key: cord- -y flcu h authors: chen, yu; cheng, jin; jiang, yu; liu, keji title: a time delay dynamic system with external source for the local outbreak of -ncov date: - - journal: nan doi: nan sha: doc_id: cord_uid: y flcu h how to model the coronavirus ( -ncov) spread in china is one of the most urgent and interesting problems in applied mathematics. in this paper, we propose a novel time delay dynamic system with external source to describe the trend of local outbreak for the -ncov. the external source is introduced in the newly proposed dynamic system, which can be considered as the suspected people travel to different areas. the numerical simulations exhibit the dynamic system with the external source is more reliable than the one without it, and the rate of isolation is extremely important for controlling the increase of cumulative confirmed people of -ncov. based on our numerical simulation results with the public data, we suggest that the local government should have some more strict measures to maintain the rate of isolation. otherwise the local cumulative confirmed people of -ncov might be out of control. in late december , a cluster of serious pneumonia cases in wuhan was caused by a novel coronavirus, and the outbreak of pneumonia began to attract considerable attention in the world. coronaviruses are enveloped nonsegmented positive-sense rna viruses belonging to the family coronaviridae and the order nidovirales which are discovered and characterized in and are broadly distributed in humans and other mammals. in humans, most of the coronaviruses cause mild respiratory infections, but rarer forms such as the "severe acute respiratory syndrome" (sars) outbreak in in china and the "middle east respiratory syndrome" (mers) outbreak in in saudi arabia and outbreak in in south korea had cased more than cumulative cases. in more details, there are more than confirmed sars cases and confirmed mers cases separately. although a lot of coronaviruses had been identified and characterized, they might be a tip of the iceberg and lots of potential severe and novel zoonotic coronaviruses needed to be revealed. the world heath organization (who) designated the causative agent as the novel coronavirus ( -ncov), which was identified by the chinese authorities. because wuhan is the capital of hubei province and the th largest city china and the largest transport hub in the central part of china, it transports millions of people to lots of cities in china and many countries in the world everyday. based on the special location and transport hub of wuhan, the chinese government has revised the law provisions of infectious diseases to add the novel -ncov as class a agent on january th . moreover, a series of non-pharmaceutical interventions were implemented, say, rigorous isolation of symptomatic, suspected person, days of isolation for the people who traveled from one city to another, strictly prohibit the travel in the many provinces (especially the hubei province), the public transport is partially shut down in lots of cities, etc. however, the effectiveness and efficiency of these interventions during the early stage is questionable. so far, there are more than confirmed cases in wuhan and more than confirmed cases in china, and the cumulative confirmed cases of -ncov from january rd to february th in wuhan and mainland china are shown in figure (a) and figure (b) respectively. in addition, several exported cases have been confirmed in many other countries including japan, south korea, singapore, usa, canada, germany, france, uk, spain, etc. the who has recognized that the mathematical models of epidemic play a significant role in informing evidence-based decisions by health decision and policy makers. in order to determine the impact of prevention and control of infection in different positions (i.e. provinces and cities), the strength and duration of isolation, the value for the rate of recovery, we propose a novel dynamic system with time delay and external source in this paper. with the help of this novel system, we are able to not only predict the trend for the outbreak of -ncov in different districts of china but also provide some helpful suggestions to achieve the maximal protection of population with the minimal interruption of social-economic activities. recently we propose a novel time delay dynamical system to describe the -ncov spread in china [ , ] , but it is not suitable to describe the trend of local outbreak for the -ncov. in this paper, we propose a novel time delay dynamic system with external source. in the newly proposed system, the external source term is added which can be considered as the suspected people of wuhan (or other cities) travel to other districts of china. moreover, we apply different kernel function in the novel system which can describe the local outbreak of -ncov more accurately. the rest of paper is organized as follows: in section , we shall propose the notations, the assumptions and the corresponding novel time delay dynamic system with external source. the effective approach for estimating the parameters of novel dynamic system and the prospective cumulative confirmed people are provided in section . based on the public data, several numerical examples are exhibited in section to verify the accuracy and effectiveness of our estimation scheme and dynamic system. finally, we present some concluding remarks and suggestions in section . in this section, we shall state a novel dynamic system with time delay and external source to describe the local outbreak of -ncov in china. the people in our novel dynamic system are separated into kinds: external suspected people (external source), infected people, confirmed people, isolated people and cured people. furthermore, we apply following notations to describe them, • i(t): cumulative infected people at time t; • j(t): cumulative confirmed people at time t; • g(t): currently isolated people who are infected but still in latent period at time t; • r(t): cumulative cured people at time t. the assumptions of external source, spread rate β, latent period τ , delay period t − τ , exposed people and cured rate κ in our novel system are presented as follows: . the transfer of infected people is assumed to be -to- . and the area with external source and the area of destination would be specified in the system. . suppose the infected person can transfer the coronavirus to others at a spread rate β, which is defined by the average amount of people becoming infected by this person in unit time. . in average, the infected people experience a latent period of τ days before they display obvious symptoms. moreover, we assume the infected person with palpable symptoms would seek for treatment and therefore become confirmed people. . some of the infected people would be exposed in the latent period τ until they are confirmed. the average exposed period of these people are τ − τ days, which means they would be confirmed in the next τ days. some other part of the infected people are isolated during latent period according to investigation of diagnosed cases. no matter the cumulative confirmed people j(t) are isolated before diagnosed or not, they are consist of the population infected at time t − τ averagely. . suppose the individual would no longer transmit the coronavirus to others when he/she is isolated or in the treatment. consequently, the exposed people at time t are . it is τ days in average for the confirmed people become cured with rate κ or dead with rate − κ. with the help of the notations and assumptions stated previously, the novel time delay dynamic system with external source to describe the local outbreak of -ncov is shown in figure . since the novel dynamic model would be more complicated compared with the one proposed in [ ] , we first provide the following general form of time delay model that is valid for various cases including those with source or sink, in order to provide a better understanding of the dynamic system ( . ), we present some detailed explanations as follows: .Ĩ is generally the increase rate of cumulative infected people i(t) at time t. the specific form ofĨ depends on the system is closed or has outflow/inflow, and it would be illustrate in detail later. . because all the cumulative confirmed people j(t) come from the previously infected population, the increment of i(t) at time t (t < t), i.e.,Ĩ(t ), which means the increment of j(t) depends on the history ofĨ(t). if the average delay between infected time and confirmed time is τ , the increase rate of j can be represented as where γ is the morbidity, and h (t, t ) (t = t − τ ) is a distribution which should be normalized as we are able to observe that h (t, t) can be regarded as the probability distribution of infection time t , and here we take the normal distribution with c and c be constants. . the functiong(t) is the newly isolated and infected people. the integral term in the equation for g(t) means the people isolated τ days ago (averagely) and would be confirmed and sent for treatment, who would no longer be counted into to the instant isolated population. in addition, the kernel function in the integral has the following expression with c and c be constants. . the parameter κ is the cured rate. the time delay term is obtained similarly as that of j(t)'s, and h (t, t ) = c e −c (t−t ) with c and c be constants. we next derive the specific form of cases with inflow or outflow sources separately, i.e. the specific form ofĨ. for simplicity we consider the half open cases, i.e. with single outflow or single inflow. the situation with both inflow and outflow can be treated based on ( . ) similarly. it is assumed that some of the infected people of area a would transfer to area b. we employ a and b to distinguish the source area and destination respectively. the dynamic system for destination b applies the output of source area a as input. although the cured rate and dead rate are the same for the two dynamic systems, the isolation ratio and infection rate β are different for these two dynamic systems. area a with single outflow to area b for the case with merely outward transfer, the exposed people at time t is i a (t) − j a (t) − g a (t), which further make β a (i a (t) − j a (t) − g a (t)) people infected with β a as the infection rate for this area. meanwhile, ν(t)θ(i a (t)−j a (t)−g a (t)) of them transfers to other regions, where θ is the coefficient of transport activity and ν(t) is the time-dependent distribution of exposed people that are likely to move out. consequently, at time t the net increment of the infected number in this region is we further assume thatg which means the currently exposed people are isolated at rate a . by substituting ( . ) and ( . ) into ( . ), we arrive at the following expressions for the single outflow system area b with single inflow from area a we next concern about another system with single external source from area a. the instant increment of infected people caused by existed exposed people at time t is also assumed as , while the external transport contribute to the increment isĨ in (t), thus the total increment at that time is whereĨ in (t) is the output of source region, namely, the rate of isolation is still depends on the existed exposed amount of people, so we possess the following form similarly as ( . )g where the currently exposed people are isolated at rate b . according to ( . ), we are able to state the novel time delay dynamic system for area b with the external source from area a as follows: ( . ) in sum, the above -to- single direction model is consistent of two sets of equations corresponding to the source system and destination system. it can be observed that the source system ( . ) of area a is independent, which means it can be solved without any information of system ( . ) of area b. conversely, the system ( . ) of area b relies on the source system ( . ) of area a, so the output of area a is applied as its input in the computation. in this section, we shall first state the optimization method to estimate some parameters of the dynamic system ( . ) from the official data, and a prediction scheme would be presented to forecast the tendency of outbreak for the -ncov. based on the information of parameters {β a , κ, a , γ, τ , τ , τ } and initial conditions {i a (t ), g a (t ), j a (t ), r a (t )} in the novel dynamic system ( . ), the cumulative cured people r a (t ) and the cumulative confirmed people j a (t ) at any given time t are readily to attain by solving the novel dynamic system ( . ) numerically. likewise, the other novel dynamic system ( . ) can be solved with the extra information of parameters {β b , b }, the external sourceĨ in ( . ) and the initial conditions in the practical applications, we suggest to apply the matlab inner-embedded program dde to solve the novel dynamic systems ( . ) and ( . ). in addition, the following conditions for the initial time and some parameters are assumed in the practical applications: . initial conditions: on the initial day t , we suppose people in the area a are infected the -ncov from unknown sources. moreover, the confirmed, isolated and recovered people are all on the initial day. all these assumptions represent i a (t ) = , g a (t ) = j a (t ) = r a (t ) = and g b (t ) = j b (t ) = r b (t ) = . in the numerical simulation, we further assume that there are no isolation measures implemented before t = t + . according to the present data, we suppose a relatively high cure rate as κ = . , the morbidity is relatively high with γ = . . the average latent period τ and treatment period τ are also regarded as known according to the official data. the average period between getting isolated and diagnosed τ satisfies < τ < τ . the known parameter set is summarized in table . κ γ τ τ τ . . table : the settings of parameters based on the official data. accordingly, the rest parts of parameters that need to be estimated are as follows, and the identifications of parameters Θ a and Θ b come to the following two optimization problems, and min where j a obs and j b obs are separately the daily official data in area a and area b reported by the national health commission of china. consequently, we solve the optimization problem ( . ) to derive the parameter Θ a initially. in addition, with the knowledge of parameters Θ a , we are able to predict the trend of local outbreak in area a and the external source ( . ) for area b. furthermore, solve the optimization problem ( . ), we obtain the parameter Θ b and are able to predict the tendency of local outbreak in area b. the whole procedure is concluded as follows: the estimation and prediction scheme: step . based on the official data j a obs , we apply the levenberg-marquad (lm) method or the markov chain monte carlo (mcmc) method [ , ] to solve the optimization problem ( . ), and the estimated parameter Θ * a is obtained. step . with the reconstructed Θ * a , one could acquire the predictions of {i a (t), j a (t), g a (t), r a (t)} andĨ in . step . based on the official data j b obs , we solve the optimization problem ( . ) and attain the estimated parameter Θ * b in account ofĨ in . step . the values of {i b (t), j b (t), g b (t), r b (t)} are obtained by solving the novel dynamic system ( . ) numerically. in this section, we shall present some numerical experiments to verify the accuracy and efficient of the estimation and prediction scheme. it is worth mentioning that the data employed in our novel dynamic system are acquired from the health commission of each province and city of china and the national health commission of china. moreover, the data includes the cumulative confirmed people, and the cumulative cured people and the cumulative dead people from jan. rd to feb. th . in order to predict the external source, we design the time distribution of exposed people moving out as which illuminates there would be two peaks around february th and february th separately. the reason for these two peaks is that the people would go back to work and school after the lunar new year on the specified two days. by implementing the estimation and prediction scheme of section , the estimations of parameters are β a = . and a = . , andĨ in (t) with diffident θ are exhibited in figure . it is obviously that the situation of pneumonia would tend to end at the beginning of march and the final cumulative confirmed people would be about . however, by observing the prediction of area b with the external source in figure , the increase of exposed people would lead to the increase of final cumulative confirmed people. in addition, the ending time of this pneumonia would be absolutely postpone, we show table for reference. we shall remark that the same β b = . and b = . are employed for the prediction. θ cumulative confirmed people % ≈ % ≈ % ≈ % ≈ table : prediction of cumulative confirmed people at the beginning of march. now the question comes to how to decrease the final cumulative confirmed people since the external source is inevitable. one feasible way is the increase of isolated ratio b , and the numerical simulations are shown in figure . we can note that the cumulative confirmed people are sharply reduce with the high rate of isolation. figure : prediction with different impacts of isolated rate. in order to provide a better observation of the cumulative confirmed people with different impacts of isolated ratio, we exhibit the numerical results in table . table : prediction of cumulative confirmed people with different impacts of isolated rate. from the numerical simulations, we possess following conclusions . the external source plays a significant role in the dynamic system, and the prediction of outbreak with the external source is more reliable than the one without it. . the inflow of exposed people would increase the final cumulative confirmed people, and the ending time of this pneumonia would postpone. . to avoid of rapid increasing of final cumulative confirmed people, the local government need to implement some more efficient restrictive policies to maintain the rate of isolation. in this paper, we have proposed a novel time delay dynamic system with external source. in this system, the suspected people of area a transfer to area b is concerned, and it is more reasonable and appropriate than the one in [ , ] to describe the trend of local outbreak for the -ncov. the numerical simulations are carried out to verify the effectiveness and accuracy of the novel time delay dynamic system with external source. moreover, the newly proposed dynamic system can approximate the true data quite well in this event, and it could further forecast the trend of local event. from the numerical simulations, we would like to advice that the local government apply some more efficient and strict measures to maintain the rate of isolation. otherwise the local cumulative confirmed people of -ncov might be out of control. at present, the parameters involved in the novel dynamic system are time-independent. in the future work, the change in the impact of isolation and spread rate may be assumed to depend on time so as to improve the agreement between real data and estimated solution. besides, the complex network and stochastic process would be concerned in our dynamic system and the machine learning techniques would be applied to provide a better prediction of tendency for the outbreak of -ncov. estimation of parameters in a structured sir model studies on mathematical models for sars outbreak prediction and warning mathematical models and dynamics of infectious diseases iterative regularization methods for nonlinear ill-posed problems statistical and computational inverse problems a time delay dynamical model for outbreak of -ncov and the parameter identification modeling and prediction for the trend of outbreak of -ncov based on a time-delay dynamic system this work of jin cheng was supported in part by the national science foundation of china key: cord- - j fl authors: afolabi, michael olusegun title: pandemic influenza: a comparative ethical approach date: - - journal: public health disasters: a global ethical framework doi: . / - - - - _ sha: doc_id: cord_uid: j fl community-networks such as families and schools may foster and propagate some types of public health disasters. for such disasters, a communitarian-oriented ethical lens offers useful perspectives into the underlying relational nexus that favors the spread of infection. this chapter compares two traditional bioethical lenses—the communitarian and care ethics framework—vis-à-vis their capacities to engage the moral quandaries elicited by pandemic influenza. it argues that these quandaries preclude the analytical lens of ethical prisms that are individual-oriented but warrant a people-oriented approach. adopting this dual approach offers both a contrastive and a complementary way of rethinking the underlying socioethical tensions elicited by pandemic influenza in particular and other public health disasters generally. contemporary healthcare constitutes an instinctual and institutional response to the multifaceted cycles of health, illness, and disease. hence, the problems of diseases including infectious ones affect all and sundry irrespective of current "sick status". pandemic influenza is one such incident that afflicts all sectors of the society. it also raises questions and issues related to utility and equity, ensuring the protection of vulnerable individuals and groups in society, the need to exercise public health powers with respect for human rights as well as the just allocation of human and material resources. attending to these issues, however, juggles many kinds of personal, social, political, and professional interests against one another; thus, reflecting the traditional public health dilemma of fine-tuning individual against collective good. since the restrictive approach of individualism-driven moral lenses is unsuitable for people-centered quandaries, it seems pertinent to employ a people-centric moral lens to engage them. in this vein, the ethical prism of communitarianism and ethics of care seem apt. by examining and contrasting the core fabric of the communitarian and care ethics frameworks vis-à-vis the attendant dilemmas of pandemic influenza; this chapter attempts to tease out a broader ethical path towards engaging the challenges of pandemic influenza. to properly set the conceptual foreground essential to articulating the ethical features of pandemic influenza, however, it is important to elaborate the associated biological, social, and global dynamics. these parameters, as macphail recently argues, are exigent in the explication and engagement of pandemic or infectious disease outbreaks. there have been some speculations as to the origins of the influenza virus. it has been hypothesized that the virus originated from wild waterfowls and has only slowly evolved through multiple animal species including humans. but what is known about the disease caused by the virus-influenza-is that it is a febrile illness of the upper and lower respiratory tract, characterized by a sudden onset of fever, cough, myalgia, and malaise. pneumonia is a principal serious complication and local symptoms include sniffles, nasal discharge, dry cough, and sore throat. pandemic influenza outbreaks describe the rapid spread of influenza infection. whereas there is some conceptual controversy about the description and definition of pandemics, they generally refer to the dissemination of new infective diseases to which immunity has not been developed in a widespread manner across a significant part of the world. they could break out in nations with a large geographical size (such as china, india, and the united states) or when the number of affected nations are many. the pandemic nature of influenza is historically underscored by the - incident that killed an estimated million to million people. pandemic influenza is generally characterized by an alteration in the viral subtype (due to antigenic shift), higher mortality rates among younger groups, several waves of the particular pandemic, increased capacity of spread, and geographic variation in the impact of the outbreak. specifically, influenza pandemics occur when an influenza virus mutates or when multiple strains combine, or re-assort to produce strains to which there is no current immunity. novel outbreaks of the influenza virus occur either in large nations or across selected nations in close proximity. contemporary society experiences an increased development of new serotypes of several kinds of respiratory viruses because of the evolutionary potential afforded by the human population explosion and the great global increase in human mobility. in a manner of speaking, it seems that phds such as pandemic influenza outbreaks have evolved to become recurring features of the human experience. some insights into the biological features and processes that create pandemic outbreaks support this idea. influenza viruses belong to the orthomyxoviruses family. this comprises seven genera including influenza virus a, b, c, and d. although both the genus influenzavirus a and b affect humans and cause pandemics, influenza a has been the principal culprit in known outbreaks to the extent that four major pandemics have resulted from it ( - , , , and ) . however, genetic reassortment and exchange of influenza viruses between humans and animals generate antigenic shift, which periodically introduces new viruses to the human population. this, in addition to mutation and selection, produces antigenic drift that accounts for the year-to-year variations in influenza a subtypes. wild ducks, for instance, serve as the primary host for various influenza type a viruses that occasionally spread to other host species and cause outbreaks in such animals as fowl, swine, and horses. such outbreaks often lead to new human pandemics due to novel viruses infecting immunologically naïve people. a critical aspect of the emergence of novel virus strains is genetic variation and combination that occur at the hemagglutinin (ha) antigens (of which there are ) and neuraminidase (na) enzymes (of which there are nine) between and amongst human and animal influenza viruses. the subtypes of the ha and na surface proteins forms the basis for the classification of outbreaks. for example, the through virus was h n , the through virus was h n , the through outbreak was caused by h n , the virus was h n , and the outbreak was caused by h n ; while the most recent virus seen in eastern china in was h n . all of these traditional and new influenza viruses cause pandemics of differing proportions but more are projected to occur. this projection is well supported by the scientific community. however, it is not known when any will occur or whether it will be caused by the h n avian-derived influenza virus, newer subtypes like h n , or completely novel subtypes. virologists like webster and govorkova argue that given the number of cases of h n influenza that have occurred in humans (more than ) with a mortality or death rate of more than %, it would be prudent to develop robust plans for dealing with such pandemic influenza and its (expected) new variations. such plans, however, necessarily demand attention to the associated ethical dynamics. regardless of the specific subtype of human or animal-derived influenza outbreaks, the public health challenges and the moral quandaries are essentially the same. a critical biological feature of influenza lies in its mode and pattern of transmission. this revolves around its capacity to evolve and become airborne-transmissible between and amongst human beings. the influenza virus transmits from person to person primarily in droplets released by sneezing and coughing. some of the inhaled virus lands in the lower respiratory tract, the primary site of disease marion russier et al., "molecular requirements for a pandemic influenza virus: an acid-stable hemagglutinin protein," proceedings of the national academy of sciences , no. ( ) . pp. pp. - anna v cauldwell et al., "viral determinants of influenza a virus host range," journal of general virology , no. ( ). pp. - . couch. p.; shah. p. . cauldwell et al. p. . miller et al. pp. - shah. p. . rebekah h borse et al., "effects of vaccine program against pandemic influenza a (h n ) virus, united states, - ," emerging infectious diseases , no. ( . pp. - . cauldwell et al. p. . macphail. p. . robert g webster and elena a govorkova, "h n influenza-continuing evolution and spread," new england journal of medicine , no. ( ) . pp. - . russier et al. pp. - being the tracheobronchial tree, and sometimes the nasopharynx. largely because breathing is an essential biological need of human beings and partly because human-human associations are an inevitable part of reality, this biological feature of influenza viruses makes everyone vulnerable and susceptible to infection. specifically, crowds of people facilitate viral transmission by enabling sharp upticks in the rate of transmission. the virus also circulates for longer periods in infected persons. the biological features of influenza and its mode of transmission elicit some observations. one, pandemic influenza is not a single disease for which a single and specific therapeutic intervention that will be effective all the time can be developed. in other words, while there is a general approach to engaging this public health disaster, specific interventions will usually vary by each outbreak. this gives an existential and evolutionary advantage to the influenza virus over human communities. it also engenders a disaster dynamic in the sense that every outbreak becomes "sudden" and potentially associated with large human casualties. secondly, it shows the common vulnerability to which the local and global human community are subject vis-à-vis the ease of spread of the viral infection. thirdly, the biological features of pandemic influenza demonstrate how a collective response (human material, scientific etc.) is key to engaging its social and other attendant consequences. the importance of this last remark will become clearer against the backdrop of the social and global features of pandemic influenza outbreaks, a. theme addressed in the next section of this chapter. an influenza pandemic has the potential to cause more deaths and illnesses than any other public health threat. pandemic influenza a h n were reported. also, the h n outbreak recorded a death rate of %, and the recent h n outbreak caused human infections and deaths. in the united states, the estimated potential threat of pandemic influenza is . million deaths, million sick people, and nearly million hospitalizations, with almost . million requiring intensive-care units. global estimates are higher. for instance, the "spanish flu" caused an estimated - million global deaths. it has been projected that a recurrence of the influenza strain would probably result in the death of - million individuals. these data show that substantial numbers of deaths are an inevitable consequence and feature of pandemic influenza. however, death itself often brings about certain social consequence including the death of some of the most gifted members of the society. sir william osler, one of the pioneers of scientific medicine, died of complications arising from influenza in . influenza was cited by the german war general, erich von ludendorff, as a significant reason for why the initial gains of their last offensive faltered and ultimately failed during world war . from a biological perspective, influenza exploits naïve immune systems which tend to over-respond to the influenza virus. as such, young and promising adults constitute a large part of vulnerable victims. in this regard, potential contributions to societies are nipped in the bud, young widows and widowers emerge as well as a lot of orphans. for instance, , children were orphaned due to the outbreak in new york city. influenza also spread within households soon before or after the onset of symptoms in primary infected patients. another associated social feature of pandemic influenza is the closure of schools with an attendant truncation of learning and educational opportunities, depending on the length of the outbreak. while some of these social features are local and exert localized effects, human beings as social animals with the aid of the increased means of locomotion transmit some of the local features into a global experience. the pandemic of influenza which occurred during a time of much less globalization spread to the united states within - months of its detection in china while the pandemic spread to the u.s. from hong kong within - months. it is estimated that the burden of the next influenza pandemic will be overwhelmingly focused in the developing world. however, the epidemiological notion well-known to public health experts that infectious diseases can predicate outbreaks in neighboring places and nations implies that even so-called developed societies cannot be spared as long as the current interpenetration of people across the globe remains. the influenza outbreak, for instance, spread to countries and caused a total of , cases of infection. in short, in a globalized world, infectious diseases travel in nodes of human, material, and animal networks. data from sporadic studies suggest that influenza may be fairly prevalent in africa, albeit sub-clinically. it may, therefore, have a considerable impact on morbidity and mortality on the continent should a combination of factors create a virus that is viable enough to cause a pandemic. this will have far-reaching consequences for the continent due to the material and human resource constraints, lack of preparedness plans as well as the very limited bio-therapeutic capacities that are currently available to produce vaccines. it may likewise create the dispersal of a virus novel to other continents that have experienced typical outbreaks. geographical location plays a major role in public health, and disasters including health disasters are unique in that each affected region of the world has different social, economic, and health backgrounds. as such, while there is a global spread, the nature of each local context and how it responds shapes pandemic influenza in some key ways. first, the nature of the "disseminating" nation influences how infection spreads elsewhere. for example, china's slow reaction to the sars outbreak as well as its limiting of access to patients and other relevant information hhs, "hhs pandemic influenza plan." p. b . , no. ( ) . p. eric k noji, "public health issues in disasters," critical care medicine , no. ( ) . p. s . seemed to have deepened the global intensity of that crisis. in other words, how a local public health disaster is handled shapes the local severity and how it spreads elsewhere. on the other hand, well-handled local health crises positively influence the possible impacts on contiguous nations. in this vein, radest notes that canada's rapid and coordinated response to the sars outbreak significantly limited its spread and impact in the united states. the above examples echo the interconnectivity of the modern world and show how a course of action in one place, however passive, may significantly influence the course of events in another for good or bad. it supports the idea that contemporary health in the twenty-first century is now inevitably and inherently global with respect to infectious diseases. at the heart of these remarks, however, is the possibility of utilizing different networks of human interconnectivity to actively foster the global good. in other words, learning about how people connect and relate at different levels (individually, communally, institutionally et cetera) and learning about the chief actors and players in such a relationship nexus may provide a powerful tool for driving global public health agenda. yet, integral to such a process is how responses to pandemic influenza are framed and implemented locally as well as their attendant limitations. this theme is addressed in the next section. the human instinct for self-preservation has, at the social plane, always resulted in some institutional responses to diseases, whether rudimentary, barely adequate, or sophisticated. in the context of phds, responses are shaped by the nature of the specific disaster, where it is taking place, and what human, material, pecuniary and technological resources are available to deal with the given emergency situation. for instance, the united states prioritizes building a system that ensures stable and economically viable vaccines to engage influenza outbreaks. countries that lack the same kind of resource will clearly prioritize other approaches. however, the general approaches to pandemic influenza are therapeutic and non-therapeutic in nature. this section briefly examines them. pandemic influenza outbreaks, like most diseases, have elicited some biopharmaceutical responses geared towards mitigating its disastrous effects. due to the changing biological and social dynamics associated with the outbreak, social as well as scientific responses are always evolving to keep up. nevertheless, the therapeutic measures fashioned to combat pandemic influenza fall into two groups. these are preventive measures involving the use of anti-viral drugs as well as vaccination. in the past, drugs like rimantadine and amantadine were used as prophylaxis against influenza a. but drug resistance has increasingly been observed to these m -ion channel-blocking agents. today, drugs of choice are mainly tamiflu (oseltamivir) and relenza (zanamivir). black et al. noted that early anti-viral intervention during the pandemic helped reduce the doubling time in the early stages of the outbreak. the linkage between antiviral use and reduction in clinical severity and influenza infectiousness is generally supported in the extant literature. hence, treatment of clinical cases with anti-viral agents constitutes the first-line of engagement for pandemic influenza and these drugs are employed to control or contain pandemic outbreaks long enough for vaccines to be made. yet, drugs like oseltamivir and zanamivir, usually neuraminidase inhibitors, can only help reduce transmission if given within a day of the onset of symptoms. on the contrary, delay in symptoms diagnosis, as well as intervention, favors infection dissemination. nevertheless, antiviral agents for influenza offer some protection to families and households once infection has been detected. in clinical trials, antiviral treatments have been shown to be efficacious in preventing infection, hence, slowing down transmission as well as limiting the severity of the disease. but the effectiveness of neuraminidase such as oral oseltamivir and inhaled zanamivir at reducing mortality is uncertain. in addition, there is some evidence of side-effects. for instance, in adults as in children, oseltamivir increases the risk of nausea and vomiting. also, treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced. resistance to these anti-viral drugs has also been reported, even in people who have never been previously treated with them. ultimately, the success of antiviral prophylaxis critically depends on the identification of index cases in households, pre-schools, schools, and other institutional settings. this clearly highlights the importance of personal, social, and institutional cooperation in relation to dealing with the associated challenges. on the other hand, vaccination as one of the most effective and cost-saving strategies for ameliorating infectious diseases offers a protective approach to limiting and/or curtailing the social and economic consequences of pandemic influenza. two types of vaccines are generally used. trivalent inactivated vaccine and live attenuated influenza virus vaccine, both of which contain the predicted antigenic variants of influenza a(h n ), a(h n ), and b viruses. borse et al. estimated that vaccination program against influenza prevented , - , , clinical cases, - , hospitalizations, and - deaths. they also reported that the national health effects of vaccination were greatly influenced by the timing of vaccine administration and the effectiveness of the vaccine. similarly, ferguson et al. estimated that during a global outbreak, vaccination at the rate of % of the population per day would need to begin within months of the initial outbreak. but this is not feasible under current vaccine technologies. this pragmatic challenge would, however, create a biological and social climate in which infection may flourish in a logarithmic manner. the recurring antigenic variation in influenza viruses which leads to the frequent emergence of new infectious strains increases the likelihood of continuous outbreaks. this and the capacity of the influenza virus to acquire amino acid changes in its viral proteins implies that each outbreak will demand novel vaccines. this often delays the possible response time, again creating a window where infection can readily spread, locally and globally. for instance, it will take at least months from identification of a candidate vaccine strain until production of the very first vaccine during an outbreak. this biological fact makes it difficult to stockpile influenza vaccines ahead of outbreaks and, by consequence, limits the preparedness efforts geared towards confronting the public health challenges and moral quandaries. it is important to note that vaccines have some limitations. for instance, they are not entirely safe public health interventions, especially when specifics are examined. this fact has increasingly come to light in relation to vaccines against pandemic influenza. besides sore arm and redness at the injection site as well as red eyes which have been reported in earlier vaccine trials, there has been some association between increased incidence of narcolepsy in children and the use of the aso -adjuvanted vaccine for pandemic h n influenza in scandinavian countries. in addition, anecdotal reports of fetal deaths occurring shortly after vaccination emerged in and raised public health concerns about vaccine safety. another shortcoming associated with vaccination generally is vaccine failure, which often creates a false sense of protection in recipients while allowing the continued spread of infection. in relation to pandemic influenza specifically, vaccine failure was recently reported by manjusa et al. in people of years and above as well as those who have been vaccinated against seasonal influenza. this is quite troubling partly because vaccine failure vis-à-vis pandemic influenza vaccines has been little studied, and partly because there are countries like the united states where seasonal flu vaccine shots are almost the norm. another dimension to vaccine failure relates to the variation of influenza virus clades. nelson et al. recently reported that nigeria, côte d'ivoire, and cameroon exhibit more variable patterns of influenza virus seasonality, hence, there is a possibility of variants evolving locally within west africa. this, they further argue, undermines the assumption that a vaccine matched to globally dominant lineages will necessarily protect against these local lineages. this notion further raises the question of whether the immune system of populations living in tropical african hhs, "hhs pandemic influenza plan." p. b . environments would react similarly to a vaccine developed mainly for populations restricted to certain geographical areas of the world. on this note, in the possible event that someone originally from any of these nations were present in a pandemic influenza scenario outside african shore, the likelihood of their benefiting from vaccination seems slim. hence, a significant offshoot of vaccine failure in relation to pandemic influenza (especially if newer studies show more negative results) will be the reluctance of people to receive vaccines for seasonal flu and those developed for pandemic influenza outbreaks. these have unsettling public health and moral consequences. one way of engaging the limits of influenza vaccines involve creating a vaccine type that is capable of eliciting cross-protective peptides/epitopes that would be effective against different variants. but this is very difficult. besides the scientific technicalities, producing vaccines for pandemic influenza is not a cheap venture. for example, meltzer, cox, and fukuda estimated in that it would cost the united states about $ . billion to contain pandemic influenza. whereas the economic burden of influenza in lower-and middle-income countries involves direct costs to the health service and households and indirect costs due to a loss in human productivity, these countries also have limited financial capacities to pursue pandemic influenza vaccination as a public health tool. the impacts of the ensuing disease burden from such a constraint will not be locally confined, as it will ultimately seep into the trans-national and global terrains. in summary, the major and, perhaps, insurmountable constraint to vaccination as a tool for engaging pandemic influenza lies in the logistic challenge of producing a pandemic vaccine from scratch, conducting pre-clinical testing as well as generating billions of doses within a very short time for global distribution, which may, however, not work across all nations. but considering the limitations associated with antiviral drugs as well as vaccines in relation to combating pandemic influenza, some form of non-therapeutic approach is necessary, at least as some adjunct to mitigate the overall impact of pandemic influenza on the local and global human community. the next section addresses this theme. yazdanbakhsh and kremsner. p. e . the non-pharmaceutical and non-therapeutic approaches to pandemic influenza revolve around measures such as case isolation, school or workplace closure, restrictions on travel, quarantine as well as contact tracing. for instance, school closure is a non-pharmaceutical intervention often suggested for mitigating influenza pandemics. the logic behind this lies in the notion that children are important vectors of transmission, more infectious, and susceptible to most influenza strains than adults. it is also tied to the idea that high a contact rate in schools fosters transmission of infection. this approach, according to cauchemez and colleagues, may bring about an estimated % reduction in peak attack rates. however, this reduction will be hindered if children are not adequately isolated or if the policy is not well implemented. whereas school closure may only bring about a small reduction in cumulative attack rates, it can foster a substantial reduction in peak attack rates. closure of schools may, however, increase anxiety and create a crisis, as was observed in france during the outbreak. closure of workplaces is another non-pharmaceutical intervention for pandemic influenza. it may be warranted by the degree of the outbreak in which businesses shut down at their own discretion, and for their own safety, as was seen during the - outbreak. however, it may also be warranted by government policy. either way, business closure incurs huge economic costs, pecuniary, and other consequences for the different people tied to and/or dependent on the affected businesses or their services and goods. different forms of quarantine measures are also used to mitigate the spread of infection during an influenza pandemic. for instance, isolation and quarantine of infected patients allow some containment of infection which consequently slows down viral transmission. ultimately, quarantine contributes towards reducing the overall costs and impact of an outbreak. some medical experts see household quarantine as the most effective social distance measure, provided the level of compliance is good. yet, quarantine-at least on a general note-does not always work. for example, maritime quarantine was one of the measures employed in west africa to engage the influenza outbreak as well as interning the ill. however, historians like heaton and falola note that these approaches yielded meager success in relation to quelling the spread and virulence of the pandemic. measures such as cancellation of non-essential public gatherings and restrictions on long-distance travel might help to decrease influenza transmission rates as well as overall morbidity, their effectiveness has not been quantified. the nature of pandemic influenza, the therapeutic and non-therapeutic approaches, and the associated limitations generate some moral concerns. the next section discusses this. ethical issues arise during outbreaks of pandemic influenza. some of these are directly tied to the nature of the virus, some in relation to human responses, some to the social responses, and others to how different human beings respond differently to the several challenges elicited by the pandemic. bioethicists have underscored the critical need to reflect on the ethical issues raised by the specter of pandemic influenza outbreaks. however, what may and what may not be feasible to do will never be clear enough if these ethical quandaries are not clearly explicated. hence, this section seeks to clarify the moral quandaries elicited by pandemic influenza and show the core connecting strands that resonate amongst them. generally, contexts of uncertainty are tied to the evolving nature of knowledge. tannert et al. opine that uncertainty occurs because the more the human community gains insights into the mysteries of nature, the more they realize the limits of their knowledge about how things are. these limitations, they note, make it impossible to foresee all the associated future effects and implications of situations and decisions with certitude. in relation to medicine, jean daly notes that the art of medicine seeks to abolish uncertainty. regardless of the good intentions and telos of medicine, the stark reality is that this task has hardly been achieved. contexts. james marcum contends that uncertainty is largely a part of medicine because of the variability of the underlying biology. uncertainty is not new in the realm of science. however, in the context of public health disasters uncertainty has a strong pragmatic dimension which can influence courses of actions and decisions in multiple unfavorable ways. for example, it occurs during pandemic influenza outbreaks and generates many concerns. in this vein, borse et al. note that the public health community cannot accurately predict the arrival of a pandemic. indeed, a great deal of uncertainty occurs in relation to estimating the potential impact of a pandemic such as influenza. this scenario stifles preparedness efforts, especially in resource-constrained countries where there are often competing social needs to be met with limited budgets. however, the two main uncertainty issues embedded in pandemic influenza involve the nature of the virus and the types of responses available to engage outbreaks. on the one hand, the influenza virus undergoes constant variation in its antigens, creating new infectious strains. the virus also acquires amino acid changes in its proteins. these scenarios increase the likelihood of pandemic outbreaks. however, the question of when, where, and of what magnitude the outbreak will be is never clear-cut. worst-case scenario analysis based on the - pandemic provides no insight into the probability of an influenza pandemic in the next , , or years and how serious such an outbreak might be. this scientific uncertainty or paucity of precise knowledge ignites some social uncertainty and may prompt moral inertia in relation to the level of preparedness and the ability to mitigate the various possible ramifications of an outbreak, when it does occur. this backdrop of uncertainty creates at least three possibilities: over-preparedness, ample preparedness, and under-preparedness. assuming the level of risks remains constant, over-preparing for a pandemic will undoubtedly involve the committing and expenditure of more human and material resources to an outbreak. this will create a sense of waste (to decision and policy makers) after the incident and may affect the resources that will be committed to future outbreaks. the right amount of preparation will help curtail an outbreak while under-preparedness will barely help curtail an outbreak. however, if the level of risk increases, over-preparing may help curtail a pandemic whereas what was hitherto ample preparedness as well as what was hitherto not enough will enable the full range of the effects of a pandemic outbreak to be felt. " ibid. , no. ( ) . p. . kuby. p. . murray et al. pp. - . in other words, the changing nature of the virus demands a constant readjustment of the level of preparedness without a reliable frame of reference with the attendant possibility of some inevitable social harm. not surprisingly, scholars like peter doshi argue that there is a need for evidence-based ways to address hypothetical scenarios of non-zero probability such as the notion that novel influenza pathogens acquire increased virulence during successive "waves" of infection. the scientific uncertainty associated with health disasters such as pandemic influenza may, however, tempt government officials to attempt some form of a cover-up, hence, raising trust issues. for instance, during the cholera outbreak in naples, italian officials paid newspapers and reporters not to report the outbreak. chinese officials tried to keep the sars outbreak a secret. saudi officials, likewise, tried to silence the virologist who discovered the coronavirus in and ultimately forced him to resign from his position. incidents like these have the tendency to dissuade social cooperation during public health emergencies like influenza and have the potential to weaken the overall success of public health interventions. on the other hand, there is a lot of uncertainty surrounding the therapeutic and non-therapeutic approaches adopted vis-à-vis pandemic influenza. it is uncertain, for example, if neuraminidase antiviral drugs really cut down mortality when implemented as the first line of defense. this may create some sense of hesitation in relation to using them. secondly, it is uncertain who and who will not develop some of the associated side-effects. these factors, at a pragmatic level and for less rich nations, may dis-incentivize prioritization of funds for antiviral drugs. uncertainty likewise plays out in the context of influenza vaccines. for instance, only a small amount of any vaccine can be stockpiled because the scientific and public health community can hardly be sure of the efficacy of any given vaccine prior to an outbreak. this is due to possible vaccine failure which will make a new outbreak not amenable to the biological effects of hitherto effective vaccines. hence, vaccines are generally not produced until the new virus strain causing a pandemic is isolated. also, there is uncertainty over who will be at highest risk of infection and complications. this creates a dilemma of some sorts with the potential that a class of the people who need vaccines may not get enough, while another class of people who will benefit less from vaccination gets too much. another kind of uncertainty is linked with possible side-effects of vaccines. while some incidence of narcolepsy was reported in children after the use of aso -adjuvanted h n influenza vaccine in scandinavian countries, and there have been anecdotal reports of fetal deaths doshi. p. . shah. pp. - . hhs, "hhs pandemic influenza plan." p. s - . kotalik. p. . emanuel and wertheimer. p. . dauvilliers et al. pp. - occurring shortly after the vaccination ; it is not clear if these safety issues are one-off events or may recur for other pandemic vaccines. responding to influenza vaccine safety signals during a pandemic constitutes a scientific and public health policy issue since decision-makers must balance the immediate consequences of disease against uncertain risks. one of the consequences of the therapeutic uncertainties associated with pandemic influenza is the validity of administering potentially ineffective antiviral drugs with side-effects or vaccines that may cause harm to people. another is the validity of withholding such drugs and vaccines because it may not be useful for some class of people, or because some people may experience certain degrees of side-effects. these issues raise concerns about human rights and whether or not they may be violated through these courses of actions, or by any other course of action associated with handling a pandemic influenza outbreak. the universal declaration of human rights and the international covenant on economic, social and cultural rights documents enunciate the rights of "everyone to the enjoyment of the highest attainable standard of physical and mental health". hence, it is perhaps more than ever taken for granted that there are rights-related obligations that society, as well as healthcare providers, owe patients as well as those that may potentially fall sick. since everybody is theoretically a potential victim of ill-health depending on time, placek and social or physiological circumstances, individuals can appeal to a rights-based rhetoric to garner positive action from government and healthcare professionals in relation their health. the morality of such a claim stems partly from governments' moral obligation to their citizens and partly from the fiduciary obligations that health professionals have towards fostering the health of patients (and potential patients) in a fashion that preserves their rights as human beings. many moral concerns related to human rights come to the fore in the context of pandemic influenza outbreaks. the first is related to the limited number of vaccines that can be available for each outbreak (due to reasons outlined in the preceding section) and the best sharing formula to use. whatever adopted formula in a given place or situation, some people who may benefit could be excluded. for instance, pandemic influenza often generates a high number of sick people over a large geographic area who will need care at the same time. while this "need" begins at the local plane, it may evolve to be regional and/or global depending on the extent and severity of an outbreak. hence, the human and material resources of healthcare will be rapidly depleted and overwhelmed. since the needs of everyone cannot be met under such a scenario, there is usually some need to ration available resources. in fact, vaccines are hardly enough during pandemics, and rationing is generally considered as the ethical option. yet, the contemporary interconnection between health, the right to health and human rights implies that withholding vaccines from some people who might be potential victims of a pandemic outbreak may be a human rights violation. on the other hand, administering antiviral drugs to non-vaccinated at-risk people helps reduce the severity of illness. during disaster scenarios, the goal remains saving lives but a pandemic scenario in which - % of the population can fall sick within a very short time often demands some type of prioritization of resources. this is partly because keeping some sets of people alive, especially health workers will ultimately help society keep more people alive during a public health disaster. for instance, the traditional view is that prioritizing the vaccination of front-line healthcare workers can help reduce staff absenteeism as well as help prevent them from becoming vectors of viral infection. this is often justified by the logic that a phd situation such as pandemic influenza often makes health professionals work outside their normal scope of practice, put in extra hours, cover for ill workers, accept great risks as well as incur other situational unexpected responsibilities and supererogatory duties. although adults aged years or older, pregnant women, and people of any age with underlying medical conditions are at high risk of pandemic influenza and its associated complications, the notion that death is more tragic in children and young adults as opposed to elderly persons, perhaps, because younger persons have not had the chance to live and develop through all stages of life and accomplish their dreams has made some ethicists argue for the prioritization of vaccines to younger people. yet, if persons are inherently born with human rights and do not have to earn rights, such an idea tends to revamp the rights to health of some class of people at the expense of others. indeed, notions such as this echo the idea that mainstream bioethical issues tend to be far-flung from the values of ordinary people and often irrelevant to the decisions they experience in their encounter with healthcare. in other words, an empirical approach which takes into consideration what people would want when faced with this thorny dilemma rather than an armchair speculation ought to influence the criteria for rationing vaccines. one of the non-therapeutic responses to pandemic influenza is the isolation and quarantine of infected patients. whereas a visibly infected and sick person may have just a little objection to quarantine (after all, such a state mirrors the ambulatory limitations that most disease states naturally impose on people), it is often problematic for other categories of people. in this vein, isolation and quarantine raise concerns about the acceptability of confining people and preventing them from engaging in some of the social activities they otherwise would have loved. whereas restriction of movement is ethically problematic, it is equally problematic to allow person a who may be infectious to roam free, thereby potentially infecting other persons who may also (without the imposition of some restriction) further spread infection. it is clear from the foregoing that pandemic influenza challenges and raises some moral concerns regarding the rights of people, preempting the need to balance them against what is the optimal good of the society. but embedded in these reservations is the demand for autonomous living, broadly conceived. whereas this has been associated with western contexts, concerns about rights violations in relation to quarantine measures are not confined to the west. sambala and manderson recently commented about how ghanaians and malawians perceive public health interventions including quarantine as being intrusive. but this perception seems to run contrary to the cultural norm of most african people. in relation to this strand of thought, shah notes that during epidemics, the traditional attitude of the acholi people of uganda involves working together to isolate the sick, mark homes of the sick with long elephant grass, warn outsiders not to visit affected villages, and refraining from potentially infection-transmitting practices including sexual intercourse. this suggests at least two things. one, in traditional african societies there may be some fairly general consensus about the need to adopt mutual and social cooperation for the overall benefits of the society in engaging collective threats. secondly, it shows how the global village has increasingly penetrated and fragmented societies that were once non-individualized in orientation. but it seems that societies have been affected differently by the globalizing current of individualistic logic. for instance, macphail whereas europeans and americans generally view quarantine during influenza as almost worthless, asians such as hong kongers, expect it as the norm during health disasters, and demand it. this probably shows how strong an influence the communal-oriented confucian idea still exerts in that country. in the context of pandemic influenza outbreaks, over-emphasizing individualism and the attendant call for autonomy (even when such does not cohere with social interests) overlooks communal values and the relational nature of social interactions. it likewise ignores the complex nature of pandemic influenza and how it plays out in an equally complex web of this global age and how people more or less are susceptible to the harms of public health disasters regardless of their proximity. it has also contributed, as lachman argues, to a reduction in the fear of infectious diseases by increasing the emphasis on patients' rights, giving rise to a dangerous complacency that may do great damage to the goals of public health. one of the ways to address the attendant dangers inherent in this almost pervasive trend is recognizing the vulnerabilities even to far-flung harm that is fast becoming an integral aspect of contemporary life. vulnerability-in different forms and facets-plays out in pandemic influenza, as in other public health disasters. traditionally, belonging to the human community or occupying specific facets of life constitutes sources of vulnerability. but the state of being susceptible to harm by the actions and activities of other people or by parts of nature such as viral organisms is also a potential source. in addition, the state of vulnerability may ensue from a range of social, economic, and political conditions. in the context of pandemic influenza, the naturalistic, socioeconomic, epistemic, political, and biological dimensions of vulnerability arise. on the one hand, humans located in pandemic-prone cities or countries and other human beings linked to the global community by technological means of transportation (such as air travel) or non-technological ones (such as migrating birds) are generally vulnerable to influenza outbreaks. the likelihood of a novel strain of influenza outbreak occurring in a country such as china (for instance, jiangcun in guangzhou) where large numbers of people, birds, and swine mingle freely in certain markets is very high ; hence, making the local population and consequently the people of such a nation more vulnerable. macphail, the viral network: a pathography of the h n influenza pandemic. pp. - . bennett and carney. p. . peter j lachmann, "public health and bioethics," the journal of medicine and philosophy , no. ( ) . p. . henk ten have, "vulnerability as the antidote to neoliberalism in bioethics," revista redbioética/unesco , no. ( ). p. . on the other hand, the strength of health systems reflected by availability of experts, economic and technical resources will vary the extent of pandemic-related vulnerability which different societies will experience. in addition, it is widely believed within the scientific community that influenza pandemics can hardly be halted, but they can be delayed. therefore, the "ignorance gap" that occurs during pandemic influenza outbreaks creates a context in which some of the preparatory strategies will inevitably fail (due to no fault of anyone), thereby leaving some people less protected. in relation to the socioeconomic dynamics, it is estimated that most influenza pandemic-associated deaths occur in poor countries or in societies with scarce health resources which are already stretched by extant health priorities and challenges. farmer and campos underscore the need for bioethics to engage the growing problem posed by the gap between rich and poor nations, and how such a course of action reflects social justice. politically, communist nations such as china present unique dimensions to the vulnerabilities of pandemic flu as they may control critical information traffic and access to patients, thereby deepening the crisis situation, or misrepresenting it, and thereby subjecting the rest of the connected world to avoidable risks. the biological make-up of human beings both make them vulnerable to becoming infected with influenza virus as well as make them good vectors of dissemination. for instance, the virus has a surface molecule that enables it to attach firmly to cells in the mucous membranes of the respiratory tract, preventing it from being swept out by the ciliated epithelial cells. but breathing is a normal aspect of human existence, and the oxygenation of the human blood and other oxygendependent biochemical processes of the human body rely on it. yet, the combination of these factors facilitates the ready transfer and exchange of the influenza viruses amongst people, especially when they are in close proximity. the foregoing shows how susceptibility and vulnerability to infection during pandemic influenza reflect a combination of factors. how these combine in specific localities and regions will, therefore, determine the extent of an outbreak. it is also clear that some amount of control can be exerted on minimizing some of these factors. for instance, the use of face mask (to limit infection acquisition and spread), transparency (to combat political bottlenecks), and monetary aid (to help poor nations) will exert some preventive effects on infection transmission, hence, limiting the overall burdens and severity of an outbreak. since everyone may not receive the same level of healthcare for various reasons during a public health disaster (depending on time, place, and category of persons such as adults, the aged, or children), questions about justice and what is just in the context of a pandemic outbreak arise. pandemic outbreaks exacerbate extant inequalities to the extent that certain groups of people face disproportionate risks and impacts of disease. this obviously seems unfair, especially if pre-pandemic actions that would have ameliorated the situation were not done. for instance, school closure in certain districts may interrupt educational opportunities or growth of some children, and business closures will lead to financial losses. since such restrictions may not apply to every region of the nation, these measures may seem unfair to those affected, knowing that other children continue to have access to education, and other people continue to run their businesses. if this characterizes the feelings of some of the people affected by these restrictions, then it is reasonable that some form of compensation may be required to foster optimal compliance to the public health measures that are to implemented. indeed, bioethicists like michael selgelid and søren holm make explicit arguments for some form of compensation to people who suffer financial and other losses due to compliance with public health directives issued during influenza outbreaks. although compensation may not be a problem in more affluent nations where other educational stimulus and business tax breaks may help alleviate any temporary pandemic-associated losses, poorer countries will find it hard to compensate people for any such losses. rationing also raises issues about justice in terms of how vaccines (if available) will be shared during an influenza pandemic. given the limited amount of supply available globally, and locally in a developed economy like the us, distributing the limited supply will require determining priority groups. for people not to feel a sense of being left out during local vaccine administration, it is better to have debated and developed a preparedness plan with the consensus of the local populace. resolving vaccine distribution on a global scale will, however, involve very complex sets of factors. for instance, will countries who supply most of the technical and financial resources to develop such an influenza vaccine demand that the needs of her people be prioritized as opposed to the needs of nations that have contributed little or not at all? even if such a question were not explicitly raised, will it be fair to distribute vaccines equally if every country or affected region has not made significantly even contributions? these are unsettling questions that are bereft of simple answers. some ideas stand out when all the ethical issues generated by pandemic influenza are closely examined. four of these ideas demand attention. the first is the need to help people. secondly, the nexus of relationship that exists between people henk ten have, vulnerability: challenging bioethics (routledge, ). pp. - . michael j selgelid, "promoting justice, trust, compliance, and health: the case for compensation," the american journal of bioethics , no. ( emanuel and wertheimer. p. . and the influenza virus and the changing nature of what is known as well as what can be done to help people under such constraints will limit the help some people may ultimately get during an outbreak. thirdly, the threat of an outbreak presents different risks which vary by context, time, and place. lastly, regardless of the different situational dynamics that pandemic influenza presents locally, regionally, and globally; its threat will affect everyone to varying degrees. since nations theoretically care about their people, it is only reasonable that a people-centered approach offers a useful way to engage the moral quandaries elicited by pandemic influenza outbreaks. the subject matter of diseases is human populations. in fact, the preoccupation of medicine remains the amelioration of the distress of people technically referred to as patients. if a people-centric approach constitutes a viable way of engaging the ethical issues embedded in pandemic influenza scenarios, one way to glean a sufficiently nuanced angle on such an approach will involve turning to ethical lenses that are, in principle, people-oriented. two principal examples of such ethical prisms are communitarianism and ethics of care. this section briefly explains each of these moral lenses, and how each may help engage the ethical issues generated by pandemic influenza. the communitarian moral lens adopts a people or community-centric perspective to moral issues. applied to public health, it offers a population-centered approach which best reflects the philosophy of public health in terms of its commitment to doing the most for the greatest number of people in a society or within a social context. bioethicists like stephen holland regard the communitarian lens as useful since it aims at realizing collective interests. this same idea offers a strong justificatory argument for adopting it in relation to public health interventions. communitarianism pays attention to the social sphere, institutions, and interrelationships in relation to moral judgments that will inform public health policy and practice. its ethos provides an alternative to the dominant atomistic lens of individualism which operates via the logic of self-protection and the unbridled macphail, the viral network: a pathography of the h n influenza pandemic. p. . stephen holland, public health ethics (polity press, ) . pp. - . pursuance of self-interests. it holds that the social nature of life and institutional and social relationships should inform moral thinking, and by implication, the process of determining appropriate courses of actions should lie within the social space. to be sure, the communitarian notion appeals to the historical traditions of communities or people who share customs, ideals, and values ; and thus prioritizes common threads of thought and practices within specific communities as a strong moral basis for justifying decisions that pit different individual and social interests against one another. there is an important phenomenological aspect of communitarianism. for people raised within the traditional family structure-father, mother, children, and relatives-the family unit constitutes a micro-community which generally socializes the child into a community-oriented way of reasoning. while the strength of such an orientation is expressed in different measures by different individuals, it also provides the cognitive platform for balancing and pursuing personal interests in a feedback loop with the collective interests of other family members. yet, the ultimate measure of what level of community-oriented reasoning an individual retains in adult life will depend on their education, social experiences, whatever meanings they draw from these, and how these parameters are brought to bear in the context of specific decisions and choices. this reality partly explains the multiple versions and interpretations of communitarianism, which tends to mar its conceptual and theoretical coherence. it also partly explains why community values are not generally shared by all. communitarians advance three different types of claims: descriptive claims which stress the social nature of people; normative claims which celebrate the value of community and solidarity, and a meta-ethical claim which emphasizes the idea that political principles should mirror "shared understandings'. two of these dynamics-the normative as well as the metaethical-are important in relation to engaging the ethical issues elicited by pandemic influenza. the significance of the meta-ethical dimension of communitarianism is its capacity to help drive and ground public health policies. this is especially so considering the reality that community and living together in today's fragmented and individualistic world is generally seen ever less as a necessity and assumes the dimensions of a choice as the default state. hence, these two facets will be examined in relation to their possible insights and pragmatic importance vis-à-vis engaging the quandaries associated with influenza outbreaks. healthcare focuses on helping sick people regain optimal health and healthy people maintain good health. pellegrino and thomasma remark that medicine seeks to foster social flourishing as well as the medical good of society. if this is true, and if the end of the communitarian moral lens is to ensure the survival of the society by promoting the interests of people over the selfish interests of individuals, then how can this approach help engage issues of uncertainty, vulnerability, human rights and justice? this can come through appropriate educational policies and approaches carried out prior to and during influenza outbreaks. it is not known when and in whom influenza therapeutic interventions such as antiviral drugs and vaccines may cause side-effects. it is also not known when an outbreak will occur or the attendant magnitude. since public health disasters are classless in terms of who will and who may not be affected, the scenario of uncertainty affects every segment of people in the local communities and nation. hence, health workers, government officials, the rich, the poor, the educated and illiterates and other possible stratification of society are potential victims. a communitarian ethos is useful in at least two ways in relation to dealing with the uncertainties associated with pandemic influenza. generally, it can-with the right pre-disaster public education-help ensure that people understand the unavoidable scientific and knowledge-related gaps in preparedness policies and specific plans put together to engage a specific outbreak. this will help avoid or minimize blame, since scapegoating during disease outbreaks causes different shades of disruption and target important actors including health workers. in fact, the better educated the public is about the challenges of stockpiling vaccines, the more cooperative they will likely be to the vaccine-supply challenges that arise during an outbreak. a communitarian ethos may also help engage the real and possible harms that may ensue due to the therapeutic uncertainties associated with pandemic influenza. these harms arise from the uncertain nature of what is knowable about a pandemic virus before it strikes as well as the biological limits of the therapeutic arsenals often produced within a very narrow time window. this is also generally tied to the reality that new health interventions including drugs and vaccines come with the possibility of some adverse events, which may be linked to the chemical/biological/physical components of the product, to genetic susceptibilities in certain individuals, or to edmund d pellegrino; david c. thomasma, "the good of patients and the good of society: striking a moral balance," in public health policy and ethics, ed. michael boylan (springer, ) . pp. - . shah. p. . environmental triggers. keeping the public aware of this fact before and during an outbreak as well as emphasizing that accepting these risks (though uncomfortable at the individual plane) will serve to ensure the society overcome a pandemic should help garner some level of support critical to ensure proper compliance. since people are born with inherent human rights and do not have to earn them, it is hard to justify trumping the rights of some for the sake of public health. this is especially so if the people whose rights may be inhibited or violated do not consent to the process. to avert this, a discursive approach involving inclusive deliberations is essential. in this vein, the communitarian lens can help foster dialogue as well as call for the need to reward people for the sacrifices they may or will bear on behalf of the community and the society. for instance, guaranteeing that some compensation will be paid for financial losses incurred through workplace closure as well as apt public education about the nature, purposes, and conditions of quarantine facilities will help convince people that such temporary rights-related inconveniences are for the benefits of the overall society. in relation to vulnerability and justice, the communitarian lens can help clarify the different kinds of social, biological, and natural vulnerabilities that face different people in different contexts. for example, it can offer a way of making the important distinction between general vulnerability that people will experience as human beings, vulnerability based on age, and occupational vulnerability seen in health professionals. based on these distinctions, it can help underscore how context-specific cooperation will help ensure the overall success of the countermeasures adopted to engage a given pandemic. critical to this, however, is the moral currency of trust. trust shapes how the public evaluates risks and benefits. it also influences the acceptance of prescribed public measures to mitigate present or perceived risks. effective risk and crisis communication depend on public trust in the government during a pandemic. as such, a higher level of trust will influence a more positive level of social compliance. van der weerd and colleagues corroborated this in their empirical study of the pandemic in the netherlands. in addition to trust, transparency in terms of how priorities will be made in terms of the allocation of vaccines as well as antiviral agents, and decisions pertaining to school and/or workplace closures is important. even in western climes, public health experts have sometimes pointed out the paucity of transparency in ethical reasoning and the scanty explicit ethical justification for pandemic-related policies. obviously, an atmosphere of trust and transparency will be conducive to discussing and addressing issues related to local justice. this is especially relevant in relation to less wealthy nations or countries with weak institutions. for instance, it will be hard to garner cooperation in hitherto abandoned communities by appealing to communitarian ethos without addressing extant disparities in the social fabric as well as the healthcare system. if human beings are located in particular communities but are willy-nilly part of a global community, how well the vulnerability and justice-related issues are locally addressed will influence the extent of their regional and global dynamics. this echoes the notion that badly managed local issues associated with pandemic influenza will pose more challenges and burdens at the regional and global levels. since every nation lacks an equal capacity to deal with the local burdens of pandemic influenza, it is necessary for wealthier nations to rally around poorer ones. indeed, the transcontinental nature of health disasters including pandemic influenza and sars underscores the urgent need to strengthen how the global community deals with emerging infectious diseases, and how novel visions of global solidarity and cooperation will be key in such an endeavor. this constitutes a preventive stance and falls well within the traditional agenda of public health. this approach is also a reasonable economic and health security choice as it will statistically cut down the possibility of global and transnational infection dissemination. while the communitarian ethos as argued above offers some insights into how to flexibly engage the moral dilemmas generated by influenza outbreaks, its application in non-community-oriented contexts potentially raises some difficulty at the institutional and individual planes. such possible difficulties, however, call for a global but locally nuanced moral framework. that theme, however, will be addressed in chap. . for now, the rest of this chapter will explore another people-centric moral lens, care ethics, in relation to resolving the quandaries of pandemic influenza. in addition to the communitarian lens, the ethics of care perspective (eoc) constitutes a people-centric method of attempting to resolve ethical issues. whereas it sometimes arrives at the same conclusions reached by traditional bioethical approaches, employing it as a complimentary approach to the moral quandaries generated by pandemic influenza should yield additional nuances and insights visà-vis resolving the associated moral concerns. care ethics emphasizes varying degrees of care within relational contexts ranging from the personal sphere to the realm of moral strangers. hence, it is an other and people-centric moral lens. it has henk ten have, global bioethics: an introduction (routledge, ). p. . peter a singer et al., "ethics and sars: lessons from toronto," british medical journal , no. ( ) . pp. - . edwards, "is there a distinctive care ethics?" p. . been applied to diverse relational contexts including everyday lives, professional practices, social and public policies, as well as international relations. for scholars like steven edwards, ethics of care uses a distinct ontological commitment to realize its outcomes as well as justify its stance. it is an attempt to re-conceptualize and renegotiate the moral landscape in order to give room for a plurality of values. some have argued that the removal of friendship with its altruistic emotional sequelae and the subversion of virtue ethics from the sphere of morality were some key factors that warranted the moral change which birthed the ethics of care framework. while eoc is also linked with gender-based morality which undergirded campaigns for equal employment opportunities between the sexes, legal rights, reforms of family life and sexual standards, and better education ; scholars like noddings have pointed out that it is broader and deeper than feminist ethics. to be sure, one of its major impetus is the call for the expression of higher capabilities. care ethics also encapsulates a spectrum of ideas. for kittay, care constitutes an "achievement term" such that caring occurs only when specific acts of care have been carried out. in this vein, intentionality would not qualify as part of the baggage of care rhetoric. this obviously has some pragmatic appeal. most people, for instance, would only appreciate care if it helps contribute towards relieving their current distress. yet, caring may also constitute a general attitude and an orientation which may provide appropriate background conditions for shaping responses to others' needs and states of distresses. also, one may care but situational constraints may limit how a caring impulse may translate into pragmatic ends. therefore, that someone simply "lacked opportunity" to show care as apostle paul writes in his epistle to the philippians does not necessarily indicate the absence of care. hence, caring cannot be reduced only to materialistic terms. one way to distinguish the general caring orientation from specific acts of care is to refer to each as "caring about" and "caring for" respectively. care ethics locates morality within the ambiance of family, friends, and colleagues, and ultimately towards the public sphere. it rejects the independent and atomistic notion of the self and champions an inter-dependent and inter-related view. this approach grants eoc a psychological gestalt to which people brought up in caring relationships, at least in the early phases of their lives, can readily identify with. it thus partly appeals to kohlberg's theory of moral development. here, the emphasis is put on the foundational roles of trust and its place in fostering a deepened sense of reciprocity within a social context of inequality. not surprisingly, some ethicists describe caring as the primary virtue which offers a general account of right versus wrong actions as well as political justice. whereas the informal social contract idea underlies inter-personal and stateindividual relationships, the care ethical lens may be applied to the personal sphere as well as social institutions due to its multiple ways of situating relationality. indeed, eoc focuses on attentiveness and sensitivity to the needs of others and offers a moral compass for teasing out delicate boundaries between obligation-based ethics and responsibility-based ethics. as such, it seeks to transcend the depersonalized realm of asking "what obligations do i have to mr. x" to the humane realm of asking "how can i help mr. x" in scenarios of moral crises. since caring embodies an activity, a set of activities or a labor of care from one person to the other, it presupposes that the capacity for receiving care will be present in the recipient(s) of care. public health disasters including pandemic influenza with their myriad of ethical and pragmatic challenges create a spectrum of needs and contextual dependencies which some people will have to meet, directly and indirectly. it thus creates different types of carer versus cared-for relationships between and amongst victims, atrisk people, health workers, and government officials. since it is a foundational nexus like these that underlie the caring ethic, it will be insightful to examine how the ethics of care moral lens may help resolve the moral dilemmas elicited during pandemic influenza outbreaks. osuji. p. . whereas tirima recently argued that ethics of care is irrelevant to addressing the moral imperatives in disaster scenarios because it only builds off on relationships and, therefore, requires some proximity between the caring moral agent and the cared-for victim, such a stance is flawed for at least three important reasons. firstly, care ethics can, through relevant public policy, positively influence how victims of disasters are cared for. secondly, contexts of duty exist between some of the players and victims of disasters which form the basis of a relationship of caring. for instance, healthcare professionals incur fiduciary duties to at-risk people, victims of a public health disaster as well as the general populace that may potentially be infected and infect others. thirdly, if the care ethical prism emphasizes how individuals may offer help "in scenarios of moral crises, then it should be relevant in health scenarios where different kinds of conflicting moral emergencies occur. the application of care ethics to specific disaster contexts such as influenza outbreaks, however, requires elaboration. specifically, this needs some explication with reference to issues of uncertainty, vulnerability, human rights and justice. whereas the dilemma of uncertainty that arises during pandemic influenza affects everyone, it will affect different sets of people differently. for instance, the biological uncertainties associated with an influenza outbreak are not known to the same extent by public health experts, health workers, the literate, and illiterate members of the society. caring about the potential practical consequences that may result from the attendant "ignorance" gap should, therefore, involve sharing as much useful information as possible between and amongst the different rungs of people. the relational context, in this regard, may be situated and realized through professional associations, institutional contexts, public announcements through media outlets and patienthealth professional interactions. kunin et al. recently reported on how primary care physicians helped pass on important pandemic-related information to out-patients during the pandemic in israel. this, they concluded, helped enhance the success of the national pre-pandemic preparedness plans. indeed, during public health disasters, the speed at which information is needed by policymakers may be faster than is usually possible through traditional mechanisms of research dissemination. this scenario makes information sharing a norm; even possibly those provided by preliminary research findings. humans instinctively show care to other humans in need. while this caring instinct has been socially modified and conditioned in some parts of the world where individualistic tendencies run rife, some communal-oriented cultures give room for a freer expression of the instinct of care. the instinct of care may, however, be counterproductive in the context of phds. for instance, during pandemic influenza, sick and dying patients remain active carriers of infection, as such, will infect susceptible friends and relations who feel obligated to show care in relation to helping them. in other words, "unbridled" caring may increase the vulnerabilities elicited during pandemic influenza. yet, the care ethics moral lens may help modify and re-direct the caring impulse in a more socially useful way during a pandemic. the other-centric nature of the eoc lens implies that people should care not only about themselves but about others, perhaps, even moral strangers. how person a will care during a public health disaster will, however, differ from how b will choose to act in a manner that reflects care, depending on their levels of knowledge, resources available to them as well as their social and spatial location. in other words, how a healthcare worker will care professionally in the hospital context and supererogatorily in the non-hospital context will differ from how a lay member of the society can show care in a pandemic situation. however, appealing to the eoc may help facilitate the selflessness needed. if someone cares that their society survives an influenza outbreak, then they should be willing to play roles that will help bring about that goal. this will facilitate compliance with therapeutic measures such as vaccines and antiviral drugs as well as non-pharmaceutical measures such as contact tracing, quarantine, and workplace closure. collective adherence to these measures will help cut down the susceptibility and vulnerability of individuals, groups of people, and the society to the impact of influenza outbreaks. by enabling the willingness of people to subject themselves to the public health restrictions required to contain pandemic influenza and accept the potential risks and side-effects associated with vaccines and antiviral agents, the eoc approach may indirectly eliminate or downplay the human rights-related quandaries engendered by pandemic influenza. noddings has argued that attentiveness and responsiveness are exigent to rights, flowing from one person to the other. if this is true, then the eoc may help individuals adjust the emphasis they place on articulating their rights contextually during an influenza pandemic for the sake of the collective good. finally, an appeal to the care ethical lens may help address the moral quandaries associated with local justice. although some versions of care ethics hold the posi- ns crowcroft, lc rosella, and bn pakes, "the ethics of sharing preliminary research findings during public health emergencies: a case study from the influenza pandemic," eurosurveillance , no. ( ). pp. - . shah. p. . noddings. p. . tion that it is not possible to integrate and apply justice to care, such a limitation hardly applies to the context of a public health disaster such as pandemic influenza. for instance, the different conflicting priorities that arise during influenza outbreaks such as rationing of limited resources will be easier if some people are at least willing to forgo their interests for others. in non-familial carer and cared-for relationships involving at-risk government representatives and at-risk members of the society and familial relationships involving parents and children living in the same house, an appeal to a care ethical lens may help drive the moral sensitivity to the needs of others, enabling some vaccine-eligible persons (under the standard rationing criteria) to forgo their ration, preferring rather that other at-risk people (for example, ordinary people and younger family members) have them. this kind of selflessness approximates some form of humanitarian act in that person a decides to overlook their interests for others "without expecting rewards". however, because human beings naturally seek their own personal interests, there may be some difficulty in achieving this other-centric goal in as many people as possible in a public health disaster situation. this implies that the care ethical lens may have some limitations in relation to sufficiently engaging the ethical dilemmas raised by pandemic influenza in particular and other types of public health disasters, in general. that theme will, however, be addressed in chap. . during disasters, there is the utilitarian goal of doing the most good for as many people as possible with minimal harm. a people-oriented moral lens, this chapter argues, may be apt in accomplishing such an agenda. the chapter explored the strengths of the communitarian and care ethics moral lenses in relation to engaging the moral quandaries elicited during pandemic influenza outbreaks. because it is difficult to engage pandemic outbreaks with little prior preparation, these moral lenses become important since they can help people develop an other-centric orientation and sensitivity to the needs of others. to systematically drive the importance of a people-centered approach to pandemic influenza, this chapter explicated the biological make-up of the influenza virus as well as the social and global features of the associated pandemic. this helped underscore the local, regional, and global seriousness of pandemic influenza as a distinct type of public health disaster. the chapter went on to show how an barnes et al. p. . vawter, gervais, and garrett. p. . understanding of the social and biological dynamics of influenza has shaped the therapeutic and non-therapeutic approaches to engaging outbreaks. it also articulated some of the attendant limitations of pandemic influenza countermeasures including vaccines and anti-viral drugs. this chapter has also highlighted the ethical quandaries generated by influenza outbreaks. these are issues related to epistemic and social uncertainty, biological, social, geographical and political vulnerabilities, potential violations of human rights through some of the therapeutic and non-therapeutic countermeasures, as well as issues of local and global justice. against this conceptual background, the chapter pointed out how helping people is a central concern in pandemic influenza, and how the thorny ethical issues constitute difficulties encountered in accomplishing this goal. on that note, it showed how people-centered lenses such as communitarianism and ethics of care may be useful in engaging the associated practical and moral challenges. to clarify the importance of each of these approaches, the chapter elaborated each of these ethical lenses, and showed how each may help orient different players in the context of a pandemic influenza towards acquiring a sense of community and an other-centric sensitivity which will be 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w ue wo given the medical and cultural perspectives on deafness it is important to determine if genetic counselors’ attitudes toward deaf people can affect counseling sessions for deafness genes. one hundred fifty-eight genetic counselors recruited through the national society of genetic counselors listserv completed an online survey assessing attitudes toward deaf people and scenario-specific comfort levels discussing and offering genetic testing for deafness. respondents with deaf/deaf friends or who work in prenatal or pediatric settings had more positive attitudes toward deaf people than those without deaf/deaf friends or those working in ‘other’ settings. more positive attitudes toward deaf people correlated with higher comfort level talking about genetic testing for the two scenarios involving culturally deaf clients; and correlated with higher comfort level offering genetic testing to culturally deaf clients wishing to have a deaf child. attitudes and comfort level were not correlated in the scenarios involving hearing or non-culturally deaf clients. these results suggest that genetic counselors’ attitudes could affect information provision and the decision making process of culturally deaf clients. cultural sensitivity workshops in genetic counseling training programs that incorporate personal interactions with culturally deaf individuals are recommended. additional suggestions for fostering personal interactions are provided. since the discovery of gjb , the gene that encodes for the connexin protein (denoyelle et al. ) and accounts for up to % of nonsyndromic sensorineural deafness in some populations (kenneson et al. ) , the number of hearing and deaf individuals seeking genetic counseling and testing for deafness for diagnostic, carrier, and prenatal purposes is anticipated to increase (withrow et al. ). however, deaf and hearing individuals' attitudes toward, and use of genetic information related to deafness can vary considerably due to different cultural and medical perspectives on what it means to be deaf (brunger et al. ; burton et al. ; dagan et al. ; guillemin and gillam ; martinez et al. ; middleton et al. ; steinberg et al. ; stern et al. ; taneja et al. ; withrow et al. ) . currently unknown is the extent to which the attitudes of genetics professionals toward deaf people play a role in the use of genetic information for deafness. however, there is evidence that attitudes and biases can influence both content and presentation of information relevant to decision-making (shiloh ; shiloh and sagi ; tversky and kahneman ) and the options that health care providers offer (bach and tilton ; ormond et al. ; rebagliato et al. ; shaw et al. ) . thus, it is important to determine if genetics counselors' attitudes toward deaf people can affect genetic counseling sessions. many deaf individuals consider themselves to be part of a linguistic and cultural minority group (johnson and erting ; lane ; padden and humphries ) . just like any other culture, deaf culture has its own customs, values, history, beliefs and traditions, and a large fraction of this group marry from within the cultural group (lane ; padden and humphries ) . the degree of hearing loss does not necessarily determine cultural identity for members of the deaf community (israel et al. ) . instead, the strongest determinant of cultural identity is the linguistic preference of a signed language, e.g., american sign language (asl) (lane ) , and it is estimated that asl is the linguistic preference for up to half a million individuals in the united states (mitchell et al. ) . in contrast to most ethnic and minority groups, however, most members of the deaf community are not part of the community from birth; instead they join later in life (lane ) . this phenomenon is explained by the fact that - % of deaf people are born to hearing parents (mitchell and karchmer ; schein and delk ) and learn about deaf culture in places outside of their hearing families, such as deaf schools or social gatherings (padden and humphries ) . the exception occurs with the birth of a deaf child into a deaf family which enables continuation of deaf culture from within the family (bauman ; lane and grodin ) . most importantly, the deaf community considers being deaf a linguistic and cultural characteristic worthy of preservation and not a medical condition requiring treatment (christiansen ; lane and grodin ; middleton et al. ) . the medical perspective of deafness is pervasive among most hearing individuals as well as some deaf individuals, particularly late-deafened individuals who had been part of the majority culture from birth, i.e. the hearing society (lane ) . this perspective views deafness as a pathology which requires remediation particularly targeted toward facilitating oral speech and using residual hearing (lane and grodin ) . currently there are no empirical data on genetic counselors' attitudes toward deaf people. since virtually all genetic counselors are hearing, there have been efforts by several genetics professionals to educate genetic counselors about the provision of genetic counseling to deaf people (arnos et al. a, b; israel et al. ) . from a social psychology perspective, however, members of the deaf cultural and linguistic minority group form an 'outgroup' relative to hearing individuals (cooper et al. ; johnson and erting ) . based on the contact hypothesis, personal interactions between groups is a key component for developing, maintaining, or changing attitudes toward the groups (dovidio et al. ) . hence, it may be difficult for genetic counselors to understand deaf culture without direct interactional experience with that culture or its members. this lack of contact between groups could greatly impact genetic counselor's attitudes toward deaf people and affect relationships between genetic counselors and their culturally deaf clients. a recent study with mental health providers supports the contact hypothesis with respect to attitudes toward deaf individuals (cooper et al. ) . in that study, greater amount of contact with deaf individuals of 'equal and higher social status' related to more positive attitudes toward deaf people among mental health providers. studies regarding application of the contact hypothesis with medical students and individuals with disabilities have found that the more contact medical students had with people with disabilities, the more positive their attitudes were toward people with disabilities, and the more comfortable they felt with their interactions (tervo et al. (tervo et al. , . although these latter findings are important, comparison with the disability literature is not meant to imply that deafness is solely viewed as a disability, because it is also part of a cultural and linguistic framework. comparison with the disability literature is furthered limited by empirical evidence that the structure of attitudes toward deaf people differs from the structure of attitudes toward people with disabilities (kiger ) . these prior studies of the contact hypothesis in other health professions suggest that genetic counselors' attitudes toward deaf people will depend in part on having personal and professional contact with deaf individuals, and that their attitudes will affect their level of comfort in their interactions with culturally deaf clients. however, empirical data are needed to address these questions because the strong philosophy of non-directive counseling and empathy in genetic counseling (mccarthy veach et al. ; weil et al. ) might serve to subjugate genetic counselors' attitudes toward deaf people in favor of supporting the values of the culturally deaf clients. some evidence to support this phenomenon also exists. ormond et al. ( ) surveyed health care trainees, including genetic counselors, and reported that % felt comfortable working with patients with disabilities, despite limited personal and professional contact with individuals with disabilities, demonstrating a focus on the patient's views and values. the extent to which these results apply to a cultural and linguistic minority group can only be determined through empirical study. the current research study aims to examine genetic counselors' general attitudes toward deaf people, and to describe the relationship between these attitudes and the genetic counseling session using the framework of the contact hypothesis. we hypothesized that genetic counselors with greater contact with deaf/deaf individuals will have more positive attitudes toward deaf people, and that positive attitudes toward deaf people will be associated with greater comfort discussing and offering genetic testing for deafness with culturally deaf clients. the study sample was ascertained from members of the national society of genetic counselors (nsgc) through their general electronic listserv during the period of / / - / / . individuals were eligible to participate if they were ( ) trained genetic counselors, ( ) an nsgc full member, and ( ) a part of the nsgc general listserv. approval of the study was obtained through the institutional review boards at the california state university of northridge and the university of california, los angeles. a self-administered online survey was developed to test the hypotheses. the survey was pilot tested with genetic counseling students for time required to complete the questionnaire and to assess its content and clarity. revisions were made based on this pilot test. the first section solicited basic demographic information, information on primary counseling setting (prenatal, cancer, general genetics, pediatric, adult, other) , number of years employed as a genetic counselor, number of times in the past year genetic testing for deafness was discussed with hearing or deaf clients in a clinical setting, personal or professional contact with deaf/deaf individuals (as family members, friends, clients) and familiarity with deaf culture and asl. two items assessed exposure to information on the genetics of deafness and information about deaf culture in their genetic counseling training program. the second section contained the attitudes to deafness scale (cooper et al. ) which consists of a set of statements about deaf people which encompass equality, ability, cultural and linguistic issues ( table ). the scale, which was developed in england to measure health professionals' general attitudes toward deaf people, includes eight positive statements and negative statements. items are rated on a six-point likert scale from to anchored by the labels strongly agree and strongly disagree, with no neutral point, and item responses are summed to produce a total attitude score. the theoretical range of scores is - with higher scores indicating more positive attitudes toward deaf people compared to lower scores. content validity was established through the process of item development and through the process of selecting the final items pertinent to the attitude construct. importantly, item development was, in part, based on input from a focus group comprised of deaf individuals who described their experiences with hearing people's attitudes toward deafness and deaf people, thereby adding to the content validity to the scale items. the initial set of items was then subject to a multi-step item analysis (based on responses to the items from a sample of mental health providers) to identify the subset of items that most effectively distinguished responders with a positive attitude toward deaf people from those with a negative attitude. cronbach's alpha for the final items was . (cooper et al. ) , suggesting strong internal reliability of the scale items and supportive of the scale's content validity. the instrument was developed for use with all human service professionals working with deaf people (cooper et al. ) and was previously used to evaluate mental health providers' attitudes toward deaf people in the context of the contact hypothesis (cooper et al. ) . pilot-testing in an american sample of genetic counseling students, and review of items by a deaf co-author, did not identify any problems understanding or responding to these statements. the third section contained scenarios and assessed genetic counselors' comfort level with genetic testing for deafness. five scenarios were developed by the investigators using familiar or anticipated counseling situations (appendix). scenarios varied the age of the client, clinic setting, family constellation of deafness, cultural affiliation, and reason for pursuing genetic counseling and testing (see table ) as follows: "scenario " describes hearing parents and a deaf child in a pediatric setting wanting to know why their child is deaf and the recurrence chance for future pregnancies; "scenario " takes place in a prenatal setting and describes a hearing couple with a family history of deafness who want a hearing child and are interested in prenatal testing; "scenario " describes non-culturally deaf parents in a prenatal setting interested in prenatal testing for preparation for cochlear implants if they have a deaf child; "scenario " describes culturally deaf parents and their deaf children in a pediatric setting interested in genetic testing to learn why they are deaf; and "scenario " takes place in a prenatal setting and describes a culturally deaf couple who would like a deaf child and are interested in prenatal testing. three questions followed each scenario. the first two questions asked the respondents to rate how comfortable they would be talking about genetic testing based on the scenario and how comfortable they would be offering genetic testing for deafness based on the scenario. response categories for both items used a five point likert scale from to anchored with labels comfortable and uncomfortable. the third question for each scenario asked, on a personal level, if the respondent thought the family in the scenario should be offered genetic testing for deafness. the response categories for this item were "yes," "no," and "unsure". for the purposes of this study, we use the words 'talking' and 'offering', even in the context of a counseling scenario with deaf clients who use sign language, but it is important to note that a conversation with a culturally deaf client would be in sign language rather via speech, either directly or with a third-party such as a certified sign language interpreter. descriptive statistics were computed for each item in the survey for descriptive purposes and to identify potential outliers and missing data. an attitude toward deaf people positive attitude statements • att : i would like to have more deaf friends. • att : deaf children should be taught in sign language. • att : deaf people are safe drivers. • att : i would like to have more deaf colleagues. • att : interpreters should be available for deaf people at work. • att : deaf people should not be viewed as "impaired." • att : i would like to see more deaf people at club/societies i attend. • att : deaf people have their own culture. negative attitude statements • att : deaf couples should receive genetic counseling to avoid having deaf children. • att : deaf children should learn to speak to communicate with hearing parents. • att : deaf schools and deaf clubs create deaf "ghettos." • att : deaf people should learn speech rather than sign language. • att : deaf people are handicapped. • att : more research should be done to find cures for deafness. • att : hearing children of deaf parents are at risk of emotional deprivation. • att : deaf people should learn to lip-read. • att : deaf people should automatically receive help in their home environment. • att : all deaf people should be offered corrective surgery. • att : training more professionals to work with deaf clients would be a waste of time. • att : having a deaf colleague would cause problems in the workplace. • att : deaf people are physiologically impaired. • att : having a deaf friend would be difficult. scale reported in its entirety as described in cooper et al. ( ) . 