpetrator of the attack and the nature of the violent attack. results: of the active iou followed between december , and may , , ( . %) had experienced violence during the last six months. variables positively associated with experiencing violence included: homelessness (or= . , % ci: . - . , p < . ), public injecting (or= . , % ci: . - . , p < . ), frequent crack use (or= . , % ci: . - . , p < . ), recent incarceration (or = . , % cl: . - . , p < . ), receiving help injecting (or = . , % cl: . - . , p < . ), shooting gallery attendance (or = . , % ci: . - . , p < . ), sex trade work (or = . , % cl: . - . , p < . ), frequent heroin injection (or= . , % cl: . - . , p < . ), and residence in the downtown eastside (odds ratio [or] = . , % ci: . - . , p < . ). variables negatively associated with experiencing violence included: being married or common-law (or = . . % ci: . - . , p < . ) and being in methadone treatment (or = . , % ci: . - . , p < . ). the most common perpetrators of the attack were acquaintances ( . %), strangers ( . %), police ( . %), or dealers ( . %). attacks were most frequently in the form of beatings ( . %), robberies ( . %), and assault with a weapon ( . %). conclusion: violence was a common experience among women !du in this cohort. being the victim of violence was associated with various factors, including homelessness and public injecting. these findings indicate the need for targeted prevention and support services, such as supportive housing programs and safer injection facilities, for women iou. introduction: although research on determinants of tobacco use among arab youth has been carried out at several ecologic levels, such research has included conceptual models and has compared the two different types of tobacco that are most commonly used among the lebanese youth, namely cigarette and argileh. this study uses the ecological model to investigate differences between the genders as related to the determinants of both cigarette and argileh use among youth. methodology: quantitative data was collected from youth in economically disadvantaged urban communities in beirut, the capital of lebanon. results: the results indicated that there are differences by gender at a variety of ecological levels of influence on smoking behavior. for cigarettes, gender differences were found in knowledge, peer, family, and community influences. for argileh, gender differences were found at the peer, family, and community l.evels. the differential prevalence of cigarette and argileh smoking between boys and girls s therefore understandable and partially explained by the variation in the interpersonal and community envi.ronment which surrounds them. interventions therefore need to be tailored to the specific needs of boys and girls. introduction: the objective of this study was to assess the relationship between parents' employment status and children' health among professional immigrant families in vancouver. our target communmes v poster sessions included immigrants from five ethnicity groups: south korean, indian, chine~e, ~ussian, and irani~ with professional degrees (i.e., mds, lawyers, engineers, ma?~ger~, and uru~ers ty professors) w h no relevant job to their professions and those who had been hvmg m the studied area at least for months. methodology: the participants were recruited by collaboration from three local community agencies and were interviewed individually during the fall of . ra#lts: totally, complete interviews were analyzed: from south-east asia, from south asia, from russia and other eastern europe. overall, . % were employed, . % were underemployed, % indicated they were unemployed. overall, . % were not satisfied with their current job. russians and other eastern europeans were most likely satisfied with their current job, while south-east asians were most satisfied from their life in canada. about % indicated that their spouses were not satisfied with their life in canada, while % believed that their children are very satisfied from their life in canada. in addition, around % said they were not satisfied from their family relationship in canada. while most of the responders ranked their own and their spouses' health status as either poor or very poor, jut % indicated that their first child's health was very poor. in most cases they ranked their children's health as excellent or very good. the results of this pilot study show that there is a need to create culturally specific child health and behavioral scales when conducting research in immigrant communities. for instance, in many asian cultures, it is customary for a parent either to praise their children profusely, or to condemn them. this cultural practice, called "saving face," can affect research results, as it might have affected the present study. necessary steps, therefore, are needed to revise the current standard health and behavioral scales for further studies by developing a new scale that is more relevant and culturally sensitive to the targeted immigrant families. metboda: database: national health survey (ministry of health www.msc.es). two thousand interviews were performed among madrid population ( . % of the whole); corresponded to older adults ( . % of the . million aged years and over). study sample constitutes . % ( out of ) of those older adults, who live in urban areas. demographic structure (by age and gender) of this population in relation to health services use (medical consultations, dentist visits, emergence services, hospitalisation) was studied using general linear model univariate procedure. a p . ), while age was associated with emergence services use ( % of the population: %, % and % of each age group) and hos~italisation ( % .oft~~ population: %, % and %, of each age ~oup) (p . ) was fou~d with respect to dennst v s ts ( % vs %), medical consultations ( % vs %), and emergence services use ( % vs %), while an association (p= . ) was found according to hospitalisation ( % vs %). age. an~ g~der interaction effect on health services use was not found (p> . ), but a trend towards bosp tal sanon (p= . ) could be considered. concl.uions: demographic structure of urban older adults is associated with two of the four health se~ices use studi~. a relation.ship ber_ween age. and hospital services use (emergence units and hospitalisanon), but not with ~ut-hosp tal sei:vices (medical and dentist consultations), was found. in addition ro age, gender also contnbutes to explam hospitalisation. . sexua experiences. we exammed the prevalence expenences relation to ethnic origin and other sociodemographic variables as wc i as y j die relation between unwanted sexual experiences, depression and agreuion. we did so for boys and prts separately. mdhods: data on unwanted sexual expcric:nces, depressive symptoms (ce.s-d), aggrc:uion (bohi-di and sociodemographic facron were collected by self-report quescionnairc:s administettd to students in the: nd grade (aged - ) of secondary schools in amsterdam, the netherlands. data on the nature ol unwanted sexual experiences were collected during penonal interviews by trained schoolnursn. ltaijtj: overall prevalences of unwanted sexual experiences for boys and girls were . % and . % respectively. unwanted sexual experiences were more often ttported by turkish ( . %), moroc· an ( . %) and surinamese/anrillian boys ( . %) than by dutch boys ( . %). moroccan and turkish girls, however, reported fewer unwanted sexual experiences (respectively . and . %) than durch girls did ( . %). depressive symptoms(or= . , cl= . - . ) covert agression ( r• . , cl• . - . ) and cmrt aggression (or= . , cl• . - . ) were more common in girls with an unwanted sexual experi· met. boys with an unwanted sexual experience reported more depressive symptoms (or= . ; cl• i . .l· . ) and oven agression (or= . , cl= . - . ) . of the reported unwanted sexual experiences rnpec· timy . % and . % were confirmed by male and female adolescents during a personal interview. cond sion: we ..:an conclude that the prevalence of unwanted sexual experiences among turkish and moroccan boys is disturbing. it is possible that unwanted sexual experiences are more reported hy boys who belong to a religion or culture where the virginity of girls is a maner of family honour and talking about sexuality is taboo. more boys than girls did not confirm their initial disdosurc of an lllwalltc:d sexual experience. the low rates of disclosure among boys suggcsu a necd to educ.:atc hcahh care providen and others who work with migrant boys in the recognition and repomng of exu.il ... iction. viramin a aupplc:tmntation i at .h'yo, till far from tafl'eted %. feedinit pracn~:n panku· lerty for new born earn demand lot of educatton ernpha a• cxdu ve hrealt fecdtnit for dnared rcnoj of months was observtd in only .s% of childrrn thoulh colckturm w. givm n rn% of mwly horn ct.ildrm. the proportion of children hclow- waz (malnounshrdl .con" a• h!jh •• . % anj "rt'i· acimy tc.. compared to data. mother's ~alth: from all is womm in ttprod~uvr •ill' poup, % were married and among marned w~ .\ % only w\"rt' u mic wmr cnntr.-:cruve mt h· odl % were married bdorc thc •ar of yean and % had thnr ftnc prcicnancy hcftitt dlt' •icr nf yean. the lt'f'vicn are not uutfactory or they arc adequate but nae unh ed opumally. of thote' l'h mothen who had deliverrd in last one year, % had nailed ntmaral eum nat on ira" oncc, .~o-... bad matt rhan four ttmn and ma ortty had heir tetanus toxotd tnin,"t or"'" nlht "'"'"· ljn r ned rn· win ronductrd . % dchvcnn and % had home deh\'t'oc'i. ~md~: the tervtcn unbud or u led are !tu than dnarame. the wr· l'kft provided are inadequate and on dechm reprcwnttng a looun t ~p of h hnto good coytti\#' ol wr· ncn. l!.ckground chanpng pnoriry cannoc be ruled out u °"" of thc coatnbutory bc f. ps-ii ia) dcpn:wioa aad anuccy ia mip'mu ia awccr._ many de wn, witco tui~bmjer. jack dekker, aart·jan lttkman, wim gonmc:n. and amoud verhoeff ~ a dutch commumry-bucd icudy thawed -moarh•·prc:yalm«i al . ' . kw anx · ay daorden and . % foi' dqrasion m anmttdam. nm .. p tficantly hlllhn than dwwhrft .. dw ~thew diffamca m pttyalcnca att probably rdarcd to tlk' largr populanoa of napaan ..\mturdam. <turkish %, moroccan %, and surinam % . lndttd. ic'wt'll ltudla hatt ~ ~ high prevalena rata among migrant poupi in rbe ncdwrlands. howc'ytt au ttlluchn iuffenod from wry low raporne rara, or med screnung talel thac lack a ~y yabdarcd ~ in order to study the prevalence of depression and anxiety, and the (barriers to) use of mental health care among the different ethnic groups the following study was recently conducted: . the study consisted of a two-step approach. the first step was mcl~ded m the ~ h ith survey of (ahs), and consisted of three screening scales for depression and aruaety (klo, g::q- and mhl- ). in this survey all respondents were asked_ permission for~ second app~ :' t consisted of a structured interview containing the cidi for aruaety and depression, and questtollllalres on health care seeking, amongst others. all respondents who gave permission for a second approachwere invited by jetter for a suuctured interview with multilingual interviewers at home at a preset date and time in the following week. . in total, dutch, turkish, moroccan and surinam respondents took part in the ahs and gave permission for a second approach. in the second step, fo~ ~ tur~h, m~roc can surinamese and dutch respondents, information from the extensive interview was available (res~nse rates between and % ). since the data collection was completed only recently (june ), prevalence estimates can be presented at the conference for the first time. we have shown that with this approach it is feasible to achieve an acceptable response rate in a study on mental health among migrants. therefore we expect that this study will provide reli· able estimates of depression and anxiety in the turkish, moroccan and surinam migrants in amstw! ~· for the first time. in addition, insight into mechanisms underlying the differences between and within ethnic groups and into barriers to mental health care will provide pretexts for the improvement of pre· vention and mental health care for migrant groups. this study aimed to determine spatial patterns of mortality and morbidity of five major health problems in an urban environment: homicides, pregnancy among adolescents ((< years old), asthma hospitalization among young children(< years old) and two mosquito-borne diseasesdengue and visceral leishmaniasis, during - . all events were obtained through the city health database and, subsequently, geoproccsscd using the address of residence and the geographical and administrative division of the municipality, composed by unit of planning (up), which in tum were formed, each one, by census tract units. two research questions were investigated: are there spatial patterns to the events dis· tribution, and moreover, are these patterns overlapping across space? we use thematic maps, index of comparative mortality/morbidity by up and the overlapped rank of the th worse up rates for each event. a spatial pattern of high rates of homicides, proportion of young mothers and hospitalization of asthma were overlapping in areas social and economically disadvantaged. for mosquito-borne diseases, high rates with great dispersion were found in unprivileged areas in contrast with very low rares among privileged ones. these results pointed toward a coexistence of heavier burden of diseases for those living in areas of the city where misery, poverty, lack of political public health may be modulating social health problems. a possible environmental intervention in one mosquito•bome disease might be playing a role in the occurrence of other. although with limitations, this study may provide useful information for a joint urban planning under the public perspective, articulated for use in health impact assessment. jalil safaei bdrod#aion: the association of socioeconomic status (ses), usually measured by income, and health status is an established result in bcalth studies. the poor and low income individuals have lower health sta· tus then_ those with higher incomes. in general. such finding has been usually obtained from sample surveys on speafic populations. a problem with many sample survey$ is that their results are not comparable aaoss ~ndaries as they may use different sampling methods, ask different questions, categorize the answers differently, or define groups differently. moreover, the sample data need to be standardized using the demographic: katurea of a ~ population. this study, however, uses the national population health survey (nphs) cycle public use mictodata files which is based on a common survey template ·~~three~ area in canada, namely montreal, toronto, and vancouver. it also utili .es the built-m stanclatdizaaon of the nphs data which accounts for its complex survey design. . ~:the stu~ usc:s two well-known measures of health inequalitythe relative index of meqaality and die concentranon indexto capture the extent of income related health inequality among poster sessions v urban female and male populations in each of the three metropolitan areas. personal income is classified into ten groups by the nphs with "no income" as the first group and "more than $ , " as the last. health status is measured by three variables -having a chronic condition (chc), self assessed health (sah), and health utility index (hui) -using appropriate indices. alternative formulations are used to calculate the standard deviations of the estimated or calculated measures. the findings of the study suggest that the measured health inequality depends on the health measure used. for chc and hui the measured inequality indices do indicate poorer health for lower income individulas, however, they are not statistically insignificant. health inequalities are more pronounced when health is measured by sah. the results do not support any systematic ranking of the three metropolitan areas in terms of health inequalities. they do not reveal any systematic pattern of inequality between men and women, either. conclusions: despite the use of highly aggregated nphs data, income related health disparities are observed in the three metropolitan areas in canada. this is more the case with self perceived (sah) health. such disparities are preventable and call for broader health policies that address poverty and low income among other social determinants of health. introduction: the analysis of health indicators under the spatial perspective is configured as an important instrument in the detection of intra-urban differentials. this study aimed to examine the spatial distribution of the births occurred in belo horizonte, in , analyzing the presence of spatial clusters of health indicators for newborns (rn) and their mothers, using data from the information system on live birth database (sinasc). method: for each covered area of the basic units of health (ubs), we calculated the proportion of: adolescent mothers, mothers with less than years of schooling, first pregnancy, mothers with four or more pregnancies, dead babies born on previous pregnancies, stillbirths, cesarean section, less than four prenatal care attendance, moderate and severe hypoxemia in the st and th minutes of life, low or very low birth weight. we used empiric bayesian methods for smoothing the estimates. for spatial analysis, the indicators obtained from the global moran (i) index and local indicators of spatial association (lisa) were used. maps were built to allow the visualization of the spatial clusters. in all analysis, significance statistics was considered p~ . . results: a total of , births of residents in belo horizonte were registered in i. the estimated bayesian proportions for the entire municipality was close to the one observed for all variables. analysis using lisa showed the presence of relevant spatial clusters for adolescent and low educated mothers, dead babies form previous pregnancies, cesarean section, low attendance to the prenatal care especially in area with low socio-demographic characteristics. three areas presented consistent clusters, with important spatial auto-correlation for almost all studied indicators. conclusion: the used methodology was configured as a great instrument of detection risk areas where clustering occurs. it can easily be incorporated in any surveillance system as a mechanism for controlling events related to births in the municipality. moreover, it can be applied to discriminate target areas for prompt public health interventions, such as improving health services access and the consolidation of better obstetric practices. introduction: gentrification, the displacement of low income and non-majority people out of longtime neighborhoods and residences is a global phenomenon. it has been identified as occurring in both developed and less developed countries and as inequality persists or increases, many communities are vulnerable to disruption and loss. while there may be some benefits to gentrification, these benefits are less likely to impact those who have been forced to move out of a gentrifying community or those who remain but economically stressed. . . . . this paper lays out a theoretical framework for dent fymg and ~ddressm~. the_ health consequences of gentrification on residents living in a community prior .to o.r durmg gent~ ~ cat. n. by drawing on the literature of housing, sociology, health and urban plannmg, t places genmf catt~n and neighborhood change into the context of other forces affecting th~ .hea.lth of vulnerable populations. it then proposes solutions to prevent or mitigate the impacts of genmf cat on. results: four main categories of consequences potentiallr re~ult from ~entr~fica~~n: !'°°r housing· related issues, spatial effects, mental health impacts and contr bunons to racial ~spanttes m heal~. the housing issues include increased susceptibility to asthma, lead exposure, allergiesl~topy an~. acetdents/ injuries. spatial effects include reduced access to health ~are, reduce~ access to obslttadinonal food sources, decreased physical activity, and increased obesity. the __ pnmary mental health effects_ :ire increased stress increased risk of depression and disruption of trad t onal support networks. in addinon to the above he~lth issues, gentrification has the potential to increase racial disparities in health by reduc· ing access to long term and multi-culturally experienced health care provide~s. conclusions: public health practice provides a framework for addressmg the health consequences of gentrification. in this context primary prevention would involve preventing gentrification in the first place along with a renewed commitment to helping distressed communities a~~ im_proving the quality ~f life for long term residents. the next layer of meeting the challenges of gentrification would be to assjst long rime residents to stay in a community and thus potentially allowing them to participate in the bene~ts of gentrification (such as better public services). only if all these efforts fail -and these other prevennon strategies must be a priority, public policy should then work to help people and instirutions move to other communities through grants and the provision of alternative safe affordable housing and neighborhoods. sarah romans, marsha cohen, and tonia forte lnh'odlletion: there has been sustained interest in urban rural (ur) differences in mental health over the last years of epidemiological research, with most studies reporting higher urban rates of mor· bidity, particularly when psychotic disorders have been studied. most recently, in britain, urban rates of non-psychotic disorder were greater than rural and semi-rural rates, both before and after the more adverse circumstances of urban dwellers were considered (paykel et al ) . surprisingly, there were no ur differences in help seeking. in canada, wang ( ) found greater urban rates for major depression only after he controlled for the confounding effects of race, immigration, employment and marital status, a result reminiscent of work from the us (blazer et ) . rural participants were less likely to have sought help for their mental health problems. in this study, we sought to examine urban/rural differences in rates of depression and help seeking in canada. method; data came from the canadian community health survey . , a community survey conducted by statistics canada of people aged and older, with the total sample size of , respon· dents, % response. analyses used weighted data; differences were assessed by chi-squared. ra.its: bivariate cross-tabulations showed a modest increase in month depression rates for urban ( . %) over rural ( . %, p= . ) dwellers; there were no ur differences when the sample was examined separately by gender and age group ( - , - , - ) . in general, more urban ( . %) than rural people ( . %, p= . ) had sought mental health treatment in the past year. there was no ur difference in helping seeking amongst those with depression (u . %, r . % ns). amongst the whole population, helping seeking was gendered with more urban men accessing help ( . %) than rural men ( . %, p= . ); this did not apply for women ( . % vs . % p= . ). ~ons: the urban-rural demographic continues to generate intriguing findings, even recently when internal migration is common and people can seek out the environment most conducive to their health, ~th physical and mental. people with depression are a disadvantaged, frequently stigmatized group, with ~r quality of life a_nd often impaired function. unlike many other factors associated wi~h urban or rural hfe per se, depression can be treated. the low help seeking rates is a cause for concern, m both the ur~n and_ rural populations. it behooves researchers, policy makers and service planners to ensutt effective services are available for both humane and economic reasons. methods: using united states census income data, we assigned the manhattan community districts to two major socioeconomic groups, manhattan i and ii. manhattan i is composed of community districts with average household incomes above the median for new york city; manhattan ii is those below. with public new york city department of health death records and us census data, we calculated a "standard" new york city population and estimated mortality rate distributions for manhattan i and ii. we then compared these age-adjusted actual mortality distributions with a standard t-test. results: we explored premature deaths using several cut-off points (before the ages of , , and ), and with subcomparisons for males and females. every comparison showed the wealthier area, manhattan i, to have significantly lower premature mortality rates than the lower income manhattan ii. further, we compared age-adjusted mortality rates among the city's five boroughs, and found no significant differences based on local geography alone. conclusions: these findings suggest that in manhattan, characterized by its extremes of