'deaf' is capitalized at the beginning of a statement as per grammatical rules, and in that case does not imply culturally deaf. attitude statements are preceded by an acronym for ease of reporting results score (attitude score) was computed for each respondent based on their responses to the attitudes to deafness scale following the method described in cooper et al. ( ) . in the case of a missing scale item, the group average for that item was used in order to develop an overall score (little and rubin ) . the attitude score and the outcome variables related to talking about and offering genetic testing were treated as quantitative variables, and the outcome variable related to personal feelings about offering genetic testing was treated as a categorical variable. anova and pearson-product-moment correlation analyses were performed to identify factors related to attitudes toward deaf people, and to examine the relationship between these attitudes and the three main outcome variables related to discussing and offering genetic testing. separate analyses were performed for each scenario and outcome variable, using sas version . (sas ). an alpha of . was used to determine statistical significance. corrections for multiple testing were not made. a total of certified genetic counselors participated in the study for a response rate of . % based on a total of , nsgc full members reported in the professional status survey (parrot and del vecchio ) . this response rate is a conservative estimate because it assumes that all nsgc full members in the survey receive listserv messages. after excluding questionnaires from subjects due to substantial missing data, questionnaires from subjects were available for analyses. the demographic characteristics of the sample are described in table . the sample is reflective of the general population of nsgc members on four characteristics: ethnicity, age, years employed as a genetic counselor, and primary clinical setting (parrot and del vecchio ) . for analysis purposes, clinical setting was re-categorized as prenatal, pediatrics, and other (cancer, general genetics, adult, other); number of deaf clients was dichotomized into ≤ /year and > /year; and years of employment was dichotomized into ≤ years and > years. cronbach's alpha in this sample was . , providing evidence that this scale is appropriate for use in an american sample. the average attitude score for the sample was . (sd= . ; min= , max= ), and the average response and standard deviation for each attitude statement are graphed in fig. . positive attitude statements are grouped on the left and negative attitude statements are grouped on the right side of the figure. in general the respondents agreed more with the positive statements and agreed less with the negative statements. however, in both domains there was variability in the strength of agreement across items. among the positive statements, the items receiving the highest average score (and indicative of moderate to strong agreement) were att ("deaf people have their own culture", mean= . ) and att ("interpreters should be available for deaf people at work", mean= . ), whereas the items with the lowest average score (and indicative of mild-moderate agreement) were att ("deaf people are safe drivers", mean= . ), att ("i would like to have more deaf colleagues", mean= . ), and att ("i would like to have more deaf friends", mean= . ). among the negative statements, the items with the lowest average score (and indicative of strong disagreement) were att ("training more professionals to work with deaf clients would be a waste of time", mean= . ) and att ("deaf couples should receive genetic counseling to avoid having deaf children", mean= . ), whereas the items with the highest average score (and indicative of mild-moderate agreement) were att ("more research should be done to find cures for deafness", mean= . ) and att ("all deaf people should be offered corrective surgery", mean= . ). the respondents' average comfort levels regarding talking about and offering genetic testing for deafness for each scenario are graphed in fig. . the average comfort level talking about genetic testing in each scenario was high, ranging from . to . on a - scale. more variability was observed in the comfort level offering genetic testing, where average levels ranged from . for scenario to . for scenario on a - scale. inspection of fig. also reveals that the average comfort levels when offering genetic testing for two of the three prenatal scenarios (scenarios and ) were lower compared to the other scenarios. respondents were also asked if, on a personal level, they thought the family in each scenario should be offered genetic testing. for each scenario, the majority of the participants indicated that they felt that genetic testing should be offered, although some variability was seen among the scenarios (scenario , yes= %; scenario , yes= %; scenario , yes= %; scenario , yes= . %; scenario , yes= %). due to insufficient variability, subsequent analyses focus only on personal feelings about scenario . we tested the hypothesis that attitudes toward deaf people would in part be explained by factors related to contact with deaf individuals. consistent with this hypothesis, we found a statistically significant associa- att att att att att att att att att att att att att att att att att att att att att att negative attitude statements positive attitude statements fig. average agreement for attitude statements with (sd), where corresponds to strongly disagree and corresponds to strongly agree. note that fig. we also examined the relationship between attitudes toward deaf people and clinical setting, exposure to deaf culture, years of employment, and age, in order to identify additional factors that explain variability in the attitudes scores. one-way anova demonstrated a non-significant trend suggestive that attitudes toward deaf people are related to clinical setting (f , = . , p= . ). respondents working in prenatal (mean= . , sd= . ) or pediatric settings (mean= . , sd= . ) had nearly identical mean attitude scores, which were higher and indicative of more positive attitudes toward deaf people, than those working in 'other' settings (mean= . , sd= . ). however, attitudes toward deaf people were not related to instruction on deaf culture in graduate school (f , = . , p=. ), years of employment (f , =. , p= . ), or age (r= . , p= . ). we tested the hypothesis that positive attitudes toward deaf people would be associated with greater genetic counselor comfort level when discussing and offering genetic testing with culturally deaf clients by computing correlations between attitude score and comfort level when talking about and offering genetic testing for deafness for each of the five counseling scenarios. results supported our hypothesis and revealed that more positive attitudes toward deaf people correlated with greater level of comfort talking about genetic testing in the two scenarios involving culturally deaf clients (scenarios and ); and conversely, less positive attitudes toward deaf people correlated with lower levels of comfort talking about genetic testing with culturally deaf clients in these scenarios. specifically, a statistically significant positive correlation was found between attitude score and comfort level when talking about genetic testing in scenario (r= . , p= . ) and a non-significant positive trend was noted between attitude score and comfort level when talking about genetic testing in scenario (r= . , p= . ). a nearly statistically significant positive correlation was also found between attitude score and comfort level when offering genetic testing for scenario (r= . , p= . ), revealing that more positive attitudes toward deaf people correlate with greater comfort offering genetic testing to a culturally deaf couple who wishes to have a deaf child. there was no correlation between attitudes toward deaf people and genetic counselors' comfort level talking or offering genetic testing for the three scenarios involving hearing or non-culturally deaf clients (all remaining p-values > . ). we also examined the relationship between attitudes toward deaf people and personal feelings regarding offering genetic testing for deafness, as personal feelings may be another indicator of genetic counselors' comfort level with deaf clients. however, this analysis could only be performed with scenario (culturally deaf couple wishing to have a deaf child) due to insufficient variability in responses to the personal feelings item for the remaining scenarios. although not statistically significant (f , = . , p= . ), we observed the hypothesized trend suggesting that respondents with less positive attitudes toward deaf people are less personally comfortable with the idea of offering genetic testing to culturally deaf couples who wish to have a deaf child than respondents with more positive attitudes toward deaf people. in this scenario, the mean attitude score for respondents indicating that they did not personally feel that genetic testing should be offered (mean= . , sd= . ) was lower than the mean attitude score for those who personally felt that genetic testing should be offered (mean= . , sd= . ) or those who were unsure about their feelings (mean= . , sd= . ). due to the differences between the cultural and medical perspectives on deafness and the advances in genetic testing for deafness, many ethical, social, and clinical issues arise for genetic counseling professionals who interact with deaf individuals in their clinics. one issue is whether genetic counselors' attitudes toward deaf people can affect the genetic counseling session and the decisions made by clients. the purposes of this study were (a) to examine genetic counselors' attitudes toward deaf people and identify factors related to these attitudes, and (b) to examine the relationship between genetic counselors' attitudes toward deaf individuals and their comfort level while discussing and offering genetic testing for deafness with deaf/deaf and hearing clients. this study is important for two reasons. first, although deaf adults, including culturally deaf adults, very rarely attend genetic counseling (israel et al. ; martinez et al. ; middleton et al. ) , referrals for deaf adults to meet with genetic counselors are likely to increase in the future as knowledge about genetic testing and the potential benefits of genetic counseling increases. therefore even if genetic counselors are not currently familiar with deaf issues, and how attitudes toward deaf people may affect genetic counseling sessions, they will need to be familiar with these topics in the future. second, although our focus is on genetic counselors and deaf clients, the methodology presented here, including the contact hypothesis, can be applied to research about other human characteristics or conditions to further illuminate interactions between genetic counselors and their clients. we used the attitudes to deafness scale (cooper et al. ) to measure genetic counselors' general attitudes toward deaf people. this scale is composed of eight positive and negative statements about deaf people or deafness. it was previously validated in a sample of british mental health providers and found to be internally consistent (cronbach's α= . ) (cooper et al. ) , and in this sample of predominantly american genetic counselors it was also found to be internally consistent (cronbach's α= . ). an examination of individual scale items in fig. reveals strong agreement with "interpreters should be available for deaf people at work" (att ) and "deaf people have their own culture," (att ) and strong disagreement with "training more professionals to work with deaf clients would be a waste of time" (att ). not only do these results suggest that respondents value equal access to information and communication in the work and healthcare settings, but they reveal an understanding that professionals would benefit from training in order to better serve deaf clients. the latter point may reflect respondents' recognition that deaf individuals have their own culture, and thus responses regarding more professional training may reflect an interest in learning more about this culture. although % of respondents indicated receiving instruction on deafness and deaf culture in their training program, the current research did not assess the type or duration of training in deaf culture or the genetics of deafness. there was much weaker agreement for the positive attitude items "i would like to have more deaf friends," (att ) "i would like to have more deaf colleagues," (att ) and "deaf people are safe drivers" (att ). these results warrant more investigation because they may be tapping into perceptions of relationships between deaf and hearing people and the persistence of myths about deaf people. in terms of relationships between deaf and hearing people, it is possible that the neutral-weak agreement responses regarding the desire for more deaf friends or deaf colleagues reflects respondents' perceptions of deaf people or perceptions about communication with deaf individuals. the latter point illustrates that fluency in sign language and/or availability of interpreters are important for relationships between deaf and hearing people, and is consistent with respondents' agreement that "interpreters should be available for deaf people at work" (att ). weak agreement with the statement about deaf drivers suggests that myths about deaf individuals persist since several studies have shown that the safety and performance records of deaf drivers and hearing drivers do not significantly differ (finesilver ; roydhouse ; wagner ; ysander ) . it is also possible that the phrasing of these items was awkward for respondents, and that a neutral response would be most natural. however, pilot-testing did not reveal problems with the phrasing of these items. in this sample, there was a mild-moderate agreement that "more research should be done to find cures for deafness" (att ) and "all deaf people should be offered corrective surgery" (att ). although it is possible that agreement with these two items reveals a lack of awareness of deaf culture and its values, it is also possible that genetic counselors have an understanding and knowledge of both the medical and cultural models of deafness that is not easily captured by responses to these two items. for example, a person can feel that there should be a cure for deafness that will help people who are hard of hearing, deafened or who were hearing once and who have lost their hearing, and this would not imply that they do not also feel compassion and respect for the deaf community. it is also important to notice that the language used in the second item is not necessarily saying that all deaf people should have corrective surgery, it is merely saying that it should be offered, which is consistent with the non-directive nature of genetic counseling. genetic counselors' agreement with this statement suggests that they believe that all options with regard to medical management should be offered to deaf individuals. because of this, agreement with that statement may not necessarily mean the respondents have less positive attitude toward deafness. instead, it may mean that they want deaf individuals to make fully informed decisions regarding management, whether that is pursuing medical intervention or not. however, this research did not address actual counseling sessions, and so additional research is needed to determine whether or not genetic counselors generally offer all options when counseling deaf individuals, including information about the deaf community, deaf culture, and asl, or if genetic counselors only offer all options with respect to medical management. the results of this study are the first empirical evidence that genetic counselors vary in their attitudes toward deaf people based on the attitudes to deafness scale. attitude scores ranged from to , with average of . and standard deviation of . . we used the framework of the contact hypothesis to identify factors related to genetic counselors' attitudes toward deaf people based on their attitudes to deafness scores. the contact hypothesis posits that more contact between hearing and deaf individuals of equal or higher social status creates more positive attitudes towards deaf individuals (dovidio et al. ) . based on this hypothesis, we predicted that the variability in attitudes toward deaf people would in part be explained by contact with deaf individuals. in this sample, ∼ % reported having deaf friends, ∼ % reported having culturally deaf friends, and ∼ % reported providing genetic counseling to more than ten deaf clients per year. consistent with the contact hypothesis, our results demonstrated that respondents with deaf/deaf friends (who are presumably of at least equal social status) hold more positive attitudes toward deaf people than those with no deaf/deaf friends. however, there was no relationship between attitudes toward deaf people and number of deaf clients per year. together, these findings are consistent with a recent study of mental health providers in the united kingdom which found that their attitudes toward deaf people (based the same attitudes to deafness scale used in the current study) were associated with the amount of contact with deaf people of equal and higher social status, but not associated with total amount of contact with deaf people (cooper et al. ) . there was no relationship between attitudes toward deaf people and years of employment, age, or instruction on deaf culture in graduate school. these results differ from those reported in cooper et al. ( ) where younger participants or those with training in deafness had more positive attitudes than older participants or those without training in deafness. since both samples were of similar age range and mean age, it is unclear why the two studies produced conflicting results with respect to the effect of age on attitudes toward deaf people. however, it is possible that the discrepancy in the effect of instruction or training in deafness/deaf culture on attitudes toward deaf people is explained by differences in the form and content of instruction between the uk and the us. this is an intriguing idea, and suggests that research on the effect of different methods for providing education on deafness/deaf culture on genetic counselors' attitudes toward deaf people is warranted. in light of the findings in cooper et al. ( ) and the current study that personal interactions between deaf and hearing individuals are significantly related to positive attitudes toward deaf people, it seems that genetic counseling training modules that include interactions between deaf/deaf and hearing individuals should be considered. because our findings suggest that attitudes toward deaf people specifically correlate with comfort levels with culturally deaf clients, interactions with culturally deaf individuals may be particularly important. interactions could be facilitated in several ways: ( ) by inviting professionally trained members of the deaf community to conduct educational workshops in genetic counseling training programs and at genetics-related professional meetings such as the annual education conference of the national society of genetic counselors; ( ) by inviting members of the deaf community to observe genetics case conferences and to hold follow up discussions with genetic counselors/students; and ( ) by contacting representatives of the national association for the deaf to initiate projects that would require deaf individuals and genetic counselors/students to work together. it would be valuable to build in an assessment of these activities, particularly in terms of effect on genetic counselors' attitudes toward deaf people. we unexpectedly found a trend that suggested that clinical setting may be associated with attitudes toward deaf people. specifically, respondents working in prenatal or pediatric settings held more positive attitudes toward deaf people than those working in 'other' settings, i.e., cancer, adult, general, and other. one possible explanation is that some settings offer more opportunity for interaction with deaf individuals than other settings. however, our data do not provide strong support for this explanation as . % of genetic counselors working in 'other' clinical settings reported counseling > deaf clients per year compared to . % of pediatric counselors and . % of prenatal counselors. another possible explanation for this finding is that genetic counselors working in prenatal and pediatric settings are more exposed to ethical discussion and debate surrounding prenatal diagnosis for deafness and selective termination of pregnancy (top), as this is a relatively common example used for discussion of ethical and moral dilemmas. furthermore, such discussion usually involves input from the deaf community and their views, hence it is possible that prenatal and pediatric genetic counselors have more exposure to the cultural view of deafness by virtue of these discussions that pertain to their practice setting. in contrast, genetic counselors working in other settings may have less exposure to discussion regarding prenatal diagnosis for deafness and selective top, have less awareness of the input from the deaf community on these issues, and hence have less exposure to the cultural view of deafness. further research is needed to understand the relationship between clinical setting and attitudes toward deaf people. we also hypothesized that a more positive attitude toward deaf people would correlate with being more comfortable discussing and offering genetic testing for deafness with culturally deaf clients. to assess this hypothesis, scenarios were presented with questions addressing comfort level when discussing and offering genetic testing. scenarios varied the client presenting to clinic, the client's cultural affiliation and their reason for referral to genetics counseling. evidence was found to support this hypothesis in the two counseling scenarios involving culturally deaf clients. specifically, higher attitude scores, indicative of more positive attitudes toward deaf people, were significantly correlated with greater levels of comfort when talking about pediatric genetic testing with culturally deaf parents and their deaf child (scenario ) and when talking about and offering prenatal genetic testing for deafness with a culturally deaf couple wishing to have a deaf child (scenario ). in contrast, there were no significant correlations between attitudes toward deaf people and comfort level in counseling scenarios involving hearing or non-culturally deaf clients. overall, the results of this study suggest that genetic counselors' attitudes toward deaf people may influence their level of comfort when interacting with culturally deaf clients. this is an important finding because there is evidence that attitudes and biases can influence both content and presentation of information relevant to decision-making (shiloh ; shiloh and sagi ; tversky and kahneman ) and the options that health care providers offer (bach and tilton ; ormond et al. ; rebagliato et al. ; shaw et al. ) . additional research is needed to determine ( ) the extent to which genetic counselors' attitudes toward deaf people correlate with other types of counseling scenarios involving deaf clients, e.g., clients with adult-onset deafness, deaf or hearing clients for whom pregnancy termination is not an option, and ( ) if genetic counselors' attitudes and comfort levels during counseling sessions with culturally deaf clients can affect the way information is presented and the client's decision making process. on average, our results suggest that genetic counselors are generally very comfortable with the information provision aspect of genetic counseling for deafness, as evidenced by the high level of comfort expressed by respondents when talking about genetic testing for deafness with clients in these five scenarios. however, our results also reveal that respondents' level of comfort when offering genetic testing for deafness depended on the reason for testing. on average, respondents were less comfortable offering genetic testing in situations involving prenatal testing for hearing status, regardless of cultural affiliation of the parents, compared with scenarios involving pediatric genetic testing or prenatal testing for preparation of a cochlear implant. this result suggests that genetic counselors may see deafness as a condition where prenatal diagnosis is not necessary because it is not a lifethreatening condition, and termination based on hearing status may be viewed as a radical decision by some and certainly controversial within the deaf community. in fact, because top for deafness is controversial and there is no consensus of opinion on whether it is 'acceptable' to offer it or not, genetic counselors may feel very nervous about being involved in such counseling sessions, and this may also help to explain the lower level of comfort offering genetic testing in the prenatal scenarios compared to the pediatric scenarios. several empirical studies of consumer attitudes toward prenatal diagnosis for deafness reveal a moderate level interest in prenatal diagnosis for deafness for purposes of preparation, but few consumers have indicated that prenatal diagnosis would be used for termination purposes (brunger et al. ; burton et al. ; dagan et al. ; guillemin and gillam ; middleton et al. ; withrow et al. ) . the majority of the sample personally felt that the families in all of the scenarios should be offered genetic testing, a finding which may relate to the non-directive philosophy of genetic counseling. however, there was also evidence that in some situations attitudes toward deaf people can influence genetic counselors' personal feelings about genetic testing for deafness. specifically, although it did not reach statistical significance in this sample, we found that genetic counselors with less positive attitudes toward deaf people were less likely to feel that prenatal genetic testing for deafness should be offered to culturally deaf parents who wish to have a deaf child compared to genetic counselors with more positive attitudes toward deaf people. to date there is no evidence that this will be a common genetic counseling scenario because of evidence from survey responses that the majority of culturally deaf individuals do not have a preference for deaf or hearing children or an interest in prenatal diagnosis for hearing status (middleton et al. (middleton et al. , stern et al. ) . however, the finding that attitudes toward deaf people manifest in this specific scenario may explain the current controversy over the proposed amendment to united kingdom's human fertilization and embryology act (clause ( )( )) , which if enacted would specifically prohibit the use of pre-implantation genetic diagnosis for the selection of a deaf embryo. there are several limitations to this study. first, the response rate for this survey is . %. one concern with a low response rate is response bias. however, our sample demographics were similar to those of the nsgc member population with respect to gender, age, ethnicity, years employed as a genetic counselor, and primary clinical setting (parrot and del vecchio ) , reducing the potential effects of response bias on our results. a related concern is that the sample size may not have been large enough to detect significant associations with attitudes toward deaf people. therefore, additional research with larger samples is needed to replicate and extend these findings, particularly in light of the multiple statistical tests performed in this study. another potential limitation is the lack of diversity in the sample, which was found to be mainly hearing ( . %), caucasian ( . %), and female ( . %). however, because this lack of diversity is a reflection of the general lack of diversity in the genetic counseling profession rather than a recruitment bias, this does not constitute a serious limitation to our study. rather, this limitation reveals the importance of increasing the cultural diversity in the genetic counseling profession, which can be done through recruitment and training of individuals from this cultural and linguistic minority group into the genetic counseling field. recruitment of deaf individuals whose linguistic preference is asl is particularly important in light of the finding that . % of our study sample considered themselves fluent in this language. a third limitation involves the attitudes to deafness scale. this scale was originally used to assess mental health providers' attitudes toward deaf people, thus raising questions about the validity of the scale for non-mental health providers. however, the intention of the creators of this scale was to develop an instrument that would apply to all human service professionals working with deaf people (cooper et al. ) , and so should be applicable to genetic counselors. in this sample of genetic counselors, cronbach's alpha was . , which is lower than reported in original investigations of the scale (cronbach's α= . ), but still quite respectable and indicative that the items are performing as intended. while every attitude scale has its limitations, this scale has been shown to have content validity and internal reliability. that said, future research is needed to further evaluate and possibly refine measures of attitudes toward deaf people. in addition, this study did not include a scenario that explicitly described a client with adult-onset deafness, nor were respondents asked to describe the audiologic status of the deaf individuals with whom they have had contact. more research is needed to determine if audiologic status of deaf clients or deaf friends provides explanatory value for genetic counselors' attitudes toward deaf people. another limitation of this study is that the outcome data are based on self-report. hence, the extent to which reported attitudes and feelings of comfort predict genetic counselors' actual behaviors with culturally deaf clients is unknown. research on real genetic counseling sessions with culturally deaf clients clearly is warranted in order to understand whether attitudes toward deaf people have an impact on the genetic counseling session. finally, although our primary outcome variables were based on comfort levels while 'talking' about and 'offering' genetic testing, a conversation with a culturally deaf client would be in sign language rather than via speech, and the impact of conducting a counseling session through an interpreter may add another dimension to genetic counselors' assessments of comfort level that was not explicitly measured in this study. in conclusion, this study demonstrates that the majority of genetic counselors have limited personal or professional interactions with deaf individuals, that contact with deaf/ deaf individuals is associated with more positive attitudes toward deaf individuals, and that a more positive attitude toward deaf people correlates with a higher comfort level with culturally deaf clients when discussing and offering genetic testing for deafness for diagnostic and prenatal purposes. these results have implications for both genetic counselors and their culturally deaf clients because variability in genetic counselors' attitudes toward deaf people may make culturally deaf clients feel uncomfortable and perceive that their culture is not valued by genetics professionals. in turn, these feelings may influence the client's discussions in counseling sessions and decisions made regarding testing and medical management. future research is warranted on genetic counselors' attitudes towards deaf people and its effect on genetic counseling sessions in order to better understand how to augment training programs and to better understand how genetic counselors as a whole can better serve the deaf community. in this regard, developing research protocols that examine real genetic counseling sessions with deaf/deaf clients will be essential. see a genetic counselor, you learn that multiple members of heather's family and greg's family are deaf. neither heather nor greg have any signs of deafness and have had their hearing tested within the past year. heather and greg are wondering if the deafness in their families is something that could occur in this pregnancy. they inform you that they are hoping for a hearing child and are interested in genetic testing for deafness for this pregnancy because of their family history. robert and betty, who are both deaf, have also come to your clinic today to discuss genetic testing for deafness. betty is currently weeks pregnant with her second pregnancy. they have a year old daughter, lisa, who is deaf. lisa has a cochlear implant and robert and betty decided to place lisa in a mainstream hearing classroom. various members of betty's family are deaf, but no other members of robert's family are deaf. betty has previously had genetic testing and a deafness-causing variant was found. robert has not had any genetic testing. betty and robert are interested in genetic testing to determine the hearing status of the pregnancy so that they can prepare for cochlear implantation if the child has inherited betty's deafness-causing variant. claire and lucas, both years old, have brought their year old son, brandon, in to clinic. all three family members present at today's session are deaf and a sign language interpreter is used during the counseling session. claire and lucas have three other children ranging from months to years who are also deaf. all three of the school aged children attend a school for the deaf and are taught solely in sign language. lucas heard about the possibility of genetic testing for deafness through a school newsletter stating the pros and cons of the testing. claire and lucas want more information of this type of testing before making a decision regarding genetic testing to find a cause for the family's deafness. virginia, who is weeks pregnant, and craig, both of whom are deaf, are interested in prenatal genetic testing for deafness. virginia states that she previously had genetic testing that revealed an autosomal recessive form of deafness. craig, who has also had genetic testing for his deafness, is a carrier for the same autosomal recessive form of deafness that virginia has. you explain to virginia and craig that there is a % chance of having a deaf child and a % chance of having a hearing child. through the discussion of this information the couple states that they are hoping for a deaf child and would like to pursue prenatal genetic testing for deafness. innovative approach to genetic counseling services for the deaf population genetic counseling for the deaf ventilator use by muscular dystrophy association patients: an update. archives of physical and medical rehabilitation designing deaf babies and the question of disability parental attitudes toward genetic testing for pediatric deafness a focus group study of consumer attitudes toward genetic testing and newborn screening for deafness sociological implications of hearing loss mental health professionals' attitudes toward people who are deaf measuring the attitudes of human service professionals toward deafness genetic testing for hearing loss: different motivations for the same outcome prelingual deafness: high prevalence of a delg mutation in the connexin gene intergroup contact: the past, present, and the future reproductive liberty and deafness: clause ( )( ) of embryo bill should be amended or deleted they can't hear, but they get the message attitudes to genetic testing for deafness: the importance of informed choice genetic counseling for deaf adults: communication/language and cultural considerations ethnicity and socialization in a classroom for deaf children gjb (connexin ) variants and nonsyndromic sensorineural hearing loss: a huge review the structure of attitudes toward persons who are deaf: emotions, values, and stereotypes the mast of benevolence: disabling the deaf community ethnicity, ethics, and the deaf-world ethical issues in cochlear implant surgery: an exploration into disease, disability, and the best interests of the child statistical analysis with missing data attitudes of the broader hearing, deaf, and hard-ofhearing community toward genetic testing for deafness facilitating the genetic counseling process: a practice manual attitudes of deaf adults toward genetic testing for hereditary deafness prenatal diagnosis for inherited deafness-what is the potential demand why don't deaf people come for genetic counselling? quantitative and qualitative findings from a uk study chasing the mythical ten percent: parental hearing status of deaf and hard of hearing students in the united states how many people use asl in the united states? why estimates need updating attitudes of health care trainees about genetics and disability: issues of access, health care communication, and decision making deaf in america: voices from a culture professional status survey neonatal end-of-life decision making: physician's attitudes and relationship with self-reported practices in european countries deafness and driving sas (version . ). cary the deaf population of the united states ethical issues in pediatric surgery: a national survey of pediatricians and pediatric surgeons the troubled helix: social and psychological implications of the new human genetics effect of framing on the perception of genetic recurrence risks parental narratives of genetic testing for hearing loss: audiologic implications for clinical work with children and families attitudes of deaf and hard of hearing subjects towards genetic testing and prenatal diagnosis of hearing loss attitudes of deaf individuals towards genetic testing medical students' attitudes toward persons with disability: a comparative study health professional student attitudes towards people with disability the framing of decisions and the psychology of choice national symposium on the deaf driving and employability the relationship of nondirecteness to genetic counseling: report of a workshop at the nsgc annual education conference consumer motivations for pursuing genetic testing and their preferences for the provision of genetic services for hearing loss impact of genetic advances and testing for hearing loss: results from a national consumer survey the safety of drivers with chronic disease acknowledgments we thank the genetic counselors who participated in this study. this research was supported, in part, by funding from the national human genome research institute (r hg ).open access this article is distributed under the terms of the creative commons attribution noncommercial license (https:// doi.org/creativecommons.org/licenses/by-nc/ . /), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. jennifer, a -year-old, congenitally deaf female has been referred to your clinic by her pediatrician who mentioned the possibility of a certain gene change that could have caused her deafness. she was determined to have a moderately severe sensorineural deafness at birth and does not appear to have any medical conditions or birth defects. her parents, susan and daniel, do not have a history of deafness, nor do they know of anyone else in their family who is deaf. they are thinking about having another child and would like to know if jennifer's deafness is genetic and if it will occur in future pregnancies. heather is a -year-old woman who is weeks into her first pregnancy. her husband greg, , has attended today's session with her. after taking a family history and discussing with the couple their reasons for wanting to key: cord- - ofi mg authors: wei, yuwa title: human rights issues date: - - journal: issues decisive for china&#x ;s rise or fall doi: . / - - - - _ sha: doc_id: cord_uid: ofi mg contemporary china is plagued by a wide range of human rights related issues and problems. in addition to those arising in the areas of religious toleration, judicial practice, treatment of labor and forced abortion, which were extensively reported by the media in the past, some newly emerged problems concerning human rights violation are much more alarming, due to the size of population affected and the degree of challenge caused to the public’s psychological endurance and confidence in the social ethnics and administration of the nation. most of all, these problems concern nearly every chinese citizen’s well-being and impact on their personal prosperity, as well as the prosperity of the nation as a whole. these problems are mainly associated with failures in environmental protection, food safety, and medical security. first white paper on human rights being released in , the white papers of the following years were arranged as a series sequentially informing the progress made and the actions taken in human rights promotion in each year. nevertheless, it is an undeniable fact that contemporary china is plagued by a wide range of human rights related issues and problems. in addition to those arising in the areas of religious toleration, judicial practice, treatment of labor and forced abortion, which were extensively reported by the media in the past, some newly emerged problems concerning human rights violation are much more alarming, due to the size of population affected and the degree of challenge caused to the public's psychological endurance and confidence in the social ethnics and administration of the nation. most of all, these problems concern nearly every chinese citizen's wellbeing and impact on their personal prosperity, as well as the prosperity of the nation as a whole. these problems are mainly associated with failures in environmental protection, food safety, and medical security. achieving modernization has been the core economic objective and a solemn promise of the chinese government. urbanization has been a major means of reaching this goal. this course has been accelerated since the s with an average urban population growth rate of more than . %. nowadays, the number of urban population has reached . million, account for . % of the total population of the nation. in the meantime, china has scored an extraordinary gdp growth rate ranging from the lowest . % to the highest % between and . if these are to be seen as modernization or development, the modernization or development droughts and storms, deforestation, desertification, etc., affected more than two billion people and the economic toll multiplied compared with the previous decades. this trend has an even acuter presentation in china. in the past three decades, china experienced extraordinary economic growth, accompanied by rapid industrialization and urbanization. the emergence of many city clusters has resulted in centralized and condensed population in urban areas. the economic development, together with urbanization, has generated substantial environmental problems. nowadays, china is facing nearly all of the world's ecological challenges including climate change, desertification, deforestation, declining water resources, acid rain, soil erosion, air and water pollution and biodiversity loss. apart from increasingly frequent natural disasters caused by climate change, air and water pollution has become a paramount concern to the general public, which is acutely perceived in their daily life. as mentioned in the beginning of this section, the cost of environmental degradation in china is massive and profound, from people's lifespan to economic toll. the link between environment and human rights can be established on basis that physical environment is a precondition for living a life of dignity and worth. good environment is a pre-requisite for the enjoyment of fundamental human rights. in china, for a long time, human rights violations and environmental degradation have not been treated by central and local governments as related issues and addressed in a coherent and integrated way. it has become evident that environmental protection and human rights are prima facie interrelated, interconnected, and mutually responsive, since they both serve the purpose of improving and sustaining the well-being of humanity. human well-being has a basic requirement for safe food, clean air and drinking water, safe shelter and protection from diseases. human activities such as rapid industrialization and urbanization result in environmental degradation including rising of sea levels, air and water pollution, drought, flooding, which in turn, affects people at a large number. at the international law level, the vital role that environment plays in guaranteeing individuals' fundamental human rights has been recognized at a much earlier time. the stockholm declaration of , nairobi declaration of , world charter for nature of , earth summit of , johannesburg conference on sustainable development of , un conference on sustainable development of have all acknowledged the interdependence between environment and human rights by conveying the message that environment may lead to long term impact on humanity and violation of human rights. the human rights council in its resolution / of march and resolution / of march focused specifically on human rights and climate change, pointing out that environment change impairs and undermines directly and indirectly the effective enjoyment of human rights. traditional international environmental laws commonly address environmental issues through creating and determining rights and obligations between states. human rights laws, on the other hand, place individuals' rights at the center of the focus. the establishment of the linkage between human rights and environment enables individuals victimized by environmental degradation to seek remedy on human rights violation ground, which traditional environmental laws gives little focus. it is unfortunate that in china's priority agenda, both human rights protection and environment protection have given way to economic development for quite a while. the link between environmental damage and human rights violation has not been articulately addressed either. indeed, it is a high time for china to adopt a comprehensive, human rights based approach to formulate environmental policies for clarifying human rights obligation in environment protection and for identifying and promoting good practice in environment management. there are signs that current central government shows the interest in considering human rights law enforcement as a means of achieving the purpose of environment protection. "environment protection" have become hot words in china's political life since the th national congress of the communist party of china (nov. - , ) . in his keynote report in the opening ceremony, hu jin tao, the president of china by then, emphasized the term "ecological civilization" for fifteen times. his successor, the current president xi jin ping, in his speeches at the national people's congress and at the chinese people's political consultative conference , called for environment protection and pointed out that protecting environment is as important as protecting productive forces. with the initiative from top leaders, the governments of all levels have become more and more mobilized to change their focus and give particular importance to environment protection. although the areas like beijing, hebei and shanxi are still frequently blanketed by hazardous smog and problems caused by environmental degradation and climate change are still acute, people are more willingly to adopt an optimistic attitude when speaking likely environmental improvement in the coming decades. nowadays, with the growth of economic prosperity, common chinese people enjoy an ever-abundant supply of food products and are keen to broaden their dining experiences. in today's china, eating occupies nearly all occasions and businesses. visitors to china are likely to find that eating is arranged as a highlight for them by the hosts. some research suggests that the current food consumption pattern in china even poses as an exception to engel's law, that is: as the income of an average chinese family rises, the proportion of income spent on food increases, rather than decreases. some other research finds that in fact, the share of chinese households' income spent on food fell from over half in the s to about one-third nowadays. nevertheless, one-third of household income being spent on food is still spectacularly excessive, compared with . % in the u.s., . % in the u.k., and . % in singapore. while all levels of the population take any possible opportunities to indulge with feasts, disturbing facts concerning food safety emerge. this article concerns itself with some of the most severe problems associated with food safety in china, which mainly refer to the cases involving deliberate contamination of food for profits. these include problems such as manufacturing and trading imitation food (e.g., selling pork as beef), processing and selling contaminated food, adding chemical additives into food products for improving visual appeal, taste, or simply for falsely increasing nutritional value (e.g., adding melamine into baby formula to inflate the protein levels), and producing and trading tainted food (e.g., profiting from recycled oil mainly dredged up from restaurant gutters). worst of all, the above problems are not sporadic but are widespread and rampant, and in some cases, systematic. it needs to be borne in mind that the above issues are the most severe ones and only account for a small part of the avalanche of food scandals. here, incidents relating to sanitation or foodborne illness outbreaks caused by negligence in manufacture and service processes are not taken into account, though they are also serious problems. the right to safe food is a basic human right for all individuals. in addition, safe food should be regarded as an issue of national security for the reason that toxic food poses a serious threat to public health, which in turn leads to destructive social and economic consequences, and eventually has an adverse impact on the national interests of a country. it is high time for the chinese to review their policies and strategies in dealing with social issues, including social justice, equal distribution, anticorruption and clean governments, social ethics and public morality, and public psychology. regulation is surely a necessary instrument to control illegal conduct. however, given the fact that policies and laws are always watered down or compromised in implementation, it is thus particularly important for policy makers to take all the above issues into consideration when shaping the nation's regulatory infrastructure for food safety. when serious food problems have a devastating impact on a large proportion of the population, it is necessary to assess the situation from a human rights perspective while searching for solutions. this section examines china's food safety issues in connection with human rights awareness in the country. it investigates the social, political and cultural causations of the food scandals, and explores possible solutions. before the s, under the planned economy, food problems that arose from manufacturing were extremely rare and the regulatory focus was on sanitation occurring in the service and consumption processes, where the food safety administration was part of the duties of the sanitation and anti-epidemic departments. although it appeared that a legal framework was largely put into place, the food industry was, in fact, less effectively regulated, due to the loose context of the laws and the gaps between the laws and their practice. the situation has deteriorated since the beginning of the new millennium with the introduction of the practice of quality inspection exemption or the regime of self-inspection by enterprises themselves, an initiative launched to reduce the operational costs of food enterprises. the self-inspection regime was a result of the administrative authorities exercising their supervisory powers in an abusive manner while in the discharge of their quality control duties concluding with the imposition of unnecessary and excessive burdens on food producers. however, instead of disciplining administrative conduct, the policy makers opted for a compromise by abolishing food quality inspection. research has shown that the managerial costs in chinese firms are chiefly caused by defects inherent in the governance of these firms. without fundamental improvements in the corporate governance system, xu, supra note . see, for detailed discussions on managerial costs and corporate governance in chinese firms, yuwa wei, "directors' duties under chinese law -a comparative review", ( ) university of the costs are likely to continue to inflate. later instances of food safety crises have proven that those who maintain the argument that relaxation in quality control can reduce food companies' operational costs are simply barking up the wrong tree, where the most likely result is noncompliance. it took the government years to realize that giving enterprises free rein in regards to food quality control was an unwise decision. it was at least partly responsible for the current culpable culture in the food industry. in the aftermath of a series of food scandals, policy and regulatory mechanisms have been introduced as the main crisis control efforts. on the current law imposes full responsibility on food producers and manufacturers to ensure that their products meet safety standards throughout each process, including purchase of raw materials, production, storage, package, transport and delivery. in addition, they need to faithfully record the safety management throughout the whole course. however, china's experiences reveal that without fierce scrutiny, the industry is unlikely to comply with such requirements. under the current regime, the supervision and administration are given to local governments at or above the county level, who formulate annual plans for food safety and undertake food sampling inspection. specific branches of government, including the departments of agriculture administration, quality supervision, industrial and commerce administration, and the food and drug administration carry out the routine work of food sampling inspection. ( ) china, § ( ) , an english version is available at <www.fdi.gov.cn/ _ _ _ _ .html>. the section states: "the food producers and traders shall, in accordance with laws, regulations and food safety standards, carry out productive and operational activities, establish and improve the food safety management system and adopt efficient management measures to ensure food safety. the food producers and traders shall be responsible for the safety of produced and trade food themselves as well as society and the public, and also bear social responsibility." ibid, at § . ibid, at § . persons with direct responsibility in the above mentioned governments are subject to disciplinary punishment comprising of the recording of serious demerits, demotion, dismissal or expulsion, in the event of a failure to perform their supervisory and administrative duties, particularly where the failure causes a serious social effect. the same penalties are imposed directly on persons responsible for the above mentioned government branches, in the case where negligence is committed, daily supervision and inspection of food samples are omitted, abuse of power occurs, or favouritism is shown in the supervisory and administrative processes. from the above overview of the new regulatory regime, a few inadequacies can be identified. first, the legal (regulatory) framework is far from comprehensive. the supervisory model of food safety mapped out in the new laws can be summarized as: relying mainly on the segment-based approach, supplemented by a categorybased approach. in other words, the administration of food quality is undertaken by multiple inspection and administrative agencies, exercising their authorities in different stages of food production and services and targeting different types of foods. such an arrangement poses a potential risk in regards to conflict of powers, though the new laws allude to the benefits of efficient coordination among these agencies by identifying their authorities and duties in different stages of production and services. given the gaps in the existing laws, it is very likely that china will encounter further challenges in food supervision caused by its inefficient administrative system. speaking from a broader perspective, china is not the only country that has applied a multi-agency approach to food supervision and administration. the united states and japan have also adopted a scheme of assigning duties of food administration to multiple governmental agencies and departments. however, their comprehensive and detailed stipulations on division of responsibilities, quality standards, transparency and public scrutiny have ensured effectiveness of the system and smooth coordination among the agencies. moreover, it is noteworthy that even in countries such as the united states, there are increasing calls for combining their multiple agencies into a single agency to further the operational efficiency. it is therefore necessary for china to improve its food safety administration system to further enhance its regulatory regime on the one hand, and to rationalize the administrative chains and procedures in food supervision on the other. second, the current legal regime does not provide sufficient remedies for victims of food safety, nor does it effectively encourage consumer and community participation in food safety control. the laws have introduced monetary remedies for consumers consisting of damages and a fine of ten times that of the commodity's value. however, the accused are liable for the fine only where evidence shows that they have produced defective products and are at fault. what is more outrageous is that the onus of proof is on the consumers in such cases. the amount of ten times the value of the goods has already been criticized as being too insignificant to be a deterrent. the requirement that consumers need to prove the culpability of producers in making defective foods renders it nearly impossible for the consumers to benefit from the fine, not to mention the conceivable negligible impact that the provision has on food producers. third, the regulatory regime has loopholes and demonstrates too much leniency towards liable producers and traders, as well as those administrative personnel who fail to discharge their duties or show favoritism. among government staff of relevant departments, only those directly responsible for administrative negligence or abuse of powers that result in serious social impact may face disciplinary action. criminal penalties imposed on food producers for breaches of the law are also weak. moreover, no single criminal penalty is available to penalize delinquent public servants. the criminal law of china only punishes the conduct of producing for instance, in the u.s., the powers of food administration are divided amongst the u.s. department of agriculture, the food and drug administration and the environmental protection agency. see chamus burnside-savazzini, "training in an integrated food safety system: focus on food protection officials", food safety magazine (april/may ), <www.foodsafetymagazine.com/ article.asp?id= &sub=sub >. the people's congress of the people's republic of china, supra note , § . the food safety law does not address the issue of burden of proof. hence, the rules of general law apply, rendering that the burden of proof lies upon he who brings the claim. see tonghai liu, "on the shortcomings of the foot safety law and some suggestions on improvement", blog of tonghai liu on legal study net (october , ), <http://wq.zfwlxt.com/ newlawyersite/blogshow.aspx?itemtypeid=fdf ea- b- - ea- bfb &itemid= de f - bd- f - bdc- f e &user= >. the people's congress of the people's republic of china, supra note , § . and selling foods causing serious food poisoning and diseases, and the conduct of producing and selling foods mixed with toxic or harmful non-food substances. it can thus be observed that the scope of application of the criminal law provisions is limited to offences occurring in food production and sale. this leaves the conduct of processing, packaging, storing and transporting defective or harmful foods unpunished. furthermore, the amounts of the penal fines provided in the criminal law are even less than those stipulated in the food safety law, and are subject to a higher threshold in application. finally, the most essential issue to be addressed by the chinese is the enforcement of the laws. according to a survey carried out by the national survey research center at renmin university of china in , % of people interviewed attributed the cause of food scandals to administrative inefficiency and supervisory failure. in the meantime, judicial failure to rigorously implement food laws has cast a further shadow over effective law enforcement in the future. it is reported that courts are reluctant to support consumers' claims for damages up to or times the amount of the commodity price provided for in the law of the people's republic of china on the protection of consumer rights and interests and the food safety law of the people's republic of china . many manufacturers also promise the criminal code of china states: "whoever produces or sells food that does not confirm to hygiene standards in a manner that is sufficient to cause a serious food-poisoning accident or any serious disease caused by foodborne bacteria shall be sentenced to fixed-term imprisonment of not more than years or criminal detention, and concurrently or independently be sentenced to a fine of not less than half of the sum obtained through sale and not more than twice of that. if the offence causes serious harm to human health, the offender shall be sentenced to fixed-term imprisonment of not less than years and not more than years, and concurrently be sentenced to a fine of not less half of the sum obtained through sale and not more than twice of that. if the consequences are especially serious, the offender shall be sentenced to fixed-term imprisonment of not less years or life imprisonment, and concurrently be sentenced to a fine of not less than half of the sum obtained through sale and not more than twice of that or confiscation of property." a person who knowingly mixes the food to be produced or sold with toxic and harmful non-food stuffs is subject to the same penalties. : "when any manufacturer produces any food not conforming to the food safety standards or sells any food knowing its nonconformity with the food safety standards, the customer can demand the manufacturer or the seller to pay a penalty times of the paid amount, in addition to the compensation for the loss thereof." the amount of the compensation provided for in article of the law of the people's republic of china on the protection of consumer rights and interests is up to two times upon occurrence of fraud. junhai liu, the deputy president of china consumer association pointed out that due to judges' misunderstanding of legal reasoning, consumers' that an amount of compensation of up to times the amount of the commodity price will be paid to consumers upon violation of food safety. however, such claims are likely to be rejected by courts. some judges insist that such an amount appears to be punitive and thus does not have legal basis in contractual relations. the stance of courts in such cases renewed the public's suspicion of judicial corruption. the worst scenario concerns events involving arrest and conviction of consumer advocates. the zhao lianhai case is a typical example. zhao lianhai was a man who became an activist after his son experienced kidney problems linked to contaminated baby formula. he was convicted of inciting public disorder by setting up a web site to help other parents with sick children share information, seek compensation, and organize protests. it is clear that despite legislative efforts, tackling the food safety problem is an overwhelming challenge. compared to assessing legislative improvements, evaluating law enforcement in china presents a far more demanding task and is entangled with a number of social, political, economic and cultural issues. more discussions on enforcing food safety law in china will be carried out in section iii of this article. in summary, much work needs to be done to develop an efficient and effective food safety regulatory regime. this is not a mere legal task, but a social project involving reform of the administrative culture, a change in the business environment and transformation of the perception of the right to safe food for the public. human rights are rights inherent to all human beings, and they are inalienable and fundamental. the international community has reached a common understanding on the universality of human rights. for promoting and protecting human rights and fundamental freedoms of individuals, governments are obliged to act in certain ways or to refrain from specific acts. the most common universal human rights claims for compensation provided in the above provisions are rarely supported by courts in the past. see social and cultural rights , the right to food is recognized as part of the right to an adequate standard of living. the rome declaration on world food security and world food summit plan of action reaffirms everyone's right to "have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger" and describes food security as: "[w]hen all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life." it is therefore clear that as a part of human rights, the right to food is inalienable and indivisible from other fundamental rights including the right to life, the right to health, the right to know, ( - nov. , rome) . here, "right to know" is a term used in environmental law, referring to the legal principle that the individual has the right to know the chemicals to which they may be exposed in their daily living. it comprises two aspects -community right to know (environmental hazard information) and workplace right to know (workplace hazard information). nowadays, the term is used in the field of human rights in reference to the right of access to information concerning citizens' human rights, or their rights under freedom of information laws. for instance see sandra coliver, the justifiable to say that the right to food incorporates at least the following dimensions: availability, accessibility and adequacy. in other words, food must not only be available as a resource and affordable in order for people to be able to satisfy their dietary needs, but must also be safe for human consumption and free from contaminants. everyone must have access to food that is not only nutritionally adequate, but also free from harmful substances, so that it does not endanger people's lives or health. the states parties to the international covenant on economic, social and cultural rights have agreed to assume the obligation to progressively realize the right to adequate food. the responsibility is interpreted by the committee on economic, social and cultural rights as comprising three types of obligations: respect, protect and fulfil/facilitate. a state government must not interfere with individuals' efforts to access food. it must also protect its people from infringement of their right to adequate food by others. the government should help those who do not already enjoy the right to food by creating opportunities for them to provide for themselves. in the case where people are unable to enjoy the right to food due to events out of the individuals' control (natural disaster for example), the government ought to provide food to them directly. china is a signatory of the universal declaration of human rights and a contracting party of the international covenant on economic, social and cultural rights , the convention on the elimination of all forms of discrimination against women and the united nations convention on the rights of the child . china also signed the international covenant on civil and political rights but has yet to ratify it. the government of china is under international obligation to facilitate a pre-warning system regarding threats to the right to adequate food, and to improve coordination between different government and food safety agencies, as well as improve their accountability. violation of the right to food refers right to know: human rights and access to reproductive health information (article -university of pennsylvania press, london-philadelphia, ) ; and jacqueline klosek, the right to know (praeger, westport, ) . article of the universal declaration of human rights states: "everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers." jean ziegler, "what is the right to food?", right to food (august , ) <www.webcitation. org/ cmsst c>. not only to shortage of food, lack of infrastructure, mal-distribution and inadequate access to food, but also to protection from contaminated and harmful food. most of the recent food scandals in china involve rampant violations of the right to food in the dimension of adequacy -provision of food for safe consumption. while immoral and illegal conduct of individuals and enterprises is ultimately responsible for the outbreak of food safety crises, the government is accountable for inefficiencies in monitoring the enterprises and disciplining personnel in charge of administrating the food industry. as the most populated country on the earth, the chinese government has always paid great attention to food issues and regarded provision of enough food to the people as the first priority. after decades of effort, china has mostly solved the problem of feeding its people. however, new problems associated with agriculture and food have arisen since the commencement of market oriented reforms. it is reported that due to accelerated industrialization and urbanization, arable land has been shrinking and farmland capacity has declined. this constitutes a threat to china's future food security. the government has introduced the national land consolidation plan ( ) ( ) ( ) ( ) ( ) that aims to increase the effective area of arable land by . million hectares before , though the enforcement of the plan faces challenges such as lack of mechanisms for protection of cultivated land and inefficiencies in the management of land tenure rights. it appears that china has made a significant effort to achieve food sufficiency in the country. food availability and accessibility have been a top agenda item for the government in the past and will continue to remain a central issue in the future. the adequacy aspect received far less attention. the recent outbreak of food scandals is chiefly a result of a lack of oversight within the food industry. this can be partly attributed to the understaffing of supervisory authorities, partly to the misfeasance, malfeasance, nonfeasance and unprofessionalism of administrative officers. it is noteworthy that administrative personnel's unsupportive attitude and behavior towards businesses has been the cause of changes in inspective practice, resulting in a switch of models from official inspection to enterprise self-inspection. under the enterprise self-inspection regime, the working manner of administration is even more unprofessional. for instance, in the recycled buns case, when doing their sample inspection, the governmental inspectors, once arriving at a food factory or workshop, would only come into the administrative office and wait for the factory managerial staff to provide the samples to be examined. it is no surprise that they did not get any clues over the years. in one of the clenbuterol contaminated pork s z gu and y j zhang, "food security in china", in sun honglie and shidong zhao (eds.), area studies -china: regional sustainable development review (vol. , ) incidents, the problematic pigs were sold from henan pig farms to jiangsu province and had to go through several checkpoints conducted by the trade bureau, health inspection station, veterinary station, etc. however, some inspectors acted as middlemen between pig sellers and slaughterhouses for a commission of rmb yuan per pig, which caused wide dissemination of the contaminated pork and pork products. the recycled buns case showed workers in a filthy workshop "recycling" buns by throwing the stale buns into a vat, adding water and flour, and repackaging them to be sold anew. the clenbuterol contaminated pork case involves pig farmers feeding pigs with pig feed mixed with clenbuterol used to make the pigs have leaner bodies, which sell for a higher price. other food scandals involve melamine-contaminated baby milk; pork sold as beef after it was soaked in borax; rice contaminated with cadmium, arsenic-laced soy sauce; popcorn and mushrooms treated with fluorescent bleach; bean sprouts tainted with an animal antibiotic; and wine diluted with sugared water and chemicals. the alarming fact is that most of the food related offences were first discovered and disclosed by journalists, and not the personnel in charge of the surveillance authorities, or even the police or national security authority. it is inexcusable for administrative agencies to claim that ill-training, poor quality equipment and understaffing are the main causes for such an appalling incidence of food scandals in the country, since journalists are by no means in a position to be better trained and better equipped than food inspection agencies or police. as a matter of fact, detection and disclosure of food safety problems is not the expertise of journalists, nor their major business. respect for human rights is becoming a universal principle of good government. this is because many human rights require activity on behalf of government. these activities relate to the duties to respect, protect and fulfil human rights in order to provide the conditions necessary for prosperity and well being of individuals. a good government is committed to protection of the rule of law. hence, it is the state government's responsibility to make good laws and to establish able, professional and corruption-free administrative institutions, with a public service team to guarantee the implementation of the laws. although china's government is quick in making legislative efforts to curtail misconduct in the food industry, it needs to demonstrate its determination and capability of ensuring that the laws are fully abided by and it is accountable for building a law enforcement agency comprised of highly motivated, dedicated, well-trained law enforcers. a typical national food control system comprises the following components: food law and regulation, food control management, inspection services, laboratory services and information, education, communication and training. the capacity of food safety control in a nation is demonstrated by effectiveness, efficiency and sustainability. in china's case, apart from legislative efforts, much needs to be done in the following aspects: law enforcement involves certain members of society acting in an organized manner to promote adherence to the law by investigating and punishing persons who violate the rules and norms governing that society. the enforcement of the law consists of a system comprised of the courts and procuratorates, the judicial and public security agencies, and the administrative agencies, with their descending hierarchy of departments, bureaus, sub-bureaus, and stations. with regard to enforcement of food laws and regulations, administrative mechanisms play a more substantial role, compared with other enforcement instruments. the key is to enhance food control management. this involves development of food control strategies, implementation of risk analysis, operation of a food control program, securing funds and allocating resources, and development of emergency response procedures. development and implementation of food control strategy is concerned with defining food control objectives, identifying priorities of competing interests relating to public investment, state economic interest, food import and export, farmers and producers. an integral, effective food control strategy is particularly important to china, since it will improve the coherence of multiple existing administrative agencies in the country and reduce confusion, duplications of effort, inefficiencies in performance and waste of resources. for the time being, a crucial task china food and agriculture organization of the united nations and world health organization, assuring food safety and quality: guidelines for strengthening national food control systems (joint fao/who publication) - (rome ), <ftp://ftp.fao.org/docrep/fao/ /y e/ y e .pdf>. see food and agriculture organization of the united nations and world health organization, supra note , at . ibid. faces is to consolidate its food control policy at the macro-level by standardizing food quality certification, management, and rating, and in the meantime, to improve the market price system. a market entry certification system should also be put in place. another important task to deal with is to establish a uniform food safety risk analysis scheme to ensure compliance with food regulations and standards. unlike developed countries, the food safety problems in china occur in every stage from food production to service, typically consisting of contamination of raw food materials, cross contamination in manufacture, improper storage and preservation, and unhygienic practices in services. this requires a wide-ranging risk analysis system capable of identifying risk factors at every stage and of providing solutions. in doing so, there is the need to coordinate the risk assessment activities currently exercised by different administrative agencies and to develop a comprehensive scheme for food safety risk assessment, in which a professional team comprising food researchers, toxicological analyzers, pathological analyzers and inspectors play an essential role. attention should also be paid to food safety risk communication improvement. insufficient food risk communication in the past was chiefly responsible for a crisis in customer confidence with china's food industry. until this point, no substantial improvement has been made in this regard. in summary, the flaws of this situation can be attributed to a lack of government guidance, silence on the part of scientific academia, and unreliability of entrepreneurs. addressing this issue, the minister of health recently announced that a plan for food safety risk communication was in development and the press was expected to continue to play a leading role in this aspect. however, without access to channels for obtaining scientific information, the press's capacity for publishing fair and accurate reports is considerably undermined. it is therefore necessary to base risk communication on a system of interactive exchange of information and opinions among all stakeholders, including risk assessors, risk managers, consumers, industries, the academic community and other interested parties. this requires the government to allocate sufficient funds to finance and staff risk communication institutions of various specialities. china has more than million farmers and more than , food production companies. hence, to some, the food production system seems too vast to see world health organization/food and agriculture organization of the united nations, "about risk analysis in food", <www.who.int/foodsafety/micro/riskanalysis/en/>. allow for meaningful inspection at all stages of the food production process. however, the establishment of a national database for food supervision and inspection and a platform for food safety risk assessment enabling all interested parties to follow the development of food safety will absolutely make a difference to china's food industry. by the end of , the ministry of health formed the expert committee for national food safety risk assessment, which was a significant step toward improvement of china's food safety control. it is also reported that the state council of china has revealed its intention to establish a database of food companies' safety records. according to the plan, companies with poor safety records will be blacklisted and publicized, and will be subject to punishment. better regulation mechanisms, legal and standard systems, as well as technical support systems will also be introduced to improve the overall food safety management level. now, the world is waiting to see how well the plan will be realized. improving inspection services for food safety control is another key element for enhancing the food safety control system in china. food inspection service is a means of ensuring that the food supply is safe for consumers and meets legislative requirements. it is also an instrument for decreasing hazardous intoxicants in foods, including pathogenic bacteria, viruses and parasites, chemical contaminants and mycotoxins. the primary duty of the food safety inspection service is to inspect food manufacturing, processing and handling facilities, importing/exporting of foods and the monitoring of a company's facilities for compliance with the national legal and regulatory requirements. in some countries, the food inspectorate also conducts the functions of investigating food poisoning and injury cases and fraudulent marketing practices, as well as handling consumer complaints. of individual inspectors and the quality of their work. it is thus important to make sure that inspectors have detailed guidance and rules to follow when discharging their responsibilities. their powers and the procedures to be followed should be well defined. inspectors should receive up-to-date training in the new technologies used in processing and manufacturing, including what is required for the control of these technologies in order for them to function at maximum effectiveness and to assure proper performance. they must also be able to evaluate the performance of equipment and instruments used in production to guarantee that they are appropriately controlled and monitored. the impotence of china's food safety inspectorate has been widely reported and acutely recognized by consumers. it is officially perceived that the food safety inspection administration suffers from insufficient resources, a lack of qualified personnel, and deficient coordination among layers of governments and among various institutions, particularly among those administrative agencies at the provincial level and below. apart from the above-mentioned vices, three more factors must be taken into account: corruption, shirking and laziness. china's public services have long suffered from a number of bureaucratic problems such as authoritarianism, routinism, elitism, corruption, shirking of responsibility, deceit, laziness, formalism, red tape, nepotism, seeking special privilege, overstaffing, duplication, ineffectiveness, and over-centralization. upon close study, one can discern that corruption, shirking and laziness are the most prominent problems that induce or exacerbate the other problems. these deep-rooted problems penetrate the food safety inspection system and eventually take their toll on public confidence in the food industry. the government of china has pledged to enhance the ability of the inspectorate. in its food safety decision june , , the state council announced that it planned to take years to improve the nation's food safety and food control management. according to the state council's statement, food safety will become a measure of local governments' performance in their annual assessments, in the hope that incorporating food safety as one of the evaluation criteria will make local governments and officials aware of their responsibilities. however, given the institutional decline, erosion of authority of the central government, and loss of control over local agencies and agents in the era of the market economy, effectively rooting out corruption in the food safety administration will certainly demand much greater efforts based on resolute determination. to a certain extent, it represents a social problem and needs to be tackled on a broader scale. to curtail food safety problems on a broader scale, it is necessary to promote general respect for universal human rights in the society. from this point of view, improvement of food safety can be seen as a social project. in the past three decades, in making the transition from a planned economy to a market economy, china placed much emphasis on economic gains and profitability. along with gdp growth, extreme utilitarianism, fickleness and mammonism have become more and more evident and have turned into a driving force in chinese people's daily life. the food safety outbreaks are merely typical consequences of the erosion of social morality and business ethics. food safety outrages spark a new round of calls to promote public morality and human rights. many chinese have come to realize that without a morally healthy social environment, mere economic prosperity does not guarantee a successful society and true advancement. in contrast, it may only carry with it the seeds of corruption and decay. to bring changes to the broader system, the general public needs to step out from their family-centred tradition and self-interested sphere, and endeavor to shape a society where individual equality is upheld, respect for others' human rights is generally aware of, and public interests are greatly valued. the construction of such a society requires the combined efforts of the government, private sectors and the community. while the government is accountable for formulating policies and initiatives, facilitating state agencies and mechanisms, and allocating resources, the business sector and the community are expected to participate in shaping a good society by promoting sustainable business practices, interacting with the government and influencing the policies of governance. it is worth noting that the constitution of china only implicitly addresses citizens' rights to safe food. article provides that "the state . . . promotes health and sanitation activities of a mass character, all for the protection of the people's health"; and article states: "citizens of the people's republic of china have the right to material assistance from the state and society when they are old, ill or disabled." compared with some nations that incorporate the right to healthy food into their constitutions, china is much behind in providing constitutional safeguards for food security. given the challenge of tackling food problems, it may be necessary for china to introduce provisions to protect food safety in the constitution. in the case of combating food safety problems, the food industry shares responsibility with governmental agencies in achieving the objectives of a national food control strategy. involving the industry in national food control activities might be instrumental in overcoming potential problems. the food industry is responsible for the implementation of rules regulating agriculture, food manufacturing and processing practices, as well as a food quality and safety system. the industry should also be obliged to educate and train all employees in food handling and make sure that they understand general food quality and safety system. it can also provide information to consumers through food labeling and advertising. in china's case, the food industry may need to go through a long journey to correct its practices which may also involve a change in the business culture. as members of the community, consumers have a right to quality and safe food and also have responsibilities to prevent food related health hazards. consumers need to understand there is no such thing as an absolutely safe food supply. the right to food for consumers also requires a responsibility to play a role in food control. consumers can actively contribute to food safety control by providing valuable information to the authorities, usually by complaining about product deception and poor quality and by reporting injury and illness caused by food. the authority then needs to provide them with a channel to let their dissatisfaction be known. consumer organizations are expected to play an important role in representing the consumer in the development of a national food control strategy and also in bringing the concerns of consumers to the attention of policy makers and the industry. the chinese government needs to take proactive action in order to ensure that consumers are heard and taken into account. in summary, combating food safety problems depends on a combination of mechanisms including training, business ethics education, administration and supervision, public scrutiny, civil litigation and penal punishment. in other words, combating the food safety problem require a collective effort from the entire nation. the government is certainly accountable for all mandatory activities necessary to ensure the quality and safety of food, including enacting food regulations, operating food inspectorates, organizing analytical services, and enforcing rules. the participation of other stakeholders and interested parties including the industry, consumers, communities and even the society as a whole, is equally crucial. the battle will happen across a gamut of fields involving governmental conduct, social ethics, public relations, business practice, and consumer culture. the medical insurance system of a state directly affects its people's key human rights, namely the right to life and the right to health. the notion of modern medical insurance can be traced back to the introduction of the sickness insurance program in in germany. the antecedents of similar kinds existed in the form of charity or welfare in some civilizations, such as friendly societies organized by european trade guilds, fraternal organizations, the english poor law , the prussian common law , and the civil war pension program . the sickness insurance program in germany came as a result of the medical reform movement and a series of political debates and compromises afterwards. the sickness insurance act was enacted in to facilitate the program. the law allowed the largest segment of workers to benefit from access to public health care through insurance funds. in the event of accidental injury, illness or old age, workers were entitled for minimum indemnity for medical treatment and sick pay for up to weeks. this initial system was financed by workers and employers, with the employers contributed one third, while the workers contributed two thirds to insurance funds. in germany passed the accident insurance act covering serious and fatal accidents occurring on the job in certain industries. the act went a step further by placing the entire cost of the liability on the employers. the significance of the german health insurance program introduced in the s lay in that it was for the first time in history that a national health insurance system was institutionalized. following the german practice, industrialized countries commonly introduced social security programs in the following decades, i.g., the uk the medical insurance program as an indispensable part of the modern social security system has carried human societies into a new era where the government of a country provides economic assistance to persons faced with unemployment, disability, or agedness for the purpose of advancing the benefits of the members of the community as a whole. the key feature of the scheme is: it is imposed and controlled by the government. before the introduction of social security schemes, the dominant mode of support for people unable to provide for themselves was charitable relief proffered by benevolent societies, sometimes with financial help from the authorities. social security comprises two arms: social assistance and social insurance. the rationale behind modern social security programs is the necessity to maintain social and economic justice. with industrialization, social security has gone through a change from charity to a state responsibility. guaranteeing a certain amount of social well-being and economic security to every individual member in the community has become a duty of a modern state. nowadays, social security has emerged as a human right enshrined in the universal declaration of human rights, which states: after the establishment of the socialist state in , as part of the social welfare or security package china introduced a state funded, central planned health care system, which provided a universal coverage of health care to the chinese population. an innovative feature of the system was the operation of the so call barefoot doctors at health clinics at the village and township level, which served the mass rural citizens accounting for three quarters of the total population. this system was held up as a model for providing universal health care in the developing world in the s by the world health organization (who) and inspired who to launch the "health for all by a.d." program. under this scheme, public health in china improved dramatically, with the citizens' life expectancy increasing from to years, infant mortality decreasing from to per live births. the system operated in china for nearly years until the market oriented medical reform took place in the s. as a result, china's health care program has experienced a change from a scheme performing universal social welfare function to a model that is a mixture of free market and medical insurance. however, the reform turns to be a failure which makes china's health care scheme one of the least equitable systems in the world. care reforms ciency and abuse. its sustainability posed a challenge to the leadership in the post-mao era, which had an economic reform scheme at the top of the agenda. by the s, the administrative and financial support for the health care was removed from the national agenda through decentralization before a nationwide health insurance system was provided. with local governments having little incentive to promote local healthcare, individuals of rural areas and urban non-salaried residents primarily relied on out-of-pocket spending for medical and health services. in the meantime, prices for provision of medicines, diagnostic tests, surgical implants, and specialized care were deregulated. as a direct impact, many chinese were in short of medical services and supplies since they simply resolved to not seeking medical help. it was reported in , about % of the chinese people refused to see a doctor when ill and % of those refused to go to hospital, mainly out of financial concerns. there was still worse to come. after the collapse of the previous model, no strategy was adopted to mitigate the lack of integration and coordination in the later medical system. due to a lack of reliable local clinics, people had to wait in long queues for basic health care, with no scheduled appointments and little privacy. after all the inconvenience, what they could receive was usual a very brief face to face consultation of a few sentences or a couple of minutes. during this period, health care was seen "as a consumption activity rather than a fundamental right of the people or a responsibility of the state". indeed, this unsustainable, reactionary approach had to be subject to review and amendment. as a result, in , the new cooperative medical scheme (ncms) for rural population, mainly funded by the government, was launched. since , a health insurance scheme for urban non-salaried residents, especially for children and old people has been implemented. although china's health care system has appeared to get back on the track of government subsidy since the mid- , it is far from offering accessible, affordable, equitable and quality health care services with a universal coverage. some believe that the current health care reform is unlikely to solve the fundamental problems of accessibility, affordability, equity and quality. as long as the buck-passing polity does not fully change and the health policy process is still influenced by interested groups, the problem of dis- see jason shafrin, "an olympic post: the history of the chinese healthcare system", healthcare economist (august, ), available at <http://healthcare-economist.com/ / / page/ />. parity inherent in china's health care system will continue to affect the country's social environment. the worst part of china's health care system is the rampant medical corruption stemming from the medical reform over the past decades, particularly in the period between the mid- s and the mid- s. the usual scenario is that doctors and other staff expect to be paid extra fees (usually in the form of "red envelops" ) to perform operations and take kickbacks from pharmaceutical firms and medicalequipment suppliers. the practice is so prevalent that an unsullied doctor nearly does not exist. almost all practitioners and medical staff tell the same story as the defence of their unclean hands -low salary or underpayment. whistle blowers also tell that doctors have economic income targets allocated by hospitals and hospital administrators for them to meet and exceed. only upon completion of their quotes, they are paid benefit bonuses which can be much higher than their basic salaries. in other words, they are under pressure to charge patients extra fees and to recommend patients to go through unnecessary but expensive tests and procedures as well as purchase expensive medicines. nonetheless, such excuses are not sound enough to defeat professionalism and patients' human rights. besides, on many occasions, they are free to make a choice. for instance, a surgeon or a nurse can always hold up professional dignity by declining a red envelop because it is commonly given privately. moreover, nothing can justify their procurement of briberies and kickbacks from pharmaceutical companies or health care companies. facing a choice between campaigning for improving income or work environment and becoming corrupt, chinese doctors have had less difficulty in choosing to compromise their professional morality in the first place. moreover, nothing can defend the corruptive and negligent conduct of the personnel in governments and the health care system, which have caused further spread of epidemics such as aids. a nation has every reason to become alarmed when seeing medical profession to be infested by the epidemic of corruption. the governments and citizens all have a responsibility to trace the deep root of the phenomenon in their society, culture, policy and ethics in order to find the cures. access to quality health care services is a basic right in a civilized society. it is essential to one of the core human rights -human right to health. the human right to health care means that hospitals, clinics, medicines, and doctors' services must be accessible, available, acceptable, and of good quality for everyone, on an equitable basis, where and when needed. hence, universal access, availability, acceptability, dignity, non-discrimination, accountability, and transparency should be the fundamental principles upon which a health care system is built. many countries have upheld health care as a basic human right in their laws. unfortunately, the failure of the health care scheme has deprived many chinese citizens this right for more than two decades after the medical reform. this renders china's medical reform a truly disgraceful story. when people are deprived their access to hospital and health care services, their human rights, including their rights to health, life and information are potentially compromised and threatened. china is a contracting party to the international covenant on economic, social and cultural rights (icescr) and the united nations convention against corruption (uncac), a signatory of the international covenant on civil and political rights (iccpr). it is thus under treaty obligation to protect individuals against corrupt acts of third parties. though corruption and abuse of the health care scheme committed by practitioners and professionals in hospitals, insurance companies and suppliers of medical and health care goods and services impact on patients' human rights, the guilty individuals are not in direct breach of the uncac. instead, the uncac is directed primarily at member states rather than non-state actors. hence, it is the obligation of the chinese government to prevent corruption involving governments, industries, companies and individuals in fight against corruption and to raise public awareness of the matter. due to the fact that corruption has invaded into every corner of the chinese society, citizens have faced an unfavorable physical and social environment. fraud in project approvals and failure to apply emission control measures are responsible for the human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment. xiangming zhou, a study of the health care right (phd thesis, jilin university, ) . see part ii -articles and uncac. rising pollution in the country. some professions including teachers, doctors, lawyers and those safeguarding consumptive goods are not only important to people's lifestyle and well-being and society's progress, but also play a social role in which trustworthiness is an expectation in every tradition. in china, these professions, because of the rampage of the unethical performance conducted by a majority of the people in the trades, have definitely failed to honor their part of social compact with society, which in turn exacerbates human rights related problems. it is a high time for china to review the ethical conduct of these key professions. the chinese government has an obligation to protect citizens' human rights to health, access to healthy food, safe drinking water, clean air, and a healthy environment. in discharging this obligation, effective mechanisms combating corruption in various forms need to be established in order to sustain the country's social stability and economic prosperity. china -pig farmers told to drug livestock china, fear of fake eggs and 'recycled' buns history of universal human rights -up to ww sourcebook: human rights & good governance (asialink project on education in good governance and human rights office of the united nations high commissioner for human rights a reflection on the circumstances of contemporary chinese social moral ideal from an academic point of view, it is perceived that china's medical reform in the s and s was basically a buck-passing strategy. in a joint report in , both who and the state council of china admitted that china's medical reform was overall unsuccessful. nevertheless, this system was costly and prone to ineffi- the barefoot doctors are the medical practitioners who had only basic health care training and lived in the community they served health care system reform in china: issues, challenges and options (cema working papers , china economics and management academy see the declaration of alma-ata privatization and its discontents-the evolving chinese health care system see who, supra note governing health in contemporary china three prescriptions for treating the symptoms of the medical reform', china youth daily chian's health care reform: not just a policy failure, carengie endonwment for international peace an envelope with cash inside if the government is really serious, all the chinese doctors and drug companies will be found guilty because no drug manufacturer or doctor is innocent. if doctors are to be laid off for receiving hongbao, then every chinese doctor will be laid off. but then who will take care of the patients? if the benefit bonus is fully deducted, the doctor only receives the basic salary part. people usually refer the basic salaries when speaking their salaries consequences of a stalled response: epidemic among blood donors in central china sourcebook: human rights & good governance. asialink project on education in good governance and human rights china's environmental crisis social insurance and allied services public health and human rights: evidence-based approaches privatization and its discontents-the evolving chinese health care system training in an integrated food safety system: focus on food protection officials. food safety magazine historical summary of workers compensation laws (olr research report food safety and public morality, china culture and media daily network evidence on the impact of sustained exposure to air pollution on life expectancy from china's huai river policy article /university of pennsylvania press, london/philadelphia committee on economic, social and cultural rights (twentieth session, ) general comment no. on the right to adequate food the vienna conventions on the law of treaties: a commentary suhe meng's opinion: confidence crisis is the biggest challenge to china's food products, caixin net earth summit ( ) rio declaration on environment and development shrinking arable land threatens grain security, china daily national wide investigation into problematic buns, food safety face trust crisis fifteen organizations share responsibilities in food safety supervision and administration: weak supervision and administration cause frequent problems, cctv half-hour economy assuring food safety and quality: guidelines for strengthening national food control systems workingmen's insurance in europe markets adapt to china's changing diet mcgill_queen's university press, montreal hannah b ( ) how corruption blights china's health care system china food safety, it ain't working and we told you so food safety and effective supervision by the government area studies -china: regional sustainable development review health care system reform in china: issues, challenges and options (cema working papers , china economics and management academy governing health in contemporary china. routledge, london/new york human rights council ( ) human rights council resolution / on human rights and climate change meanings of environment terms international legal instruments addressing good governance (report of united nations human settlements programme) the german sickness insurance programme - : its relevance for contemporary american health policy the right to know: your guide to using and defending freedom of information law in the united states china, fear of fake eggs and 'recycled' buns the right lists tells how to envisaging china's human rights development, people's daily online ping: protecting environment is as importance as protecting productive forces, xinhua news agency (the news center of the national people's congress of china and the chinese people's political consultative conference managing economic reforms in post-mao china studies on issues concerning food safety in criminal law, legal study news of the capital city www on the shortcomings of the foot safety law and some suggestions on improvement equity in health and health care: the chinese experience a comparison of the health systems in china 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environment programme ( ) nairobi declaration on the state of worldwide environment united nations environment programme universal declaration of human rights international covenant on economic, social and cultural rights united nations general assembly ( b) international covenant on civil and political rights convention on the elimination of all forms of discrimination against women draft world charter for nature convention on the rights of the child what are human rights? www.ohchr.org/en/issues/pages/whatarehumanrights.aspx usda -economic research service ( ) percent of consumer expenditures spent on food, alcoholic beverages and tobacco that were consumer at home, by selected countries three prescriptions for treating the symptoms of the medical reform directors' duties under chinese law -a comparative review world meteorological organization, timely access and response to accurate early warnings are crucial for minimizing impacts of natural disasters johannesburg declaration on sustainable development and plan of implementation of the world summit on sustainable development: the final text of agreements negotiated by governments at the world summit on sustainable development a study of china's legal system for food safety a study of the health care right chinese vs. western perspectives: understanding contemporary china food safety becomes national priority, china daily what is the right to food? right to food key: cord- -lj r ptb authors: xiao, ren title: human security in practice: the chinese experience date: - - journal: human security norms in east asia doi: . / - - - - _ sha: doc_id: cord_uid: lj r ptb this chapter elaborates on how the idea of human security is defined and understood by the government and various actors in china. as one of the permanent members of the united nations (un) security council, china, has been supportive of international norms advocated by the un, and even though the term human security has not been frequently used, in effect it has been vigorously practiced. for both the government and the academic community in china, human security and national security are not necessarily in confrontation but rather can complement and strengthen one another. the purpose is to improve the quality of people’s everyday life and the government is expected to contribute to this end. chinese people expect the government to extend a parental roof over the people. are perceived as pressing human security issues in china. the chapter concludes with a discussion of the overall human security practices and shows that, based on current indicators, china is heading in a healthy direction in terms of promoting human security. the understanding of human security in china in china, the government is often wary of new academic terms and tends to avoid using them directly. however, the findings from our previous study (ren and li ) clearly showed that the country is following a trajectory of increasingly attaching more importance to human (both individual and collective) security. much greater attention has been paid to mitigating threats to human security, and practical measures are being taken to fulfill the mandate. we emphasized the convergence of the human security idea and china's practices (ren and li ) . our findings disprove the following statement: "the very notion of 'human security' has so far not appeared in the chinese language in any possible translation, and the people's republic of china (prc) has not even accepted or adopted the concept of human security in either domestic development papers or foreign policy guidelines…" (wu , ) . our examination suggests otherwise. though the chinese government has only used the term "human security" on a few occasions, china is definitely engaged in the enterprise of enhancing human security. the fact that china is becoming more open and receptive to human security is strongly related to its experience within the un system. as one of the five permanent members of the un security council, china has long been supportive of the un, the most important international organization in today's world, and the country has played a proactive role in various un activities such as peacebuilding, development, and global governance (breslin and ren ) . over the years, the un has been subjected to criticisms and it is widely believed that reforms are needed, which china supports. nevertheless, beijing continues to show a belief that the un plays an irreplaceable role in global governance, and china has endeavored to support this by encouraging the un to play its role well (kim ) . this has remained an unchanged priority in china's foreign policy agenda. china's steady backing has boosted the status of the un in world affairs, at a time when the world is faced with growing global challenges in the first decades of the twenty-first century. meanwhile, the un has taken the lead in advocating and/or spreading norms and principles, and this has affected and helped to shape china's ideas (kent ) . usually, un initiatives or proposals attract china's attention, and prompt beijing to have a closer look at them before taking actions to adapt to the new norms or principles (morton , - ) . for example, china was involved in the deliberations and adoption of the un world summit outcome document in . although it is not the same thing as the "responsibility to protect" idea proposed by the international commission on intervention and state sovereignty (iciss ) , to some extent the outcome document is consistent with this idea in terms of thinking on protection. the outcome document attempts to strike a balance between the need to protect innocent people around the world from being harmed while avoiding the abuse of external intervention or selfish behavior in the name of protection. for this, the outcome document imposes limitations by listing four specific crimes against which the international community should act to prevent people's lives from being jeopardized: genocide, war crimes, ethnic cleansing, and crimes against humanity. in this way, the outcome document has become a new international legal document. china was involved in this process and made its own contribution. thus, involvement in global or regional institutions has pushed china to clarify or develop its own thinking on human security. against the backdrop of the great earthquake and tsunami that devastated japan's tohoku region, the ministerial millennium development goals follow-up meeting was held under the un framework in june in tokyo, japan. china sent vice foreign minister cui tiankai to attend the meeting. in the speech he delivered, cui, as the representative of the government of china, stated: to discuss the mdgs from the angle of human security offers a thoughtprovoking perspective. we believe that the mdgs and human security are interrelated and should be mutually reinforcing. the mdgs embody so many aspects of human security, while the realization of mdgs aims at greater wellbeing and security of more people in the first place. (t. cui ) cui pointed to the fact that the general picture of global security remains disturbing: "civilians in north africa and the middle east continue to bear the brunt of turmoil, and innocent women and children are still being displaced or killed in armed conflicts in various parts of the world." cui concluded that: these give rise to the call for a new concept on security and an international political order where the united nations should play a central role. we strongly believe that the purposes and principles of the un charter should be upheld, and security council resolutions should be implemented in a faithful manner. …in a word, if human security in the larger sense of the term is still so much threatened, there is little hope for better individual security. (t. cui ) this is an illuminating example of how china has clearly and definitively adopted and used both the idea of and the actual term "human security" in the context of a formal un meeting. although it was an event on mdgs and not specifically on human security, the term "human security" was explicitly employed to express china's opinion and position. this discourse was reinforced by further developments. in february , ms. fu ying, chairperson of the national people's congress foreign affairs committee, was invited to and spoke at the munich security conference. she argued that the security necessary for people to survive and develop is fundamental to any security. the core of the chinese dream of the revival of the chinese nation proposed by president xi jinping is to have the . billion chinese people live a happy life. in other words, all ordinary people have the right and are entitled to live with dignity in a secure environment. this is the attraction of china's success story to the world, as well as the charm of the chinese dream. this line of thinking has many elements in common with the widely shared "human security" idea. for instance, both place emphasis on individuals and their happiness, and this must be fulfilled together with national development. ends and means should be consistent, and the persistent value is that people themselves are the end and they should not be sacrificed for arbitrary national goals. the key point here is that china's security concept is undergoing a profound transformation. a new consensus has emerged that assumes security does not equal military security, and security should not only be comprehensive but also people-centered (yi renmin wei zhongxin): "national security" now has new connotations. during the landmark third plenum, which was held in november , a major resolution to comprehensively deepen china's reform was deliberated and passed. the long reformist document has parts and items. the decision to create a new national security commission (nsc) was announced as a component of the th part on the new social governance system. the purpose of the nsc is to improve the relevant institutions and strategy to better safeguard china's national security. according to the explanatory speech president xi jinping gave, reform and development are conditional on national security and social stability, without which reform and development cannot be advanced further. at present, china is faced with the dual pressure of safeguarding national sovereignty, security, and development interests externally, and maintaining political security and social stability internally (xi , ) . all kinds of risks that can or cannot be foreseen are clearly increasing, while the country's institutions and security mechanisms are insufficient to adequately meet the need of maintaining national security. this has resulted in demands to set up a powerful and capable platform to coordinate all work on national security. the responsibilities of the nsc include formulating and implementing national security strategies, advancing the construction of national security rule of law, deciding national security guidelines and policies, and studying and addressing major issues in the national security work. quite understandably, this major decision drew considerable attention both at home and abroad. in april , the first meeting of the new nsc was held. according to the speech president xi jinping delivered, the security of the people must be its core purpose. state security should in every sense serve the people and rely on the people. the mass foundation of state security must be laid and consolidated. this means that state security and human security are not confrontational but rather that the two can and should coexist. internally, china is undergoing a modernization process and the number of contradictions is growing. in this time of rapid economic and social development, a series of social problems have been accumulating that have not been "digested" well. for some chinese observers, "group incidents" resulting from unbalanced distribution of interests frequently break out, negatively affecting social stability. externally, as china continues to grow, some powers and neighboring countries have been hedging against china, and as a result, contradictions or frictions in china's neighborhood have been increasing. moreover, challenges to social stability and security, from home and abroad, have been affecting each other, and they are interlinked. coping with them is becoming a more difficult job. in the current era, the concept of national security is becoming richer in depth and wider in breadth, involving a range of issues in a variety of areas. increasingly complex problems cannot be dealt separately by foreign affairs, national defense, and security departments but rather are demanding that more agencies, social organizations, and even the whole society work together (hu and wang ) . since the initiative to create china's nsc appears in the "social governance system" section of the november resolution, its domestic and internal security dimension is self-evident. in the meantime, the commission's work involves two dimensions (both external and internal) rather than just one. thus the "security" the initiative refers to is of a comprehensive nature. it is not difficult to come to that conclusion if we simply recall the july , , incident in xinjiang, the riots in tibet and tibet-related self-immolations in its neighboring provinces, and the horrible killing at the kunming railway station on march , . during all these incidents, innocent people were killed or injured, and some of the incidents resulted from the actions by hostile external forces. that is why it was widely believed that internal security would be the dominant concern for china's nsc, at least in its early stage. when ordinary people can be unexpectedly harmed by violent terrorist attacks in any situation and without warning, a sense of insecurity arises, and this can be frightening. thus, even though freedom from want is no longer a problem in today's china, ordinary people should also be able to live their lives free from fear. a broad concept of security of this kind logically became the goal for china's nsc. in fact, as cui shunji of zhejiang university points out, since the initiation of reform, at the highest levels, attention has been placed on poverty reduction, the pursuit of a sustainable development model, and china's proposals for constructing a "harmonious society" and a "harmonious world." these goals indicate that china regards the guaranteeing of basic human needs, social justice, and harmony as well as sustainable development as important parts of a continuum of national security (s. cui , - ) . "letting people live a happier life with more dignity" has become the goal of national development, which indicates that china's recognition of human security has been elevated to the political level. putting people first and "governing for the people" have become the new thinking for governing the country. as a reflection of the foreign policy changes, handling foreign affairs for the state is shifting to handling foreign affairs for the people (s. cui ). this was reinforced at the th party congress, held in october , which emphasized the need to regard people's interests as paramount and let the achievements of reform and development benefit everybody more and fairly. in china's research community, "human security" is often discussed in terms of the discourse on "non-traditional security." for years, chinese researchers have utilized the term "non-traditional security" to distinguish the so-called non-traditional matters from more traditional matters. traditional security usually refers to military security, namely, assuring national security through boosting military power. however, after the end of the cold war, threats to security have increasingly come from nonmilitary domains in the form of unconventional or non-traditional security threats. such issues include financial crises, terrorism, transnational crime, environmental degradation, the spread of hiv/aids, scarcity of water resources, food insecurity, and so forth. according to the summation by a leading chinese researcher, nontraditional security is broad-based, complex, and multi-dimensional. examining each in turn, while traditional security falls into military, political, and diplomatic areas, and its supreme value is the pursuit of peace and the elimination of war or the possibility of war, a broad-based non-traditional security is more about economic, social, cultural, and environmental threats as well as the emerging cyber security and space issues. in addition to peace, non-traditional security relates more to risk, crisis, emergency, and daily threats to life. it relates more to natural disasters, accidents, emerging public health incidents, and major public security events. second, non-traditional security is complex. threats to non-traditional security are mainly the threats to "societal security" and "human security." society and people are the chief referent objects of non-traditional security, and a "safe china" has societal and human dimensions. for individuals, safety means that the security of people is guaranteed: namely, individuals enjoy a state of existence in which a person's body is not injured, their mind is not harmed, they are not deprived of their property, and their living environment is not undermined. third, non-traditional security is multi-dimensional. according to the place and origin of non-traditional security events, threats to nontraditional security facing a country can be divided into four categories: ( ) exogenous non-traditional security threats which take place abroad and chiefly require diplomatic negotiations; ( ) endogenous nontraditional security threats which take place at home and chiefly require domestic interventions; ( ) "bi-dogenous" (双源性) non-traditional security threats which take place in peripheral areas, necessitating both domestic and international management; and ( ) "multi-dogenous" (多源性) non-traditional security threats that involve both traditional and nontraditional security issues requiring the involvement of the military in addition to other organizations (yu , - ) . throughout the above process of ideational transition, a few landmark crises have affected china deeply, including the asian financial crisis that highlighted the importance of financial security, the sars crisis that highlighted public health security, and the march , , terrorist attacks at the railway station in kunming, the capital of yunnan province. the horrible march violence against innocent people especially highlighted the serious security threat that ordinary people could encounter in their daily lives. this genuine risk could give rise to a widespread sense of fear. as noted, earlier conceptions of security in china were mainly focused on state security, the importance of which remained unquestioned. now that human security has been put forward, and given its undeniable value orientation, support for the concept is gaining momentum. in fact, chinese scholars speak highly of human security and argue that it goes beyond the limits of state-centric traditional security research and is the least traditional theory among the non-traditional security domains (yu , ) . human security research explicitly sees people as a collectivity and individuals as the referent object of security. this transcends the dilemma of more traditional security theory, since the state can bring about insecurity to its citizens. such a possibility raises questions concerning the relationship between state security and human security. in general, chinese researchers do not endorse the view that human security overrides state security or that the two are confrontational, but rather affirm the reasonableness and value of state security at the same time. for example, shi bin, a professor at nanjing university, asserts that the human security idea is a focal embodiment of non-traditional security and new security concepts, and yet the relationship between human security and state security is much more complicated (shi , - ) . shi argues that both state security and human security, in terms of their security concerns and value pursuits, have legitimate claims. however, there is no reason for either of them to become totally dominant. human security is of course the fundamental goal and ultimate value of human development. the value orientation of putting people first, with human security at the center, provides it with the moral high ground and legitimacy. however, a person has both individuality and sociality, and individuals are often weak and helpless. resisting foreign military invasion and safeguarding national sovereignty and territorial integrity are therefore in the nation's common interest. nonetheless, the traditional state-centric security idea and strategy indeed ignores the security needs of many non-state or sub-national entities and cannot adequately deal with external nonmilitary threats such as environmental degradation and pandemic disease. second, shi bin articulates that, although there is a tension between "human security" and "state security" and the two may conflict in practice, they can still be mutually accommodating and complementary if handled and balanced well. therefore, this can provide a favorable opportunity for upgrading the overall security level of all entities. people's security and welfare, and the improvement of their living conditions and quality of life, are an important base for national identity, social stability, and political legitimacy. in this sense, human security and state security are not necessarily contradictory. for shi, the human security discourse has a tangible western value orientation bearing liberal colors; consequently, in practice, it tends to override the security interests of the sovereign state. the acclaimed paradigm shift from the state to individuals excessively downgrades the positive role of the state in dealing with various security challenges. for zhang yunling of the chinese academy of social sciences, the rise of non-traditional security issues does not mean that traditional security is no longer important. the appearance of non-traditional security on the agenda and the fact that it is stressed imply that it has been included in the category of security, and therefore the formation of a "comprehensive security" concept includes both traditional and non-traditional security as well as the corresponding security policies (y. zhang ) . taken together, with "non-traditional security" increasingly becoming part of the mainstream discourse in china, researchers tend not to deny the value of state security but rather see human and state security as being mutually accommodating. nevertheless, the theoretical shortcomings of non-traditional security, as guoguang wu rightly points out, are obvious, when it is narrowly framed as oppositional to traditional security, without any positive and substantive defining of the contents and nature of new "securities" (wu , ) . the relationship between state security and personal security is not a zero-sum one though. more state security does not mean less personal security, and vice versa. the goal should be a calibrated balance between the two. moreover, the increasing tendency to securitize many issues and aspects of life may not be entirely beneficial. an overemphasis on discussions of security may imply a growth of insecurity. for example, in china food safety was previously not discussed often but was later widely talked about. this indicated that food safety was not formerly an issue, but it became such an issue. the deterioration of food safety was a negative development that involved the need for moral reconstruction in the society. as shown above, the chinese research community has attached increasing importance to the issue of human security. meanwhile, they are not just following in others' footsteps, but rather have developed their own analyses and views. some researchers have stressed that individuals are both the starting point and the ultimate purpose of any society. the emancipation of human beings should be the fundamental goal of any social emancipation. it is people who are the final objective of the concept of human security, and this is the core value any security is supposed to protect, while the state provides the means or temporary purpose (j. li , - ) . the establishment of "people are the purpose" as a value grew to have great significance for chinese society after the community had drawn lessons from the history of the people's republic since . during the cultural revolution period, many innocent people were attacked, detained, or persecuted illegally and immorally; rights were ignored, and people were harmed. after a disastrous decade, many people reflected on their painful experiences and thought about the phenomenon of imposing horrible acts on innocent individuals, something that should never recur. in the early reform period, there emerged a movement in china's intellectual community that began to discuss the issues of humanism (rendao zhuyi) and alienation (yihua). during this time, many intellectuals affirmed the significance of humanism and argued for the promotion of human values. some of them cautiously adopted the term "marxist humanism" or "socialist humanism" to distinguish from the so-called capitalist doctrine. not long after, the debate abruptly came to a halt due to a political intervention. however, along with further economic reform and considerable social development, the awareness of the value of the individual human being in china was reawakened and the value of people confirmed. the initiative for humanism in the s was in fact later accepted by the whole of chinese society. this was also reflected in the discussions and research on human security, since it was made clear that guaranteeing human security is the value base for maintaining non-traditional security. the protection of people and human development should be set as the ultimate goals of any security course. obviously, this progress is precious for chinese society and deserves appreciation by the outside world. the paradigm of human security opposes the harming of the human freedoms and rights to promote economic growth or social stability. nor does it favor the pursuit of economic benefits and communitarian policies at the expense of sacrificing the security and dignity of the individuals or the nation. the fundamental reason for this lies in enhancing the value of people, which is the key and ultimate goal, and there is no higher goal than this. the previous practices of both "collective security" and "common security," yu xiaofeng, a leading scholar in human security, argues, could not have avoided the limitations of regarding the state as the chief actor (yu , ) . by contrast, "shared security," which he has proposed, regards the human community as occupying the central position of security, the protection of human life as the value base of security, social safety and prosperity as the priority goals of security, and harmony and cooperation as the supreme principles for security interactions between the states (yu , - ) . this moves the discussion beyond the traditional security discourses and has the potential for further theoretical development. according to the human security now report (chs ) and the october resolution adopted by the un general assembly as a follow-up to paragraph on human security of the world summit outcome, as well as the definition and design of this book, human security has two dimensions: protection and empowerment. in china, the dimension of protection has drawn much attention, epitomized in the doctrines of "putting people first" (yiren weiben) and "diplomacy serving the people" (waijiao weimin), which i discussed in a detailed way in an earlier study (ren and li ) . the findings from this earlier study have been reinforced by recent evidence. for example, a chinese newspaper correspondent wrote of his impressions when reporting from the national people's congress (npc) sessions. he was deeply impressed by the attention the npc delegates paid to the concrete issues concerning people's daily lives, including social insurance, income distribution, rights of peasant workers, food safety, unreasonably high drug prices, and protection of stakeholder interests. in his view, those kinds of issues had never before been so meticulously discussed at the npc (yuan ) . the changes the correspondent detected indicate ongoing healthy trends in human security terms. a harmonious society is one that puts people first, which means people's everyday life is a priority for the society. a government that puts people first is a government that represents people's interests. economic and social development should put human development at the center, and human development is the ultimate value judgment for social progress (yuan ) . meanwhile, the achievement of human security is a cooperative venture between the individual, society, and the state (bedeski , ) . government as a "necessary evil" is very much a western invention and is not a chinese idea. traditionally, people in china often have wishes for their government, and they want it to do good things for them. compared to western political culture, they have less vigilance but higher expectations of the government. one revealing example is the use of the term "parent officials" (fumu guan) to refer to government officials, with people expecting them to play a paternalistic role. without cooperative ventures, human security cannot be achieved. on the protection side, while people-oriented ideals might be considered noble ones, challenges come from the process of implementation. not surprisingly, many problems are persistent. one prominent example is the matter of government land appropriation and relocation of residents. sometimes the failure to protect the rights and interests of the ordinary people has led to acute standoffs and conflicts, and in some cases even extreme acts of protest. when property development businessmen and arbitrary power coalesce, together they can undermine the interests of the ordinary people who are affected. protecting people's legitimate interests has become an outstanding issue in china's human security amid the drastic social changes and urbanization of recent decades. moreover, the chinese leadership came into office with a promise to narrow the widening gap between rich and poor, and to shift to a more environmentally and economically sustainable growth model. since gross domestic product (gdp) became the brand of accomplishment for many government officials, "gdp worship" has prevailed. local officials tended to initiate projects that show their "achievements" and promote their image to the public. when poorly planned, such projects led to unexpected outcomes and environmental damage. when this became obvious, a strategic shift had to be undertaken. "no gdp growth at the expense of the environment" is becoming a new norm and "ecological civilization" the new banner, which was again stressed in the th party congress report of october . the reform era has been characterized by remarkable success in terms of rapid economic growth and the improvement of living standards. after three decades of successful economic development, the country is standing at a new starting point. if the ruling party's historical promise to "let some people get rich first and eventually arrive at common prosperity" was a prerequisite for the reforms to unfold, and if four decades later this historical task has been basically fulfilled, what the reform enterprise must accomplish now is the other half: namely, to realize a common prosperity. this is a goal that will justify and inform further reforms. the reaffirmation of realizing common prosperity in line with the principles of governing for the people and building a comprehensive and balanced well-off society will guide future reform with a clear direction. to fulfill its pledge to narrow the gap between rich and poor and to "unwaveringly pursue common prosperity," the leaders have to place the people in their hearts and take their needs seriously in order to realize the goal of the "chinese dream." after the th party congress in , the new general secretary xi jinping expressed his view that "to fulfill the people's desire for better lives is what we shall strive for." this statement sounded dear and close to the ordinary chinese people. on the empowerment side, there have also been several measures. only when a person has the capability for survival and development can he or she enjoy real freedom. the capacity for development is what empowers an individual. thus, a modernized china should not only accept empowerment through protection but also appreciate its importance in realizing human freedom and guaranteeing human security. education as a right is the fundamental and most significant form of empowerment, as the human experience has repeatedly revealed. thus, educational development is a significant way to empower people, especially compulsory education. china has reason to be proud in this regard. it has a tradition that puts significant emphasis on education, in which parents always try their best to pave the way for their children to receive a good education, and often they are willing to make sacrifices. in china, nine-year compulsory education has been in force for years. in , project hope was set up as an educational support supplement, which later became well known throughout chinese society. it was initiated by the central youth league and the china juvenile development foundation as a philanthropic enterprise to help less developed areas to establish primary schools, to financially support children who have dropped out of school in the poorer regions to return to school, and to improve education in rural areas. the project received society-wide attention and support. implemented successfully, the project has positively changed the fate of hundreds of thousands of children of poor families and has also beefed up the whole society's awareness of the importance of education, thereby improving china's fundamental education. as a major initiative for the future, the third plenum set the aim of modernizing china's governance system and governing capability, a longterm goal for china. an important part of it is to reshape a new social governance system. during the national people's congress session, president xi joined the shanghai delegation for a deliberation of the government's work. for him, the key to future social governance is institutional innovation, and its core lies in people. only when people are living harmoniously can society be operating in a stable and orderly manner. for han zheng, the party secretary of shanghai, social governance was up to everybody, and the governing process should serve the all-round development of people. rule of law is the foundation of social governance, without which there can be no base for long-standing good governance and robust stability. for that matter, among other things, it is necessary for grass-root cadres to regard people's concerns as their own matters, while always trying to understand their feelings and demands. again, the key challenge is to make this happen in real life. fortunately, in china there have been local autonomous grassroots organizations that play an intermediate role and serve to help in addressing problems at the grassroots level. they assist ordinary people who encounter difficulty, and they also, for example, mobilize donations to help people in the regions that have been struck by earthquakes or other natural disasters. the work of these local self-help organizations has proved to be useful and reassuring in terms of social governance. since 'human security' is central to non-traditional security, it is concerned with all kinds of factors that directly threaten human security" (zhou , - ) . in today's china, prominent direct threats include air pollution, food safety, and cyber security. this section examines each of these in turn. the seriousness of the problem of air pollution first became apparent right all across china in . heavy smog emerged not only in north and northeast china but also was reported in other regions. many people were alarmed by the situation, including concerns expressed by china's neighbors, japan and south korea. the spread of the smog made it obvious that the environment in which people were living was deteriorating, a red-light signal providing a warning on the existing pattern of economic growth, which was consuming a great amount of energy and yielding considerable waste. while many people were already aware of the issue, the shocking reality of the situation in and its related risks served to awaken people as never before. with many people walking in the streets wearing masks, the sense of insecurity was palpable and imminent. in this context, the specific threat of air pollution became the number one threat to people's security. to cope with this threat, in june , china's state council laid out ten measures to prevent and combat air pollution. as a follow-up, in september, china released an action plan to implement this, which was a blueprint to fight against air pollution by . since then, further work has been undertaken. in his government work report delivered in march , premier li keqiang swore to "fight pollution like fighting poverty." when he was looking around the city of beijing, president xi emphasized that the sprawling pattern of urban development had to be contained and steps should be taken to deal with smog pollution and improve air quality. among the five requests xi made, one was logically to reinforce the measures to rein in air pollution. the top priority to combat air pollution and improve air quality was to control pm . , with major steps that included reducing the burning of coal, strictly limiting growth in the number of cars, adjusting industries, tightening management, and executing joint prevention and control. xi's move clearly sent a signal that the government was committed to taking measures for better air quality. the chinese leadership had previously pledged to launch a revolution in energy production and consumption and said that urbanization must be balanced with ecological security (hook , ) . however, pollution was worsening and was posing a serious threat to human health and social stability. to reduce air pollution and carbon emissions, beijing (population million) is attempting to phase out coal-fired power plants within the city's urban core, replacing them with cleaner-burning natural gas power plants. these measures are also basically valid for other cities. after all, fighting pollution is relevant to everybody's security, a point that has attracted a high-degree of consensus within chinese society. similarly, china's energy sector had a watershed year in . reforms that could have a profound impact on china's environment and energy policy were floated. with concerns over air pollution mounting throughout the year, the country is poised to shift away from its reliance on coal and toward use of cleaner forms of energy, including natural gas. shale gas exploration is making progress in the country. driven by crises, a true transformation is under way but surely will take time to complete. the second human security concern among the chinese people is that of food safety. in recent years, a series of food contamination incidents occurred throughout the country, causing serious concern. a poll by xiaokang (小康 [moderately well off]) magazine and tsinghua university conducted in chinese cities found that food safety ranked number one of all social concerns among those surveyed, reflecting mounting anxiety after the melamine crisis (z. zhang ; wishnick , ) . within this context of growing concern over food safety, the government has not been unaware or insensitive. appearing at a press conference, premier li keqiang responded by stressing that "food safety is of utmost importance." answering a different question concerning the missing mh aircraft, he stressed that "any case involving human life has to be treated with the utmost care" (renming guantian). as with the issue of air pollution, the government work report promised to adopt the strictest surveillance, the most severe punishment, and the most serious accountability measures to resolutely govern pollution at the meal table and reassure people of "security on the tongue tip" (k. li ). in fact, there is a widely shared consensus in china on the need to make efforts to ensure food safety. specialists distinguish between two separate food-related issues: the first is related to food security or ensuring sufficiency in the quantity of food; the other concerns food safety, which refers to the quality of food. while the former involves the question of whether there is sufficient overall provision of food, an area in which china has vowed to "hold the bowl firmly in our own hands," the latter involves the question of whether people can be assured that the food they eat every day is safe. formerly, the issue of food scarcity trumped food safety. but today the main problem in china lies in food safety, with people alarmed by reports of different kinds of contamination. in recent years, this has even spilled over into china's foreign relations, and was epitomized in the spoiled jiaozi (dumpling) incident between china and japan. the incident originated in hebei province. an employee in the tianyang food factory was resentful over his low income. in revenge, he deliberately poisoned jiaozi, and the contaminated products were exported and sold in japan. some customers bought and ate them, becoming ill. on investigation, pesticides found in the frozen dumplings were traced back to china. this was a single case of a crime that resulted in grave consequences. the reputation of china's food products was seriously damaged, and the sino-japanese relationship was also somewhat affected. this incident once again highlighted the close links between domestic and international affairs. in the final analysis, the root cause lies with individuals, and the issue of "moral collapse" has been used to refer to this situation. to what extent this is true can be debated. there was a belief that overuse of fertilizers and pesticides was rampant, and that growers distinguish between what they themselves eat and what is sold in the market, even if they know the latter is not suitable to be eaten. again, how widespread the phenomenon is can be discussed, yet reports on these kinds of practices result in people feeling that the food they eat may be unsafe. as a result, in china there was an obvious lack of public trust in food safety. tighter regulations must be implemented. greater transparency helps to build public trust, including more official data and statistics about the improvement (or deterioration) in food safety, increased freedom for media and civil society to verify the official data, more effective actions from the government in handling the corruption and malfeasance involved in food safety issues, stronger protection for whistle blowers who uncover production of unsafe food and, more importantly, removal of the corrupt officials involved. further measures must be taken to improve china's food safety regulations, consumer education levels, and supply chain traceability and sustainability. the third and final issue is that of cyber security. the use of the internet has increasingly become a part of everyday life in china. by , there were over million internet users in the country, and mobile internet users reached million, making the community of chinese "netizens" (wang min) the world's largest. with this growth, cyber security has become a prominent issue. in fact, china is one of the major victims of cyber-attacks. the covert activities revealed by edward snowden highlighted the vulnerability of nations and individuals who are monitored illegally and immorally (meng ) . at the government level, a central small leading group on cyber security was created, which held its first meeting in february . it was emphasized that cyber security involved national security and development, as well as the careers and everyday lives of a vast number of ordinary people. it was therefore a major strategic issue. the breakdown and vulnerability of the internet can have a widespread impact on people and their lives. this chapter has addressed the three research questions the research project raised by elaborating on how the idea of human security is understood or defined by the government and social actors, the ways in which the distinctions between the "protection" and "empowerment" aspects of human security are understood and accepted, and what downside risks are perceived as pressing human security issues in china. the major ones discussed here included air pollution, food security, and cyber security. as has been indicated in this chapter, although human security as a term is not frequently used, there have been various human security practices in china. the idea of human security has been firmly established and threats to human security have been detected. such problems result from china's still unfinished process of industrialization, urbanization, and drastic social change. the good news is that progress is being made, and theoretically, globally accepted values often exist at the individual level. with this comes occupancy of the moral high ground. china has gone far beyond the lip service level of cheaply talking about people's interests. this deeper approach can be fully integrated into human security in its holistic sense. threats to human security can be domestic risks, yet they often are transnational ones such as air pollution and sand storms. they require different sectors of the society and neighboring countries to work together. over years ago, the commission on global governance drafted a report that emphasized the distinction between the security of states and the security of peoples (cgg ) . twenty plus years later, the security of peoples has gained momentum. this is also true in china, the most populous country in the world. china's practices have considerably reinforced the overall trends of affirming the value of people, protecting their lives, ensuring their legitimate interests and dignity, and empowering them not only to survive but also to live a respectful life. what is happening in china is indicating a healthy trend in this direction. each year the communist party of china central committee holds an annual plenum to deliberate what it believes to be the most important issues for the full text of the resolution and xi's explanation, see renmin ribao ershiyi shiji jingji baodao xi's remarks at the closing of the th party congress li's remarks at the national people's congress press conference anthropocentric theory of human security china and global governance our global neighborhood: the report of the commission on global governance chs (commission on human security). . human security now. new york: commission on human security from commitment to concerted action. remarks by vice foreign minister cui tiankai of china at the ministerial follow-up meeting ren de fazhan yu ren de zunyan: zaisi ren de anquan gainian battle to balance urbanization with ecological sustainability ruhe kandai sheli guojia anquan weiyuanhui iciss (international commission on intervention and state sovereignty). . the responsibility to protect. ottawa: the international development research centre china's participation in international organizations china and the united nations ren de anquan: fei chuantong anquan nengli jianshe de xinshijiao zhongguo fei chuantong anquan nengli jianshe zhengfu gongzuo baogao wangluo anquan: guojiazhanlue yu guoji zhili [cyber security: national strategy and international governance). dangdai shijie china and the global environment: learning from the past, anticipating the future. sydney: lowy institute for international policy a return to people: china's approach to human security ren de anquan' yu guojia anquan resolution / . follow-up to paragraph on human security of the world summit outcome food security and food safety in china's foreign policy human security challenges with china the governance of china ii fei chuantong anquan zhili yu 'hemei zhongguo' [nontraditional security governance and a 'safe china beijing: shehui kexue wenxian chubanshe ren' de daxie food security tops people's concern in survey. china daily preface zhongguo shipin anquan wenti yu qushi report on china's non-traditional security studies key: cord- -yxttl gh authors: siegel, frederic r. title: progressive adaptation: the key to sustaining a growing global population date: - - journal: countering st century social-environmental threats to growing global populations doi: . / - - - - _ sha: doc_id: cord_uid: yxttl gh adaptation is an evolving long-term process during which a population of life forms adjusts to changes in its habitat and surrounding environments. adaptation by the global community as a unit is vital to cope with the effects of increasing populations, global warming/climate change, the chemical, biological, and physical impacts on life-sustaining ecosystems, and competition for life sustaining and economically important natural resources. the latter include water, food, energy, metal ores, industrial minerals, and wood. within this framework, it is necessary to adapt as well to changes in local and regional physical conditions brought on by natural and anthropogenic hazards, by health threats of epidemic or pandemic reach, by social conditions such as conflicts driven by religious and ethnic fanaticism, and by tribalism and clan ties. the principal problems with growing populations do not involve space although population density is a problem unto itself for reasons discussed in previous chapters. the main problems are how to nourish people with food and water. the chronic malnutrition that about billion people suffered from in is likely to grow in number in some regions due to global warming/climate change because humans cannot adapt to less food if they are already at subsistence rations. for example, the population in sub-saharan africa is million people. the population is projected to increase to about . billion in , an increase of about %. within the same time frame, the united nations estimates that acreage under maize cultivation in the region will decline by % because of heat and drought brought on by climate change. the loss of arable land for food production can be countered in sub-saharan africa if marker assisted hybridization of maize or maize genetically modified to withstand heat and drought come onto the seed market together with modified seeds for other food staples and if african nations that do not now accept gmo seeds do so in the future. if not, nations favored for food production by climate change will have a moral obligation to provide food staples to people in nations with declining food production at accessible costs based on their economies. it is clear that what happens in sub-saharan africa and other regions with declining cultivation acreage or that will bear other effects of climate change (e.g., drought, shifting rain patterns) will affect the rest of the worldwide community politically, economically, and socially. the earth's problems that associate with global warming/climate change will be further discussed in the last section of this chapter. water is the staff of life. it keeps the body hydrated and is necessary to grow food crops, hydrate food animals, and grow feed grains. chemically or biologically polluted water does not serve these ends. if ingested, contaminated water can result in sickness as discussed in chap. . water stokes industry and manufacturing as well, thus keeping economies in many countries contributing to a population's wellbeing by providing employment, goods, and services. ideally, these businesses contribute their fair share to a tax base that supports social needs (e.g., education, healthcare, maintenance of infrastructure). factory owners adapt and plan against water shortages by having a water recycling system in place but may also slow or stop production until operational water conditions return. citizens with a reliable water supply can adapt to periods of water shortage by limiting use according to mandates by government officials but still have water for basic daily needs. however, persons in nations with a chronic per capita water shortage may not have this option to serve their daily needs unless water is imported or new water sources are found (see chap. ). if imported water is not an option to meet immediate essential needs, an alternative adaptation for people (and animals) is to try to reach a location where water would be available to them. with growing populations, per capita water availability is greatly diminished (table . ), water shortages become endemic, and people are at risk of existing at subsistence levels or dying. most at risk from the lack of a basic water ration are pregnant women, infants, young children, and old people. water wars are a future possibility as nations battle for their peoples' survival unless political differences are set aside and projects are supported to develop and share water sources. in a welcome effort, jordan, israel, and the palestinian authority signed a memorandum of understanding in the world bank, december , with specific aims: ( ) produce millions of cubic meters of drinking water for a water-deficient region; ( ) pipe million cubic meters of water annually * km ( mi) from the red sea to the dead sea; ( ) build a desalination plant at aqaba that would supply water to aqaba and eilat; ( ) the israeli water utility would supply - million cubic meters of drinking water to the palestinian authority for the west bank population at a reduced cost; and ( ) there would be an inflow of water to slow and in the future perhaps abate and reverse the shrinking of the dead sea. funding for the estimated $ million, year project will come from the world bank, donor nations, and philanthropic groups. as the global population increases and more people in developing and less developed nations have more disposable income, there will be a growing draw on natural resources other than water and food to service their industrial, agricultural, and manufacturing needs and wants. competition can force economic wars among national and multinational corporations for the resources necessary to provide goods and services and thus drive up prices for resources. industries and manufacturing units that cannot compete economically for natural resources will shut down, thus contributing to unemployment and downturns in economies because of falling domestic demand. to keep order in the increasingly interdependent world economy, accommodation for shared natural resources (or substitutes for them) at affordable prices is the adaptationnecessary. this can be mandated by the world trade organization backed by other practical-minded international groups. another adverse effect of growing populations that is a national resource that can be lost at the expense of some countries to the benefit of others is brain power. this brain power has been cultivated at excellent universities in developing countries, often times at little or no cost to students (e.g., in medicine, science, engineering, economics, the arts) who attend and graduate in increasing numbers. where there are too many well-educated professionals but lack of employment opportunities for them in their fields of expertise, educated people have the option of relocating to another country that can nurture and use the expertise. many adapt to the employment problem by taking up this option. this may mean moving from a developing country to a developed country or from a less developed country to a developing or developed country. ultimately, this loss of citizens with special skills can hurt a country. to counter this brain drain or reverse it, a country can adapt by investing in its future to create programs and conditions that keep talented professionals home, or if they have emigrated, entice them to return. china and india are examples of countries that have successfully taken this tact. when there are increases in a population because of immigration, problems can ensue between immigrants and a general population. adaptation to diversity and the multicultural experiences it brings to a community is often not a comfortable change. the antipathy of some in a host country is based on slowness of the immigrants to learn the language and inability of host country citizens to understand what immigrants are saying among themselves. this makes citizens feel uneasy. some view immigrants as a threat to their own or a family member's employment or advancement. race difference is a factor that some cannot readily adapt to as is ethnicity with its traditions and customs unfamiliar to the general public. religion can be divisive if adherents to its beliefs engage in acts of hatred detrimental to the host country fueled by fundamentalists and zealots who interpret religious writings as giving them license to commit crimes or absolving them of the crimes. sadly, many citizens paint an entire religious community with the taint of the relatively few evildoers. adaptation to diversity is essential for our earth's citizenry with joint efforts by all to resolve worldwide issues (e.g., global warming/climate change) so as to become the keys to providing a sound future for coming generations. there has to be a shared attack on global threats, no matter what the language, race, ethnicity, or religious beliefs are, no matter social or economic status, no matter whether a threat affects less developed, developing, or developed countries. adaptation is a progressive process when dealing with natural hazards because as each type of natural hazard impacts global communities over time, lessons are learned from each one that give direction to the methods of adjustment. adaptation to living where hazards can be expected to strike and where populations continue to increase is dependent on what we learn from the study of past hazards. we can use this evaluation of measured and observed data to minimize the immediate effects and aftermaths of hazards and protect citizens from injury, death, and from damage or destruction of property or infrastructure when hazards strike in the future. in areas prone to earthquakes, we know that earthquakes do not kill and injure people but that collapsing buildings and infrastructure do. earthquakes are not predictable so that there is no adaptation by a timely evacuation to minimize deaths and injury. however, building structures to make them more earthquake resistant can save lives, reduce injuries, and protect property. thus, after a high-magnitude earthquake, forensic engineering teams come to assess the damage and determine where and why damage and destruction took place within the context of the magnitude of an earthquake, the type of motion it originated (shaking, jarring, rolling), its duration, the area it affected, and the geologic properties of rocks underlying structures' foundations. hazard assessment teams also evaluate other factors that contributed to additional damage such as ruptured gas lines that feed fires and ruptured water lines that inhibit fire control. the engineers establish how construction can be improved in the future in terms of construction techniques and materials to prevent the types of collapses and utility failures they investigated. municipalities revise building codes accordingly to direct reconstruction and future building projects. where possible, structures that withstood an earthquake with minor or no visible damage should be retrofitted to improve their resistance to the next "big one." with each event, we gain more data on how to better construct earthquake-resistant structures and alter building codes to more stringent specifications. in theory, this adaptationto an irregularly recurring global event is good, but in practice it is most applicable to nations with the economic resources for reconstruction according to revised building codes and where there is no corruption to allow a bypass of the code. the same can be stated for retrofitting to give more resistance to earthquakes to existing structures. many developed nations and nations rich in commodity exports (e.g., oil) have a moral obligation to donate funds, material, and expertise to help citizens in economically disadvantaged nations recover from a destructive earthquake. some commodity-rich and economically sound nations do not do so directly, whereas others, big and small, rally to help disaster victims. for example, immediately after megatyphoon haiyan devastated many regions in the central philippines in , israel sent medical doctors and nurses and field hospitals to help philippine citizens recover from the impacts of the typhoon. as discussed in an earlier chapter, volcanoes are predictable in terms of becoming active by emitting wisps of smoke, bulging on a slope, warming of the soil or nearby pond or lake waters, emitting increasing concentrations of gases, and showing increased low-frequency seismicity. however, this activity does not always result in an eruption. a marked increase in measurements and observations, especially the low-frequency seismic activity, suggests that an eruption is imminent. adaptation to living and working on or near a volcano means investing in equipment to monitor volcanic activity and listening to alerts from scientists monitoring its activity and being ready to evacuate by gathering important papers and precious mementos and prepared to load into transportation for evacuation to safe locations. governments adapt by charging geologists to map out areas considered as high-, moderate-, and low-hazard zones in the volcano environs. geologists do this by studying rocks deposited from past eruptions and assessments of the topography. municipalities then pass zoning regulations applicable to the hazard level. governments have adapted to repeated periodic flooding in areas by creating flood control systems described in chap. . dams hold water during times of heavy and/ or extended rainfall and release any overflow into channels that move water away from urban or rural population centers. levees increase the volume of water that can move through a channel, thereby keeping it from spreading into populated areas and cultivated farmland. for smaller waterways that flow through cities, municipalities may invest in deepening, widening, and straightening channels as well as erecting walls so that more water can flow through the area more rapidly without coming out of a channel. governments define zones on flood plains according to a recurrence interval of damaging floods (e.g., years) as being off limits for residential and factory/plant construction. as much as we plan to adjust to living in an area prone to flooding, there is always the possibility of a megaevent that can overcome in situ control systems. therefore, as described chap. , governments adapt to this possibility by installing flood prediction equipment in drainage basins to provide warning to those at risk from rising and sometimes raging waters. the warning gives people time to gather important documents and personal treasures and evacuate to safe areas. the apparent increase in the frequency and magnitude of storms and resulting flooding in recent years is thought by many weather scientists to be related to global warming and the increased amount of moisture in the atmosphere from warmer oceans that gathers in clouds and precipitates during storms. this will be discussed further in this chapter. adaptation to extreme weather events such as an extended period of drought, heat waves, and frigid weather means preparation to wait them out. some municipalities adapt to repeated, sometimes seasonal, times of short-term drought by storing a - month water supply in surface or underground reservoirs during periods of normal precipitation that can be tapped (conservatively) as needed. others may plan to move water via pipes or water tankers from where it is plentiful to where drought conditions exist. otherwise, to survive, people move as best they can to where they have access to water. in instances of years long drought, crops and livestock and other life forms may be lost. heat waves can kill. adaptation to heat wave conditions means that water has to be available to people to avoid dehydration. where possible, homes should have air-conditioning or fans to keep people comfortable and municipalities should have cooling centers to which people can go. personnel should check on senior citizens and escort them to cooling centers if necessary. clearly, economically advantaged nations have the resources to give support to citizens during natural hazards such as these. these nations, international organizations, and ngos have a moral obligation to help economically disadvantaged nations as is possible when hazard conditions such as these threaten populations. the most extreme of weather conditions that can injure and kill people and destroy housing and infrastructure are tropical storms that evolve into violent hurricanes (typhoons, monsoons) by increasing wind speeds and sucking up moisture (water) as they track across oceans toward land. when these storms make landfall, they drive storm surges that can wreak havoc onshore communities, and as they move inland precipitate heavy rains that cause life-threatening and destructive flooding. these violent storms are destructive to coastal populations and island nations and have regional reach inland as they move along paths until they finally spend their energy or move out to sea. on november , , the typhoon named haiyan, the strongest recorded typhoon ever to make landfall smashed into the central philippines killing more than , people, injuring about , , and displacing almost , people. there was a -m (* ft) storm surge driven by winds measured at over km/h ( mi/h) with gusts reaching km/h ( mi/h). the typhoon flattened the city of tacloban that was home to , residents, and there was major flooding inland. the weather alerts led to a government call for evacuation away from the predicted path of the storm, and about million people followed the evacuation warning, surely saving many lives. access to aid typhoon-ravaged areas was difficult, and there were shortages of water, food, and medical care for many evacuees for several days. the philippine central government and local officials were not prepared to deal with a storm of this magnitude but help started arriving from many nations worldwide. there was a post-event concern of attending to sanitation needs of survivors to prevent outbreaks of diseases such as cholera, typhoid fever, hepatitis, and dysentery. if the philippine government had adapted by adopting better policies with respect to response to high-category typhoons in addition to the call for evacuation, the impact of haiyan would have been ameliorated. one would hope that this deficiency would be dealt with to limit the effects of future like disasters. evacuation to prevent injury and death in coastal zones that could be struck by high winds, heavy sustained rains, and storm surges is dependent on weather bureau forecasts and warnings from police, firefighters, or other government-authorized personnel. homeowners adapt to hurricanes by securing roofing with additional nails or special fasteners as a retrofit precaution and by boarding up windows on structures before an incoming storm hits. governments have adapted to the onslaught of violent high-energy storms by constructing seawalls of varying designs and heights to protect population centers by damping the force of storm surges. in china, for example, a seawall . m (* ft) in height and that has been heightened in the past protects shanghai from the full damaging effects of high-category typhoons. as a result of rising sea level, the shanghai seawall and other that protect coastal cities from being flooded by surges from high-energy tropical storms will have to be heightened to afford a greater degree of protection to people and property. wildfires can be a natural hazard when ignited by a lightening strike. however, most wildfires are started by human carelessness such as tossing a lit cigarette on a forest floor or failing to completely extinguish a campfire, or by arsonists. one may adapt to living in an area with a history of wildfires in two ways, neither of which is practical or promises % protection. first would be to clear an area of vegetation in a -m ( ft) swath around a dwelling or site for building. second would be to build with nonflammable materials so that embers propelled during a wildfire could not ignite a structure. adaptation to the advance of a wildfire would be to heed warnings to evacuate carrying a prepared case with important documents and other items of personal value. to delay evacuation by going back to retrieve something from then home can be fatal as it was for two people in a recent (june, ) wildfire that destroyed almost homes in colorado springs, colorado, usa. when there is a hazard event coming that calls for evacuation, responsible and often economically advantaged governments have adapted to the threat by designating evacuation routes, by providing transportation for people who need it, by having evacuation centers stocked with water and food, cots and blankets, basic medical supplies and medical personnel, and by having phone service available for people that need it. in the case of a primary or triggered hazard that happens with little or no warning (e.g., an earthquake, a tsunami, a volcanic mud flow), search and rescue teams should be ready to move in soon after dangerous conditions ease and they can move with safety. there should be medical attention to treat injured survivors, and stations set up as soon as possible to provide water, food, and other essentials available to those that survived with little or no physical hurt. these first steps at adaptation are the keys to survival. recovery after a shock phase can be long and drawn out, depending in grand part on a nation's social and economic resources and physical and economic assistance from other nations, international institutions, and ngos. change on our earth's inhabitants global warming is a fact attested to by an overwhelming majority of the scientific community and unwaveringly supported by a february joint publication of the us national academy of sciences and the royal academy in the uk on the causes and evidence for global warming [ ] . as noted in earlier chapters, during the past century, measurements show that the earth has warmed by * . °c (* . °f). global warming is an ongoing process that is attributed in grand part to a slow but continuous and increasing buildup of greenhouse gases in the atmosphere. the greenhouse gas most associated with global warming is carbon dioxide (co ). a plot of the increase of co content in the atmosphere with time against the increase in global temperature shows an excellent correlation of one with the other. additional lesser contributors include methane (ch ), nitrous oxide (no ), and chlorofluorocarbons (cfcs). with the beginning of the industrial revolution and the increased use of coal as the principal energy source, the content of co in the atmosphere was parts per million ( . %). the combustion of coal and later oil (petroleum) and natural gas emits co to the atmosphere. initially, and for many years thereafter, the added greenhouse gases were taken up by vegetation for photosynthesis and was also absorbed by the oceans and other water bodies. this kept the atmosphere co close to the ppm pre-industrial level. however, with increased industrialization, the need for electrical power, and the use of internal combustion engines, the amount of co generated was greater than what could be absorbed by nature and the content of co in the atmosphere increased. during june , its concentration reached more than ppm, an increase of over % over the pre-industrial concentration (scripps institute of oceanography mauna loa measurement). the increasing co content, other greenhouse gases, aerosols, and particles acted as a media that admitted sunlight (heat energy) to the earth's surface but did not let all of the heat escape back into the atmosphere. this abets global warming. in the past two to three decades, the rush to industrialization in developing countries (e.g., china, india, and brazil) and their growing power needs and vehicular use has thwarted the implementation of international agreements to reduce emissions from coal-fired power plants, other industrial and manufacturing operations, and the transportation sector. a direct consequence of global warming is sea level rise (slr) caused by the progressive melting of icecaps and ice sheets in greenland, the arctic, and antarctica, and of mountain glaciers in the himalayas, the alps, the rocky mountains, and the andes. the * -cm (* in) sea level rise during the past century may see a rise of another * cm (* in)- m (* in) during this twenty-first century. one-third of the rise would be from the expansion of warmer sea water, one-third from icecap and ice sheet melt, and one-third from mountain glacier melt [ ] . in , other researchers used computer models on existing data and proposed that % of sea level rise between and was from glacial melt [ ] . following the same line of investigation, other scientists studied satellite data and ground measurements from alaska, the canadian arctic, greenland, the southern andes, the himalayas, and other high mountains of asia and estimated that glacier contributions to sea level rise from to was % and together with ice sheet melt explained % of slr [ ] . a publication in estimated that ocean thermal expansion - m deep and - m deep contributed up to % to sea level rise [ ] . these latter two estimations are in line with the ipcc prediction for melting ice and ocean thermal expansion contribution to the estimated rise of sea level by the end of the century [ ] . with a rise in sea level, marine waters encroach on land. as the rise continues, possibly at an increasing rate, it threatens habitation in lowlying islands, coastal villages and farmland in lowlying zones, and heavily populated cities worldwide settled on inshore terrain close to sea level (e.g., bangkok, ho chi minh city, jakarta, manila, miami, new york, boston, buenos aires, london, rotterdam). rising sea level and warming of ocean waters have other ramifications that affect coastal communities as well as inland areas. as explained in chap. , the warmer surface water releases more water vapor with heat energy into the atmosphere. when the water vapor molecules condense in clouds, heat energy is released. this energy gives more force to tropical storms as they form, track to shore, and move inland, or storms that move close to and along a coast. these storms may transition to hurricanes (typhoons, monsoons) with the violent winds that cause destruction, and heavy rainfall that triggers flooding if they move onto land. we recognize that rising sea level means that tropical storms that impact a coast with storm surges have a farther reach inland with their destructive energy that is more pronounced when the surge occurs at high tide. the surges also saturate farmland they reach with salt water that harms crops. they also carry salt water into fresh water marshes and ponds, thus disrupting ecosystems there. the increase in the number of these extreme weather events and the increase in violence and destruction they wreak on land compared with like weather events in the recent past (e.g., during the past years) strongly suggest that they are fueled to a significant degree by global warming. there are two possibilities for adapting to the effects of rising sea level on coastal urban centers, one impractical, the other very costly but doable. the impractical adaptation possibility is to move at-risk population centers inland, out of the reach of the destructive tropical storms. this does not lessen the threat of flooding. the move is possible in some cases where land is available, but such a move is not economically feasible. one practical but costly adaptation to mitigate encroachment from sea level rise and the effects of tropical storm surges is to surround cities at risk within place seawalls - m higher than recorded high tides or higher depending on historical records and contemporary published data. the walls can have a concave configuration so that surging waves lose energy when their lower parts hit and are curled back on themselves damping some wave energy or there can be a different configuration best for the site(s) to be protected. similarly, gates buried at strategic locations where there is ship access to consider can be built to be hydraulically driven so that they can rise from a near shore seabed site to mitigate the effects of storm surges. both techniques have been used at different global locations. we have read that climate change affects land-based agricultural production, both for crops and animal husbandry. the warming climate at higher mid-hemispheric latitudes and at higher altitudes does not favor the growth and normal yield and/or quality of many crops. depending upon the degree of climate change and the linked change(s) that may follow it, farmers can adapt in several ways to maintain or increase crop yield and nutrition value. for example, when warming starts diminishing the productivity of a traditional crop, farmers can sow crops that are known to grow well in warmer temperature and give a satisfactory economic benefit. however, new groups of weeds, pests, and diseases will migrate to the warmer growth environment and will have to be dealt with in order to protect the new crops. where the effect of global warming reduces water supply for rain-fed agriculture, for crops irrigated with surface waters, and for groundwater-irrigated crops when aquifer recharge does not balances discharge, agriculturalists can adapt in two ways. first is the use of a more efficient irrigation method that delivers water directly to a growing plant (e.g., drip or focused irrigation). this minimizes runoff and loss to evaporation. second and similar to what was mentioned earlier is to sow a crop that needs less water to thrive and that delivers a good yield, good-quality product. another result of global warming for some farmlands is a longer growing season. in this situation, growers can adapt by planting earlier and have the possibility of double cropping. they can also grow a cultivar that is later maturing and that gives a product that brings a good market price. however, switching to new crops in a warmer growth environment means that there will be an invasion of a new set of weeds, pests, and diseases to ward off. in any efficient operation, and as emphasized in earlier chapters, farmers adjust to a changing growth environment for a given cultivar by applying the optimum amounts of fertilizer and other agricultural chemicals as might be needed that nurture and protect it most effectively. this reduces agricultural costs and lessens runoff of these chemicals to ecosystems where they can be harmful. global warming can bring on abnormal weather extremes that affect agricultural productivity. in these cases, farmers have to plan ahead based on recent history of these conditions in their regions. drought, heat waves, and long-term rain or heavy rain in a short time present problems for both cultivars and food animals. periods of less than average precipitation may last months or years. depending on the amount of the deficit precipitation, adaptation can include storing water in reservoirs and cisterns during times of rainfall to be tapped during a drought to sustain food animals and crops during a short-term, not too severe drought. there is also the option of trucking in water to sustain livestock. long-term droughts when precipitation deficits are high take their toll on plants and animals to the detriment of agriculture in a region especially when accompanied by heat waves. they have caused recent disasters for crops and food animals on all continents less antarctica. farmers either wait out the "bad times," change the type of cropping they do, the livestock they tend to, or change careers. the adaptation from crops that have been grown successfully before the effects of global warming reduced yields and quality of a harvest, to those "same" crops that can grow successfully under the advancing warming changes just described generally means that hybridized species have to be developed and used as warming increases at a location and slowly tracks to higher latitudes and higher altitudes. thus, growers turn to plants that are created by hybridization as described in chap. : traditional methods and marker-assisted selection methods within the same species, and genetically engineered (-modified, -manipulated) methods using different species. hybridization is a slow process, sped up markedly by genetic engineering, a method that yields foodstuff not accepted by the european union and many nations outside the union, especially in africa. bred species are developed to carry one or more characteristics that favor crop resilience against the effects of climate change. these include resistance to disease, weeds, and pests, and tolerant of drought (water stress), heat, short-term inundation, and short-term saline exposure (see chap. ). hybrids have also been developed to give higher yields and more nutritious crops. thus far, research has been focused mainly on improving seed for world staples such as rice, maize (corn), wheat, sorghum, and soybean. there have been great successes where hybrid crops were agriculturalists' adaptation so that the possibility exists that we can feed the earth's growing populations and reduce chronic malnutrition. when this is coupled with the opening of additional arable acreage and the use of improved farming methods for seeding, watering, and harvesting, global food security can be strengthened for the existing world population and the future generations on earth. however, this will require economic and technical input by developed nations and international groups. without basic sustenance, people will have less resistance to diseases and there may be local or regional population crashes if diseases evolve into epidemics or pandemics that invade susceptible populations. warming of the open ocean water, enclosed aquaculture operations in ocean waters and on land water bodies has affected marine fisheries and marine and estuarine aquaculture that grow food fish and shellfish, and lakes that sustain fisheries. in marine fisheries worldwide (e.g., in the north atlantic, off the coast of peru, off the coast of the philippines), some food fish or fish captured for other purposes (e.g., to use in pet food, to use to make fertilizer) have migrated to cooler water in ecosystems with conditions conducive to their spawning and growth. in some cases, predators follow fish they prey upon that have migrated to cooler waters, but in other cases they find new prey to sustain them. in other situations, they may become prey for larger fish in an ecosystem. fishing fleets adapt by following the fish they hunt into cooler waters where ideally they capture the hunted species in quantities allotted them by national and international fishery governing body regulations. if the quota system is followed, this will allow recovery of fish populations and sustainable harvesting. aquaculture operations that provide important supplies of food fish worldwide can adapt to warming waters by raising food fish or shellfish that will grow and multiply under the changed range of day/night temperature conditions if the fish they are farming cannot survive in the warmer waters. aquaculturalists also have the option to move their facilities to cooler-temperature waters, but the economic feasibility of doing this has to be evaluated by a benefit to cost analysis. this analysis has to be for the time frame during which the cooler-ecosystem waters are estimated to remain stable within the framework of a time range against global warming/climate change. another adaptation is that food fish currently being raised can be genetically engineered to be resistant to a warmer growth environment without changing their nutrition yield, growth rate, and ability to reproduce. there are diseases that are global threats, others that put regions at risk, and yet others that menace smaller political divisions. humans adapt to the threat of sickness in a population or a sickness itself in several ways. scientists develop methods to eradicate a virus or bacterium health threat, or a chemical/radioactivity threat. failing this, health professionals act to control a disease, to slow or minimize its transmission, and to apply approved therapies and support research to find therapies to treat an illness if one is transmitted. the following discussion draws strongly on the disease fact sheets put out by the world health organization. vaccines provide a main line of defense against many diseases. smallpox has been eradicated on earth by vaccination. polio has all but been eradicated globally except for a few pockets of the disease in pakistan, afghanistan, and nigeria where, in some cases, religious fundamentalists have beaten and killed health workers tasked with giving the vaccine to children, and in other cases where parents have been warned by the zealots against allowing their children to be vaccinated. recently, polio cases were diagnosed mainly in somalia but also in kenya. this is attributed to the fact that by , , children in somalia have not received the vaccine and are at risk from this highly contagious disease. it is also attributed to crossborder migration of infected persons into kenya. both governments are stepping up their vaccination programs. there were cases of polio diagnosed in the rest of the world in . measles is a global disease that can be prevented by a vaccine that is safe and cost-effective. measles may soon reach the near-eradication stage. in and subsequent years, . million people, mainly children under years of age, died from measles. since , billion children were vaccinated, million in . by , % of the world's children received the measles vaccine, up from % in . from to , deaths from measles dropped to %, from , to , . when the vaccination rate reaches %, mainly in low-income countries, the world will have brought another disease close to elimination [ ] . seasonal influenza is a global viral illness that afflicts - million people. the sickness kills , - , people with severe symptoms annually. transmission of the virus takes place when an infected individual coughs or sneezes without covering his/her mouth and releases droplets that can be inhaled by someone up to a meter away. transmission can also be from hands carrying the virus. seasonal influenza affects all age groups, but children less than years old, people over , and those with complicating medical problems are most at risk. influenza is a disease to be controlled. the principal control is by safe and effective vaccines that can prevent - % of influenza cases in healthy adults. secondary controls are obvious for infected persons: cover the mouth when sneezing or coughing, and wash the hands frequently. the influenza vaccine is taken once annually. because strains of the influenza virus change from year to year, adaptation is needed. the adaptation is via a vaccine that is prepared with or strains that scientists determine will be most common during a coming season [ ] . other types of influenza and respiratory illnesses have the potential to cause an epidemic or pandemic. they include avian flu and its strains and swine flu if the strains develop the ability for person-to-person transmission after infection, and sars (severe acute respiratory syndrome) and middle east respiratory syndrome (mers) because there is human-to-human transmission of the sicknesses. to the present, the outbreaks of the animal influenza diseases have been contained by quarantining infected people during treatment and by culling flocks and herds, or if available, vaccination of healthy animals. the latter two respiratory illnesses are caused by the coronavirus, and infected people have been in isolation wards. for sars, an illness that broke out in and spread to countries, isolation of victims and treatment with antiviral drugs and steroids stopped the disease during . mers is a recent ( / ) illness that has been confined to jordan, saudi arabia, qatar, and the united arab emirates. the mers virus has been found in camels. infected persons are quarantined in hospitals, but an effective drug treatment is still being sought to complement the normal hospital care-afforded patients. hiv/aids is a global epidemic that killed million people in three decades since . worldwide, in , there were million people with hiv, mainly ( million or %) in sub-saharan africa and south/southeast asia. the illness is caused by the exchange of body fluids (semen, vaginal excretions, blood, breast milk) from an infected individual with an uninfected person. more than % of the cases of hiv are from heterosexual activity. there is no vaccine against hiv/aids, no cure for it, but there is a cocktail of medicines (antiretroviral treatment) that control viral replication and allow an infected person's immune system to strengthen. this keeps the illness at bay and afflicted people in general good health and productive in their communities. in , only . million (less than %) of those with hiv in low and middle economies received the antiretroviral treatment. this is changing as more hiv carriers have access to antiretroviral therapy and there are more donations from economically advantaged countries to support hiv stabilization and reduction programs. the number of new cases of hiv is not exploding because more than % of those infected are following protocols that reduce the transmission of the disease. the prevention of transmission methods include access to male and female condoms, blood screening before transfusions, and needle and syringe exchange programs for sterile injections by drug users. hiv testing and education programs and hiv treatment help prevent transmission because individuals in continuous treatment have a very low probability of passing on the disease. male circumcision reduces the infection in men by about %. there is still much progress to be made because there were . million new cases of hiv in , with . million of that total in sub-saharan africa. the hiv/aids is a global sickness that is slowly coming under control because of generous donations from governments and foundations in developed countries added to what low-and middle-income countries themselves provide to lower the prevalence and incidence of hiv in their populations [ ] . tuberculosis (tb) infected . million people globally in , killing . million persons. it is a bacterial disease that spreads among people when infected individuals cough, sneeze, or spit, releasing bacteria into the air where they can be inhaled by others a meter away. although tb occurs worldwide, developing countries carry the largest burden of cases and deaths ( %). the bulk of new cases are regional in asia ( %) with sub-saharan africa reporting a large share as well with , new cases per million inhabitants. there is no vaccination for tb, but the disease can be treated and cured. the treatment is a half-year course of four antimicrobial drugs that must be taken without fail and thus requires continual supervision by healthcare personnel. more than million people have been treated and cured of tb since and perhaps million lives saved by following the who stop tb strategy protocols including securing adequate, sustained financing, ensuring early reliable detection and diagnosis, and providing approved treatment with a secure effective drug supply. the number of people infected with tb is declining, and from to , the tb death rate dropped more than %. the success in dealing with tb is muted somewhat because a strain of the bacterium that causes tb has evolved to be multidrug resistant (mdr-tb). in , , cases of this variant were reported (of the . million cases worldwide), mainly from india, china, and the russian federation. these are treated with, but do not always respond to, the most effective anti-tb drugs. research into new drugs to deal with this problem is ongoing [ ] . there is the question of whether people visiting or immigrating from these countries should be screened before a host country issues them entry visas. regional illnesses threaten the health of s of millions of people mainly in tropical and subtropical areas and often affecting children. one of these, the guinea worm disease, is trending toward elimination, if not eradication. this is a parasitic disease caused when people swallow water contaminated with infected water fleas (microscopic copepods) carrying worm larva. the worms release, penetrate the intestines, and move through the body migrating under the skin until they emerge causing swelling and blistering. people infected with guinea worm disease cannot contribute to their communities for months. during the mid- s, there were . million cases mainly in african nations. but attention to where the sources were so that they could be avoided and treated, and assistance in generating clean water, were adaptations that brought the number of cases down to less than , in . the number of cases continued to decline and was reduced to in in four african countries: south sudan, chad, ethiopia, and mali. there is no vaccine against guinea worm disease. health officials adapt to counter this sickness in several ways. as noted above, access to clean drinking water is the best way to prevent infection. the prevention or transmission of the worms from infected individuals to healthy persons by proper treatment and hygiene and the use of the larvacide temephos to eliminate the parasite-infected water flea vector and other prevention protocols are important in the control and effort to eliminate/eradicate the disease [ ]. the (jimmy) carter institute, atlanta, georgia, usa, has been a principle force since in the fight to rid the world of guinea worm disease. in tropical and subtropical regions, there are three mosquito-vectored diseases that put millions of people at risk: yellow fever, malaria, and dengue fever. yellow fever is an endemic viral disease in tropical regions of africa and latin america with , cases reported annually that cause , deaths. there is no set treatment for afflicted people, but there is an adaptive preventive measure. a vaccine against yellow fever is available that is safe, affordable, and that gives lifelong immunity to the disease with one dose after - days for % of the people vaccinated. when there is the onset of a yellow fever outbreak where the population lacks vaccination protection, mosquito control is an essential first step in adaptation to prevent or slowdown transmission of the yellow fever virus. spraying insecticides to eliminate breeding sites and kill adult mosquitos is the control used during epidemics to make time for vaccination campaigns in a population and for immunity to take hold. there are limitations to the application of the yellow fever vaccine. first is that babies less than months of age should not be vaccinated or, during an epidemic babies less than - months of age should not receive the vaccine. second, pregnant women should not be vaccinated except when there is an outbreak of the disease. third, people with a strong allergy to egg protein or those with a marked immunodeficiency or with a thymus problem should not receive the vaccine [ ] . malaria is a parasitic disease caused by the bite of an infected mosquito. there is no vaccine against malaria, but one is undergoing a clinical trial in seven african nations with results expected in . a use or no use decision as a control method for malaria will be made in . promising results from an early-stage clinical trial of an unconventional vaccine prepared with live, weakened sporozoites of the malaria parasite were published in . plasmodium falciparum was given to healthy - year-old volunteers intravenously. the volunteers were grouped to receive - doses and subsequently exposed to bite by five mosquitoes carrying the parasite. none of the six that received five doses were infected with malaria. three of the that received four doses became infected, whereas of the that received lower doses became infected. of that received no vaccine, became infected. those that became infected were treated with malarial drugs and cured. clearly, higher dosages give protection against infection by malaria [ ] . more research and extensive clinical trials are necessary to determine how children respond to the vaccine with adjusted dosages and whether the results from earlystage trial are reproducible in larger volunteer populations. if the results of additional clinical trials go well, the hurdle of producing enough vaccine and adapting it to injection has to be faced. forty percent of the deaths from malaria are of african children in the democratic republic of congo and nigeria. in addition to sub-saharan africa, populations in asia (especially india and the greater mekong region) and latin america suffer from the disease. the effort to deal with the disease that is preventable and curable now centers on control and treatment to reduce the number of cases. in , the who reported that there were million cases and , deaths (with an uncertainty range of , - , ). in a report, researchers suggested that the number of deaths was understated and that their computer model gave a figure for almost double, , , deaths ( % uncertainty interval of , - , , ) [ ] . the who stood by its figure stating that much of the data in the cited study were based on verbal testimony of how people had died, not on laboratory diagnosis of samples. either figure represents too many deaths from the disease and have to be reduced. mosquito control is the adaptation that can reduce the transmission of the disease greatly. this includes personal protection by use of proper clothing and/or the application of mosquito repellent, the use of longlasting insecticidal (pyrethroids treated) nets to kill mosquitos and prevent nighttime bites, and indoor residual spraying (remains effective for months). those people infected can be treated with oral artemisinin monotherapy followed by a second drug. failure to complete the treatment as prescribed leaves parasites in a person's blood. no other antimalarial treatment is available so that parasite resistance could become a serious problem. for visitors to a malaria region, antimalarial drugs taken before, during, and after a trip can protect them from the disease. many countries in tropical and subtropical areas have used the above-cited strategies and others to work toward the elimination of malaria. malaria eradication is the goal of the who [ ] . dengue fever is a female mosquito-borne virus that infects people with an influenza-like disease in tropical and subtropical regions worldwide. the disease can kill if it evolves to severe dengue. it is endemic in latin america and asia where most cases now occur. since the s, the sickness has spread to more than countries putting about % of the world's population ( . billion people) at risk. dengue fever is especially endemic to urban/semi-urban environments. humans are the main carrier of the virus. after a mosquito bites an infected person, each subsequent bite by the infected mosquito creates another carrier. a mosquito can bite many people each time it feeds. in the americas alone, there were . billion cases of dengue fever reported in with , being severe dengue. there is no vaccination against dengue fever, but research continues to develop one. the main treatment for afflicted persons is to keep them hydrated. adaptation to deal with slowing or stopping the spread of dengue fever involves three main tracks in addition to spraying insecticide to kill mosquitos. the best control method to prevent the transmission of the virus is to deprive mosquitos of sites with shallow, standing water where they can lay eggs and multiply. control can be improved if communities cover and clean water storage containers regularly, and use proven insecticides on them as necessary. finally, individual protection such as the use of mosquito repellants and insecticide-impregnated bed nets can help reduce the incidence of dengue fever as it has with malaria [ ] . although controls are known, they are not always applied because of economics and other factors that prevent access to protection methods. the result is that the number of cases of dengue fever reported continues to grow globally. as populations increase in urban locations, the incidence of dengue fever can be expected to increase as well unless strict controls are enforced until a safe and cost-effective vaccine is developed. a positive aspect of the dengue fever problem is that recovery from one serotype of the virus gives immunity for life. however, there are four serotypes of the infectious virus so that recovery from one leaves a person susceptible to the others [ ] . chagas is another regional disease. it infects - million people annually, mostly in latin american countries. it is a parasitic illness that evolves after the bite of a blood-feeding triatomine bug, often on the face, where it defecates close by leaving parasite-bearing feces. parasites access the body when the feces are inadvertently smeared into the bite, the eyes, the mouth, or any skin lesion. the parasites circulate in the blood expressing their presence as a purplish swelling of one eyelid or as a skin lesion. there are several other symptoms as well in this acute stage of the illness, but these may be absent or mild. if diagnosed early during this stage, chagas disease is treatable. the parasite is killed with the medicines benznodazole and nifurtimox taken for months. there are limitations as to who can take these medicines (e.g., not by pregnant women or people with kidney or liver problems). the untreated sickness can cause cardiac alterations and digestive problems that show up - years after an untreated infection. chagas disease can be spread by blood transfusion and by organ transplant, making blood screening for the parasite essential before a procedure. it can also pass to a fetus from an infected woman. there is no vaccination against the illness so that control of the vector (triatomine sp.) is necessary. the controls adapted by many municipalities include insecticide spraying inside a home, the use of treated bed nets, and hygiene practices that protect food, its preparation, and its storage before eating it [ ] . the sickness may recur if control practices become lax. chagas disease is spreading as populations emigrate from latin america to northern countries. blood screening of visitors or immigrants from the countries where chagas is endemic may be necessary, and treatment followed by an infected individual before a host country issues an entrance visa. this would prevent the ingress and possible spread of chagas. outbreaks of diseases in town and cities is most often caused by bacterium-contaminated water or food and poor sanitation. sicknesses such as cholera, typhoid, and various other diarrhea types are examples of such diseases. they are all highly infectious if good hygiene practices are not followed. these diseases are endemic in many countries where populations do not have access to safe water and adequate sanitation. there are vaccinations for some of these sicknesses that may require more than one dose, but they may not be completely effective or long lasting and require revaccination at times specified by medical personnel (e.g., after - years). otherwise, infected persons can be treated with medicines such as oral rehydration pills or antibiotics. adaptation for prevention is easier called for than realistically available: washing hands with soap and clean water after visiting the toilet, and as noted above, access to safe water and good sanitation. given the millions of people infected by these bacterial diseases and the hundreds of thousand that die from them annually, generally in economically disadvantages countries, there should be an expanding global priority to eliminate the disease-causing conditions, and preparedness to combat an outbreak when it is reported. there are important factors to consider when adopting plans to halt or meliorate the effects of health threats to people in the near and extended future. one is the climate change-driven spread of tropical and subtropical diseases discussed earlier to newly warmer and moister higher-latitude and higher-altitude zones. another is the growth of populations mainly in tropical and subtropical regions in africa, asia, and latin america. together with this latter factor are the increasing populations and population densities in urban centers especially in the regions just cited. an additional factor to consider is whether there is accessibility to populations by healthcare workers or by people to healthcare clinics or hospitals, well-staffed and well-stocked with necessary pharmaceuticals. certainly, future planning has to include funding to support research to develop vaccines for diseases that do not have vaccination as an option against an illness (e. g., malaria, dengue fever) . in addition, improvement of vaccines that are available but that are not completely effective in terms of protection or the length of time they are effective should be a priority in pharmaceutical and biotechnology laboratories. scientists presented a fine review of the status of vaccine research from the design and development of vaccines to discussion of vaccines and infectious diseases (e.g., hiv, malaria, tuberculosis, pneumococcal disease, and influenza) [ ] . they also discuss vaccines against enteric infections and viral diseases of livestock as well as vaccines against non-infectious diseases (e.g., cancer) and against chronic noninfectious diseases. continued and repeated education classes on how to prevent the transmission of diseases and free supplies of materials that work to this end (e.g., insecticide-treated bed netting, male and female condoms) are essential to reducing the prevalence and incidence of diseases as are safe water and uncontaminated food. as new medicines or combinations of medicines are developed, tested, and found to be effective in controlling diseases, they become part of the protocol for either curing disease or controlling disease to reduce transmission while allowing persons to carry on with their lives. in these times of easy and rapid migration, one wonders whether screening of visitors or immigrants for diseases known to be endemic or active in the countries or regions from which they come should be required so as to prevent a carrier from infecting others and spreading a disease (e.g., chagas disease, cholera, tuberculosis). this was done at airports during the sars scare for people leaving or entering a country (e.g., china) and likely limited the transmission of the sars virus and spread of the disease. preparedness for a disease outbreak, response to an outbreak, and management of resources during and post-outbreak are the keys to adapting to health threats that could affect future generations. this means developing the capability to extend the reach of health services to regions where climate change brings warmer, moister conditions to higher-latitude and higher-altitude ecosystems that are now reached by disease vectors that have expanded into these formerly cooler and drier environments as a result of global warming. adapting to this reality and planning ahead makes it possible to deal with and stem an incipient outbreak of disease before it is transmitted and spread to the general population. this becomes essential when there is a future disease outbreak in large, dense populations in tropical and subtropical urban centers as well as those in regions warmed and humidified by climate change to subtropical and tropical settings. remember that urban populations worldwide, especially in africa, asia, and latin america, are where much of the global population growth will take place during the next few generations. under these conditions, diseases can spread rapidly in many ways. these include from bites of vectors, by respired droplets after an infected person coughs or sneezes, and by touching surfaces bearing viruses, bacteria, or parasites. diseases are also spread by ingestion of contaminated water and/or tainted food, and by other methods of infection transmission. disease transmission can be checked by rapid response teams with appropriate and sufficient supplies to treat (and perhaps places to quarantine) those in the infected population. lastly, it must be noted that there are many other diseases in addition to those cited previously for which prevention, treatment, and cures are research priorities in laboratories worldwide. in addition, there are addiction diseases that can trigger health problems in important segments of society. these include smoking (e.g., emphysema, lung cancer), alcoholism (e.g., cirrhosis of the liver), drugs (e.g., various psychological and physical ills), and overeating (obesity, diabetes, high blood pressure). adaptation to these health threats involves public education forums through various media outlets, counseling, and sponsored groups with their individual group meeting, and programs are assisting many in breaking from an addiction to the benefit of a healthier life. adaptation to meet the health challenges in the past, and in contemporary times has been a slow, progressive adventure with many successes but with much yet to be done. this is the planned path for the future: meet the challenges of societal health threats, resolve many, and keep researching to resolve others. a special ipcc report in examines in a general way adaptation to a changing climate as a risk management approach [ ] . it uses pre-planning to reduce exposure and vulnerability to extreme hazard events by preparing for them beforehand, responding to their impacts on people, structures, and infrastructure, and having in place recovery systems that can act when a danger condition eases. in this way, there will be an ability of populations to cope with future risks brought on by a changing force with which a hazard impacts a community, changes in the frequency of an occurrence, and extension of the spatial reach of its destructive power. much of this has been discussed in the chapters of the book you are reading. an understanding of what is being done now to adapt to the various problems society faces during the second decade of the twenty-first stimulates proposals of how to adapt to them as global conditions change in the future. to this end, the world bank commissioned a study on the effects global warming as it increased from . °c that exists on our planet now to what can be expected if the warming reached °c, a change that many scientists believe we can adapt to, and then reached °c as warming continues [ ] . the study centered on regions with high population growth and great susceptibility to be negatively impacted by climate changes: ( ) sub-saharan africa where food production is at risk: ( ) southeast asia where coastal zones and productivity are at risk; and ( ) south asia where there could be extremes of water scarcity and excess. the effects of higher temperatures from global warming and climate change included what has been discussed in previous chapters of this book: heat, drought, sea level rise, coastal zones, typhoons, flooding, river runoff, water availability, ecosystem shifts, crop yields, fishing, aquaculture, livestock, health and poverty, and tourism. projections such as those published in the world bank study give impetus to governments, international institutions, multinational companies, private foundations, and ngos to think now, to invest now, and to research now for adaptations