wealth and poverty, health status, as measured by premature mortality, does vary significantly with the local income level. in manhattan, the relative average income by community district varies as much as : . this ratio is greater than that found in the other cities we have studied: for example, the range among tokyo's kus is half that in manhattan, or about : . paris has shown the longest life expectancy and changing premature mortality rates. from our preliminary work, we expect to find less variation in premature mortality rates in comparable cities. this study will continue to explore the relationship of premature mortality rates and life expectancy to income levels and different health systems among wcp cities with a view to measuring health policy options. introduction: according to the world health organization (who), smoking-related illness is currently the world's second major cause of death, currently responsible for one out of ten adult deaths worldwide. the who's framework convention on tobacco control (fctc) aims to reduce tobaccorelated disease and deaths by changing national public policies. mexico, which, according to the who, had smoking prevalences of % among adults in and % among health care providers (hcps) in , ratified the fctc in . objective: to examine knowledge of and attitudes towards cigarette smoking and smoking cessation among hcps, and clinical practices regarding smoking cessation. methods: in june , a convenience sample of hcps from one public clinic in urban oaxaca, mexico, part of mexico's national network of public health care clinics, were interviewed in spanish using a verbally administered questionnaire that was standard among all participants. during primary care outpatient visits, hcps were observed treating patients to assess the relative importance of smoking cessation as a health care priority. results: of the hcps interviewed, including ten physicians, three nurses, and five medical students, % reported smoking regularly. all hcps reported assessing patients' history of smoking, knowledge of the health risks associated with smoking, and feeling qualified to discuss these risks with patients. all hcps reported counseling patients who currently smoked to quit. all hcps reported recommending nicotine replacement therapy (eg., patch and/or gum) and/or behavioral therapy (eg., psychologist, support groups) to patients who smoked. all hcps reported that there was no government funding for smoking cessation, and that all costs associated with smoking cessation were patients' out-of-pocket expenses. observation of hcp interaction with patients revealed that hcps always inquired about smoking history with new patients and rarely inquired about smoking history with returning patients. hcps were not observed counseling patients who reported current smoking on smoking cessation methods and its benefits. observation of the clinical environment suggested a focus on preventative child health (eg., immunization, water-borne illnesses), family planning, and chronic diseases (eg., diabetes, hypertension). conclusions: while the mexican government has made smoking cessation a public health priority and hcps report addressing smoking cessation, observation of hcps suggests: ) smoking status is assessed only in new patients; and ) smoking cessation methods are not addresse~. observ_atio~ of hcps and the clinical environment in a public clinic in oaxaca suggests that smoking cessation s of lower priority than other heath care issues. p - (a) urban agriculture and food and nutrition security in kampala, uganda fiona yeudall, renee sebastian, abdelrahman lubowa, selahadin ibrahim, and donald cole introduction: urban agriculture is an important livelihood strategy contributing to household food security by increasing access and availability to food in urban settings (koc et al., ) . the purpose of poster sessions v rhis study was to examine relationships between child nutritional securiry outcomes, household food security, and urban agriculture activiries in kampala, uga~da. . . questionnaires assessing socio-demographic, farmmg and household food secunry (hfsi characreristics were administered to households. food diversiry was ~lculate~ from ~e number of foods consumed over hours for one child ( - years) per household. heigh~ weight,. nud-upper·ann· circumference (muac) and tricep skinfolds (tsf) were measured for the mdex child. z-sc.ores for height-for·age (haz), weighr-for-age (waz) and body mass index (zbmi) were ~~ulated usmg cen· rres for disease control and prevenrion reference data. z-scores for body composition measures were calculated using nhanes i and ii data for african americans. the lms method was used to c~.t for skewed z·score indices. all dara was checked for normaliry and univariable and backward mulnvanablc linear regression analysis conducted. ruwlts: household food securiry was significantly associated with wealth (b= . , p< 'a acre were more dependenr on assets for hfs. although sex of head of household was ~ot related to j-:ifs, it modi· fied relationships in rhar female headed households had greater food securtry when fai:mmg less than , acre compared ro male headed households, and vice versa. hfs was significantly associated with food diversiry (s= . , p). urbanization, especially in developing countries, has substantially increased the vulnerability of rhe mass of low-income urban dwellers. the livelihoods and quality of life for many of the poor espe· cially in larin america, asia, and africa, have deteriorated significantly over the years. urban areas are increasingly unable to provide for their populations, resulting in poverry, massive unemploymenr, job cuts, poor housing, lack of or poor public services, and a compromised health status. botswana, a country rhat lies in the sourhern parr of africa, has had its share of urban problems such as rhe mush· rooming of squarters and low-income urban sertlements. despite efforts to address the substandard living conditions in low-income urban areas, these problems have continued to grow. these living con· diuons are porenrially stressful to rhe residenrs and likely affects their health. the primary aim of the udy wa to examine the complex relationship between communiry-level stressors and interveners and health-related quality of life among residents of low-income neighborhoods in francistown, botswana. u i"" a croa -icctional quantitative design (both descriptive and explanatory) and using primarily cloae-mded interview• with a random sample of residents, this study examined the role of chrome life trnson and environmental quality on overall health status qualiry of life) and the physical, psy· chological and level of independence domains of health. the major hypothesis of the study was that community-levrl stre sor would influence health-related quality of life and that social capital would moderate these relationships. findings indicate that neighborhood quality is a powerful predictor of healrh tatu rhan socioeconomic status and individual life stressors. social capital was also found to he a ificant positive predictor of healrh and also moderator of structural factors. social capital moderated the effects of low environmental quality on level of indrpendence and on physical health outcomn, but nor on psychological and global health outcomes. these findings suggest that as the environment get betttr. stresson are reduced, hence promoting berter health outcomes. the study ends with implication• for social justice, public health and social work practice, and research, focusing mostly on the ~ole of social capital and the environmental quality in predicting health outcomes. spt· cafically • anenhon should be focused on political and civic society's commitment for social justice and poveny alleviation, ~uction of the threat of insecuriry and violence; cultivating social capital and good governance; and improving the health and social environments, especially housing and environ· mental aiutanon to name a few. urban and other uprisings by non-elites that lead to transitions, can disrupt sexual and injection "risk" networks that transmit infectious diseases by changing mixing patterns. they can also weaken urban social networks, their associated protective norms and their informal social control mechanisms which can lead to increased sexual and drug risk behaviors and violence (fullilove ; wallace & wallace , aral , friedman & reid hankins et al ) . for example, the revolution and transition to theocratic rule, and subsequent urban and national conflicts, have been followed by many urban youth in iran engaging in clandestine high-risk sexual and drug behaviors. in palestine, conflicts and restrictions on movement have led to increased fatalities from chronic diseases due to limited access to hospitals and modern medical facilities (union of palestinian medical relief committees); and heroin use and violence-related blood exposure have also increased. social movements "from below" that are rooted both in urban social network dynamics and in underlying patterns of injustice can have both protective and risky effects. for example, the social movements that led to the collapse of the ussr and its dependent governments in other countries-with subsequent increases in sex trade, alcoholism, drug use, tuberculosis, hiv, stis, and mortality in many localities-were based originally on such city-based movements in eastern europe. their impacts on health were mediated by urban social dynamics and structures. some urban social movements have improved health by prevent· ing the spread of hiv, hepatitis and other diseases. examples include movements of (a) gays and lesbians and (b) drug users. these have been rooted in social networks that overlap with risk networks. theories of urban health should include social conflict as a core concept. mechanisms that generate conflicts and the pathways by which conflicts affect health should be a major part of urban health research agendas. p - (c) demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital (lasuth) chest clinic john bako, adewale akeredolu, and wale alabi tuberculosis has become a resurgent public health problem in recent times in the world. because resources are limited, control programmes frequently must target population at greatest risk. the purpose of this study was to study the demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital. a total of patients who have been both radiologically and bacteriologically confirmed tuberculosis patients were used for this study between january and march. ( %) were males, while ( %) were females. notable risk factors among patients with tuberculosis were overcrowding ( . % ), homelessness ( . %) cigarette smoking ( . % ), alcoholism ( . %), non vaccination ( %), secondary contact ( . %) and poor knowledge ( . l 'x,). man· agement history patterns among the patients were herbs ( . 'yo), orthodox medicine ( .h . .l'x.). intervention targeting early-identified groups may be an effective way to reduce the incidence of tuber· culosis. such intervention should focus on health education, modification of life style and improvement of standard of living. p - (c) profiles in urban health in cities of the americas in the countries of the americas, there is an increasing migration of national and international populations to urban centers. this presentation will focus on some of the issues created by this influx of populations, the ways that cities in countries are dealing with them, and the efforts to promote local participation and solutions in management and decision-making. the methodology used to collect this information has been to draw upon and analyze information produced by the mayor's and ministry of health and development offices in each of the cities under consideration. an analysis of the impact of urbanization on health and health determinants will be presented. the information covers issues such as health status by geographic areas within the cities, highlighting issues such as marginality, barriers and physical, economic and cultural constructs and inequities in the delivery of and access to essential services (such as health, education, water, and basic sanitation). issues of governance and citizen participation will be highlighted to provide insight in~o the balance of power and mechanisms for decision-making at the local level. part of the analysis will show the relationship between democratic processes and social participation. public ~olicies will be reviewed to indicate those that are most beneficial in promoting health and overcoming barriers to it, as well as ways of capitalizing on local assets and resources. final~y, evidence of effectiveness of various strategies will be indicated. the presentation will conclude wuh suggesuons for future strategic directions to improve the quality of life and the promotion of health in large urban centers of the americas. introduction: much of the illicit drug in mexico is concentrated in northern border areas. the mile border between the u.s. and mexico is also characterized by migration; the border crossing between tijuana, baja california, mexico and san diego, california, u.s.a. is rep~rt~dl~ the busiest land border crossing in the world. we attempt to describe the migration scene among m ect on drug users (idus) m tijuana and investigate service needs. methods: migration trends were investigated in a cross-sectional study conducted from february to june among idus in tijuana. enrollment criteria included informed consent, being years or older, and having injected drugs within the prior month. subjects were recruited by respondent-dnven sampling and were administered a quantitative survey and serology for hiv, hcv, and syphilis. logistic regression was used to compare idus who had migrated to the u.s. versus those who had not. results: of idus enrolled, % were male and median age and age at first injection were and , respectively. drug combinations injected most frequently in the past months were heroin ( % and crystal methamphetamine mixed with heroin ( %). of those enrolled, responded to quesnons on migration and drug treatment and were included in this analysis. although % had resided in tijuana for at least years, % of users were born outside of baja california. working outside of mexico was common, with % working abroad in the last years ( % in u.s.), and % in the past year. in the last months, % of idus had crossed the border to the u.s., with % crossing at least once per month. those working outside of mexico in the past year were less likely to have ever received substance abuse treatment, [ % vs. %, or . , ] and were marginally less likely to have received drug treatment in the past months [ % vs. %, or . , % ci ( . - . )]. drug use patterns, age and gender did not differ between migrants and non-migrants, although migrants were more likely to report being in need of substance abuse treatment ( % vs. %, respectively). conclusions: migration is common among idus in tijuana. maintaining drug treatment regimens and determining how to best target education and services to a highly mobile population pose challenges to officials on both sides of the border. these data underscore the need to develop coordinated binational prevention and treatment efforts. introduction: despite the expanding literature on the important role public policy plays in influencing the broader determinants of the public\'s health, profound differences exist among jurisdictions in rhe attention placed upon such activities. we take an international perspective on health by examining rhe d?minant public _health paradigms of canada, usa, uk, and sweden and exploring how these paradigms shape public health practice. _method: we carefully analyze governmental and public health agencies documents to discern ~he dommant para~igms driving public health approaches and practices. we also consider the unique paht · cal and economic contexts within each nation and consider how these contexts drive public health pahcy and approaches. . . ~u~: the canadian and usa public health communities -with some exceptions --focus upon m~ividuahzed approaches to risk management. in contrast, the uk and swedish public health scenes are oriented toward broader approaches to health determinants. we find that the extent to which govern· ments, public health agencies and public health workers concern themselves with public policy approaches £<_> ~ddress ~ro.ad~r .determinants of health depends upon the particular health parad'.~ adhered. ~o withm each urisd ctton. and whether a paradigm is adopted depends upon the ideologi~a and pol~ncal context of each nation. nations such as sweden that have a long tradition of public policies promonng social jus~ce an~ equity are naturally receptive to evolving population health concepts. '[he usa represen~ a ~bey en~ro~~t where such is~ues are clear!~ subordinate. ., our findings mdicate that there s a strong political component that influences pubh ~ealth a~proaches and practi~ within the jurisdictions examined. the implications are that those seek· m~ to raise the broader detennmants of the public's health should work in coalition to raise these issues with non-health organizations and age · ca d d th · - badrgrollnd: in developed countries, social inequalities in health have endured or even worsened comparatively throughout different social groups since the s. in france, a country where access to medical and surgical care is theoretically affordable for everyone, health inequalities are among the high· est in western europe. in developing countries, health and access to care have remained critical issues. in madagascar, poverty has even increased in recent years, since the country wenr through political crisis and structural adjustment policies. objectives. we aimed to estimate and compare the impact of socio· economic status but also psychosocial characteristics (social integration, health beliefs, expectations and representation, and psychological characteristics) on the risk of having forgone healthcare in these dif· fercnt contexts. methods: population surveys conducted among random samples of households in some under· served paris neighbourhoods (n= ) and in the whole antananarivo city (n= ) in , using a common individual questionnaire in french and malagasy. reslllts: as expected, the impact of socioeconomic status is stronger in antananarivo than in paris. but, after making adjustments for numerous individual socio-economic and health characteristics, we observed in both cities a higher (and statically significant) occurrence of reponed forgone healthcare among people who have experienced childhood and/or adulthood difficulties (with relative risks up to and .s respectively in paris and antananarivo) and who complained about unhealthy living conditions. in paris, it is also correlated with a lack of trust in health services. coneluions: aside from purely financial hurdles, other individual factors play a role in the non-use of healthcare services. health insurance or free healthcare seems to be necessary hut not sufficienr to achieve an equitable access to care. therefore, health policies must not only focus on the reduction of the financial barriers to healthcare, but also must be supplemented by programmes (e.g. outreach care ser· vices, health education, health promotion programmes) and discretionary local policies tailored to the needs of those with poor health concern .. acknowledgments. this project was supported by the mal>io project and the national institute of statistics (instat) in madagascar, and hy the development research institute (ird) and the avenir programme of the national institute of health and medical research (inserm) in france. for the cities of developing countries, poverty is often described in terms of the living standard~ of slum populations, and there is good reason to believe that the health risks facing these populations are even greater, in some instances, than those facing rural villagers. yet much remains to be learned ahour the connections between urban poverty and health. it is not known what percentage of all urban poor live in slums, that is, in communities of concentrated poverty; neither is it known what proportion of slum residents are, in fact, poor. funhermore, no quantitative accounting is yet available that would sep· arare the health risks of slum life into those due to a househoid•s own poverty and those stemminic from poveny in the surrounding neighborhood. if urban health interventions are to be effectively targeted in developing countries, substantial progress must be made in addressing these cenrral issues. this paper examines poverty and children's health and survival using two large surveys, one a demographic and health survey fielded in urban egypt (with an oversampling of slums) and the other a survey of the slums of allahabad, india. using multivariate statistical methods. we find, in both settings: ( substan· rial evidence of living standards heterogeneity within the slums; ( strong evidence indicating that household-level poverty is an imponant influence on health; and ( ) staristically significant (though less strong) evidence that with household living standards held constant, neighborhood levels of poverty adversely affect health. the paper doses with a discussion of the implications of these findings for the targeting of health and poverty program interventions. p - (a) urban environment and the changing epidemiological surfacr. the cardiovascular ~ &om dorin, nigeria the emergence of cardiovascular diseases had been explained through the concomitants o_f the demographic transition wherein the prevalent causes of morbidity and monality ~hangr pr~mmant infectious diseases to diseases of lifestyle or chronic disease (see deck, ) . a ma or frustration m the v poster sessions case of cvd is its multifactural nature. it is acknowledged that the environment, however defined is the d · f · t' b tween agents and hosts such that chronic disease pathogenesis also reqmre a me an o mterac ion e . spatio-temporal coincidence of these two parties. what is not clear is which among ~ever~( potennal fac· · h b pace exacerbate cvd risk more· and to what extent does the ep dem olog cal trans · tors m t e ur an s ' . . . . tion h othesis relevant in the explanation of urban disease outlook even the developmg cities like nigeri~: thesis paper explorer these within a traditional city in nigeria. . . . the data for the study were obtained from two tertiary level hospitals m the metropolis for years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the data contain reported cases of cvd in the two facilities for the period. adopting a series of parametric and non-parametric statistics, we draw inferences between the observed cases of cvds and various demographic and locational variables of the patients. findings: about % of rhe cases occurred in years ( ) ( ) ( ) coinciding with the last year of military rule with great instability. . % occurred among male. . % also occurred among people aged - years. these are groups who are also likely to engage in most stressful life patterns. ~e study also shows that % of all cases occurred in the frontier wards with minor city areas also havmg their •fair' share. our result conformed with many empirical observation on the elusive nature of causation of cvd. this multifactoral nature had precluded the production of a map of hypertension that would be consistent with ideas of spatial prediction. cvd -cardiovascular diseases. mumbai is the commercial capital of india. as the hub of a rapidly transiting economy, mumbai provides an interesting case study into the health of urban populations in a developing country. with high-rise multimillion-dollar construction projects and crowded slums next to each other, mumbai presents a con· trast in development. there are a host of hi-tech hospitals which provide high quality care to the many who can afford it (including many westerners eager to jump the queue in their healthcare systems-'medical tour· ism'), at the same time there is a overcrowded and strained public healthcare system for those who cannot afford to pay. voluntary organizations are engaged in service provision as well as advocacy. the paper will outline role of the voluntary sector in the context of the development of the healthcare system in mumbai. mumbai has distinct upper, middle and lower economic classes, and the health needs and problems of all three have similarities and differences. these will be showcased, and the response of the healthcare system to these will be documented. a rising hiv prevalence rate, among the highest in india, is a challenge to the mumbai public healthcare system. the role of the voluntary sector in service provision, advocacy, and empowerment of local populations with regards to urban health has been paramount. the emergence of the voluntary sector as a major player in the puzzle of urban mumbai health, and it being visualized as voices of civil society or communiry representatives has advantages as well as pitfalls. this paper will be a unique attempt at examining urban health in india as a complex web of players. the influence of everyday socio·polirical-cultural and economic reality of the urban mumbai population will be a cross cutting theme in the analysis. the paper will thus help in filling a critical void in this context. the paper will thus map out issues of social justice, gender, equiry, effect of environment, through the lens of the role of the voluntary sector to construct a quilt of the realiry of healthcare in mumbai. the successes and failures of a long tradi· tion of the active advocacy and participation of the voluntary sector in trying to achieve social justice in the urban mumbai community will be analyzed. this will help in a better understanding of global urban health, and m how the voluntary sector/ngos fir into the larger picture. ba~und: o~er. half _of n~irobi's . million inhabitants live in illegal informal settlements that compose yo of the city s res dent al land area. the majority of slum residents lack access to proper san· iranon and a clean and adequate water supply. this research was designed to gain a clearer understand· mg of what kappr · · · h f . . opnate samtanon means or the urban poor, to determine the linkages between gender, hvehhoods, and access to water and sanitation, and to assess the ability of community sanitation blocks to meet water and sanitation needs in urban areas. m~tbojs_: _a household survey, gender specific focus groups and key informant interviews were conducted m maih saba, a peri-urban informal settlement. qualitative and quantitative research tools were u~ to asses~ the impact and effectiveness of community sanitation blocks in two informal settlements. results ropna e samtarmn me u es not only safe and clean latrines, but also provision ° adequate drainage and access to water supply for cleaning of clothes and homes. safety and cleanliness poster sessions v were priorities for women in latrines. levels of poverty within the informal settlements were identified and access to water and sanitation services improved with increased income. environmental health problems related to inadequate water and sanitation remain a problem for all residents. community sanitation blocks have improved the overall local environment and usage is far greater than envisioned in the design phase. women and children use the blocks less than men. this is a result of financial, social, and safety constraints. the results highlight the importance a need to expand participatory approaches for the design of water and sanitation interventions for the urban poor. plans need to recognize "appropriate sanitation" goes beyond provision of latrines and gender and socioeconomic differences must be taken into account. lessons and resources from pilot projects must be learned from, shared and leveraged so that solutions can be scaled up. underlying all the challenges facing improving water and sanitation for the urban poor are issues of land tenure. p - (c) integrating tqm (total quality management), good governance and social mobilization principles in health promotion leadership training programmes for new urban settings in countries/ areas: the prolead experience susan mercado, faren abdelaziz, and dorjursen bayarsaikhan introduction: globalization and urbanization have resulted in "new urban settings" characterized by a radical process of change with positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas and fast-growing slums and vulnerable populations. the key role of municipal health governance in mitigating and modulating these processes cannot be overemphasized. new and more effective ways of working with a wide variety of stakeholders is an underpinning theme for good governance in new urban settings. in relation to this, organizing and sustaining infrastructure and financing to promote health in cities through better governance is of paramount importance. there is a wealth of information on how health promotion can be enhanced in cities. despite this, appropriate capacity building programmes to enable municipal players to effectively respond to the challenges and impacts on health of globalization, urbanization and increasing inequity in new urban settings are deficient. the who kobe centre, (funded by the kobe group( and in collaboration with regional offices (emro, searo, wpro) with initial support from the japan voluntary contribution, developed a health promotion leadership training programme called "prolead" that focuses on new and autonomous structures and sustainable financing for health promotion in the context of new urban settings. methodology: country and/or city-level teams from areas, (china, fiji, india, japan, lebanon, malaysia, mongolia, oman, philippines, republic of korea, tonga and viet nam) worked on projects to advance health promotion infrastructure and financing in their areas over a month period. tools were provided to integrate principles of total quality management, good governance and social mobili .ation. results: six countries/areas have commenced projects on earmarking of tobacco and alcohol taxes for health, moblization of sports and arts organizations, integration of health promotion and social health insurance, organizational reforms, training in advocacy and lobbying, private sector and corporate mobilization and community mobilization. results from the other six areas will be reported in ..;obcr. conclusions: total quality management, good governance and social mobilization principles and skills are useful and relevant for helping municipal teams focus on strategic interventions to address complex and overwhelming determinants of health at the municipal level. the prolead training programmes hopes to inform other processes for building health promotion leadership capacity for new urban settings. the impact of city living and urbanization on the health of citizens in developing countries has received increasing attention in recent years. urban areas contribute largely to national economies. however, rapid and unplanned urban growth is often associated with poverty, environmental degradation and population demands that outstrip service capacity which conditions place human health at risk. local and national governments as well as multi national organizations are all grappling with the challenges of urbanization. with limited data and information available, urban health characteristics, including the types, quantities, locations and sources in kampala, are largely unknown. moreover, there is n? basis for assessing the impact of the resultant initiatives to improve health ~onditions amo~g ~o": ": um ties settled in unplanned areas. since urban areas are more than the aggregation ?f ~?pie w~th md_ v dual risk factors and health care needs, this paper argues that factors beyond the md v dual, mcludmg the poster sessions v · i d h · i · ment and systems of health and social services are determinants of the health soc a an p ys ca environ . of urban populations. however, as part of an ongoing study? ~s pape~ .addresses the basic concerns of urban health in kampala city. while applying the "urban hvmg conditions and the urban heal~ pen· alty" frameworks, this paper use aggregated urban health d~ta t~ explore the role of place an~ st tu· tions in shaping health and well-being of the population m kampala by understanding how characteristics of the urban environment and specific features of the city are causally related to health of invisible and forgotten urban poor population: results i~dica~e that a .range o~ urb~n he~l~h hazards m the city of kampala include substandard housing, crowdmg, mdoor air poll.ut on, msuff c ent a~d con· taminated water, inadequate sanitation and solid waste management services, vector borne .diseases, industrial waste increased motor vehicle traffic among others. the impact of these on the envtronment and community.health are mutually reinforcing. arising out of the withdra"'.al of city pl~nning systems and service delivery systems or just planning failure, thousands of people part cularl~ low-mc~me groups have been pushed to the most undesirable sections of the city where they are faced with ~ va_r ety ~f envj· ronmental insults. the number of initiatives to improve urban health is, however, growing mvolvjng the interaction of many sectors (health, environment, housing, energy, transportation and urban planning) and stakeholders (local government, non governmental organizations, aid donors and local community groups). key words: urban health governance, health risks, kampala. introduction: the viability of urban communities is dependent upon reliable and affordable mass transit. in particular, subway systems play an especially important role in the mass transit network, since they provide service to vast numbers of ridersseven of the subway systems worldwide report over one billion passenger rides each year. surprisingly, given the large number of people potentially affected, very little is known about the health and safety hazards that could affect both passengers and transit workers; these include physical (e.g., noise, vibration, accidents, electrified sources, temperature extremes), biological (e.g., transmission of infectious diseases, either through person-to-person spread or vector-borne, for example, through rodents), chemical (e.g., exposure to toxic and irritant chemicals and metals, gas emissions, fumes), electro-magnetic radiation, and psychosocial (e.g., violence, workstress). more recently, we need to consider the threat of terrorism, which could take the form of a mass casualty event (e.g., resulting from conventional incendiary devices), radiological attack (e.g., "dirty bomb"), chemical terrorist attack (e.g., sarin gas), or bioterrorist attack (e.g., weapons grade anthrax). given the large number of riders and workers potentially at risk, the public health implications are considerable. methods: to assess the hazards associated with subways, a structured review of the (english) litera· ture was conducted. ruults: based on our review, non-violent crime, followed by accidents, and violent crimes are most prevalent. compared to all other forms of mass transit, subways present greater health and safety risks. however, the rate of subway associated fatalities is much lower than the fatality rate associated with automobile travel ( . vs. . per million passenger miles), and cities with high subway ridership rates have a % lower per capita rate of transportation related fatalities than low ridership cities ( . versus . annual deaths per , residents). available data also suggest that subway noise levels and levels of air pollutants may exceed recommended levels. . ~: there is a paucity of published research examining the health and safety hazards associated with subways. most of the available data came from government agencies, who rely on passively reported data. research is warranted on this topic for a number of reasons, not only to address important knowled~ gaps, but also because the population at potential risk is large. importantly, from an urban perspecnve, the benefits of mass transit are optimized by high ridership ratesand these could be adversely affu:ted by unsafe conditions and health and safety concerns. veena joshi, jeremy lim. and benjamin chua ~ ~rban health issues have moved beyond infectious diseases and now centre largely on chrome diseases. diabetes is one of the most prevalent non-communicable diseases globally. % of adult ¥ benefit in providing splash pads in more parks. given the high temperature and humidity of london summers, this is an important aspect and asset of parks. interviewed parents claimed to visit city parks anywhere between to days per week. corrduion: given that the vast majority of canadian children are insufficiently active to gain health benefits, identifying effective qualities of local parks, that may support and foster physical activity is essential. strategies to promote activity within children's environments are an important health initiative. the results from this study have implications for city planners and policy makers; parents' opinions of, and use of city parks provides feedback as to the state current local parks, and modifications that should be made for new ones being developed. this study may also provide important feedback for health promoters trying to advocate for physical activity among children. introdt clion: a rapidly increasing proportion of urban dwellers in africa live below the poverty line in overcrowded slums characterized by uncollected garbage, unsafe water, and deficient sanitation and overflowing sewers. this growth of urban poverty challenges the commonly held assumption that urban populations enjoy better health than their rural counterparts. the objectives of this study are (i) to compare the vaccination status, and morbidity and mortality outcomes among children in the slums of nairobi with rural kenya, and (ii) to examine the factors associated with poor child health in the slums. we use data from demographic and health survey representative of all slum settlements in nairobi city carried out in by the african population & health research center. a total of , women aged - from , households were interviewed. our sample consists of , children aged - months. the comparison data are from the kenya demographic and health survey. the outcomes of interest include child vaccination status, morbidity (diarrhea, fever and cough) and mortality, all dichotomized. socioeconomic, environmental, demographic, and behavioral factors, as well as child and mother characteristics, are included in the multivariate analyses. multilevel logistic regression models are used. l'nlimin ry rest lts: about % of children in the slums had diarrhea in the two weeks prior to the survey, compared to % of rural children. these disparities between the urban poor anj the rural residents are also observed for fever ( % against %), cough ( % versus %), infant mortality ( / against / ), and complete vaccination ( % against %). preliminary multivariate results indicate that health service utilization and maternal education have the strongest predictive power on child morbidity and mortality in the slums, and that household wealth has only minor, statistically insignificant effects. conclruion: the superiority of health of urban children, compared with their rural counterparts, masks significant disparities within urban areas. compared to rural residents, children of slum dwellers in nairobi are sicker, are less likely to utilize health services when sick, and stand greater risk to die. our results suggest policies and programs contributing to the attainment of the millennium development goal on child health should pay particular attention to the urban poor. the insignificance of socioeconomic status suggests that poor health outcomes in these communities are compounded by poor environmental sanitation and behavioral factors that could partly be improved through female education and behavior change communication. introduction: historic trade city surat with its industrial and political peace has remained a center of attraction for people from all the comers of india resulting in to pop.ulatio~ explosio~ a~d stressed social and service infrastructure. the topography,dimate and demographic profile of the city s threat to the healthy environment. aim of this analysis is to review the impact of managemt'nt reform on health indicators. method: this paper is an analysis of the changing profile of population, sanitary infr~s~rucrure, local self government management and public health service reform, secondary health stat st cs data, health indicator and process monitoring of years. . . health of entire city and challenge to the management system. plague outbr~ak ( ) was the turning point in the history of civic service management including p~blic ~e~lth service management. ~ocal self government management system was revitalized by reg~lar_ field v s ts o~ al~ cadre~, _decentraltzanon of power and responsibility, equity, regular vigilant momtormg, commumcanon facility, ream_approach and people participation. reform in public health service management was throu_gh stan~~rd zed intervention protocol, innovative intervention, public private partnership, community part c panon, academic and service institute collaboration and research. sanitation service coverage have reached nearer to universal. area covered by safe water supply reached to %( ) from % ( ) and underground drainage to % ( ) from % ( ) the overhauling of the system have reflected on health indicators of vector and water born disease. malaria spr declined to . ( ) from . 'yo(! ) and diarrhea case report declined to ( ) from ( ). except dengue fever in no major disease outbreaks are reported after . city is recipient of international/national awards/ranking for these achievements. the health department have developed an evidence and experience based intervention and monitoring system and protocol for routine as well as disaster situation. the health service and management structure of surat city have emerged as an urban health model for the country. introduction: the center for healthy communities (chc) in the department of family and com· munity medicine at the medical college of wisconsin developed a pilot project to: ) assess the know· ledge, attitudes, and behaviors of female milwaukee public housing residents related to breast cancer; develop culturally and literacy appropriate education and screening modules; ) implement the developed modules; ) evaluate the modules; and ) provide follow-up services. using a community-based participatory research model the chc worked collaboratively with on-site nurse case management to meet these objectives. methods: a "breast health kick off event" was held at four separate milwaukee public housing sites for elderly and disabled adults. female residents were invited to complete a -item breast health survey, designed to accommodate various literacy levels. responses were anonymous and voluntary. the survey asked women about their previous physical exams for breast health, and then presented a series of state· ments about breast cancer to determine any existing myths. the final part gathered information about personal risk for breast cancer, the highest level of education completed, and whether the respondents h;td ever used hormone replacement therapy and/or consumed alcohol. responses were collected for descriptive analysis. results: a total of surveys (representing % of the total female population in the four sites) were completed and analyzed. % reported that they had a physical exam in the previous rwo years. % of respondents indicated they never had been diagnosed with breast cancer. % reported having had a mammogram and % having had a clinical breast exam. those that never had a mammogram reported a fear of what the provider would discover or there were not any current breast problems ro warrant an exam. % agreed that finding breast cancer early could lower the chance of dying of cancer. over % reported that mammograms were helpful in finding cancer. however, % believed that hav· ing a mammogram actually prevents breast cancer. % indicated that mammograms actually cause cancer and % reported that a woman should get a mammogram only if there is breast cancer in her family. conclusion: this survey indicates that current information about the importance of mammograms and clinical breast exams is reaching traditionally underserved women. yet there are still critical oppor· tunities to provide valuable education on breast health. this pilot study can serve as a tool for shaping future studies of health education messages for underserved populations. located in a yourh serv· ~ng agency m downtow~ ottawa, the clinic brings together community partners to provide primary medical care. and dent~i hygiene t? the street youths of ottawa aged - . the primary goal of the project is to provide accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. these efforts respond to the pre-existing body of evidence suggesting that the principle barrier in accessing such care for these youths are feelings of intimidation and vulnerability in the face of a complex healthcare system. the bruyere fhn satellite clinic is located in the basement of a downtown drop-in and brings together a family medicine physician and her residents, a dental hygienist and her nd year students, a nurse practitioner, a chiropodist and public health nurses to provide primary care. the clinic has been extremely busy and well received by the youth. this workshop will demonstrate how five community organizations have come together to meet the needs of high risk youths in ottawa. this presentation will showcase the development of the clinic from its inception through its first year including reaction of the youths, partnerships and lessons learned. it will also focus on its sustainability without continued funding. we hope to have developed a model of service delivery that could be reproduced and sustained in other large cities with faculties of medicine. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative-a) semi structured interviews with providers & partners b)focus groups with youth quantitative a)electronic medical records for months records (budget, photos, project information). results: ) successfully built and opened a medicaudental clinic which will celebrate its year anniversary in august. ) over youths have been seen, and we have had over visits. conclusion: ) the clinic will continue to operate beyond the month project funding. ) the health of high risk youth in ottawa will continue to improve due to increased access to medical services. p - (a) health services -for the citizens of bangalore -past, present and future savita sathyagala, girish rao, thandavamurthy shetty, and subhash chandra bangalore city, the capital of karnataka with . million is the th most populous city in india; supporting % of the urban population of karnataka, it is considered as one of the fastest growing cities in india. known as the 'silicon valley of india', bangalore is nearly years old. bangalore city corporation (bmp), is a local self government and has the statutory commitment to provide to the citizens of bangalore: good roads, sanitation, street lighting, safe drinking water apart from other social obligations, cultural development and poverty alleviation activities. providing preventive and promotive heahh services is also a specific component. the objective of this study was to review the planning process with respect to health care services in the period since india independence; the specific research questions being what has been the strategies adopted by the city planners to address to the growing needs of the population amidst the background of the different strategies adopted by the country as a whole. three broad rime ranges have been considered for analysis: the s, s and the s. the salient results are: major area of focus has been on the maternal and child care with activities ranging from day-care to in-patient-care; though the number of institutions have grown from to the current day , their distribution has been far from satisfactory; obtaining support from the india population projects and major upgradarions have been undertaken in terms of infrastructure; over the years, in addition to the dispensaries of modern system of medicine, local traditional systems have also been initiated; the city has partnered with the healthy cities campaign with mixed success; disease surveillance, addressing the problems related to the emerging non-communicable diseases including mental health and road traffic injuries are still in its infancy. isolated attempts have been made to address the risks groups of elderly care and adolescent care. what stands out remarkably amongst the cities achievements is its ability to elicit participation from ngos, cbos and neighbourhood groups. however, the harnessing of this ability into the health sector cannot be said totally successful. the moot question in all the above observed development are: has the city rationally addressed it planning needs? the progress made so far can be considered as stuttered. the analysis and its presentation would identify the key posirive elements in the growth of banglore city and spell a framework for the new public health. introduction: anaemia associated with pregnancy is a major public health problem all over the world. different studies in different parts of india shown prevalence of anaemia between - %. anaemia remains a serious health problem in pregnancy despite of strong action taken by the government of india through national programmes. in the present study we identified th~ social beha~iors, responsible for low compliance of if a tablets consumption in pregnancy at community level and intervention was given with new modified behaviors on trial bases. . in vadodara