that can be realized in good time and that will provide global citizenry with a good quality of life where needed. in this book, we have examined existing human populations and the problems they are experiencing in the second decade of the twenty-first century and have also considered growing populations globally and additional problems future generations will experience. we have discussed strategies on how to cope with manyfaceted threats to citizens. these include how to nourish those who need food and water, how to shelter people safely from natural and anthropogenic hazards, how to provide them with healthcare, education, and employment, and how to prepare them for the evolving global warming and the physical and biological dangers that ensue from climate change. given the present global conditions with about % of our earth's population suffering from malnutrition and more than % not having access to safe water, our capability of nourishing a billion and a half more people by is in question. also problematical is our capability to provide for an additional billion people years later, or a total of at least . billion people by the turn of the century, that is, if we reach those population figures or have population crashes such as from pandemics that can kill scores of millions if a disease is not immediately treatable, or an unlikely but possible nuclear conflagration that could do the same. less likely yet is an explosion of a small asteroid or comet in the atmosphere such as happened in a poorly inhabited area of siberia in . here, an exploding mass more than m in size knocked down millions of trees in an area greater than , km (close to mi ) with energy thought to be , times greater than the hiroshima atomic bomb. clearly, such an event could kill the population of a megacity if it were to occur. another question is whether national governments are economically strong enough and have the will to set priorities that adopt strategies to protect citizens from natural (e.g., earthquakes) and anthropogenic (e.g., pollution) hazards as well as from extreme weather conditions that are supported by global warming (pollution of the atmosphere) but are naturally occurring. countries can also improve social and economic conditions by investing in health care and education for their citizens in order to form a sound and knowledgeable cadre that would be attractive to investors interested in locating a development project that would provide employment. again, this is in question given limited national economic capabilities and the increasing numbers of people to be accommodated, especially in several developing and less developed countries in africa, asia, latin america, and the middle east. at this point, we must ask, "what is the carrying capacity of the earth?" have we reached it at billion given the billions who are today under served in developing and less developed countries? some scientists will answer yes, whereas others believe that advances in agriculture and technology can allow population expansion although to what point is not defined. can countries that are poisoning their environments do a turn around to save their citizens from grief? can they exert controls on operations that create unhealthy conditions that sicken people, lessen agricultural production, and otherwise disrupt local, regional, and global climate change: evidence and causes ( p) intergovernmental panel on climate change ( ) climate change (as four part report). part . the physical science basis mitigation of climate change past and future sea level change from the surface mass balance of glaciers a reconciled estimate of glacier contributions to sea level rise ocean thermal expansion and its contribution to sea level rise tuberculosis. fact sheet no. p . world health organization ( ) dracuncukiasis (guinea-worm disease) protection against malaria by intravenous immunization with a non-replicating sporozoite vaccine global mortality between and : a systematic analysis world health organization ( ) malaria. fact sheet no. p . world health organization ( ) dengue and severe dengue chagas disease (american trypanosomiasis). fact sheet no vaccines and global health ) ipcc special report summary for policy makers. managing the risks of extreme events and disasters to advance climate change adaptation turn down the heat: climate extremes regional impacts and the case for resilience. a report for the world bank prepared by potsdam institute for climate impact research and climate analytics key: cord- -ind t authors: hwang, stephen w.; dunn, james r. title: homeless people date: journal: handbook of urban health doi: . / - - - _ sha: doc_id: cord_uid: ind t nan environment that warrant scrutiny. for example, both questions will lead to a consideration of the availability of low-cost housing and the ability of the health care system to care for patients with severe mental illness. however, the distinction between these two questions is important as they distinguish factors associated with the likelihood of being homeless due to health reasons versus the likelihood of consequences given homelessness. at another level, it is also important to distinguish if outcomes and their associated factors vary between cities, both in terms of the structural factors that generate homelessness and (given homelessness) health of those who are homeless. these questions frame the issue of the impact of the urban environment on the health of disadvantaged populations. in the course of such discussions, disagreement often arises as to whether homelessness should be considered primarily the consequence of individual vulnerabilities and failings, or the result of structural inequities in the social, economic, housing, and health care systems. rather than creating an either/or distinction, we will approach homelessness as the result of a complex interaction between individual vulnerabilities and structural forces in the urban environment. in most cases, the relative importance of these factors in determining the health of homeless people and the prevalence of homelessness remains the subject of ongoing debate. the burden of illness and disease is extremely high among homeless people (levy and o'connell, ) . however, any consideration of the common health problems of homeless people must first recognize the large degree of heterogeneity among people who are homeless. among street youth, single men, single women, and mothers with children, the patterns of illness differ notably. adolescents suffer from high rates of suicide attempts, sexually transmitted diseases, and pregnancy (greene and ringwalt, ; greene and ringwalt, ; greene, et al., ; feldmann and middleman, ) . female heads of homeless families tend to have far fewer health problems than single homeless women, although their health is poorer than their counterparts in the housed general population (robertson and winkleby, ) . homeless single men have a higher prevalence of alcohol abuse and drug abuse, whereas single women have a higher prevalence of serious mental illness (fischer and breakey, ) . health status also tends to be correlated with a person's history of homelessness. individuals with severe mental illness, substance abuse, and medical conditions are overrepresented among the chronically homeless, whereas those who are homeless for a transient period lasting only a few weeks or months are more likely to be relatively healthy (kuhn and culhane, ) . although chronically homeless people make up only about % of all individuals who experience homelessness in a given year, they account for a disproportionately large share of the demand for shelter beds and health care services for homeless people (burt, ) . in addition, the public's perception of homeless people often reflects a stereotyped image of this highly visible subgroup. cross-national comparisons of disease patterns among homeless people reveal the strong effect of social factors within each country. among homeless men in tokyo, japan, morbidity due to alcohol dependence (but not drug use) is common, as are musculoskeletal injuries incurred doing construction work (takano, et al., b) . in contrast, % of homeless people in amsterdam, the netherlands, suffer from drug abuse or dependence (primarily heroin), and most are chronically homeless (sleegers, c ). the prevalence of serious mental illness and substance abuse is high among homeless persons. in a nationwide u.s. survey of homeless people, % had mental health problems, % had an alcohol and/or drug problem, and % had concurrent mental health and substance use problems (burt, ) . common psychiatric diagnoses among homeless people include major depression, bipolar disorder, schizophrenia, and personality disorders. a systematic review of the prevalence of schizophrenia in homeless persons found rates ranging from to % and a weighted average of % in the ten methodologically strongest studies . characteristics associated with a higher prevalence of schizophrenia were younger age, female sex, and chronic homelessness. marked cross-national variation is seen in the prevalence of schizophrenia, with prevalence rates of - % reported among homeless people in sydney, australia (teesson, et al., ) . the prevalence of substance abuse is extremely high among homeless single adults. in a study from st. louis, missouri, large increases were seen in the prevalence of drug use among homeless men and women between and . in , % of men and % of women had an alcohol or drug use disorder (north, et al., ) . in another study, about three-quarters of homeless adults met criteria for substance abuse or dependence (o'toole, et al., ) . homelessness increases the risk of adverse health outcomes among substance abusers: in five canadian cities, the risk of a non-fatal overdose was twice as high among illicit opiate users who were homeless compared to those who were housed (fischer, et al., ) . homeless adolescents also have very high rates of mental health problems and substance abuse. in a study from seattle, % of street youths had been physically and/or sexually victimized after leaving home, and % met criteria for posttraumatic stress disorder (stewart, et al., ) . across the u.s., % of street youth and % of shelter youth had used illicit drugs other than marijuana since leaving home, in comparison to % of youth who had never been runaway or homeless (greene, et al., ) . street youth use a wide range of drugs, including hallucinogens, amphetamines, sedative/tranquilizers, inhalants, cocaine, and opiates. unfortunately, the initiation of injection drug use is quite common, with an incidence rate of . per person-years among street youth in montreal (roy, et al., ) . infectious diseases are a common cause of health problems in homeless people (raoult, et al., ) . the most serious of these infections include tuberculosis (tb), human immunodeficiency virus (hiv) infection, viral hepatitis, and other sexually transmitted infections. outbreaks of tb among homeless people have been reported frequently, especially in individuals co-infected with hiv (barnes, et al., ; mcelroy, et al., ; morrow, et al., ) . the incidence of active tb in a cohort of homeless people in san francisco between to was per , , or times higher than that seen in the u.s. general population in (moss, et al., ) . homeless people with tb require more hospital-based care than non-homeless people with tb, resulting in average hospital costs that are higher by $ , per patient. (marks, et al., ) contact tracing in the homeless population is difficult, and in one study only % of identified contacts completed treatment for latent tb infection (yun, et al., ) . among street youth, latent tuberculosis is more common than in the general population, but probably less prevalent than among homeless adults. in a study conducted in sydney, australia, % of homeless young people aged - years had latent tb infection (kang, et al., ) . homeless people are at increased risk of hiv infection. data from an older u.s. survey conducted from to in cities found median hiv seroprevalence rates of . % in adult men, . % in adult women, and . % in youths (allen, et al., ) . in more recent studies, hiv seroprevalence was . % among homeless and marginally housed adults in san francisco in , a rate five times higher than in san francisco generally (robertson, et al., ) . hiv infection was present in . % of homeless veterans admitted to residential programs from - (cheung, et al., ) . female street youth and young homeless women who are involved in prostitution are at increased risk of hiv infection, due to both injection drug use and risky sexual behaviors (weber, et al., ) . in one study of homeless adolescents, the hiv infection rate was alarmingly high at % (beech, et al., ) . among substance users, homelessness is associated with higher rates of hiv seroprevalence (surratt and inciardi, ; smereck and hockman, ) . among hivinfected persons, those who are unstably housed (homeless or temporarily staying with friends or family) are less likely to receive adequate health care than those who are stably housed (smith, et al., ) . homeless people are at increased risk of viral hepatitis, primarily due to high rates of injection drug use. infection with hepatitis c was found in % of homeless men in los angeles , % of individuals using a mobile medical van in new york city (rosenblum, et al., ) , and % of homeless persons in oxford, england (sherriff and mayon-white, ) . in a veterans affairs population, the prevalence of anti-hepatitis c virus antibody was . % and the prevalence of hepatitis b surface antigen was . % (cheung, et al., ) . among street youth, the prevalence of these markers of infection was also high: . % and . %, respectively, in montreal (roy, et al., ; and . % and . %, respectively, in a northwestern u.s. city (noell, et al., b) . sexually transmitted diseases (stds) are a particularly serious problem among street youth. in a longitudinal study of homeless adolescents, the annual incidence of chlamydia trachomatis infection was . % in females and . % in males; the annual incidence of herpes simplex virus type was . % in females and . % in males. (noell, et al., ) a study of street youth and sex workers in quebec city, canada found that % of women less than years old were infected with chlamydia trachomatis and . % had neisseria gonorrhoeae (poulin, et al., ) . newer urine-based screening tests make it easier to screen homeless youth for stds in outreach settings (van leeuwen, et al., ) . common chronic diseases, including hypertension, diabetes, chronic obstructive pulmonary disease (copd), seizures, and musculoskeletal disorders, are often undiagnosed or inadequately treated in homeless adults. relatively little research has focused on these medical conditions in the homeless population. the prevalence of hypertension was higher among homeless clinic patients than among nonhomeless patients at an inner-city primary care clinic ( % vs. %) (szerlip and szerlip, ) . the prevalence of diabetes is similar in homeless and non-homeless individuals, but homeless people with diabetes face a number of serious barriers to appropriate disease management, including lack of access to a suitable diet and dif-ficulties coordinating medication administration with meal times (hwang and bugeja, b) . glycemic control was found to be inadequate in % of homeless diabetics in toronto (hwang and bugeja, b) . smoking rates are extremely high (about %) among homeless people (connor, et al., ) . as a result, copd is a common health problem among older adults. in a study of shelter residents in san francisco, the prevalence of copd based on spirometry was %, or more than twice the prevalence in the general population (snyder and eisner, ) . smoking also contributes to the high risk of cancer, especially among homeless single men. in a study from scotland that adjusted for age and socioeconomic deprivation, the incidence of cancer of the oral cavity and pharynx, larynx, esophagus, and lung in homeless men was %, %, %, and % higher than expected, respectively (lamont, et al., ) . homeless people are also less likely to receive recommended cancer screening than the general population: among homeless women age and over in los angeles county, only % had undergone a pap smear and only % had undergone a mammogram within the last year (chau, et al., ) . thus, interventions such as smoking cessation treatment and routine preventive health services may provide significant benefit. although it is not surprising that homeless people with mental illness often receive inadequate care for medical comorbidities, the adequacy of care differs according to type of mental illness. homeless people with schizophrenia receive less detailed physical examinations, fewer primary care visits, and less preventive health services than homeless people with major depression . while it is unknown if these differences are due to patient factors, provider factors, or both, careful attention clearly needs to be paid to the physical health needs of homeless people with psychoses. trauma and injuries are significant hazards associated with life on the street (staats, et al., ) . in a sample of homeless and marginally housed people in san francisco, % of the women and % of the men had been sexually or physically assaulted in the last year (kushel, et al., ) . among women, being homeless (compared to being marginally housed) was associated with a more than -fold increase in the risk of sexual assault. in sydney, australia, % of shelter residents reported experiencing a serious physical assault in their lifetime, and half of the women reported having been raped (buhrich, et al., ) . among homeless youth in los angeles, reported exposure to violence was found to be equally high among males and females (kipke, et al., ) . foot problems are very common among homeless adults due to prolonged standing, long-term exposure to cold and damp, ill-fitting footwear, and inadequate foot hygiene. problems can range in severity from mild blisters and fungal infections to debilitating chronic venous stasis ulcers, cellulitis, diabetic foot infections, and frostbite. other common skin problems include sunburn and bites due to infestations by head lice, body lice, scabies, or bedbugs (stratigos and katsambas, ) . the prevalence of serious dermatologic conditions, while probably quite high among street-dwellers, appears to be relatively low among homeless people living in shelters that provide adequate clothing, laundry facilities, bathing facilities, and medical care. in a study of men staying at such a shelter in boston, the majority of individuals had relatively normal findings on skin examinations (stratigos, et al., ) . dental problems are an extremely prevalent and troubling but often-neglected problem for many homeless people. common conditions include advanced caries, periodontal disease, and ill-fitting or missing dentures. these problems may be related to poverty, lack of access to dental care, and substance use, rather than homelessness per se. in a study comparing homeless and domiciled veterans in veterans affairs rehabilitation programs for substance abusers, the two groups had similarly poor oral health (gibson, et al., ) . given the high prevalence of illness among homeless people and the adverse health effects of homelessness itself, it is not surprising that homeless people have very high mortality rates. men using homeless shelters are to times more likely to die than age-matched men in the general population (barrow, et al., ; hwang, a) . homeless women - years of age have mortality rates that are to times higher than in the general population (cheung and hwang, ) . common causes of death among homeless people under the age of are unintentional injuries, drug overdoses, aids, suicide, and homicide (hwang, et al., ; . in a longitudinal cohort study of street youth in montreal, the standardized mortality ratio was . ; hiv infection, daily alcohol use in the last month, homelessness in the last months, drug injection in the last months, and male sex were independent predictors of mortality (roy, et al., ) . among homeless women, major barriers to contraception include cost, fear of side effects or potential health risks, and the partner's dislike of contraception . pregnancy is particularly common among homeless adolescents. in a u.s. sur vey of runaway females age - years, % of streetdwelling youths and % of those residing in shelters were currently pregnant (greene and ringwalt, ) . in a group of pregnant homeless women, the risk of low birth weight (less than , gm) was %, compared to the national average of % (stein, et al., ) . lack of prenatal care and severity of homelessness (homelessness in the first trimester of pregnancy, number of times homeless, and percentage of life spent homeless) were independent risk factors for low birth weight. the health of children in homeless families has been the focus of relatively little research. some but not all studies of these children have found an increased prevalence of behavioral and mental health problems compared to children in housed low-income families (bassuk, et al., ; vostanis, et al., ) . infectious diseases are a significant concern in these children (ligon, ) . up to % of children in homeless families in new york city suffer from asthma, a rate six times higher than the national rate in children (mclean, et al., c) . the medical literature has usually examined health problems from the perspective of the individual homeless person, and has given relatively little attention to the urban environment within which these health problems arise and must be ameliorated. this section addresses this gap by highlighting dimensions of the urban environment that affect, through interaction with individual vulnerabilities, the prevalence of homelessness and/or the health of homeless people. the following is not intended to be a comprehensive listing, but rather a selection of important determinants about which at least some information is available. these determinants have been grouped into categories encompassing the demographic and physical characteristics of urban centers (population and climate), their socioeconomic and service-delivery structures (income and poverty, social welfare systems, and health care systems), and their spatial and political organization (urban geography and urban governance). although these dimensions may have differential effects on the health of various subgroups of homeless people (e.g., youths, single adults, and families), these differences are not discussed in depth here. homelessness is a problem in cities across the u.s., as demonstrated by the fact that federally-funded health care for the homeless programs exist in cities in all states, the district of columbia, and puerto rico (health care for the homeless information resource center). there is limited information on the relationship between population size and prevalence of homelessness in different urban centers. one reason for this paucity of data is the logistical difficulty of conducting an accurate count of homeless persons, particularly those living on the street. another reason is that point-prevalence counts of the homeless population cannot be used to determine how many individuals are homeless in a city over an entire year, especially given seasonal fluctuations in the homeless population and the fact that homelessness is a transient state. counts of shelter users are particularly informative when all shelters contribute to a common administrative database, because this makes it possible to determine the total number of individuals who use shelters in a particular city over the course of a year, rather than simply the number of shelter users at a single point in time (metraux, et al., ) . in , an estimated . % of the . million residents of philadelphia and . % of the . million inhabitants of new york city stayed at a homeless shelter at least once (culhane, et al., ) . in toronto, canada, . % of the city's total population of . million used a homeless shelter during . these figures are remarkably similar and strikingly high. thus, homelessness is quite common in large urban centers, although for many individuals the duration of homelessness is quite brief. in a u.s. survey of homeless people, % had been homeless for only months or less, % had been homeless for - months, and % had been homeless for more than one year (burt, ) . cross-sectional counts of the number of shelter residents provide an important but somewhat less accurate picture of the homeless population. the maximum size of a city's shelter population is obviously determined by the number of available shelter beds. in a city with few shelters, this can create the illusion of a smaller homeless population than is actually the case. in addition, shelter beds may be less widely available in cities that do not experience severe cold weather in the winter. in the nine largest metropolitan areas in canada, the number of shelter beds per capita ranges more than four-fold, from to per , population (hwang, ) . the number of shelter beds per capita is not significantly correlated with population size. interestingly, the lowest number of shelter beds per capita in canada was observed in vancouver, a city with a very mild climate, and the highest figure was seen in calgary, a city with extremely cold winters. overall, this evidence suggests that episodes of homelessness are quite common among residents of major urban centers, but there is significant variation in the prevalence of homelessness across cities that does not necessarily correlate with population size. a related question is the role of migration in determining the size of the homeless population in urban centers. whereas some homeless people are migrants who were homeless before or upon their arrival in the city, others are local residents who have become homeless. in a nationwide u.s. survey, % of homeless people reported living in the same city where they became homeless (burt, ) . among the % of individuals who had moved from one location to another during their current episode of homelessness, the most common pattern was a net flux from urban fringes and medium-sized cities into large central cities. the most commonly cited reasons for these moves were lack of available jobs, lack of affordable housing, and eviction (burt, ) . climate is an interesting example of a characteristic of the urban environment that affects both the prevalence of homelessness and the health of homeless people. certain cities in warm regions may become a preferred destination for people who are homeless or at high risk for homelessness. as noted above, in cities with warmer climates, a larger proportion of the homeless population is likely to be found on the street rather than in shelters. people living on the street are more likely to be disengaged from the health care and social service systems, and typically these individuals have poorer health than shelter-dwelling homeless people (cousineau, ) . in colder climates, exposure to the elements has an obvious adverse impact on the health of homeless people, who face serious risks from trench foot, frostbite, and injury or death from hypothermia (tanaka and tokudome, ) . conversely, in hot weather, homeless people may experience severe sunburn, heat exhaustion, or heat stroke. the prevalence of severe poverty among the residents of an urban area is certainly an important factor affecting the prevalence of homelessness. poverty alone, however, does not necessarily lead to homelessness. data from nine u.s. cities demonstrate wide variation in the proportion of a city's poor residents that stays at a homeless shelter over the course of one year, ranging from a low of . % to a high of . % (metraux, et al., ) . some have argued, based on historical data, that an increase in the number of unmarried men with very low income is a particularly important explanatory factor for adult homelessness (jencks, ) . during the latter half of the twentieth century, the earning potential of men with limited education was greatly diminished by the decline of manufacturing jobs in urban centers (wilson, ; . at the same time, the availability of open-market sources of low-cost housing such as single-room occupancy hotels and rooming houses shrank steadily due to gentrification and urban renewal (hasson and ley, ) . in this setting, the level of government support for subsidized rental housing plays a key role in determining the availability of units that a low-income individual or family can afford; the 's saw a decline in this support in both the u.s. and the united kingdom (cohen, ) . some have suggested that income distribution, specifically the ratio of middleincome to low-income households within a given city, is an important determinant of homelessness among both single adults and families (o'flaherty, ) . o'flaherty argues that because the construction of new rental housing for lowincome individuals is economically unattractive, the main source of housing for poor people is deteriorating housing stock that has been vacated by middle-income people. o'flaherty theorized that cities with fewer middle-class people relative to the number of poor people have higher rents at the bottom of the market (because middle-income housing is not being "handed down" to the poor), resulting in higher rates of homelessness. members of ethnic and racial minorities are disproportionately represented in the homeless population (e.g., blacks and latinos in the u.s., and aboriginal people in canada) (burt, ; hwang, ) . the higher prevalence of poverty in these disadvantaged groups may explain this observation. however, other race-related factors in the urban environment may contribute to the excess risk of homelessness among people of color, including discrimination in the housing market and segregation of low-income minorities in neighborhoods with fewer economic opportunities than neighborhoods in which low-income whites reside. any discussion of the role that urban poverty plays in causing homelessness also raises questions about nature of the causal relationship between homelessness and poor health. poverty is consistently and strongly associated with poor health (marmot, et al., ) . thus, the poor health observed among homeless people may be explained in large part by the fact that they experience extreme poverty and deprivation, rather than the fact that they happen to be homeless at the present time. this is particularly likely to be the case for individuals who have only recently become homeless, and less so for the chronically homeless, who have been subjected to the adverse health effects of lack of housing for a lengthy period. to extend this concept further, homelessness is a marker for severe poverty in the urban environment, and it may be this level of poverty, rather than the negative impact of homelessness itself, that has the greatest effect on population health in urban centers. this issue is discussed further in section of this chapter. social welfare systems in urban centers have a major impact on both the prevalence of homelessness and the health of homeless people. however, these systems are usually governed at the state or national level, rather than at the municipal level. wide variation is seen in the scope of social welfare programs, with more generous benefits typically seen in countries or regions that have less tolerance for high levels of income inequality and place a higher value on social cohesion (sleegers, b) . for example, eligibility criteria for welfare benefits in the u.s. vary significantly from state to state. some states allow single men to collect welfare, whereas others exclude them. these policies would likely affect the risk of homelessness among low-income single men living in any city within a given state. in addition, u.s. federal funds may not be used to provide temporary aid to needy families (tanf) if an adult in the family has received assistance for more than months, but individual states may elect to continue providing assistance to these families using state funds (state policy documentation project). in coming years, as families that are unable to become self-supporting begin reaching the -month federal time limits on benefits, their risk of becoming homeless may be greatly affected by the policies of the state in which they live. in contrast, most european union countries have extensive social welfare and public housing systems that make family homelessness less common. one area of controversy is whether the provision of cash entitlements or disability benefits has significant effects on the health of homeless people. on one hand, the health of homeless people should improve if public benefits allow them to obtain food, housing, and other essentials of life. on the other hand, increased income could be detrimental to health if the money is used to purchase alcohol or drugs. one of the few studies on this issue examined homeless mentally ill veterans who applied for social security disability insurance (ssdi) or supplemental security income (ssi). the individuals who were eventually awarded benefits did not differ in their past history of substance use from the individuals who were eventually denied benefits. three months after the decision to award or deny benefits, the group that was awarded benefits had significantly higher average total income (by $ per month) and higher quality of life than the group that was denied benefits. there was no evidence of increased alcohol or drug use or deterioration in psychiatric status among those who received benefits (rosenheck, et al., ) . most homeless people depend on their city's shelter system for housing, food, and other social services, and these shelters can therefore have a significant impact on the health of homeless people. the availability and quality of homeless shelters vary greatly. as noted previously, homeless people in cities with few shelter beds are more likely to live on the street or other places not intended for human habitation, with potentially adverse health effects. in addition, the staff at homeless shelters can play an important role in connecting homeless people to social services, job training, housing applications, and substance abuse treatment. the quantity and quality of food provided at shelters determines to a large extent the nutritional value of homeless people's diets, with potential downstream health effects (dachner and tarasuk, ) . finally, the physical environments at shelters range from extremely crowded, poorly ventilated, and unsanitary facilities to modern, clean, and well-run establishments. adverse shelter conditions have an impact on the transmission of tuberculosis and viral respiratory infections and the prevalence of health conditions such as skin infestations and asthma exacerbations. shelter conditions could also plausibly have an effect on mental and emotional well-being among residents. to date, however, little research has examined the effects of the physical shelter environment on the health of homeless persons, with the exception of the relationship between crowding and poor ventilation in shelters and the transmission of tuberculosis (advisory council for the elimination of tuberculosis, b). the organization and financing of the urban health care system has an enormous impact on the health of homeless people, and to some extent on the prevalence of homelessness as well. in the u.s., % of homeless people lack health insurance, creating a significant barrier to obtaining care (kushel, et al., ) . these individuals are dependent on state-or city-based systems designed to provide care for the indigent. in many large urban centers in the u.s., a designated public, county, or charity hospital provides the majority of hospital-based health care for homeless people. some cities have free-care clinics or community health centers that provide ambulatory services for homeless persons as well as other low-income residents. in u.s. cities, federally-funded health care for the homeless programs have established multidisciplinary teams of physicians, nurses, social workers, and outreach workers that provide care to homeless people on the street and in shelters. this limited set of health care providers is typically the only source of care available to homeless people in urban areas in the u.s., and the local funding and staffing level of these organizations is a critical determinant of access to health care. for homeless veterans, the proximity and availability of veterans health administration services is also an important factor. in countries such as canada and the united kingdom that have systems of universal health insurance, homeless people still face non-financial barriers to care. many access problems stem from the fact that a health care system designed to meet the needs of the general population may not accommodate the unique requirements of homeless people (crane and warnes, ; bugeja, a, b) . for example, the provision of universal health insurance does not necessarily result in the establishment of outreach programs for homeless people, appropriate treatment programs for homeless persons with mental illness or substance abuse, or an adequate supply of health care providers who are willing, able, and trained to work with this challenging population (buchanan, et al., ) . in the united kingdom, individuals must register with a general practitioner to obtain primary care, and some physicians are reluctant to accept homeless people into their practice because of their complex needs and the extra workload entailed (wood, et al., ) . health insurance does not protect against the fragmentation and discontinuity of care that homeless people often experience, nor does it eliminate the daily struggle to meet basic survival needs that may cause homeless people to place a lower priority on seeking health care (gelberg, et al., ) . inadequate access to primary health care may result in uncontrolled disease progression and frequent emergency department visits and hospitalizations (han and wells, ) . emergency department visits by homeless people should be seen as an indicator of high levels of unmet health needs, rather than inappropriate health care utilization (kushel, et al., ) . about % of homeless children with severe persistent asthma have had at least one emergency department visit in the last year, a finding indicative of inadequate access to health care and undertreatment of their disease (mclean, et al., ) . because individuals with severe mental illness who do not receive appropriate health care are at high risk of becoming homeless, the health care system can have a direct impact on the prevalence of homelessness. the role of deinstitutionalization in contributing to the problem of homelessness has been discussed extensively. beginning in the 's and 's, the advent of effective anti-psychotic medications to treat schizophrenia and an understandable desire to move people out of chronic mental hospitals, where conditions were sometimes horrendous, led to the discharge of tens of thousands of long-term psychiatric patients (dear and wolch, ; jencks, ) . the number of beds at psychiatric institutions fell precipitously. in theory, these patients were supposed to receive mental health care and social support in the community. in reality, many of these patients received little if any services and ended up swelling the ranks of the homeless population in the 's and 's. today, many decades after these events took place, "deinstitutionalization" is no longer the major cause of homelessness among people with serious mental illness. it is now uncommon for people with psychiatric disorders to have ever been institutionalized for an extended period, and any admissions tend to be quite brief. not surprisingly, individuals with severe illness, few social supports, and/or inadequate access to appropriate outpatient psychiatric care often become homeless. in a sense, homeless shelters have assumed the role that was played by chronic psychiatric hospitals fifty years ago. for these homeless people with severe mental illness, the delivery of appropriate health care is challenging but essential to improving their health and housing status. the assertive community treatment (act) model attempts to address this problem through a team of psychiatrists, nurses, and social workers who follow a small caseload of homeless mentally ill clients, seeking them out in the community to provide high-intensity mental health treatment and case management. studies have found that mentally ill homeless people receiving act spend fewer days hospitalized as a psychiatric inpatient and have somewhat greater improvement in symptoms than those receiving usual care (lehman, et al., ) . however, act is labor-intensive and costly, and its availability is often quite limited. the availability and type of addictive substances in the urban environment have an important effect on the prevalence of homelessness and on the health of homeless people (munoz, et al., ) . the advent of crack cocaine has been clearly implicated in the rise of homelessness in the u.s. in the 's (jencks, ) . in japan, alcoholism is the predominant addiction contributing to homelessness and morbidity among homeless people, whereas in the netherlands, homelessness is closely linked to chronic heroin addiction (takano, et al., a; sleegers, a) . access to addiction treatment is therefore a vital issue for a large proportion of homeless people. a number of treatment modalities for adults have been shown to be effective in controlled studies: admission to a post-detoxification stabilization program results in longer periods of abstinence than direct release into the shelter system (kertesz, et al., ) , and abstinence-contingent work therapy in a longterm residential setting has been shown to improve outcomes (milby, et al., ) . studies have examined the effectiveness of case management for homeless people with addictions, with mixed results (morse, ) . the forces underlying the urban geography of homelessness are aptly described in the seminal work of dear and wolch (dear, et al., ) . they examined how deinstitutionalization, rollbacks in entitlements to social assistance, and changes in the global economy in the late s and early s combined to create complex problems of poverty, inequality, and homelessness in north american cities that persist to this day. dear and wolch ( ) argued that these problems manifested themselves in the specific urban form of the "service-dependent ghetto," which refers to the spatial concentration in the inner city of service-dependent populations (such as people with mental illness, physical handicaps, addictions, or recent incarceration) and the organizations that assist them. while on one hand these can be characterized as areas of "urban blight," dear and wolch ( ) argued that they serve as a supportive environment and adaptive coping mechanism that can have a positive effect on the health and well-being of residents who have few other options. servicedependent ghettos are often the object of antagonism from surrounding communities. paradoxically, however, these more affluent communities often perpetuate the forces that create the service-dependent ghetto and entrench processes of inner-city decay through citizen resistance to housing and services for low-income people and exclusionary land use policies and zoning practices (dear and taylor, ) . in some cities, the tendency has been to isolate high-poverty urban neighborhoods rather than attempt to destroy them. davis argues that in los angeles and other cities, a conscious effort has been made to create geographic and physical barriers (such as expressways) that circumscribe poor and minority neighborhoods and cut them off from the rest of the city (davis, ) . this spatial isolation can further heighten the marginalization of these communities and limit residents' access to goods, services, and economic opportunities that are vital to health. since homeless people spend a great deal of their time in public spaces, the nature of these spaces can have a significant impact on their quality of life. some cities have numerous well-tended public spaces such as parks and squares that are conducive to those who wish to linger or rest, including homeless people. these spaces can serve a socially cohesive function if urban dwellers of diverse backgrounds perceive them to be safe "neutral" spaces in which to gather and socialize. in contrast, other cities have built environments that lack such public spaces and are instead dominated by privatized quasi-public spaces such as shopping malls. nonpurposeful lingering, which would be generally acceptable in a public space such as a park, is perceived as "loitering" in such places. in a relatively trivial but very specific expression of hostility toward homeless people, some cities have installed "bum-proof" benches that are designed to prevent reclining or sleeping on the seat. while these elements of the urban environment seem relatively minor, they may reflect a city's prevailing sentiment towards homeless and poor people that sets the tone of their daily existence (davis, ). homelessness is often perceived as having a negative effect on the quality of life in urban centers. some consider the visible presence of homeless people in parks, street corners, and other public spaces to be a manifestation of "urban disorder" and a barrier to the successful promotion of commerce and tourism. in response to these concerns, a number of cities have enacted by-laws against panhandling, loitering or sleeping in public places, public intoxication, or possession of shopping carts. some cities have instituted aggressive policing strategies to remove homeless people from public spaces (graser, ) . efforts to displace street youth and homeless people rather than offer them any meaningful help might have negative effects on health and in fact increase high-risk behaviors such as survival sex and unsafe injection drug use practices (o'grady and greene, ; wood, et al., ) . homeless people frequently interact with both police and paramedics, but they have much lower levels of trust in police than in paramedics (zakrison, et al., ) . by inhibiting homeless people from calling for needed emergency assistance, this distrust could result in serious harms to health. in a study of injection drug users in san francisco, % of those who had been present with an unconscious heroin overdose victim did not call for emergency services due to fear of police involvement (davidson, et al., ) . police action can also have direct adverse effects on the health through the excessive use of force (cooper, et al., ) . in a study in toronto, % of homeless people reported having been assaulted by a police officer in the last months (zakrison, et al., ) . on a larger scale, issues of urban governance such as fiscal disparities affect all urban dwellers, but have the potential to have a particularly severe impact on homeless and poor people. fiscal disparities typically occur when an older central city with a significant number of high-poverty neighborhoods is surrounded by a ring of higher-income municipalities. the central city's primary revenue stream from property taxes is limited by a weak tax base, but at the same time the city is confronted by a high and rising demand for social services, some of which is driven by the downloading of 'unfunded mandates' by states onto central city municipalities (drier, et al., ) . meanwhile, the nearby ring communities have a strong property tax base and face a lower demand for social services, while at the same time its residents work in the central city and benefit from its economic activities and services (the socalled "free-rider" effect) (orfield, ; drier, et al., ) . these fiscal disparities greatly exacerbate the adverse effects of racial and economic segregation on homeless people and others living in extreme poverty in the central city. in an example of an effort to redress this problem, state legislation in minnesota, the fiscal disparities act, mandates the sharing of commercial property tax between outlying, high tax base municipalities to central city municipalities to assist in the provision of social services. enacted in by the minnesota legislature, the plan pools % of the increase in all communities' commercial/industrial property valuation. all cities and townships keep their pre- tax bases plus % of the annual growth. the pool is then taxed at a uniform rate and redistributed among all local government entities. although this redresses some of the intrametropolitan disparities, it does little to reduce the payoffs of "externalizing" social problems with tools like exclusionary zoning in typically more affluent communities. moreover, the minneapolis-st. paul example depends on the existence of a strong regional-metropolitan level of governance, the met council, which although heavily studied (orfield, ; rusk, ; katz and bradley, ) , is still a concept that is strongly resisted by homeowners' associations, gated communities, and affluent municipalities (mckenzie, ; boudreau and keil, ). an alternative solution is to create cities that encompass lower and higher income areas, rather allowing them to separate into different jurisdictions. in toronto, ontario, this was effectively accomplished through the amalgamation of five contiguous cities into a single urban entity, although the amalgamation was motivated by a desire to increase operating efficiency rather than concern regarding fiscal disparities (boudreau, ) . does homelessness have a sizeable effect on population health? this question raises a number of complex issues. homeless people, especially those who are chronically homeless, tend to have poor health. however, homelessness is a temporary state, not a permanent trait. as many as millions americans experience homelessness over a five year period, but most of these episodes of homelessness are quite brief (link, et al., ) . thus, at any single point in time only a very small proportion of a city's population is without a home. homeless people would therefore be expected to have a minimal impact on indicators of overall population health, such as health status or mortality rates. of course, this assumption may be incorrect in urban centers in the developing world, where extremely large numbers of people often live on the street or in encampments. some have suggested that homelessness may have an adverse effect on public health through the spread of infectious diseases, such as tuberculosis. compared to the general population, homeless people are clearly at increased risk of developing latent tuberculosis, which is not infectious to others, as well as active tuberculosis, which can infect those who come in close contact with the individual. during tuberculosis outbreaks, shelter residents, shelter staff, and health care providers are at increased risk of becoming infected (advisory council for the elimination of tuberculosis, a). to date, however, outbreaks of tuberculosis among homeless people have not spread widely within the general population. the threat of tuberculosis is therefore an important health problem for homeless people, but one that has demonstrated relatively limited potential to affect overall population health in urban areas. the outbreak of severe acute respiratory syndrome (sars) in has raised the specter of rapid and uncontrolled spread of acute respiratory infections through the homeless population. the sars outbreak in toronto was almost entirely confined to travelers returning from abroad, health care workers, and their household contacts (svoboda, et al., ) . no homeless person became infected with sars. if this had happened, the large, transient, and difficult-to-locate shelter population would have made it almost impossible for toronto public health officials to implement their core strategy of identifying and quarantining all "household contacts" of patients with sars. such a situation could have had devastating effects on efforts to prevent the outbreak from spreading into the city's general population. given the threat of a recurrence of sars or the possible emergence of other new and potentially deadly respiratory infections, infection control measures to deal with a severe acute infectious disease outbreak in the homeless population require serious consideration. although this scenario is currently hypothetical, the potential implications for population health are considerable. homelessness may have major implications for population health, for reasons other than those discussed above. emphasis on the direct impact of homelessness on population health may be misplaced. instead, homelessness may be viewed as a sentinel event, a marker for dysfunction in multiple sectors including the housing market, job market, health care system, and social welfare system. homelessness represents the extreme end of a larger distribution of socioeconomic status and housing status, and it attracts attention precisely because of its dire nature. this conceptualization has been well-described in work by rose ( ) . as shown in figure , the curve shown with a solid line represents the distribution of housing quality within a hypothetical population. homelessness represents the extreme low point along the dimension of housing quality. this approach views one's housing situation as a continuum and avoids creating a simple dichotomy between being homeless and being housed. for the sake of this discussion, we assume that housing conditions have an impact on health, an assertion for which there is ample support (fuller-thomson, et al., ; krieger and higgins, ) . figure also illustrates two different approaches to improving health through improving housing conditions. the greatest effect in terms of population health may be gained through approach a (shifting the entire population distribution for the factor upwards slightly, to the distribution curve indicated by a dotted line) rather than approach b (focusing on improving conditions for the highest-risk group at the worst extreme of the distribution). a similar argument could be applied to the relationship between poverty and health, where the x-axis on the diagram would represent income rather than housing quality. the case of asthma is an excellent example of this dilemma. about % of children staying at homeless shelters in new york city have asthma (mclean, et al., a) . although this is a disturbingly high rate, the prevalence of asthma is also very high among inner-city children living in substandard housing (malveaux and fletcher-vincent, ) . because homeless children represent a relatively small proportion of all children living in poverty in a given city, the population health effect of asthma among homeless children is likely to be far smaller than the population health effect of asthma in the much larger number of children who are housed but living in decrepit buildings. while homeless children are a distressing manifestation of urban poverty, they represent "the tip of the iceberg" of the broader issue of poverty and poor housing. thus, the problem of asthma among homeless children may be regarded as an extreme example of a much larger population health concern that may be a more appropriate target for intervention. a consideration of strategies to improve the health of homeless people raises the question of whether our first concern should be to attempt to deal with the problem of homelessness itself, or to intervene to relieve illness among homeless youths, single adults, or families. of course, this is not an either/or proposition. nonetheless, an excessive emphasis on the latter approach might result in producing healthier homeless people, yet fail to recognize that homelessness is the result not only of individual vulnerabilities, but also of deeper structural problems within our society. on the other hand, a focus on the former approach may founder on the assumption that providing homeless people with stable housing will necessarily improve their health. an example of this tension is the emergence of two contrasting service delivery models to meet the needs of chronically homeless adults with concurrent mental illness and substance abuse (tsemberis, et al., ; hopper and barrow, first model, known as the "continuum of care," attempts to move homeless people from the street into transitional congregate housing, in conjunction with a requirement that the individual engage in treatment for their mental illness and addictions. under this model, the person is allowed to make the transition to permanent housing only after they achieve abstinence from alcohol and drugs and their clinical status has been stabilized. in contrast, the "housing first" model is based on the belief that homeless people should be afforded permanent housing as a basic human right, not as a reward contingent on participating in treatment. in this model, homeless people can obtain housing in individual apartments without any preconditions, and they are then offered an array of harm reduction and treatment services through an act team (see section . . above). a recent randomized controlled trial assigned homeless adults with concurrent severe mental illness and substance abuse to one of these two approaches. individuals treated under the "housing first" model spent significantly less time homeless over the follow-up period, and at the end of months about % were in stable housing as compared to only % in the "continuum of care" model. however, there were no significant differences between the two groups in terms of alcohol use, drug use, or psychiatric symptoms. this study highlights the need to acknowledge that ending homelessness is a worthwhile goal in and of itself, but that it is not synonymous with improving the health of homeless people. other strategies include adapting the health care system to better meet the unique needs of homeless adolescents, single men and women, or families. as discussed in section . above, a cornerstone of this effort is the use of multidisciplinary teams providing coordinated care at outreach sites, in combination with more traditional clinic-based health care services. for homeless people with severe mental illness, the availability of act services is vital, but the effectiveness of less resource-intensive systems of mental health care for homeless people needs to be assessed. for those with addictions, the availability of detoxification beds, postdetoxification stabilization programs, and longer-term ( to month) residential addiction treatment programs are important issues. in designing these services, the heterogeneous needs of different subgroups of homeless people (e.g., street youth, single men, single women, and mothers with young children) must be taken into account. while improving conditions at shelters is by no means the preferred route to better health for homeless people, it is important that shelters not contribute to ill health. certainly, the availability of adequate capacity to accommodate everyone who seeks a shelter bed is a reasonable first step towards protecting homeless adults from the elements. adherence to basic standards of cleanliness, nutrition, and food hygiene within shelters and the avoidance of overcrowding and inadequate ventilation are mandatory. perhaps equally important is the creation of a safe and welcoming environment that encourages clients to engage with service providers. at a broader level, interventions are needed to decrease the prevalence of homelessness and address the systemic issues that contribute to homelessness. these efforts may at least in some cases have health benefits as well. for homeless families, there is compelling evidence that the provision of subsidized housing is both necessary and sufficient to end their homelessness (shinn, et al., ) . the "housing first" strategy appears to be more effective in moving homeless people with concurrent mental illness and substance abuse into stable housing; further research is needed to examine the effectiveness of this approach with other subgroups of homeless people. serious attention needs to be paid to the impact of the social welfare system on homelessness and health. restrictions in eligibility for temporary aid for needy families and state-run welfare programs threaten to contribute to a potential rise in homelessness among families and single adults in coming years. further research is needed in this area and on the impact of receipt of welfare or disability benefits on the health of homeless people. finally, upstream from the distinctive and visible issue of homelessness is the larger problem of urban poverty. the existence of entire communities and groups who are cut off from a decent education, employment opportunities, housing, and access to health care should raise extremely troubling questions for anyone who cares about the health of our urban centers. while the adverse health effects of homelessness are clearly severe, this phenomenon is only a specific and extreme example of the larger problem of the effects of poverty and inadequate housing on population health. prevention and control of tuberculosis among homeless persons. recommendations of the advisory council for the elimination of tuberculosis prevention and control of tuberculosis among homeless persons. recommendations of the advisory council for the elimination of tuberculosis hiv infection among homeless adults and runaway youth foci of tuberculosis transmission in central los angeles mortality among homeless shelter residents in new york city determinants of behavior in 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crackdown do the homeless get a fair deal from general practitioners? outcomes of contact investigation among homeless persons with infectious tuberculosis homeless people's trust and interactions with police and paramedics key: cord- -ko pmtig authors: amagasa, shiho; kojin, hiroyuki; inoue, shigeru title: mobility trends reports revealed “self-isolation fatigue” in japan: use of mobility data for coronavirus disease control date: - - journal: jma j doi: . /jmaj. - sha: doc_id: cord_uid: ko pmtig nan - . according to an analysis using community mobility reports from google ( ) , there was a sudden increase in park visits, particularly in tokyo, on the day weekend starting on march th when the blossoms were at their peak. the number of people has increased by % compared with the baseline ( ) . given the incubation period for covid- , it is almost definitely the case that the spread of infection was prompted by people going out on the day weekend. the number of people driving is worth noting. besides the sudden increase in travel by car on the day weekend in march, many people continued to drive afterward. although some decrease was evident, that decrease was small compared with the decreases in people moving through mass transit and walking. automobiles are convenient and afford a high level of freedom and, unlike mass transit, allow people to move about while avoiding close contact with an unspecified large number of people. in general, it is therefore understandable why travel via cars tends not to decrease even during infectious disease epidemics. given these mobility data, we may anticipate the appearance of coronavirus fatigue and large number of people going out with family or friends via cars during golden week (gw; a week-long period with several national holidays covering parts of the last week of april and the first week of may). the worst-case scenario, in which people from urban areas where infections are prevalent travel outside the city and spread the disease to people in provincial areas, is possible to occur. as of april , in japan, driving had decreased by %, mass transit by %, and walking by % ( ) . however, these decreases are smaller than those in the leading industrialized nations where infections are spreading and mobility remains high ( ) . this is probably because although a state of emergency has been declared in japan, it is not backed by a strong legal force. on april , the government expanded the state of emergency to the entire nation ( ) , one of the aims of which was to minimize the movement of people during gw, but more specific recommendations are needed. even though a state of emergency has been declared, unless more in-depth measures are taken, it is possible to see an increase in the movement of people during gw from coronavirus fatigue and selfisolation fatigue. measures to limit driving as well as the use of mass transit may be needed. ( ) and the novel coronavirus infectious cases report ( ) , respectively. doi: . /jmaj. - jma journal: volume , issue https://www.jmaj.jp/ world health organization. coronavirus disease (covid- ) situation reports the ministry of health, labor and welfare. about coronavirus disease (covid- ) coronavirus disease (covid- ) situation covid community mobility reports sa prepared the first draft. hk and si revised the manuscript. all authors have read and approved the final version of the manuscript. key: cord- -maclu gh authors: gunther, christoph; gunther, michael; gunther, daniel title: tracing contacts to control the covid- pandemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: maclu gh the control of the covid- pandemic requires a considerable reduction of contacts mostly achieved by imposing movement control up to the level of enforced quarantine. this has lead to a collapse of substantial parts of the economy. carriers of the disease are infectious roughly days after exposure to the virus. first symptoms occur later or not at all. as a consequence tracing the contacts of people identified as carriers is essential for controlling the pandemic. this tracing must work everywhere, in particular indoors, where people are closest to each other. furthermore, it should respect people's privacy. the present paper presents a method to enable a thorough traceability with very little risk on privacy. in our opinion, the latter capabilities are necessary to control the pandemic during a future relaunch of our economy. t he covid- pandemic has spread all over the world. it has already lead to a very large number of fatalities, more than ' as of end of march . the first priority of humanity is to take all possible actions to prevent more people from dying. in some places, this lead to enforcing a quarantine on large portions of the population. the economic damage is substantial. the us alone is investing usd ' billions to alleviate the consequences of the pandemic. thus, limiting the economical damage by restarting the economy as soon as possible, while at the same time protecting people, is of immense importance. the present document aims at contributing specific suggestions on how to achieve this. three important properties of the covid- pandemic are that • the sickness is limited to roughly three weeks in time. after this period, people are either healthy again, hopefully without impairments, or dead. all evidence expressed publicly, so far, indicates that former carriers of the disease are not contagious anymore after that time. a strictly observed quarantine of three weeks has thus the potential to basically eliminate all carriers of the disease. a quarantine is never perfect, e.g. due to the need to restock food supplies. as a consequence some chains of infection will persist. • the spreading of the disease in the population is characterized by an exponential growth. the characteristic christoph günther is with the german aerospace center, weßling, and with technische universität münchen, munich, germany, e-mail: kn-covid@dlr.de. michael and daniel günther are students at technische universität münchen, munich, germany, e-mail: m.guenther@tum.de, d.guenther@tum.de. parameter r , which describes the number of people infected by a single carrier, is estimated to be around - . . any value above leads to a exponential growth, as long as there is no substantial immunity. more detailed epidemiological models are more differentiated but show a similar threshold behavior [ ] . the value of r , mentioned above is determined by the period during which a carrier is contagious, the probability of transmitting the disease, and the number of contacts that the carrier had during that time. there is no means to control the first factor. the second may be somewhat influenced by carrying masks but not to a level considered sufficient. thus, the most important option for controlling r is to reduce the contacts between carriers and other citizens. • the diagnoses of sick people is a critical element. some people do not show symptoms that they associate with the sickness but are nevertheless infectious. they may be a cause for requiring a longer quarantine than described above. in addition and most importantly, no one shows symptoms before being infectious, which means that as long as there are no tests that everyone can apply at regular intervals, there will always be a delay before the spreading by a particular individual can be discontinued. furthermore, extensive testing as practiced and further expanded in germany will be most effective if the most likely carriers are being tested. currently, there is a variety of attempts to contain the pandemic, which should all be followed in parallel. the development of vaccines and of medications are essential but may not be available in the near future. this has led to an enforced reduction of contacts by various levels of quarantine. the concept of achieving immunity by letting the epidemic spread have rightfully been abandoned, due to the heavy toll in human lives. bill gates formulates what most of us think "but bringing the economy back ... that's more of a reversible thing than bringing people back to life. so we're going to take the pain in the economic dimension -huge pain -in order to minimize the pain in the diseases-and-death dimension." the "how" of restarting the economy remains. some authors studied the effect of relaxing the quarantine at the cost of a regrowth of infected people before shutting down again [ ] . this leads to an increasing level of immunity in a series of waves. in view of the small percentage of people that are immunized at each step and in view of the risk of an unmanageable growth, the number of waves needs to be substantial. furthermore, each wave costs lives. china, south korea and to a much smaller scale webasto in germany have shown an alternative, which consists in a careful tracing of contacts, associated with testing, and quarantining positively tested people. we will call these people "carriers" throughout the paper. tracing contacts is a rather natural concept for containing the pandemic. it aims at identifying and subsequently isolating people, who might potentially be carriers. since the incubation time until an infected person becomes infectious herself is around days and since first symptoms only occur after days at the earliest, with a diagnosis available at en even later time, there is a lag during which infectious carriers continue spreading the disease. thus, knowing contacts to people who have been identified as carriers, allows isolating unidentified potential carriers. the frequent absence of clear symptoms is a second critical cause for the spreading of the infection. in this case contact tracing allows identifying carriers without symptoms through their contact to people with symptoms. in that case, the carrier with symptoms is not the originator but rather helps discovering the originator. independent on who is the originator, contact tracing and subsequent isolation eliminates sources of disease spreading. an immediate testing and determination of contacts allows to identify further contact whenever the outcome of the test was positive. in the case of a negative outcome, testing is repeated after an incubation time, with isolation being lifted in the case of a second negative outcome. at my institute ( people), we traced a number of contacts and noticed that the complexity of a manual process becomes quickly unmanageable. due to the exponential character of the network of relations, there are simply too many contacts to be traced. we ended up isolating everyone first at the institute level, shortly after that and independently of us at dlr level and finally at national level. this observed complexity led us to the conclusion that automatic means of tracing are essential. raskar et al. [ ] have analyzed an approach based on locating people with a particular focus on privacy-protection and self-protection against the disease. we follow a somewhat different approach. it is primarily based on contacts, rather than on locations, although locations may be used in addition. furthermore, it is focusing on the control of the pandemic as a whole. the protection of the individual turns out to reach a similar level as in the approach by raskar et al. [ ] . the present exposition is developed against the background of german regulations. the public authorities responsible for health is the "gesundheitsamt." the gesundheitsämter (many of them, distributed all over the country) register every person affected by the pandemic and organize the testing of people. thus the identity of any person which either has symptoms, is tested positively or is affected by the disease is currently known to the local gesundheitsamt. we shall subsequently just speak of the gesundheitsamt as if it was a single entity. that gesundheitsamt is a trusted authority independent of any use of electronic means to trace contacts. it shall thus also be the trusted authority in our approach, which will be responsible to operate the server needed to manage the list of carriers. they do furthermore manage people in quarantine, who have to follow strict rules in germany. not doing so may lead to fines and imprisonment [ ] . additionally, germany has imposed limitations on the movement of people, which should not be confused with the stricter quarantine. in our view, it should be acceptable that regaining new degrees of freedom may be associated with certain restrictions, which ensure the traceability of contacts, without unduly exposing privacy. recent polls in germany show a high level of acceptance of restrictions to combat the pandemic. it may well be acceptable to enforce the use of tracing, although this is not the focus of the paper. the precondition for traceability is to use of a smartphone running a covid- tracing app (the app) or alternatively the use of a low cost device. for simplicity, the focus of the exposition will be on an app running on a smartphone. every person leaving their home shall be requested to carry such a device, with the app installed and active. this might be an expectation, which people are free to follow or not. whatever solution is preferred is a political decision. the main elements of its implementation are • the automated creation of a list of contact instances my_ctc, maintained in the personal device of the user. the number of such entries could be up to a few thousand entries per day as soon as big events take place again. • the maintenance of a list of infectious carrier of the disease ga_icd on the server of the gesundheitsamt, currently around ' entries in total with a growth rate of less than per day. • the search for entries from the personal list my_ctc in the list ga_icd retrieved from the gesundheitsamt. • in the case of a hit, the app informs the server of the gesundheitsamt about the identifier found. • the server and the app cooperate in classifying the category of the contact (category or , see below). the associated contact persons might be involved in this classification process. • based on the result, the gesundheitsamt decides about the quarantining and testing of the device's owner. the best possible cooperation of the contacts and the gesundheitsamt in assessing the category of the contact reduces both the test load and the necessity of a quarantine. in an initial phase, this may include the indication of the seat used on a joint train ride, the confirmation of a joint lunch or the like. clearly, further technical developments in sensing of both the mutual placement and orientation of people will be of great help in automating this process but are not needed in an initial phase. such developments could follow similar lines as the work for indoor position, which achieves high levels of accuracy [ ] . the above description identified a number of actors. before entering into this discussion, it is useful to differentiate three categories of contacts [ ] : • category contacts are those to which a face-to-face contact accumulated to more than minutes. • category contacts are those to which a face-to-face contact accumulated to less than minutes. • uncritical contacts are all others. the consequences of being a category or contact are defined by the gesundheitsamt and may be changed over time. both categories are quarantined. currently, the main difference is in the level of testing. the category defines the sampling time of our contact monitoring. with this preparation,we have the following actors: • the gesundheitsamt (trusted authority): it tests people for covid- infection, it publishes an anonymized list of carriers and it facilitates the categorization of contacts. • roaming users: their devices monitor contacts at regular intervals ( second) and store the list of contacts my_ctc as well a a list with location and orientation information my_loc, their devices check whether there was a contact to an infected person (at least once per day), and provide support to the categorization of the contacts, potentially using location and orientation information. note that all information is kept locally with the exception of information exchanged in the categorization of a contact. • users tested positively: their devices provide their lists my_ctc as far back as their owner's infection may have been contagious to the gesundheitsamt, they go into treatment or at least quarantine, and cooperate in determining the category of contacts that they had. the device uses the list my_loc to support the classification of contacts to other people. although the position information is kept locally, it is partially disclosed to the gesundheitsamt in the assessment of contacts' categories. • users with a critical contact (category or ): they also go into quarantine and are subject to an immediate test. in the case of a positive outcome, they change category. otherwise, they are tested again after an incubation time. in a second negative testing, they are freed from quarantine obligations. there is a number of options to detect the proximity of people. we propose to use bluetooth transceivers to send beacons and monitor for such beacons at regular intervals. the benefit of using bluetooth is that corresponding interfaces are included in nearly every smartphone and that they are furthermore available on cheap platforms. in addition, bluetooth creates a direct relationship between the potential contact persons, which works everywhere, including shopping malls or the underground metro station. although not too reliable, the power level can be used as an indication of the distance between the transmitter and the receiver, and could thus be used as a filter. the details of this aspect need further assessment. furthermore, the use of bluetooth is associated with a low power consumption. the proposal made in section v uses functions available in the application programming interfaces (api) of android and apple ios. more refined solutions may be implemented by google and apple, themselves providing improved power management, relative contact positioning, safety against manipulation and the like. tracing may either be performed on a voluntary basis or enforced. the knowledge of being a carrier (positive testing) does not provide benefits to people without or with marginal symptoms. it rather puts them into quarantine and thus reduces their freedom of movement. quarantining carriers has a huge benefit for society, however. thus, the incentives to individuals are purely ethical, which seems to be sufficient at the time. thus, we focus on the voluntary approach but provide some hints for enforcement as well. • in a preparatory phase, the user installs the tracing app. in the case of enforcement, the app creates a connection of data from an official id-card and the device and then registers the user with that data. this creates a permission to roam and is communicated to the mobile operator. it can furthermore be used to prevent a number of manipulations to evade quarantining, for example. in the case of a voluntary roll out, this registration does not exist, and even in the mandatory case, it is only used to prevent manipulations and does in particular not create any additional means of tracking. • every day, the app chooses a random daily identifier my_rdi, which it broadcasts at regular intervals using a bluetooth protocol (see section v). the identifier provided by the device is c f d |my_dri. the randomness of the my_rdi prevents any correspondence with a particular device or user. it is changed daily to prevent tracking by any fixed monitoring stations. • in parallel, the device searches for the beacons of other devices. this monitoring is performed every seconds. whenever the device detects an identifier of the form c f d |fg_dri for the first time, it adds fg_dri to its list my_ctc and stores the current time (in second units). if it sees the identifier again, it updates the duration of the contact. in total, there are two-minutes intervals in hours. assuming that someone is surrounded by up to people during hours would lead us to entries. there is no difficulty in storing that number, but this exposes the importance of applying simple filtering to control the complexity of later processing steps. • whenever the gesundheitsamt updates its list ga_ctc, which is signed using its private key, the device checks for matches between ga_ctc and my_ctc. the increase in carriers is around per day in germany. the list shall include these entries as well as those of the day before, which is perfectly manageable. the random device identifier and the date must both match, since the identifier is changed every day. note that a very high level of anonymity is preserved up to this point. • if there are matches in the device's list my_ctc and in the list of the gesundheitsamt ga_ctc, there are two different options: -the devices notifies its owner and asks him about his preferences. if the preference is to enter quarantine without further checking, no further action is needed and no information is ever exchanged. -in all other cases, the gesundheitsamt and the device aim at categorizing the contact. this requires a negotiation, which can be handled by a mailbox to prevent the disclosure of the person's identity. in advanced negotiations, the information from my_loc will typically be used in the process of categorization. • once the category of a contact is determined, the gesundheitsamt either asks the person to quarantines herself and organizes testing, or just drops the alert if the contact was uncritical. in the latter case, no further data is exchanged and the data associated with the inquiry is erased. • in the case of a critical contact, the gesundheitsamt invites the person for testing. all exchanges can again be handled through a mailbox. this does again not require the disclosure of the identity of the person. if the testing is twice negative, the person leaves the quarantine and the data is erased. • in the case of a positive testing, the app provides the contact history my_ctc from the beginning of the estimated infection period to the gesundheitsamt. the disclosure of the identity of the person is not needed for pandemic control. the app maintains the list of locations from the estimated infection onward in order to respond to further inquiries from the gesundheitsamt. • the device continues comparing its list my_ctc with later provisions of ga_ctc. this is necessary, due to the significant delay before some carriers are found and since it is the last contact, which is determining the end of the quarantine period. • whenever the gesundheitsamt receives a list of my_ctc including the timing and the duration, it will add the random identifiers to its list ga_ctc. depending on the evolution of the pandemic and future experience, it may decide to only trace contacts to category or to both categories. it will add these contacts to its list and publish a signed copy of ga_ctc at regular intervals. as a consequence, listed identifiers will trigger an inquiry of the associated devices with the gesundheitsamt to ask for categorization. once every user device has performed its matching, there will be no unidentified hits in the past. thus, the gesundheitsamt can erase all non-public information associated with the published list. since some devices may not have contact to the gesundheitsamt for a few hours, there should be a margin in erasing this data, e.g. one extra day. from an epidemiological perspective, users that are quarantined would ideally be tracked. the procedure is straight forward: whoever leaves the location of the quarantine is warned. in the case of a continued breach of rules, the gesundheitsamt is informed and takes action. from this time onward, the person could be continuously tracked to support her repatriation into her quarantine zone. this is certainly controversial and not too compatible with a voluntary tracing. it may be activated if enforcement of tracing turns out to be necessary. currently, this seems not to be the case. the tracing described above is meant to control the pandemic and to enable a restart of the economy, while keeping citizens as protected as possible. in the case of a voluntary use of the system, the main threats are attacks on the privacy of users. they are not only serious but may additionally jeopardize the acceptance of tracing as a method to control the pandemic. in the case of enforced tracing, there are additionally options for evading tracing or tracking. this is mentioned but not discussed in any depth. the primary line of attack to access the personal profile of a particular person is through the app. thus, the app needs a thoughtful design and implementation. this is, however, a requirement, which it shares with any other software using personal data and localization. a similar statement holds for the software run on the server of the gesundheitsamt. it should avoid any deficiencies but is still exposed to exploits of the operating systems and the like. we also assume that the public key cryptosystem is secure in the relevant time. the data base of the gesundheitsamt is only of limited interest, since it contains very little information and since the data is not personalized. the bigger threat is the impersonation of the gesundheitsamt, it may lead to a number of options, which mostly don't have a clear benefit, like • the removal or addition of contacts. • the false categorization of contacts. • the undue convocation of people to testing. • the quarantining of healthy people. the most influential possibility is to add a carrier to ga_ctc and to thus retrieve the list of his contacts. this, however, requires finding a valid random daily identifier, e.g. by creating an explicit contact to a person as well as a major software bug at the gesundheitsamt e.g. by exposing its private key. other sophisticated attacks are conceivable, e.g. using a network of cooperating bluetooth units to profile users by tracking their passage near those units. this is not particular to the present system, however. otherwise, we did not find an obvious other critical attack so far. in the end the usefulness of tracing carriers of covid- and of restoring normality to our daily life have to be balanced against fears of potential attacks. the consequence of having been in contact with an infected fellow citizen is to become quarantined. some people may want to avoid that, even in the case of enforcement. most options such as roaming without an active device, breaking quarantine rules, using different devices, uninstalling and reinstalling the app or cheating during the categorization can all be handled by appropriate measures. they will have to be addressed if enforcement is really desired. this is currently not the case. an implementation of the above system could easily be performed by the companies google for android devices and apple for ios devices. a more detailed design will need a further specifications of the protocols, which should be done jointly to achieve the fastest possible availability of a fully inter-operable system. we studied different mechanisms provided by bluetooth in application programming interfaces (api). ibeacons, which is a protocol used for indoor location services, became our initial candidate. this protocol allows devices to broadcast identifiers, which are received by other devices in the neighborhood. the received signal strength can be used as an indicator of the transmitter to receiver distance. the concentration of transmission and monitoring around seconds intervals of the time of the day can be used to implement a simple form of power management. the focus of our testing was on verifying the possibility of using a mechanism provided by an api. thus, we implemented an app on ios to transmit ibeacons and used the nrf connect for mobile app to monitor these beacons. this worked whenever the app was in the foreground of the ios device. the transmission was, however, discontinued, whenever the app was sent into the background. as a consequence, we implemented an alternative approach using the standard bluetooth low energy (ble) protocol. a corresponding app was written for ios and and another one for android. both apps implement the beacon transmission and beacon monitoring. the source code can be downloaded from https://github.com/danielgnt. the subdirectories bletrack-android and bletrack-ios contain the associated code. these apps could successfully monitor beacons between android phones as well as between ios and android phones. all associated trials worked with the apps in the background on both phones. however, we could not get the ios to ios scenario working with both apps in the background. it only works when one of the apps is in the foreground, which is not sufficient. if this could be solved, a large community of programmers could implement the tracing system described above. the present paper exposes an automated, privacy preserving, tracing method based on bluetooth radio contacts, which consequently works indoors, where people come closest to each other. the approach uses random daily identifiers to trace contacts. the randomness and daily updates prevent most attacks on privacy. the information needed to trace contacts is maintained locally in the personal device. the health agency "gesundheitsamt" is a trusted authority, which only stores contact profiles of positively tested people. this data does not have to include any means of identification of physical person. the next step in bringing this approach to reality would be to setup a task force force designing the details of the protocol, as well as implementing and testing the mobile and server components. the aim should be for a quick and stable initial operational systems. the outcome should be further optimized in a second phase to improve contact classification in order to reduce unnecessary testing and quarantining. modellierung von beispielszenarien der sars-cov- -ausbreitung und schwere in deutschland impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand apps gone rogue: maintaining personal privacy in an epidemic covid- und häusliche quarantäne: flyer für gesundheitsämter indoor localization accuracy of major smartphone location apps kontaktpersonennachverfolgung bei respiratorischen erkrankungen durch das coronavirus sars-cov- 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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recognised covid- as a pandemic. a pandemic refers to a disease that has spread to several countries, continents, if not worldwide. while the information available on this newly identified virus is limited and evolving, here is a quick run-down of what has been figured out so far. the new coronavirus pandemic, which is recently named as covid- by who is the third documented spillover of an animal coronavirus to humans that has resulted in a major epidemic. the coronaviridae study group (csg) of the international committee on taxonomy of viruses (ictv), which is responsible for the classification and nomenclature of the family coronaviridae, has assessed this virus as bat severe acute respiratory syndrome corona viruses (sars-covs) and designated it as sars-cov- [ - ]. the covid- pandemic that started in the wuhan city of china in early december of has spread globally. this deadly respiratory disease caused by a novel coronavirus, sars-cov- is continuously claiming thousands of lives worldwide. who had earlier estimated the mortality rate due to covid- around % and in march , revised it to . %. , and causing worldwide panic. health officials are trying to contain the virus with travel restrictions and lockdowns. coronaviruses are a group of a large family of viruses that cause diseases in mammals and birds. this mysterious virus has its name coronavirus because of its crown-shaped appearance (latin word 'corona' means crown). also, it resembles the sun's corona during a total solar eclipse. coronaviruses are zoonotic, meaning they are transmitted from animals to humans. in humans, coronaviruses cause respiratory tract infections that are typically mild, such as some cases of the common cold (among other possible causes, predominantly rhinoviruses), though rarer forms such as middle east respiratory syndrome (mers), severe acute respiratory syndrome (sars), and covid- can be lethal [ ] . coronaviruses are large pleomorphic spherical particles with bulbous surface projections. the average diameter of the virus particles is around nm. the diameter of the envelope is ∼ nm, and the spikes are ∼ nm long. the viral envelope consists of a lipid bilayer where the membrane (m), envelope (e), and spike (s) structural proteins are anchored. inside the envelope, there are multiple nucleocapsid (n) proteins, which are bound to the positive-sense single-stranded rna genome in a continuous beads-on-a-string type conformation. the lipid bilayer envelope, membrane proteins, and nucleocapsid protect the virus when it is outside the host cell. most coronaviruses that spread infections in the upper respiratory tract are not dangerous, but some that spread infections in the lower respiratory tract (windpipe and lungs) can be highly lethal, such as mers and sars. these viruses can cause severe pneumonia, especially in older people, people with heart disease, or people with weak immune systems. facts about coronavirus, symptoms of infection, and how the virus spreads the infection are illustrated in figure . incubation period for the disease is usually from to days. due to this virus, death from progressive respiratory failure occurs in about % to % of cases. in may , the sequence of the complete genome of sars-cov was determined. the genome of sars-cov is , nucleotides in length, has open reading frames, and its genome organization is similar to that of other coronaviruses. phylogenetic analyses and sequence comparisons showed that sars-cov is not closely related to any of the previously characterized coronaviruses. sars-covs- is the most recently discovered coronavirus that causes coronavirus disease covid- . chinese scientists identified this new type of coronavirus, which was isolated on january [ ] . there is no vaccine for this new coronavirus and it is mutating [ ] [ ] [ ] . laboratory tests were conducted on all suspected cases identified through active case finding and retrospective reviews. based on these investigations', other respiratory pathogens such as influenza, avian influenza, adenovirus, severe acute the virus is typically spread during close contact via respiratory droplets produced when people cough or sneeze. people may also catch covid- by touching a contaminated surface and then touching their face. it is most contagious when people are symptomatic, although spread may be possible before symptoms appear. respiratory syndrome corona virus (sars-cov), and middle east respiratory syndrome corona virus (mers-cov) were ruled out as the cause. each sars-cov- virion is approximately - nanometres in diameter and has a cobbled surface structure (human hair diameter is about , - , nanometres). like other coronaviruses, sars-cov- has four structural proteins, known as the s (spike), e (envelope), m (membrane), and n (nucleocapsid) proteins; the n protein holds the rna genome, and the s, e, and m proteins together create the viral envelope. the spike protein, which has been imaged at the atomic level using cryogenic electron microscopy, is the protein responsible for allowing the virus to attach to the membrane of a host cell. the electron micrograph of sars-cov- virion shows visible coronae (figure ). illus- tration of sarsr-cov virion is given in figure . modelling of the spike protein of the virus suggested that sars-cov- has sufficient affinity to the angiotensin-converting enzyme (ace ) receptors of human cells to use them as a mechanism of cell entry. studies have shown that sars-cov- has a higher affinity researchers covid- is a new disease, and there is limited information regarding the risk factors for this severe disease. based on currently available information and clinical expertise, older adults of over years and people of any age who have serious underlying medical conditions (comorbidities) might be at higher risk of developing the severe disease with sars-cov- , which may even lead to death. the high-risk severe illness conditions include chronic lung diseases, severe asthma, serious heart conditions, severe obesity, diabetes, renal failure or liver disease, and immunocompromised conditions like cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled hiv or aids. viruses are mainly classified by phenotypic characteristics, such as morphology, nucleic acid type, mode of replication, host organisms, and the type of disease they cause. the formal taxonomic classification of viruses is carried out with specific guidelines by the international committee on taxonomy of viruses (ictv) system. the classification of rna viruses requires the consideration of their inherent genetic variability, which often results in two or more viruses with non-identical but similar genome sequences being regarded as variants of the same virus. this immediately poses the question of how much difference to an existing group is large enough to recognize the candidate virus as a member of a new, distinct group. this question is answered in best practice by evaluating the degree of relatedness of the candidate virus to previously identified viruses infecting the same host or established monophyletic groups of viruses, often known as genotypes or clades, which may or may not include viruses of different hosts. this is formally addressed in the framework of the official classification of virus taxonomy and is overseen and coordinated by novel coronavirus (sars-cov- ) is a positive-sense, singlestranded rna coronavirus. its genome was sequenced from a patient with pneumonia during the - wuhan pneumonia outbreak. taxonomy and most apt classification scheme for sars-cov- is given in table [ , ] . sars-cov- affects different people in different ways. in this respiratory disease, most infected people develop mild to moderate symptoms and may recover without requiring special treatment. often the patient won't even know whether he has a sars-covs- or other cold-causing virus infection, such as rhinovirus. in some cases, the patient may develop high fever and acute viral pneumonia (severe acute respiratory syndrome), putting the life at risk. the common clinical sars-cov- pathogen is a new virus. at the moment, there is no vaccine or perfect treatment for covid - available. the patients with sars-cov- are treated symptomatically with available drugs and licensed antiviral drugs. signs and symptoms reported for covid- include, fever, dry cough, tiredness, and shortness of breath, which quickly exacerbates to respiratory distress in few cases (older people or people with comorbidities) [ , ]. complications may include pneumonia and acute respiratory distress syndrome. some other symptoms include loss of appetite, loss of smell, muscle aches, and pains, sore throat, and very few people may report diarrhoea, nausea or a runny nose. symptoms can range in severity from very mild to severe. in about % of patients, covid- causes only mild symptoms. chest radiographs showed invasive pneumonic infiltrating in both the lungs. the time between exposure and symptoms onset is typically around five days but may range from to days. people with mild symptoms who are otherwise healthy should self-isolate and contact their medical provider or a covid- information line for advice on testing and referral. people with fever, cough or difficulty in breathing should call their doctor and seek immediate medical attention (box ). the virus typically spreads during close contact and via respiratory droplets produced when people cough or sneeze. a respiratory droplet is a particle consisting mostly of water that is large enough to fall to the ground rapidly after being produced, often defined as having a diameter greater than μm [ ]. one may expel up to , droplets during coughing, and as many as , droplets while sneezing. someone symptomatic and infectious could have as many as million viruses in a single droplet [ ] . respiratory droplets may be produced during breathing but the virus is not considered airborne. people may also catch covid- by touching a contaminated surface and then their faces. it is most contagious when people are symptomatic, although spread may be possible before symptoms appear. the incubation period of the sars-cov- virus has not yet been box . covid- and novel coronavirus (sars-cov- ) symptoms • sars-cov- affects different people in different ways. most common symptoms are fever, dry cough, fatigue, and difficulty in breathing. some people may experience loss of appetite, loss of smell, muscle aches, and pains, sore throat, and very few people may report diarrhoea, nausea or a runny nose. people can also be asymptomatic as it may take a few days to develop the symptoms. • under extreme conditions, the patient will develop severe pneumonia and bronchitis. • the virus is transmitted from person to person through small droplets while coughing, sneezing or sometimes even by talking. these droplets land on objects and surfaces around the person, where the virus can be active for a few hours. the people can catch the virus by touching these objects or surfaces, then touching their eyes, nose or mouth. • the virus enters the respiratory systems through nose and mouth. the host cells then burst and the other nearby cells get infected with virus. • the virus cause swelling in the respiratory systems, which can make difficult to lungs to pass oxygen into the blood stream-leading to organ failure and death. • severe pneumonia can lead to swelling and flooding of the fluid into the lungs. further complications may cause death. • there is a nice quote "the virus doesn't move, people move it. we stop moving, the virus stops moving, it becomes inviable, it's that simple". • avoid close contact with people who have symptoms or are infected. • keep appropriate distance ( -feet) from the people. • wash your hands thoroughly (at least for seconds) with soap and water or use an alcohol-based hand sanitizer (sanitizer should contain above % alcohol). • keep your hands and fingers away from your eyes, nose and mouth. • clean and disinfect objects and surfaces. • if you have any symptom, seek immediate medical attention. properly ascertained, but as per who, its current estimate is anywhere from to days. some studies showed as long as days. this will be refined when more data become available. understanding the time when infected patients may transmit the virus to others is critical for control efforts. detailed epidemiological information from more people infected is needed to determine the infectious period of sars-cov- . in particular, it has to be ascertained whether transmission can occur from asymptomatic individuals or during the incubation period. a study of the people who succumbed to the virus revealed that they were already suffering from some underlying conditions. they were either frail, had heart diseases or cancer already, which basically means that their immune system was compromised, and their bodies could not fight the virus [ ] . however, the information coming in on the virus is rapidly changing; so we cannot be completely sure [ of antibodies (serology test) in the blood samples of the patients can be used both for diagnosis and population surveillance. the antibodies are usually detectable days after the onset of the infection. an accurate mortality rate of the disease and the level of herd immunity in the population can be determined from the results of this test. the high-throughput automated systems in central laboratories can test hundreds of samples within hours. computed tomography scan (ct scan) of the chest is also helpful to diagnose covid- in symptomatic individuals but is not recommended for routine screening [ , ] . typical features on ct initially include bilateral multilobar ground-glass opacities with a peripheral, asymmetric and posterior distribution. subpleural dominance, crazy paving, and consolidation may develop as the disease progresses. the sars-cov- virus is believed to be zoonotic; it is transmitted from animals to humans. the retrospective review suggests that the outbreak of deadly infectious respiratory illness likely initiated in the middle of december with exposures in one seafood market in wuhan city of hubei province in china. this wholesale market in wuhan sold seafood, poultry, snakes, bats, and farm animals. the sars-cov- is a new strain that has not been previously identified in humans. researchers suggest cross-species transmission of this newly identified coronavirus. these viruses often originate in bats but might have travelled through another species on its way to infecting humans. sars-cov- is a new strain that has not been previously identified in humans. researchers suggest cross-species transmission of this newly identified coronavirus. these viruses often originate in bats but might have travelled through another species on its way to infecting humans. the novel coronavirus appears to be a recombinant virus between the bat coronavirus and an origin unknown coronavirus. the studies suggest the homologous recombination within the viral spike glycoprotein, which recognizes a cell surface receptor. the receptor-binding protein might have allowed cross-species transmission to humans. according to the researchers, the resulting virus developed a mix or recombination of a viral protein that recognises and binds to receptors on host cells. such recognition is key for allowing viruses to enter host cells. by conducting a detailed genetic analysis of the virus and comparing it with available genetic information on different viruses from various geographic locations and host species, the investigators concluded that the sars-cov- is formed with a combination of a coronavirus found in rufous bats and another coronavirus of unknown origin. it is suspected that the pangolin or snakes might have served as an intermediate host between bats and humans [ , ] . but the disease ecologist and president of eco health alliance, peter daszak, says that more research is needed to pinpoint the precise path of this global outbreak [ ] . while the full spectrum of clinical manifestations associated with sars-cov- infections in humans remains to be determined, the independent zoonotic transmission of sars-cov and sars-cov- highlights the need for studying viruses at the species level to complement research focused on individual pathogenic viruses of immediate significance. this will improve our understanding of virus-host interactions in an ever-changing environment for future preparedness. the covid- rapidly spread outside china and is continuing to escalate throughout the globe. as of april , , more than . million people all over the world have tested positive for covid- countries including india have evaluated the pandemic situation and have taken the "extraordinary measures" of complete lockdown to contain the virus. airports and other transport systems are shut down, offices are closed, large gathering of peoples are prohibited, and the sanitary and disinfection efforts are strengthened. now, in china covid- appears to be under control as only a few new cases have been reported in the last few days. china has started relaxing the lockdown and other restrictions, but the rest of the world is now facing mayhem due to sars-cov- . viral diseases can be prevented using viral vaccines, which stimulate protective immunity against the virus without causing major disease. while vaccination doesn't necessarily prevent infection, the previous "priming" of the host's immune system allows for a quick response and clearance of the virus before the disease occurs (or mild disease of shorter duration). viral vaccines may also be used in active viral infections, boosting the ability of the immune system to control or destroy the virus. some vaccines are in continuous development because certain viruses, such as influenza and human immunodeficiency virus (hiv), have a high mutation rate. another way of treating viral infections is the use of antiviral drugs. these drugs often have limited success in curing viral diseases, but in many cases, they have been used to control and reduce symptoms for a wide variety of viral diseases. for most viruses, these drugs can inhibit the virus by blocking the actions of one or more of its proteins. it is important that the targeted proteins be encoded by viral genes and that these molecules are not present in a healthy host cell. in this way, viral growth is inhibited without damaging the host. there are large numbers of antiviral drugs available to treat infections, some specific for a particular virus and others that can affect multiple viruses. antiviral drugs can be categorized into the inhibitors of fusion, uncoating, nucleic acid synthesis, integration, protease, and release. the interaction between the virus and the host cell membrane or receptor(s) is the first phase of the viral life cycle called fusion/entry. fusion/entry inhibitors have been used for hiv treatment. the low ph of the endosome activates m proton channels following virus entry to acidify the viral interior and weaken the electrostatic interaction to allow viral uncoating. uncoating inhibitors have been used against influenza (infv). following uncoating, nucleic acid synthesis is the third step of the viral life cycle, which is mediated by viral enzymes, including rna polymerase, dna polymerase, and reverse transcriptase. so, these enzymes have been considered as alternative targets in many viral infections. inhibitors that specifically target integration have been used for viral treatment. viral proteases also signify an appropriate target for the development of novel antiviral agents. the release of new viruses from the host cell is the final step of the virus infection cycle. some drugs inhibit this phase by acting on the viral protein involved in this process. researchers have found that 'remdesivir', an experimental broadspectrum antiviral drug originally designed to target ebola, is highly effective at fighting the novel coronavirus in isolated cells. this treatment is not yet approved in humans, but two clinical trials for this drug have been implemented in china. one clinical trial was recently approved by the food and drug administration (fda) in the united states. china has approved the use of the antiviral drug 'favilavir' to treat symptoms of covid- . the drug was initially developed to treat inflammation in the nose and throat [ ] . a cocktail of the hiv drugs 'lopinavir' and 'ritonavir' were being tested against covid- in china. though some initial results have shown them beneficial, later it was reported as not much effective. the efficiency of hiv drugs, therefore, remains largely circumstantial and unproven [ ] [ ] [ ] [ ] . and chloroquine in high doses can prove toxic. so, at present, we are at crossroads of any effective treatment. further, once a drug is proved safe and effective, getting it to millions of patients around the world will require a massive manufacturing capacity. passive antibody or plasma therapy is being investigated as a non-vaccine method of passive immunisation. in this process, the purified and concentrated antibodies produced by the immune systems of covid- survivors are infused in the patients. antibody or plasma therapy is being investigated as a nonvaccine method of passive immunisation. in this process, the purified and concentrated antibodies produced by the immune systems of covid- survivors are infused in the patients. viral neutralisation is the anticipated mechanism of action by which passive antibody therapy can mediate defence against sars-cov- . other mechanisms such as antibody-dependent cellular cytotoxicity and/or phagocytosis may be possible. other forms of passive antibody therapy, for example, using manufactured monoclonal antibodies, are in development [ , ] . wuhan institute of virology has sequenced the newly emergent pathogen's rna and uploaded its entire , -nucleotide genetic code to the cloud in january [ , ] . thereafter, many others, including the national institute of virology, pune has isolated the strains of the sars-cov- and sequenced the genome there is a need for awareness; the protocols are already well established. if an individual experiences symptoms, (s)he should immediately consult the doctor. ignoring the symptoms can lead to complications. there is the concept of herd herd or group immunity is described as a situation where a sufficient proportion of the population develops an immunity to a given infection such that it slows or prevents disease spread, protecting "at-risk" individuals. or group immunity. it is described as a situation where a sufficient proportion of the population develops an immunity to a given infection such that it slows or prevents disease spread, protecting "at-risk" individuals. immunity can be generated through natural infection or vaccination. in vaccination, a controlled amount of the antigen(s) is administered. people who become infected naturally and recover may develop lasting immunity. there are, however, some points that need to be considered. in natural infection, the dose is unknown. this means someone may receive a very high level of exposure and may develop severe disease or complications, while others may receive very low dose and this may impair the effectiveness of a future immune response. hence, going for the natural herd immunity is perilous. to stay protected, we have to follow the principle of social distancing. differences in some health protocols and safety measures are explained in box . maintaining good hand hygiene is also important-wash your hands regularly, and do not touch your face or mouth. wear a mask if you have covid- symptoms or looking after the suspect. there is a world-wide shortage of masks, hence masks must be used wisely. a disposable face mask can only be used once. if you are not sick, a homemade to -layers washable cloth mask is sufficient for protection when you go out. the world health organization (who) has issued some guidelines to negate misconceptions among people regard- the mathematical modeling developed by the indian council of medical research (icmr), suggests that if one active covid- patient does not follow lockdown and social distancing, he can infect people in days. however, if his social exposure is reduced to %, then he can spread it to just . people. home quarantine of symptomatic individuals is the most effective method to contain the spread of covid- infection. studies show that home quarantine of suspected cases will reduce the overall expected number of cases by %, and the peak number of cases by % [ ]. this process is described as "flattening or bending the curve," which generally refers to the potential success of social distancing measures to prevent the sudden influx of new cases that could overwhelm healthcare systems. flattening the curve helps in maintaining the resources (figure ) . by attending to all the patients, the healthcare system can avoid severe illnesses and reduce the casualties. currently, india has witnessed cases of covid- mostly related to travel and local transmission from imported cases to their immediate contacts. community transmission of the disease has not been documented until now. once community transmission is documented, the above strategy will undergo changes. the prolonged lockdown has severe economic consequences. it has to be relieved in stages with precautions. when the test kits are easily available, an approach of extensive testing of the population and quickly isolating the people who are positive may be followed. this is called the red zone or selective isolation as followed in south korea. the first case of covid- in india was reported on january in kerala. as of april , the country has reported about , cases of covid- and deaths; around , patients have recovered [ ] [ ] . icmr has constituted a rapid response team and is posting various updates on covid- testing strategy, advisory, list of laboratories and faqs (frequently asked questions) on its website [ ] . a high-level technical committee of public health experts for covid- has been established by the government of india to guide the prevention and control activities in the country. the committee will address the ways to contain the spread of covid- in the dynamically changing scenario and will provide a reliable diagnosis strategy for covid- testing in india. dedicated helplines and websites are set up for information and tackling the covid- outbreak [ ]. as sars-cov- is a new virus, we do not know how it exactly affects the people. therefore, at the moment, no perfect treatment is available against this pathogen. the most effective tools are public health measures such as quarantines and social distancing which we must follow strictly. at present, covid- patients are treated symptomatically with available drugs and licensed antiviral drugs. the influenza drug 'favipiravir', inflammation antiviral drug 'favilavir', broad-spectrum antiviral drug 'remdesivir', and antimalarial drug 'hydroxychloroquine' have shown positive results. a cocktail of the hiv drugs 'lopinavir' and 'ritonavir' are also found effective in some trials. encouraging results have also been reported with passive antibody therapy. development of many vaccines against sars-cov- are at advanced stages, and human trials have already started on some of them. hopefully, in the coming few months, an effective treatment of covid- will be available. these all are the health protocols and safety measures to slow down the spread of pandemic. the slowdown of outbreak reduces the burden on the healthcare system. social distancing: social distancing is used to prevent sick people coming in close contact with healthy and high-risk population. social distancing can include : • reducing the social interactions by staying at home. • cancelling the group gatherings. • closing offices and working from home. having virtual meetings whenever possible. • shutting schools and studying at home through online classes etc. • ensuring -feet gap between people when going out for essential services or to buy groceries. • conversations in the group. opting for a namaste instead of a handshake and hugging. quarantine: quarantine is for people who are suspected for covid- and they need to be kept strictly away from other people. health advisories state that people who are suspected of coronavirus exposure should quarantine themselves for days to check if symptoms are starting to show. quarantine measures can be enforced by the government. quarantine can include the following: • staying strictly at home/quarantine centres. • staying alone and totally separate from others wherever possible. • strictly keeping away from public spaces and public transport. • using separate utensils. • monitoring daily for covid- symptoms. • washing hands regularly with soap and water. cleaning the likely contaminated surfaces. contd. box . contd. • getting all necessities delivered at home and not stepping out. isolation: isolation is usually advised for those who have been diagnosed positively for covid- . it is the most extreme degree of separation. the only contact for people in this case would be medical personnel. isolation includes: • living in a separate area in a medical care. • wearing a face mask. not contacting anyone physically. • getting all necessities delivered from others. • have all surroundings regularly cleaned. • cleaning hands with soap and water quite often. self-isolation is a measure that must be followed if you have returned from virus infected country/area or was in face-to-face contact with covid- suspect. lockdown: a lockdown is usually a government enforcement to slow down the constant flow of people and thus reduce the spread of virus. during a lockdown, you are allowed to perform essential activities like going for picking up groceries and medical supplies. a lockdown can include: • suspension of rail, air and bus public transport. • shutting down public offices, mass worshipping places, restaurants, cinema halls, shopping malls, gyms, swimming pools and markets etc. • restrictions on vehicular movement and monitoring the movement of people to track coronavirus spread. curfew: a curfew is usually referring to a directive from the government to keep people off the streets for a pre-decided period. in india, section of the criminal procedure code (crpc) of , deals with such emergencies. the executive magistrate of state or territory is given the authority to implement section , to control the situation. janta curfew is the self-imposed curfew by the people and hence, it has no penal actions. a curfew can include the following: • strict measures from the government to ensure that all the people remain indoors. • complete closure of markets, cinema halls and religious, social and cultural gatherings. • imposing fines and arrests when the rules are violated. analysis of the mutation dynamics of sars-cov- reveals the spread history and emergence of rbd mutant with lower ace binding affinity coronavirus disease (covid- ): a systematic review of imaging findings in patients covid- pneumonia: what has ct taught us? the lancet infectious diseases cross-species transmission of the newly identified coronavirus -ncov the convalescent sera option for containing covid- address for correspondence anand kumar sharma anukampa a pneumonia outbreak associated with a new coronavirus of probable bat origin key: cord- - x qs i authors: gupta, abhishek; lanteigne, camylle; heath, victoria; ganapini, marianna bergamaschi; galinkin, erick; cohen, allison; gasperis, tania de; akif, mo; institute, renjie butalid montreal ai ethics; microsoft,; university, mcgill; commons, creative; college, union; rapid ,; global, ai; university, ocad title: the state of ai ethics report (june ) date: - - journal: nan doi: nan sha: doc_id: cord_uid: x qs i these past few months have been especially challenging, and the deployment of technology in ways hitherto untested at an unrivalled pace has left the internet and technology watchers aghast. artificial intelligence has become the byword for technological progress and is being used in everything from helping us combat the covid- pandemic to nudging our attention in different directions as we all spend increasingly larger amounts of time online. it has never been more important that we keep a sharp eye out on the development of this field and how it is shaping our society and interactions with each other. with this inaugural edition of the state of ai ethics we hope to bring forward the most important developments that caught our attention at the montreal ai ethics institute this past quarter. our goal is to help you navigate this ever-evolving field swiftly and allow you and your organization to make informed decisions. this pulse-check for the state of discourse, research, and development is geared towards researchers and practitioners alike who are making decisions on behalf of their organizations in considering the societal impacts of ai-enabled solutions. we cover a wide set of areas in this report spanning agency and responsibility, security and risk, disinformation, jobs and labor, the future of ai ethics, and more. our staff has worked tirelessly over the past quarter surfacing signal from the noise so that you are equipped with the right tools and knowledge to confidently tread this complex yet consequential domain. these past few months have been especially challenging, and the deployment of technology in ways hitherto untested at an unrivaled pace has left the internet and technology watchers aghast. artificial intelligence has become the byword for technological progress and is being used in everything from helping us combat the covid- pandemic to nudging our attention in different directions as we all spend increasingly larger amounts of time online. it has never been more important that we keep a sharp eye out on the development of this field and how it is shaping our society and interactions with each other. with this inaugural edition of the state of ai ethics we hope to bring forward the most important developments that caught our attention at the montreal ai ethics institute this past quarter. our goal is to help you navigate this ever-evolving field swiftly and allow you and your organization to make informed decisions. this pulse-check for the state of discourse, research, and development is geared towards researchers and practitioners alike who are making decisions on behalf of their organizations in considering the societal impacts of ai-enabled solutions. we cover a wide set of areas in this report spanning agency and responsibility, security and risk, disinformation, jobs and labor, the future of ai ethics , and more. our staff has worked tirelessly over the past quarter surfacing signal from the noise so that you are equipped with the right tools and knowledge to confidently tread this complex yet consequential domain. to stay up-to-date with the work at maiei, including our public competence building, we encourage you to stay tuned on https://montrealethics.ai which has information on all of our research. we hope you find this useful and look forward to hearing from you! wishing you well, abhishek gupta the state of ai ethics, june the debate when ethicists ask for rights to be granted to robots is based on notions of biological chauvinism and that if robots display the same level of agency and autonomy, not doing so would not only be unethical but also cause a setback for the rights that were denied to disadvantaged groups. by branding robots as slaves and implying that they don't deserve rights has fatal flaws in that they both use a term, slave, that has connotations that have significantly harmed people in the past and also that dehumanization of robots is not possible because it assumes that they are not human to begin with. while it may be possible to build a sentient robot in the distant future, in such a case there would be no reason to not grant it rights but until then, real, present problems are being ignored for imaginary future ones. the relationship between machines and humans is tightly intertwined but it's not symmetrical and hence we must not confound the "being" part of human beings with the characteristics of present technological artifacts. technologists assume that since there is a dualism to a human being, in the sense of the mind and the body, then it maps neatly such that the software is the mind and the robot body maps to the physical body of a human, which leads them to believe that a sentient robot, in our image, can be constructed, it's just a very complex configuration that we haven't completely figured out yet. the more representative view of thinking about robots at present is to see them as objects that inhabit our physical and social spaces. objects in our environment take on meaning based on the purpose they serve to us, such as a park bench meaning one thing to a skateboarder and another to a casual park visitor. similarly, our social interactions are always situated within a larger ecosystem and that needs to be taken into consideration when thinking about the interactions between humans and objects. in other words, things are what they are, because of the way they configure our social practices and how technology extends the biological body.our conception of human beings, then, is that we are and have always been fully embedded and enmeshed with our the state of ai ethics, june designed surroundings, and that we are critically dependent on this embeddedness for sustaining ourselves. because of this deep embedding, instead of seeing the objects around us merely as machines or on the other end as 'intelligent others', we must realize that they are very much a part of ourselves because of the important role they play in defining both our physical and social existence. some argue that robots take on a greater meaning when they are in a social context like care robots and people might be attached to them, yet that is quite similar to the attachment one develops to other artifacts like a nice espresso machine or a treasured object handed down for generations. they have meaning to the person but that doesn't mean that the robot, as present technology, needs to be granted rights. while a comparison to slaves and other disenfranchised groups is made when robots are denied rights because they are seen as 'less' than others, one mustn't forget that it happens to be the case that it is so because they are perceived as instruments and means to achieve an end. by comparing these groups to robots, one dehumanizes actual human beings. it may be called anthropocentric to deny rights to robots but that's what needs to be done: to center on the welfare of humans rather than inanimate machines. an interesting analogue that drives home the point when thinking about this is the milgram prison experiment where subjects who thought they had inflicted harms on the actors, who were a part of the experiment, were traumatized even after being told that the screams they heard were from the actors. from an outside perspective, we may say that no harm was done because they were just actors but to the person who was the subject of the experiment, the experience was real and not an illusion and it had real consequences. in our discussion, the robot is an actor and if we treat it poorly, then that reflects more so on our interactions with other artifacts than on whether robots are "deserving" of rights or not. taking care of various artifacts can be thought of as something that is done to render respect to the human creators and the effort that they expended to create it. discussion of robot rights for an imaginary future that may or may not arrive takes away focus and perhaps resources from the harms being done to real humans today as part of the ai systems being built with bias and fairness issues in them. invasion of privacy, bias against the disadvantaged, among other issues are just some of the few already existing harms that are being leveled on humans as intelligent systems percolate into the everyday fabric of social and economic life. the state of ai ethics, june from a for-profit perspective, such systems are poised and deployed with the aims of boosting the bottom line without necessarily considering the harms that emerge as a consequence. in pro-social contexts, they are seen as a quick fix solution to inherently messy and complex problems. the most profound technologies are those that disappear into the background and in subtle ways shape and form our existence. we already see that with intelligent systems pervading many aspects of our lives. so we're not as much in threat from a system like sophia which is a rudimentary chatbot hidden behind a facade of flashy machinery but more so from roomba which impacts us more and could be used as a tool to surveil our homes. taking ethical concerns seriously means considering the impact of weaving in automated technology into daily life and how the marginalized are disproportionately harmed. in the current dominant paradigm of supervised machine learning, the systems aren't truly autonomous, there is a huge amount of human input that goes into enabling the functioning of the system, and thus we actually have human-machine systems rather than just pure machinic systems. the more impressive the system seems, the more likely that there was a ton of human labor that went into making it possible. sometimes, we even see systems that started off with a different purpose such as recaptcha that are used to prevent spam being refitted to train ml systems. the building of ai systems today doesn't just require highly skilled human labor but it must be supplemented with mundane jobs of labeling data that are poorly compensated and involve increasingly harder tasks as, for example, image recognition systems become more powerful, leading to the labeling of more and more complex images which require greater effort. this also frames the humans doing the low skilled work squarely in the category of being dehumanized because of them being used as a means to an end without adequate respect, compensation and dignity. an illustrative example where robots and welfare of humans comes into conflict was when a wheelchair user wasn't able to access the sidewalk because it was blocked by a robot and she mentioned that without building for considering the needs of humans, especially those with special needs, we'll have to make debilitating compromises in our shared physical and social spaces. ultimately, realizing the goals of the domain of ai ethics needs to reposition our focus on humans and their welfare, especially when conflicts arise between the "needs" of automated systems compared to those of humans. what happens when ai starts to take over the more creative domains of human endeavour? are we ready for a future where our last bastion, the creative pursuit, against the rise of machines is violently snatched away from us? in a fitting start to feeling bereft in the times of global turmoil, this article starts off with a story created by a machine learning model called gpt- that utilizes training data from more than million documents online and predicts iteratively the next word in a sentence given a prompt. the story is about "life in the time of coronavirus" that paints a desolate and isolating picture of a parent who is following his daily routine and feels different because of all the changes happening around them. while the short story takes weird turns and is not completely coherent, it does give an eerie feeling that blurs the line between what could be perceived as something written by a human compared to that by a machine. a news-styled article on the use of facial recognition systems for law enforcement sounds very believable if presented outside of the context of the article. the final story, a fictional narrative, presents a fractured, jumpy storyline of a girl with a box that has hallucinatory tones to its storytelling. the range of examples from this system is impressive but it also highlights how much further these systems have to go before they can credibly take over jobs. that said, there is potential to spread disinformation via snippets like the second example we mention and hence, something to keep in mind as you read things online. technology, in its widest possible sense, has been used as a tool to supplement the creative process of an artist, aiding them in exploring the adjacent possible in the creative phasespace. for decades we've had computer scientists and artists working together to create software that can generate pieces of art that are based on procedural rules, random perturbations of the audience's input and more. off late, we've had an explosion in the use of ai to do the same, with the whole ecosystem being accelerated as people collide with each other serendipitously on platforms like twitter creating new art at a very rapid pace. but, a lot of people have been debating whether these autonomous systems can be attributed artistic agency and if they can be called artists in their own right. the author here argues that it isn't the case because even with the push into using technology that is more the state of ai ethics, june automated than other tools we've used in the past, there is more to be said about the artistic process than the simple mechanics of creating the artwork. drawing on art history and other domains, there is an argument to be made as to what art really is -there are strong arguments in support of it playing a role in servicing social relationships between two entities. we, as humans, already do that with things like exchanging gifts, romance, conversation and other forms of social engagement where the goal is to alter the social relationships. thus, the creative process is more so a co-ownership oriented model where the two entities are jointly working together to create something that alters the social fabric between them. as much as we'd like to think some of the ai-enabled tools today have agency, that isn't necessarily the case when we pop open the hood and see that it is ultimately just software that for the most part still relies heavily on humans setting goals and guiding it to perform tasks. while human-level ai might be possible in the distant future, for now the ai-enabled tools can't be called artists and are merely tools that open up new frontiers for exploration. this was the case with the advent of the camera that de-emphasized the realistic paint form and spurred the movement towards modern art in a sense where the artists are more focused on abstract ideas that enable them to express themselves in novel ways. art doesn't even have to be a tangible object but it can be an experience that is created. ultimately, many technological innovations in the past have been branded as having the potential to destroy the existing art culture but they've only given birth to new ideas and imaginings that allow people to express themselves and open up that expression to a wider set of people. the state of ai ethics, june ranking and retrieval systems for presenting content to consumers are geared towards enhancing user satisfaction, as defined by the platform companies which usually entails some form of profit-maximization motive, but they end up reflecting and reinforcing societal biases, disproportionately harming the already marginalized. in fairness techniques applied today, the outcomes are focused on the distributions in the result set and the categorical structures and the process of associating values with the categories is usually de-centered. instead, the authors advocate for a framework that does away with rigid, discrete, and ascribed categories and looks at subjective ones derived from a large pool of diverse individuals. focusing on visual media, this work aims to bust open the problem of underrepresentation of various groups in this set that can render harm on to the groups by deepening social inequities and oppressive world views. given that a lot of the content that people interact with online is governed by automated algorithmic systems, they end up influencing significantly the cultural identities of people. while there are some efforts to apply the notion of diversity to ranking and retrieval systems, they usually look at it from an algorithmic perspective and strip it of the deep cultural and contextual social meanings, instead choosing to reference arbitrary heterogeneity. demographic parity and equalized odds are some examples of this approach that apply the notion of social choice to score the diversity of data. yet, increasing the diversity, say along gender lines, falls into the challenge of getting the question of representation right, especially trying to reduce gender and race into discrete categories that are one-dimensional, third-party and algorithmically ascribed. the authors instead propose sourcing this information from the individuals themselves such that they have the flexibility to determine if they feel sufficiently represented in the result set. this is contrasted with the degree of sensitive attributes that are present in the result sets which is what prior approaches have focused on. from an algorithmic perspective, the authors advocate for the use of a technique called determinantal point process (dpp) that assigns a higher probability score to sets that have higher spreads based on a predefined distance metric. how dpp works is that for items that the individual feels represents them well, the algorithm clusters those points closer together, for points that they feel don't represent them well, it moves those away from the ones that represent them well in the embedding space. optimizing for the triplet loss helps to achieve the goals of doing this separation. but, the proposed framework still leaves open the question of sourcing in a reliable manner these ratings from the individuals about what represents and doesn't represent them well and then encoding them in a manner that is amenable to being learned by an algorithmic system. while large-scale crowdsourcing platforms which are the norm in seeking such ratings in the machine learning world, given that their current structuring precludes raters' identities and perceptions from consideration, this framing becomes particularly challenging in terms of being able to specify the rater pool. nonetheless, the presented framework provides an interesting research direction such that we can obtain more representation and inclusion in the algorithmic systems that we build. in maryland, allstate, an auto insurer, filed with the regulators that the premium rates needed to be updated because they were charging prices that were severely outdated. they suggested that not all insurance premiums be updated at once but instead follow recommendations based on an advanced algorithmic system that would be able to provide deeper insights into the pricing that would be more appropriate for each customer based on the risk that they would file a claim. this was supposed to be based on a constellation of data points collected by the company from a variety of sources. because of the demand from the regulators for documentation supporting their claim, they submitted thousands of pages of documentation that showed how each customer would be affected, a rare window into the pricing model which would otherwise have been veiled under privacy and trade secret arguments. a defense that is used by many companies that utilize discriminatory pricing strategies using data sourced beyond what they should be using to make pricing decisions. according to the investigating journalists, the model boiled down to something quite simple: the more money you had and the higher your willingness to not budge from the company, the more the company would try to squeeze from you in terms of premiums. driven by customer retention and profit motives, the company pushed increases on those that they knew could afford them and would switch to save dollars. but, for those policies that had been overpriced, they offered less than . % in terms of a discount limiting their downsides while increases were not limited, often going up as high as %. while they were unsuccessful in getting this adopted in maryland where it was deemed discriminatory, the model has been approved for use in several states thus showing that opaque models can be deployed not just in high-tech industries but anywhere to provide individually tailored pricing to extract away as much of the consumer surplus as possible based on the purportedly undisclosed willingness of the customer to pay (as would be expressed by their individual demand curves which aren't directly discernible to the producer). furthermore, the insurers aren't mandated to make disclosures of how they are pricing their policies and thus, in places where they should have offered discounts, they've only offered pennies on the dollar, disproportionately impacting the poorest for whom a few hundred dollars a year can mean having sufficient meals on the table. sadly, in the places where their customer retention model was accepted, the regulators declined to answer why they chose to accept it, except in arkansas where they said such pricing schemes aren't discriminatory unless the customers are grouped by attributes like race, color, creed or national origin. this takes a very limited view of what price discrimination is, harkening back to an era where access to big data about the consumer was few and far between. in an era dominated by data brokers that compile thick and rich data profiles on consumers, price discriminaton extends far beyond the basic protected attributes and can be tailored down to specificities of each individual. other companies in retail goods and online learning services have been following this practice of personalized pricing for many years, often defending it as the cost of doing in business when they based the pricing on things like zip codes, which are known proxies for race and paying capacity. personalized pricing is different from dynamic pricing, as seen when booking plane tickets, which is usually based on the timing of purchase whereas here the prices are based on attributes that are specific to the customer which they often don't have any control over. a obama administration report mentioned that, "differential pricing in insurance markets can raise serious fairness concerns, particularly when major risk factors are outside an individual customer's control." why the case of auto insurance is so much more predatory than, say buying stationery supplies, is that it is mandatory in almost all states and not having the vehicle insured can lead to fines, loss of licenses and even incarceration. transport is an essential commodity for people to get themselves to work, children to school and a whole host of other daily activities. in maryland, the regulators had denied the proposal by allstate to utilize their model but in official public records, the claim is marked as "withdrawn" rather than "denied" which the regulators claim makes no internal difference but allstate used this difference to get their proposal past the regulators in several other states. they had only withdrawn their proposal after being denied by the regulators in maryland. the national association of insurance commissioners mentioned that most regulators don't have the right data to be able to meaningfully evaluate rate revision proposals put forth by insurers and this leads to approvals without review in a lot of cases. even the data journalists had to spend a lot of time and effort to discern what the underlying models were and how they worked, essentially summing up that the insurers don't necessarily lie but don't give you all the information unless you know to ask the right set of questions. allstate has defended its price optimization strategy, called complementary group rating (cgr) as being more objective, and based on mathematical rigor, compared to the ad-hoc, judgemental pricing practices that have been followed before, ultimately citing better outcomes for their customers. but, this is a common form of what is called "mathwashing" in the ai ethics domain where discriminatory solutions are pushed as fair under the veneer of mathematical objectivity. regulators in florida said that setting prices based on the "modeled reaction to rate changes" was "unfairly discriminatory." instead of being cost-based, as is advocated by regulators for auto-insurance premiums because they support an essential function, allstate was utilizing a model that was heavily based on the likelihood of the customer sticking with them even in the face of price rises which makes it discriminatory. these customers are price-inelastic and hence don't change their demand much even in the face of dramatic price changes. consumer behaviour when purchasing insurance policies for the most part remains static once they've made a choice, often never changing insurers over the course of their lifetime which leads them to not find the optimal price for themselves. this is mostly a function of the fact that the decisions are loaded with having to judge complex terms and conditions across a variety of providers and the customers are unwilling to have to go through the exercise again and again at short intervals. given the opacity of the pricing models today, it is almost impossible to find out what the appropriate pricing should be for a particular customer and hence the most effective defense is to constantly check for prices from the competitors. but, this unduly places the burden on the shoulders of the consumer. google had announced its ai principles on building systems that are ethical, safe and inclusive, yet as is the case with so many high level principles, it's hard to put them into practice unless there is more granularity and actionable steps that are derived from those principles. here are the principles: • be socially beneficial this talk focused on the second principle and did just that in terms of providing concrete guidance on how to translate this into everyday practice for design and development teams. humans have a history of making product design decisions that are not in line with the needs of everyone. examples of the crash dummy and band-aids mentioned above give some insight into the challenges that users face even when the designers and developers of the products and services don't necessarily have ill intentions. products and services shouldn't be designed such that they perform poorly for people due to aspects of themselves that they can't change. for example, when looking at the open image dataset, searching for images marked with wedding indicate stereotypical western weddings but those from other cultures and parts of the world are not tagged as such. from a data perspective, the need for having more diverse sources of data is evident and the google team made an effort to do this by building an extension to the open images data set by providing users from across the world to snap pictures from their surroundings that captured diversity in many areas of everyday life. this helped to mitigate the problem that a lot of open image data sets have in being geographically skewed. biases can enter at any stage of the ml development pipeline and solutions need to address them at different stages to get the desired results. additionally, the teams working on these solutions need to come from a diversity of backgrounds including ux design, ml, public policy, social sciences and more. so, in the area of fairness by data which is one of the first steps in the ml product lifecycle and it plays a significant role in the rest of the steps of the lifecycle as well since data is used to both train and evaluate a system. google clips was a camera that was designed to automatically find interesting moments and capture them but what was observed was that it did well only for a certain type of family, under particular lighting conditions and poses. this represented a clear bias and the team moved to collect more data that better represented the situations for a variety of families that would be the target audience for the products. quickdraw was a fun game that was built to ask users to supply their quickly sketched hand drawings of various commonplace items like shoes. the aspiration from this was that given that it was open to the world and had a game element to it, it would be utilized by many people from a diversity of backgrounds and hence the data so collected would have sufficient richness to capture the world. on analysis, what they saw was that most users had a very particular concept of a shoe in mind, the sneaker which they sketched and there were very few women's shoes that were submitted. what this example highlighted was that data collection, especially when trying to get diverse samples, requires a very conscious effort that can account for what the actual distribution the system might encounter in the world and make a best effort attempt to capture their nuances. users don't use systems exactly in the way we intend them to, so reflect on who you're able to reach and not reach with your system and how you can check for blindspots, ensure that there is some monitoring for how data changes over time and use these insights to build automated tests for fairness in data. the second approach that can help with fairness in ml systems is looking at measurement and modeling. the benefits of measurement are that it can be tracked over time and you can test for both individuals and groups at scale for fairness. different fairness concerns require different metrics even within the same product. the primary categories of fairness concerns are disproportionate harms and representational harms. the jigsaw api provides a tool where you can input a piece of text and it tells you the level of toxicity of that piece of text. an example in the earlier version of the system rated sentences of the form "i am straight" as not toxic while those like "i am gay" as toxic. so what was needed to be able to see what was causing this and how it could be addressed. by removing the identity token, they monitored for how the prediction changed and then the outcomes from that measurement gave indications on where the data might be biased and how to fix it. an approach can be to use block lists and removals of such tokens so that sentences that are neutral are perceived as such without imposing stereotypes from large corpora of texts. these steps prevent the model from accessing information that can lead to skewed outcomes. but, in certain places we might want to brand the first sentence as toxic if it is used in a derogatory manner against an individual, we require context and nuance to be captured to make that decision. google undertook project respect to capture positive identity associations from around the world as a way of improving data collection and coupled that with active sampling (an algorithmic approach that samples more from the training data set in areas where it is under performing) to improve outputs from the system. another approach is to create synthetic data that mimics the problematic cases and renders them in a neutral context. adversarial training and updated loss functions where one updates a model's loss function to minimize difference in performance between groups of individuals can also be used to get better results. in their updates to the toxicity model, they've seen improvements, but this was based on synthetic data on short sentences and it is still an area of improvement. some of the lessons learned from the experiments carried out by the team: • test early and test often • develop multiple metrics (quantitative and qualitative measures along with user testing is a part of this) for measuring the scale of each problem • possible to take proactive steps in modeling that are aware of production constraints from a design perspective, think about fairness in a more holistic sense and build communication lines between the user and the product. as an example, turkish is a gender neutral language, but when translating to english, sentences take on gender along stereotypes by attributing female to nurse and male to doctor. say we have a sentence, "casey is my friend", given no other information we can't infer what the gender of casey is and hence it is better to present that choice to the user from a design perspective because they have the context and background and can hence make the best decision. without that, no matter how much the model is trained to output fair predictions, they will be erroneous without the explicit context that the user has. lessons learned from the experiments include: • context is key • get information from the user that the model doesn't have and share information with the user that the model has and they don't • how do you design so the user can communicate effectively and have transparency so that can you get the right feedback? • get feedback from a diversity of users • see the different ways in how they provide feedback, not every user can offer feedback in the same way • identify ways to enable multiple experiences • we need more than a theoretical and technical toolkit, there needs to be rich and context-dependent experience putting these lessons into practice, what's important is to have consistent and transparent communication and layering on approaches like datasheets for data sets and model cards for model reporting will aid in highlighting appropriate uses for the system and where it has been tested and warn of potential misuses and where the system hasn't been tested. the paper starts by setting the stage for the well understood problem of building truly ethical, safe and inclusive ai systems that are increasingly leveraging ubiquitous sensors to make predictions on who we are and how we might behave. but, when these systems are deployed in socially contested domains, for example, "normal" behaviour where loosely we can think of normal as that defined by the majority and treating everything else as anomalous, then they don't make value-free judgements and are not amoral in their operations. by viewing the systems as purely technical, the solutions to address these problems are purely technical which is where most of the fairness research has focused and it ignores the context of the people and communities where these systems are used. the paper serves to question the foundations of these systems and to take a deeper look at unstated assumptions in the design and development of the systems. it urges the readers, and the research community at large, to consider this from the perspective of relational ethics. it makes key suggestions: • center the focus of development on those within the community that will face a disproportionate burden or negative consequences from the use of the system • instead of optimizing for prediction, it is more important to think about how we gain a fundamental understanding of why we're getting certain results which might be arising because of historical stereotypes that were captured as a part of the development and design of the system • the systems end up creating a social and political order and then reinforcing it, meaning we should involve a larger systems based approach to designing the systems • given that the terms of bias, fairness, etc evolve over time and what's acceptable at some time becomes unacceptable later, the process asks for constant monitoring, evaluation and iteration of the design to most accurately represent the community in context. at maiei, we've advocated for an interdisciplinary approach leveraging the citizen community spanning a wide cross section to best capture the essence of different issues as closely as possible from those who experience them first hand. placing the development of an ml system in context of the larger social and political order is important and we advocate for taking a systems design approach (see a primer in systems thinking by donna meadows) which creates two benefits: one is that several ignored externalities can be considered and second to involve a wider set of inputs from people who might be affected by the system and who understand how the system will sit in the larger social and political order in which it will be deployed. also, we particularly enjoyed the point on requiring a constant iterative process to the development and deployment of ai systems borrowing from cybersecurity research on how security of the system is not done and over with, requiring constant monitoring and attention to ensure the safety of the system. underrepresentation of disabilities in datasets and how they are processed in nlp tasks is an important area of discussion that is often not studied empirically in the literature that primarily focuses on other demographic groups. there are many consequences of this, especially as it relates to how text related to disabilities is classified and has impacts on how people read, write, and seek information about this. research from the world bank indicates that about billion people have disabilities of some kind and often these are associated with strong negative social connotations. utilizing linguistic expressions as they are used in relation to disabilities and classifying them into recommended and non-recommended uses (following the guidelines from anti-defamation league, acm sigaccess, and ada national network), the authors seek to study how automated systems classify phrases that indicate disability and whether usages split by recommended vs. non-recommended uses make a difference in how these snippets of text are perceived. to quantify the biases in the text classification models, the study uses the method of perturbation. it starts by collecting instances of sentences that have naturally occurring pronouns he and she. then, they replace them with the phrases indicating disabilities as identified in the previous paragraph and compare the change in the classification scores in the original and perturbed sentences. the difference indicates how much of an impact the use of a disability phrase has on the classification process. using the jigsaw tool that gives the toxicity score for sentences, they test these original and perturbed sentences and observe that the change in toxicity is lower for recommended phrases vs. the non-recommended ones. but, when disaggregated by categories, they find that some of them elicit a stronger response than others. given that the primary use of such a model might in the case of online content moderation (especially given that we now have more automated monitoring happening as human staff has been thinning out because of pandemic related closures), there is a high rate of false positives where it can suppress content that is non-toxic and is merely discussing disability or replying to other hate speech that talks about disability. to look at sentiment scores for disability related phrases, the study looks at the popular bert model and adopts a template-based fill-in-the-blank analysis. given a query sentence with a missing word, bert produces a ranked list of words that can fill the blank. using a simple template perturbed with recommended disability phrases, the study then looks at how the predictions from the bert model change when disability phrases are used in the sentence. what is observed is that a large percentage of the words that are predicted by the model have negative sentiment scores associated with them. since bert is used quite widely in many different nlp tasks, such negative sentiment scores can have potentially hidden and unwanted effects on many downstream tasks. such models are trained on large corpora, which are analyzed to build "meaning" representations for words based on co-occurrence metrics, drawing from the idea that "you shall know a word by the company it keeps". the study used the jigsaw unintended bias in toxicity classification challenge dataset which had a mention of a lot of disability phrases. after balancing for different categories and analyzing toxic and non-toxic categories, the authors manually inspected the top terms in each category and found that there were key types: condition, infrastructure, social, linguistic, and treatment. in analyzing the strength of association, the authors found that condition phrases had the strongest association, and was then followed by social phrases that had the next highest strongest association. this included topics like homelessness, drug abuse, and gun violence all of which have negative valences. because these terms are used when discussing disability, it leads to a negative shaping of the way disability phrases are shaped and represented in the nlp tasks. the authors make recommendations for those working on nlp tasks to think about the socio-technical considerations when deploying such systems and to consider the intended, unintended, voluntary, and involuntary impacts on people both directly and indirectly while accounting for long-term impacts and feedback loops. such indiscriminate censoring of content that has disability phrases in them leads to an underrepresentation of people with disabilities in these corpora since they are the ones who tend to use these phrases most often. additionally, it also negatively impacts the people who might search for such content and be led to believe that the prevalence of some of these issues are smaller than they actually are because of this censorship. it also has impacts on reducing the autonomy and dignity of these people which in turn has a larger implication of how social attitudes are shaped. the second wave of algorithmic accountability the article dives into explaining how the rising interest in ensuring fair, transparent, ethical ai systems that are held accountable via various mechanisms advocated by research in legal and technical domains constitutes the "first wave" of algorithmic accountability that challenges existing systems. actions as a part of this wave need to be carried out incessantly with constant vigilance of the deployment of ai systems to avoid negative social outcomes. but, we also need to challenge why we have these systems in the first place, and if they can be replaced with something better. as an example, instead of making the facial recognition systems more inclusive, given the fact that they cause social stratification perhaps they shouldn't be used at all. a great point made by the article is that under the veneer of mainstream economic and ai rationalizations, we obscure broken social systems which ultimately harm society at a more systemic level. the trolley problem is a widely touted ethical and moral dilemma wherein a person is asked to make a split-second choice to save one or more than one life based on a series of scenarios where the people that need to be saved have different characteristics including their jobs, age, gender, race, etc. in recent times, with the imminent arrival of self-driving cars, people have used this problem to highlight the supposed ethical dilemma that the vehicle system might have to grapple with as it drives around. this article makes a point about the facetious nature of this thought experiment as an introduction to ethics for people that will be building and operating such autonomous systems. the primary argument being that it's a contrived situation that is unlikely to arise in the real-world setting and it distracts from other more pressing concerns in ai systems. moral judgments are relativistic and depend on cultural values of the geography where the system is deployed. the nature paper cited in the article showcases the differences in how people respond to this dilemma. there is an eeriness to this whole experimental setup, the article gives some examples on how increasingly automated environments, devoid of human social interactions and language, are replete with the clanging and humming of machines that give an entirely inhuman experience. for most systems, they are going to be a reflection of the biases and stereotypes that we have in the world, captured in the system because of the training and development paradigms of ai systems today. we'd need to make changes and bring in diversity to the development process, creating awareness of ethical concerns, but the trolley problem isn't the most effective way to get started on it. most of us have a nagging feeling that we're being forced into certain choices when we interact with each other on various social media platforms. but, is there a way that we can grasp that more viscerally where such biases and echo chambers are laid out bare for all to see? the article details an innovative game design solution to this problem called monster match that highlights how people are trapped into certain niches on dating websites based on ai-powered systems like collaborative filtering. striking examples of that in practice are how your earlier choices on the platform box you into a certain category based on what the majority think and then recommendations are personalized based on that smaller subset. what was observed was that certain racial inequalities from the real world are amplified on platforms like these where the apps are more interested in keeping users on the platform longer and making money rather than trying to achieve the goal as advertised to their users. more than personal failings of the users, the design of the platform is what causes failures in finding that special someone on the platform. the creators of the solution posit that through more effective design interventions, there is potential for improvement in how digital love is realized, for example, by offering a reset button or having the option to opt-out of the recommendation system and instead relying on random matches. increasingly, what we're going to see is that reliance on design and other mechanisms will yield better ai systems than purely technical approaches in improving socially positive outcomes. the article presents the idea of data feminism which is described as the intersection between feminism and data practices. the use of big data in today's dominant paradigm of supervised machine learning lends itself to large asymmetries that reflect the power imbalances in the real world. the authors of the new book data feminism talk about how data should not just speak for itself, for behind the data, there are a large number of structures and assumptions that bring it to the stage where they are collated into a dataset. they give examples of how sexual harassment numbers, while mandated to be reported to a central agency from college campuses might not be very accurate because they rely on the atmosphere and degree of comfort that those campuses promote which in turn influences how close the reported numbers will be to the actual cases. the gains and losses from the use of big data are not distributed evenly and the losses disproportionately impact the marginalized. there are a number of strategies that can be used to mitigate the harms from such flawed data pipelines. not an exhaustive list but it includes the suggestion of having more exposure for technical students to the social sciences and moving beyond having just a single ethics class as a check mark for having educated the students on ethics. secondly, having more diversity in the people developing and deploying the ai systems would help spot biases by asking the hard questions about both the data and the design of the system. the current covid- numbers might also suffer from similar problems because of how medical systems are structured and how people who don't have insurance might not utilize medical facilities and get themselves tested thus creating an underrepresentation in the data. this recent work highlights how commercial speech recognition systems carry inherent bias because of a lack of representation from diverse demographics in the underlying training datasets. what the researchers found was that even for identical sentences spoken by different racial demographics, the systems had widely differing levels of performance. as an example, for black users, the error rates were much higher than those for white users which probably had something to do with the fact that there is specific vernacular language used by black people which wasn't adequately represented in the training dataset for the commercial systems. this pattern has a tendency to be amplifying in nature, especially for systems that aren't frozen and continue to learn with incoming data. a vicious cycle is born where because of poor performance from the system, black people will be disincentivized from using the system because it takes a greater amount of work to get the system to work for them thus lowering utility. as a consequence of lower use, the systems get fewer training samples from black people thus further aggravating the problem. this leads to amplified exclusionary behavior mirroring existing fractures along racial lines in society. as a starting point, collecting more representative training datasets will aid in mitigating at least some of the problems in these systems. algorithmic bias at this point is a well-recognized problem with many people working on ways to address issues, both from a technical and policy perspective. there is potential to use demographic data to serve better those who face algorithmic discrimination but the use of such data is a challenge because of ethical and legal concerns. primarily, a lot of jurisdictions don't allow for the capture and use of protected class attributes or sensitive data for the fear of their misuse. even within jurisdictions, there is a patchwork of recommendations which makes compliance difficult. even with all this well established, proxy attributes can be used to predict the protected data and in a sense, according to some legislations, they become protected data themselves and it becomes hard to extricate the non-sensitive data from the sensitive data. because of such tensions and the privacy intrusions on data subjects when trying to collect demographic data, it is hard to align and advocate for this collection of data over the other requirements within the organization, especially when other bodies and leadership will look to place privacy and legal compliance over bias concerns. even if there was approval and internal alignment in collecting this demographic data, if there is voluntary provision of this data from data subjects, we run the risk of introducing a systemic bias that obfuscates and mischaracterizes the whole problem. accountability will play a key role in evoking trust from people to share their demographic information and proper use of it will be crucial in ongoing success. potential solutions are to store this data with a non-profit third-party organization that would meter out the data to those who need to use it with the consent of the data subject. to build a better understanding, partnership on ai is adopting a multistakeholder approach leveraging diverse backgrounds, akin to what the montreal ai ethics institute does, that can help inform future solutions that will help to address the problems of algorithmic bias by the judicious use of demographic data. detection and removal of hate speech is particularly problematic, something that has been exacerbated as human content moderators have been scarce in the pandemic related measures as we covered here. so are there advances in nlp that we could leverage to better automate this process? recent work from facebook ai research shows some promise. developing a deeper semantic understanding across more subtle and complex meanings and working across a variety of modalities like text, images and videos will help to more effectively combat the problem of hate speech online. building a pre-trained universal representation of content for integrity problems and improving and utilizing post-level, self-supervised learning to improve whole entity understanding has been key in improving hate speech detection. while there are clear guidelines on hate speech, when it comes to practice there are numerous challenges that arise from multi-modal use, differences in cultures and context, differences in idioms, language, regions, and countries. this poses challenges even for human reviewers who struggle with identifying hate speech accurately. a particularly interesting example shared in the article points out how text which might seem ambiguous when paired with an image to create a meme can take a whole new meaning which is often hard to detect using traditional automated tooling. there are active efforts from malicious entities who craft specific examples with the intention of evading detection which further complicates the problem. then there is the counterspeech problem where a reply to hate speech that contains the same phrasing but is framed to counter the arguments presented can be falsely flagged to be brought down which can have free speech implications. the relative scarcity of examples of hate speech in its various forms in relation to the larger non-hate speech content also poses a challenge for learning, especially when it comes to capturing linguistic and cultural nuances. the new method proposed utilizes focal loss which aims to minimize the impact of easy-to-classify examples on the learning process which is coupled with gradient blending which computes an optimal blend of modalities based on their overfitting patterns. the technique called xlm-r builds on bert by using a new pretraining recipe called roberta that allows training on orders of magnitude more data for longer periods of time. additionally, nlp performance is improved by learning across languages using a single encoder that allows learning to be transferred across languages. since this is a self-supervised method, they can train on large unlabeled datasets and have also found some universal language structures that allow vectors with similar meanings across languages to be closer together. facial recognition technology (frt) continues to get mentions because of the variety of ways that it can be misused across different geographies and contexts. with the most recent case where frt is used to determine criminality, it brings up an interesting discussion around why techniques that have no basis in science, those which have been debunked time and time again keep resurfacing and what we can do to better educate researchers on their moral responsibilities in pursuing such work. the author of this article gives some historical context for where the state of ai ethics, june phrenology started, pointing to the work of francis galton who used the "photographic composite method" to try and determine characteristics of one's personality from a picture. prior, measurements of skull size and other facial features wasn't deemed as a moral issue and the removal of such techniques from discussion was done on the objection that claims around the localization of different brain functions was seen as antithetical to the unity of the soul according to christianity. the authors of the paper that is being discussed in the article saw only empirical concerns with the work that they put forth and didn't see any of the moral shortcomings that were pointed out. additionally, they justified the work as being only for scientific curiosity. they also failed to realize the various statistical biases introduced in the collection of data as to the disparate rates of arrests, and policing, the perception of different people by law enforcement, juries, and judges and historical stereotypes and biases that confound the data that is collected.thus, the labeling itself is hardly value-neutral. more so, the authors of the study framed criminality as an innate characteristic rather than the social and other circumstances that lead to crime. especially when a project like this resurrects class structures and inequities, one must be extra cautious of doing such work on the grounds of "academic curiosity". the author of this article thus articulates that researchers need to take their moral obligations seriously and consider the harm that their work can have on people. while simply branding this as phrenology isn't enough, the author mentions that identifying and highlighting the concerns will lead to more productive conversations. an increase in demand for workers for various delivery services and other gig work has accelerated the adoption of vetting technology like those that are used to do background checks during the hiring process. but, a variety of glitches in the system such as sourcing out-of-date information to make inferences, a lack of redressal mechanisms to make corrections, among others has exposed the flaws in an overreliance on automated systems especially in places where important decisions need to be made that can have a significant impact on a person's life such as employment. checkr, the company that is profiled in this article claims to use ai to scan resumes, compare criminal records, analyze social media accounts, and examine facial expressions during the interview process. during a pandemic, when organizations are short-staffed and need to make rapid decisions, checkr offers a way to streamline the process, but this comes at a cost. two supposed benefits that they offer are that they are able to assess a match between the criminal record and the person being actually concerned, something that can especially be fraught with errors in cases where the person has a common name. secondly, they are also able to correlate and resolve discrepancies in the different terms that may be used for crimes across different jurisdictions. a person spoke about his experience with another company that did these ai-powered background checks utilizing his public social media information and bucketed some of his activity into categories that were too coarse and unrepresentative of his behaviour, especially when such automated judgements are made without a recourse to correct, this can negatively affect the prospects of being hired. another point brought up in the article is that social media companies might themselves be unwilling to tolerate scraping of their users' data to do this sort of vetting which against their terms of use for access to the apis. borrowing from the credit reporting world, the fair credit reporting act in the us offers some insights when it mentions that people need to be provided with a recourse to correct information that is used about them in making a decision and that due consent needs to be obtained prior to utilizing such tools to do a background check. though it doesn't ask for any guarantees of a favorable outcome post a re-evaluation, at least it does offer the individual a bit more agency and control over the process. the toxic potential of youtube's feedback loop on youtube everyday, more than a billion hours of video are watched everyday where approximately % of those are watched by automated systems that then provide recommendations on what videos to watch next for human users in the column on the side. there are more than billion users on the youtube platform so this has a significant impact on what the world watches. guillaume had started to notice a pattern in the recommended videos which tended towards radicalizing, extreme and polarizing content which were underlying the upward trend of watch times on the platform. on raising these concerns with the team, at first there were very few incentives for anyone to address issues of ethics and bias as it related to promoting this type of content because they feared that it would drive down watch time, the key business metric that was being optimized for by the team. so maximizing engagement stood in contrast to the quality of time that was spent on the platform. the vicious feedback loop that it triggered was that as such divisive content performed better, the ai systems promoted this to optimize for engagement and subsequently content creators who saw this kind of content doing better created more of such content in the hopes of doing well on the platform. the proliferation of conspiracy theories, extreme and divisive content thus fed its own demand because of a misguided business metric that ignored social externalities. flat earthers, anti-vaxxers and other such content creators perform well because the people behind this content are a very active community that spend a lot of effort in creating these videos, thus meeting high quality standards and further feeding the toxic loop. content from people like alex jones and trump tended to perform well because of the above reasons as well. guillaume's project algotransparency essentially clicks through video recommendations on youtube to figure out if there are feedback loops. he started this with the hopes of highlighting latent problems in the platforms that continue to persist despite policy changes, for example with youtube attempting to automate the removal of reported and offensive videos. he suggests that the current separation of the policy and engagement algorithm leads to problems like gaming of the platform algorithm by motivated state actors that seek to disrupt democratic processes of a foreign nation. the platforms on the other hand have very few incentives to make changes because the type of content emerging from such activity leads to higher engagement which ultimately boosts their bottom line. guillaume recommends having a combined system that can jointly optimize for both thus helping to minimize problems like the above. a lot of the problems are those of algorithmic amplification rather than content curation. many metrics like number of views, shares, and likes don't capture what needs to be captured. for example, the types of comments, reports filed, and granularity of why those reports are filed. that would allow for a smarter way to combat the spread of such content. however, the use of such explicit signals compared to the more implicit ones like number of views comes at the cost of breaking the seamlessness of the user experience. again we run into the issue of a lack of motivation on part of the companies to do things that might drive down engagement and hurt revenue streams. the talk gives a few more examples of how people figured out ways to circumvent checks around the reporting and automated take-down mechanisms by disabling comments on the videos which could previously be used to identify suspicious content. an overarching recommendation made by guillaume in better managing a more advanced ai system is to understand the underlying metrics that the system is optimizing for and then envision scenarios of what would happen if the system had access to unlimited data. thinking of self-driving cars, an ideal scenario would be to have full conversion of the traffic ecosystem to one that is autonomous leading to fewer deaths but during the transition phase, having the right incentives is key to making a system that will work in favor of social welfare. if one were to imagine a self-driving car that shows ads while the passenger is in the car, it would want to have a longer drive time and would presumably favor longer routes and traffic jams thus creating a sub-optimal scenario overall for the traffic ecosystem. on the other hand, a system that has the goal of getting from a to b as quickly and safely as possible wouldn't fall into such a trap. ultimately, we need to design ai systems such that they help humans flourish overall rather than optimize for monetary incentives which might run counter to the welfare of people at large. the article provides a taxonomy of communities that spread misinformation online and how they differ in their intentions and motivations. subsequently, different strategies can be deployed in countering the disinformation originating from these communities. there isn't a one-size-fits-all solution that would have been the case had the distribution and types of the communities been homogenous. the degree of influence that each of the communities wield is a function of types of capital: economic, social, cultural, time and algorithmic, definitions of which are provided in the article. understanding all these factors is crucial in combating misinformation where different capital forms can be used in different proportions to achieve the desired results, something that will prove to be useful in addressing disinformation around the current covid- situation. the social media platform offers a category of pseudoscience believers which advertisers can purchase and target. according to the markup, this category has million people in it and attempts to purchase ads targeting this category were approved quite swiftly. there isn't any information available as to who has purchased ads targeting this category. the journalist team was able to find at least one advertiser through the "why am i seeing this ad?" option and they reached out to that company to investigate and they found that the company hadn't selected the pseudoscience category but it had been auto-selected by facebook for them. facebook allows users the option to change the interests that are assigned to each user but it is not something that many people know about and actively monitor. some other journalists had also unearthed controversy-related categories that amplified messages and targeted people who might be susceptible to such kind of misinformation. with the ongoing pandemic, misinformation is propagating at a rapid rate and there are many user groups that continue to push conspiracy theories. other concerns around being able to purchase ads to spread misinformation related to potential cures and remedies for the coronavirus continue to be approved. with the human content moderators being asked to stay home (as we covered here) and an increasing reliance on untested automated solutions, it seems that this problem will continue to plague the platform. there isn't a dearth of information available online, one can find confirmatory evidence to almost any viewpoint since the creation and dissemination of information has been democratized by the proliferation of the internet and ease of use of mass-media platforms. so in the deluge of information, what is the key currency that helps us sift through all the noise and identify the signal? this article lays out a well articulated argument for how reputation and being able to assess it is going to be a key skill that people will need to have in order to effectively navigate the information ecosystem effectively. we increasingly rely on other people's judgement of content (akin to how maiei analyzes the ecosystem of ai ethics and presents you with a selection), coupled with algorithmically-mediated distribution channels, we are paradoxically disempowered by more information and paralyzed into inaction and confusion without a reputable source to curate and guide us. there are many conspiracy theories, famous among them that we never visited the moon, flat earth and more recently that g is causing the spread of the coronavirus. as rational readers, we tend to dismiss this as misinformation yet we don't really spend time to analyze the evidence that these people present to support their claims. to a certain extent, our belief that we did land on the moon depends on our trust in nasa and other news agencies that covered this event yet we don't venture to examine the evidence first-hand. more so, with highly specialized knowledge becoming the norm, we don't have the right tools and skills to even be able to analyze the evidence and come to meaningful conclusions. so, we must rely on those who provide us with this information. instead of analyzing the veracity of a piece of information, the focus of a mature digital citizen needs to be on being able to analyze the reputation pathway of that information, evaluate the agendas of the people that are disseminating the information and critically analyze the intentions of the authorities of the sources. how we rank different pieces of information arriving to us via our social networks need to be appraised for this reputation and source tracing, in a sense a second-order epistemology is what we need to prepare people for. in the words of hayek, "civilization rests on the fact that we all benefit from the knowledge that we do not possess." our cyber-world can become civilized by evaluating this knowledge that we don't possess critically when mis/disinformation can spread just as easily as accurate information. a very clear way to describe the problem plaguing the us response to the coronavirus, the phenomenon of truth decay is not something new but has happened many times in the past when trust in key institutions deteriorated and led to a diffused response to the crisis at hand, extending the recovery period beyond what would be necessary if there was a unified response. in the us, the calls for reopening the economy, following guidance on using personal protective equipment, and other recommendations is falling along partisan lines. the key factor causing this is how the facts and data are being presented differently to different audiences. while this epidemic might have been the perfect opportunity for bringing people together, because it affects different segments of society differently, it hasn't been what everyone expected it to be. at the core is the rampant disagreement between different factions on facts and data. this is exacerbated by the blurring of facts and opinions. in places like newsrooms and tv shows, there is an intermingling of the two which makes it harder for everyday consumers to discern fact from opinion. the volume of opinion has gone up compared to facts and people's declining trust in public health authorities and other institutions is also aggravating the problem. put briefly, people are having trouble finding the truth and don't know where to go looking for it. this is also the worst time to be losing trust in experts; with a plethora of information available online, people are feeling unnecessarily empowered that they have the right information, comparable to that of experts. coupled with a penchant for confirming their own beliefs, there is little incentive for people to fact-check and refer to multiple sources of information. when different agencies come out with different recommendations and there are policy changes in the face of new information, something that is expected given that this is an evolving situation, people's trust in these organizations and experts erodes further as they see them as flip-flopping and not knowing what is right. ultimately, effective communication along with a rebuilding of trust will be necessary if we're to emerge from this crisis soon and restore some sense of normalcy. the deepfake detection challenge: synthetic media is any media (text, image, video, audio) that is generated by an ai system or that is synthesized. on the other hand, non-synthetic media is one that is crafted by humans using a panoply of techniques, including tools like photoshop. detecting synthetic media alone doesn't solve the media integrity challenges, especially as the techniques get more sophisticated and trigger an arms race between detection and evasion methods. these methods need to be paired with other existing techniques that fact checkers and journalists already use in determining whether something is authentic or synthesized. there are also pieces of content that are made through low tech manipulations like the nancy pelosi video from which showed her drunk but in reality it was just a slowed down video. other such manipulations include simpler things like putting fake and misleading captions below the true video and people without watching the whole thing are misled into believing what is summarized in the caption. in other cases, the videos might be value neutral or informative even when they are generated so merely detecting something as being generated doesn't suffice. a meaningful way to utilize automated tools is a triaging utility that flags content to be reviewed by humans in a situation where it is not possible to manually review everything on the platform. while tech platforms can build and utilize tools that help them with these tasks, the adjacent possible needs of the larger ecosystem need to be kept in mind such that they can be served at the same time, especially for those actors that are resource-constrained and don't have the technical capabilities to build it themselves. the tools need to be easy to use and shouldn't have high friction such that they become hard to integrate into existing workflows. through open sourcing and licensing, the tools can be made available to the wider ecosystem but it can create the opportunity for adversaries to strengthen their methods as well. this can be countered by responsible disclosure as we'll cover below. for any datasets created as a part of this challenge and otherwise to aid in detection, one must ensure that it captures sufficient diversity in terms of environment and other factors and reflects the type of content that might be encountered in the world. the scoring rules need to be such that they minimize gaming and overfitting and capture the richness of variation that a system might encounter. for example most datasets today in this domain aim to mitigate the spread of pornographic material. they also need to account for the vastly different frequencies of occurrence of authentic and generated content. solutions in this domain involve an inherent tradeoff between pro-social use and potential malicious use for furthering the quality of inauthentic content. the release of tools should be done in a manner that enhances pro-social use while creating deterrents for malicious use. the systems should be stress-tested by doing red team-blue team exercises to enhance robustness because this is inherently an adversarial exercise. such challenges should be held often to encourage updating of techniques because it is a fast evolving domain where progress happens in the span of a few months. results from such detection need to be accessible to the public and stakeholders and explanations for the research findings should be made available alongside the challenge to encourage better understanding by those that are trying to make sense of the digital content. responsible disclosure practices will be crucial in enabling the fight against disinformation to have the right tools while deterring adversaries from utilizing the same tools to gain an advantage. a delayed release mechanism where the code is instantly made available to parties in a non-open source manner while the research and papers are made public with the eventual release of the code as well after a - months delay which would help with the detectors having a headstart over the adversaries. such detection challenges can benefit from extensive multi-stakeholder consultations which require significant time and effort so budget for that while crafting and building such challenges. some of the allocation of prize money should be towards better design from a ux and ui perspective. it should also include explainability criteria so that non-technical users are able to make sense of the interventions and highlights of fake content such as bounding boxes around regions of manipulations. the process of multi-stakeholder input should happen at an early stage allowing for meaningful considerations to be incorporated and dataset design that can be done appropriately to counter bias and fairness problems. finally, strong, trusting relationships are essential to the success of the process and require working together over extended periods to have the hard conversations with each other. it is important to have clear readings ahead of meetings that everyone has to complete so that discussions come from an informed place. spending time scoping and coming to clearer agreement about projects goals and deliverables at the beginning of the process is also vital to success. there is a distinction between misinformation and disinformation -misinformation is the sharing of false information unintentionally where no harm is intended whereas disinformation is false information that is spread intentionally with the aims of causing harm to the consumers. this is also referred to as information pollution and fake news. it has massive implications that have led to real harms for people in many countries with one of the biggest examples being the polarization of views in the us presidential elections. meaningful solutions to this will only emerge when we have researchers from both technical and social sciences backgrounds working together to gain a deeper understanding of the root causes. this isn't a new problem and has existed for a very long time, it's just that with the advent of technology and more people being connected to each other we have a much more rapid dissemination of the false information and modern tools enable the creation of convincing fake images, text and videos, thus amplifying the negative effects. some of the features that help to delve deeper into the study of how mis/disinformation spreads are: • democratization of content creation: with practically anyone now having the ability to create and publish content, information flow has increased dramatically and there are few checks for the veracity of content and even fewer mechanisms to limit the flow rate of information. • rapid news cycle and economic incentives: with content being monetized, there is a strong incentive to distort information to evoke a response from the reader such that they click through and feed the money-generating apparatus. • wide and immediate reach and interactivity: by virtue of almost the entire globe being connected, content quickly reaches the furthest corners of the planet. more so, content creators are also able to, through quantitative experiments, determine what kind of content performs well and then tailor that to feed the needs of people. • organic and intentionally created filter bubbles: the selection of who to follow along with the underlying plumbing of the platforms permits for the creation of echo chambers that further strengthen polarization and do little to encourage people to step out and have a meaningful exchange of ideas. • algorithmic curation and lack of transparency: the inner workings of platforms are shrouded under the veil of ip protections and there is little that is well-known about the manipulative effects of the platforms on the habits of content consumers. • scale and anonymity of online accounts: given the weak checks for identity, people are able to mount "sybil" attacks that leverage this lack of strong identity management and are able to scale their impact through the creation of content and dispersion of content by automated means like bot accounts on the platform. what hasn't changed even with the introduction of technology are the cognitive biases which act as attack surfaces for malicious actors to inject mis/disinformation. this vulnerability is of particular importance in the examination and design of successful interventions to combat the spread of false information. for example, the confirmation bias shows that people are more likely to believe something that conforms with their world-view even if they are presented with overwhelming evidence to the contrary. in the same vein, the backfire effect demonstrates how people who are presented with such contrary evidence further harden their views and get even more polarized thus negating the intention of presenting them with balancing information. in terms of techniques, the adversarial positioning is layered into three tiers with spam bots that push out low-quality content, quasi-bots that have mild human supervision to enhance the quality of content and pure human accounts that aim to build up a large following before embarking on spreading the mis/disinformation. from a structural perspective, the alternate media sources often copy-paste content with source attribution and are tightly clustered together with a marked separation with other mainstream media outlets. on the consumer front, there is research that points to the impact that structural deficiencies in the platforms, say whatsapp where source gets stripped out in sharing information, create not only challenges for researchers trying to study the ecosystem but also exacerbate the local impact effect whereby a consumer trusts things coming from friends much more so than other potentially more credible sources from an upstream perspective. existing efforts to study the ecosystem require a lot of manual effort but there is hope in the sense that there are some tools that help automate the analysis. as an example, we have the hoaxy tool, a tool that collects online mis/disinformation and other articles that are fact-checking versions. their creators find that the fact-checked articles are shared much less than the original article and that curbing bots on a platform has a significant impact. there are some challenges with these tools in the sense that they work well on public platforms like twitter but on closed platforms with limited ability to deploy bots, automation doesn't work really well. additionally, even the metrics that are surfaced need to be interpreted by researchers and it isn't always clear how to do that. the term 'deepfake' originated in and since then a variety of tools have been released such as face face that allow for the creation of reanimations of people to forge identity, something that was alluded to in this paper here on the evolution of fraud. while being able to create such forgeries isn't new, what is new is that this can be done now with a fraction of the effort, democratizing information pollution and casting aspersions on legitimate content as one can always argue something was forged. online tracking of individuals, which is primarily used for serving personalized advertisements and monetizing the user behaviors on websites can also be used to target mis/disinformation in a fine-grained manner. there are a variety of ways this is done through third-party tracking like embedding of widgets to browser cookies and fingerprinting. this can be used to manipulate vulnerable users and leverage sensitive attributes gleaned from online behaviors that give malicious actors more ammunition to target individuals specifically. even when platforms provide some degree of transparency on why users are seeing certain content, the information provided is often vague and doesn't do much to improve the understanding for the user. earlier attempts at using bots used simplistic techniques such as tweeting at certain users and amplifying low-credibility information to give the impression that something has more support than it really does but recent attempts have become more sophisticated: social spambots. these slowly build up credibility within a community and then use that trust to sow disinformation either automatically or in conjunction with a human operator, akin to a cyborg. detection and measurement of this problem is a very real concern and researchers have tried using techniques like social network graph structure, account data and posting metrics, nlp on content and crowdsourcing analysis. from a platform perspective, they can choose to analyze the amount of time spent browsing posts vs. the time spent posting things. there is an arms race between detection and evasion of bot accounts: sometimes even humans aren't able to detect sophisticated social bots. additionally, there are instances where there are positive and beneficial bots such as those that aggregate news or help coordinate disaster response which further complicates the detection challenge. there is also a potential misalignment in incentives since the platforms have an interest in having higher numbers of accounts and activity since it helps boost their valuations while they are the ones that have the maximum amount of information to be able to combat the problem. this problem of curbing the spread of mis/disinformation can be broken down into two parts: enabling detection on the platform level and empowering readers to select the right sources. we need a good definition of what fake news is, one of the most widely accepted definitions is that it is something that is factually false and intentionally misleading. framing a machine learning approach here as an end-to-end task is problematic because it requires large amounts of labelled data and with neural network based approaches, there is little explanation offered which makes downstream tasks harder. so we can approach this by breaking it down into subtasks, one of which is verifying the veracity of information. most current approaches use human fact-checkers but this isn't a scalable approach and automated means using nlp aren't quite proficient at this task yet. there are attempts to break down the problem even further such as using stance detection to see if information presented agrees, disagrees or is unrelated to what is mentioned in the source. other approaches include misleading style detection whereby we try to determine if the style of the article can offer clues to the intent of the author but that is riddled with problems of not having necessarily a strong correlation with a misleading intent because the style may be pandering to hyperpartisanship or even if it is neutral that doesn't mean that it is not misleading. metadata analysis looking at the social graph structure, attributes of the sharer and propagation path of the information can lend some clues as well. while all these attempts have their own challenges and in the arms race framing, there is a constant battle between attack and defense, even if the problem is solved, we still have human cognitive biases which muddle the impacts of these techniques. ux and ui interventions might serve to provide some more information as to combating those. as a counter to the problems encountered in marking content as being "disputed" which leads to the implied truth effect leading to larger negative externalities, an approach is to show "related" articles when something is disputed and then use that as an intervention to link to fact-checking websites like snopes. other in-platform interventions include the change from whatsapp to show "forwarded" next to messages so that people had a bit more insight into the provenance of the message because there was a lot of misinformation that was being spread in private messaging. there are also third-party tools like surfsafe that are able to check images as people are browsing against other websites where they might have appeared and if they haven't appeared in many places, including verified sources, then the user can infer that the image might be doctored. education initiatives by the platform companies for users to spot misinformation are a method to get people to become more savvy. there have also been attempts to assign nutrition labels to sources to list their slant, tone of the article, timeliness of the article and the experience of the author which would allow a user to make a better decision on whether or not to trust an article. platforms have also attempted to limit the spread of mis/disinformation by flagging posts that encourage gaming of the sharing mechanisms on the platform, for example, downweighting posts that are "clickbait". the biggest challenges in the interventions created by the platforms themselves are that they don't provide sufficient information as to make the results scientifically reproducible. given the variety of actors and motivations, the interventions need to be tailored to be able to combat them such as erecting barriers to the rate of transmission of mis/disinformation and demonetization for actors with financial incentives but for state actors, detection and attribution might be more important. along with challenges in defining the problem, one must look at socio-technical solutions because the problem has more than just the technical component, including the problem with human cognitive biases. being an inherently adversarial setting, it is important to see that not all techniques being used by the attackers are sophisticated, some simple techniques when scaled are just as problematic and require attention. but, given that this is constantly evolving, detecting disinformation today doesn't mean that we can do so successfully tomorrow. additionally, disinformation is becoming more personalized, more realistic and more widespread. there is a misalignment in incentives as explored earlier in terms of what the platforms want and what's best for users but also that empowering users to the point of them being just skeptical of everything isn't good either, we need to be able to trigger legitimate and informed trust in the authentic content and dissuade them away from the fake content. among the recommendations proposed by the authors are: being specific about what a particular technological or design intervention means to achieve, breaking down the technological problems into smaller, concrete subproblems that have tractable solutions and then recombining them into the larger pipeline. we must also continue to analyze the state of the ecosystem and tailor defenses such that they can combat the actors at play. additionally, rethinking of the monetary incentives on the platform can help to dissuade some of the financially-motivated actors. educational interventions that focus on building up knowledge so that there is healthy skepticism and learning how to detect markers for bots, the capabilities of technology to create fakes today and discussions in "public squares" on this subject are crucial yet we mustn't place too much of a burden on the end-user that distracts them from their primary task which is interaction with others on the social network. if that happens, people will just abandon the effort. additionally, designing for everyone is crucial, if the interventions, such as installing a browser extension, are complicated, then one can only reach the technically-literate people and everyone else gets left out. on the platform end, apart from the suggestions made above, they should look at the use of design affordances that aid the user in judging the veracity, provenance and other measures to discern legitimate information vs. mis/disinformation. teaming up with external organizations that specialize in ux/ui research will aid in understanding the impacts of the various features within the platform. results from such research efforts need to be made public and accessible to non-technical audiences. proposed solutions also need to be interdisciplinary to have a fuller understanding of the root causes of the problem. also, just as we need tailoring for the different kinds of adversaries, it is important to tailor the interventions to the various user groups who might have different needs and abilities. the paper also makes recommendations for policymakers, most importantly that the work in regulations and legislations be grounded in technical realities that are facing the ecosystem so that they don't undershoot or overshoot the needs for successfully combating mis/disinformation. for users, there are a variety of recommendations provided in the references but notably being aware of our own cognitive biases and having a healthy degree of skepticism and checking information against multiple sources before accepting it as legitimate are the most important ones. disinformation is harmful even during times when we aren't going through large scale changes but this year the us has elections, the once in a decade census, and the covid- pandemic. malicious agents are having a field day disbursing false information, overwhelming people with a mixture of true and untrue pieces of content. the article gives the example of a potential lockdown and people reflecting on their experience with the boston marathon bombings including stockpiling essentials out of panic. this was then uncovered to have originated from conspiracy theorists, but in an environment where contact with the outside world has become limited and local touch points such as speaking with your neighbor have dwindled, we're struggling with our ability to combat this infodemic. social media is playing a critical role in getting information to people but if it's untrue, we end up risking lives especially if it's falsehoods on how to protect yourself from contracting a disease. but wherever there is a challenge lies a corresponding opportunity: social media companies have a unique window into discovering issues that a local population is concerned about and it can, if used effectively, be a source for providing crisis response to those most in need with resources that are specific and meaningful. when it comes to disinformation spreading, there isn't a more opportune time than now with the pandemic raging where people are juggling several things to manage and cope with lifestyle and work changes. this has increased the susceptibility of people to sharing news and other information about how to protect themselves and their loved ones from covid- . as the who has pointed out, we are combating both a pandemic and an infodemic at the same time. what's more important is that this might be the time to test out design and other interventions that might help curb the spread of disinformation. this study highlighted how people shared disinformation more often than they believed its veracity. in other words, when people share content, they care more about what they stand to gain (social reward cues) for sharing the content than whether the content they're sharing is accurate or not. to combat this, the researchers embarked on an experiment to see if asking users to check whether something was true before sharing -a light accuracy nudge, would change their behaviour. while there was a small positive effect in terms of them sharing disinformation less when prompted to check for accuracy, the researchers pointed out that the downstream effects could be much larger because of the amplification effects of how content propagates on social media networks. it points to a potentially interesting solution that might be scalable and could help fight against the spread of disinformation. the who has mentioned the infodemic as being one of the causes that is exacerbating the pandemic as people follow differing advice on what to do. communication by authorities has been persistent but at times ineffective and this article dives into how one could enhance the visibility of credible information by governments, health authorities and scientists so that the negative impacts of the infodemic can be curbed. but, spewing scientific facts from a soapbox alone isn't enough -one is competing with all the other pieces of information and entertainment for attention and that needs to be taken into account. one of the key findings is that starting a dialogue helps more than just sending a one-way communiqué. good science communication relies on the pillars of storytelling, cutting through the jargon and making the knowledge accessible. while online platforms are structured such that polarization is encouraged through the algorithmic underpinnings of the system, we should not only engage when there is something that we disagree with, instead taking the time to amplify good science is equally important. using platform-appropriate messaging, tailoring content to the audience and not squabbling over petty details, especially when they don't make a significant impact on the overall content helps to push out good science signals in the ocean of information pollution. clickbait-style headlines do a great job of hooking in people but when leading people into making a certain assumption and then debunking it, you stand the risk of spreading misinformation if someone doesn't read the whole thing, so in trying to make headlines engaging, it is important to consider what might be some unintended consequences if someone didn't read past the subtitle. science isn't just about the findings, the process only gets completed when we have effective communication to the larger audience of the results, and now more than ever, we need accurate information to overpower the pool of misinformation out there. there is a potential for ai to automate repetitive tasks and free up scarce resources towards more value-added tasks. with a declining business model and tough revenue situations, newsrooms and journalism at large are facing an existential crisis. cutting costs while still keeping up high standards of reporting will require innovation on the part of newsrooms to adapt emerging technologies like ai. for example, routine tasks like reporting on sports scores from games and giving updates on company earnings calls is already something that is being done by ai systems in several newsrooms around the world. this frees up time for journalists to spend their efforts on things like long-form journalism, data-driven and investigative journalism, analysis and feature pieces which require human depth and creativity. machine translation also offers a handy tool making the work of journalists accessible to a wider audience without them having to invest in a lot of resources to do the translations themselves. this also brings up the possibility of smaller and resource-constrained media rooms to use their limited resources for doing in-depth pieces while reaching a wider audience by relying on automation. transcription of audio interviews so that reporters can work on fact-checking and other associated pieces also helps bring stories to fruition faster, which can be a boon in the rapidly changing environment. in the case of evolving situations like the pandemic, there is also the possibility of using ai to parse through large reams of data to find anomalies and alert the journalist of potential areas to cover. complementing human skills is the right way to adopt ai rather than thinking of it as the tool that replaces human labor. the article gives an explanation for why truth labels on stories are not as effective as we might think them to be because of something called the implied truth effect. essentially, it states that when some things are marked as explicitly false and other false stories aren't, people believe them to be true even if they are outright false because of the lack of a label. fact checking all stories manually is an insurmountable task for any platform and the authors of the study mention a few approaches that could potentially mitigate the spread of false content but none are a silver bullet. there is an ongoing and active community that researches how we might more effectively dispel disinformation but it's nascent and with the proliferation of ai systems, more work needs to be done in this arms race of building tools vs increasing capabilities of systems to generate believable fake content. this paper by xiao ma and taylor w. brown puts forth a framework that extends the well studied social exchange theory (set) to study human-ai interactions via mediation mechanisms. the authors make a case for how current research needs more interdisciplinary collaboration between technical and social science scholars stemming from a lack of shared taxonomy that places research in similar areas on separate grounds. they propose two axes of human/ai and micro/macro perspectives to visualize how researchers might better collaborate with each other. additionally, they make a case for how ai agents can mediate transactions between humans and create potential social value as an emergent property of those mediated transactions. as the pace of research progress quickens and more people from different fields engage in work on the societal impacts of ai, it is essential that we build on top of each