urban. anganwadies out of were selected from the list by random sampling for tips (trials of improved practices) study. . . participants: pregnant women ( , intervention group+ , control. group) registered m the above anganwadies. study was conducted in to three phases: phase: . formative research and baseline survey (frbs). data was collected from all pregnant women to identify behaviors that are responsible for low compliance of ifa tablets. both qualitative and quantitative data were collected. haemoglobin was estimated of all pregnant women by haemo-cue. phase: . phase of tips. behaviors were identified both social & clinical for low compliance of ifa tablets consumption in pregnancy from frbs and against those, modified behaviors were proposed to pregnant women in the intervention group on trial bases by health education. trial period of weeks was given for trial of new behaviors to pregnant women in the interven· tion group. phase: . in this phase, feedbacks on behaviors tried or not tried were taken from pregnant women in intervention group. haemoglobin estimation was carried out again in all pregnant women. at the end of the study, messages were formulated on the bases of feedbacks from the pregnant women. results: all pregnant women in the intervention group had given positive feedback on new modified behaviors after intervention. mean haemoglobin concentration was higher in intervention group ( . ± . gm%) than control group ( . ± . gm%). ifa tablets compliance was improved in intervention group ( . %) than control group ( . %). conclusion: all pregnant women got benefits after trial of new modified behaviors in the intervention group. messages were formulated from the new modified behaviors, which can be used for longterm strategies for anaemia control in the community. introduction: in order to develop a comprehensive mch handbook for pregnant women and to assess its effect among them, a pilot study was carried out at the maternal and child health training institute (mchti), in dhaka, bangladesh. methods: from mchti a sample of pregnant women was selected and all subjects were women who were attending the first visit of their current pregnancy by using a random sampling method. of the subjects, women were given the mch handbook as case and women were not given the handbook as control. data on pre and post intervention of the handbook from the cases and controls were taken from data recording forms between the st of november and st of october, and data was analysed by using a multilevel analysis approach. this was a hospital-based action (case-control) research, and was applied in order to measure the outcome of pre and post intervention following the introduction of the handbook. data was used to assess the effects of utilisation of the handbook on women's knowledge, practice and utilisation of mch services. results: this study showed that the change of knowledge about antenatal care visits was . % among case mothers. knowledge of danger signs improved . %, breast feeding results . %, vaccination . % and family planning results improved . % among case. results showed some positive changes in women's attitudes among case mothers and study showed the change of practice in antenatal care visits was .u. % in the case. other notable changes were: change of practice in case mother's tetanus toxoid (ti), . %; and family planning . %. in addition, handbook assessment study indicated that most women brought the handbook on subsequent visits ( . %), the handbook was highly utilised (i.e. it was read by . %, filled-in by . %, and was used as a health education tool by . %). most women kept the handbook ( . %) and found it highly useful ( . %) with a high client satisfaction rate of . %. conclusion: pregnant women in the case group had higher knowledge, better practices, and higher utilisation of mch services than mothers in the control groups who used alternative health cards. if the handbook is developed with a focus on utilising a problem-oriented approach and involving the recomendations .of end~users, it is anticipated that the mch handbook will contribute significantly to ensuring the quahry of hfe of women and their children in bangladesh. after several meetmgs to identify the needs of the community, a faso clinic was opened at ncfs. health care professionals from smh joined with developmental and social service workers from ncfs to implement the faso diagnostic process and to provide culturally appropriate after-care. the clinic is unique in that its focus is the high risk urban aboriginal population of toronto. it accepts referrals of not only children and youth, but also of adults. lessons learned: response to the faso clinic at native child and family services has been overwhelming. aboriginal children with f asd are receiving timely diagnosis and interventions. aboriginal youth and adults who have been struggling with poveny, substance abuse, and homelessness are more willing to enter the ncfs centre for diagnosis and treatment. aboriginal infants prenatally exposed to alcohol born at st. michael's hospital or referred by other centres have access to the developmental programs located in both of the partnering agencies. the presentation will describe the clinic's development, and will detail the outcomes described, including interventions unique to the aboriginal culture. p - (c) seeds, soil, and stories: an exploration of community gardening in southeast toronto carolin taran, sarah wakefield, jennifer reynolds, and fiona yeudall introduction: community gardens are increasingly seen as a mechanism for improving nutrition and increasing food security in urban neighbourhoods, but the evidence available to support these claims is limited. in order to begin to address this gap in a way that is respectful of community knowledge and needs, the urban gardening research opportunities workgroup (ugrow) project explored the benefits and potential risks of community gardening in southeast toronto. the project used a community-based research (cbr) model to assess community gardens as a means of improving local health. the research process included interviews, focus groups, and participant observation (documented in field notes). we also directly engaged the community in the research process, through co-learning activities and community events which allowed participants to express their views and comment on emerging results. most of the research was conducted by a community-based research associate, herself a community gardener. key results were derived from these various sources through line-by-line coding of interview transcripts and field note review, an interactive and iterative process which involved both academic and community partners. results: these various data sources all suggest that enhanced health and access to fresh produce are important components of the gardening experience. they also highlight the central importance of empowering and community-building aspects of gardening to gardeners. community gardens were thought to play a role in developing friendships and social support, sharing food and other resources, appreciating cultural diversity, learning together, enhancing local place attachment and stewardship, and mobilizing to solve local problems (both inside and outside the garden). potential challenges to community gardens as a mechanism for communiry development include bureaucratic resistance to gardens, insecure land tenure and access, concerns about soil contamination, and a lack of awareness and under· standing by community members and decision-makers of all kinds. conclusion: the results highlight many health and broader social benefits experienced by commu· nity gardeners. they also point to the need for greater support for community gardening programs, par· ticularly ongoing the ongoing provision of resources and education programs to support gardens in their many roles. this research project is supported by the wellesley central health corporation and the centre for urban health initiatives, a cihr funded centre for research development hased at the univer· sity of toronto. p - (c) developing resiliency in children living in disadvantaged neighbourhoods sarah farrell, lorna weigand, and wayne hammond the traditional idea of targeting risk reduction by focusing on the development of eff~ctive coping strategies and educational programs has merit in light of the research reportmg_ that_ ~ lupl.e forms of problem behaviour consistently appear to be predicted by increasing exposure to den_uf able risk factors. as a result, many of the disadvantaged child and youth studies have focused on trymg to better _unde.r· stand the multiple risk factors that increase the likelihood of the development of at nsk behaviour m ch ldren/youth and the potential implications for prevention. this in turn has led t_o. the conclus on that community and health programs need to focus on risk reduction by helpm~ md v duals develop more effective coping strategies and a better understanding of the limitations of cenam pathologies, problematic v poster sessions coping behaviours and risk factors potentially inheren~ in high needs co~unities. ~owever, another ai:ea of research has proposed that preventative interventions should cons de~ .~rotecnve fa~ors alo~~ with reducing risk factors. as opposed to just emphasizing problems, vulnerab ht es, and deficits, a res liencybased perspective holds the belief that children, youth and their families. have strengths, reso~ce.s and the ability to cope with significant adversity in ways that are not only effective, but tend to result m mcreased ability to constructively respond to future adversity. with this in mind, a participatory research project sponsored by the united way of greater toronto was initiated to evaluate and determine the resiliency profiles of children - years (n = ) of recent immigrant families living in significantly disadvantaged communities in the toronto area. the presentation will provide an overview of the identified protective factors (both intrinsic and extrinsic) and resiliency profiles in an aggregated format as well as a summary of how the children and their parents interpreted and explained these strength-based results. as part of the focus groups, current community programs and services were examined by the participants as to what might be best practices for supporting the development and maintaining of resiliency in children, families and communities. it was proposed that the community model of assessing resiliency and protective factors as well as proposed best strength-based practice could serve as a guide for all in the community sector who provide services and programs to those in disadvantaged neighbourhoods. p - (c) naloxone by prescription in san francisco, ca and new york, ny emalie huriaux the harm reduction coalition's overdose project works to reduce the number of fatal overdoses to zero. located in new york, ny and san francisco, ca, the overdose project provides overdose education for social service providers, single-room occupancy hotel (sro) residents, and syringe exchange participants. the project also conducts an innovative naloxone prescription program, providing naloxone, an opiate antagonist traditionally administered by paramedics to temporarily reverse the effects of opiate overdose, to injection drug users (idus). we will describe how naloxone distribution became a reality in new york and san francisco, how the project works, and our results. the naloxone prescription program utilizes multiple models to reach idus, including sro-and street-based trainings, and office-based trainings at syringe exchange sites. trainings include information on overdose prevention, recognition, and response. a clinician conducts a medical intake with participants and provides them with pre-filled units of naloxone. in new york, funding was initially provided by tides foundation. new york city council provides current funding. new york department of mental health and hygiene provides program oversight. while the new york project was initiated in june , over half the trainings have been since march . in san francisco, california endowment, tides foundation, and san francisco department of public health (sfdph) provide funding. in addition, sfdph purchases naloxone and provides clinicians who conduct medical intakes with participants. trainings have been conducted since november . to date, nearly individuals have been trained and provided with naloxone. approximately of them have returned for refills and reported that they used naloxone to reverse an opiate-related overdose. limited episodes of adverse effects have been reported, including vomiting, seizure, and "loss of friendship." in new york, individuals have been trained and provided with naloxone. over overdose reversals have been reported. over half of the participants in new york have been trained in the south bronx, the area of new york with the highest rate of overdose fatalities. in san francisco, individuals have been trained and provided with naloxone. over overdose reversals have been reported. the majority of the participants in san francisco have been trained in the tenderloin, th street corridor, and mission, areas with the highest rates of overdose fatalities. the experience of the overdose project in both cities indicates that providing idus low-threshold access to naloxone and overdose information is a cost-effective, efficient, and safe intervention to prevent accidental death in this population. p - (c) successful strategies to regulate nuisance liquor stores using community mobilization, law enforcement, city council, merchants and researchers tahra goraya presenta~ion _will discuss ~uccessful environmental and public policy strategies employed in one southen: cahf?rmna commumty to remedy problems associated with nuisance liquor stores. participants ~ be given tools to understand the importance of utilizing various substance abuse prevention str~tegi~ to change local policies and the importance of involving various sectors in the community to a~_ st with and advocate for community-wide policy changes. recent policy successes from the commultles of pa~ad~na and altad~na will highlight the collaborative process by which the community mobilized resulnng m several ordmances, how local law enforcement was given more authority to monitor poster sessions v nonconforming liquor stores, how collaborative efforts with liquor store owners helped to remove high alcohol content alcohol products from their establishments and how a community-based organiz,uion worked with local legislators to introduce statewide legislation regarding the regulation of nuisance liquor outlets. p - (c) "dialogue on sex and life": a reliable health promotion tool among street-involved youth beth hayhoe and tracey methven introduction: street involved youth are a marginalized population that participate in extremely risky behaviours and have multiple health issues. unfortunately, because of previous abuses and negative experiences, they also have an extreme distrust of the adults who could help them. in , toronto public health granted funding to a non governmental, nor for profit drop-in centre for street youth aged - , to educate them about how to decrease rhe risk of acquiring hiv. since then the funding has been renewed yearly and the program has evolved as needed in order to target the maximum number of youth and provide them with vital information in a candid and enjoyable atmosphere. methods: using a retrospective analysis of the six years of data gathered from the "dialogue on sex and life" program, the researchers examined the number of youth involved, the kinds of things discussed, and the number of youth trained as peer leaders. also reviewed, was written feedback from the weekly logs, and anecdotal outcomes noted by the facilitators and other staff in the organization. results: over the five year period of this program, many of youth have participated in one hour sessions of candid discussion regarding a wide range of topics including sexual health, drug use, harm reduction, relationship issues, parenting, street culture, safety and life skills. many were new youth who had not participated in the program before and were often new to the street. some of the youth were given specific training regarding facilitation skills, sexual anatomy and physiology, birth control, sexually transmitted infections, hiv, substance use/abuse, harm reduction, relationships and discussion of their next steps/future plans following completion of the training. feedback has been overwhelmingly positive and stories of life changing decisions have been reported. conclusion: clearly, this program is a successful tool to reach street involved youth who may otherwise be wary of adults and their beliefs. based on data from the evaluation, recommendations have been made to public health to expand the funding and the training for peer leaders in order ro target between - new youth per year, increase the total numbers of youth reached and to increase the level of knowledge among the peer leaders. p - (c) access to identification and services jane kali replacing identification has become increasingly more complex as rhe government identification issuing offices introduce new requirements rhar create significant barriers for homeless people to replace their id. new forms of identification have also been introduced that art' not accessible to homekss peoplt-(e.g. the permanent resident card). ar rhe same time, many service providers continue to require identifi· cation ro access supports such as income, housing, food, health care, employment and employmt·nt training programs. street health, as well as a number of other agencies and community health centres, h, , been assisting with identification replacement for homeless peoplt· for a number of years. the rnrrt·nr challenges inherent within new replacement requirements, as well as the introduction of new forn ' of identification, have resulted in further barriers homeless people encounter when rrring to access t:ssential services. street health has been highlighting these issues to government identification issuing offices, as well as policy makers, in an effort to ensure rhar people who are homeless and marginalized have ac'ess to needed essential services. bandar is a somali word for •·a safe place." the bandar research project is the product of the regent park community health centre. the research looks ar the increasing number of somali and afri· can men in the homeless and precariously house population in the inner city core of down~own toronto. in the first phase of the pilot project, a needs assessment was conducted to dennfy barners and issues faced by rhe somali and other african men who are homeless and have add cr ns issues. th_e second phase of rhe research project was to identify long rerm resources and service delivery mechamsms that v poster sessions would enhance the abiity of this population to better access detox, treatment, and post treatment ser· vices. the final phase of the project was to facilitate the development of a conceptual model of seamless continual services and supports from the streets to detox to treatment to long term rehabilitation to housing. "between the pestle and mortar" -safe place. p - (c) successful methods for studying transient populations while improving public health beth hayhoe, ruth ewert, eileen mcmahon, and dan jang introduction: street youth are a group that do not regularly access healthcare because of their mis· trust of adults. when they do access health care, it is usually for issues severe enough for hospitalization or for episodic care in community clinics. health promotion and illness prevention is rarely a part of their thinking. thus, standard public health measures implemented in a more stable population do not work in this group. for example, pap tests, which have dearly been shown to decrease prevalence of cer· vical cancer, are rarely done and when they are, rarely followed up. methods to meet the health care needs and increase the health of this population are frequently being sought. methods: a drop-in centre for street youth in canada has participated in several studies investigating sexual health in both men and women. we required the sponsoring agencies to pay the youth for their rime, even though the testing they were undergoing was necessary according to public health stan· dards. we surmised that this would increase both initial participation and return. results: many results requiring intervention have been detected. given the transient nature of this population, return rates have been encouraging so far. conclusion: it seems evident that even a small incentive for this population increases participation in needed health examinations and studies. it is possible that matching the initial and follow-up incentives would increase the return rate even further. the fact that the youth were recruited on site, and not from any external advertising, indicates that studies done where youth trust the staff, are more likely to be successful. the presentation will share the results of the "empowering stroke prevention project" which incor· porated self-help mutual aids strategies as a health promotion methodology. the presentation will include project's theoretical basis, methodology, outcomes and evaluation results. self-help methodology has proven successful in consumer involvement and behaviour modification in "at risk," "marginalized" settings. self-help is a process of learning with and from each other which provides participants oppor· tunities for support in dealing with a problem, issue, condition or need. self-help groups are mechanisms for the participants to investigate existing solutions and discover alternatives, empowering themselves in this process. learning dynamic in self-help groups is similar to that of cooperative learning and peertraining, has proven successful, effective and efficient (haller et al, ) . the mutual support provided by participation in these groups is documented as contributory factor in the improved health of those involved. cognizant of the above theoretical basis, in the self-help resource centre initiated the "empowering stroke prevention project." the project was implemented after the input from health organizations, a scan of more than resources and an in-depth analysis of risk-factor-specific stroke prevention materials indicated the need for such a program. the project objectives were:• to develop a holistic and empowering health promotion model for stroke prevention that incorporates selfhelp and peer support strategies. • to develop educational materials that place modifiable risk factors and lifestyle information in a relevant context that validates project participants' life experiences and perspectives.• to educate members of at-risk communities about the modifiable risk factors associated with stroke, and promote healthy living. to achieve the above, a diverse group of community members were engaged as "co-editors" in the development of stroke prevention education materials which reflected and validated their life experiences. these community members received training to become lay health promoters (trained volunteer peer facilitators). in collaboration with local health organizations, these trained lay health promoters were then supported in organizing their own community-based stroke prevention activities. in addition, an educational booklet written in plain language, entitled healthy ways to prevent stroke: a guide for you, and a companion guide called healthy ways to pre· vent stroke: a facilitator's guide were produced. the presentation will include the results of a tw<>tiered evaluation of the program methodology, educational materials and the use of the materials beyond the life of the project. this poster presentation will focus on the development and structure of an innovative street outreach service that assists individuals who struggle mental illness/addictions and are experiencing homelessness. the mental health/outreach team at public health and community services (phcs) of hamilton, ontario assists individuals in reconnecting with health and social services. each worker brings to the ream his or her own skills-set, rendering it extremely effective at addressing the multidimensional and complex needs of clients. using a capacity building framework, each ream member is employed under a service contract between public health and community services and a local grassroots agency. there are public health nurses (phn), two of whom run a street health centre and one of canada's oldest and most successful needle exchange programs, mental health workers, housing specialists, a harm reduction worker, youth workers, and a united church minister, to name a few. a community advisory board, composed of consumers and professionals, advises the program quarterly. the program is featured on raising the roors 'shared learnings on homelessness' website at www.sharedlearnings.ca. through our poster presentation participants will learn how to create effective partnerships between government and grassroots agencies using a capacity building model that builds on existing programs. this study aims to assess the effects of broadcasting a series of documentary and drama videos, intended to provide information about the bc healthguide program in farsi, on the awareness about and the patterns of the service usage among farsi-speaking communities in the greater vancouver area. the major goals of the present study were twofold; ( ) to compare two methods of communications (direct vs. indirect messages) on the attitudes and perceptions of the viewers regarding the credibility of messengers and the relevance of the information provided in the videos, and ( ) to compare and contrast the impact of providing health information (i.e., the produced videos) via local tvs with the same materials when presented in group sessions (using vcr) on participants' attitudes and perceptions cowards the bc healrhguide services. results: through a telephone survey, farsi-speaking adults were interviewed in november and december . the preliminary findings show that % of the participants had seen the aired videos, from which, % watched at least one of the 'drama' clips, % watched only 'documentary' clip, and % watched both types of video. in addition, % of the respondents claimed that they were aware about the program before watching the aired videos, while % said they leaned about the services only after watching the videos. from this group, % said they called the bchg for their own or their "hildren's health problems in the past month. % also indicated that they would use the services in the future whenever it would be needed. % considered the videos as "very good" and thought they rnuld deliver relevant messages and % expressed their wish to increase the variety of subjects (produ\:e more videos) and increase the frequency of video dips. conclusion: the results of this study will assist public health specialists in bc who want to choose the best medium for disseminating information and apply communication interventions in multi\:ultural communities. introduction: many theorists and practitioners in community-based research (cbr) and knowledge transfer (kt) strongly advocate for involvement of potential users of research in the development of research projects, yet few examples of such involvement exist for urban workplace health interventions. we describe the process of developing a collaborative research program. methods: four different sets of stakeholders were identified as potential contributors to and users of the research: workplace health policy makers, employers, trade unions, and health and safety associations. representatives of these stakeholders formed an advisory committee which met quarterly. over the month research development period, an additional meetings were held between resc:ar~h~rs and stakeholders. in keeping with participant observation approaches, field notes of group and md v ~ ual meetings were kept by the two co-authors. emails and telephone calls were also documented. qu~h tative approaches to textual analysis were used, with particular attention paid to collaborattve v poster sessions relationships established (as per cbr), indicators of stakeholders' knowledge utilization (as per kt), and transformations of the proposed research (as per cbr). results: despite initial strong differences of opinion both among stakeho~ders .an~ between stakeholders and researchers, goodwill was noted among all involved. acts of rec~proc ty included mu.rual sharing of assessment tools, guidance on data utilization to stakeho~der orga~ zat ns, and suggestions on workplace recruitment to researchers. stakeholders demonstrated mcreases m concep~ual. un~erstand ing of workplace health e.g. they more commonly discussed more complex,. psychosocial md cators of organizational health. stakeholders made instrumental use of shared materials based on research e.g. adapting their consulting model to more sophisticated dat~ analysis. sta~ehol?~rs recogni_zed the strategic use of their alliance with researchers e.g., transformational leadership trainmg as a~ inducement to improve health and safety among small service franchises. stakeholders helped re-define the research questions, dramatically changed the method of recruitment from researcher cold call to stakeholderbased recruitment, and strongly influenced pilot research designs. owing a great deal to the elaborate joint development process, the four collaboratively developed pilot project submissions which were all successfully funded. conclusion: the intensive process of collaborative development of a research program among stakeholders and researchers was not a smooth process and was time consuming. nevertheless, the result of the collaborative process was a set of projects that were more responsive to stakeholder needs, more feasible for implementation, and more broadly applicable to relevant workplace health problems. introduction: environmental groups, municipal public health authorities and, increasingly, the general public are advocating for reductions in pesticide use in urban areas, primarily because of concern around potential adverse health impacts in vulnerable populations. however, limited evidence of the relative merits of different intervention strategies in different contexts exists. in a pilot research project, we sought to explore the options for evaluating pesticide reduction interventions across ontario municipalities. methods: the project team and a multi-stakeholder project advisory committee (pac), generated a list of potential key informants (kl) and an open ended interview guide. thirteen ki from municipal government, industry, health care, and environmental organizations completed face to face or telephone interviews lasting - minutes. in a parallel process, a workshop involving similar representatives and health researchers was held to discuss the role of pesticide exposure monitoring. minutes from pac meetings, field notes taken during ki interviews, and workshop proceedings were synthesized to generate potential evaluation methods and indicators. results: current evaluation activities were limited but all kls supported greater evaluation effons beginning with fuller indicator monitoring. indicators of education and outreach services were imponant for industry representatives changing applicator practices as well as most public health units and environmental organizations. lndictors based on bylaw enforcement were only applicable in the two cities with bylaws, though changing attitudes toward legal approaches were being assessed in many communities. the public health rapid risk factor surveillance system could use historical baseline data to assess changes in community behaviour through reported pesticide uses and practices, though it had limited penetration in immigrant communities not comfortable in english. pesticide sales (economic) data were only available in regional aggregates not useful for city specific change documentation. testing for watercourse or environmental contamination might be helpful, but it is sporadic and expensive. human exposure monitoring was fraught with ethical issues, floor effects from low levels of exposure, and prohibitive costs. clinical episodes of pesticide exposure reported to the regional poison centre (all ages) or the mother risk program (pregnant or breastfeeding women) are likely substantial underestimates that would be need to be supplemented with sentinel practice surveillance. focus on special clinical populations e.g., multiple chemical sensitivity would require additional data collection efforts . . conc~ons: broad support for evaluation and multiple indicators were proposed, though con-s~raints associate~ with access, coverage, sensitivity and feasibility were all raised, demonstrating the difficulty of evaluating such urban primary prevention initiatives. interventionists. an important aim of the youth monitor is to learn more about the health development of children and adolescents and the factors that can influence this development. special attention is paid to emo· tional and behavioural problems. the youth monitor identifies high-risk groups and factors that are associated with health problems. at various stages, the youth monitor chancrs the course of life of a child. the sources of informa· tion and methods of research are different for each age group. the results arc used to generate various kinds of repons: for children and young persons, parents, schools, neighbourhoods, boroughs and the municipality of rotterdam and its environs. any problems can be spotted early, at borough and neigh· bourhood level, based on the type of school or among the young persons and children themselves. together with schools, parents, youngsters and various organisations in the area, the municipal health service aims to really address these problems. on request, an overview is offered of potentially suitable interventions. the authors will present the philosophy, working method, preliminary effects and future developments of this instrument, which serves as the backbone for the rotterdam local youth policy. social workers to be leaders in response to aging urban populations: the practicum partnership program sarah sisco, alissa yarkony, and patricia volland "'" tliu:tion: across the us, . % of those over live in urban areas. these aging urban popu· lations, including the baby boomers, have already begun encounter a range of heahh and mental hcahh conditions. to compound these effects, health and social service delivery fluciuates in cities, whit:h arc increasingly diverse both in their recipients and their systems. common to other disciplines (medicine, nursing, psychology, etc.) the social work profession faces a shortage of workers who are well-equipped to navigate the many systems, services, and requisite care that this vast population requires. in the next two decades, it is projected that nearly , social workers will be required to provide suppon to our older urban populations. social workers must be prepared to be aging-savvy leaders in their field, whether they specialize in gerontology or work across the life span. mllhotu: in , a study conducted at the new york academy of medicine d<> :umcntcd the need for improved synchroniciry in two aspects of social work education, classroom instruction and the field experience. with suppon from the john a. hanford foundation, our team created a pilot proj~"t entitled the practicum pannership program (ppp) in master's level schools of social work, to improvt" aginr exposure in field and classroom content through use of the following: i) community-university partnrr· ships, ) increased, diverse student field rotations, ll infusion of competcn ."}'·drivm coursework, enhancement of field instructors' roles, and ) concentrated student recruitment. we conductt"d a prr· and post-test survey into students' knowledge, skills. and satisfaction. icarlja: surveys of over graduates and field inltnk."tors rcflected increased numlk-n of . rrm:y· univmity panncrships, as well as in students placed in aging agencin for field placements. there wa marked increase in student commitments to an aging specialization. onr year por.t·gradu:nion rcvealrd that % of those surveyed were gainfully employed, with % employed in the field of aginic. by com· bining curricular enhancement with real-world experiences the ppp instilled a broad exposurr for llu· dents who worked with aging populations in multiple urban settings. coltdtuion: increased exposure to a range of levels of practicr, including clinical, policy/ajvocaq, and community-based can potentially improve service delivery for older adulh who live in elfin, and potentially improve national policy. the hanford foundation has now elected to uppon cxpantion of the ppp to schools nationwide (urban and rural) to complement other domntic initiatives to cnhalk"c" holistic services for older adults across the aging spectrum. bodrgnn.ntl: we arc a team of rcscarcbcn and community panncn working tcj c(her to develop an in"itepth understanding of the mental health needs of homeless youth ~ages to ) (using qualiutivc and quantitative methods ' panicipatory rncarch methods). it is readily apparmt that '-neless youth cxpcricnce a range of mental health problems. for youth living on the street, menul illnew may be either a major risk factor for homelessnal or may frequently emcsge in response to coping with rhe multitudinous stressors associated with homclcslllcsi including exposure to violence, prasutt to pamaplte in v poster sessions survival sex and/or drug use. the most frequent psychiatric diagnoses amongst the homeless gencrally include: depression, anxiety and psychosis. . . . the ultimate ob ective of the pr~am of rei:e~ is to ~evelop a plan for intervention to meet the mental health needs of street youth. prior t_o pl~nnmg mtervenbons, .it is necessary to undertake a comprehensive assessment ~f mental health needs m this ~lnerable populanon. thus, the immediate objective of this research study is to undertake a comprehensive assessment of men· tal health needs. . . melbotlology: a mixed methodology triangulating qualitative, participatory acnon and quantitative methods will capture the data related to mental health needs of homeless youth. a purposive sample of approximately - subjecrs. ages to , is currently being ~ted ~participate from the commu.nity agencies covenant house, evergreen centre fo~ srrc;et youth, turning p? ?t and street ~ serv~. youth living on the street or in short -term residennal programs for a mmimum of month pnor to their participation; ages to and able to give infonned consent will be invited to participate in the study. o..tcomes: the expected outcome of this initial survey will be an increased understanding of mental health needs of street youth that will be used to develop effective interventions. it is anticipated that results from this study will contribute to the development of mental health policy, as well as future programs that are relevant to the mental health needs of street youth. note: it is anticipated that preliminary quantitative data ( subjects) and qualitative data will be available for the conference. the authors intend to present the identification of the research focus, the formation of our community-based team, relevance for policy, as well as preliminary results. p - (a) the need for developing a firm health policy for urban informal worken: the case of despite their critical role in producing food for urban in kenya, urban farmers have largely been ignored by government planners and policymakers. their activity is at best dismissed as peripheral eveo, inappropriate retention of peasant culture in cities and at worst illegal and often some-times criminal· ized. urban agriculture is also condemned for its presumed negative health impact. a myth that contin· ues despite proof to the contrary is that malarial mosquitoes breed in maize grown in east african towns. however, potential health risks are insignificant compared with the benefits of urban food production. recent studies too rightly do point to the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women-headed households. since the millennium declaration, health has emerged as one of the most serious casualties consequent on the poverty, social exclusion, marginalisation and lack of sustain· able development in africa. hiv/aids epidemic poses an unprecedented challenge, while malaria, tuber· culosis, communicable diseases of childhood all add to the untenable burden. malnutrition underpins much ill-health and is linked to more than per cent of all childhood deaths. kenya's urban poor people ~ace ~ h~ge burde~ of preventable and treatable health problems, measured by any social and bi~ medical md cator, which not only cause unnecessary death and suffering, but also undermine econonuc development and damage the country's social fabric. the burden is in spite of the availability of suitable tools and re:c=hnology for prevention and treatment and is largely rooted in poverty and in weak healah •rstems. this pa~ therefore challenges development planners who perceive a dichotomy instead of con· tmuum between informal and formal urban wage earners in so far as access to health services is con· cemed. it i~ this gap that calls for a need to developing and building sustainable health systems among the urban mformal ~wellers. we recommend a focus on an urban health policy that can build and strengthen the capacity of urban dwellers to access health services that is cost-effective and sustainable. such ~ health poli<=>: must strive for equity for the urban poor, displaced or marginalized; mobilise and effect ~ely use sufficient sustainable resources in order to build secure health systems and services. special anenti_on. should ~ afforded hiv/aids in view of the unprecedented challenge that this epidemic poses to africa s economic and social development and to health services on the continent. methods: a review of the literature led us to construct three simple models and a composite model of exposure to traffic. the data were collected with the help of a daily diary of travel activities using a sample of cyclists who went to or come back from work or study. to calculate the distance, the length of journey, and the number of intersections crossed by a cyclist different geographic information systems (gis) were operated. statistical analysis was used to determine the significance between a measure of exposure on the one hand, and the sociodemographic characteristics of the panicipants or their geographic location on the other hand. restlltj: our results indicate that cyclists were significantly exposed to road accidents, no matter of where they live or what are their sociodemographic characteristics. we also stress the point that the fact of having been involved in a road accident was significantly related to the helmet use, but did not reduce the propensity of the cyclists to expose themselves to the road hazards. condlllion: the efforts of the various authorities as regards road safety should not be directed towards the reduction of the exposure of the vulnerable users, but rather towards the reduction of the dangers to which they could face. keywords: cyclist, daily diary of activities, measures of exposure to traffic, island of montreal. p - (a) intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods olumuyiwa akinbamijo intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods abstract urbanization panicularly in nigerian cities, ponends unprecedented crises of grave dimensions. from physical and demographic viewpoints, city growth rates are staggering coupled with gross inabilities to cope with the consequences. environmental and social ills associated with unguarded rapid urbanization characterize nigerian cities and threaten urban existence. this paper repons the findings of a recent study of the relationship between environmental health across inrraurban residential communities of akure, south west nigeria. it discuses the typical urbanization process of nigerian cities and its dynamic spatial-temporal characteristics. physical and socio-demographic attributes as well as the levels and effectiveness of urban infrastructural services are examined across the core residential districts and the elite residential layouts in the town. the incidence rate of cenain environmentally induced tropical diseases across residential neighborhoods and communes is examined. salient environmental variables that are germane to health procurement in the residential districts, incidence of diseases and diseases parasitology, diseases prevention and control were studied. field data were subjected to analysis ranging from the univariate and bivariate analysis. inferential statistics using the chi-square test were done to establish the truthfulness of the guiding hypothesis. given the above, the study affirms that there is strong independence in the studied communities, between the environment and incidence of diseases hence health of residents of the town. this assertion, tested statistically at the district levels revealed that residents of the core districts have very strong independence between the environment and incidences of diseases. the strength of this relationship however thins out towards the city peripheral districts. the study therefore concludes that since most of the city dwellers live in urban deprivation, urban health sensitive policies must be evolved. this is to cater for the urban dwellers who occupy fringe peripheral sites where the extension of facilities often times are illegally done. urban infrastructural facilities and services need be provided as a matter of public good for which there is no exclusive consumption or access even for the poorest of the urban poor. many suffer from low-self esteem, shame and guilt about their drug use. in addition, they often lack suppon or encounter opposition from their panners, family and friends in seeking treatment. these personal barriers are compounded by fragmented addiction, prenatal and social care services, inflexible intake systems and poor communication among sectors. the experience of accessing adequate care between services can be overwhelming and too demanding. the toronto centre for substance use in pregnancy (t-cup) is a unique program developed to minimize barriers by providing kone-stop" comprehensive healthcare. t-cup is a primary care based program located in the department of family medicine at st. joseph\'s health centre, a community teaching hospital in toronto. the interdisciplinary staff provides prenatal and addiction services, case management, as well as care of newborns affected by substance use. regular care plan meetings are held between t-cup, labour and delivery nurses and social workers in the y poster sessions maternity and child care program. t-cup also connects "'.omen with. inpatient treatment programs and community agencies such as breaking the cycle, an on-site counselmg group for pregnant substance users. · f · d d h ith method: retrospective chart review, qualitative patient ~ans action stu ~· an ea care provider surveys are used to determine outcomes. primary outcomes mclude changes m maternal su~tance use, psychosocial status and obstetrical complications (e.g. pre-rupture of membrane, pre-eclampsia, placen· ral abruption and hemorrhage). neonatal measures ~~nsisted of .bir~h pa_rame~ers, length of h~spital st.ay and complications (e.g. feral distress, meconium stammg, resuscitation, aund ce, hypoglycemia, seventy of withdrawal and treatment length). chart review consisted of all t-cup patients who met clinical cri· reria for alcohol or drug dependence and received prenatal and intra-partum care at st. joseph's from october to june . participants in the qualitative study included former and current t-cup patients. provider surveys were distributed on-site and to a local community hospital. raulb: preliminary evaluation has demonstrated positive results. treatment retention and satisfaction rates were high, maternal substance use was markedly reduced and neonatal outcomes have shown to be above those reported in literature. conclusion: this comprehensive, primary care model has shown to be optimal in the management of substance use in pregnancy and for improving neonatal outcomes. future research will focus on how this inexpensive program can be replicated in other health care settings. t-cup may prove to be the optimal model for providing care to pregnant substance users in canada. lntrod ction: cigarette smoking is one of the most serious health problems in taiwan. the prevalence of smoking in is . % in males . % in females aged years and older. although the government of taiwan passed a tobacco hazards control act in , it has not been strongly enforced in many places. therefore, community residents have often reported exposure of second hand smoke. the purpose of the study was to establish a device to build up more smoke-free environments in the city of tainan. methods: unique from traditional intervention studies, the study used a healthy city approach to help build up smoke-free environments. the major concept of the approach is to build up a healthy city platform, including organizing a steering committee, setting up policies and indicators, creating intersectoral collaboration, and increasing community participation. first, more than enthusiastic researchers, experts, governmental officers, city counselors and community leaders in tainan were invited in the healthy city committee. second, smoke-free policies, indicators for smoke-free environments, and mechanisms for inter-departmen· tal inspections were set up. third, community volunteers were recruited and trained for persuading related stakeholders. lastly, both penalties and rewards were used for help build up the environments. raults: aher two-year ( aher