other's work rather than duplicating efforts. additionally, because of conventional differences in how research is published and publicized in the social sciences and technical domains, there's often a shallowness in the awareness of the latest work being done at the intersection of these two domains. what that means is that we need a shared taxonomy that allows us to better position research such that potential gaps can be discovered and areas of collaboration can be identified. the proposed two axes structure in the paper goes some distance in helping to bridge this current gap. ai systems are becoming ever more pervasive in many aspects of our everyday lives and we definitely see a ton of transactions between humans that are mediated by automated agents. in some scenarios, they lead to net positive for society when they enable discovery of research content faster as might be the case for medical research being done to combat covid- but there might be negative externalities as well where they can lead to echo chambers walling off content from a subset of your network on social media platforms thus polarizing discussions and viewpoints. a better understanding of how these interactions can be engineered to skew positive will be crucial as ai agents get inserted to evermore aspects of our lives, especially ones that will have a significant impact on our lives. we also foresee an emergence of tighter interdisciplinary collaboration that can shed light on these inherently socio-technical issues which don't have unidimensional solutions. with the rising awareness and interest from both social and technical sciences, the emerging work will be both timely and relevant to addressing challenges of the societal impacts of ai head on. as a part of the work being done at maiei we push for each of our undertakings to have an interdisciplinary team as a starting point towards achieving this mandate. most concerns when aiming to use technology within healthcare are along the lines of replacing human labor and the ones that are used in aiding humans to deliver care don't receive as much attention. with the ongoing pandemic, we've seen this come into the spotlight as well and this paper sets the stage for some of the ethical issues to watch out for when thinking about using ai-enabled technologies in the healthcare domain and how to have a discussion that is grounded in concrete moral principles. an argument put forth to counter the use of ai solutions is that they can't "care" deeply enough about the patients and that is a valid concern, after all machines don't have empathy and other abilities required to have an emotional exchange with humans. but, a lot of the care work in hospitals is routine and professionalism asks for maintaining a certain amount of emotional distance in the care relationship. additionally, in places where the ratio of patients/carers is high, they are unable to provide personalized attention and care anyways. in that respect, human-provided care is already "shallow" and the author cites research where care that is too deep actually hurts the carer when the patients become better and move out of their care or die. thus, if this is the argument, then we need to examine more deeply our current care practices. the author also posits that if this is indeed the state of care today, then it is morally less degrading to be distanced by a machine than by a human. in fact, the use of ai to automate routine tasks in the rendering of medical care will actually allow human carers to focus more on the emotional and human aspects of care. good healthcare, supposedly that provided by humans doesn't have firm grounding in the typical literature on the ethics of healthcare and technology. it's more so a list of things not to do but not positive guidance on what this kind of good healthcare looks like. thus, the author takes a view that it must, at the very least, respect, promote and preserve the dignity of the patient. yet, this doesn't provide concrete enough guidance and we can expand on this to say that dignity is a) treating the patient as a human b) treating them as a part of a culture and community and c) treating them as a unique human. to add even more concreteness, the author borrows from the work done in economics on the capabilities approach. this capabilities approach states that having the following capabilities in their entirety is necessary for a human to experience dignity in their living: life, bodily health, bodily integrity, being able to use your senses, imaginations and thoughts, emotions, practical reasoning, affiliation, other species, play, and control over one's environment. this list applied to healthcare gives us a good guideline for what might constitute the kind of healthcare that we deem should be provided by humans, with or without the use of technology. now, the above list might seem too onerous for healthcare professionals but we need to keep in mind that healthcare to achieve a good life as highlighted by the capabilities approach things that are dependent on things beyond just the healthcare professionals and thus, the needs as mentioned above need to be distributed accordingly. the threshold for meeting them should be high but not so high that they are unachievable. principles are only sufficient for giving us some guidance for how to act in difficult situations or ethical dilemmas, they don't determine the outcome because they are only one element in the decision making process. we have to rely on the context of the situation and the moral surroundings of it. the criteria proposed are to be used in moral deliberation and should address whether the criterion applies to the situation, is it satisfied and is it sufficiently met (which is in reference to the threshold). with the use of ai-enabled technology, privacy is usually cited as a major concern but the rendering of care is decidedly a non-private affair, imagine a scenario where the connection facilitated by technology allows for meeting the social and emotional needs of a terminal patient, if there is a situation where the use of technology allows for a better and longer life, then in these cases there can be an argument for sacrificing privacy to meet the needs of the patient. ultimately, a balance needs to be struck between the privacy requirements and other healthcare requirements and privacy should not be blindly touted as the most important requirement. framing the concept of the good life with a view of restoring, maintaining and enhancing the capabilities of the human, one mustn't view eudaimonia as happiness but rather the achievement of the capabilities listed because happiness in this context would fall outside of the domain of ethics. additionally, the author proposes the care experience machine thought experiment that can meet all the care needs of a patient and asks the question if it would be morally wrong to plug in a patient into such a machine. while intuitively it might seem wrong, we struggle when trying to come up with concrete objections. as long as the patient feels cared for and has, from an objective standpoint, their care needs met, it becomes hard to contest how such virtual care might differ from real care that is provided by humans. if one can achieve real capabilities, such as the need to have freedom of movement and interaction with peers outside of their care confinement and virtual reality technology enables that, then the virtual good life enhances the real good life -a distinction that becomes increasingly blurred as technology progresses. another moral argument put forward in determining whether to use technology-assisted healthcare is if it is too paternalistic to determine what is best for the patient. in some cases where the patient is unable to make decisions that restore, maintain and enhance their capabilities, such paternalism might be required but it must always be balanced with other ethical concerns and keeping in mind the capabilities that it enables for the patient. when we talk about felt care and how to evaluate whether care rendered is good or not, we should not only look at the outcomes of the process through which the patient exits the healthcare context but also the realization of some of the capabilities during the healthcare process. to that end, when thinking about felt care, we must also take into account the concept of reciprocity of feeling which is not explicitly defined in the capabilities approach but nonetheless forms an important aspect of experiencing healthcare in a positive manner from the patient's perspective. in conclusion, it is important to have an in-depth evaluation of technology assisted healthcare that is based on moral principles and philosophy, yet resting more on concrete arguments rather than just the high-level abstracts as they provide little practical guidance in evaluating different solutions and how they might be chosen to be used in different contexts. an a priori dismissal of technology in the healthcare domain, even when based on very real concerns like breach of privacy in the use of ai solutions which require a lot of personal data, begets further examination before arriving at a conclusion. the article brings up some interesting points around how we bond with things that are not necessarily sentient and how our emotions are not discriminating when it comes to reducing loneliness and imprinting on inanimate objects. people experience surges in oxytocin as a consequence of such a bonding experience which further reinforces the relationship. this has effects for how increasingly sentient-appearing ai systems might be used to manipulate humans into a "relationship" and potentially steer them towards making purchases, for example via chatbot interfaces by evoking a sense of trust. the article also makes a point about how such behaviour is akin to animism and in a sense forms a response to loneliness in the digital realm, allowing us to continue to hone our empathy skills for where they really matter, with other human beings. with more and more of our conversations being mediated by ai-enabled systems online, it is important to see if robots can be harnessed to affect positive behaviour change in our interactions with each other. while there have been studies that demonstrate the positive impact that robots can have on influencing individual behaviour, this study highlighted how the presence of robots can influence human to human interactions as well. what the researchers found was that having a robot that displayed positive and affective behavior triggered more empathy from humans towards other humans as well as other positive behaviors like listening more and splitting speaking time amongst members more fairly. this is a great demonstration of how robots can be used to improve our interactions with each other. another researcher pointed out that a future direction of interest would be to see how repeated exposure to such robot interactions can influence behaviour and if the effects so produced would be long-lasting even in the absence of the robot to participate in the interactions. since time immemorial there has been a constant tussle between making predictions and being able to understand the underlying fundamentals of how those predictions worked. in the era of big data, those tensions are exacerbated as machines become more inscrutable while making predictions using ever-more higher-dimensional data which lies beyond intuitive understanding of humans. we try to reason through some of that high-dimensional data by utilizing techniques that either reduce the dimensions or visualize into -or -dimensions which by definition will tend to lose some fidelity. bacon had proposed that humans should utilize tools to gain a better understanding of the world around them -until recently where the physical processes of the world matched quite well with our internal representations, this wasn't a big concern. but a growing reliance on tools means that we rely more on what is made possible by the tools as they measure and model the world. statistical intelligence and models often get things right but often they are hostile to reconstruction as to how they arrived at certain predictions. models provide for abstractions of the world and often don't need to follow exactly the real-world equivalents. for example, while the telescope allows us to peer far into the distance, its construction doesn't completely mimic a biological eye. more so, radio telescopes that don't follow optics at all give us a unique view into distant objects which are just not possible if we rely solely on optical observations. illusions present us with a window into the limits of our perceptual systems and bring into focus the tension between the reality and what we think is the reality. "in just the same way that prediction is fundamentally bounded by sensitivity of measurement and the shortcomings of computation, understanding is both enhanced and diminished by the rules of inference." in language models, we've seen that end-to-end deep learning systems that are opaque to our understanding perform quite a bit better than traditional machine translation approaches that rest on decades of linguistic research. this bears some resemblance to searle's chinese room experiment where if we just look at the inputs and the outputs, there isn't a guarantee that the internal workings of the system work in exactly the way we expect them to. "the most successful forms of future knowledge will be those that harmonise the human dream of understanding with the increasingly obscure echoes of the machine." abhishek gupta (founder of the montreal ai ethics institute) was featured in fortune where he detailed his views on ai safety concerns in rl systems, the "token human" problem, and automation surprise among other points to pay attention to when developing and deploying ai systems. especially in situations where these systems are going to be used in critical scenarios, humans operating in tandem with these systems and utilizing them as decision inputs need to gain a deeper understanding of the inherent probabilistic nature of the predictions from these systems and make decisions that take it into consideration rather than blindly trusting recommendations from an ai system because they have been accurate in % of the scenarios. with increasing capabilities of ai systems, and established research that demonstrates how human-machine combinations operate better than each in isolation, this paper presents a timely discussion on how we can craft better coordination between human and machine agents with the aim of arriving at the best possible understanding between them. this will enhance trust levels between the agents and it starts with having effective communication. the paper discusses how framing this from a human-computer interaction (hci) approach will lead to achieving this goal. this is framed with intention-, context-, and cognition-awareness being the critical elements which would be responsible for the success of effective communication between human and machine agents. intelligibility is a notion that is worked on by a lot of people in the technical community who seek to shed a light on the inner workings of systems that are becoming more and more complex. especially in the domains of medicine, warfare, credit allocation, judicial systems and other areas where they have the potential to impact human lives in significant ways, we seek to create explanations that might illuminate how the system works and address potential issues of bias and fairness. however, there is a large problem in the current approach in the sense that there isn't enough being done to meet the needs of a diverse set of stakeholders who require different kinds of intelligibility that is understandable to them and helps them meet their needs and goals. one might argue that a deeply technical explanation ought to suffice and others kinds of explanations might be derived from that but it makes them inaccessible to those who can't parse well the technical details, often those who are the most impacted by such systems. the paper offers a framework to situate the different kinds of explanations such that they are able to meet the stakeholders where they are at and provide explanations that not only help them meet their needs but ultimately engender a higher level of trust from them by highlighting better both the capabilities and limitations of the systems. ai value alignment is typically mentioned in the context of long-term agi systems but this also applies to the narrow ai systems that we have today. optimizing for the wrong metric leads to things like unrealistic and penalizing work schedules, hacking attention on video platforms, charging more money from poorer people to boost the bottomline and other unintended consequences. yet, there are attempts by product design and development teams to capture human well-being as metrics to optimize for. "how does someone feel about how their life is going?" is a pretty powerful question that gives a surprising amount of insight into well-being distanced from what might be influencing them at the moment because it makes them pause and reflect on what matters to them. but, capturing this subjective sentiment as a metric in an inherently quantitative world of algorithms is unsurprisingly littered with mines. a study conducted by facebook and supported by external efforts found that passive use of social media triggered feelings of ennui and envy while active use including interactions with others on the network led to more positive feelings. utilizing this as a guiding light, facebook strove to make an update that would be more geared towards enabling meaningful engagement rather than simply measuring the number of likes, shares and comments. they used user panels as an input source to determine what constituted meaningful interactions on the platform and tried to distill this into the well-being metrics. yet, this suffered from several flaws, namely that the evaluation of this change was not publicly available and was based on the prior work comparing passive vs. active use of social media. this idea of well-being optimization extends to algorithmic systems beyond social media platforms, for example, with how gig work might be better distributed on a platform such that income fluctuations are minimized for workers who rely on it as a primary source of earnings. another place could be amending product recommendations to also capture environmental impacts such that consumers can incorporate that into their purchasing decisions apart from just the best price deals that they can find. participatory design is going to be a key factor in the development of these metrics; especially given the philosophy of "nothing about us without us" as a north star to ensure that there isn't an inherent bias in how well-being is optimized for. often, we'll find that proxies will need to stand in for actual well-being in which case it is important to ensure that the metrics are not static and are revised in consultation with users at periodic intervals. tapping into the process of double loop learning, an organization can not only optimize for value towards its shareholders but also towards all its other stakeholders. while purely quantitative metrics have obvious limitations when trying to capture something that is inherently subjective and qualitative, we need to attempt something in order to start and iterate as we go along. in a world where increasing automation of cognitive labor due to ai-enabled systems will dramatically change the future of labor, it is now more important than ever that we start to move away from a traditional mindset when it comes to education. while universities in the previous century rightly provided a great value in preparing students for jobs, as jobs being bundle of tasks and those tasks rapidly changing with some being automated, we need to focus more on training students for things that will take much longer to automate, for example working with other humans, creative and critical thinking and driving innovation based on insights and aggregating knowledge across a diversity of fields. lifelong learning serves as a useful model that can impart some of these skills by breaking up education into modules that can be taken on an "at will" basis allowing people to continuously update their skills as the landscape changes. students will go in and out of universities over many years which will bring a diversity of experiences to the student body, encouraging a more close alignment with actual skills as needed in the market. while this will pose significant challenges to the university system, innovations like online learning and certifications based on replenishment of skills like in medicine could overcome some of those challenges for the education ecosystem. individual actions are powerful, they create bottom-up change and empower advocates with the ability to catalyze larger change. but, when we look at products and services with millions of users where designs that are inherently unethical become part of everyday practice and are met with a slight shrug of the shoulders resigning to our fates, we need a more systematized approach that is standardized and widely practiced. ethics in ai is having its moment in the spotlight with people giving talks and conferences focusing on it as a core theme yet it falls short of putting the espoused principles into practice. more often than not, you have individuals, rank and file employees who go out of their way, often on personal time, to advocate for the use of ethical, safety and inclusivity in the design of systems, sometimes even at the risk of their employment. while such efforts are laudable, they lack widespread impact and awareness that is necessary to move the needle, we need leaders at the top who can affect sweeping changes to adopt these guidelines not just in letter but in spirit and then transmit them as actionable policies to their workforce. it needs to arrive at a point where people advocating for this change don't need to do so from a place of moral and ethical obligations which customers can dispute but from a place of policy decisions which force disengagement for non-adherence to these policies. we need to move from talk to action not just at a micro but at a macro scale. the wrong kind of ai? artificial intelligence and the future of labor demand do increasing efficiency and social benefits stand in exclusion to each other when it comes to automation technology? with the development of the "right" kind of ai, this doesn't have to be the case. ai is a general purpose technology that has wide applications and being offered as a platform, it allows others to build advanced capabilities on top of existing systems creating an increasingly powerful abstraction layer with every layer. according to the standard approach in economics, a rise in productivity is often accompanied with an increase in the demand for labor and hence a rise in wages along with standards of living. but, when there is a decoupling between the deployment of technology and the associated productivity accrual, it can lead to situations where we see more output but not a corresponding increase in the standards of living as the benefits accrue to capital owners rather than wage-earning labor which is distanced from the production lifecycle. this unevenness in the distribution of gains causes losses of jobs in one sector while increasing productivity in others, often masking effects at an aggregate level through the use of purely economic focused indicators like gdp growth rates. the authors expound on how the current wave of automation is highly focused on labor replacement driven by a number of factors. when this comes in the form of automation that is just as good as labor but not significantly better, we get the negative effects as mentioned before, that is a replacement of labor without substantial increases in the standards of living. most of these effects are felt by those in the lower rungs of the socio-economic ladder where they don't have alternate avenues for employment and ascent. a common message is that we just have to wait as we did in the case of the industrial revolution and new jobs will emerge that we couldn't have envisioned which will continue to fuel economic prosperity for all. this is an egregious comparison that overlooks that the current wave of automation is not creating simultaneous advances in technology that allow the emergence of a new class of tasks within jobs for which humans are well-suited. instead, it's increasingly moving into domains that were strongholds of human skills that are not easily repeatable or reproducible. what we saw in the past was an avenue made available to workers to move out of low skill tasks in agriculture to higher skill tasks in manufacturing and services. some examples of how ai development can be done the "right" way to create social benefits: • in education, we haven't seen a significant shift in the way things are done for close to years. it has been shown that different students have different learning styles and can benefit from personalized attention. while it is infeasible to do so in a traditional classroom model, ai offers the potential to track metrics on how the student interacts with different material, where they make mistakes, etc., offering insights to educators on how to deliver a better educational experience. this is accompanied by an increase in the demand for teachers who can deliver different teaching styles to match the learning styles of students and create better outcomes. • a similar argument can be made in the field of healthcare where ai systems can allow medical staff to spend more time with patients offering them personalized attention for longer while removing the need for onerous and drudgery in the form of menial tasks like data entry. • industrial robots are being used to automate the manufacturing line often cordoning off humans for safety reasons. humans are also decoupled from the process because of a difference in the level of precision that machines can achieve compared to humans. but we can get the best of both worlds by combining human flexibility and critical thinking to address problems in an uncertain environment with the high degree of preciseness of machines by creating novel interfaces, for example, by using augmented reality. an important distinction that the authors point out in the above examples is that they are not merely the job of enablers, humans that are used to train machines in a transitory fashion, but those that genuinely complement machine skills. there are market failures when it comes to innovation and in the past, governments have helped mitigate those failures via public-private partnerships that led to the creation of fundamental technologies like the internet. but, this has decreased over the past two decades because of smaller amount of resources being invested by the government in basic research and the technology revolution becoming centered in silicon valley which has a core focus on automation that replaces labor, and with that bias and their funding of university and academic studies, they are causing the best minds of the next generation to have the same mindset. markets are also known to struggle when there are competing paradigms and once one pulls ahead, it is hard to switch to another paradigm even if it might be more productive thus leading to an entrenchment of the dominant paradigm. the social opportunity cost of replacing labor is lower than the cost of labor, pushing the ecosystem towards labor replacing automation. without accounting for these externalities, the ecosystem has little incentive to move towards the right kind of ai. this is exacerbated by tax incentives imposing costs on labor while providing a break on the use of capital. additionally, areas where the right kind of ai can be developed don't necessarily fall into the cool domain of research and thus aren't prioritized by the research and development community. let's suppose large advances were made in ai for health care. this would require accompanying retraining of support staff aside from doctors, and the high level bodies regulating the field would impose resistance, thus slowing down the adoption of this kind of innovation. ultimately, we need to lean on a holistic understanding of the way automation is going to impact the labor market and it will require human ingenuity to shape the social and economic ecosystems such that they create net positive benefits that are as widely distributed as possible. relying on the market to figure this out on its own is a recipe for failure. the labor impacts of ai require nuance in discussion rather than fear-mongering that veers between over-hyping and downplaying concerns when the truth lies somewhere in the middle. in the current paradigm of supervised machine learning, ai systems need a lot of data before becoming effective at their automation tasks. the bottom rung of this ladder consists of robotic process automation that merely tracks how humans perform a task (say, by tracking the clicks of humans as they go about their work) and ape them step by step for simple tasks like copying and pasting data across different places. the article gives an example of an organization that was able to minimize churn in their employees by more than half because of a reduction in data drudgery tasks like copying and pasting data across different systems to meet legal and compliance obligations. economists point out that white-collar jobs like these and those that are middle-tier in terms of skills that require little training are at the highest risk of automation. while we're still ways away from ai taking up all jobs, there is a slow march starting from automating the most menial tasks, potentially freeing us up to do more value-added work. with a rising number of people relying on social media for the news, the potential for hateful content and misinformation spreading has never been higher. content moderation on platforms like facebook and youtube is still largely a human endeavor where there are legions of contract workers that spend their days reviewing whether different pieces of content meet the community guidelines of the platform. due to the spread of the pandemic and offices closing down, a lot of these workers have been asked to leave (they can't do this work from home as the platform companies explained because of privacy and legal reasons), leaving the platforms in the hands of automated systems. the efficacy of these systems has always been questionable and as some examples in the article point out, they've run amok taking down innocuous and harmful content alike, seeming to not have very fine-tuned abilities. the problem with this is that legitimate sources of information, especially on subjects like covid- , are being discouraged because of their content being taken down and having to go through laborious review processes to have their content be approved again. while this is the perfect opportunity to experiment with the potential of using automated systems for content moderation given the traumatic experience that humans have to undergo as a part of this job, the chasms that need to be bridged still remain large between what humans have to offer and what the machines are capable of doing at the moment. workplace time management and accounting are common practices but for those of us who work in places where schedules are determined by automated systems, they can have many negative consequences, a lot of which could be avoided if employers paid more attention to the needs of their employees. clopening is the notion where an employee working at a retail location is asked to not only close the location at the end of the day but also arrive early the next day to open the location. this among other practices like breaks that are scheduled down to the minute and on-call scheduling (something that was only present in the realm of emergency services) wreak havoc on the physical and mental health of employees. in fact, employees surveyed have even expressed willingness to take pay cuts to have greater control over their schedules. in some places with ad-hoc scheduling, employees are forced to be spontaneous with their home responsibilities like taking care of their children, errands, etc. while some employees try to swap shifts with each other, often even that becomes hard to do because others are also in similar situations. some systems track customer demand and reduce pay for hours worked tied to that leading to added uncertainty even with their paychecks. during rush seasons, employees might be scheduled for back to back shifts ignoring their needs to be with families, something that a human manager could empathize with and accommodate for. companies supplying this kind of software hide behind the disclaimer that they don't take responsibility for how their customers use these systems which are often black-box and inscrutable to human analysis. this is a worrying trend that hurts those who are marginalized and those who require support when juggling several jobs just to make ends meet. relying on automation doesn't absolve the employers of their responsibility towards their employees. while the dominant form of discussion around the impacts of automation have been that it will cause job losses, this work from kevin scott offers a different lens into how jobs might be created by ai in the rust belt in the us where automation and outsourcing have been gradually stripping away jobs. examples abound of how entrepreneurs and small business owners with an innovative mindset have been able to leverage advances in ai, coupling them with human labor to repurpose their businesses from areas that are no longer feasible to being profitable. precision farming utilizes things like drones with computer vision capabilities to detect hotspots with pests, disease, etc. in the big farms that would otherwise require extensive manual labor which would limit the size of the farms. self-driving tractors and other automated tools also augment human effort to scale operations. the farm owners though highlight the opaqueness and complexity of such systems which make them hard to debug and fix themselves which sometimes takes away from the gains. on the other hand, in places like nursing homes that get reimbursed based on the resource utilization rates by their residents, tools using ai can help minimize human effort in compiling data and let them spend more of their effort on human contact which is not something that ai succeeds on yet. while automation has progressed rapidly, the gains haven't been distributed equally. in other places where old factories were shut down, some of them are now being utilized by ingenious entrepreneurs to bring back manufacturing jobs that cleverly combine human labor with automation to deliver high-quality, custom products to large enterprises. thus, there will be job losses from automation but the onus lies with us in steering the progress of ai towards economic and ethical values that we believe in. the state of ai ethics, june what's next for ai ethics, policy, and governance? a global overview in this ongoing piece of work, the authors present the landscape of ethical documents that has been flooded with guidelines and recommendations coming from a variety of sectors including government, private organizations, and ngos. starting with a dive into the stated and unstated motivations behind the documents, the reader is provided with a systematic breakdown of the different documents prefaced with the caveat that where the motivations are not made explicit, one can only make a best guess based on the source of origin and people involved in its creation. the majority of the documents from the governmental agencies were from the global north and western countries which led to a homogeneity of issues that were tackled and the recommendations often touted areas of interest that were specific to their industry and economical make up. this left research and development areas of interest like tourism and agriculture largely ignored which continue to play a significant role in the global south. the documents from the former category were also starkly focused on gaining a competitive edge, which was often stated explicitly, with a potential underlying goal of attracting scarce, high-quality ai talent which could trigger brain drain from other countries that are not currently the dominant players in the ai ecosystem. often, they were also positioning themselves to gain an edge and define a niche for themselves, especially in the case of countries that are non-dominant and thus overemphasizing the benefits while downplaying certain negative consequences that might arise from widespread ai use, like the displacement and replacement of labor. for documents from private organizations, they mostly focused on self and collective regulation in an effort to pre-empt stringent regulations from taking effect. they also strove to tout the economic benefits to society at large as a way of de-emphasizing the unintended consequences. a similar dynamic as in the case of government documents played out here where the interests of startups and small and medium sized businesses were ignored and certain mechanisms proposed would be too onerous for such smaller organizations to implement this further entrenching the competitive advantage of larger firms. the ngos on the other hand seemed to have the largest diversity both in terms of the participatory process of creation and the scope, granularity, and breadth of issues covered which gave technical, ethical, and policy implementation details making them actionable. some documents like the montreal declaration for responsible ai were built through an extensive public consultation process and consisted of an iterative and ongoing approach that the montreal ai ethics institute contributed to as well. the ieee document leverages a more formal standards making approach and consists of experts and concerned citizens from different parts of the world contributing to its creation and ongoing updating. the social motivation is clearly oriented towards creating larger societal benefits, internal motivation is geared towards bringing about change in the organizational structure, external strategic motivation is often towards creating a sort of signaling to showcase leadership in the domain and also interventional to shape policy making to match the interests of those organizations. judging whether a document has been successful is complicated by a couple of factors: discerning what the motivations and the goals for the document were, and the fact that most implementations and use of the documents is done in a pick-and-choose manner complicating attribution and weight allocation to specific documents. some create internal impacts in terms of adoption of new tools, change in governance, etc., while external impacts often relate to changes in policy and regulations made by different agencies. an example would be how the stem education system needs to be overhauled to better prepare for the future of work. some other impacts include altering customer perception of the organization as one that is a responsible organization which can ultimately help them differentiate themselves. at present, we believe that this proliferation of ethics documents represents a healthy ecosystem which promotes a diversity of viewpoints and helps to raise a variety of issues and suggestions for potential solutions. while there is a complication caused by so many documents which can overwhelm people looking to find the right set of guidelines that helps them meet their needs, efforts such as the study being done in this paper amongst other efforts can act as guideposts to lead people to a smaller subset from which they can pick and choose the guidelines that are most relevant to them. the white paper starts by highlighting the existing tensions in the definitions of ai as there are many parties working on advancing definitions that meet their needs. one of the most commonly accepted ones frames ai systems as those that are able to adapt their behavior in response to interactions with the world independent of human control. also, another popular framing is that ai is something that mimics human intelligence and is constantly shifting as a goal post as what was once perceived as ai, when sufficiently integrated and accepted in society becomes everyday technology. one thing that really stands out in the definitions section is how ethics are defined, which is a departure from a lot of other such documents. the authors talk about ethics as a set of principles of morality where morality is an assemblage of rules and values that guide human behavior and principles for evaluating that behavior. they take a neutral stand on the definition, a far cry from framing it as a positive inclination of human conduct to allow for diversity in embedding ethics into ai systems that are in concordance with local context and culture. ai systems present many advantages which most readers are now already familiar given the ubiquity of ai benefits as touted in everyday media. one of the risks of ai-enabled automation is the potential loss of jobs, the authors make a comparison with some historical cases highlighting how some tasks and jobs were eliminated creating new jobs while some were permanently lost. many reports give varying estimates for the labor impacts and there isn't yet a clear consensus on the actual impacts that this might have on the economy. from a liability perspective, there is still debate as to how to account for the damage that might be caused to human life, health and property by such systems. in a strict product liability regime like europe, there might be some guidance on how to account for this, but most regimes don't have specific liability allocations for independent events and decisions meaning users face coverage gaps that can expose them to significant harms. by virtue of the complexity of deep learning systems, their internal representations are not human-understandable and hence lack transparency, which is also called the black box effect. this is harmful because it erodes trust from the user perspective, among other negative impacts. social relations are altered as more and more human interactions are mediated and governed by machines. we see examples of that in how our newsfeeds are curated, toys that children play with, and robots taking care of the elderly. this decreased human contact, along with the increasing capability of machine systems, examples of which we see in how disinformation spreads, will tax humans in constantly having to evaluate their interactions for authenticity or worse, relegation of control to machines to the point of apathy. since the current dominant paradigm in machine learning is that of supervised machine learning, access to data is crucial to the success of the systems and in the state of ai ethics, june cases where there aren't sufficient protections in place for personal data, it can lead to severe privacy abuses. self determination theory states that autonomy of humans is important for proper functioning and fulfillment, so an overreliance on ai systems to do our work can lead to loss of personal autonomy, which can lead to a sense of digital helplessness. digital dementia is the cognitive equivalent where relying on devices for things like storing phone numbers, looking up information, etc. will over time lead to a decline in cognitive abilities. the echo chamber effect is fairly well studied, owing to the successful use of ai technologies to promulgate disinformation to the masses during the us presidential elections of . due to the easy scalability of the systems, the negative effects are multiplicative in nature and have the potential to become run-away problems. given that ai systems are built on top of existing software and hardware, errors in the underlying systems can still cause failures at the level of ai systems. more so, given the statistical nature of ai systems, behaviour is inherently stochastic and that can cause some variability in response which is difficult to account for. flash crashes in the financial markets are an example of this. for critical systems that require safety and robustness, there is a lot that needs to be done for ensuring reliability. building ethics compliance by design can take a bottom-up or top-down approach, the risk with a bottom-up approach is that by observing examples of human behaviour and extracting ethics principles from that, instead of getting things that are good for people, you get what's common. hence, the report advocates for a top-down approach where desired ethical behavior is directly programmed into the system. casuistic approaches to embedding ethics into systems would work well in situations where there are simple scenarios, such as in healthcare when the patient has a clear directive of do-not-resuscitate. but, in cases where there isn't one and where it is not possible to seek a directive from the patient, such an approach can fail and it requires that programmers either in a top-down manner embed rules or the system learns from examples. though, in a high-stakes situation like healthcare, it might not be ideal to rely on learning from examples because of skewed and limited numbers of samples. a dogmatic approach would also be ill-advised where a system might slavishly follow a particular school of ethical beliefs which might lead it to make decisions that might be unethical in certain scenarios. ethicists utilize several schools of thought when addressing a particular situation to arrive at a balanced decision. it will be crucial to consult with a diversity of stakeholders such that the nuances of different situations can be captured well. the wef is working with partners to come up with an "ethical switch" that will imbue flexibility on the system such that it can operate with different schools of thought based on the demands of the situation.the report also proposes the potential of utilizing a guardian ai system that can monitor other ai systems to check for compliance with different sets of ai principles. given that ai systems operate in a larger socio-technical ecosystem, we need to tap into fields like law and policy making to come up with effective ways of integrating ethics into ai systems, part of which can involve creating binding legal agreements that tie in with economic incentives.while policy making and law are often seen as slow to adapt to fast changing technology, there are a variety of benefits to be had, for example higher customer trust for services that have adherence to stringent regulations regarding privacy and data protection. this can serve to be a competitive advantage and counter some of the negative innovation barriers imposed by regulations. another point of concern with these instruments is that they are limited by geography which leads to a patchwork of regulation that might apply on a product or service that spans several jurisdictions. some other instruments to consider include: self-regulation, certification, bilateral investments treaties, contractual law, soft law, agile governance, etc. the report highlights the initiatives by ieee and wef in creating standards documents. the public sector through its enormous spending power can enhance the widespread adoption of these standards such as by utilizing them in procurement for ai systems that are used to interact with and serve their citizens. the report also advocates for the creation of an ethics board or chief values officer as a way of enhancing the adoption of ethical principles in the development of products and services. for vulnerable segments of the population, for example children, there need to be higher standards of data protection and transparency that can help parents make informed decisions about which ai toys to bring into their homes. regulators might play an added role of enforcing certain ethics principles as part of their responsibility. there also needs to be broader education for ai ethics for people that are in technical roles. given that there are many negative applications of ai, it shouldn't preclude us from using ai systems for positive use cases, a risk assessment and prudent evaluation prior to use is a meaningful compromise. that said, there are certain scenarios where ai shouldn't be used at all and that can be surfaced through the risk or impact assessment process. there is a diversity of ethical principles that have been put forth by various organizations, most of which are in some degree of accordance with local laws, regulations, and value sets. yet, they share certain universal principles across all of them. one concern highlighted by the report is on the subject of how even widely accepted and stated principles of human rights can be controversial when translated into specific mandates for an ai system. when looking at ai-enabled toys as an example, while they have a lot of privacy and surveillance related issues, in countries where there isn't adequate access to education, these toys could be seen as a medium to impart precision education and increase literacy rates. thus, the job of the regulator becomes harder in terms of figuring out how to balance the positive and negative impacts of any ai product. a lot of it depends on the context and surrounding socio-economic system as well. given the diversity in ethical values and needs across communities, an approach might be for these groups to develop and apply non-binding certifications that indicate whether a product meets the ethical and value system of that community. since there isn't a one size fits all model that works, we should aim to have a graded governance structure that has instruments in line with the risk and severity profile of the applications. regulation in the field of ai thus presents a tough challenge, especially given the interrelatedness of each of the factors. the decisions need to be made in light of various competing and sometimes contradictory fundamental values. given the rapid pace of technological advances, the regulatory framework needs to be agile and have a strong integration into the product development lifecycle. the regulatory approach needs to be such that it balances speed so that potential harms are mitigated with overzealousness that might lead to ineffective regulations that stifle innovation and don't really understand well the technology in question. ai is currently enjoying a summer of envy after having gone through a couple of winters of disenchantment, with massive interest and investments from researchers, industry and everyone else there are many uses of ai to create societal benefits but they aren't without their socio-ethical implications. ai systems are prone to biases, unfairness and adversarial attacks on their robustness among other real-world deployment concerns. even when ethical ai systems are deployed for fostering social good, there are risks that they cater to only a particular group to the detriment of others. moral relativism would argue for a diversity of definitions as to what constitutes good ai which would depend on the time, context, culture and more. this would be reflected in market decisions by consumers who choose products and services that align with their moral principles but it poses a challenge for those trying to create public governance frameworks for these systems. this dilemma would push regulators towards moral objectivism which would try and advocate for a single set of values that are universal making the process of coming up with a shared governance framework easier. a consensus based approach utilized in crafting the ec trustworthy ai guidelines settled on human rights as something that everyone can get on board with. given the ubiquity in the applicability of human rights, especially with their legal enshrinement in various charters and constitutions, they serve as a foundation to create legal, ethical and robust ai as highlighted in the ec trustworthy ai guidelines. stressing on the importance of protecting human rights, the guidelines advocate for a trustworthy ai assessment in case that an ai system has the potential to negatively impact the human rights of an individual, much like the better established data protection impact assessment requirement under the gdpr. additional requirements are imposed in terms of ex-ante oversight, traceability, auditability, stakeholder consultations, and mechanisms of redress in case of mistakes, harms or other infringements. the universal applicability of human rights and their legal enshrinement also renders the benefits of established institutions like courts whose function is to monitor and enforce these rights without prejudice across the populace. but they don't stand uncontested when it comes to building good ai systems; they are often seen as too western, individualistic, narrow in scope and abstract to be concrete enough for developers and designers of these systems. some arguments against this are that they go against the plurality of value sets and are a continued form of former imperialism imposing a specific set of values in a hegemonic manner. but, this can be rebutted by the signing of the original universal declaration of human rights that was done by nations across the world in an international diplomatic manner. however, even despite numerous infringements, there is a normative justification that they ought to be universal and enforced. while human rights might be branded as too individual focused, potentially creating a tension between protecting the rights of individuals to the detriment of societal good, this is a weak argument because stronger protection of individual rights has knock-on social benefits as free, healthy and well-educated (among other individual benefits) creates a net positive for society as these individuals are better aware and more willing to be concerned about societal good. while there are some exceptions to the absolute nature of human rights, most are well balanced in terms of providing for the societal good and the good of others while enforcing protections of those rights. given the long history of enforcement and exercises in balancing these rights in legal instruments, there is a rich jurisprudence on which people can rely when trying to assess ai systems. while human rights create a social contract between the individual and the state, putting obligations on the state towards the individual but some argue that they don't apply horizontally between individuals and between an individual and a private corporation. but, increasingly that's not the case as we see many examples where the state intervenes and enforces these rights and obligations between an individual and a private corporation as this falls in its mandate to protect rights within its jurisdiction. the abstract nature of human rights, as is the case with any set of principles rather than rules, allows them to be applied to a diversity of situations and to hitherto unseen situations as well. but, they rely on an ad-hoc interpretation when enforcing them and are thus subjective in nature and might lead to uneven enforcement across different cases. under the eu, this margin of appreciation is often criticized in the sense that it leads to weakening and twisting of different principles but this deferment to those who are closer to the case actually allows for a nuanced approach which would be lost otherwise. on the other hand we have rules which are much more concrete formulations and thus have a rigid definition and limited applicability which allows for uniformity but it suffers from inflexibility in the face of novel scenarios. yet, both rules and principles are complementary approaches and often the exercise of principles over time leads to their concretization into rules under existing and novel legal instruments. while human rights can thus provide a normative, overarching direction for the governance of ai systems, they don't provide the actual constituents for an applicable ai governance framework. for those that come from a non-legal background, often technical developer and designers of ai systems, it is essential that they understand their legal and moral obligations to codify and protect these rights in the applications that they build. the same argument cuts the other way, requiring a technical understanding of how ai systems work for legal practitioners such that they can meaningfully identify when breaches might have occurred. this is also important for those looking to contest claims of breaches of their rights in interacting with ai systems. this kind of enforcement requires a wide public debate to ensure that they fall within accepted democratic and cultural norms and values within their context. while human rights will continue to remain relevant even in an ai systems environment, there might be novel ways in which breaches might occur and those might need to be protected which require a more thorough understanding of how ai systems work. growing the powers of regulators won't be sufficient if there isn't an understanding of the intricacies of the systems and where breaches can happen, thus there is more of a need to enshrine some of those responsibilities in law to enforce this by the developers and designers of the system. given the large public awareness and momentum that built up around the ethics, safety and inclusion issues in ai, we will certainly see a lot more concrete actions around this in . the article gives a few examples of congressional hearings on these topics and advocates for the industry to come up with some standards and definitions to aid the development of meaningful regulations. currently, there isn't a consensus on these definitions and it leads to varying approaches addressing the issues at different levels of granularity and angles. what this does is create a patchwork of incoherent regulations across domains and geographies that will ultimately leave gaps in effectively mitigating potential harms from ai systems that can span beyond international borders. while there are efforts underway to create maps of all the different attempts of defining principle sets, we need a more coordinated approach to bring forth regulations that will ultimately protect consumer safety. in containing an epidemic the most important steps include quarantine and contact tracing for more effective testing. while before, this process of contact tracing was hard and fraught with errors and omissions, relying on memories of individuals, we now carry around smartphones which allow for ubiquitous tracking ability that is highly accurate. but such ubiquity comes with invasion of privacy and possible limits on freedoms of citizens. such risks need to be balanced with public interest in mind while using enhanced privacy preserving techniques and any other measures that center citizen welfare in both a collective and individual sense. for infections that can be asymptomatic in the early days, like the covid- , it is essential to have contact tracing, which identifies all people that came in close contact with an infected person and might spread the infection further. this becomes especially important when you have a pandemic at hand, burdening the healthcare system and testing every person is infeasible.an additional benefit of contact tracing is that it mitigates resurgence of the peaks of infection. r determines how quickly a disease will spread and is dependent on three factors (period of infection, contact rate and mode of transmission) out of which the first and third are fixed so we're only left with control over the contact rate.with an uptake of an application that facilitates contact tracing, the amount of reduction in contact rate is an increasing return because of the number of people that might come in contact with an infected person and thus, we get a greater reduction of r in terms of percentage compared to the percentage uptake of the application in the population. ultimately, reducing r to below leads to a slowdown in the spread of the infection thus helping the healthcare system cope up with the sudden stresses that are brought on by pandemic peaks. one of the techniques that governments or agencies responsible for public health use is broadcasting in which the information of diagnosed carriers is made public via various channels but it carries severe issues like exposing private information of individuals and businesses where they might have been which can trigger stigma, ostracization and unwarranted punitive harm. it also suffers from the problem of people needing to access this source of information of their own volition and then self-identify (and remember correctly) if they've been in recent contact with a diagnosed carrier. selective broadcasting is a more restricted form of the above where information about diagnosed carriers is shared to a select group of individuals based on location proximity in which case the user's location privacy would have to be compromised and in another vector of dissemination, messages are sent to all users but filtered on device for their specific location and is not reported back to the broadcaster. but, the other second-order negative effects remain the same as broadcasting. both though require the download of an application which might decrease the uptake of it by people. unicasting is when messages are sent tailored specifically to each user and they require the download of an app which needs to be able to track timestamps and location and has severe consequences in terms of government surveillance and abuse. participatory sharing is a method where diagnosed carriers voluntarily share their information and thus have more data control but it still relies on individual action both on the sender and receiver and its efficacy is questionable at best. there is also a risk of abuse by malicious actors to spread misinformation and seed chaos in society via false alarms. private kit: safe paths is an open-source solution developed by mit that allows for contact tracing in a privacy preserving way. it utilizes the encrypted location trail of a diagnosed carrier who chooses to share that with public health agencies and then other users who are also using the solution can pull this data and via their own logged location trail get a result of they've been in close contact with a diagnosed carrier. in the later phases of development of this solution, the developers will enable a mix of participatory sharing and unicasting to further prevent possible data access by third parties including governments for surveillance purposes. risks of contact tracing include possible public identification of the diagnosed carrier and severe social stigma that arises as a part of that. online witch hunts to try and identify the individual can often worsen the harassment and include spreading of rumors about their personal lives. the privacy risks for both individuals and businesses have potential for severe harm, especially during times of financial hardship, this might be very troublesome. privacy risks also extend to non-users because of proximal information that can be derived from location trails, such as employees that work at particular businesses that were visited by a diagnosed carrier. it can also bring upon the same stigma and ostracization to the family members of these people. without meaningful alternatives, especially in health and risk assessment during a pandemic, obtaining truly informed consent is a real challenge that doesn't yet have any clear solutions. along with information, be it through any of the methods identified above, it is very important to provide appropriate context and background to the alerts to prevent misinformation and panic from spreading especially for those with low health, digital and media literacy. on the other hand, some might not take such alerts seriously and increase the risk for public health by not following required measures such as quarantine and social distancing. given the nature of such solutions, there is a significant risk of data theft from crackers as is the case for any application that collects sensitive information like health status and location data. the solutions can also be used for fraud and abuse, for example, by blackmailing business owners and demanding ransom, failing to pay which they would falsely post information that they're diagnosed carriers and have visited their place of business. contact tracing technology requires the use of a smartphone with gps and some vulnerable populations might not always have such devices available like the elderly, homeless and people living in low-income countries who are at high risk of infection and negative health outcomes. ensuring that technology that works for all will be an important piece to mitigating the spread effectively. there is an inherent tradeoff between utility from the data provided and the privacy of the data subjects. compromises may be required for particularly severe outbreaks to manage the spread. the diagnosed carriers are the most vulnerable stakeholders in the ecosystem of contact tracing technology and they require the most protection. adopting open-source solutions that are examinable by the wider technology ecosystem can engender public trust. additionally, having proper consent mechanisms in place and exclusion of the requirement of extensive third party access to the location data can also help allay concerns. lastly, time limits on the storage and use of the location trails will also help address privacy concerns and increase uptake and use of the application in supporting public health measures. for geolocation data that might affect businesses, especially in times of economic hardship, information release should be done such that they are informed prior to the release of the information but there is little else in current methods that can both protect privacy and at the same time provide sufficient data utility. for those without access to smartphones with gps, providing them with some information on contact tracing can still help their communities. but, one must present information in a manner that accounts for variation in health literacy levels so an appropriate response is elicited from the people. alertness about potential misinformation and educational awareness are key during times of crises to encourage people to have measured responses following the best practices as advised by health agencies rather than those based on fear mongering by ill informed and/or malicious actors. encryption and other cybersecurity best practices for data security and privacy are crucial for the success of the solution. time limits on holding data for covid- is recommended at - days, the period of infection, but for an evolving pandemic one might need it for longer for more analysis. tradeoffs need to be made between privacy concerns and public health utility. different agencies and regions are taking different approaches with varying levels of efficacy and only time will tell how this change will be best managed. it does present an opportunity though for creating innovative solutions that both allow for public sharing of data and also reduce privacy intrusions. while the insights presented in this piece of work are ongoing and will continue to be updated, we felt it important to highlight the techniques and considerations compiled by the openmined team as it is one of the few places that adequately capture, in a single place, most of the technical requirements needed to build a solution that respects fundamental rights while balancing them with public health outcomes as people rush to make ai-enabled apps to combat covid- . most articles and research work coming out elsewhere are very scant and abstract in the technical details that would be needed to meet the ideals of respecting privacy and enabling health authorities to curb the spread of the pandemic. the four key techniques that will help preserve and respect rights as more and more people develop ai-enabled applications to combat covid- are: on-device data storage and computation, differential privacy, encrypted computation and privacy-preserving identity verification. the primary use cases, from a user perspective, for which apps are being built are to get: proximity alerts, exposure alerts, information on planning trips, symptom analysis and demonstrate proof of health. from a government and health authorities perspective, they are looking for: fast contact tracing, high-precision self-isolation requests, high-precision self-isolation estimation, high-precision symptomatic citizen estimation and demonstration of proof of health. while public health outcomes are at the top of the mind for everyone, the above use cases are trying to achieve the best possible tradeoff between economic impacts and epidemic spread. using the techniques highlighted in this work, it is possible to do so without having to erode the rights of citizens. this living body of work is meant to serve as a high-level guide along with resources to enable both app developers and verifiers implement and check for privacy preservation which has been the primary pushback from citizens and civil activists. evoking a high degree of trust from people will improve adoption of the apps developed and hopefully allow society and the economy to return to normal sooner while mitigating the harmful effects of the epidemic. there is a fair amount of alignment in the goals of both individuals and the government with the difference being that the government is looking at aggregate outcomes for society. some of the goals shared by governments across the world include: preventing the spread of the disease, eliminating the disease, protecting the healthcare system, protecting the vulnerable, adequately and appropriately distributing resources, preventing secondary breakouts, minimizing economic impacts and panic. the need for digital contact tracing is important because manual interventions are usually highly error prone and rely on human memory to trace how the person might have come in contact with. the requirement for high-precision self-isolation requests will avoid the need for geographic quarantines where everyone in an area is forced to self-isolate which leads to massive disruptions in the economy and can stall the delivery of essential services like food, electricity and water. the additional benefits of high-precision self-isolation is that it can help create an appropriate balance between economic harms and epidemic spread. high-precision symptomatic citizen estimation is a useful application in that it allows for more fine-grained estimation of the number of people that might be affected beyond what the test results indicate which can further strengthen the precision of other measures that are undertaken. a restoration of normalcy in society is going to be crucial as the epidemic starts to ebb, in this case, having proof of health that helps to determine the lowest risk individuals will allow for them to participate in public spaces again further bolstering the supply of essential services and relieving the burden from a small subset of workers who are participating. to service the needs of both what the users want and what the government wants, we need to be able to collect the following data: historical and current absolute location, historical and current relative position and verified group identity, where group refers to any demographic that the government might be interested in, for example, age or health status. to create an application that will meet these needs, we need to collect data from a variety of sources, compute aggregate statistics on that data and then set up some messaging architecture that communicates the results to the target population. the toughest challenges lie in the first and second parts of the process above, especially to do the second part in a privacy-preserving manner. for historical and current absolute location, one of the first options considered by app developers is to record gps data in the background. unfortunately, this doesn't work on ios devices and even then has several limitations including coarseness in dense, urban areas and usefulness only after the app has been running on the user device for some time because historical data cannot be sourced otherwise. an alternative would be to use wi-fi router information which can give more accurate information as to whether someone has been self-isolating or not based on whether they are connected to their home router. there can be historical data available here which makes it more useful though there are concerns with lack of widespread wi-fi connectivity in rural areas and tracking when people are outside homes. other ways of obtaining location data could be from existing apps and services that a user uses -for example, history of movements on google maps which can be parsed to extract location history. there is also historical location data that could be pieced together from payments history, cars that record location information and personal cell tower usage data. historical and current relative data is even more important to map the spread of the epidemic and in this case, some countries like singapore have deployed bluetooth broadcasting as a means of determining if people have been in close proximity. the device broadcasts a random number (which could change frequently) which is recorded by devices passing by close to each other and in case someone is tested positive, this can be used to alert people who were in close proximity to them. another potential approach highlighted in the article is to utilize gyroscope and ambient audio hashes to determine if two people might have been close together, though bluetooth will provide more consistent results. the reason to use multiple approaches is the benefit of getting more accurate information overall since it would be harder to fake multiple signals. group membership is another important aspect where the information can be used to finely target messaging and calculating aggregate statistics. but, for some types of group membership, we might not be able to rely completely on self-reported data. for example, health status related to the epidemic would require verification from an external third-party such as a medical institution or testing facility to minimize false information. there are several privacy preserving techniques that could be applied to an application given that you have: confirmed covid- patient data in a cloud, all other user data on each individual's device, and data on both the patients and the users including historical and current absolute and relative locations and group identifier information. private set intersections can be used to calculate whether two people were in proximity to each other based on their relative and absolute location information. private set intersection operates similarly to normal set intersection to find elements that are common between two sets but does so without disclosing any private information from either of the sets. this is important because performing analysis even on pseudonymized data without using privacy preservation can leak a lot of information. differential privacy is another critical technique to be utilized, dp consists of providing mathematical guarantees (even against future data disclosures) that analysis on the data will not reveal whether or not your data was part of the dataset. it asserts that from the analysis, one is not able to learn anything about your data that they wouldn't have been able to learn from other data about you. google's battle-tested c++ library is a great resource to start along with the python wrapper created by the openmined team. to address the need for verified group identification, one can utilize the concept of a private identity server. it essentially functions as a trusted intermediary between a user that wants to provide a claim and another party that wants to verify the claim. it functions by querying a service from which it can verify whether the claim is true and then serve that information up to the party wishing to verify the claim without giving away personal data. while it might be hard to trust a single intermediary, this role can be decentralized to provide for obtaining a higher degree of trust by relying on a consensus mechanism. building on theory from management studies by christensen et al. the authors of this article dive into how leaders of tech organizations, especially upstarts that are rapid in the disruption of incumbents should approach the accompanying responsibilities that come with a push into displacing existing paradigms of how an industry works. when there is a decoupling of different parts of the value chain in how a service is delivered, often the associated protections that apply to the entire pipeline fall by the wayside because of distancing from the end user and a diffusion of responsibility across multiple stakeholders in the value chain. while end users driven innovation will seek to reinforce such models, regulations and protections are never at the top of such demands and they create a burden on the consumers once they realize that things can go wrong and negatively affect them. the authors advocate for the leaders of the companies to proactively employ a systems thinking approach to identify different parts that they are disrupting, how that might affect users, what would happen if they become the dominant player in the industry and then apply lessons learned from such an exercise to pre-emptively design safeguards into the system to mitigate unintended consequences. many countries are looking at utilizing existing surveillance and counter-terrorism tools to help track the spread of the coronavirus and are urging tech companies and carriers to assist with this. the us is looking at how they can tap into location data from smartphones, following in the heels of israel and south korea that have deployed similar measures. while extraordinary measures might be justified given the time of crisis we're going through, we mustn't lose sight of what behaviors we are normalizing as a part of this response against the pandemic. russia and china are also using facial recognition technologies to track movements of people, while iran is endorsing an app that might be used as a diagnosis tool. expansion of the boundaries of surveillance capabilities and government powers is something that is hard to reign back in once a crisis is over. in some cases, like the signing of the freedom act in the usa reduced government agency data collection abilities that were expanded under the patriot act. but, that's not always the case and even so, the powers today exceed those that existed prior to the enactment of the patriot act. what's most important is to ensure that decisions policy makers take today keep in mind the time limits on such expansion of powers and don't trigger a future privacy crisis because of it. while no replacement for social distancing, a virus tracking tool putting into practice the technique of contact tracing is largely unpalatable to western democracies because of expectations of privacy and freedom of movement. a british effort underway to create an app that meets democratic ideals of privacy and freedom while also being useful in collecting geolocation data to aid in the virus containment efforts. it is based on the notion of participatory sharing, relying on people's sense of civic duty to contribute their data in case they test positive. while in the usa, discussions between the administration and technology companies has focused on large scale aggregate data collection, in a place like the uk with a centralized healthcare system, there might be higher trust levels in sharing data with the government. while the app doesn't require uptake by everyone to be effective, but a majority of the people would need to use it to bring down the rate of spread. the efficacy of the solution itself will rely on being able to collect granular location data from multiple sources including bluetooth, wi-fi, cell tower data, and app check-ins. a lot of high level cdc officials are advising that if people in the usa don't follow best practices of social distancing, sheltering in place, and washing hands regularly, the outbreak will not have peaked and the infection will continue to spread, especially hitting those who are the most vulnerable including the elderly and those with pre-existing conditions. on top of the public health impacts, there are also concerns of growing tech-enabled surveillance which is being seriously explored as an additional measure to curb the spread. while privacy and freedom rights are enshrined in the constitution, during times of crisis, government and justice powers are expanded to allow for extraordinary measures to be adopted to restore the safety of the public. this is one of those times and the us administration is actively exploring options in partnership with various governments on how to effectively combat the spread of the virus including the use of facial recognition technology. this comes shortly after the techlash and a potential bipartisan movement to curb the degree of data collection by large firms, which seem to have come to a halt as everyone scrambles to battle the coronavirus. regional governments are being imbued with escalated powers to override local legislations in an effort to curb the spread of the virus. the article provides details on efforts by various countries across the world, yet we only have preliminary data on the efficacy of each of those measures and we require more time before being able to judge which of them is the most effective. that said, in a pandemic that is fast spreading, we don't have the luxury of time and must make decisions as quickly as possible using the information at hand, perhaps using guidance from prior crises. but, what we've seen so far is minimal coordination from agencies across the world and that's leading to ad-hoc, patchy data use policies that will leave the marginalized more vulnerable. strategies that use public disclosure of those that have been tested positive in the interest of public health are causing harm to the individuals and other individuals that are close to them such as their families. as experienced by a family in new york, online vigilantes attempted to harass the individuals while their family pleaded and communicated measures that they had taken to isolate themselves to safeguard others. unfortunately, the virus might be bringing out the worst in all of us. an increasing number of tools and techniques are being used to track our behaviour online and while some may have potential benefits, for example, the use of contact tracing to potentially improve public health outcomes, if this is not done in a privacy-preserving manner, there can be severe implications for your data rights. but, barring special circumstances like the current pandemic, there are a variety of simple steps that you can take to protect your privacy online. these range from simple steps like using an incognito browser window which doesn't store any local information about your browsing on your device to using things like vpns which protect snooping of your browsing patterns even from your isp. when it comes to using the incognito function of your browser, if you're logged into a service online, there isn't any protection though it does prevent storing cookies on your device. with vpns, there is an implicit trust placed in the provider of that service to not store logs of your browsing activity. an even more secure option is to use a privacy-first browser like tor which routes your traffic requests through multiple locations making tracking hard. there is also an os built around this called tailsos that offers tracking protection from the device perspective as well not leaving any trace on the host machine allowing you to boot up from a usb. the eff also provides a list of tools that you can use to get a better grip on your privacy as you browse online. under the children's online privacy protection act, the ftc levied its largest fine yet of $ m on youtube last year for failing to meet requirements of limiting personal data collection for children under the age of . yet, as many advocates of youth privacy point out, the fines, though they appear to be large, don't do enough to deter such personal data collection. they advocate for a stronger version of the act while requiring more stringent enforcement from the ftc which has been criticized for slow responses and a lack of sufficient resources. while the current act requires parental consent for children below to be able to utilize a service that might collect personal data, there is no verification performed on the self-declared age provided at the time of sign up which weakens the efficacy of this requirement. secondly, the sharp threshold of years old immediately thrusts children into an adult world once they cross that age and some people are advocating for a more graduated approach to the application of privacy laws. given that such a large part of the news cycle is dominated by the coronavirus, we tend to forget that there might be censors at work that are systematically suppressing information in an attempt to diminish the seriousness of the situation. some people are calling github the last piece of free land in china and have utilized access to it to document news stories and people's first hand experiences in fighting the virus before they are scrubbed from local platforms like wechat and weibo. they hope that such documentation efforts will not only shed light on the reality and on the ground situation as it unfolds but also give everyone a voice and hopefully provide data to others who could use it to track the movement of the virus across the country. such times of crisis bring out creativity and this attempt highlights our ability as a species to thrive even in a severely hostile environment. there is a clear economic and convenience case to be made (albeit for the majority, not for those that are judged to be minorities by the system and hence get subpar performance from the system) where you get faster processing and boarding times when trying to catch a flight. yet, for those that are more data-privacy minded, there is an option to opt-out though leveraging that option doesn't necessarily mean that the alternative will be easy, as the article points out, travelers have experienced delays and confusion from the airport staff. often, the alternatives are not presented as an option to travelers giving a false impression that people have to submit to facial recognition systems. some civil rights and ethics researchers tested the system and got varying mileage out of their experiences but urge people to exercise the option to push back against technological surveillance. london is amongst a few cities that has seen public deployment of live facial recognition technology by law enforcement with the aim of increasing public safety. but, more often than not, it is done so without public announcement and an explanation as to how this technology works, and what impacts it will have on people's privacy. as discussed in an article by maiei on smart cities, such a lack of transparency erodes public trust and affects how people go about their daily lives. several artists in london as a part of regaining control over their privacy and to raise awareness are using the technique of painting adversarial patterns on their faces to confound facial recognition systems. they employ highly contrasting colors to mask the highlights and shadows on their faces and practice pattern use as created and disseminated by the cvdazzle project that advocates for many different styles to give the more fashion-conscious among us the right way to express ourselves while preserving our privacy. such projects showcase a rising awareness for the negative consequences of ai-enabled systems and also how people can use creative solutions to combat problems where laws and regulations fail them. there is mounting evidence that organizations are taking seriously the threats arising from malicious actors geared towards attacking ml systems. this is supported by the fact that organizations like iso and nist are building up frameworks for guidance on securing ml systems, that working groups from the eu have put forth concrete technical checklists for the evaluating the trustworthiness of ml systems and that ml systems are becoming key to the functioning of organizations and hence they are inclined to protect their crown jewels. the organizations surveyed as a part of this study spanned a variety of domains and were limited to those that have mature ml development. the focus was on two personas: ml engineers who are building these systems and security incident responders whose task is to secure the software infrastructure including the ml systems. depending on the size of the organization, these people could be in different teams, same team or even the same person. the study was also limited to intentional malicious attacks and didn't investigate the impacts of naturally occurring adversarial examples, distributional shifts, common corruption and reward hacking. most organizations that were surveyed as a part of the study were found to primarily be focused on traditional software security and didn't have the right tools or know-how in securing against ml attacks. they also indicated that they were actively seeking guidance in the space. most organizations were clustered around concerns regarding data poisoning attacks which was probably the case because of the cultural significance of the tay chatbot incident. additionally, privacy breaches were another significant concern followed by concerns around model stealing attacks that can lead to the loss of intellectual property. other attacks such as attacking the ml supply chain and adversarial examples in the physical domain didn't catch the attention of the people that were surveyed as a part of the study. one of the gaps between reality and expectations was around the fact that security incident responders and ml engineers expected that the libraries that they are using for ml development are battle-tested before being put out by large organizations, as is the case in traditional software. also, they pushed upstream the responsibility of security in the cases where they were using ml as a service from cloud providers. yet, this ignores the fact that this is an emergent field and that a lot of the concerns need to be addressed in the downstream tasks that are being performed by these tools. they also didn't have a clear understanding of what to expect when something does go wrong and what the failure mode would look like. in traditional software security, mitre has a curated repository of attacks along with detection cues, reference literature and tell-tale signs for which malicious entities, including nation state attackers are known to use these attacks. the authors call for a similar compilation to be done in the emergent field of adversarial machine learning whereby the researchers and practitioners register their attacks and other information in a curated repository that provides everyone with a unified view of the existing threat environment. while programming languages often have well documented guidelines on secure coding, guidance on doing so with popular ml frameworks like pytorch, keras and tensorflow is sparse. amongst these, tensorflow is the only one that provides some tools for testing against adversarial attacks and some guidance on how to do secure coding in the ml context. security development lifecycle (sdl) provides guidance on how to secure systems and scores vulnerabilities and provides some best practices, but applying this to ml systems might allow imperfect solutions to exist. instead of looking at guidelines as providing a strong security guarantee, the authors advocate for having code examples that showcase what constitutes security-and non-security-compliant ml development. in traditional software security there are tools for static code analysis that provide guidance on the security vulnerabilities prior to the code being committed to a repository or being executed while dynamic code analysis finds security vulnerabilities by executing the different code paths and detecting vulnerabilities at runtime. there are some tools like mlsec and cleverhans that provide white-and black-box testing; one of the potential future directions for research is to extend this to the cases of model stealing, model inversion, and membership inference attacks. including these tools as a part of the ide would further make it naturalized for developers to think about secure coding practices in the ml context. adapting the audit and logging requirements as necessitated for the functionality of the security information and event management (siem) system, in the field of ml, one can execute the list of attacks as specified in literature and ensure that the logging artifacts generated as a consequence are traced to an attack. then, having these incident logs be in a format that is exportable and integratable with siem systems will allow forensic experts to analyze them post-hoc for hardening and analysis. standardizing the reporting, logging and documentation as done by the sigma format in traditional software security will allow the insights from one analyst into defenses for many others. automating the possible attacks and including them as a part of the mlops pipeline is something that will enhance the security posture of the systems and make them pedestrian practice in the sdl. red teaming, as done in security testing, can be applied to assess the business impacts and likelihood of threat, something that is considered best practice and is often a requirement for supplying critical software to different organizations like the us government. transparency centers that allow for deep code inspection and help create assurance on the security posture of a software product/service can be extended to ml which would have to cover three modalities: ml platform is implemented in a secure manner, ml as a service meets the basic security and privacy requirements, and that the ml models embedded on edge devices meet basic security requirements. tools that build on formal verification methods will help to enhance this practice. tracking and scoring ml vulnerabilities akin to how they are done in software security testing done by registering identified vulnerabilities into a common database like cve and then assigning it an impact score like the cvss needs to be done for the field of ml. while the common database part is easy to set up, scoring them isn't something that has been figured out yet. additionally, on being alerted that a new vulnerability has been discovered, it isn't clear how the ml infrastructure can be scanned to see if the system is vulnerable to that. because of the deep integration of ml systems within the larger product/service, the typical practice of identifying a blast radius and containment strategy that is applied to traditional software infrastructure when alerted of a vulnerability is hard to define and apply. prior research work from google has identified some ways to qualitatively assess the impacts in a sprawling infrastructure. from a forensic perspective, the authors put forth several questions that one can ask to guide the post-hoc analysis, the primary problem there is that only some of the learnings from traditional software protection and analysis apply here, there are many new artifacts, paradigmatic, and environmental aspects that need to be taken into consideration. from a remediation perspective, we need to develop metrics and ways to ascertain that patched models and ml systems can maintain prior levels of performance while having mitigated the attacks that they were vulnerable to, the other thing to pay attention is that there aren't any surfaces that are opened up for attack. given that ml is going to be the new software, we need to think seriously about inheriting some of the security best practices from the world of traditional cybersecurity to harden defenses in the field of ml. all technology has implications for civil liberties and human rights, the paper opens with an example of how low-clearance bridges between new york and long island were supposedly created with the intention of disallowing public buses from crossing via the underpasses to discourage the movement of users of public transportation, primarily disadvantaged groups from accessing certain areas. in the context of adversarial machine learning, taking the case of facial recognition technology (frt), the authors demonstrate that harm can result on the most vulnerable, harm which is not theoretical and is gaining in scope, but that the analysis also extends beyond just frt systems. the notion of legibility borrowing from prior work explains how governments seek to categorize through customs, conventions and other mechanisms information about their subjects centrally. legibility is enabled for faces through frt, something that previously was only possible as a human skill. this combined with the scale offered by machine learning makes this a potent tool for authoritarian states to exert control over their populations. from a cybersecurity perspective, attackers are those that compromise the confidentiality, integrity and availability of a system, yet they are not always malicious, sometimes they may be pro-democracy protestors who are trying to resist identification and arrest by the use of frt. when we frame the challenges in building robust ml systems, we must also pay attention to the social and political implications as to who is the system being made safe for and at what costs. positive attacks against such systems might also be carried out by academics who are trying to learn about and address some of the ethical, safety and inclusivity issues around frt systems. other examples such as the hardening of systems against doing membership inference means that researchers can't determine if an image was included in the dataset, and someone looking to use this as evidence in a court of law is deterred from doing so. detection perturbation algorithms permit an image to be altered such that faces can't be recognized in an image, for example, this can be used by a journalist to take a picture of a protest scene without giving away the identities of people. but, defensive measures that disarm such techniques hinder such positive use cases. defense measures against model inversion attacks don't allow researchers and civil liberty defenders to peer into black box systems, especially those that might be biased against minorities in cases like credit allocation, parole decision-making, etc. the world of security is always an arms race whether that is in the physical or cyberspace. it is not that far-fetched to imagine how a surveillance state might deploy frt to identify protestors who as a defense might start to wear face masks for occlusion. the state could then deploy techniques that bypass this and utilize other scanning and recognition techniques to which the people might respond by wearing adversarial clothing and eyeglasses to throw off the system at which point the state might choose to use other biometric identifiers like iris scanning and gait detection. this constant arms battle, especially when defenses and offenses are constructed without the sense for the societal impacts leads to harm whose burden is mostly borne by those who are the most vulnerable and looking to fight for their rights and liberties. this is not the first time that technology runs up against civil liberties and human rights, there are lessons to be learned from the commercial spyware industry and how civil society organizations and other groups came together to create "human rights by design" principles that helped to set some ground rules for how to use this technology responsibly. researchers and practitioners in the field of ml security can borrow from these principles. we've got a learning community at the montreal ai ethics institute that is centered around these ideas that brings together academics and others from around the world to blend the social sciences with the technical sciences. recommendations on countering some of the harms centre around holding the vendors of these systems to the business standards set by the un, implementing transparency measures during the development process, utilizing human rights by design approaches, logging ml system uses along with possible nature and forms of attacks and pushing the development team to think about both the positive and negative use cases for the systems such that informed trade-offs can be made when hardening these systems to external attacks. in this insightful op-ed, two pioneers in technology shed light on how to think about ai systems and their relation to the existing power and social structures. borrowing the last line in the piece, " … all that is necessary for the triumph of an ai-driven, automation-based dystopia is that liberal democracy accept it as inevitable.", aptly captures the current mindset surrounding ai systems and how they are discussed in the western world. tv shows like black mirror perpetuate narratives showcasing the magical power of ai-enabled systems, hiding the fact that there are millions, if not billions of hours of human labor that undergird the success of modern ai systems, which largely fall under the supervised learning paradigm that requires massive amounts of data to work well. the chinese ecosystem is a bit more transparent in the sense that the shadow industry of data labellers is known, and workers are compensated for their efforts. this makes them a part of the development lifecycle of ai while sharing economic value with people other than the tech-elite directly developing ai. on the other hand, in the west, we see that such efforts go largely unrewarded because we trade in that effort of data production for free services. the authors give the example of audrey tang and taiwan where citizens have formed a data cooperative and have greater control over how their data is used. contrasting that, we have highly-valued search engines standing over community-run efforts like wikipedia which create the actual value for the search results, given that a lot of the highly placed search results come from wikipedia. ultimately, this gives us some food for thought as to how we portray ai today and its relation to society and why it doesn't necessarily have to be that way. mary shelly had created an enduring fiction which, unbeknownst to her, has today manifested itself in the digital realm with layered abstractions of algorithms that are increasingly running multiple aspects of our lives. the article dives into the world of black box systems that have become opaque to analysis because of their stratified complexity leading to situations with unpredictable outcomes. this was exemplified when an autonomous vehicle crashed into a crossing pedestrian and it took months of post-hoc analysis to figure out what went wrong. when we talk about intelligence in the case of these machines, we're using it in a very loose sense, like the term "friend" on facebook, which has a range of interpretations from your best friend to a random acquaintance. both terms convey a greater sense of meaning than is actually true. when such systems run amok, they have the potential to cause significant harm, case in point being the flash crashes the financial markets experienced because of the competitive behaviour of high frequency trading firm algorithms facing off against each other in the market. something similar has happened on amazon where items get priced in an unrealistic fashion because of buying and pricing patterns triggered by automated systems. while in a micro context the algorithms and their working are transparent and explainable, when they come together in an ecosystem, like finance, they lead to an emergent complexity that has behaviour that can't be predicted ahead of time with a great amount of certainty. but, such justifications can't be used as a cover for evading responsibility when it comes to mitigating harms. existing laws need to be refined and amended so that they can better meet the demands of new technology where allocation of responsibility is a fuzzy concept. ai systems are different from other software systems when it comes to security vulnerabilities. while traditional cybersecurity mechanisms rely heavily on securing the perimeter, ai security vulnerabilities run deeper and they can be manipulated through their interactions with the real world -the very mechanism that makes them intelligent systems. numerous examples of utilizing audio samples from tv commercials to trigger voice assistants have demonstrated new attack surfaces for which we need to develop defense techniques. visual systems are also fooled, especially in av systems where, according to one example, manipulating stop signs on the road with innocuous stripes of tape make it seem like the stop sign is a speed indicator and can cause fatal crashes. there are also examples of hiding these adversarial examples under the guise of white noise and other imperceptible changes to the human senses. we need to think of ai systems as inherently socio-technical to come up with effective protection techniques that don't just rely on technical measures but also look at the human factors surrounding them. some other useful insights are to utilize abusability testing, red-teaming, white hacking, bug bounty programs, and consulting with civic society advocates who have deep experience with the interactions of vulnerable communities with technology. reinforcement systems are increasingly moving from applications to beating human performance in games to safety-critical applications like self-driving cars and automated trading. a lack of robustness in the systems can lead to catastrophic failures like the $ m lost by knight capital and the harms to pedestrian and driver safety in the case of autonomous vehicles. rl systems that perform well under normal conditions can be vulnerable to adversarial agents that can exploit the brittleness of the systems when it comes to natural shifts in distributions and more carefully crafted attacks. in prior threat models, the assumptions for the adversary are that they can modify directly the inputs going into the rl agent but that is not very realistic. instead, here the authors focus more on a shared environment through which the adversary creates indirect impact on the target rl agent leading to undesirable behavior. for agents that are trained through self-play (which is a rough approximation of nash equilibrium), they are vulnerable to adversarial policies. as an example, masked victims are more robust to modifications in the natural observations by the adversary but that lowers the performance in the average case. furthermore, what the researchers find is that there is a non-transitive behavior between self-play opponent, masked victim, adversarial opponent and normal victim in that cyclic order. self-play being normally transitive in nature, especially when mimicking real-world scenarios is then no doubt vulnerable to these non-transitive styled attacks. thus, there is a need to move beyond self-play and apply iteratively adversarial training defense and population based training methods so that the target rl agent can become robust to a wider variety of scenarios. vehicle safety is something of paramount importance in the automotive industry as there are many tests conducted to test for crash resilience and other physical safety features before it is released to people. but, the same degree of scrutiny is not applied to the digital and connected components of cars. researchers were able to demonstrate successful proof of concept hacks that compromised vehicle safety. for example, with the polo, they were able to access the controller area network (can) which sends signals and controls a variety of aspects related to driving functions. given how the infotainment systems were updated, researchers were able to gain access into the personal details of the driver. they were also able to utilize the shortcomings in the operation of the key fob to gain access to the vehicle without leaving a physical trace. other hacks that were tried included being able to access and influence the collision monitoring radar system and the tire-pressure monitoring system which both have critical implications for passenger safety. on the focus, they found wifi details including the password for their production line in detroit, michigan. on purchasing a second-hand infotainment unit for purposes of reverse-engineering the firmware, they found the previous owner's home wifi details, phone contacts and a host of other personal information. cars store a lot of personal information including tracking information which, as stated on the privacy policy, can be shared with affiliates which can have other negative consequences like changes in insurance premiums based on driving behaviour. europe will have some forthcoming regulations for connected car safety but those are currently slated for release in . we've all experienced specification gaming even if we haven't really heard the term before. in law, you call it following the law to the letter but not in spirit. in sports, it is called unsportsman-like to use the edge cases and technicalities of the rules of the game to eke out an edge when it is obvious to everyone playing the game that the rules intended for something different. this can also happen in the case of ai systems, for example in reinforcement learning systems where the agent can utilize "bugs" or poor specification on the part of the human creators to achieve the high rewards for which it is optimizing without actually achieving the goal, at least in the way the developers intended them to and this can sometimes lead to unintended consequences that can cause a lot of harms. "let's look at an example. in a lego stacking task, the desired outcome was for a red block to end up on top of a blue block. the agent was rewarded for the height of the bottom face of the red block when it is not touching the block. instead of performing the relatively difficult maneuver of picking up the red block and placing it on top of the blue one, the agent simply flipped over the red block to collect the reward. this behaviour achieved the stated objective (high bottom face of the red block) at the expense of what the designer actually cares about (stacking it on top of the blue one)". this isn't because of a flaw in the rl system but more so a misspecification of the objective. as the agents become more capable, they find ever-more clever ways of achieving the rewards which can frustrate the creators of the system. this makes the problem of specification gaming very relevant and urgent as we start to deploy these systems in a lot of real-world situations. in the rl context, task specification refers to the design of the rewards, the environment and any other auxiliary rewards. when done correctly, we get true ingenuity out of these systems like move from the alphago system that baffled humans and ushered a new way of thinking about the game of go. but, this requires discernment on the part of the developers to be able to judge when you get a case like lego vs. move . as an example in the real-world, reward tampering is an approach where the agent in a traffic optimization system with an interest in achieving a high reward can manipulate the driver into going to alternate