two-year ( - execution of the project, the results qualitatively showed that smoke-free environments in tainan were widely accepted and established, including smoke-free schools, smoke-free workpla~es, smoke-free households, smoke-free internet shops, and smoke-free restaurants. smoke~s were. effectively educated not to smoke in public places. community residents including adults and children m the smoke-free communities clearly understand the adverse effects of environmental tobacco smoke and actively participated anti-smoking activities. conclruions: healthy city platform is effective to conquer the barrier of limited anti-smoking rc:sources. nor. only can it enlar:ge community actions for anti-smoking campaigns, but also it can provide par_merships for collaboratjon. by establishing related policies and indicators the effects of smoke· free environments can be susta ·ned a d th · · · ' · n e progression can be monitored m a commuruty. these issues are used ~· oi::c it~ goals, weuha identifies issues that put people's health at risk. presently, team com~u:c: ran ee~tion !earns. (iats) that design integrative solutions ~tesj'°~ g om six to fifteen members. methods in order to establish wo-poster sessions v projects for weuha, the following approach was undertaken: i. a project-polling template was created and sent to all members of the alliance for their input. each member was asked to identify thdr top two population groups, and to suggest a project on which to focus over a - month period for each identified population. . there was a % response to the poll and the top three population groups were identified. data from the toronto community health profile database were utilized to contextualize the information supplied for these populations. a presentation was made to the steering committee and three population-based projects were selected, leaders identified and iats formed. three population-based projects: the population-based projects and health care issues identified are: newcomer prenatal uninsured women; this project will address the challenges faced by providers to a growing number of non-insured prenatal women seeking care. a service model where the barrier of "catchments" is removed to allow enhanced access and improved and co-ordinated service delivery will be pilot-tested. children/obesity/diab etes: using a health promotion model this team will focus on screening, intervention, and promoting healthy lifestyles (physical activity and nutrition) for families as well as for overweight and obese children. seniors health promotion and circle of discharge: this team will develop an early intervention model to assist seniors/family unit/caregivers in accessing information and receiving treatment/care in the community. the circle of discharge initiative will address ways of utilizing community supports to keep seniors in the community and minimize readmissions to acute care facilities. results/expected outcomes: coordinated and enhanced service delivery to identified populations, leading to improved access, improved quality of life, and health care for these targeted populations. introduction: basic human rights are often denied to high-risk populations and people living with hiv/aids. their rights to work and social security, health, privacy, non discrimination, liberty and freedom of movement, marriage and having a family have been compromised due to their sero-positive status and risk of being positive. the spread of hiv/aids has been accelerating due to the lack of general human rights among vulnerable groups. to formulate and implement effective responses needs dialogue and to prevent the epidemic to go underground barriers like stigma need to be overcome. objective: how to reduce the situation of stigma, discrimination and human rights violations experienced by people living with hiv/aids and those who are vulnerable to hiv/aids. methodology and findings: consultation meetings were strm.-rured around presentations, field visits, community meetings and group work to formulate recommendations on how govt and ngos/cbos should move forward based on objective. pakistan being a low prevalence country, the whole sense of compl;u:enc.:y that individuals are not subject to situations of vulnerable to hiv is the major threat to an explosion in th•· epidemic, therefore urgent measures are needed to integrate human rights issues from the very start of the response. the protection and promotion of human rights in an integral component of ;tll responses to the hiv/aids epidemic. it has been recognized that the response to hiv/aios must he multi sectoral and multi faceted, with each group contributing its particular expertise. for this to occur along with other knowlcdg<" more information is required in human rights abuses related to hiv/ aids in a particular scenario. the ~·on sultarion meetings on hiv/aids and human rights were an exemplary effort to achieve the same ohj<..:tivc. recommendations: the need for a comprehensive, integrated and a multi-sectoral appro;u.:h in addressing the issue of hiv/aids was highlighted. the need social, cultural and religious asp•·ct' to he: prominently addressed were identified. it was thought imperative measures even in low prevalence countries. education has a key role to play, there is a need for a code of ethics for media people and h<"alth care providers and violations should be closely monitored and follow up action taken. p - (c) how can community-based funding programs contribute to building community capacity and how can we measure this elusive goal? mary frances maclellan-wright, brenda cantin, mary jane buchanan, and tammy simpson community capacity building is recognized by the public health agency of canada (phac) as an important strategy for improving the overall health of communities by enabling communities to addre~s priority issues such as social and economic determinants of health. in / phac.:, alberta/nwf region's population health fund (phf) supported community-based projects to build community capacity on or across the determinants of health. specifically, this included creating accessible and sup· portive social and physical environments as well as creating tools and processes necessary for healthy policy development and implementation. the objective of this presentation is to highlight how the community capacity building tool, developed by phac ab/nwf region, can demonstrate gains in v poster sessions · · the course of a pror· ect and be used as a reflective tool for project planning and community capacity over . . . . i · a art of their reporting requirements, pro ect sites completed the community caparny eva uanon. s p . . th t i ii i'd d . building tool at the beginning and end of their ~ne-year prorect. e oo ~o ects va an reliable data in the context of community-based health prorects. developed through a vigorous ~nd collabora ve research process, the tool uses plain languag~ to expl~re nine key f~atures o~ commuruty cap~city with 't ch with a section for contextual information, of which also mdude a four-pomt raong ems, ea f fu d · scale. results show an increase in community capacity over the course o the nde prorects. pre and post aggregate data from the one-year projects measure~ statistic.ally si~n~ficant changes for of the scaled items. projects identified key areas of commumty capacity bmldmg that needed strengthemng, such as increasing participation, particularly among people with low incomes; engaging community members in identifying root causes; and linking with community groups. in completing the tool, projects examined root causes of the social and economic determinants of health, thereby exploring social justice issues related to the health of their community. results of the tool also served as a reflec· cion on the process of community capacity building; that is, how the project outcomes were achieved. projects also reported that the tool helped identify gaps and future directions, and was useful as a project planning, needs assessment and evaluation tool. community capacity building is a strategy that can be measured. the community capacity building tool provides a practical means to demonstrate gains in community capacity building. strengthening the elements of community capacity building through community-based funding can serve as building blocks for addressing other community issues. needs of marginalized crack users lorraine barnaby, victoria okazawa, barb panter, alan simpson, and bo yee thom background: the safer crack use coalition of toronto (scuc) was formed in in response to the growing concern for the health and well-being of marginalized crack users. a central concern was the alarm· ing hepatitis c rate ( %) amongst crack smokers and the lack of connection to prevention and health ser· vices. scuc is an innovative grassroots coalition comprised of front-line workers, crack users, researcher! and advocates. despite opposition and without funding, scuc has grown into the largest crack specific harm reduction coalition in canada and developed a nationally recognized sarer crack kit distribution program (involving community-based agencies that provide outreach to users). the success of our coalition derives from our dedication to the issue and from the involvement of those directly affected by crack use. setting: scuc's primary service region is greater toronto, a diverse, large urban centre. much ofour work is done in areas where homeless people, sex trade workers and drug users tend to congregate. recently, scuc has reached out to regional and national stakeholders to provide leadership and education. mandate: our mandate is to advocate for marginalized crack users and support the devdopmentof a com.p.rehensive harm reduction model that addresses the health and social needs facing crack users; and to fac htare the exchange of information between crack users, service providers, researchers, and policy developers across canada. owrview: the proposed workshop will provide participants with an overview of the devdopment of scuc, our current projects (including research, education, direct intervention and consultation), our challenge~ and s~ccesses and the role of community development and advocacy within the coalition. pre-senter~ will consist of community members who have personal crack use experience and front-line work· ers-, sc.uc conducted a community-based research project (toronto crack users perspectives, ) , in w~ich s focus groups with marginalized crack users across toronto were conducted. participants iden· t f ed health and social issues affecti h b · · · d " red . . ng t em, arrsers to needed services, personal strategies, an oue recommendations for improved services. presenters will share the methodology, results and recommen· datmns resulting from the research project. conc/usio": research, field observations and consultations with stakeholders have shown that cradck shmoke~s are at an. increased risk for sexually transmitted infections hiv/aids hepatitis c, tb an ot er serious health issues health · ff, · ' ' · · . · issues a ectmg crack users are due to high risk behavmurs, socio· economic factors, such as homeless d. · · · · d · . . ness, scrsmmat on, unemployment, violence incarceraoons, an soc a so at on, and a lack of comprehe · h i h · ' ns ve ea t and social services targeting crack users. · · sinct · s, owever arge remains a gross underesurnaoon. poster sessions v these are hospital-based reports and many known cases go unreported. however teh case, young age at first intercourse, inconsistent condom use and multiple partnersplace adolescents at high risks for a diverse array of stls, including hiv. about % of female nigerian secondary school students report initiating sexual intercourse before age years. % of nigerian female secondary school students report not using a condom the last time they had sexual intercourse. more than % of urban nigerian teens report inconsistent condom use. methods: adolescents were studied, ages to , from benin city in edo state. the models used were mother-daughter( ), mother -son( ), father -son ( ), and father-daughter( ). the effect of parent-child sexual communicationat baseline on child\'s report of sexual behavior, to months later were studied. greater amounts of sexual risk communication were asociated with markedly fewer episodes of unprotected sexual intercourse, reduced number of sexual partners and fewer episodes of unprotected sexual intercourse. results: this study proved that parents can exert more influence on the sexual knowledge attitudes and practise of their adolescent children through desired practises or rolemodeling, reiterating their values and appropriate monitoring of the adolescents\' behavior. they also stand to provide information about sexuality and various sexual topics. parental-child sexual communication has been found to be particularly influential and has been associated with later onset of sexual initiation among adolescents, less sexual activity, more responsible sexual attitudes including greater condom use, self efficacy and lower self -reported incidence of stis. conclusions: parents need to be trained to relate more effectively with their children/wards about issues related to sex and sexuality. family -based programs to reduce sexual risk-taking need to be developed. there is also the need to carry out cross-ethnicaland cross-cultural studies to identify how parent-child influences on adolescent sexual risk behavior may vary in different regions or countries, especially inthis era of the hiv pandemic. introduction: public health interventions to identify and eliminate health disparities require evidence-based policy and adequate model specification, which includes individuals within a socioecological context, and requires the integration of biosociomedical information. multiple public and private data sources need to be linked to apportion variation in health disparities ro individual risk factors, the health delivery system, and the geosocial environment. multilevel mapping of health disparities furthers the development of evidence-based interventions through the growth of the public health information network (phin-cdc) by linking clinical and population health data. clinical encounter data, administrative hospital data, population socioenvironmental data, and local health policy were examined in a three-level geocoded multilevel model to establish a tracking system for health disparities. nj has a long established political tradition of "home rule" based in elected municipal governments, which are responsible for the well-being of their populations. municipalities are contained within counties as defined by the us census, and health data are linked mostly at the municipality level. marika schwandt community organizers from the ontario coaliti~n again~t pove~, .along ":ith ~edical practitioners who have endorsed the campaign and have been mvolved m prescnbmg special diet needs for ow and odsp recipients, will discuss the raise the rates campaign. the organizati~n has used a special diet needs supplement as a political tool, meeting the urgent needs o.f .poor ~ople m toront~ while raising the issues of poverty as a primary determinant of health and nutrtnous diet as a preventative health mea· sure. health professionals carry the responsibility to ensure that they use all means available to them to improve the health of the individuals that they serve, and to prevent future disease and health conditions. most health practitioners know that those on social assistance are not able to afford nutritious foods or even sufficient amounts of food, but many are not aware of the extra dietary funds that are available aher consideration by a health practitioner. responsible nurse practitioners and physicians cannot, in good conscience, ignore the special needs diet supplement that is available to all recipients of welfare and disabiliry (ow and odsp). a number of toronto physicians have taken the position that all clients can justifiably benefit from vitamins, organic foods and high fiber diets as a preventative health measure. we know that income is one of the greatest predictors of poor health. the special needs diet is a health promotion intervention which will prevent numerous future health conditions, including chronic conditions such as cardiovascular disease, cancer, diabetes and osteoporosis. many communiry health centres and other providers have chosen to hold clinics to allow many patients to get signed up for the supplement at one time. initiated by the ontario coalition against poverty, these clinics have brought together commu· niry organizers, community health centers, health practitioners, and individuals, who believe that poverty is the primary determinant of poor health. we believe that rates must be increased to address the health problems of all people on social assistance, kids, elders, people with hiv/aids -everyone. even in the context of understaffing, it could be considered a priority activity that has potentially important health promotion benefits. many clients can be processed in a two hour clinic. most providers find it a very interesting, rewarding undertaking. in the ontario coalition for social justice found that a toronto family with two adults and two kids receives $ , . this is $ , below the poverty line. p - (c) the health of street youth compared to similar aged youth beth hayhoe and ruth ewert . lntrod~on: street youth are at an age normally associated with good health, but due to their risky ~hav ours and th~ conditions in which they live, they experience health conditions unlike their peer~ an more stable env r~nments. in addition, the majority of street youth have experienced significant physical, sexual ~nd em.ot onal abuse as younger children, directly impacting many of the choices they make around their physical and emotional health. we examined how different their health really is. . , methodl: using a retrospective analysis of the years of data gathered from yonge street mis· ~ • evergreen health centre, the top conditions of youth were examined and compared with national tren~s for similar aged youth. based on knowledge of the risk factors present in the group, rea· sons for the difference were examined. d' ~its: street youth experience more illness than other youth their age and their illnesses can bt . irect t ·~kc~ to the. conditions in which they live. long-term impacts of abus~ contribute to such signif· ~~nt t e t d~slpl air that youth may voluntarily engage in behaviours or lack of self care in the hope at t cir ve~ w perhaps come to a quicker end. concl non: although it has ion b k h th' dy clearly shows d'fi . h g ee~ no~n t at poverty negatively affects health, ~siu be used to make ; erence m t .e health of this particular marginalized population. the infonnanon can relates to th . ecommendatio.ns around public policy that affects children and youth, especially as it e r access to appropriate health care and follow up. p - (cl why do urban children · b gt . tarek hussain an adesh die: how to save our children? the traditional belief that urban child alid. a recent study (dhs d fr r~n are better off than rural children might be no longer v urban migrants are highata th om h c~untn~s i demonstrates that the child survival prospects of rural· er an t ose m their r j · · ·grants. in bangladesh, currently million ~r~ ~ gm and lower than those of urban non-idi million. health of the urban ~ p~e are hvmg m urban area and by the year , it would be so the popu at on s a key a eals that urban poor have the worse h h . concern. recent study on the urban poor rev ea t situation than the nation as a whole. this study shows that infant poster sessions v mortality among the urban poor as per thousand, which are above the rural and national level estimates. the mortality levels of the dhaka poor are well above those of the rest of the city's population but much of the difference in death rates is explained by the experience of children, especially infants. analyzing demographic surveillance data from a large zone of the city containing all sectors of the population, research showed that the one-fifth of the households with the least possessions exhibited u child mortality almost three times as high as that recorded by the rest of the population. why children die in bangladesh? because their parents are too poor to provide them with enough food, clean water and other basic needs to help them avoid infection and recover from illness. researchers believed that girls are more at risk than boys, as mothers regularly feed boys first. this reflects the different value placed on girls and boys, as well as resources which may not stretch far enough to provide for everyone. many studies show that housing conditions such as household construction materials and access to safe drinking water and hygienic toilet facilities are the most critical determinants of child survival in urban areas of developing countries. the present situation stressed on the need for renewed emphasis on maternal and child healthcare and child nutrition programs. mapping path for progress to save our children would need be done strategically. we have the policies on hand, we have the means, to change the world so that every child will survive and has the opportunity to develop himself fully as a healthy human being. we need the political will--courage and determination to make that a reality. p - (c) sherbourne health centre: innovation in healthcare for the transgendered community james read introduction: sherbourne health centre (shc), a primary health care centre located in downtown toronto, was established to address health service gaps in the local community. its mission is to reduce barriers to health by working with the people of its diverse urban communities to promote wellness and provide innovative primary health services. in addition to the local communities there are three populations of focus: the lesbian, gay, bisexual, transgendered and transexual communities (lgbtt); people who are homeless or underhoused; and newcomers to canada. shc is dedicated to providing health services in an interdisciplinary manner and its health providers include nurses, a nurse practitioner, mental health counsellors, health promoters, client-resource workers, and physicians. in january shc began offering medical care. among the challenges faced was how to provide responsive, respectful services to the trans community. providers had considerable expertise in the area of counselling and community work, but little in the area of hormone therapy -a key health service for those who want to transition from one gender to another. method: in preparing to offer community-based health care to the trans community it was clear that shc was being welcomed but also being watched with a critical eye. trans people have traditionally experienced significant barriers in accessing medical care. to respond to this challenge a working group of members of the trans community and health providers was created to develop an overall approach to care and specific protocols for hormone therapy. the group met over a one year period and their work culminated in the development of medical protocols for the provision of hormone therapy to trans individuals. results: shc is currently providing health care to registered clients who identify as trans individuals (march ) through primary care and mental health programs. in an audit of shc medical charts (january to september ) female-to-male (ftm) and male-to-female (mtf) clients were identified. less than half of the ftm group and just over two-thirds of the mtf group presented specifically for the provision of hormones. based on this chart audit and ongoing experience shc continues to update and refine these protocols to ensure delivery of quality care. conclusion: this program is an example of innovative community-based health delivery to a population who have traditionally faced barriers. shc services also include counselling, health promotion, outreach and education. p - (c) healthy cities for canadian women: a national consultation sandra kerr, kimberly walker, and gail lush on march , the national network on environment and women's health held a pan-canadian consultation to identify opportunities for health research, policy change, and action. this consultation also worked to facilitate information sharing and networking between canadian women working as urban planners, policy makers, researchers, and service workers on issues pertaining to the health of women living in canadian cities. methods: for this research project, participants included front-line service workers, policy workers, researchers, and advocates from coast to coast, including francophone women, women with disabilities, racialized women, and other marginalized groups. the following key areas were selected as topics for du.bnes i alto kading .:auk of end·sugr ieaal clileue ia singapore, accounting for more than so% of new can singapore (nkfs) to embark on a prevention program (pp) empo~r d ahc j u f dieir condition bttter, emphasizing education and disease sdf·managemen lkilla a. essennal camponenn of good glycaemic control. we sought explore the effects of a pecialijed edu.:a on pro· pun od glycacmic conuol, as indicated by, serum hba ic values budine serum hba ic values were determined before un<k-rgmng the education progr ;am, which couisted of comprehensive dietary advice, ideal weight goals, and improving lipid profiln. serum hbaic values were obtained ar , , months later to determine impact of the program. analy • wu done uling paired !·tests significant reduction in hba le levels from ro month• was observed in females, chinese race, older age group(> so yean). ohew-ibmi ~ .nwm , wai hip ratio> l),up to primary and above secondary level education and those having om urine iclt showed that increasing hbalc levels ( ) had increasing urmary protein ( .± ; . ±i ih so± ) and crearinine (s .s ± s ± ; ioi± s) levels fbg rnults showed that the management nf d abetn m the nkfs preven· tion programme is effec;rive. results also indicated har hba le leve have a linnr trend wnh unnary protein and creatinine which are imponant determinants of renal diseate tal family-focused cinical palbway promoce politivc outcollln for ua inner city canu allicy ipmai jerrnjm care llctivirits in preparation for an infanr'' dilchargr honlr, and art m endnl lo improve effi.:k'fl.:tn of c.are. lere i paucity of tttran:h, and inconsi trncy of rnulta on ht-•m!*- of f m ly·fc"-'uw d nm a: to determinr whrthrr implrmentation of family.focuted c:pt n ntnn.tt.tl unit w"n mg an inner city ;ommunity drcl't'aki leftarh of lf•y (i.osi and rromclll'i family uo•fkllon and rt. j nest for dikhargr. md odt: family-focuk"d cpi data wm coll«ted for all infant• horn btrwttn and wft"k• t"lal mi atr who wrtt . dm ed to the ntonatal unit lmgdl of -.y . n. . day'o p c o.osi ind pma . d•mr., ho.nr . t . n. . ± i. i wb, p < o.os) wett n« fiamly f.lfrt n the pre.(]' poup. ~ .fxtmon icofn for famihn wrre high. and families noctd thc:y wnr mott prepued to ah thrar t..lby "'-· thett was .a cosi uving of s , (cdn) per patient d teharpd home n the pmi-cp poap c.-pated the p"''lfoup· cortclaion· lmplrmrnr.rion of family·foanrd c:p. in a nrona . i umt tc"fyidi an nnn an com· muniry decre.ned length of'"'" mft with a high dcgrft of family uujamon, and wrre coll~nt at least % percent of the kathmandu population lives in slum like conditions with poor access to basic health services. in these disadvantaged areas, a large proportion of children do not receive treatment due to inaccessibility to medical services. in these areas, diarrhea, pneumonia, and measles, are the key determinants of infant mortality. protein energy malnutrition and vitamin a deficiency persists and communicable diseases are compounded by the emergence of diseases like hiv/aids. while the health challenges for disadvantaged populations in kathmandu are substantial, the city has also experienced various forms of innovative and effective community development health programs. for example, there are community primary health centers established by the kathmandu municipality to deliver essential health services to targeted communities. these centers not only provide equal access to health services to the people through an effective management system but also educate them hy organizing health related awareness programs. this program is considered one of the most effective urban health programs. the paper/presentation this paper will review large, innovative, and effective urhan health programs that are operating in kathmandu. most of these programs are currently run by international and national ngos a) early detection of emerging diseases in urban settings through syndromic surveillance: data pilot study kate bassil of community resources, and without adequate follow-up. in november shelter pr.oviders ~et with hospital social workers and ccac to strike a working group to address some of th~ issues by mcre.asing knowledge among hospital staff of issues surrounding homelessness, and to build a stro?g workmg relationship between both systems in hamilton. to date the hswg has conducted four w~lkmg to~ of downtown shelters for hospital staff and local politicians. recently the hswg launched its ·~ool.k t for staff working with patients who are homeless', which contains community resources and gu dehnes to help with effective discharge plans. a scpi proposal has been submitted to incre~se the capacity of the hswg to address education gaps and opportunities with both shelters and hospitals around homelessness and healthcare. the purpose of this poster presentation is to share hamilton's experience and learnings with communities who are experiencing similar issues. it will provide for intera~tion around shared experiences and a chance to network with practitioners across canada re: best practices. introduction and objectives: canadians view health as the biggest priority for the federal government, where health policies are often based on models that rely on abstract definitions of health that provide little assistance in the policy and analytical arena. the main objectives of this paper are to provide a functional definition of health, to create a didactic model for devising policies and determining forms of intervention, to aid health professionals and analysts to strategize and prioritize policy objectives via cost benefit analysis, and to prompt readers to view health in terms of capacity measures as opposed to status measures. this paper provides a different perspective on health, which can be applied to various applications of health such as strategies of aid and poverty reduction, and measuring the health of an individual/ community/country. this paper aims to discuss theoretical, conceptual, methodological, and applied implications associated with different health policies and strategies, which can be extended to urban communities. essentially, our paper touches on the following two main themes of this conference: •health status of disadvantaged populations; and •interventions to improve the health of urban communities.methodology: we initially surveyed other models on this topic, and extrapolated key aspects into our conceptual framework. we then devised a theoretical framework that parallels simple theories of physkal energy, where health is viewed in terms of personal/societal health capacities and effort components.after establishing a theoretical model, we constructed a graphical representation of our model using selfrated health status and life expectancy measures. ultimately, we formulated a new definition of health, and a rudimentary method of conducting cost benefit analysis on policy initiatives. we end the paper with an application example discussing the issues surrounding the introduction of a seniors program.results: this paper provides both a conceptual and theoretical model that outlines how one can go about conducting a cost-benefit analysis when implementing a program. it also devises a new definition and model for health barred on our concept of individual and societal capacities. by devising a definition for health that links with a conceptual and theoretical framework, strategies can be more logically constructed where the repercussions on the general population are minimized. equally important, our model also sets itself up nicely for future microsimulation modeling and analysis.implications: this research enhances one's ability to conduct community-based cost-benefit analysis, and acts as a pedagogical tool when identifying which strategies provide the best outcome. p - (a) good playgrounds are hard to find: parents' perceptions of neighbourhood parks patricia tucker, martin holmes, jennifer irwin, and jason gilliland introduction: neighbourhood opportunities, including public parks and physical activity or sports fields hav~ been. iden.tified as correlates to physical activity among youth. increasingly, physical activity among children s bemg acknowledged as a vital component of children's lives as it is a modifiable determinant of childh~d obesity. children's use of parks is mainly under the influence of parents; therefore, the purpose of this study was to assess parents' perspectives of city parks, using london ontario as a case study.m~~: this qualitative study targeted a heterogeneous sample of parents of children using local parks w thm london. parents with children using the parks were asked for minutes of their time and if willing, a s.hort interview was conducted. the interview guide asked parents for their opinion 'of city parks, particularly the one they were currently using. a sample size of parents is expected by the end of the summer.results: preliminary findings are identifying parents concern with the current jack of shade in local parks. most parents have identified this as a limitation of existing parks, and when asked what would make the parks better, parents agree that shade is vital. additionally, some parents are recognizing the v poster sessions focused discussions during the consultation: . women in _poverty . women with disability . immi· grant and racialized women . the built and _physica_l environment. . . . . r its· participants voiced the need for integration of the following issues withm the research and policy :::na; t) the intersectional nature of urban women's health i~sues wh~ch reflects the reality of women's complex lives ) the multisectional aspect of urban wo_m~n s health, ss~es, which reflects the diversity within women's lives ) the interse~roral _dynamics within _womens hves and urban health issues. these concepts span multiple sectors -mdudmg health, educat n, and economics -when leveraging community, research, and policy support, and engaging all levels of government.policy jmplicatiom: jn order to work towards health equity for women, plans for gender equity must be incorporated nationally and internationally within urban development initiatives: • reintroduce "women" and "gender" as distinct sectors for research, analysis, advocacy, and action. •integrate the multisectional, intersectional, and intersecroral aspects of women's lives within the framework of research and policy development, as well as in the development of action strategies. • develop a strategic framework to house the consultation priorities for future health research and policy development (for example, advocacy, relationship building, evidence-based policy-relevant research, priority initiatives}.note: research conducted by nnewh has been made possible through a financial contribution from health canada. the views expressed herein do not necessarily represent the views of health canada.p - (c) drugs, culture and disadvantaged populations leticia folgar and cecilia rado lntroducci n: a partir de un proyecto de reducci n de daiios en una comunidad urbana en situ· aci n de extrema vulnerahilidad surge la reflexion sobre el lugar prioritario de los elementos sociocuhurales en el acceso a los servicios de salud de diferentes colectivos urbanos. las "formas de hacer, pensar y sentir" orientan las acciones y delimitan las posibilidades que tienen los individuos de definir que algo es o no problema, asf como tambien los mecanismos de pedido de ayuda. el analisis permanenre del campo de "las culturas cotidianas" de los llamados "usuarios de drogas" aporta a la comprension de la complejidad del tema en sus escenarios reales, y colabora en los diseiios contextualizados de politicas y propuestas socio-sanitarias de intervenci n, tornandolas mas efectivas.mitodos: esta experiencia de investigaci n-acci n que utiliza el merodo emografico identifica elementos socio estructurales, patrones de consumo y profundiza en los elementos socio-simb icos que estructuran los discursos de los usuarios, caracterizandolos y diferenciandolos en tanto constitutivos de identidades socia les que condicionan la implementaci n del programas de reduccion de daiios.resultados: los resultados que presentaremos dan cuenta de las caracteristicas diferenciadas v relaciones particulares ~ntre los consumidores de drogas en este contexto espedfico. a partir de este e~tudio de caso se mtentara co ? enzar a responder preguntas que entendemos significativas a la hora de pensar intcrvcnciones a la med da de poblaciones que comparten ciertas caracteristicas socio-culturales. (cuales serian las .motivaciones para el cambio en estas comunidades?, cque elementos comunitarios nos ayudan a i:nnstnur dema~~a? • cque tenemos para aprender de las "soluciones" que ellos mismos encuenrran a los usos problemat cos? methods: our study was conducted by a team of two researchers at three different sites. the mapping consisted of filling in a chart of observable neighbourhood features such as graffiti, litter, and boarded housing, and the presence or absence of each feature was noted for each city block. qualitative observations were also recorded throughout the process. researchers analyzed the compiled quantitative and qualitative neighbourhood data and then analyzed the process of data collection itself.results: this study reveals the need for further research into the effects of physical environments on individual health and sense of well-being, and perception of investment in neighbourhoods. the process reveals that perceptions of health and safety are not easily quantified. we make specific recommendations about the mapping methodology including the importance of considering how factors such as researcher social location may impact the experience of neighbourhoods and how similar neighbourhood characteristics are experienced differently in various spaces. further, we discuss some of the practical considerations around the mapping exercise such as recording of findings, time of day, temperature, and researcher safety.conclusion: this study revealed the importance of exploring conceptions of health and well-being beyond basic physical wellness. it suggests the importance of considering one's environment and one's own perception of health, safety, and well-being in determining health. this conclusion suggests that attention needs to be paid to the connection between the workplace and the external environment it is situated in. the individual's workday experience does not start and stop at the front door of their workplace, but rather extends into the neighbourhood and environment around them. our procedural observations and recommendations will allow other researchers interested in the effect of urban environments on health to consider using this innovative methodology. introduction: responding ro protests against poor medical attention for sexually assaulted women and deplorable conviction rates for sex offenders, in the late s, the ontario government established what would become over hospital-based sexual assault care and treatment centres (sactcs) across the province. these centres, staffed around the clock with specially trained heath care providers, have become the centralized locations for the simultaneous health care treatment of and forensic evidence collection from sexually assaulted women for the purpose of facilitating positive social and legal outcomes. since the introduction of these centres, very little evaluative research has been conducted to determine the impact of this intervention. the purpose of our study was to investigate it from the perspectives of sexually assaulted women who have undergone forensic medical examinations at these centres.method: women were referred to our study by sactc coordinators across ontario. we developed an interview schedule composed of both closed and open-ended questions. twenty-two women were interviewed, face-to-face. these interviews were approximately one-to-two hours in length, and were transcribed verbatim. to date, have been analyzed for key themes.results: preliminary findings indicate that most women interviewed were canadian born ( 'yo), and ranged in age from to years. a substantial proportion self-identified as a visible minority ( 'x.). approximately half were single or never married ( %) and living with a spouse or family of origin ( %). most were either students or not employed ( %). two-thirds ( %) had completed high school and onethird ( %) was from a lower socio-economic stratum. almost two-fifths ( %) of women perceived the medical forensic examination as revictimizing citing, for example, the internal examination and having blood drawn. the other two-thirds ( %) indicated that it was an empowering experience, as it gave them a sense of control at a time when they described feeling otherwise powerless. most ( %) women stated that they had presented to a centre due to health care concerns and were very satisfied ( % ) with their experiences and interactions with staff. almost all ( %) women felt supported and understood.conclusions: this research has important implications for clinical practice and for appropriately addressing the needs of sexually assaulted women. what is apparent is that continued high-quality medical attention administered in the milieu of specialized hospital-based services is essential. at the same time, we would suggest that some forensic evidence collection procedures warrant reevaluation. the study will take an experiential, approach by chroruclmg the impa~ of the transition f m the streets to stabilization in a managed alcohol program through the techruque of narrative i~:uiry. in keeping with the shift in thinking in the mental health fie!~ ~his stu~y is based on a paradigm of recovery rather than one of pathology. the "inner views of part c pants hves as they portray their worlds, experiences and observations" will be presented (charm~z, , ~· ~)-"i?e p~ of the study is to: identify barriers to recovery. it will explore the exj?cnence of ~n~t zanon pnor to entry into the program; and following entry will: explore the meanmg ~nd defirutto~s of r~overy ~~d the impact of the new environment and highlight what supports were instrumental m movmg pan apants along the recovery paradigm.p -st (a) treating the "untreatable": the politics of public health in vancouver's inner city introdudion: this paper explores the everyday practices of therapeutic programs in the treadnent of hiv in vancouver's inner city. as anthropologists have shown elsewhere, therapeutic programs do not siinply treat physical ailments but they shape, regulate and manage social lives. in vancouver's inner city, there are few therapeutic options available for the treatment of -ilv. public health initiatives in the inner city have instead largely focused on prevention and harm reduction strategies such as needle exchange programs, safe injection sites, and safer-sex education. epidemiological reports suggest that less than a quarter of those living with hiv in the downtown eastside (dtes) are taking antiretroviral therapies raising critical questions regarding the therapeutic economy of antiretrovirals and rights to health care for the urban poor.methods: this paper is drawn from ethnographic fieldwork in vancouver's otes neighborhood focusing on therapeutic programs for hiv treatment among "hard-to-reach" populations. the research includes participant-observation at inner city health clinics specializing in the treatment of hiv; semi· structured interviews with hiv positive participants, health care professionals providing hiv treatment, and administraton working in the field of inner city public health; and, lastly, observation at public meetings and conferences surrounding hiv treatment.r.awlts: hiv prevention and treatment is a central concern in the lives of many residents living in the inner city -although it is just one of many health priorities afflicting the community. concerns about drug resistance, cost of antiretrovirals, and illicit drug use means that hiv therapy for most is characterized by the daily observation of their medicine ingestion at health clinics or pharmacies. daily observed treatment (dot) is increasingly being adopted as a strategy in the therapeutic management of "untreatable" populations. dot programs demand a particular type of subject -one who is "compliant" to the rules and regimes of public health. over emphasis on "risky practices," "chaotic lives," and "~dh~rence" preve~ts the public health system from meaningful engagement with the health of the marginalized who continue to suffer from multiple and serious health conditions and who continue to experience considerable disparities in health.~ the ~ffec~s of hiv in the inner city are compounded by poverty, laclc of safe and affordable houamg, vanous llegal underground economies increased rates of violence and outbreaks of ~~~·~ly tr~nsmitted infections, hepatitis, and tuberculosi: but this research suggests 'that public health uunauves aimed at reducing health disparities may be failing the most vulnerable and marginal of citiztl s. margaret malone ~ vi~lence that occurs in families and in intimate relationships is a significant urban, ~unity, and pu~hc health problem. it has major consequences and far-reaching effects for women, ~~--renho, you~ sen on, and families. violence also has significant effects for those who provide and ukllc w receive health care violence · · i · · . all lasses, · is a soc a act mvolvmg a senous abuse of power. it crosses : ' : ' ~ s;nden, ag~ ~ti~, cultures, sexualities, abilities, and religions. societal responseshali ra y oc:used on identificatton, crisis intervention and services for families and individuajs.promoten are only "-"--:-g to add h · ' · i in intimate relationshi with"-~"'.". ress t e issues of violence against women and vjoence lenga to consider i~ m families. in thi_s p~per, i analyze issues, propose strategies, and note c~· cannot be full -...l'-~ whork towards erad canng violence, while arguing that social justice and equity y -. ucvcu w en thett are people wh mnhod: critical social theory, an analysis that addresses culturally and ethnically diverse communities, together with a population health promotion perspective frame this analysis. social determinants of health are used to highlight the extent of the problem of violence and the social and health care costs.the ottawa charter is integrated to focus on strategies for developing personal skills, strengthening community action, creating supportive environments, devdoping healthy public policies, and re-orientating health and social services. attention is directed to approaches for working with individuals, families, groups, communities, populations, and society.ratdts: this analysis demonstrates that a comprehensive interdisciplinary, multisectoral, and multifaceted approach within an overall health promoting perspective helps to focus on the relevant issues, aitical analysis, and strategies required for action. it also illuminates a number of interacting, intersecting, and interconnecting factors related to violence. attention, which is often focused on individuals who are blamed for the problem of violence, is redirected to the expertise of non-health professionals and to community-based solutions. the challenge for health promoters working in the area of violence in families and in intimate relationships is to work to empower ourselves and the communities with whom we work to create health-promoting urban environments. social justice, equiry, and emancipatory possibilities are positioned in relation to recommendations for future community-based participatory research, pedagogical practices for health care practitioners, and policy development in relation to violence and urban health. the mid-main community health center, located in vancouver british columbia (bc), has a diverse patient base reflecting various cultures, languages, abilities, and socio-economic statuses. due to these differences, some mid-main patients experience greater digital divide barriers in accessing computers and reputable, government produced consumer health information (chi) websites, such as the bc healthguide and canadian health network. inequitable access is problematic because patient empowerment is the basis of many government produced chi websites. an internet terminal was introduced at mid-main in the summer of , as part of an action research project to attempt to bridge the digital divide and make government produced chi resources useful to a broad array of patients. multi-level interventions in co-operation with patients, with the clinic and eventually government ministries were envisioned to meet this goal. the idea of implementing multi-level interventions was adopted to counter the tendency in interactive design to implement a universal solution for the 'ideal' end-user [ ), which discounts diversity. to design and execute the interventions, various action-oriented and ethnographic methods were employed before and during the implementation of the internet terminal. upon the introduction of the internet terminal, participant observation and interviews were conducted using a motion capture software program to record a digital video and audio track of patients' internet sessions. this research provided insight into the spectrum of patients' capacities to use technology to fulfil their health information needs and become empowered. at the mid-main clinic it is noteworthy that the most significant intervention to enhance the usefulness of chi websites for patients appeared to be a human rather than a technological presence. as demonstrated in other ethnographic research of community internet access, technical support and capacity building is a significant component of empowerment ( ). the mid-main wired waiting room project indicates that medical practitioners, medical administrators, and human intermediaries remain integral to making chi websites useful to patients and their potential empowerment. ( ) over the past years the environmental yo~th alliance has been of~ering a.youth as~t. mappin~ program which trains young people in community research and evaluation. wh ~st the positive expenenc~ and relationships that have developed over this time attest to the success of this program, no evaluations has yet been undertaken to find out what works for t.he youth, what ~ould be changed, and what long term outcomes this approach offers for the youth, their local community, and urban governance. these topics will be shared and discussed to help other community disorganizing and uncials governments build better, youth-driven structures in the places they live.p - (a) the world trade center health registry: a unique resource for urban health researchers deborah walker, lorna thorpe, mark farfel, erin gregg, and robert brackbill introduction: the world trade center health registry (wfchr) was developed as a public health response to document and evaluate the long-term physical and mental health effects of the / disaster on a large, diverse population. over , people completed a wfchr enrollment baseline survey, creating the largest u.s. health registry. while studies have begun to characterize / bealth impacts, questions on long-term impacts remain that require additional studies involving carefully selected populations, long-term follow-up and appropriate physical exams and laboratory tests. wtchr provides an exposed population directory valuable for such studies with features that make ita unique resource: (a) a large diverse population of residents, school children/staff, people in lower man· hattan on / including occupants of damaged/destroyed buildings, and rescue/recovery/cleanup work· ers; (b) consent by % of enrollees to receive information about / -related health studies; (c) represenration of many groups not well-studied by other researchers; (c) email addresses of % of enrollees; (d) % of enrollees recruited from lists with denominator estimates; and (e) available com· parison data for nyc residents. wfchr strives to maintain up-to-date contact information for all enrollees, an interested pool of potential study participants. follow-up surveys are planned.methods: to promote the wtchr as a public health resource, guidelines for external researcher.; were developed and posted on (www.wtcregistry.org) which include a short application form, a twopage proposal and documentation of irb approval. proposals are limited to medical, public health, or other scientific research. researchers can request de-identified baseline data or have dohmh send information about their studies to selected wfchr enrollees via mail or email. applications are scored by the wtchr review committee, comprised of representatives from dohmh, the agency for toxic subst~nces and disease registry, and wtchr's scientific, community and labor advisory committees. a data file users manual will be available in early fall .