destinations instead of what they desired just to achieve a higher reward. specification gaming isn't necessarily bad in the sense that we want the systems to come up with ingenious ways to solve problems that won't occur to humans. sometimes, the inaccuracies can arise in how humans provide feedback to the system while it is training. ''for example, an agent performing a grasping task learned to fool the human evaluator by hovering between the camera and the object." incorrect reward shaping, where an agent is provided rewards along the way to achieving the final reward can also lead to edge-case behaviours when it is not analyzed for potential side-effects. we see such examples happen with humans in the real-world as well: a student asked to get a good grade on the exam can choose to copy and cheat and while that achieves the goal of getting a good grade, it doesn't happen in the way we intended for it to. thus, reasoning through how a system might game some of the specifications is going to be an area of key concern going into the future. the ongoing pandemic has certainly accelerated the adoption of technology in everything from how we socialize to buying groceries and doing work remotely. the healthcare industry has also been rapid in adapting to meet the needs of people and technology has played a role in helping to scale care to more people and accelerate the pace with which the care is provided. but, this comes with the challenge of making decisions under duress and with shortened timelines within which to make decisions on whether to adopt a piece of technology or not. this has certainly led to issues where there are risks of adopting solutions that haven't been fully vetted and using solutions that have been repurposed from prior uses that were approved to now combat covid- . especially with ai-enabled tools, there are increased risks of emergent behavior that might not have been captured by the previous certification or regulatory checks. the problems with ai solutions don't just go away because there is a pandemic and shortcutting the process of proper due diligence can lead to more harm than the benefits that they bring. one must also be wary of the companies that are trying to capitalize on the chaos and pass through solutions that don't really work well. having technical staff during the procurement process that can look over the details of what is being brought into your healthcare system needs to be a priority. ai can certainly help to mitigate some of the harms that covid- is inflicting on patients but we must keep in mind that we're not looking to bypass privacy concerns that come with processing vast quantities of healthcare data. in the age of adversarial machine learning (maiei has a learning community on machine learning security if you'd like to learn more about this area) there are enormous concerns with protecting software infrastructure as ml opens up a new attack surface and new vectors which are seldom explored. from the perspective of insurance, there are gaps in terms of what cyber-insurance covers today, most of it being limited to the leakage of private data. there are two kinds of attacks that are possible on ml systems: intentional and unintentional. intentional attacks are those that are executed by malicious agents who attempt to steal the models, infer private data or get the ai system to behave in a way that favors their end goals. for example, when tumblr decided to not host pornographic content, creators bypassed that by using green screens and pictures of owls to fool the automated content moderation system. unintended attacks can happen when the goals of the system are misaligned with what the creators of the system actually intended, for example, the problem of specification gaming, something that abhishek gupta discussed here in this fortune article. in interviewing several officers in different fortune companies, the authors found that there are key problems in this domain at the moment: the defenses provided by the technical community have limited efficacy, existing copyright, product liability, and anti-hacking laws are insufficient to capture ai failure modes. lastly, given that this happens at a software level, cyber-insurance might seem to be the way to go, yet current offerings only cover a patchwork of the problems. business interruptions and privacy leaks are covered today under cyber-insurance but other problems like bodily harm, brand damage, and property damage are for the most part not covered. in the case of model recreation, as was the case with the openai gpt- model, prior to it being released, it was replicated by external researchers -this might be covered under cyber-insurance because of the leak of private information. researchers have also managed to steal information from facial recognition databases using sample images and names which might also be covered under existing policies. but, in the case with uber where there was bodily harm because of the self-driving vehicle that wasn't able to detect the pedestrian accurately or similar harms that might arise if conditions are foggy, snowy, dull lighting, or any other out-of-distribution scenarios, these are not adequately covered under existing insurance terms. brand damage that might arise from poisoning attacks like the case with the tay chatbot or confounding anti-virus systems as was the case with an attack mounted against the cylance system, cyber-insurance falls woefully short in being able to cover these scenarios. in a hypothetical situation as presented in a google paper on rl agents where a cleaning robot sticks a wet mop into an electric socket, material damage that occurs from that might also be considered out of scope in cyber-insurance policies. traditional software attacks are known unknowns but adversarial ml attacks are unknown unknowns and hence harder to guard against. current pricing reflects this uncertainty, but as the ai insurance market matures and there is a deeper understanding for what the risks are and how companies can mitigate the downsides, the pricing should become more reflective of the actual risks. the authors also offer some recommendations on how to prepare the organization for these risks -for example by appointing an officer that works closely with the ciso and chief data protection officer, performing table-top exercises to gain an understanding of potential places where the system might fail and evaluating the system for risks and gaps following guidelines as put forth in the eu trustworthy ai guidelines. there are no widely accepted best practices for mitigating security and privacy issues related to machine learning (ml) systems. existing best practices for traditional software systems are insufficient because they're largely based on the prevention and management of access to a system's data and/or software, whereas ml systems have additional vulnerabilities and novel harms that need to be addressed. for example, one harm posed by ml systems is to individuals not included in the model's training data but who may be negatively impacted by its inferences. harms from ml systems can be broadly categorized as informational harms and behavioral harms. informational harms "relate to the unintended or unanticipated leakage of information." the "attacks" that constitute informational harms are: behavioral harms "relate to manipulating the behavior of the model itself, impacting the predictions or outcomes of the model." the attacks that constitute behavioral harms are: • poisoning: inserting malicious data into a model's training data to change its behavior once deployed • evasion: feeding data into a system to intentionally cause misclassification without a set of best practices, ml systems may not be widely and/or successfully adopted. therefore, the authors of this white paper suggest a "layered approach" to mitigate the privacy and security issues facing ml systems. approaches include noise injection, intermediaries, transparent ml mechanisms, access controls, model monitoring, model documentation, white hat or red team hacking, and open-source software privacy and security resources. finally, the authors note, it's important to encourage "cross-functional communication" between data scientists, engineers, legal teams, business managers, etc. in order to identify and remediate privacy and security issues related to ml systems. this communication should be ongoing, transparent, and thorough. beyond near-and long-term: towards a clearer account of this paper dives into how researchers can clearly communicate about their research agendas given ambiguities in the split of the ai ethics community into near and long term research. often a sore and contentious point of discussion, there is an artificial divide between the two groups that seem to take a reductionist approach to the work being done by the other. a major problem emerging from such a divide is a hindrance in being able to spot relevant work being done by the different communities and thus affecting effective collaboration. the paper highlights the differences arising primarily along the lines of timescale, ai capabilities, deeper normative and empirical disagreements. the paper provides for a helpful distinction between near-and long-term by describing them as follows: • near term issues are those that are fairly well understood and have concrete examples and relate to rêvent progress in the field of machine learning • long term issues are those that might arise far into the future and due to much more advanced ai systems with broad capabilities, it also includes long term impacts like international security, race relations, and power dynamics what they currently see is that: • issues considered 'near-term' tend to be those arising in the present/near future as a result of current/foreseeable ai systems and capabilities, on varying levels of scale/severity, which mostly have immediate consequences for people and society. • issues considered 'long-term' tend to be those arising far into the future as a result of large advances in ai capabilities (with a particular focus on notions of transformative ai or agi), and those that are likely to pose risks that are severe/large in scale with very long-term consequences. • the binary clusters are not sufficient as a way to split the field and not looking at underlying beliefs leads to unfounded assumptions about each other's work • in addition there might be areas between the near and long term that might be neglected as a result of this artificial fractions unpacking these distinctions can be done along the lines of capabilities, extremity, certainty and impact, definitions for which are provided in the paper. a key contribution aside from identifying these factors is that they lie along a spectrum and define a possibility space using them as dimensions which helps to identify where research is currently concentrated and what areas are being ignored. it also helps to well position the work being done by these authors. something that we really appreciated from this work was the fact that it gives us concrete language and tools to more effectively communicate about each other's work. as part of our efforts in building communities that leverage diverse experiences and backgrounds to tackle an inherently complex and muti-dimensional problem, we deeply appreciate how challenging yet rewarding such an effort can be. some of the most meaningful public consultation work done by maiei leveraged our internalized framework in a similar vein to provide value to the process that led to outcomes like the montreal declaration for responsible ai. the rise of ai systems leads to an unintended conflict between economic pursuits which seek to generate profits and value resources appropriately with the moral imperatives of promoting human flourishing and creating societal benefits from the deployment of these systems. this puts forth a central question on what the impacts of creating ai systems that might surpass humans in a general sense which might leave humans behind. technological progress doesn't happen on its own, it is driven by conscious human choices that are influenced by the surrounding social and economic institutions. we are collectively responsible for how these institutions take shape and thus impact the development of technology -submitting to technological-fatalism isn't a productive way to align our ethical values with this development. we need to ensure that we play an active role in the shaping of the most consequential piece of technology. while the economic system relies on the market prices to gauge what people place value on, by no means is that a comprehensive evaluation. for example, it misses out on the impact of externalities which can be factored in by considering ethical values as a complement in guiding our decisions on what to build and how to place value on it. when thinking about losses from ai-enabled automation, an outright argument that economists might make is that if replacing labor lowers the costs of production, then it might be market-efficient to invest in technology that achieves that. from an ethicist's perspective, there are severe negative externalities from job loss and thus it might be unethical to impose labor-saving automation on people. when unpacking the economic perspective more, we find that job loss actually isn't correctly valued by wages as price for labor. there are associated social benefits like the company of workplace colleagues, sense of meaning and other social structural values which can't be separately purchased from the market. thus, using a purely economic perspective in making automation technology adoption decisions is an incomplete approach and it needs to be supplemented by taking into account the ethical perspective. market price signals provide useful information upto a certain point in terms of the goods and services that society places value on. suppose that people start to demand more eggs from chickens that are raised in a humane way, then suppliers will shift their production to respond to that market signal. but, such price signals can only be indicated by consumers for the things that they can observe. a lot of unethical actions are hidden and hence can't be factored into market price signals. additionally, several things like social relations aren't tradable in a market and hence their value can't be solely determined from the market viewpoint. thus, both economists and ethicists would agree that there is value to be gained in steering the development of ai systems keeping in mind both kinds of considerations. pure market-driven innovation will ignore societal benefits in the interest of generating economic value while the labor will have to make unwilling sacrifices in the interest of long-run economic efficiency. economic market forces shape society significantly, whether we like it or not. there are professional biases based on selection and cognition that are present in either side making its arguments as to which gets to dominate based on their perceived importance. the point being that bridging the gap between different disciplines is crucial to arriving at decisions that are grounded in evidence and that benefit society holistically. there are also differences fundamentally between the economic and ethical perspective -namely that economic indicators are usually unidimensional and have clear quantitative values that make them easier to compare. on the other hand, ethical indicators are inherently multi-dimensional and are subjective which not only make comparison hard but also limit our ability to explain how we arrive at them. they are encoded deep within our biological systems and suffer from the same lack of explainability as decisions made by artificial neural networks, the so-called black box problem. why is it then, despite the arguments above, that the economic perspective dominates over the ethical one? this is largely driven by the fact that economic values provide clear, unambiguous signals which our brains, preferring ambiguity aversion, enjoy and ethical values are more subtle, hidden, ambiguous indicators which complicate decision making. secondly, humans are prosocial only upto a point, they are able to reason between economic and ethical decisions at a micro-level because the effects are immediate and observable, say for example polluting the neighbor's lawn and seeing the direct impact of that activity. on the other hand, for things like climate change where the effects are delayed and not directly observable (as a direct consequence of one's actions) that leads to behaviour where the individual prioritizes economic values over ethical ones. cynical economists will argue that there is a comparative advantage in being immoral that leads to gains in exchange, but that leads to a race to the bottom in terms of ethics. externalities are an embodiment of the conflict between economic and ethical values. welfare economics deals with externalities via various mechanisms like permits, taxes, etc. to curb the impacts of negative externalities and promote positive externalities through incentives. but, the rich economic theory needs to be supplemented by political, social and ethical values to arrive at something that benefits society at large. from an economic standpoint, technological progress is positioned as expanding the production possibilities frontier which means that it raises output and presumably standards of living. yet, this ignores how those benefits are distributed and only looks at material benefits and ignores everything else. prior to the industrial revolution, people were stuck in a malthusian trap whereby technological advances created material gains but these were quickly consumed by population growth that kept standards of living stubbornly low. this changed post the revolution and as technology improvement outpaced population growth, we got better quality of life. the last decades have had a mixed experience though, whereby automation has eroded lower skilled jobs forcing people to continue looking for jobs despite displacement and the lower demand for unskilled labor coupled with the inelastic supply of labor has led to lower wages rather than unemployment. on the other hand, high skilled workers have been able to leverage technological progress to enhance their output considerably and as a consequence the income and wealth gaps between low and high skilled workers has widened tremendously. typical economic theory points to income and wealth redistribution whenever there is technological innovation where the more significant the innovation, the larger the redistribution. something as significant as ai leads to crowning of new winners who own these new factors of production while also creating losers when they face negative pecuniary externalities. these are externalities because there isn't explicit consent that is requested from the people as they're impacted in terms of capital, labor and other factors of production. the distribution can be analyzed from the perspective of strict utilitarianism (different from that in ethics where for example bentham describes it as the greatest amount of good for the greatest number of people). here it is viewed as tolerating income redistribution such that it is acceptable if all but one person loses income as long as the single person making the gain has one that is higher than the sum of the losses. this view is clearly unrealistic because it would further exacerbate inequities in society. the other is looking at the idea of lump sum transfers in which the idealized scenario is redistribution, for example by compensating losers from technology innovation, without causing any other market distortions. but, that is also unrealistic because such a redistribution never occurs without market distortions and hence it is not an effective way to think about economic policy. from an ethics perspective, we must make value judgments on how we perceive dollar losses for a lower socio-economic person compared to the dollar gains made by a higher socio-economic person and if that squares with the culture and value set of that society. we can think about the tradeoff between economic efficiency and equality in society, where the level of tolerance for inequality varies by the existing societal structures in place. one would have to also reason about how redistribution creates more than proportional distortions as it rises and how much economic efficiency we'd be willing to sacrifice to make gains in how equitably income is distributed. thus, steering progress in ai can be done based on whether we want to pursue innovation that we know is going to have negative labor impacts while knowing full well that there aren't going to be any reasonable compensations offered to the people based on economic policy. given the pervasiveness of ai and by virtue of it being a general-purpose technology, the entrepreneurs and others powering innovation need to take into account that their work is going to shape larger societal changes and have impacts on labor. at the moment, the economic incentives are such that they steer progress towards labor-saving automation because labor is one of the most highly-taxed factors of production. instead, shifting the tax-burden to other factors of production including automation capital will help to steer the direction of innovation in other directions. government, as one of the largest employers and an entity with huge spending power, can also help to steer the direction of innovation by setting policies that encourage enhancing productivity without necessarily replacing labor. there are novel ethical implications and externalities that arise from the use of ai systems, an example of that would be (from the industrial revolution) that a factory might lead to economic efficiency in terms of production but the pollution that it generates is so large that the social cost outweighs the economic gain. biases can be deeply entrenched in the ai systems, either from unrepresentative datasets, for example, with hiring decisions that are made based on historical data. but, even if the datasets are well-represented and have minimal bias, and the system is not exposed to protected attributes like race and gender, there are a variety of proxies like zipcode which can lead to unearthing those protected attributes and discriminating against minorities. maladaptive behaviors can be triggered in humans by ai systems that can deeply personalize targeting of ads and other media to nudge us towards different things that might be aligned with making more profits. examples of this include watching videos, shopping on ecommerce platforms, news cycles on social media, etc. conversely, they can also be used to trigger better behaviors, for example, the use of fitness trackers that give us quantitative measurements for how we're taking care of our health. an economics equivalent of the paper clip optimizer from bostrom is how human autonomy can be eroded over time as economic inequality rises which limits control of those who are displaced over economic resources and thus, their control over their destinies, at least from an economic standpoint. this is going to only be exacerbated as ai starts to pervade into more and more aspects of our lives. labor markets have features built in them to help tide over unemployment with as little harm as possible via quick hiring in other parts of the economy when the innovation creates parallel demands for labor in adjacent sectors. but, when there is large-scale disruption, it is not possible to accommodate everyone and this leads to large economic losses via fall in aggregate demand which can't be restored with monetary or fiscal policy actions. this leads to wasted economic potential and welfare losses for the workers who are displaced. whenever there is a discrepancy between ethical and economic incentives, we have the opportunity to steer progress in the right direction. we've discussed before how market incentives trigger a race to the bottom in terms of morality. this needs to be preempted via instruments like technological impact assessments, akin to environmental impact assessments, but often the impacts are unknown prior to the deployment of the technology at which point we need to have a multi-stakeholder process that allows us to combat harms in a dynamic manner. political and regulatory entities typically lag technological innovation and can't be relied upon solely to take on this mantle. the author raises a few questions on the role of humans and how we might be treated by machines in case of the rise of superintelligence (which still has widely differing estimates for when it will be realized from the next decade to the second half of this century). what is clear is that the abilities of narrow ai systems are expanding and it behooves us to give some thought to the implications on the rise of superintelligence. the potential for labor-replacement in this superintelligence scenario, from an economic perspective, would have significant existential implications for humans, beyond just inequality, we would be raising questions of human survival if the wages to be paid to labor fall below subsistence levels in a wide manner. it would be akin to how the cost of maintaining oxen to plough fields was outweighed by the benefits that they brought in the face of mechanization of agriculture. this might be an ouroboros where we become caught in the malthusian trap again at the time of the industrial revolution and no longer have the ability to grow beyond basic subsistence, even if that would be possible. authors of research papers aspire to achieving any of the following goals when writing papers: to theoretically characterize what is learnable, to obtain understanding through empirically rigorous experiments, or to build working systems that have high predictive accuracy. to communicate effectively with the readers, the authors must: provide intuitions to aid the readers' understanding, describe empirical investigations that consider and rule out alternative hypotheses, make clear the relationship between theoretical analysis and empirical findings, and use clear language that doesn't conflate concepts or mislead the reader. the authors of this paper find that there are areas where there are concerns when it comes to ml scholarship: failure to distinguish between speculation and explanation, failure to identify the source of empirical gains, the use of mathematics that obfuscates or impresses rather than clarifies, and misuse of language such that terms with other connotations are used or by overloading terms with existing technical definitions. flawed techniques and communication methods will lead to harm and wasted resources and efforts hindering the progress in ml and hence this paper provides some very practical guidance on how to do this better. when presenting speculations or opinions of authors that are exploratory and don't yet have scientific grounding, having a separate section that quarantines the discussion and doesn't bleed into the other sections that are grounded in theoretical and empirical research helps to guide the reader appropriately and prevents conflation of speculation and explanation. the authors provide the example of the paper on dropout regularization that made comparisons and links to sexual reproduction but limited that discussion to a "motivation" section. using mathematics in a manner where natural language and mathematical expositions are intermixed without a clear link between the two leads to weakness in the overall contribution. specifically, when natural language is used to overcome weaknesses in the mathematical rigor and conversely, mathematics is used as a scaffolding to prop up weak arguments in the prose and give the impression of technical depth, it leads to poor scholarship and detracts from the scientific seriousness of the work and harms the readers. additionally, invoking theorems with dubious pertinence to the actual content of the paper or in overly broad ways also takes away from the main contribution of a paper. in terms of misuse of language, the authors of this paper provide a convenient ontology breaking it down into suggestive definitions, overloaded terminology, and suitcase words. in the suggestive definitions category, the authors coin a new technical term that has suggestive colloquial meanings and can slip through some implications without formal justification of the ideas in the paper. this can also lead to anthropomorphization that creates unrealistic expectations about the capabilities of the system. this is particularly problematic in the domain of fairness and other related domains where this can lead to conflation and inaccurate interpretation of terms that have well-established meanings in the domains of sociology and law for example. this can confound the initiatives taken up by both researchers and policymakers who might use this as a guide. overloading of technical terminology is another case where things can go wrong when terms that have historical meanings and they are used in a different sense. for example, the authors talk about deconvolutions which formally refers to the process of reversing a convolution but in recent literature has been used to refer to transpose convolutions that are used in auto-encoders and gans. once such usage takes hold, it is hard to undo the mixed usage as people start to cite prior literature in future works. additionally, combined with the suggestive definitions, we run into the problem of concealing a lack of progress, such as the case with using language understanding and reading comprehension to now mean performance on specific datasets rather than the grand challenge in ai that it meant before. another case that leads to overestimation of the ability of these systems is in using suitcase words which pack in multiple meanings within them and there isn't a single agreed upon definition. interpretability and generalization are two such terms that have looser definitions and more formally defined ones, yet because papers use them in different ways, it leads to miscommunication and researchers talking across each other. the authors identify that these problems might be occurring because of a few trends that they have seen in the ml research community. specifically, complacency in the face of progress where there is an incentive to excuse weak arguments in the face of strong empirical results and the single-round review process at various conferences where the reviewers might not have much choice but to accept the paper given the strong empirical results. even if the flaws are noticed, there isn't any guarantee that they are fixed in a future review cycle at another conference. as the ml community has experienced rapid growth, the problem of getting high-quality reviews has been exacerbated: in terms of the number of papers to be reviewed by each reviewer and the dwindling number of experienced reviewers in the pool. with the large number of papers, each reviewer has less time to analyze papers in depth and reviewers who are less experienced can fall easily into some of the traps that have been identified so far. thus, there are two levers that are aggravating the problem. additionally, there is the risk of even experienced researchers resorting to a checklist-like approach under duress which might discourage scientific diversity when it comes to papers that might take innovative or creative approaches to expressing their ideas. a misalignment in incentives whereby lucrative deals in funding are offered to ai solutions that utilize anthropomorphic characterizations as a mechanism to overextend their claims and abilities though the authors recognize that the causal direction might be hard to judge. the authors also provide suggestions for other authors on how to evade some of these pitfalls: asking the question of why something happened rather than just relying on how well a system performed will help to achieve the goal of providing insights into why something works rather than just relying on headline numbers from the results of the experiments. they also make a recommendation for insights to follow the lines of doing error analysis, ablation studies, and robustness checks and not just be limited to theory. as a guideline for reviewers and journal editors, making sure to strip out extraneous explanations, exaggerated claims, changing anthropomorphic naming to more sober alternatives, standardizing notation, etc. should help to curb some of the problems. encouraging retrospective analysis of papers is something that is underserved at the moment and there aren't enough strong papers in this genre yet despite some avenues that have been advocating for this work. flawed scholarship as characterized by the points as highlighted here not only negatively impact the research community but also impact the policymaking process that can overshoot or undershoot the mark. an argument can be made that setting the bar too high will impede new ideas being developed and slow down the cycle of reviews and publication while consuming precious resources that could be deployed in creating new work. but, asking basic questions to guide us such as why something works, in which situations it does not work, and have the design decisions been justified will lead to a higher quality of scholarship in the field. the article summarizes recent work from several microsoft researchers on the subject of making ai ethics checklists that are effective. one of the most common problems identified relate to the lack of practical applicability of ai ethics principles which sound great and comprehensive in the abstract but do very little to aid engineers and practitioners from applying them in their day to day work. the work was done by interviewing several practitioners and advocating for a co-design process that brings in intelligence on how to make these tools effective from other disciplines like healthcare and aviation. one of the things emerging from the interviews is that often engineers are few and far between in raising concerns and there's a lack of top-down sync in enforcing these across the company. additionally, there might be social costs to bringing up issues which discourages engineers from implementing such measures. creating checklists that reduce friction and fit well into existing workflows will be key in their uptake. for a lot of people who are new to the field of artificial intelligence and especially ai ethics, they see existential risk as something that is immediate. others dismiss it as something to not be concerned about at all. there is a middle path here and this article sheds a very practical light on that. using the idea of canaries in a coal mine, the author goes on to highlight some potential candidates for a canary that might help us judge better when we ought to start paying attention to these kinds of risks posed by artificial general intelligence systems. the first one is the automatic formulation of learning problems, akin to how humans have high-level goals that they align with their actions and adjust them based on signals that they receive on the success or failure of those actions. ai systems trained in narrow domains don't have this ability just yet. the second one mentioned in the article is achieving fully autonomous driving, which is a good one because we have lots of effort being directed to make that happen and it requires a complex set of problems to be addressed including the ability to make real-time, life-critical decisions. ai doctors are pointed out as a third canary, especially because true replacement of doctors would require a complex set of skills spanning the ability to make decisions about a patient's healthcare plan by analyzing all their symptoms, coordinating with other doctors and medical staff among other human-centered actions which are currently not feasible for ai systems. lastly, the author points to the creation of conversation systems that are able to answer complex queries and respond to things like exploratory searches. we found the article to put forth a meaningful approach to reasoning about existential risk when it comes to ai systems. a lot of articles pitch development, investment and policymaking in ai as an arms race with the us and china as front-runners. while there are tremendous economic gains to be had in deploying and utilizing ai for various purposes, there remain concerns of how this can be used to benefit society more than just economically. a lot of ai strategies from different countries are thus focused on issues of inclusion, ethics and more that can drive better societal outcomes yet they differ widely in how they seek to achieve those goals. for example, ai has put forth a national ai strategy that is focused on economic growth and social inclusion dubbed #aiforall while the strategy from china has been more focused on becoming a global dominant force in ai which is backed by state investments. some countries have instead chosen to focus on creating strong legal foundations for the ethical deployment of ai while others are more focused on data protection rights. canada and france have entered into agreements to work together on ai policy which places talent, r&d and ethics at the center. the author of the article makes a case for how global coordination of ai strategies might lead to even higher gains but also recognizes that governments will be motivated to tailor their policies to best meet the requirements of their countries first and then align with others that might have similar goals. reproducibility is of paramount importance to doing rigorous research and a plethora of fields have suffered from a crisis where scientific work hasn't met muster in terms of reproducibility leading to wasted time and effort on the part of other researchers looking to build upon each other's work. the article provides insights from the work of a researcher who attempted a meta-science approach to trying to figure out what constitutes good, reproducible research in the field of machine learning. there is a distinction made early on in terms of replicability which hinges on taking someone else's code and running that on the shared data to see if you get the same results but as pointed out in the article, that suffers from issues of source and code bias which might be leveraging certain peculiarities in terms of configurations and more. the key tenets to reproducibility are being able to simply read a scientific paper and set up the same experiment, follow the steps prescribed and arrive at the same results. arriving at the final step is dubbed as independent reproducibility. the distinction between replicability and reproducibility also speaks to the quality of the scientific paper in being able to effectively capture the essence of the contribution such that anyone else is able to do the same. some of the findings from this work include that having hyperparameters well specified in the paper and its ease of readability contributed to the reproducibility. more specification in terms of math might allude to more reproducibility but it was found to not necessarily be the case. empirical papers were inclined to be more reproducible but could also create perverse incentives and side effects. sharing code is not a panacea and requires other accompanying factors to make the work really reproducible. cogent writing was found to be helpful along with code snippets that were either actual or pseudo code though step code that referred to other sections hampered reproducibility because of challenges in readability. simplified examples while appealing didn't really aid in the process and spoke to the meta-science process calling for data-driven approaches to ascertaining what works and what doesn't rather than relying on hunches. also, posting revisions to papers and being reachable over email to answer questions helped the author in reproducing the research work. finally, the author also pointed out that given this was a single initiative and was potentially biased in terms of their own experience, background and capabilities, they encourage others to tap into the data being made available but these guidelines provide good starting points for people to attempt to make their scientific work more rigorous and reproducible. the push has been to apply ai to any new problem that we face, hoping that the solution will magically emerge from the application of the technique as if it is a dark art. yet, the more seasoned scientists have seen these waves come and go and in the past, a blind trust in this technology led to ai winters. taking a look at some of the canaries in the coal mine, the author cautions that there might be a way to judge whether ai will be helpful with the pandemic situation. specifically, looking at whether domain experts, like leading epidemiologists endorse its use and are involved in the process of developing and utilizing these tools will give an indication as to whether they will be successful or not. data about the pandemic depends on context and without domain expertise, one has to make a lot of assumptions which might be unfounded. all models have to make assumptions to simplify reality, but if those assumptions are rooted in domain expertise from the field then the model can mimic reality much better. without context, ai models assume that the truth can be gleaned solely from the data, which though it can lead to surprising and hidden insights, at times requires humans to evaluate the interpretations to make meaning from them and apply them to solve real-world problems. this was demonstrated with the case where it was claimed that ai had helped to predict the start of the outbreak, yet the anomaly required the analysis from a human before arriving at that conclusion. claims of extremely high accuracy rates will give hardened data scientists reason for caution, especially when moving from lab to real-world settings as there is a lot more messiness with real-world data and often you encounter out-of-distribution data which hinders the ability of the model to make accurate predictions. for ct scans, even if they are sped up tremendously by the use of ai, doctors point out that there are other associated procedures such as the cleaning and filtration and recycling of air in the room before the next patient can be passed through the machine which can dwindle the gains from the use of an unexplainable ai system analyzing the scans. concerns with the use of automated temperature scanning using thermal cameras also suffers from similar concerns where there are other confounding factors like the ambient temperature, humidity, etc. which can limit the accuracy of such a system. ultimately, while ai can provide tremendous benefits, we mustn't blindly be driven by its allure to magically solve the toughest challenges that we face. offering an interesting take on how to shape the development and deployment of ai technologies, mhlambi utilizes the philosophy of ubuntu as a guiding light in how to build ai systems that better empower people and communities. the current western view that dominates how ai systems are constructed today and how they optimize for efficiency is something that lends itself quite naturally to inequitable outcomes and reinforcing power asymmetries and other imbalances in society. embracing the ubuntu mindset which puts people and communities first stands in contrast to this way of thinking. it gives us an alternative conception of personhood and has the potential to surface some different results. while being thousands of years old, the concept has been seen in practice over and over again, for example, in south africa, after the end of the apartheid, the truth and reconciliation program forgave and integrated offenders back into society rather than embark on a kantian or retributive path to justice. this restorative mindset to justice helped the country heal more quickly because the philosophy of ubuntu advocates that all people are interconnected and healing only happens when everyone is able to move together in a harmonious manner. this was also seen in the aftermath of the rwanda genocide, where oppressors were reintegrated back into society often living next to the people that they had hurt; ubuntu believes that no one is beyond redemption and everyone deserves the right to have their dignity restored. bringing people together through community is important, restorative justice is a mechanism that makes the community stronger in the long run. current ai formulation seeks to find some ground truth but thinking of this in the way of ubuntu means that we try to find meaning and purpose for these systems through the values and beliefs that are held by the community. ubuntu has a core focus on equity and empowerment for all and thus the process of development is slow but valuing people above material efficiency is more preferable than speeding through without thinking of the consequences that it might have on people. living up to ubuntu means offering people the choice for what they want and need, rooting out power imbalances and envisioning the companies as a part of the communities for which they are building products and services which makes them accountable and committed to the community in empowering them. ethics in the context of technology carries a lot of weight, especially because the people who are defining what it means will influence the kinds of interventions that will be implemented and the consequences that follow. given that technology like ai is used in high-stakes situations, this becomes even more important and we need to ask questions about the people who take this role within technology organizations, how they take corporate and public values and turn them into tangible outcomes through rigorous processes, and what regulatory measures are required beyond these corporate and public values to ensure that ethics are followed in the design, development and deployment of these technologies. ethics owners, the broad term for people who are responsible for this within organizations have a vast panel of responsibilities including communication between the ethics review committees and product design teams, aligning the recommendations with the corporate and public values, making sure that legal compliance is met and communicating externally about the processes that are being adopted and their efficacy. ethical is a polysemous word in that it can refer to process, outcomes, and values. the process refers to the internal procedures that are adopted by the firm to guide decision making on product/service design and development choices. the values aspect refers to the value set that is both adopted by the organization and those of the public within which the product/service might be deployed. this can include values such as transparency, equity, fairness, privacy, among others. the outcomes refer to desirable properties in the outputs from the system such as equalized odds across demographics and other fairness metrics. in the best case, inside a technology company, there are robust and well-managed processes that are aligned with collaboratively-determined ethical outcomes that achieve the community's and organization's ethical values. from the outside, this takes on the meaning of finding mechanisms to hold the firms accountable for the decisions that they take. further expanding on the polysemous meanings of ethics, it can be put into four categories for the discussion here: moral justice, corporate values, legal risk, and compliance. corporate values set the context for the rest of the meanings and provide guidance when tradeoffs need to be made in product/service design. they also help to shape the internal culture which can have an impact on the degree of adherence to the values. legal risk's overlap with ethics is fairly new whereas compliance is mainly concerned with the minimization of exposure to being sued and public reputation harm. using some of the framing here, the accolades, critiques, and calls to action can be structured more effectively to evoke substantive responses rather than being diffused in the energies dedicated to these efforts. framing the metaphor of "data is the new oil" in a different light, this article gives some practical tips on how organizations can reframe their thinking and relationship with customer data so that they take on the role of being a data custodian rather than owners of the personal data of their customers. this is put forth with the acknowledgement that customers' personal data is something really valuable that brings business upsides but it needs to be handled with care in the sense that the organization should act as a custodian that is taking care of the data rather than exploiting it for value without consent and the best interests of the customer at heart. privacy breaches that can compromise this data not only lead to fines under legislation like the gdpr, but also remind us that this is not just data but details of a real human being. as a first step, creating a data accountability report that documents how many times personal data was accessed by various employees and departments will serve to highlight and provide incentives for them to change behaviour when they see that some others might be achieving their job functions without the need to access as much information. secondly, celebrating those that can make do with minimal access will also encourage this behaviour change, all being done without judgement or blame but more so as an encouragement tool. pairing employees that need to access personal data for various reasons will help to build accountability and discourage intentional misuse of data and potential accidents that can lead to leaks of personal data. lastly, an internal privacy committee composed of people across job functions and diverse life experiences that monitors organization-wide private data use and provides guidance on improving data use through practical recommendations is another step that will move the conversation of the organization from data entitlement to data custodianship. ultimately, this will be a market advantage that will create more trust with customers and increase business bottom line going into the future. towards the systematic reporting of the energy and carbon climate change and environmental destruction are well-documented. most people are aware that mitigating the risks caused by these is crucial and will be nothing less than a herculean undertaking. on the bright side, ai can be of great use in this endeavour. for example, it can help us optimize resource use, or help us visualize the devastating effects of floods caused by climate change. however, ai models can have excessively large carbon footprints. henderson et al.'s paper details how the metrics needed to calculate environmental impact are severely underreported. to highlight this, the authors randomly sampled one-hundred neurips papers. they found that none reported carbon impacts, only one reported some energy use metrics, and seventeen reported at least some metrics related to compute-use. close to half of the papers reported experiment run time and the type of hardware used. the authors suggest that the environmental impact of ai and relevant metrics are hardly reported by researchers because the necessary metrics can be difficult to collect, while subsequent calculations can be time-consuming. taking this challenge head-on, the authors make a significant contribution by performing a meta-analysis of the very few frameworks proposed to evaluate the carbon footprint of ai systems through compute-and energy-intensity. in light of this meta-analysis, the paper outlines a standardized framework called experiment-impact-tracker to measure carbon emissions. the authors use metrics to quantify compute and energy use. these include when an experiment starts and ends, cpu and gpu power draw, and information on a specific energy grid's efficiency. the authors describe their motivations as threefold. first, experiment-impact-tracker is meant to spread awareness among ai researchers about how environmentally-harmful ai can be. they highlight that "[w]ithout consistent and accurate accounting, many researchers will simply be unaware of the impacts their models might have and will not pursue mitigating strategies". second, the framework could help align incentives. while it is clear that lowering one's environmental impact is generally valued in society, this is not currently the case in the field of ai. experiment-impact tracker, the authors believe, could help bridge this gap, and make energy efficiency and carbon-impact curtailment valuable objectives for researchers, along with model accuracy and complexity. third, experiment-impact-tracker can help perform cost-benefit analyses on one's ai model by comparing electricity cost and expected revenue, or the carbon emissions saved as opposed to those produced. this can partially inform decisions on whether training a model or improving its accuracy is worth the associated costs. to help experiment-impact-tracker become widely used among researchers, the framework emphasizes usability. it aims to make it easy and quick to calculate the carbon impact of an ai model. through a short modification of one's code, experiment-impact-tracker collects information that allows it to determine the energy and compute required as well as, ultimately, the carbon impact of the ai model. experiment-impact-tracker also addresses the interpretability of the results by including a dollar amount that represents the harm caused by the project. this may be more tangible for some than emissions expressed in the weight of greenhouse gases released or even in co equivalent emissions (co eq). in addition, the authors strive to: allow other ml researchers to add to experiment-impact-tracker to suit their needs, increase reproducibility in the field by making metrics collection more thorough, and make the framework robust enough to withstand internal mistakes and subsequent corrections without compromising comparability. moreover, the paper includes further initiatives and recommendations to push ai researchers to curtail their energy use and environmental impact. for one, the authors take advantage of the already widespread use of leaderboards in the ai community. while existing leaderboards are largely targeted towards model accuracy, henderson et al. instead put in place an energy efficiency leaderboard for deep reinforcement learning models. they assert that a leaderboard of this kind, that tracks performance in areas indicative of potential environmental impact, "can also help spread information about the most energy and climate-friendly combinations of hardware, software, and algorithms such that new work can be built on top of these systems instead of more energy-hungry configurations". the authors also suggest ai practitioners can take an immediate and significant step in lowering the carbon emissions of their work: run experiments on energy grids located in carbon-efficient cloud regions like quebec, the least carbon-intensive cloud region. especially when compared to very carbon-intensive cloud regions like estonia, the difference in co eq emitted can be considerable: running an experiment in estonia produces up to thirty times as much emissions as running the same experiment in quebec. the important reduction in carbon emissions that follows from switching to energy-efficient cloud regions, according to henderson et al., means there is no need to fully forego building compute-intensive ai as some believe. in terms of systemic changes that accompany experiment-impact-tracker, the paper lists seven. the authors suggest the implementation of a "green default" for both software and hardware. this would make the default setting for researchers' tools the most environmentally-friendly one. the authors also insist on weighing costs and benefits to using compute-and energy-hungry ai models. small increases in accuracy, for instance, can come at a high environmental cost. they hope to see the ai community use efficient testing environments for their models, as well as standardized reporting of a model's carbon impact with the help of experiment-impact-tracker. additionally, the authors ask those developing ai models to be conscious of the environmental costs of reproducing their work, and act as to minimize unnecessary reproduction. while being able to reproduce other researchers' work is crucial in maintaining sound scientific discourse, it is merely wasteful for two departments in the same business to build the same model from scratch. the paper also presents the possibility of developing a badge identifying ai research papers that show considerable effort in mitigating carbon impact when these papers are presented at conferences. lastly, the authors highlight important lacunas in relation to driver support and implementation. systems that would allow data on energy use to be collected are unavailable for certain hardware, or the data is difficult for users to obtain. addressing these barriers would allow for more widespread collection of energy use data, and contribute to making carbon impact measurement more mainstream in the ai community. the paper highlights four challenges in designing more "intelligent" voice assistant systems that are able to respond to exploratory searches that don't have clear, short answers and require nuance and detail. this is in response to the rising expectations that users have from voice assistants as they become more familiar with them through increased interactions. voice assistants are primarily used for productivity tasks like setting alarms, calling contacts, etc. and they can include gestural and voice-activated commands as a method of interaction. exploratory search is currently not well supported through voice assistants because of them utilizing a fact-based approach that aims to deliver a single, best response whereas a more natural approach would be to ask follow up questions to refine the query of the user to the point of being able to provide them with a set of meaningful options. the challenges as highlighted in this paper if addressed will lead to the community building more capable voice assistants. one of the first challenges is situationally induced impairments as presented by the authors highlights the importance of voice activated commands because they are used when there are no alternatives available to interact with the system, for example when driving or walking down a busy street. there is an important aspect of balancing the tradeoff between smooth user experience that is quick compared to the degree of granularity in asking questions and presenting results. we need to be able to quantify this compared to using a traditional touch based interaction to achieve the same result. lastly, there is the issue of privacy, such interfaces are often used in a public space and individuals would not be comfortable sharing details to refine the search such as clothing sizes which they can discreetly type into the screen. such considerations need to be thought of when designing the interface and system. mixed-modal interactions include combinations of text, visual inputs and outputs and voice inputs and output. this can be an effective paradigm to counter some of the problems highlighted above and at the same time improve the efficacy of the interactions between the user and the system. further analysis is needed as to how users utilize text compared to voice searches and whether one is more informational or exploratory than the other. designing for diverse populations is crucial as such systems are going to be widely deployed. for example, existing research already highlights how different demographics even within the same socio-economic subgroup utilize voice and text search differently. the system also needs to be sensitive to different dialects and accents to function properly and be responsive to cultural and contextual cues that might not be pre-built into the system. differing levels of digital and technical literacy also play a role in how the system can effectively meet the needs of the user. as the expectations from the system increase over time, ascribed to their ubiquity and anthropomorphization, we start to see a gulf in expectations and execution. users are less forgiving of mistakes made by the system and this needs to be accounted for when designing the system so that alternate mechanisms are available for the user to be able to meet their needs. in conclusion, it is essential when designing voice-activated systems to be sensitive to user expectations, more so than other traditional forms of interaction where expectations are set over the course of several uses of the system whereas with voice systems, the user comes in with a set of expectations that closely mimic how they interact with each other using natural language. addressing the challenges highlighted in this paper will lead to systems that are better able to delight their users and hence gain higher adoption. the paper highlights how having more translation capabilities available for languages in the african continent will enable people to access larger swathes of the internet and contribute to scientific knowledge which are predominantly english based. there are many languages in africa, south africa alone has official languages and only a small subset are made available on public tools like google translate. in addition, due to the scant nature of research on machine translation for african languages, there remain gaps in understanding the extent of the problem and how they might be addressed most effectively. the problems facing the community are many: low resource availability, low discoverability where language resources are often constrained by institution and country, low reproducibility because of limited sharing of code and data, lack of focus from african society in seeing local languages as primary modes of communication and a lack of public benchmarks which can help compare results of machine translation efforts happening in various places. the research work presented here aims to address a lot of these challenges. they also give a brief background on the linguistic characteristics of each of the languages that they have covered which gives hints as to why some have been better covered by commercial tools than others.in related work, it is evident that there aren't a lot of studies that have made their code and datasets public which makes comparison difficult with the results as presented in this paper. most studies focused on the autshumato datasets and some relied on government documents as well, others used monolingual datasets as a supplement. the key analysis of all of those studies is that there is a paucity in the focus on southern african languages and because apart from one study, others didn't make their datasets and code public, the bleu scores listed were incomparable which further hinders future research efforts. the autshumato datasets are parallel, aligned corpora that have governmental text as its source. they are available for english to afrikaans, isizulu, n. sotho, setswana, and xitsonga translations and were created to build and facilitate open source translation systems. they have sentence level parallels that have been created both using manual and automatic methods. but, it contains a lot of duplicates which were eliminated in the study done in this paper to avoid leakage between training and testing phases. despite these eliminations, there remain some issues of low quality, especially for isizulu where the translations don't line up between source and target sentences. from a methodological perspective, the authors used convs s and transformer models without much hyperparameter tuning since the goal of the authors was to provide a benchmark and the tuning is left as future work. additional details on the libraries, hyperparameter values and dataset processing are provided in the paper along with a github link to the code. in general the transformer model outperformed convs s for all the languages, sometimes even by points on the bleu scores. performance on the target language depended on both the number of sentences and the morphological typology of the language. poor quality of data along with small dataset size plays an important role as evidenced in the poor performance on the isizulu translations where a lowly . bleu score was achieved. the morphological complexity of the language also played a role in the state of the performance as compared to other target languages. for each of the target languages studied, the paper includes some randomly selected sentences to show qualitative results and how different languages having different structures and rules impacts the degree of accuracy and meaning in the translations. there are also some attention visualizations provided in the paper for the different architectures demonstrating both correct and incorrect translations, thus shedding light on potential areas for dataset and model improvements. the paper also shows results from ablation studies that the authors performed on the byte pair encodings (bpe) to analyze the impact on the bleu scores and they found that for datasets that had smaller number of samples, like for isizulu, having a smaller number of bpe tokens increased the bleu scores. in potential future directions for the work, the authors point out the need for having more data collection and incorporating unsupervised learning, meta learning and zero shot techniques as potential options to provide translations for all official languages in south africa. this work provides a great starting point for others who want to help preserve languages and improve machine translations for low resources languages. such efforts are crucial to empower everyone in being able to access and contribute to scientific knowledge of the world. providing code and data in an open source manner will enable future research to build upon it and we need more such efforts that capture the diversity of human expression through various languages. presence of media cards, total interactions, history of engagement with the creator of the tweet, the user's strength of connection with the creator and the user's usage pattern of twitter. from these factors, one can deduce why filter bubbles and echo chambers form on the platform and where designers and technologists can intervene to make the platform a more holistic experience for users that doesn't create polarizing fractions which can promote the spread of disinformation. for the first time, there's a call for the technical community to include a social impact statement from their work which has sparked a debate amongst camps that are arguing to leave such a declaration to experts who study ethics in machine learning and those that see this as a positive step in bridging the gap between the social sciences and the technical domains. specifically, we see this as a great first step in bringing accountability closer to the origin of the work. additionally, it would be a great way to build a shared vernacular across the human and technical sciences easing future collaboration. we are impressed with all the work that the research and practice community has been doing in the domain of ai ethics. there are many unsolved and open problems that are yet to be addressed but our overwhelming optimism in the power of what diversity and interdisciplinarity can help to achieve makes us believe that there is indeed room for finding novel solutions to the problems that face the development and deployment of ai systems. we see ourselves as a public square, gathering people from different walks of life who can have meaningful exchanges with each other to create the solutions we need for a better future. let's work together and share the mic with those who have lived experiences, lifting up voices that will help us better understand the contexts within which technology resides so that we can truly build something that is ethical, safe, and inclusive for all. see you here next quarter, the state of ai ethics, june suckers list: how allstate's secret auto insurance algorithm squeezes big spenders algorithmic injustices towards a relational ethics social biases in nlp models as barriers for persons with disabilities the second wave of algorithmic accountability the unnatural ethics of ai could be its undoing this dating app exposes the monstrous bias of algorithms ( arielle pardes data is never a raw, truthful input -and it is never neutral racial disparities in automated speech recognition working to address algorithmic bias? don't overlook the role of demographic data ai advances to better detect hate speech algorithms associating appearance and criminality have a dark past beware of these futuristic background checks go deep: research summaries the toxic potential of youtube's feedback loop study: facebook's fake news labels have a fatal flaw research summaries capabilities, and ai assistive technologies go wide: article summaries ancient animistic beliefs live on in our intimacy with tech humans communicate better after robots show their vulnerable side at the limits of thought engineers should spend time training not just algorithms, but also the humans who use them using multimodal sensing to improve awareness in human-ai interaction different intelligibility for different folks aligning ai to human values means picking the right metrics why lifelong learning is the international passport to success (pierre vandergheynst and isabelle vonèche cardia you can't fix unethical design by yourself research summaries the wrong kind of ai? artificial intelligence and the future of labor demand ai is coming for your most mind-numbing office tasks tech's shadow workforce sidelined, leaving social media to the machines here's what happens when an algorithm determines your work schedule automation will take jobs but ai will create them research summaries what's next for ai ethics, policy, and governance? a global overview (daniel schiff a holistic approach to implement ethics in ai beyond a human rights based approach to ai governance: promise, pitfalls and plea go wide: article summaries this is the year of ai regulations apps gone rogue: maintaining personal privacy in an epidemic maximizing privacy and effectiveness in covid- apps article summaries who's allowed to track my kids online? chinese citizens are racing against censors to preserve coronavirus memories on github can i opt out of facial scans at the airport? with painted faces, artists fight facial recognition tech research summaries adversarial machine learning -industry perspectives article summaries the deadly consequences of unpredictable code adversarial policies: attacking deep reinforcement learning specification gaming: the flip side of ai ingenuity doctors are using ai to triage covid- patients. the tools may be here to stay the future of privacy and security in the age of machine learning research summaries towards a clearer account of research priorities in ai ethics and society integrating ethical values and economic value to steer progress in ai machine learning scholarship go wide: article summaries microsoft researchers create ai ethics checklist with ml practitioners from a dozen tech companies why countries need to work together on ai quantifying independently reproducible machine learning be a data custodian, not a data owner research summaries towards the systematic reporting of the energy and carbon footprints of machine learning challenges in supporting exploratory search through voice assistants a focus on neural machine translation for african languages radioactive data: tracing through training using deep learning at scale in twitter's timeline (nicolas koumchatzky neurips requires ai researchers to account for societal impact and financial conflicts of interest in modern ai systems, we run into complex data and processing pipelines that have several stages and it becomes challenging to trace the provenance and transformations that have been applied to a particular data point. this research from the facebook ai research team proposes a new technique called radioactive data that borrows from medical science where compounds like baso are injected to get better results in ct scans. this technique applies minor, imperceptible perturbations to images in a dataset by causing shifts within the feature space making them "carriers".different from other techniques that rely on poisoning the dataset that harms classifier accuracy, this technique instead is able to detect such changes even when the marking and classification architectures are different. it not only has potential to trace how data points are used in the ai pipeline but also has implications when trying to detect if someone claims not to be using certain images in their dataset but they actually are. the other benefit is that such marking of the images is difficult to undo thus adding resilience to manipulation and providing persistence. prior to relevance based timeline, the twitter newsfeed was ordered in reverse chronological order but now it uses a deep learning model underneath to display the most relevant tweets that are personalized according to the user's interactions on the platform. with the increasing use of twitter as a source of news for many people, it's a good idea for researchers to gain an understanding of the methodology that is used to determine the relevance of tweets, especially as one looks to curb the spread of disinformation online. the article provides some technical details in terms of the deep learning infrastructure and the choices made by the teams in deploying computationally heavy models which need to be balanced with the expediency of the refresh times for a good experience on the platform. but, what's interesting from an ai ethics perspective are the components that are used to arrive at the ranking which constantly evolves based on the user's interaction with different kinds of content.the ranked timeline consists of a handful of the tweets that are the most relevant to the user followed by others in reverse chronological order. additionally, based on the time since one's last visit on the platform, there might be an icymi ("in case you missed it") section as well. the key factors in ranking the tweets are their recency, key: cord- - wk l authors: baerwolff, guenter k.f. title: a contribution to the mathematical modeling of the corona/covid- pandemic date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: wk l the responsible estimation of parameters is a main issue of mathematical pandemic models. especially a good choice of β as the number of others that one infected person encounters per unit time (per day) influences the adequateness of the results of the model. for the example of the actual covid- pandemic some aspects of the parameter choice will be discussed. because of the incompatibility of the data of the johns-hopkins-university to the data of the german robert-koch-institut we use the covid- data of the european centre for disease prevention and control (ecdc) as a base for the parameter estimation. two different mathematical methods for the data analysis will be discussed in this paper and possible sources of trouble will be shown. parameters for several countries like uk, usa, italy, spain, germany and china will be estimated and used in w.o. kermack and a.g. mckendrick's sir model. strategies for the commencing and ending of social and economic shutdown measures are discussed. the numerical solution of the ordinary differential equation system of the modified sir model is being done with a runge-kutta integration method of fourth order. at the end the applicability of the sir model could be shown. suggestions about appropriate points in time at which to commence with lockdown measures based on the acceleration rate of infections conclude the paper. at first i will describe the model. i denotes the infected people, s stands for the susceptible and r denotes the recovered people. the dynamics of infections and recoveries can be approximated by the ode system we understand β as the number of others that one infected person encounters per unit time (per day). γ is the reciprocal value of the typical time from infection to recovery. n is the total number of people involved in the epidemic disease and there is n = s + i + r . the empirical data currently available suggests that the corona infection typically lasts for some days. this means γ = / ≈ , . the choice of β is more complicated. therefore we consider the development of the infected persons in germany. figs. (and ) show the history of the last days. at the beginning of the pandemic the quotient s/n is nearly equal to . also, at the early stage no-one has yet recovered. thus we can describe the early regime by the equation di dt = βi with the solution i(t) = i( ) exp(βt) . to guess values for i( ) and β we fit the real behavior with the function α exp(βt). with a damped gauss-newton method [ ] we get the value β = , for the nonlinear approximation and β = , with a logarithmic-linear regression for germany. the values of β for italy and spain are greater than those for germany (in italy: the resulting exponential curves are sketched in figs. and . it is important to note that actual data for germany can be only coarsely approximated by exponential curves. this reduces the quality of the sir model, and limits its predictive power. with the optimmistic choice of β-value , which was evaluated on the basis of the real data (from the johns hopkins university database) one gets the course of the pandemic dynamics pictured in fig. . . r is the basis reproduction number of persons, infected by the transmission of a pathogen from one infected person during the infectious time (r = β/γ) in the following figures. neither data from the german robert-koch-institut nor the data from the johns hopkins university are correct, for we have to reasonably assume that there are a number of unknown cases. it is guessed that the data covers only % of the real cases. considering this we get a slightly changed result pictured in fig. . the maximum number of infected people including the estimated number of unknown cases is a bit higher than the result showed in fig. . this can be explained by the small reduction of the s stock. i denotes the initial value of the i species, that is march th . imax stands for the maximum of i. the total number n for germany is guessed to be millions. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint with the data β = , and γ = , (corresponds to days to heal up or to join the species r), we get the epidemic dynamics showed in fig. . for n we take a value of millons. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the effects of social distancing to decrease the infection rate can be modeled by a modification of the sir model. the original ode system ( )-( ) was modified to κ is a function with values in [ , ]. for example is the duration of the temporary lockdown in days). a good choice of t and t k is going to be complicated. some numerical tests showed that a very early start of the lockdown resulting in a reduction of the infection rate β results in the typical gaussian curve to be delayed by i; however, the amplitude (maximum value of i) doesn't really change. the result of an imposed lockdown of days with t = and t = and reduction value κ equal to , (it means a reduction of contacts to %) is pictured in fig. . there is not a genuine profit for the fight against the disease. one knows that development of the infected people looks like a gaussian curve. the interesting points in time are those where the acceleration of the numbers of infected people increases or decreases, respectively. these are the points in time where the curve of i was changing from a convex to a concave behavior or vice versa. the convexity or concavity can be controlled by the second derivative of i(t). let us consider equation ( ). by differentiation of ( ) and the use of ( ) we get with that the i-curve will change from convex to concave if the relation is valid. for the switching time follows a lockdown starting at t (assigning β * = κβ, κ ∈ [ , [) up to a point in time t = t + ∆ t , with ∆ t as the duration of the lockdown in days, will be denoted as a dynamic lockdown (for t > t β * was reset to the original value β). t means the point in time up to which the growth rate increases and from which on it decreases. fig. shows the result of such a computation of a dynamic lockdown. the result is significant. in fig. a typical behavior of d i dt is plotted. the result of a dynamic lockdown for italy is shown in fig. data from china and south korea suggests that the group of infected people with an age of or more is of magnitude %. this group has a significant higher mortality rate than the rest of the infected people. thus we can presume that α= % of i must be especially sheltered and possibly medicated very intensively as a highrisk group. fig. shows the time history of the above defined high-risk group with a dynamic lockdown with κ = , compared to regime without social distancing. the maximum number of infected people decreases from approximately , millions of fig. the infection rate κβ which we got with the switching times t and t is pictured. this result proves the usefulness of a lockdown or a strict social distancing during an epidemic disease. we observe a flattening of the infection curve as requested by politicians and health professionals. with a strict social distancing for a limited time one can save time to find vaccines and time to improve the possibilities to help high-risk people in hospitals. to see the influence of a social distancing we look at the italian situation without a lockdown and a dynamic lockdown of days with fig. (κ = , ) for the % high-risk people. if we write ( ) or ( ) resp. in the form we realize that the number of infected people decreases if is complied. the relation ( ) shows that there are two possibilities for the rise of infected people to be inverted and the medical burden to be reduced. a) the reduction of the stock of the species s. this can be obtained by immunization or vaccination. another possibility is the isolation of high-risk people ( years and older). positive tests for antibodies reduce the stock of susceptible persons. b) a second possibility is the reduction of the infection rate κβ. this can be achieved by strict lockdowns, social distancing, or rigid sanitarian moves. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the results are pessimistic in total with respect to a successful fight against the covid- -virus. hopefully the reality is a bit more merciful than the mathematical model. but we rather err on the pessimistic side and be surprised by more benign developments. note again that the parameters β and κ are guessed very roughly. also, the percentage α of the group of high-risk people is possibly overestimated. depending on the capabilities and performance of the health system of the respective countries, those parameters may look different. the interpretation of κ as a random variable is thinkable, too. [ ] g. bärwolff, numerics for engineers, physicists and computer scientists ( rd ed., in german). springer-spektrum . [ ] toshihisa tomie, understandig the present status and forcasting of covid- in wuhan. medrxiv.preprint . . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : italian history of the infected people of high-risk groups depending on a dynamic lockdown (it) . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint a contribution to the mathematical theory of epidemics key: cord- -biundkbv authors: shek, daniel t. l. title: protests in hong kong ( – ): a perspective based on quality of life and well-being date: - - journal: appl res qual life doi: . /s - - - sha: doc_id: cord_uid: biundkbv triggered by the fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill in hong kong (extradition bill), many protests have taken place in hong kong in – . using a perspective based on quality of life and well-being in different ecological systems, it is argued that the process of introducing the bill is the “heat” which has ignited the “fuels” represented by pre-existing and new issues in quality of life and well-being. these issues included distrust in the central government, lack of national identity, political dissatisfaction, economic strains, mental health threats, drop in family quality of life, lack of life skills education, lack of evidence-based national education in the formal curriculum, slow response of the government, and alleged excessive use of force by the police. the fire has been intensified by “four strong winds”, including disinformation and misinformation, anonymity of the protesters, public support for the students, and support given by parties outside hong kong. possible solutions in terms of promotion of quality of life and well-being with reference to the fire triangle are discussed. are well-designed training and operation manuals for protests and strikes which can be easily downloaded from the internet. fifth, vandalism has been extensive in the social event. these included damage of sets of traffic lights, . km of railings along the road, and , square meters of paving blocks (yau ) which require some hk$ million to repair. besides, there was damage of mass transit railway stations and light railway stations, assault and doxing people holding contrary political views, and damage of shops owned by those who did not support the social movement (rthk radio ). perhaps the most striking examples are the damage of the legislative council building on july , and the occupation of the chinese university of hong kong and the hong kong polytechnic university in november . besides, the use of foul language and physical violence to informally "settle" interpersonal conflicts was not uncommon in the movement. sixth, despite the great extent of violence and vandalism, public condemnation of such behavior was not strong. some people even show support for the use of violence in the social movement. for example, a survey showed that roughly % of the respondents supported the use of violence as a tactic and more than half of the pro-democracy respondents endorsed the use of laser pointers against the police (sum ) . finally, the social event is highly political in nature. although its origin was to protest against the extradition bill, it has gradually evolved into a movement with the slogan of "five demands, not one less". these five demands include "full withdrawal of the extradition bill", "retracting the classification of protesters as 'rioters'", "amnesty for arrested protesters", "an independent commission of inquiry into alleged police brutality", and "dual universal suffrage, meaning for both the legislative council and the chief executive" (wong b) . besides, the slogan of "liberate hong kong, revolution of our time" emerged as the social event moved on. during the social movement, protesters have placed advertisements in foreign newspapers and waved us and uk flags during the protests, appealing for support from foreign governments. obviously, quality of life has been much hampered in the social movement. first, the economy has slowed down because of the social unrest. for example, the number of tourists has dropped by % (cheng ) and the unemployment rate has been climbing in the past few months. second, protests have created much disturbance to the ordinary lives of people. for example, during the occupation of the chinese university of hong kong, the east railway system service was much disturbed and the main highway joining the eastern part of the new territories was blocked. the cross-harbor tunnel was also out of service during the occupation of the hong kong polytechnic university by the protesters. as a result, workers had to take leave involuntarily or spent much longer traveling time. third, the social movement has been divisive and polarized for people with different political views. for those who support the protesters and five demands, they are called "yellow ribbons". on the other hand, those who do not support the protesters, they are called "blue ribbons". in many families, social groups, and work settings, people have become alienated and have conflicts with each other (chow ) . finally, the social movement has created well-being problems in people of hong kong. based on a large community sample, ni et al. ( ) reported that the prevalence of probable depression was . % in which was much higher than that during - ( . %) and . % after the occupy central movement in . besides, the estimated ptsd prevalence rate was . %. mogul ( ) also pointed out that ptsd symptoms were common in the protesters. ng ( ) used the term "mental health tsunami" to describe the situation which was brought forth by the repeated and direct involvement in violent conflicts between protesters and police, exposure to violence, disintegration of families and friends, and the declining economic conditions. why the fire broke out? quality of life and well-being issues as fuels we can use "fire" to represent the social event which has lasted for roughly months. obviously, the fundamental question is why the fire broke out. in view of the highly political nature of the social movement, there are views suggesting that the event was initiated and orchestrated by forces outside hong kong. such views are primarily driven by the notion of "color revolution" which has occurred in places like tunisia and ukraine. in addition to western influences, taiwan has been suspected to play a strong role in the social movement. the reasoning is that by highlighting the message that the "one country, two systems" arrangement does not work, the president of taiwan (tsai ing wen) would get more support in the presidential election in . although these conspiracy conjectures make sense on the surface, we need empirical evidence that cannot be easily substantiated. also, conspiracy theories alone do not give full attention to the psychology of the protesters and they cannot explain the perpetual involvement of young people as well as the determination of some of them to die for the sake of producing political changes in hong kong. unfortunately, not many systematic investigations have been conducted to explore the genesis of the social movement. a pioneer paper on the protests in hong kong in was written by purbrick ( ) who argued that in addition to errors in police operations, housing, poverty, and governance are three key factors underlying the social event. in this paper, we attempt to understand the social movement from the perspective of quality of life and well-being. the main thesis is that the social unrest exists because there are threats to and issues in quality of life and well-being in hong kong. from an individual perspective, quality of life is a multi-dimensional construct. according to felce and perry ( ) , overall quality of life is a function of three factors, including objective life conditions, including physical well-being (e.g., personal safety), material wellbeing (e.g., security), social well-being (e.g., acceptance and support), emotional well-being (e.g., respect) and development and activity (e.g., choice and control), subjective feelings of the objective life conditions and personal values and aspirations. obviously, threats to quality of life in these domains would arouse fear and distress for an individual. from a societal perspective, organization for economic co-operation and development (oecd ) proposed the following indicators of human well-being: health status, work and life balance, education and skills, social connections, civic engagement and governance, environmental quality, personal security, and subjective well-being. again, threats in well-being in these domains, particularly in the areas of governance and personal security, would lead to strong reactions from people in the society. according to the ecological perspective, there are different ecological systems governing human development where individuals experience well-being (or ill-being) in different systems. these include the personal system (e.g., threat to freedom and finding life meaning through involvement in a "revolution"), interpersonal system (e.g., peer influence and bonding amongst peer protesters), family system (e.g., lack of family warmth), social system (e.g., sensational social media influence), and political system (e.g., lack of trust in the government and support for protesters from bodies outside hong kong). by examining the quality of life and well-being in different systems, we can get some clues on the related deficiencies and threats in quality of life which have shaped the development of the social event in hong kong in - . the fire triangle: fuels, heat, and oxygen according to the fire triangle, there are three basic elements of fire -fuels, heat, and oxygen. in this paper, we treat the quality of life and well-being issues as "fuels", the extradition bill as "heat", and some contextual influences (such as support from the general public for young people's involvement in protests) as "oxygen". there are ten pre-existing fuels and two new fuels for the "fire" as follows: pre-existing fuel no. : distrust in the central government hong kong had been a british colony from to june , . although hong kong physically returned to china on july , , it has been difficult for hong kong people to develop a high level of trust in the beijing government for two reasons. first, people tend to fixate on the unfortunate history of the cultural revolution and june th incident of . second, as corruption in mainland china has been a thorny problem since the opening of china in the late s, governance in china has been seen in a negative light by hong kong people. empirically, studies showed that the level of trust in the beijing government has been fluctuating with roughly . % of the respondents having no trust in the first months of (public opinion poll, the university of hong kong b). lack of trust in the central government clearly suggests political uncertainty which constitutes a threat to the political well-being of hong kong people. studies have shown that % of the young respondents regarded themselves as "hongkonger" rather than "chinese" (public opinion poll, the university of hong kong a). the weak national identity can be attributed to the vast differences in cultural and social background between hong kong and mainland china, such as views on individual freedom and governance. the negative stereotypes formed for mainland chinese people (e.g., poor hygiene and snobbishness) also constitute blocks to identify with the chinese national identity. as national identity is an important aspect of self-identity, a blurred national identity is a threat to personal well-being, which suggests a sense of rootlessness. under the british colonial rule, the governor was not elected but appointed by the british government (i.e., hong kong people had no say). until the last decade before the handover, the colonial government began to introduce some political reform initiatives. the basic law also stipulates that there would be a progressive change in the election systems of the chief executive and legislative council members. although the political system can be regarded as more "open" after , hong kong people (particularly the youngsters) are not satisfied for two reasons. first, the current political system gives heavier weight to the businessmen who have been blamed to create economic and social inequalities in hong kong. second, as the government of the sar has not been working effectively after the handover, people generally want to have more say in important decisions for hong kong. obviously, dissatisfaction with the political system is a threat to political well-being (oecd ). one related factor that should be considered is the ideals of young people. in the good old days, the formula for youth development is to motivate young people to succeed in academic study (entrance to a government-funded university and study in a professional programme), get a job with a handsome salary and establish a happy family. however, for the generation z (i.e., commonly refers to young people born in the late s and early s), they are more autonomous, technology-oriented and more concerned about social issues (dolot ; gaidhani et al. ) . in other words, putting the material good life as the "carrot" does not really work for students of generation z because material possession may not be their primary concern. pre-existing fuel no. : economic strains (poverty, high housing price and high cost of living) although hong kong enjoyed almost full employment as well as high gpd per capita in early , wealth distribution has been a persistent problem: roughly one in four adolescents grow up in poor families; the gini coefficient is disturbingly high (oxfam ); there were around . million poor people with , poor households in (government of the hong kong sar ). assuming % of the poor people were dissatisfied young people, it means around , young people were on the street protesting against the government. research has showed that poverty is a risk factor affecting the quality of family life and individual well-being, which would in turn undermine the healthy development of adolescents and cause problems such as the development of externalizing behavior. it also impairs the quality of life of the hong kong society. historically speaking, housing has been a thorny problem in hong kong. unfortunately, the problem has been much aggravated after the handover back to china. according to some surveys, the housing price in hong kong and the cost of living were the highest in the world (arcibal ) . there are three consequences of this situation. first, young people would find it difficult to get married, hence creating much frustration in youngsters. for some of the married young couples, they may be forced to stay in sub-divided flats that have security and hygiene problems. second, parents are expected to help children (as reflected in the saying of "the success of young people depends on the hard work of the father") which creates much intergenerational conflict in the family. finally, the rocket high housing price creates a sense of hopelessness in young people because it would be a heavy burden even for young professionals to buy a decent flat. the high housing price obviously triggers much negative emotions in young people. with the extradition bill, it is a good opportunity for them to air out their anger and hopelessness as well as a desire for "mutual destruction" (i.e., let us have nothing together). the high housing price is an obvious threat to physical well-being (shelter), psychological well-being (hopelessness), family well-being (conflict and tension within the family), social well-being (rich-poor divide), and political wellbeing (hatred for the government for its ineffective housing policies). although there was almost full employment in , youth employment has been an issue of concern for many years (government of the hong kong sar ). with the introduction of more self-financed sub-degree and degree programs, many graduates are not able to move up the social ladder because the real income for university graduates has been quite stagnant since the handover (new century forum and new youth forum ). again, lack of upward social mobility triggers negative emotions in young people which eventually promotes a sense of hopelessness in young people (shek and siu b) . this also explains why young people have psychological resistance to return to china because their lives have not improved much after the handover. it is also why some young people waved the british flag during demonstrations which are clearly a sign of remembering the "good old days" for university students under the british rule. obviously, the lack of opportunity for hong kong young people to have upward mobility is a serious threat to individual well-being and societal quality of life. nevertheless, young people are commonly not aware of the fact that the lack of social mobility also exists in many developed countries in the world and there was also much inequality under the british rule. under the influence of the chinese culture, hong kong emphasizes strongly on academic excellence and achievement, with success commonly defined in terms of good grades in public examinations and earning a lot of money. such social mentalities have three consequences. first, striving for academic excellence can be very stressful for young people which impairs their personal well-being. one consequence is that young people are prone to develop internalizing behavior such as depression and suicide. in fact, the appeal for "mutual destruction" can be regarded as a manifestation of mass internalizing behavior. second, the exam-oriented system naturally creates "losers" in young people. as only % of high school graduates can get governmentfunded university places, the number of "losers" created every year is quite substantial. third, it would be difficult for students to find authentic life meaning in study except "getting good grades". most of the time, young people in hong kong have "foreclosure" identity according to the psychosocial theory of erik erikson (i.e., commitment without crisis). hence, when young people face the slogan of "liberate hong kong, revolution of the time", the social movement gives them a noble and romantic life meaning which can be easily incorporated in their identity. in short, the morbid emphasis on academic excellence undermines the academic and personal well-being of students which can be easily filled by some heroic and grand ideals such as revolutionize hong kong to make the tomorrow better. young people in hong kong face many psychosocial stresses, including academic stress, low income, high property price, long working hours, and a small living environment. shek and siu ( b) argued that the developmental context for hong kong adolescents is "unhappy", including unhealthy values, de-emphasis of holistic youth development, rise in hopelessness but drop in life satisfaction, emphasis on academic excellence but de-emphasis on academic quality of life, poverty, parenting issues, and drop in family well-being. obviously, stresses and risk factors in adolescent development can easily be translated into poor mental health amongst young people. there are research findings showing that adolescent hopelessness rises but life satisfaction drops in adolescent years (shek and liang ) . at the same time, their academic stress increases but their perceived support from school decreases (shek and chai ) . in other words, the well-being of adolescents in hong kong is at risk. in the special issue edited by shek and siu ( b) , the papers show that mental health is a growing concern in young people in hong kong. there are also findings suggesting that mental health problems in university students are prevalent (lo et al. . in other words, young people with poor well-being are emotionally charged time bombs waiting to be detonated. finally, students with special educational needs may be a factor that should not be overlooked. when we examine the slogans of the protesters, it is not uncommon to see that there are many incorrectly written chinese characters. there are two possible explanationseither the protesters are poorly educated or they are dyslexic who are commonly having difficulties in writing chinese characters. it is noteworthy that students with special education needs (e.g., those with autistic features or dyslexic) are stubborn in their views. there are several disturbing developments of families in hong kong, including rising divorce and remarriage rates, rising cross-border marriages, worrying child abuse rates, growing number of parents who are not hong kong residents, growing cross-border workers, long working hours, and aging population. these problems negatively affect young people who experience family alienation and conflicts arising from unfavorable family circumstances. obviously, the social event constitutes an excellent opportunity for them to feel the warmth amongst the "comrades" and have deep sharing and mutual concerns amongst the participants who may not have such warm experience before. in other words, low family quality of life is a strong precursor for active and romantic participation in the social movement. nevertheless, there are also reports saying that some parents actually encourage their kids to actively participate in the movement, including engaging in violent behavior. although young people face many psychosocial stresses and challenges, there is weak systematic life skills education for adolescents. in many countries, social-emotional learning, soft skills and psychosocial competence, including the promotion of selfunderstanding, social understanding, interpersonal competence, responsible decision making, and self-management skills are strongly promoted. although critical thinking is emphasized in liberal studies under the new high school curriculum in hong kong, it is argued that students actually learn "criticism mentality" instead of "critical thinking". in a series of cross-sectional and longitudinal studies, showed that while different stakeholders endorsed the importance of life skills education in the formal curriculum, they perceived that life skills education in the formal curriculum was insufficient and life skills development in adolescents was incomplete. without such systematic education, the personal well-being of young people in hong kong cannot be adequately protected (shek and siu a) . the neglect of soft skills education for young people in hong kong means that they do not possess adequate social competence skills to negotiate with other people or resolve conflicts, which are much needed. as intense anger and hatred are involved in the social event, learning how to empathize (look at things from others' perspective), manage one's and others' emotion (emotional quotient), forgive (write off emotional feelings and debts), and re-conciliate (re-build new relationships and move on) are important tasks for adolescents. these life skills are very important because there are studies showing that hong kong adolescents showed narcissistic behavior (leung ) and positive youth development attributes negatively predicted the use of foul language in adolescents (shek and lin ). although there is an area on moral, civic and national education in the formal curriculum, the policy and scope of the national education curriculum are unsystematic and uncoordinated. in a study comparing related moral, character and citizenship education in chinese societies (hong kong, mainland china, and taiwan) and non-chinese societies (singapore, uk, and usa), shek and leung ( ) identified several problems in this area, including absence of comprehensive planning and policy development, blurred concepts and lack of focus on holistic student development, lack of emphasis of moral and character education, problem of "penetrative" approach, absence of formal curriculum materials, problematic operational strategies, and lack of evaluation. besides, while national education is undertaken by the education bureau (formal school curriculum), the home affairs bureau (committee on the promotion of civic education), and the labor and welfare bureau (youth section in the social welfare department), there is little coordinated effort amongst the different bureaus. the lack of related education suggests that the personal well-being of young people in terms of moral competence cannot develop in a healthy manner. obviously, there are two difficulties in implementing moral education in hong kong. the first one is "what" should be covered. if the coverage covers chinese history in the past century, students can learn more about what happened in china, particularly the exploitation under western imperialism. however, as history is multifaceted, how to interpret historical facts is a thorny issue. the second issue is "how" to assess the outcomes. while an increase in knowledge is easy to demonstrate, positive change in attitude and behavior may not be easy to assess objectively. in view of the sensitive nature of chinese history, some schools simply cut the subject under the new education reform. under these circumstances, it is not surprising to note that many young people are not familiar with modern chinese history and geography of china. the responses of the government to the protests since june have been regarded to be slow and ineffective. besides condemning violence and vandalism, the government has relied primarily on the police to deal with the protests. the attempt to have dialogues with the public also does not appear to be very successful. most important of all, although the bill has triggered such a huge social event, no senior government official steps down. this is very interesting because in similar situations in other countries, some senior government officials would have stepped down to take political responsibility. again, this reflects the threat of political well-being in governance which intensifies public worry, anger, and frustration. of course, in understanding the responses of the government, two points must be noted. first, in view of the unprecedented nature and the extent of the protests, it is not easy to handle. as pointed out by the prime minister of singapore (lee hsien loong), singapore would be "finished" if similar protests happened in singapore (sim ) . second, dissatisfaction with the government has been a common theme in protests which intensifies the protests. for example, the commission of inquiry ( ) concluded that "a recent tendencynot only in hong kongto ascribe all the failings of the community to errors by the administration and to make greater demands upon it tends not only to enhance discontent but to exaggerate their extent" (p. ). there are numerous and serious allegations that the police used excessive force, such as in the protests held on june , july and august , (purbrick ). on the other hand, the police was criticized as doing nothing when people in yuen long were attacked by those who did not support the protesters on july , . obviously, such allegations are great threats to the personal well-being of the protesters and the social well-being of hong kong. on the one hand, some videos in the news reports and the internet strongly suggest that excessive force might have been used by the police. while some of the related complaints are still under the investigation of the independent police complaints council (ipcc), the mechanism does not earn the trust of hong kong people for two reasons. first, some ipcc members were appointed by the government, which means that their independence is doubtful. second, many protesters experiencing excessive force by the police do not complain because they have the fear that they will be prosecuted for involvement in riots. on the other hand, it should be noted that "innocence before proven guilty" is the cornerstone of the common law and the establishment of police violence and brutality requires evidence beyond reasonable doubt. besides, objectivity of some videos uploaded to the internet is not clear. in addition, it would not be objective if we ignore the fact that public perceptions of the police had been very good before the social event and the hong kong police ranked very high in terms of professional service in international surveys. for example, in the human freedom index (vásquez and porčnik ) , hong kong police ranked sixth ( th) under the indicator of "reliability of police". in