~suits: three external applications have been approved in , including one &om a non-u.s. ~esearcher, all requesting information to be sent to selected wtchr enrollees. the one completed mail· mg~~ wtchr enrollee~ (o , wfc tower evacuees) generated a positive survey response rate. three additional researchers mtend to submit applications in . wfchr encourages collaborations between researchers and labor and community leaders.conclusion: studies involving wtchr enrollees will provide vital information about the long· term health consequences of / . wtchr-related research can inform communities, researcher.;, policy makers, health care providers and public health officials examining and reacting to and other disasters. t .,. dp'"f'osed: thi is presentation will discuss the findings of attitudes toward the repeat male client iden· ie as su e a and substance us'n p · · · · i · 'd . . - g. articipants will learn about some identified effective strategies or service prov ers to assist this group of i · f men are oft · d bl men. n emergency care settings, studies show that this group en viewe as pro emaric patient d i r for mental health p bl h h an are more ikely to be discharged without an assessmen !) ea rofr ems t. an or er, more cooperative patients (forster and wu · hickey er al., · r y resu ts om this study suggest th · · ' ' l · d tel' mining how best to h . d at negative amtudes towards patients, difficu nes e · as well pathways l_e_ p patientsblan ~ck of conrinuity of care influence pathways to mental health care. • uc\:ome pro emat c when p ti k · che system. m a ems present repeatedly and become "get stuc id methods: semi-structured intervie d . · (n= ), ed nurses (n= ) other ed ;s were con ucted with male ed patients (n= ), ed phys oans ' sta (n= ) and family physicians (n= ). patients also completed a poster sessions v diagnostic interview. interviews were tape-recorded, transcribed verbatim and managed using n . transcripts were coded using an iterative process and memos prepared capture emergent themes. ethics approval was obtained and all participants signed a detailed informed consent form.introduction: urban settings are particularly susceptible to the emergence and rapid spread of nt•w or rare diseases. the emergence of infectious diseases such as sars and increasing concerns over the next influenza pandemic has heightened interest in developing and using a surveillance systt·m which detects emerging public health problems early. syndromic surveillance systems, which use data b, scd on symptoms rather than disease, offer substantial potential for this by providing near-real-rime data which are linked to an automated warning system. in toronto, we are piloting syndromic data from the · emergency medical services (ems) database to examine how this information can be used on an ongoing basis for the early detection of syndromes including heat-related illness (hri), and influenza-like-illness (ill). this presentation will provide an outline of the planned desi_gn of this system and proposed evaluation. for one year, call codes which reflect heat-related illness or influenza-like-illness will be selected and searched for daily using software with a multifactorial algorithm. calls will he stratified by call code, extracted from the -ems database and transferred electronically to toronto public health. the data will be analyzed for clusters and aberrations from the expected with the realtime outbreak and disease surveillance (rods) system, a computer-based public health tool for the early detection of disease outbreaks. this -ems surveillance system will be assessed in terms of its specificity and sensitivity through comparisons with the well-established tracking systems already in place for hr! and ill. others sources of data including paramedic ambulance call reports of signs and . this study will introduce complementary data sources t~ the ed ch e~ complamt an~ o~~rthe-counter pharmacy sales syndromic surveillance data currently bemg evaluated m ~ther ontar~o cltles. . syndromic surveillance is a unique approach to proactive(~ dete~tmg early c.hangesm the health status of urban communities. the proposed study aims to provide evidence of differential effectiveness through investigating the use of -ems call data as a source of syndromic surveillance information for hr! and ili in toronto. introduction: there is strong evidence that primary care interventions, including screening, brief advi<:e, treatment referral and pharmacotherapy are effective in reducing morbidity and mortality caused by substance abuse. yet physicians are poor at intervening with substance users, in part because of lack of time, training and support. this study examines the hypothesis that shared care in addictions will result in decreased substance use and improved health status of patients, as well as increased use of primary care interventions by primary care practitioners (pcps). methods: the addiction medicine service (ams) at st. joseph's health centre's family medicine department is in the process of being transformed from its current structure as a traditional consult service into a shared care model called addiction shared care (asc). the program will have three components: education, office systems and clinical shared care. as opposed to a traditional consult service, the patient will be booked with both a primary care liaison worker (pcl) and addictions physician. patients referred from community physicians, the emergency department and inpatient medical and psychiatric wards will be recruited for the study as well as pcps from the surrounding community. the target sample size is - physicians and a similar number of patients. after initial consult, patient will be recruited into the study with their consent. the shared-case model underlines the interaction and collaboration with the patient's main pcp. asc will provide them with telephone consults, advice, support and re-assessment for their patients, as well as educational sessions and materials such as newsletters and informational kits.results: the impact of this transition on our patient care and on pcp's satisfaction with the asc model is currently being evaluated through a grant provided by the ministry of health & long term care. a retrospective chart review will be conducted using information on the patient's substance use, er/clinic visits, and their health/mood status. pcp satisfaction with the program will be measured through surveys and focus groups. our cost-effectiveness analysis will calculate the overall cost of the program per patient..conclusion: this low-cost service holds promise to serve as an optimal model and strategy to improve outcomes and reduce health care utilization in addict patients. the inner city public health project introduction the inner city public health project (icphp) was desi.gned to explore new an~ innovative ways to reach marginalized inner city populations that par-t c pate m high health-nsk beha~ ors. much of this population struggles with poverty, addictions, mental illness and homelessness, creatmg barriers to accessing health services and receiving follow-up. this pro ect was de~igned to evaluat~ .~e success of offering clinics in the community for testing and followup of communicable diseases uuhzmg an aboriginal outreach worker to build relationships with individuals and agencies. v n(demographics~ history ~f testi~g ~nd immunization and participation in various health-risk behaviors), records of tesnng and mmumzat ons, and mterviews with partner agency and project staff after one year.. results: t~e chr ~as i~strumental in building relationships with individuals and partner agencies ' .° the c~mmun_ ~ re_sultmg m req~ests for on-site outreach clinics from many of the agencies. the increase m parnc pat n, the chr mvolvement in the community, and the positive feedback from the agen? staff de~onstrated that.the project was successfully creating partnerships and becoming increasingly integrated m the community. data collected from clients at the initial visit indicated that the project was reaching its target populations and highlighted the unique health needs of clients, the large unmet need for health services and the barriers that exist to accessing those services. ~usion: the outreach clinics were successful at providing services to target populations of high health-nsk groups and had great support from the community agencies. the role of the chr was critical to the success of the project and proved the value of this category of health care worker in an urban aboriginal population. the unmet health needs of this disadvantaged population support the need for more dedicated resources with an emphasis on reducing access barriers. building a caring community old strathcona's whyte avenue, a district in edmonton, brought concern about increases in the population of panhandlers, street people and homeless persons to the attention of all levels of government. the issue was not only the problems of homelessness and related issues, but feelings of insecurity and disempowerment by the neighbourhood residents and businesses. their concerns were acknowledged, and civic support was offered, but it was up to the community itself to solve the problem. within a year of those meetings, an adult outreach worker program was created. the outreach worker, meets people in their own environments, including river valley camps. she provides wrap-around services rooted in harm reduction and health promotion principles. her relationship-based practice establishes the trust for helping clients with appropriate housing, physical and/or mental health issues, who have little or no income and family support to transition from homelessness. the program is an excellent example of collaboration that has been established with the businesses, community residents, community associations, churches, municiple services, and inner-city agencies such as boyle street community services. statistics are tracked using the canadian outcomes research institute homes database, and feedback from participants, including people who are street involved. this includes an annual general meeting for community and people who are homeless. the program's holistic approach to serving the homeless population has been integral, both in creating community awareness and equipping residents and businesses to effectively interact with people who are homeless. through this community development work, the outreach worker engages old strathcona in meeting the financial and material needs of the marginalized community. the success of this program has been surprising -the fact is that homeless people's lives are being changed; one person at a time and the community has been changed in how they view and treat those without homes. over two years, the program has successfully connected with approximately seventy-five individuals who call old strathcona home, but are homeless. thirty-six individuals are now in homes, while numerous others have been assisted in obtaining a healthier and safer lifestyles by becoming connected with other social/health agencies. the program highlights the roots of homelessness, barriers to change and requirements for success. it has been a thriving program and a model that works by showing how a caring community has rallied together to achieve prosperous outcomes. the spn has created models of tb service delivery to be used m part~ers~ p with phannaceunca compa-. · · -. t' ns cooperatives and health maintenance orgamzanons (hmos). for example, the mes, c v c orgamza , . · b tb d' · spn has established a system with pharmaceutical companies that help patients to uy me cmes at a special discounted rate. this scheme also allows patients to get a free one-_month's worth of~ dru_g supply if they purchase the first months of their regimen. the sy_s~e~s were ~es gned to be cm~pattble with existing policies for recording and documentation of the ph hppme national tuberculosis program (ntp). aside from that, stakeholders were also encouraged to be dots-enabled through the use of m~nual~ and on-line training courses. the spn initiative offers an alternative in easing the burden of tb sc:rv ce delivery from rhe public sector through the harnessing of existing private-sector (dsos). the learnmgs from the spn experience would benefit groups from other locales that _work no~ only on ~ but other health concerns as well. the spn experience showcases how well-coordinated private sector involvements help promote social justice in health delivery in urban communities.p - (c) young people in control; doing it safe. the safe sex comedy juan walter and pepijn v. empelen introduction: high prevalence of chlamydia and gonorrhoea have been reported among migrants youth in amsterdam, originating from the dutch antilles, suriname and sub-sahara africa. in addition, these groups also have high rates of teenage-pregnancy (stuart, ) and abortions (rademakers ), indicating unsafe sexual behaviour of these young people. young people (aged - ) from the so· called urban scene (young trendsetters in r&b/hip hop music and lifestyle) in amsterdam have been approached by the municipal health service (mhs) to collaborate on a safe sex project. their input was to use comedy as vehicle to get the message a cross. for the mhs this collaboration was a valuable opportunity to reach a hard-to-reach group.mdhods: first we conducted a need assessment by means of a online survey to assess basic knowledge and to similtaneously examine issues of interest concerning sex, sexuality, safer sex and the opposite sex. second, a small literature study was conducted about elements and essential conditions for succesful entertainment & education (e&e) (bouman ), with as most important condition to ensure that the message is realistic (buckingham & bragg, ) . third a program plan was developed aiming at enhancing the stl/hiv and sexuality knowledge of the young people and addressing communication and educational skills, by means of drama. subsequently a safe sex comedy show was developed, with as main topics: being in love, sexuality, empowerment, stigma, sti, hivand safer sex. the messages where carried by a mix of video presentation, stand up comedy, spoken word, rap and dance.results: there have been two safe sex comedy shows. the attendance was good; the group was divers' with an age range between and year, with the majority being younger than year. more women than men attended the show. the story lines were considered realistic and most of the audients recognised the situations displayed. eighty percent of the audients found the show entertaining and % found it edm:arional. from this %, one third considers the information as new. almost all respondents pointed our that they would promote this show to their friends.con.clusion: the s.h<_>w reached the hard-to-reach group of young people out of the urban scene and was cons d_ered entert~mmg, educational and realistic. in addition, the program was able in addressing important issues, and impacted on the percieved personal risk of acquiring an sti when not using condoms, as well as on basic knowledge about stl's. introduction: modernity has contributed mightily to the marginality of adults who live with mental illnesses and the subsequent denial of opportunities to them. limited access to social, vocational, educational, and residential opportunities exacerbates their disenfranchisement, strengthening the stigma that has been associated with mental illness in western society, and resulting in the denial of their basic human rights and their exclusion from active participation in civil society. the clubhouse approach tn recovery has led to the reduction of both marginality and stigma in every locale in which it has been implemented judiciously. its elucidation via the prism of social justice principles will lead to a deeper appreciation of its efficacy and relevance to an array of settings. methods: a review of the literature on social justice and mental health was conducted to determine core principles and relationships between the concepts. in particular, fondacaro and weinberg's ( ) conceptualization of social justice in community psychology suggests the desirability of the clubhouse approach in community mental health practice. a review of clubhouse philosophy and practice has led to the inescapable conclusion that there is a strong connection between clubhouse philosophy-which represents a unique approach co recovery--and social justice principles. placing this highly effective model of community mental health practice within the context of these principles is long overdue. via textual analysis, we will glean the principles of social justice inherent in the rich trove of clubhouse literature, particularly the international standards of clubhouse development.results: fondacarao and weinberg highlight three primary social justice themes within their community psychology framework: prevention and health promotion; empowerment, and a critical pnsp<"<·tive. utilizing the prescriptive principles that inform every detail of clubhouse development and th<" movement toward recovery for individuals at a fully-realized clubhouse, this presentation asserts that both clubhouse philosophy and practice embody these social justice themes, promote human rights, and empower clubhouse members, individuals who live with mental illnesses, to achieve a level of wdl-heing and productivity previously unimagined.conclusion: a social justice framework is critical to and enhances an understanding of the clubhouse model. this model creates inclusive communities that lead to opportunities for full partic pil!ion civil society of a previously marginalized group. the implication is that clubhouses that an· based on the international standards for clubhouse programs offer an effective intervention strategy to guarantee the human rights of a sizable, worthy, and earnest group of citizens. to a drastic increase in school enrollment from . million in to . million in .s. however, while gross enrollment rates increased to °/., in the whole country after the introduction of fpe, it remained conspicuously low at % in the capital city, nairobi. nairobi city's enrollment rate is lower .than thatof all regions in the country except the nomadic north-eastern province. !h.e.d sadvantage of children bas_ed in the capital city was also noted in uganda after the introduction of fpe m the late s_-many_ education experts in kenya attribute the city's poor performance to the high propornon of children hvmg m slums, which are grossly underserved as far as social services are concerned. this paper ~xammes the impact of fpe and explores reasons for poor enrollment in informal settlements m na rob city. methods: the study utilizes quantitative and qualitative schooling data from the longitudinal health and demographic study being implemented by the african population and health research center in two informal settlements in nairobi. descriptive statistics are used to depict trends in enrollment rates for children aged - years in slum settlements for the period - . results: the results show that school enrollment has surprisingly steadily declined for children aged - while it increased marginally for those aged - . the number of new enrollments (among those aged years) did not change much between and while it declined consistently among those aged - since . these results show that the underlying reasons for poor school attendance in poverty-stricken populations go far beyond the lack of school fees. indeed, the results show that lack of finances (for uniform, transportation, and scholastic materials) has continued to be a key barrier to schooling for many children in slums. furthermore, slum children have not benefited from fpe because they mostly attend informal schools since they do not have access to government schools where the policy is being implemented.conclusion: the results show the need for equity considerations in the design and implementation of the fpe program in kenya. without paying particular attention to the schooling needs of the urban poor children, the millennium development goal aimed at achieving universal primary education will remain but a pipe dream for the rapidly increasing number of children living in poor urban neighborhoods.ps- (c) programing for hiv/aids in the urban workplace: issues and insights joseph kamoga hiv/aids has had a major effect on the workforce. according to !lo million persons who are engaged in some form of production are affectefd by hiv/aids. the working class mises out on programs that take place in communities, yet in a number of jobs, there are high risks to hiv infection. working persons sopend much of their active life time in workplaces and that is where they start getting involved in risky behaviour putting entire families at risk. and when they are infected with hiv, working people face high levels of seclusion, stigmatisation and some miss out on benefits especially in countries where there are no strong workplace programs. adressing hiv/aids in the workplace is key for sucessfull responses. this paper presents a case for workplace programing; the needs, issues and recommendations especially for urban places in developing countries where the private sector workers face major challenges.