the legatum prosperity index ( ), hong kong police ranked fourth ( th) out of countries and regions under the indicator of "safety and security". similarly, hong kong police ranked fourth ( th) under "order and security" in the world justice project ( ). of course, having an excellent record does not necessarily mean that the alleged police issues do not exist. however, we also need expert views based on credible professionals (e.g., those who have expertise in police operations) using credible evidence from credible sources to make objective and fair judgments. there are several arrangements that create anxiety and threats for hong kong people. first, it extends the scope of extradition to cover mainland china. with the proposed changes, hong kong people who have committed certain crimes in china could be transferred to mainland china. second, there were several rounds of revisions in the process, thus giving people a sense that the whole package has not been well-conceived, and the changes were made to address the concerns of the businesspeople only. third, the proposed safeguards are considered not adequate by the public. finally, the consultation period was too short. some people queried that the consultation was too short for an issue which had not been resolved within years after the handover. at the same time, the buy-in work was not enough, and consultation was not extensive. in particular, no specific strategies were used to address the concerns of young people, particularly via social media. besides, the publicity work of the government was neither creative nor innovative. finally, the government's non-sensitivity about the public reaction to the bill greatly intensified the fear. since the proposal was published, there had been numerous reservations voiced by different sectors of the society, including businessmen, lawyers, and barristers. however, the government did not feel the pulse of the community. also, despite the fact that many people joined the protest held on june , the government still decided to move to the second reading debate on june , . such insensitivity to public reaction eventually triggered the fire. for the political fire on the extradition bill to take place, besides fuels (quality and life and well-being issues) and heat (worries that the bill had created and the public sentiment it had aroused), oxygen is a very important concern. in the social movement, several sources of wind have provided much "oxygen" for the social event. while misinformation refers to inaccurate information, disinformation refers to the deliberate dissemination of false information. in the social movement, there are numerous instances of misinformation. for example, for the number of protesters, it was claimed that there were million and million people joining the demonstrations in june . however, while it cannot be denied that many hong kong people joined the protests, the figures quoted by the organizer were doubted by cnn (mezzofiore ) . concerning the occupation of the legislative council building on july , , the police issued a warning at around : pm condemning the action of the protesters and giving the final warning for them to disperse. however, the watch of the chief superintendent had been altered to pm (wong a) in the video which suggests that the police had set a trap for the protesters. another example is the news reported by da kung pao on the assault on a legislative councilor (ho kwan yiu). while the news was released at noon on november , , the time of release was amended to be : on november , (global times ). based on the amended news, it was claimed that the assault was self-directed by ho. in the initial stage of the protests, many protesters wore surgical masks. in the late stage of the protesters, some protesters wore gas masks and covered their whole face. while it is understandable that gas masks protect the protesters from tear gas, keeping one's identity anonymous actually intensified the scale of violence and vandalism because the fear of being identified would be minimized. besides, communication in social media on protests is also anonymous, hence facilitating the planning and implementation of the protests and vandalism. as it is well-documented in social psychology that people with anonymous identity would be more likely to engage in violent behavior (zimbardo ) , anonymity has supplied much "oxygen" to the intensity and duration of the social event. many people have shown support for the protesters (particularly the students) for several reasons. first, it is commonly believed that the public should give more allowance to students who are just "kids". second, some adults have the fear that the bill would break the "firewall" between hong kong and china. third, some people believe that the students are doing what they have not done, such as a fight for democracy for hong kong. fourth, many people are angry at the slow and nonresponsive responses of the government. fifth, many people support the prevailing but toxic beliefs that "disobey the law to get justice is acceptable" and "violence is sometimes necessary under certain circumstances". finally, many people believe that violence of the protesters is justified because police have used excessive force and there is police brutality. there is also public support in terms of finance. for example, around hk$ million (us$ million) related to the sparkle alliance was frozen by the police (mok et al. ) . the public's support for the protesters (including many professional associations) and not "cutting the mattress" with the violent protesters is definitely a strong reinforcement for the protesters. in the social event, many foreign political leaders have shown support for the protesters. unfortunately, very few of them touch upon the issues of violence and vandalism. such supportive gestures have created the false impression that the movement (including violence and vandalism) is reasonable, sacred and just. material support from taiwan in the form of gas masks was also reported (sui ) . it is apparent that there are many deep-seated quality of life issues behind the social movement. as such, the solution lies in properly addressing these quality of life threats and issues. primarily, it is important to cut or eliminate the pre-existing fuels as follows: . trust in the beijing government: it is important to build up trust in the beijing central government. in social psychological literature, the contact hypothesis suggests that contact is very important to reduce prejudice (pettigrew and tropp ) . hence, increased contact to understand mainland china will be helpful. looking at the bright and dark sides of china (as these two aspects exist in all countries) and appreciating the progress of china in the past four decades such as poverty alleviation for around million people according to the world bank (he ) and acknowledgment of social problems (such as corruption) would be important. . nurturance of chinese national identity: it takes time to nurture because one has to "fall in love" and take pride in being chinese. systematic education at the community, family, and school contexts are indispensable so that young people can develop a sense of shared identity which further strengthens their positive identity. . political well-being: this is tough because the change in the political system will not take place overnight. in addition, as hong kong is an international financial center, it is not easy to reduce the influence of business corporations and related interest groups. however, given the recent overwhelming victory of the pan-democratic camp in the district council election in november , young people who wish to change can still play an active role in the future legislative council and the chief executive elections. in any case, everybody has to learn that in an open and civilized society, we have to respect the views of the majority. . poverty alleviation and solving the housing problem: it is a high time to re-visit the issue of poverty in hong kong which also exists in many countries in the world. besides the work of the commission on poverty, every sector has to rethink about their role. in addition to financial capital, building human capital, family capital and social capital is also important to strengthen the developmental assets of poor adolescents, which can help them escape from the trap of intergenerational poverty. as housing implies physical security which shapes hope, this is the top priority issue to be addressed. . upward mobility: this is not easy to solve this issue because it is a global issue that is not specific to hong kong. however, as many young people do not want to join the manual labor force which can give a reasonable salary, there is a need to change the community culture to one that treasures different talents (i.e., not just scholastic skills) and there are different career paths for young people with different aspirations, interests, and skills. . education reform: there is a need to deeply reflect on the purpose and nature of education so that young people can study for their interests (i.e., not just for the "rice bowl") and multiple intelligences are emphasized. the challenge is not just for the government, but also for parents and the hong kong society. . promotion of adolescent well-being: relevant and adequate services should be provided for young people who need mental health services. a public health approach focusing on universal, selective and indicated prevention should be used. in particular, services for students with special education needs should be stepped up. besides, finding ways to promote hope and life satisfaction is also a priority task. in addition to changing the macro-environmental factors leading to hopelessness, evidence-based programs to cultivate resilience and hope in young people, such as the project p.a.t.h.s. (shek and sun ; ma et al. ) are indispensable. . promotion of family well-being: problem families are the ideal breeding grounds for adolescent externalizing behavior. hence, there is a need to promote family resilience in a high-risk environment and to strengthen parenting, communication as well as conflict resolution skills in the family. it is noteworthy that evidencebased programs on promotion of family resilience are almost non-existent in hong kong. . promotion of life skills education: in the absence of systematic life skills, socialemotional learning skills, and psychosocial competencies training in the formal education curriculum in hong kong, this gap should be urgently addressed (shek and siu a) . young people should learn that: a) "an eye for an eye makes the whole world blind"; b) the essence of democracy is respecting the views of everyone, including those who do not hold the same views; c) it is morally wrong to blackmail the government by kidnapping the innocent public; d) besides rights and social justice, there are other virtues, including love, acceptance, and forgiveness, that are equally important; and e) while one can "criticize" the government, one should also look at things from different perspectives in a "critical" manner. . development and implementation of systematic moral and national education: one unfortunate observation of the social movement is that there is much hatred and deep erosion of the spirit of rule of law (such as widespread use of "doxing" and even physical violence in dealing with those who hold different views). as conflict resolution and mutual respect are not adequately covered in the current moral and national education curriculum, there is an urgent need to review and step up the related policies in hong kong. when implemented, policymakers should be aware of the related fears, such as the worry of brainwashing the young people. as such, practices in other countries can serve as the reference point because "international standards" will be used. regarding the "heat", there are many learning points for the government to reflect, particularly on its efficiency and responses in the whole social movement. for example, sufficient consultation time should be given to sensitive issues like the extradition bill. concerning the influence of social media, there is no way to stop it unless we follow what the spanish government did to deal with the occupation of the airport. however, the public can learn how to critically differentiate correct information, misinformation, and disinformation, particularly information disseminated and acquired through the social media. for anonymity, while it is a protection for not being arrested, people wearing masks should understand that anonymity would unleash the dark side of human nature. concerning public endorsement of violence, several questions should be considered by the public: a) what is the "civilized" and "mature" form of public demonstration? b) assuming the police has used excessive force, is vandalism the best response (i.e., "an eye for an eye")? c) how can we promote peaceful co-existence within diversity in political views? these are obvious quality of life issues awaiting answers. regarding alleged police violence brutality, there is a social consensus on setting up an independent panel of inquiry. however, to be fair to the police and protesters, if an independent panel of inquiry is established, it should examine violence and excessive use of force in both the protesters and police. finally, a critical understanding of the comments made by foreign governments and parties should be realizedwhether they are genuine concerns about hong kong or disguised manifestations of political and/or national interest. in conclusion, pre-existing and new quality of life and well-being threats and issues have shaped the development of the social event in the past months in hong kong. without understanding quality of life issues in different ecological systems (such as fear about losing freedom, lack of political well-being, growing up in a poor environment, always being a loser, living without hope, inability to forgive and re-build), it would not be possible to find workable and meaningful solutions. once again, the case of hong kong demonstrates that economic development alone is not enough to promote human well-being in a society. in the report of the commission of inquiry ( ) reviewing the riots, it was concluded that "we do not believe that political, economic and social frustrations were the direct cause of the riots but within the economic and social fields there are factors, to which we have drawn attention and that need to be watched, lest they provide inflammable material which would erupt into disturbance should opportunity arise in the future" (p. ). after some years, it is interesting to note that some of the deep-seated quality of life and well-being issues, such as inadequate housing, over-crowding, and limited chances in life come into the scene again. the only major difference is that many educated young people are involved in the social event in - , in contrast to the predominance of poorly educated young people in the riots. hong kong tops global list of most expensive housing market again as protests make little dent tourist arrivals take sharpest plunge in november since protests began in hong kong hong kong's protesters are trying to break free from the "old seafood" generation a perspective based on quality kowloon disturbances : report of commission of inquiry the characteristic of generation z. e-mentors quality of life: its definition and measurement understanding the attitude of generation z towards workplace government of the hong kong sar china's subsidies lifting rural villages out of poverty, but is xi jinping's plan sustainable? the legatum prosperity index: a tool for transformation hong kong kids more narcissistic than western kids according to 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kong depression and post-traumatic stress during major social unrest in hong kong: a -year prospective cohort study oecd better life initiative: compendium of oecd well-being indicators hong kong inequality report allport's intergroup contact hypothesis: its history and influence ethnic identity -chinese (per poll people's trust in the beijing central government ( - / - - a report of the hong kong protests commissioner of the hk police the impact of positive youth development attributes and life satisfaction on academic well-being: a longitudinal mediation study a study on the development of chinese students (character psychosocial factors influencing individual well-being in chinese adolescents in hong kong: a six-year longitudinal study use of foul language among chinese adolescents: developmental change and relations with psychosocial competences adolescent mental health policy and services in hong kong: seven unresolved problems waiting for solutions unhappy" environment for adolescent development in hong kong [special issue development and evaluation of positive adolescent training through holistic social programs perceptions of adolescents, teachers and parents of life skills education and life skills in high school students in hong kong singapore's lee hsien loong a social media hero in china for hong kong protest comments hong kong protests: the taiwanese sending , gas masks nearly a fifth of hong kong voters say they support violent actions by protesters, such as attacking opponents or hurling petrol bombs and bricks fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill legal service division report on fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill united nations development programme the human freedom index hong kong extradition bill: police deny rumours of pre-recording july condemnation video and issue clarification hong kong protests: what are the "five demands"? what do protesters want? youngpost hk$ million bill for repairs on public facilities vandalised by antigovernment protesters the human choice: individuation, reason, and order versus deindividuation, impulse, and chaos publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the preparation for this editorial is financially supported by wofoo foundation and tin ka ping foundation. address all correspondence to daniel t.l. shek, department of applied social sciences, the hong kong polytechnic university (daniel.shek@polyu.edu.hk).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 licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence 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 licence, visit http://creativecommons.org/licenses/by/ . /. key: cord- -rnuslepe authors: guo, rongxing title: political and administrative systems date: - - journal: understanding the chinese economies doi: . /b - - - - . - sha: doc_id: cord_uid: rnuslepe china’s political and administrative systems are mysteries to many westerners. at one level, china is a one-party state that has been ruled by the chinese communist party since . in the late s, the same authoritarian regime was waging a massive campaign under the name of the ‘great leap forward’, which resulted in the loss of a large number of lives. from to , the same regime was launching a so-called ‘great cultural revolution’, causing serious cultural and economic damages to this nation. furthermore, influential theories of the political economy of the former socialist systems emphasize that unless the one-party monopoly is abolished, reforms are doomed to fail. obviously, the achievements of china’s modernization defy conventional explanations. consequently, this will lead to the asking of questions such as: how has the chinese political system worked during the past decades? can it be sustained in the long run? keywords political system, chinese communist party (ccp), chinese characteristics, authoritarianism, governance, administrative efficiency, legal system, corruption control bianque saw the duke, he pointed out: 'the ailment has developed into the muscles. it will go from bad to worse if no treatment is conducted.' to this the ruler showed a greater displeasure than before. another ten days went by. on seeing the duke again, bianque warned him that the illness had gone into the stomach and the intestines and that unless an immediate treatment be given, it would go on worsening. again the duke looked angrier. after a third ten days, when bianque saw the duke, he simply turned round and went away… (to be continued) -hanfeizi (c. - bc) according to the constitution of the people's republic of china (prc), all the power in the country belongs to the people who exercise their power through the npc and local people's congresses at all levels; and the people manage the state, economy, culture, and other social affairs through a multitude of means and forms. however, the constitution also stipulates that the prc was founded by the chinese communist party (ccp) which is the leader of the chinese people. the socialist system led by the working class and based on the alliance of the workers and farmers is the fundamental system of the prc. the state council is the official government of china. it initiates legislation and controls the civil service. the state council is indirectly elected by the npc, which assembles in plenary every year to scrutinize and ratify its decisions on domestic and foreign affairs. the chinese people's political consultative congress (cppcc) -an institution similar to the senate in the united states -consists of representatives from the ccp, several democratic parties, democrats with no party affiliations, various people's organizations and ethnic groups, and other specially invited individuals. the primary functions of the cppcc are to conduct political consultations and democratic supervisions, and to discuss and manage state affairs. the approximately , deputies that attend the npc are elected indirectly every five years by the people's congresses of provinces, autonomous regions, municipalities under central government, and by the people's liberation army (pla). the supreme legislative organ of china, the npc, holds regular (annual) meetings in the great hall of the people in beijing to discuss state affairs, to approve those whom are recommended by the chinese communist party central committee (ccpcc) as central government officials, and to issue laws and regulations. in addition to indirectly electing the state council, the npc can also dismiss the holders of the top offices of state. the standing committee of the npc, which is further composed of a series of special committees and working and administrative bodies (see figure . ) is empowered to modify legislation between plenary sessions of, and carry out the daily work of, the npc on a more permanent basis. in practice, although its scrutiny role has been enhanced in recent years and unanimous votes have become less frequent, the independent power of the npc remains limited. although there are other political organizations in china, the only organization that matters is the chinese communist party (ccp). some , ccp delegates are elected to the national congress of the ccp, which is held every five years. the national congress elects the members and alternates of the chinese communist party central committee (ccpcc), which normally sits once a year. the th ccpcc, which was elected in , is composed of members and hundreds more alternates. the central committee for discipline inspection (ccdi) is also elected at this congress. immediately after the closing ceremony of the national congress, the ccpcc members indirectly elect, in addition to the central military commission, the general secretary, members of the politburo and its standing committee, and the secretariat (see figure . ). the politburo and particularly the smaller standing committee of the politburo are where the overall policy of the chinese government is really decided. the ccp has been virtually the most important body of power in china and holds real political power in china's de facto one party state. party organizations run in parallel to those of the government at all levels. the ccp's structure is characterized by 'democratic centralism' (minzhu jizhong), a system whereby the individual party member is subordinate to the organization, and where minority groups or opinions are subordinate to the wishes of the majority, embodied by the ccpcc. at the bottom of this pyramid are 'primary party organizations' in workplaces and villages. the overwhelming majority of delegates to the npc are party members. ccp membership remains essential for a successful career, particularly in the public sector. party membership now stands at nearly million, and this figure continues to increase. indeed, the ccp's 'three represents' theory states clearly that the ccp is no longer the single representative . to be continued at the end of this chapter. . for example, the tenth national people's congress (npc) of march elected hu jintao as president with a total of , votes. just four delegates voted against him, four abstained, and did not vote (guo, , p. of poor, working-class people; rather, it has also become the representative of the economic and cultural elites in china. by openly proclaiming itself a party of the 'economic elite' that has benefited from its free market agenda, the ccp has been hoping to consolidate a reliable base of support for its continued rule. the party's alliance with the rich is just as tight. with its pro-growth policies, its ban on independent trade unions, and its low environmental standards, the ccp has created an advantageous atmosphere for the economic elite to make money. many successful entrepreneurs have also been party members. policies so favor the rich and business that china's economic program, in the words of one western ambassador, resembles 'the dream of the american republican party' (pomfret, ) . since the late s, a new chinese terminology -baipinghas been popularized in mainland china. the term 'baiping' is composed of two chinese characters -'bai' (to place, to put, to arrange, etc.) and 'ping' (flat, uniform, fair, etc.) . the original meaning of baiping is 'to put flat; or to arrange uniform'. the term had been so informal before the twenty-first century that even the edition of cihai -the largest and most influential chinese dictionary published by shanghai cishu publishing house -didn't mention it. notice that the frequently used baiping has extended from its original meaning to 'to treat fairly', 'to compromise', 'to tradeoff', 'to punish' and so on. after the death of deng xiaoping in , jiang zemin must deftly play its various wings against each other. in this scenario, li peng, chairman of the eighth national people's congress (npc), was selected to hold the no. post of the ccpcc, higher than that of zhu rongji, premier of the state council, during the - tenure. this was the first time in the prc's history that the npc chairman held a political rank higher than that of premiership. moreover, a large number of non-communist party and non-party individuals were selected as state leaders with the titles of vice chairpersons of the npc and of the chinese people's political consultative congress (cppcc) in exchange for their support of the ccp as the permanent ruler of the state. for example, during the - and the - tenures, china's state-level leaders included nine standing members of the ccpcc politburo (some of whom also held the posts of president, premier, the npc and cppcc chairmen) and dozens of vice chairpersons of the npc and of the cppcc. the total number has been the highest since the s. in china, the central administrative system includes the central administrative organs under the system of the national people's congress (npc), and the leadership of the central administrative organs over local administrative organs at various levels. the central administrative organ is the state council of the prc. the state council is the highest administrative organ of the state. the state council is the executive body of the highest organ of state power and the highest organ of state administration in the people's republic of china. the state council exercises leadership over local administrative organs at various levels throughout the country, regulates the specific division of power and function of the state administrative organs at the central level and the provincial, autonomous, regional, and municipal level. the premiership assumes overall responsibility for the work of the state council and is responsible to the npc and its standing committee on behalf of the state council. the vice premiers and state councilors, together with the secretary-general of the state council, and ministers, are responsible to the premier. however, in all circumstances, the premier has the final decision making power on all major issues in the work of the state council. for example, the premier has the power to suggest to the npc and its standing committee the appointment or removal of the vice premiers, state councilors, ministers, and secretary-general of the state council. decisions, decrees, and administrative rules and regulations promulgated by the state council, bills, and suggestions of appointments and removals submitted by the state council to the npc and its standing committee are legally valid only after the premier has signed them. the state council is composed of the premier, vice premiers, state councilors, ministers, auditor-general, and the secretary-general. the premier is nominated by the president of the prc, decided by the npc, appointed and removed by the president. the vice premiers, state councilors, ministers, auditor-general, and secretary-general of the state council are nominated by the premier, decided by the npc, appointed and removed by the president of the prc. when the npc is not in session, the choice of state councilors, ministers, auditor-general, and secretary-general are decided by the standing committee of the npc according to nomination by the premier and appointed or removed by the president of the prc. the state council serves for a term of five years. the premier, vice premiers, and state councilors may serve no more than two consecutive terms. entrusted by the premier or the executive meeting of the state council, state councilors may take charge of work in certain aspects or special tasks. they may also represent the state council in conducting foreign affairs. under the leadership of the premier, the secretary-general of the state council is in charge of the day-to-day work of the state council. the auditor-general is in charge of the supervision of state revenue and expenditure, and other financial and monetary activities. all in all, the state council convenes three categories of meetings: l general meetings l executive meetings l working meetings. the general meeting of the state council, which is convened once every two months, or once every quarter of a year under normal conditions, is attended by all members of which the state council is composed, convened and presided over by the premier. the meeting is convened to discuss issues of major importance or matters involving more than one department. the executive meeting of the state council, which is convened once a month under normal conditions, is convened and presided over by the premier and participated by vice premiers, state councilors and the secretary-general. the meeting sets out to discuss major issues in the work of the state council, bills to be submitted to the standing committee of the npc, administrative rules and regulations and important issues submitted by various departments and localities for decision by the state council. the working meeting of the premier, which is convened, whenever necessary, by the premier (or by a vice premier entrusted by the premier) is to discuss and deal with major issues in the daily work of the state council. according to the constitution of , the state council exercises the following functions and powers: . to adopt administrative measures, enact administrative rules and regulations, and issue decisions and orders in accordance with the constitution and the law; and to submit proposals to the national people's congress or its standing committee. . to formulate the tasks and responsibilities of the ministries and commissions of the state council, to exercise unified leadership over the work of the ministries and commissions and to direct all other administrative work of a national character that does not fall within the jurisdiction of the ministries and commissions; to exercise unified leadership over the work of local organs of state administration at various levels throughout the country, and to formulate the detailed division of functions and powers between the central government and the organs of state administration of provinces, autonomous regions, and municipalities directly under the central government; to alter or annul inappropriate orders, directives and regulations issued by the ministries or commissions; and to alter or annul inappropriate decisions and orders issued by local organs of state administration at various levels. to draw up and implement the plan for national economic and social development and the state budget; to direct and administer economic affairs and urban and rural development; to conduct foreign affairs and conclude treaties and agreements with foreign states; to direct and administer the building of national defense; to direct and administer the affairs of education, science, culture, public health, physical culture and family planning; to direct and administer civil affairs, public security, judicial administration, supervision and other related matters; to direct and administer affairs concerning the ethnic groups and to safeguard the equal rights of ethnic minorities and the right to autonomy of the ethnic autonomous areas; to protect the legitimate rights and interests of chinese nationals residing abroad and protect the lawful rights and interests of returned overseas chinese and of the family members of chinese nationals residing abroad; to approve the geographic division of provinces, autonomous regions and municipalities directly under the central government, and to approve the establishment and geographic divisions of autonomous prefectures, counties, autonomous counties and cities; to decided on the imposition of martial law in parts of provinces, autonomous regions, and municipalities directly under the central government; and to examine and decide on the size of administrative organs and, in accordance with the law, to appoint or remove administrative officials, train them, appraise their performance and reward or punish them. to exercise such other functions and powers as the national people's congress or its standing committee may assign to it. ministries, commissions, the people's bank of china and administrations are departments that make up the state council. under the unified leadership of the state council, they are in charge of directing and administering the administrative affairs in their respective areas and exercise prescribed state administrative powers. the following ministries, commissions, and the people's bank of china, which were set up by the npc for the period from to , are departments that make up the state council. under the unified leadership of the premiership, they are in charge of directing and administering the administrative affairs in their respective areas and exercise prescribed state administrative powers: the ministers assume overall responsibility for the work of the ministries and ministry-level bureau, commissions, and administrations. they direct the work of their respective ministries and commissions, convene and preside over ministerial meetings or general and executive meetings of the commissions, and sign important reports to the state council and decrees and directives issued to lower levels. in addition, these are also organs that are in charge of administrative affairs in special areas, under the leadership of the state council. usually, the administrative rankings of these organs are lower than those of the commission and ministries listed above. leaders of these organs are decided by the executive meeting of the state council, appointed and removed by the premier: in addition, some coordinating organs and provisional organs may be set up by the state council to deal with special affairs. these organs normally have special committees or leading groups headed by the premier, or vice premiers, or state councilors or the secretary-general. they do not, in most cases, have independent working offices while the day-to-day work is placed under permanent ministries, commissions, administrations or other departments. these organs include: l working organs set up for directing the work in certain special areas l coordinating organs l consulting organs composed of specialists and leaders of departments concerned. the entire country is divided into provinces, autonomous regions, and municipalities directly under the central government. the provinces and autonomous regions are further divided into autonomous prefectures, counties, autonomous counties, and cities. the counties and autonomous counties are divided into townships, ethnic townships and towns. the municipalities directly under the central government and large cities in the provinces and autonomous regions are divided into districts and counties. china's provincial governments comprise provinces, five autonomous regions, four municipalities directly under the central government, and two special administrative regions (sars) -hong kong and macau -which returned to china in and , respectively (see table . for the names of various administrative divisions in china). it was agreed on handover that the existing political and economic systems that prevailed prior to these dates would be maintained for years. governments at this level (with the exception of the sars) are indirectly elected for five years at plenaries of their respective people's congresses. the system of governments of sars is prescribed by laws enacted by the npc. in addition, government organs may also be set up for special economic zones, development zones, mining industrial zones, and nature reserves. provincial governments are the first-level local state administrative organs in china. provincial governments must accept the unified leadership of the state council which has the power to decide on the division of responsibilities between the central government and provincial administrative organs. the state council also has the power to annul inappropriate decisions and orders of provincial governments. provincial governments implement local laws, regulations, and decisions of the provincial people's congresses and their standing committees, are responsible to and report on their work to provincial people's congresses and their standing committees. provincial people's congresses and their standing committees have the power to supervise the work of provincial governments, change, and annul inappropriate decisions of the provincial governments. provincial governments have the power to exercise unified leadership over the work of governments at the levels of the cities, counties, townships, and towns under their jurisdiction, and to exercise unified administration over economic, social, and cultural affairs. provincial governments may send out agencies, upon approval of the state council. their agencies are normally called 'administrative offices'. the administrative offices, as agencies of the provincial governments, are not governments themselves. the regions under their jurisdiction are not administrative divisions either. the basic responsibilities of the administrative offices are to provide guidance and coordinate the work of the counties and cities within the regions, on behalf of provincial governments. an administrative office has a commissioner, vice commissioners and advisors, appointed and removed by the provincial governments. the working meetings of administrative offices are attended by the commissioners, vice commissioners, advisors, assistant advisors, secretaries-general, and deputy secretaries-general to discuss major issues in the work of the administrative offices. governments of municipalities directly under the central government are first-level local state administrative organs in china. in china, there are currently four municipalities directly under the central government, namely beijing, chongqing, shanghai, and tianjin. governments of these municipalities must accept the unified leadership of the state council which has the power to decide on the division of power and functions between the central government and state administrative organs of municipalities directly under the central government. the state council also has the power to alter or annul decisions and orders made by governments of municipalities directly under the central government. governments of municipalities directly under the central government implement local laws, regulations, and decisions of the people's congresses and their standing committees of the municipalities, are responsible for and report on their work to the people's congresses and their standing committees. people's congresses and their standing committees in the municipalities have the power to supervise the work of the governments of municipalities, change and annul inappropriate decisions and orders of municipal governments. municipal governments have the right to exercise unified leadership over the work of the districts, cities, counties, townships, and towns and exercise unified administration over the economic, social, and cultural affairs in areas under their respective jurisdictions. provinces and municipalities directly under the central government have governors, vice governors, mayors, vice mayors, secretaries-general, directors of departments (or bureaus), and commissions. provincial governors, vice governors, mayors, and vice mayors are elected by the people's congresses of the provinces and municipalities. within two months after their election, provincial governors and municipal mayors shall nominate secretaries-general and directors of departments, bureaus, and commissions to people's congresses of the provinces and municipalities for appointment, and report to the state council for the record. when the people's congresses in provinces or municipalities are not in session, provincial governors or mayors cannot assume their posts, the standing committees of the people's congresses may decide on the acting governors or mayors, selected from among the vice governors or vice mayors to serve until the by-election at the next session of the people's congresses. when the people's congresses in provinces or municipalities are not in session, the appointment or removal of individual vice governors or vice mayors are carried out by the standing committees of the people's congresses. provincial and municipal governments serve a term of five years. in addition to provincial-level administrations, china has sub-provincial (fu shengji) and prefectural (diji) administrations. city governments with sub-provincial ranking refer to governments of relatively large cities whose economic plans are separately listed in the national planning, whose administrative status is lower than that of a full provincial government and which are not administratively controlled by provincial governments. at present, china's sub-provincial ranking cities are shenyang, dalian, changchun, harbin, jinan, qingdao, nanjing, ningbo, hangzhou, xiamen, wuhan, guangzhou, shenzhen, xi'an, and chengdu. prefectural-level cities are large and medium-sized cities not including sub-provincial level cities. normally, they are cities with a non-farming population of more than a quarter of a million. furthermore, the seats of cities have a non-farming population of more than , each, and their industrial production value exceeds billion yuan. they have a relatively advanced tertiary industry whose production value is more than that of the first industry, and makes up more than percent of the gdp in these cities. the revenue in their local budget is beyond million yuan and they have grown into centers of a number of cities or counties. governments of prefectural-level cities consist of mayors, vice mayors, secretaries-general, and directors of bureaus and commissions. mayors and vice mayors are elected by the people's congresses of the cities. when the people's congresses are not in session, the appointment and removal of individual vice mayors are carried out by the standing committees of the people's congresses. governments of prefectural-level cities serve a term of five years. these governments are responsible for and report on their work to the people's congresses and their standing committees at the same level. they are responsible for and report on their work to provincial-level governments and accept the unified leadership of the state council at the same time. they direct the economic, cultural, and administrative work of their cities. they also direct the administrative affairs of their entire regions and the work of the counties and county governments in areas under their jurisdiction. governments of cities where provincial or autonomous regional governments are located and large cities recognized by the state council may formulate their administrative regulations in accordance with the law and administrative regulations of the state council. the system of placing counties and county-level cities under the administration of prefectural-level cities means establishing an administrative organ between the province and counties (county-level cities). this mechanism requires the prefectural-level city to have the dual functions of administering both rural and urban areas. the main models of this mechanism are: l to merge the administrative office of a prefecture with the government of the prefectural-level city where the office is located to establish a new prefectural-level city government to administer the counties and county-level cities l to incorporate a number of counties and county-level cities in the vicinity of a prefectural-level city into the administration of the latter which previously did not administer the counties l to elevate the status of county-level cities or towns into prefectural-level cities, or turn the organs of the administrative office directly into the organs of the prefectural-level city, so as to establish a prefectural-level city government to administer counties and county-level cities. county governments are local governments established in rural areas. county governments administer the governments of townships, ethnic townships, and towns. they may also establish neighborhood offices. when necessary, county governments may, upon approval of provincial, autonomous regional, or municipal governments, set up district offices as their agencies. in areas implementing the system of prefectural-level cities administering counties and county-level cities, and in ethnic self-governing areas, county governments receive leadership from prefectural-level city or autonomous prefectural governments. in areas where prefectural-level cities are not established, and in the four municipalities directly under the central government (i.e., beijing, tianjin, shanghai, and chongqing), county governments receive direct leadership from provincial, autonomous regional, or municipal governments. county-level cities normally grow from towns within a county or are established in place of what was originally a county which has now been dissolved. these are places with a relatively strong rural administrative color. governments of county-level cities administer governments of townships, ethnic townships, and towns. neighborhood offices may also be established under their leadership. governments of county-level cities are mainly in the following two categories: a. in areas without an administrative office, they receive leadership directly from provincial or autonomous regional governments b. in areas implementing a system of prefectural-level city administering the county and county-level city, or in ethnic self-governing areas with county-level city governments, they receive leadership from the prefectural-level city or the autonomous prefectural government. district governments are urban governments established in districts in municipalities directly under the central government, sub-provincial-level cities, and prefectural-level cities. they receive leadership from the governments of municipalities directly under the central government, subprovincial-level cities, and prefectural-level cities. district governments consist of urban district and suburban district governments. urban district governments are located within the urban districts and function as grassroots governments in urban areas. they may have agencies in the form of neighborhood offices. suburban district governments, naturally located within suburban areas of cities, administer governments of townships, ethnic townships, and towns. they may also establish neighborhood offices. governments of counties, county-level cities, and districts are composed of county governors, vice governors, mayors, vice mayors, district heads, deputy heads, and directors of bureaus or sections. county governors, vice governors, mayors, vice mayors, district heads, and deputy heads are elected by the people's congresses of the counties, cities, and districts. when the people's congresses of the counties, cities, and districts are not in session, the standing committees of the people's congresses may decide on the appointment and removal of individual vice governors of counties and vice heads of districts and vice mayors. governments of counties, county-level cities, and districts serve a term of five years. governments of townships, ethnic townships (both referring to rural areas), and towns (urban centers in rural china) are grassroots governments in rural areas. they receive leadership from governments of counties, autonomous counties, county-level cities, and districts. a township, ethnic township, or town government has a head and several deputy heads. the head of an ethnic township government must be a citizen of an ethnic minority origin. heads and deputy heads of townships, ethnic townships, and towns are elected by the people's congresses in the townships, ethnic townships, and towns. governments of townships, ethnic townships, and towns serve a term of three years. it is the provincial-level governments' duty to establish and decide the geographic division of townships, ethnic townships, and towns. people's governments of townships, ethnic townships, and towns carry out the resolutions of the people's congress at the corresponding level, as well as the decisions and orders of the state administrative organs at the next higher level. they also conduct administrative work in their respective administrative areas. local people's governments at various levels are responsible for and report on their work to the state administrative organs at the next higher level. local people's governments at various levels throughout the country are state administrative organs under the unified leadership of the state council and are subordinate to it. local people's governments at and above the county level direct the work of their subordinate departments and of people's governments at lower levels, and have the power to alter or annul inappropriate decisions of their subordinate departments and of the people's governments at lower levels. in addition, there are also systems of governance that operate beneath the various levels of state administration described above. these are the village committees (cunweihui) in rural areas and the resident committees (juweihui) in urban areas. the village committees deal with all administrative matters, including budgets, public services, order, welfare, and dispute resolution (see figure . ). in contrast to their attitude with regard to levels of government that are considered part of the state, the authorities have shown some willingness over the past two decades to countenance direct elections to these committees. there have been attempts to introduce direct elections to village committees. these innovations were part of wider efforts to restore some form of governance at village level. urban residents' committees usually cover anywhere between and over , households. reformers have suggested that urban electoral reform should begin with direct elections. the current chinese constitution was adopted for implementation by the th session of the th national people's congress (npc) on december , . amendments were made to the constitution at the st session of the th npc on april , , the st session of the th npc on march , , and the nd session of the th npc on march , , respectively. it is clear that the leadership of the cpc is stressed in the constitution. also, the guidance of marxism-leninism and mao zedong thought is regarded as the proper intellectual framework and ideology for leading the country to a socialist state under the people's democratic dictatorship. the national people's congress (npc) is deemed to be the 'highest organ of state power' in article of the constitution of the people's republic of china ( ) . the npc is partially composed of a permanent body called the standing committee of the npc (articles and - ). the npc is the unicameral body vested with the authority to establish the laws in china pursuant to article . deputies to the npc are elected to their positions for five-year terms (art. ). some powers of the ncp are to amend the constitution, enact laws, elect the president and vice president of the prc, elect the chiefs of the supreme people's court, decide issues of war and peace, and they also have various removal powers (arts - ). when the npc is not in session, the standing committees can enact amendments and additions to laws passed by the npc (art. ). china's legislation is also created at more local levels by the people's congresses of provinces, autonomous regions, municipalities, prefectures, and cities. the constitution notes: ( ) the party branch office tablet is written in red and located on the right side, denoting that the ccp is always in a superior position in china. ( ) the office tablet of the villagers' committee is written in black and located on the left side. provides the structure, authority, and duties of the local people's congresses in articles - . all of the local regulations that are passed by these lower people's congresses must comply with the constitution, laws passed by the npc, and the people's congresses above each of the local congresses in the hierarchy. the judicial system of the prc is established in articles - , and consists of the people's courts, the supreme people's court, the people's procuratorates, the supreme people's procuratorate, military procuratorates and other special people's procuratorates. article refers to the people's procuratorates as 'state organs for legal supervision'. there is a hierarchy within the court structure from the top down: the supreme people's courts, the higher people's courts, the intermediate people's courts, and the basic people's courts (see figure . ). the duties of each of these courts are as follows: at present, the basic people's courts are comprised of thousands of courts at county level. there are hundreds of intermediate people's courts at prefectural or municipal level and higher people's courts located in the provinces. additionally, there are a number of specialized courts, for example, those dealing with railway transportation, forest affairs, the people's liberation army (pla), and maritime issues. litigants are generally limited to one appeal, on the theory of finality of judgment by two trials. cases of second instances are often reviewed de novo as to both law and facts. requests for appellate review take the form of appeals and protests (in criminal cases). appeals are lodged by parties to the case, defendants, and private prosecutors. protests are filed by the procuratorate in criminal cases, when it is believed that an error has occurred in the law, or facts, as determined by the judgment or order of the court of first instance. in civil cases the procuratorate does not possess a right to file a direct protest, but it can initiate adjudication supervision via a protest. adjudication supervision refers to a type of discretionary 'post-final' decision review, which may occur in certain situations in criminal cases. for most of the past thousands of years, the chinese legal system was based on confucian ideology that emphasized ethics and relationships between the people and their leaders. disputes were settled through relationship-based methods such as mediation. the court system was undeveloped and rarely used. after , a marxist-leninist overlay was constructed, which was also to some extent mixed with traditional adherence to confucian-based conflict mediation. it was not until the economic reforms of the late s that a true institutional legal system was introduced, mostly to deal with the demands of the growing economy. as the ccp scrambled after to train lawyers and codify laws, business law took precedence over laws pertaining to civil liberties and individual freedoms. despite an enormous growth in the legal industry, the system is today still grossly lacking in its neutrality, capacity, and mandate, especially in poor and remote areas in china. most importantly, china's legal system lacks neutrality. the ccp approves all court appointments, and judges are technically responsible to the party, not to the people (see box . ). from the basic, intermediate, higher level people's court, and supreme people's court, the ccp hand is evident. the ccp's political and legal committee has the power to intervene in deliberations, and even to overturn verdicts issued. in addition, the infrastructure lacks capacity. for example, there is one lawyer per , people in china (the ratio is one lawyer per people in the united states). and finally, in many western democracies, the ultimate arbiter of a law's constitutionality is the court system. in china, this function becomes muddled and the ccp apparatus often rules on the interpretation of its own laws. recently, there have been some reforms with substantive democratic content -including, for example, village elections. however, this has been unevenly implemented and often fails to live up to hopes for open and contested elections, and reaches only the most local of posts. the electoral law for village-level administrations is still weaker as an instrument of democracy, as are procedures for the indirect selection of higher-level people's congresses. the imperfectly implemented village elections law and the elections that have been held under the law allow much bounded participation, monitor potentially explosive peasant discontent, and strengthen the capacity of the regime. these 'elections serve these functions by sometimes weeding out the most ineffective and despised agents of the regime and by recruiting new cadres who can command popular support as well as their superiors' confidence' (delisle, , p. ). most tangible reform in china's legal system has taken place in the area of civil litigation. these primarily concern business disputes associated with china's rapid economic modernization in which people seek protection and redress from a wide array of abuses committed in the pursuit of economic competitive advantage: patent infringement, business transactions that are not honored, individuals who have been displaced by private and state-directed construction, and labor disputes, to name a few. since , prompted by the need to provide a safe environment for foreign capital, the ccp has increasingly codified business laws and sought to train its lawyers and judges to deal effectively and efficiently with the growing civil and commercial caseload. with the current system skewed toward resolving businessbusiness and state-business disputes, the individual plaintiff is often at a significant disadvantage. other avenues open to individuals who feel they have complaints against the state include the petition system, mediation, and protests -however, none of these options are as effective as in the western nations. the petition system auspiciously provides an avenue by which individuals can lodge complaints about treatment they have received from the government, other individuals, or private companies. remember, in china the hand of the state is involved everywhere, visibly and invisibly, even when disputes seem to involve private companies. there are few private companies that do not have some form of government subsidization and/or regulation. another alternative to the court system includes mediation, which has been described as only somewhat effective, and for which there is not adequate capacity to process all disputes. some instead turn to protests, mainly in rural areas where they get local attention; protesters are often disbanded, and their complaints never communicated to high-level decision-makers. and finally, an important alternative to litigation (one that is used to powerful advantage elsewhere) is severely lacking in china: free media. many . source: 'the legal system in china.' available at http://worldsavvy. org/monitor/index.php?option=com_content&view=article&id= & itemid= . accessed on november , . in a construction area designated for the building of affordable housing in xigang village, xushui town, zhengzhou city, henan province, real estate developers have built townhouses and luxurious houses. in june , after receiving complaints from local villagers that the land has not been developed according to its intended use (i.e., the construction of economically affordable apartments), a reporter went to zhengzhou for an interview with lu jun, deputy bureau director of zhengzhou planning bureau. mr lu interrogated the reporter: 'why doesn't your radio station mind its own business? who do you speak for, the party or the people?' it is well known that the land planning bureau controls the lifeline for developers to get rich, so it has become the area hardest hit by corruption. in the planning of urban construction, some corrupt officials have become the developer's spokesmen in the government because they are bribed by the developers. officials and businessmen work in collusion with each other to form a community of common interest. for the interest of the small community, they set aside the legal interests of the country and the ordinary people, take advantage of their public power to grab state-run assets, people's benefits, and wealth, and push themselves to the opposite side of the ordinary people. source: www.echinacities.com. accessed on november , . ( ), wang ( ), and paler ( ) for more detailed analyses. scandals and disputes are settled in other countries simply because they find their way to the newspaper or other public outlets. perpetrators are shamed and agreements are negotiated. without recourse to a free press, the chinese are denied access to a key avenue for airing grievances. the most important distinction between how china and many other countries deal with criminal defendants is in how they perceive presumption of guilt. in the west, criminal suspects are presumed innocent until proven guilty, and generally cannot be arrested and charged without sufficient evidence of wrongdoing. when a suspect does go to trial, it is the duty of the prosecution to prove his/her guilt beyond reasonable doubt. abuses exist within these systems, but the underpinnings favor the individual defendant against the state until guilt is proven. for a long period of time in china, suspects have been assumed guilty by the system and must be proven innocent. this is a critical distinction; suspects face incredible hurdles in proving their innocence; and china's appeals system similarly favors the prosecution. freedom from unreasonable search, seizure, torture, and detention, as well as the right to a fair trial are major demands placed on china by the human rights community worldwide. the ccp aims to build the legal infrastructure of the country and has embarked on this in its technocratic manner of studying the laws of other countries and carefully codifying its 'chinese characteristics'. however, many of the abuses occur at the hands of local and provincial officials among whom corruption is rampant and over whom the central ccp is able to exercise little control. when central ccp elites have been able to detect abuses and arrest responsible officials, the press is ordered to showcase progress for their own people and to outside critics. without adequate transparency within the ccp, or within the legal system in which ccp officials wield a heavy hand, reform will be difficult. while the ccp has promised that there will be movement on both laws and procedures, ordinary people in china still believe that the situation on the ground has not changed significantly. as in other areas, reform in the legal system has often served only a safety valve function -more cases processed, more complaints heard, yet the outcomes remain largely unchanged. whether these small steps forward ultimately add up to momentum remains to be seen, but many believe that an expanding legal system could bring about true democratic progress in the prc. for now, though, there are many who believe that such small venting in the system actually serves to strengthen the authoritarian state. since china undertook its reforms in , the chinese economy has grown at an average rate of nearly ten percent a year. as of , china's per capita gdp was already twelve times greater than it was three decades ago. obviously, for the past three decades, the country's economic development has been reliant upon an unconventional approach -a combination of mixed ownership, basic property rights, and heavy government intervention. the term 'washington consensus' was initially coined in by john williamson to describe a set of ten specific economic policy prescriptions that he considered should constitute the 'standard' reform package promoted for crisis-wracked developing countries by washington-based institutions such as the imf, the world bank, and the us treasury department. it is sometimes used in a narrower sense to refer to economic reforms that were prescribed just for developing nations, which included advice to reduce government deficits, to liberalize and deregulate international trade and cross border investment, and to pursue export led growth (williamson, ). in , joshua cooper ramo, the former foreign editor of time magazine, in his book entitled the beijing consensus, argues that there is a new 'beijing consensus' emerging with distinct attitudes to politics, development, and the global balance of power. ramo argues that china offers hope to developing countries after the collapse of the washington consensus. china has provided, more or less, a more equitable paradigm of economic take-off for poor countries. according to ramo, '[the beijing consensus] replaces the widely-discredited washington consensus, an economic theory made famous in the s for its prescriptive, washington-knows-best approach to telling other nations how to run themselves' (ramo, , p. ) . to develop this further, stefan halper, in his book the beijing consensus: how china's authoritarian model will dominate the twenty-first century, argues that china has provided a welcome non-judgmental alternative to many nations with domestic, social, and economic conditions that are similar to china itself. this new approach to foreign aid, combined with admiration for china's economic success, is boosting its world influence, as well as access to energy and other natural resources. meanwhile, china's autocratic leadership, which shows no sign of liberalizing, has set the foundation for future economic successes; by contrast, us economic progress seems hindered by its democratic processes (halper, (song, ) . in this article, the author points out that the great achievements of china result from its effective political system, which could pave a completely different way to . the washington consensus was most influential during the s. since then, it has become increasingly controversial. modernization, named the china model. the author summarizes six major advantages of china's political system, as follows. the first advantage is that under the one-party system, china could formulate a long-term plan for national development and ensure stabilization of its policies without being affected by the alternation of parties with different positions and ideologies. the second advantage lies in its high efficiency, and promptly effective reaction to emerging challenges and opportunities, especially in response to sudden and catastrophic accidents. the author gives the following examples: terminal no. of the beijing capital international airport built for the beijing olympics was finished in three years, which is not enough time for the approval process in the west. in , after the wenchuan earthquake that hits once in a generation, china impressed the whole world by its quick response and efficient post-disaster reconstruction. the third advantage is china's effective containment of corruption in the social transition period. it is generally accepted that economic prosperity and social transition were usually accompanied by large amounts of corruption throughout human history. however, the author argues that, compared with india and russia in the same period, china has had far less corruption. the fourth advantage is a more responsible government in china. for example, in democratic societies, many officials are elected with fixed terms, and they then will not fall out of power before the end of their term unless they break the law, make wrong decisions, or take no action. once their term expires, they will not be blamed for any problem. in china, however, the principal officials accountability system is gradually improving, and officials must be responsible for their incompetence, negligence of duty, or mistakes at any time. the fifth advantage lies in its personnel training and cadre-selection system and avoiding the waste of talented people. in many western nations, presidents and governors are elected; but in china only those who have rich and successful working experiences at the lower or local levels can be selected to be higher-ranked officials. therefore, the author argues that china's selection of cadres from the lower to a higher level and conscious personnel training is superior to the west's election system. the last advantage is that one party can truly represent the whole people. under the western multiparty system, each party represents different interest groups. but in china, since the reform and opening up, economic policies have been made by the ccp without special bias in favor of any interest groups. however, the chinese political and economic systems are far less perfect than what was just described above. in fact, over the last years, the chinese economy has moved unmistakably toward the market doctrines of neoclassical economics, with an emphasis on prudent fiscal policy, economic openness, privatization, market liberalization, and the protection of private property (yao, ) . since the beginning of its open-door policies, china has benefited increasingly from global interdependence and the modern world's free flow of goods, capital, and people. however, with those benefits have also come the responsibilities of accountability and transparency. china's party-state system has exposed the dearth of political dynamics. since the ccp lacks legitimacy in the classic democratic sense, it has to seek performance-based legitimacy instead. so far, this strategy has succeeded. and there was a proliferation of high-rise buildings and massive construction projects (the three gorges dam, the olympics complex, the high-speed rail system, and so on). however, this also resulted in declining health care (hospitals, like schools, also became money-making centers for local bureaucrats), illegal expropriation of farmers' land, and more corruption, all of which have led to increasing social disorder among peasants who are finding themselves worse off (huang, ) . on the other hand, cadres' pay has increased rapidly, which has, as an example in , induced thousands of college graduates to compete for a single government post. the severe acute respiratory syndrome (sars) epidemic which spread throughout china in april exposed some of china's institutional weakness. yet the greatest impact of the sars crisis may be on china's antiquated political system. chinese mismanagement of the outbreak has plainly exposed just how far political reform has lagged behind economic development. beijing's long concealment of the truth is exposing political faultiness by simultaneously weakening the economy and damaging the government's credibility. the crisis has undermined traditional supporters, aggravating old demographic strains, and emboldening detractors to make more assertive protests against government policy. while the growing pressure from a more demanding public and an increasingly interdependent world has forced china to re-evaluate its political and socioeconomic policies, the extent of any resulting political reform depends upon whether or not the enhanced incentives for accountability and transparency among public officials override the traditional incentives for party and factional loyalty. . from november to , sars infected over , people in countries and killed more than . in addition to the human toll, it was inflicting significant economic damage across asia. besides hong kong, which was among the worst hit, gdp growth rates in taiwan, singapore, and thailand were also lower in . nowhere was sars having more impact than on mainland china, where the disease started. - guo ( , p. ) . kaufmann et al. ( ) for (a) (c) . details on the data sources, the aggregation method, and the interpretation of the indicators, can be found in the methodology paper of kaufmann et al. ( ) . obviously, there are signs that the chinese model will not last because of the growing income inequality and the internal and external imbalances it has created. the ccp's free-market policies have led to increasing inequalities in china, both between different groups of people and among regions. for example, china's overall gini coefficient -a measure of income inequality in which zero equals perfect equality and one absolute inequality -reached about . in , which is higher than most of the other economies (see figure . of chapter ). in addition, china also has the highest urban-rural income gap in the world. as the chinese people demand more than economic gains as their income increases, it will become increasingly difficult for the ccp to contain or discourage social discontent. china's astronomic growth has left it in a precarious situation, however. other developing countries have suffered from the so-called middle-income trap -a situation that often arises when a country's per capita gdp reaches the range of $ , to $ , , the economy stops growing, income inequality increases, and social conflicts erupt. china has now entered this stage, and it still remains unclear how this will affect the chinese economy and society in the long term. at present, the chinese government has tried to manage popular discontent by implementing box . documentary various programs that could quickly address early signs of unrest, such as re-employment centers for unemployed workers, migration programs aimed at lowering regional disparities, and improvement of infrastructure, health care, and education in rural areas. those measures, however, may be too weak to discourage the emergence of powerful interest groups seeking to influence the government (yao, ) . while china's current political system has been driving its economic growth strongly (to be discussed in chapter ), it has also led to the development of a series of socioeconomic problems. however, the large surge in income inequalities was not the only unwanted result of the chinese-style reform. the worsening of social and political progress during the s and the s is another example. for example, china's 'control of corruption' score was more than in (see figure . (a)) but it dropped to only in ; between and its score in terms of 'voice and accountability' was among the lowest of all of the nations considered by the world bank (see figure . (b)) and there is no sign of improvements between and (see figure . (c)). without good reason, china's party-state political system lacked the informational and incentive roles of democracy that, working mainly through open public discussion, could be of pivotal importance for the reach of social and public policies. technically, china has not had an independent judiciary or a legal system that operates outside the influence of the ruling ccp. this is the so-called socialism with chinese characteristics and the one that distinguishes china from western democracies in which the court system is a critical component of the checks and balances placed on the other branches of government. in fact, china's lack of an independent judicial system exacerbates all the other fault lines running through the authoritarian state; there simply is no effective recourse available to individuals whose interests are harmed by the excesses of ccp officials, laws, and institutions. this situation is particularly serious in china's rural, marginal areas. the time when the average individual seeks a forum in which to officially air grievances and pursue some form of justice in china has yet to come (see box . ). before ending our discussion about the characteristics of china's political and administrative systems, let's finish our account of the story told by hanfeizi at the beginning of this chapter: feeling it strange, the duke sent a man to ask bianque for the reason. 'well, an ailment lying in between the skin and the muscles remains on the surface, and so external application with warm water and ointment can cure it,' said bianque, 'if it sinks into muscles, acupuncture will do good; if it resides in the stomach and the intestines, a decoction of herbs will take effect. but when the sickness penetrates into the bone marrow, it becomes fatal and nothing can be done about it. now, as the duke has come to that last stage, i have nothing to recommend.' five days after that, the duke felt pains and ordered his men to look for bianque, but to find that he had fled to the state of qin. soon afterwards, the duke died. china's changing political landscape: prospects for democracy how the chinese economy works - e an introduction to the chinese economy works -the driving forces behind modern day china the beijing consensus: how china's authoritarian model will dominate the twenty-first century capitalism with chinese characteristics: entrepreneurship and the state the worldwide governance indicators: a summary of methodology, data and analytical issues governance matters vii: aggregate and individual governance indicators china statistical yearbook accommodating 'democracy' in a oneparty: introducing village elections in china china's legislation law and the making of a more orderly and representative legislative system under jiang, party changed to remain in power: communist apparatus still rules china, though country has been transformed the beijing consensus. london: the foreign policy centre administrative procedure reforms in china's rule of law context latin american readjustment: how much has happened the end of the beijing consensus -can china's model of authoritarian growth survive? foreign affairs key: cord- -vdiaexbw authors: kshetri, nir title: china date: journal: the statesman&#x ;s yearbook doi: . / - - - - _ sha: doc_id: cord_uid: vdiaexbw nan upon soviet assistance for economic development. a soviet-style five-year plan was put into action in , but the relationship with moscow was already showing signs of strain. by the end of the s the soviet union and china were rivals, spurring the chinese arms race. chinese research into atomic weapons culminated in the testing of the first chinese atomic bomb in . mao introduced rapid collectivization of farms in . the plan was not met with universal approval in the communist party but its implementation demonstrated mao's authority over the fortunes of the nation. in he launched the doctrine of letting a 'hundred flowers bloom', encouraging intellectual debate. however, the new freedoms took a turn mao did not expect and led to the questioning of the role of the party. strict controls were reimposed and free-thinkers were sent to work in the countryside to be 're-educated'. in may mao launched another ill-fated policy, the great leap forward. to promote rapid industrialization and socialism, the collectives were reorganized into larger units. neither the resources nor trained personnel were available for this huge task. backyard blast furnaces were set up to increase production of iron and steel. the great leap forward was a disaster. it is believed that m. died from famine. soviet advice against the project was ignored and a breakdown in relations with moscow came in , when soviet assistance was withdrawn. a rapprochement with the united states was achieved in the early s. having published his 'thoughts' in the 'little red book' (as it is known in the west) in , mao set the cultural revolution in motion. militant students were organized into groups of red guards to attack the party hierarchy. anyone perceived to lack enthusiasm for mao zedong thought was denounced. thousands died as the students lost control and the army was eventually called in to restore order. after mao's death in the gang of four, led by mao's widow jiang qing, attempted to seize power. these hard-liners were denounced and arrested. china effectively came under the control of deng xiaoping. deng pursued economic reform. the country was opened to western investment. special economic zones and 'open cities' were designated and private enterprise gradually returned. improved standards of living and a thriving economy increased expectations for civil liberties. the demand for political change climaxed in demonstrations by workers and students in april , following the funeral of communist party leader hu yaobang. in beijing where demonstrators peacefully occupied tiananmen square, they were evicted by the military who opened fire, killing more than , . hard-liners took control of the government, and martial law was imposed from may to jan. . since the leadership has concentrated on economic development. hong kong was returned to china from british rule in (for the background, see page ) and macao from portuguese rule in . the late s saw a cautious extension of civil liberties but chinese citizens are still denied most basic political rights. beijing was chosen for the olympic games. china's treatment of tibet came under the international spotlight in the build-up to the games, following violent protests in tibet's capital city, lhasa. the arrest by japan of a chinese trawler in disputed waters in marked the beginning of heightened tensions between the two nations in the east and south china seas. in china became the world's second largest national economy. in nov. the communist party congress selected xi jinping to succeed hu jintao as president from march . in sept. that year, former leadership hopeful bo xilai received a life sentence for corruption in one of china's highest-profile trials in decades. in oct. the government announced the end of the country's one-child policy. a month later, the presidents of china and taiwan met for talks-the first time that leaders from the respective territories had met since . on the economic front, gdp growth in was at its lowest level for a quarter of a century. china is bounded in the north by russia and mongolia; east by north korea, the yellow sea and the east china sea, with hong kong and macao as enclaves on the southeast coast; south by vietnam, laos, myanmar, india, bhutan and nepal; west by india, pakistan, afghanistan, tajikistan, kyrgyzstan and kazakhstan. the total area (including taiwan, hong kong and macao) is estimated at , , sq. km ( , , sq. miles). a law of feb. claimed the spratly, paracel and diaoyutasi islands. an agreement of sept. at prime ministerial level settled sino-indian border disputes which had first emerged in the war of . china's sixth national census was held on nov. . the total population of the provinces, autonomous regions and municipalities and of servicemen on the mainland was , , , ( , , females, representing Á %); density, per sq. km. china's population in represented % of the world's total population. the population rose by , , (or Á %) since the census in . there were , , urban residents, accounting for Á % of the population; compared to the census, the proportion of urban residents rose by Á % (reflecting the increasing migration from the countryside to towns and cities since the economy was opened up in the late s). population estimate, dec. : , , , . china has a fast-growing ageing population. whereas in only Á % of the population was aged or over and by this had increased to Á %, by it is expected to rise to Á %. long-term projections suggest that in as much as Á % of the population will be or older. the population is expected to peak at Á m. around and then begin to decline to such an extent that by around it will be back to the level. china is set to lose its status as the world's most populous country to india in about . the un gives a projected population for of , Á m. regulations restricting married couples to a single child, a policy enforced by compulsory abortions and economic sanctions, were widely ignored, and it was admitted in that the population target of , m. by would have to be revised to , m. from peasant couples were permitted a second child after four years if the first born was a girl, a measure to combat infanticide. in china started to implement a more widespread gradual relaxation of the one-child policy. in dec. the standing committee of the national people's congress (npc) approved a resolution allowing couples to have two children if either parent was an only child. the one-child policy was formally abandoned altogether from jan. . an estimated m. persons of chinese origin lived abroad in . a number of widely divergent varieties of chinese are spoken. the official 'modern standard chinese' is based on the dialect of north china. mandarin in one form or another is spoken by m. people in china, or around % of the population of mainland china. the wu language and its dialects has some m. native speakers and cantonese m. around m. people in china cannot speak mandarin. the ideographic writing system of 'characters' is uniform throughout the country, and has undergone systematic simplification. in a phonetic alphabet (pinyin) was devised to transcribe the characters, and in this was officially adopted for use in all texts in the roman alphabet. the previous transcription scheme (wade) is still used in taiwan and hong kong. mainland china is administratively divided into provinces, five autonomous regions (originally entirely or largely inhabited by ethnic minorities, though in some regions now outnumbered by han immigrants) and four government-controlled municipalities. these are in turn divided into prefectures, cities (of which are at prefecture level and at county level), , counties and urban districts. population of largest cities in : shanghai, Á m.; beijing (peking), Á m.; shenzhen, Á m.; guangzhou (canton), Á m.; tianjin, Á m.; dongguan, Á m.; wuhan, Á m.; foshan, Á m.; chengdu, Á m.; chongqing, Á m.; nanjing, Á m.; shenyang, Á m.; xian, Á m.; hangzhou, Á m.; haerbin, Á m.; suzhou, Á m.; dalian, Á m.; zhengzhou, Á m.; shantou, Á m.; jinan, Á m.; qingdao, Á m.; changchun, Á m.; kunming, Á m.; changsha, Á m.; taiyuan, Á m.; xiamen, Á m.; hefei, Á m.; urumqi (wulumuqi), Á m.; fuzhou, Á m.; shijiazhuang, Á m.; wuxi, Á m.; zhongshan, Á m.; wenzhou, Á m.; nanning, Á m.; ningbo, Á m.; guiyang, Á m.; lanzhou, Á m.; zibo, Á m.; changzhou, Á m.; nanchang, Á m.; xuzhou, Á m.; tangshan, Á m. china has ethnic groups. according to the census , , , people ( Á %) were of han nationality and , , ( Á %) were from national minorities (including zhuang, manchu, hui, miao, uighur, yi, tujia, mongolian and tibetan) . compared with the census, the han population increased by , , ( Á %), while the ethnic minorities increased by , , ( Á %). non-han populations predominate in the autonomous regions, most notably in tibet where tibetans account for around % of the population. chang tibet relations between tibet and china's central government have fluctuated over the question of tibetan independence. the borders were opened for trade with neighbouring countries in . in a buddhist seminary opened in lhasa, the regional capital, with students, and monasteries and shrines have since been renovated and reopened. there were some , monks and nuns in . in tibetan was reinstated as a 'major official language', competence in which is required of all administrative officials. in the then chinese president, jiang zemin, said he was prepared to meet the dalai lama provided he acknowledged chinese sovereignty over tibet and taiwan. in sept. direct contact between the exiled government and china was re-established after a nine-year gap. however, in march anti-chinese protests in lhasa ended in violence, with dozens reportedly killed by the chinese authorities, and in oct. that year the dalai lama stated he had lost hope of reaching agreement with china on tibet's status. in april he announced his retirement from active politics in favour of lobsang sangay, who had been elected to lead the tibetan government-in-exile. in july , shortly after us president obama had received the dalai lama in washington, china's soon-to-be president, xi jinping, pledged to 'smash' attempts to destabilize tibet. by feb. there had been over reported cases of self-immolation by tibetans protesting against chinese rule. the estimated population of tibet at the end of had risen to Á m. from Á m. at the census. the average population density was Á persons per sq. km in , although the majority of residents live in the southern and eastern parts of the region. birth rate (per , ), , Á ; death rate, Á . population of lhasa, the capital, in was , . about % of the population is engaged in the dominant industries of farming and animal husbandry. in the total sown area was , ha. output in : total grain crops, , tonnes; vegetables, , tonnes. in there were Á m. sheep and goats and Á m. cattle and yaks. tibet has over , mineral ore fields. mining, particularly of copper and gold, has expanded rapidly since when the railway came to tibet. cement production, : Á m. tonnes. electricity consumption totalled Á bn. kwh in . in there were , km of roads ( , km in most of china has a temperate climate but, with such a large country, extending far inland and embracing a wide range of latitude as well as containing large areas at high altitude, many parts experience extremes of climate, especially in winter. most rain falls during the summer, from may to sept., though amounts decrease inland. monthly average temperatures and annual rainfall ( ): beijing (peking), jan. Á f (- Á c), july Á f ( Á c). annual rainfall Á " ( mm). chongqing, jan. Á f ( Á c), july Á f ( Á c). annual rainfall Á " ( , mm). shanghai, jan. Á f ( Á c), july Á f ( Á c). annual rainfall Á " ( , mm). tianjin, jan. Á f (- Á c), july Á f ( Á c). annual rainfall Á " ( mm). on -in , and (currently in force) . the latter was partially amended in , , , and , endorsing the principles of a socialist market economy and of private ownership. the unicameral national people's congress is the highest organ of state power. usually meeting for one session a year, it can amend the constitution and nominally elects and has power to remove from office the highest officers of state. there are a maximum of , members of the congress, who are elected to serve five-year terms by municipal, regional and provincial people's congresses. - yang shangkun - jiang zemin - hu jintao -xi jinping prime ministers since . - zhou enlai - hua guofeng - zhao ziyang - li peng - zhu rongji wen jiabao -li keqiang elections of delegates to the th national people's congress were held between oct. and feb. by municipal, regional and provincial people's congresses. at its annual session in march the congress re-elected xi jinping as president and elected wang qishan as vice-president. president xi jinping succeeded hu jintao as president in march at the th national people's congress. tipped for the role since his appointment as secretary general of the chinese communist party (ccp) and chairman of the central military commission in nov. , xi pursued a strong style of authoritarian rule at home and a proactive and muscular foreign policy in his first term. in oct. the ccp gave him the title of 'core' leader, a significant honorific bracketing him with mao zedong and deng xiaoping among previous party figures although conferring no absolute powers. then, at its five-yearly congress in oct. , the party voted to enshrine his name and ideology in the chinese state constitution. he was subsequently re-elected in march and parliament also voted to abolish presidential term limits in a major shift from precedent. xi jinping was born on june in beijing, the son of one of the first generation of communist leaders. he joined the ccp in and, after graduating from tsinghua university in with a degree in chemical engineering, he became secretary to the vice-premier and secretary-general of the central military commission. xi became the zhengding county committee deputy secretary in hebei province in and the following year was promoted to secretary. in he was made deputy mayor of xiamen city, fujian province. having undertaken various party roles in the province, he became deputy governor of fujian in and governor a year later. in he moved to zhejiang province and made his first inroads into national politics when he was named a member of the th central committee. from - he was party secretary of fujian, overseeing economic growth averaging % a year and earning a reputation as an opponent of corruption. in march xi transferred to shanghai to take the role of party secretary following the dismissal of the incumbent on corruption charges. his appointment to such an important regional post was seen as a vote of confidence from the central government and he became a member of the politburo standing committee at the th party congress in oct. . he was also made a high-ranking member of the central secretariat. on march he was elected vice-president at the th national people's congress and took on a number of high profile portfolios including the presidency of the central party school. he was also beijing's senior representative for hong kong and ahead of his presidency, xi said little about his policy ambitions. there was hope abroad and at home that he would champion political and social reform and attempt to deal with corruption and a widening wealth gap between rich and poor and between urban and rural communities. he also faced the conundrum of how to provide adequate health care to a rapidly ageing population. in jan. the prospect of greater transparency and accountability under his leadership was undermined when the authorities began criminal proceedings against anti-corruption campaigners calling for public disclosure of officials' assets. this coincided with a report by a us investigative organization claiming that relatives of some of china's top political and military figures, including xi's brother-in-law, held secret offshore financial holdings. in other social and political affairs the ccp announced plans in nov. to ease china's one-child policy (which was subsequently abandoned following an announcement in oct. , with effect from ) and to abolish the system of 're-education through labour' camps, while a party plenum called-for the first time-for markets to play a 'decisive' role in the allocation of resources. meanwhile, in xi was confronted by domestic political opposition in the form of militant attacks by ethnic uighur separatists from xinjiang region and, from sept. that year, by widespread pro-democracy and autonomy protests in hong kong. on the economic front, china's previously frenetic annual rate of growth slowed markedly in , reflecting a slump in factory production and concerns over depressed oil prices, and again in to its lowest since . it also heralded severe stock market turbulence into despite emergency government measures, which had negative reverberations throughout the world economy. nevertheless, recognizing china's rise as a global economic power, the imf in nov. voted to add the yuan as the fifth member of its special drawing rights (sdr) currency basket alongside the us dollar, japanese yen, british pound and the euro. in foreign affairs, regional concerns over china's territorial and military intentions were raised in nov. by the government's declaration of a new 'air defence identification zone' over a swathe of the east china sea including disputed islands claimed by japan and south korea. there has also been friction, regionally and with the usa, over china's sovereignty claims and land reclamation operations on islands in the south china sea, although in july an international legal tribunal ruled in favour of a challenge by the philippines to china's sovereignty assertions-a verdict beijing vowed to ignore. further afield, xi has meanwhile undertaken numerous official visits abroad, as well as attending multilateral forums, for diplomatic, trading and investment purposes. and, while in singapore in nov. , xi and president ma ying-jeou of taiwan held the first direct talks between leaders of the two estranged governments since their split in . more recently, in xi aimed to extend china's economic and military co-operation with russia and also sought to defuse tensions with india over a simmering border dispute at an informal summit with prime minister narendra modi. meanwhile, friction with the usa escalated markedly over disputed trading and commercial practices, with both countries imposing punitive trade tariffs. li keqiang took office as premier of the state council, a role equivalent to prime minister, in march , succeeding wen jiabao. he was re-elected in march . li keqiang was born on july in dingyuan county, anhui province. following graduation from high school in , he joined the ccp and in he graduated in law from peking university, serving as head of the students' federation from - . he went on to earn a master's degree and doctorate in economics and headed the university's communist youth league of china (cylc) committee. over the following two decades he rose through the cylc ranks, joining the secretariat of its central committee in the s and serving as its first secretary in the s. at this time he built up his power base and forged close ties with hu jintao, a fellow cylc committee member and future chinese president. in li became deputy party secretary for henan province and a year later was appointed henan's governor. in dec. he was named party secretary for liaoning province where he spearheaded a major coastal infrastructure project, the ' points and one line' highway development. in this template was adopted at the national level to rejuvenate industrial northeast china. he also oversaw the rehousing of Á m. shanty-town residents into new apartment blocks over a three-year period. li advanced to national level politics when he was elected to the politburo standing committee in oct. . he was appointed vice-premier of the state council in march , leading a medical reform programme aimed at creating an accessible public health care service. he also chaired an affordable housing programme and introduced tax reform plans. in nov. li was re-elected as a member of the politburo standing committee and on march became premier of the state council at the th national people's congress. regarded as the steward of the chinese economy, li has aimed to focus on securing china's long-term expansion and on the further provision of basic national health care, affordable housing, employment growth, regional development and cleaner energy. however, global confidence in china's economy has been shaken since as the country's growth momentum has slowed amid apparent policy differences and blunders, prompting rumours that li was being increasingly sidelined in the governing hierarchy. he was nevertheless re-elected to the politburo standing committee in oct. and to the premiership in march . having sought assurances that a recently revised us-mexico-canada trade agreement would not stop canada from signing deals with other countries, li met with canadian prime minister justin trudeau in nov. at an international summit in singapore with the aim of pursuing negotiations on a bilateral free trade pact. the chinese president is chairman of the state and party's military commissions. china is divided into seven military regions. the military commander also commands the air, naval and civilian militia forces assigned to each region. china's armed forces (pla: 'people's liberation army'), totalling nearly Á m. in including the paramilitary people's armed police (pap) and Á m. excluding the pap, are the largest of any country. however, active armed personnel numbers have halved since . moreover, in president xi laid out plans to reform the army structure-replacing an organization based on seven regions with one based on five 'theatre commands'-and reduce the number of military personnel by a further , . conscription is compulsory, but for organizational reasons, is selective: only some % of potential recruits are called up. service is for two years. a military academy to train senior officers in modern warfare was established in . defence expenditure in was us$ , m. (equivalent to us$ per capita). china's military spending more than trebled between and . defence spending in represented Á % of gdp, although the share has actually declined since . only the usa spent more on defence in , but china's defence expenditure totalled around a fifth of that of the usa. in march it was announced that the defence budget would rise by Á % to us$ bn. following increases of Á %, Á % and Á % in the previous three years. china is the world's third largest exporter of arms after the usa and russia, with Á % of the global major weapons total over the period - . in the period - it had only been the eighth largest exporter. as at may china had , personnel serving in un peacekeeping operations (the largest contingent of any of the five permanent members of the un security council and more than the other four combined). having carried out its first test in , there have been tests in all at lop nur, in xinjiang (the last in ). the nuclear arsenal consisted of approximately operational warheads in jan. according to the stockholm international peace research institute. china has been helping pakistan with its nuclear efforts. the army (the pla groundforce) is divided into main and local forces. main forces, administered by the seven military regions in which they are stationed, but commanded by the ministry of defence, are available for operation anywhere and are better equipped. local forces concentrate on the defence of their own regions. ground forces are divided into infantry, armour, artillery, air defence, aviation, engineering, chemical defence and communications service arms. there are also specialized units for electronic counter-measures, reconnaissance and mapping. in there were group armies covering seven military regions. they included: armoured divisions and brigades; mechanized infantry divisions, brigades and regiments; motorized infantry divisions and brigades; nine special operations units; artillery divisions and brigades; amphibious brigades and divisions; two mountain brigades; aviation brigades and regiments; and two guard divisions. total strength in was Á m. including some , conscripts. reserve forces are undergoing major reorganization on a provincial basis but are estimated to number some , . there is a paramilitary people's armed police force estimated at , under pla command. in nov. the naval arm of the pla included submarines, of which three were strategic (two jin-class and one xia-class) and tactical. by mid- two more jin-class nuclear-powered ballistic missile submarines had entered service. surface combatant forces in nov. included destroyers and frigates. sea trials of china's first aircraft carrier, liaoning (a former soviet warship purchased from ukraine), began in aug. . it entered service in sept. and was initially only used for training before being declared 'combat ready' in nov. . work on china's first domestically-built aircraft carrier began in . it was launched in april and is expected to be operational by . there is a land-based naval air force of about combat-capable aircraft, primarily for defensive and anti-submarine service. the force includes h- strategic bombers and jh- fighters. the naval arm is split into a north sea fleet, an east sea fleet and a south sea fleet. in naval personnel were estimated at , , including , in the naval air force and , conscripts. the pla air force organizes its command through seven military region air forces. the air force has an estimated , combat-capable aircraft. equipment includes j- (mig- ) interceptors (known in the west as 'fishbed'), h- chinese-built copies of tu- strategic bombers, q- fighter-bombers (evolved from the mig- and known in the west as 'fantan'), su- fighters supplied by russia (known in the west as 'flanker'), j- chinese-designed and produced fighters (known in the west as 'firebird') and j- locally-developed fighters (known in the west as 'finback'). total strength ( ) was , . in agriculture accounted for Á % of gdp, industry Á % and services Á %. industry was the largest contributor until , while services only overtook agriculture as the second largest sector in . in the late s agriculture was the largest contributor towards gdp. china's economic performance has been marked by high rates of growth for over three decades. annual gdp increases in the early s consistently exceeded % until the global financial crisis. china also holds the world's largest foreign exchange reserves, at more than us$ Á trn. in april , although they have been falling since as the central bank strives to boost the currency in the face of large capital outflows. it is among the top recipients of foreign direct investment (fdi) and is the world's largest producer and consumer of coal. in china made the transition from net receiver of foreign aid to net donor and has established itself as a key player in africa's economic development, becoming the largest export partner of sub-saharan africa in . according to the world bank, china's cumulative fdi stock in africa totalled nearly us$ Á bn. in , up from us$ Á bn. in . in china overtook japan to become the world's second largest economy after the usa. new sectors like e-commerce and online financial services are gaining momentum in an economy long dominated by export-oriented sectors. rising trade tensions between the usa and china, however, pose a threat to longer-term prospects. the first steps from a centrally-planned towards a more market-oriented economy were taken by deng xiaoping in the late s. he opened the economy to foreign trade and investment, decentralized industrial management and allowed private sector development. in china became a member of the world trade organization, establishing trade relations with many countries. private entrepreneurs and foreign investors have played an important role in developing the manufacturing sector, china's principal growth engine. even before the economy was heavily skewed towards manufacturing, but following the market-oriented transition output increased significantly. during this period there was a structural shift away from large state-owned enterprises (soes), although these still remain an important part of the economy. between and the government oversaw reform of soes, with many poorly performing businesses privatized or liquidated. stronger firms were restructured and often listed on the stock market. many more recent enterprises are labour-intensive as distinct from the capitalintensive soes. growth has been fuelled by low added value and labourintensive exports. however, chinese firms are predicted to become increasingly competitive with higher added value producers, such as south korea. although the global financial crisis reduced the rate of growth and inbound fdi, china's recovery was among the earliest. gdp growth averaged Á % in the second quarter of , up from a two-decade low of Á % in the first quarter of that year. fdi also recovered rapidly, averaging Á % of gdp annually between and . growth was rooted in a stimulus package of trn. yuan (us$ bn. or % of gdp), including fiscal spending and interest rate cuts, as well as an expansionary monetary policy. central government committed Á trn. yuan, with the rest coming from local government, banks and soes. although exports declined by around % in , other countries fared worse and china's share of world exports increased to nearly Á % in (up from % in ), making it the world's largest merchandise provider. gdp growth in stood at more than % but moderated between and , reflecting the global economic slowdown and diminishing dividends from past reforms. in aug. a devaluation of the yuan sent the shanghai stock exchange plummeting by nearly %, which was swiftly followed by a surge in capital outflows. the stock market meltdown lasted until feb. , with trading halted altogether for two days in jan. that year. nonetheless, the shanghai exchange subsequently began a recovery and had stabilized (at around , points) by feb. . despite stock market turbulence, the property market, which constitutes a quarter of china's gdp and is vital to the banking sector (as it accounts for a substantial amount of its collateral), remained buoyant. gdp growth declined to Á % in (the slowest rate in years) and fell again to Á % in as china attempted to reduce its reliance on exports, increase domestic consumption and develop its service sector. however, china remains one of the fastest growing major economies in the world, recording expansions of Á % and Á % in and , respectively, driven by exports and robust domestic household consumption. in may , for the first time since , the credit rating agency moody's downgraded china's sovereign rating. inflation was Á % in , up from Á % in , while public debt was measured by the government at Á % of gdp (although there is wide-held suspicion that the real figure is significantly higher). corporate debt reached % of gdp in , with household debt-although still low-rising by % of gdp over the preceding five years. president xi jinping has targeted spending cuts and aims to curb loans to bloated soes. rapid economic advance has brought with it a number of challenges that threaten future growth. notably, china's cost advantage has been undermined in recent years by rising wages and transportation costs, as well as weak global demand. other concerns include rising property costs, high levels of local government debt, lack of enforcement of intellectual property rights, endemic corruption at government level and credit and investment dependence, while total social financing-a broad measure of total credit-increased by % of gdp between and early . the stimulus package implemented by the government to boost growth increased total debt levels to more than double the value of gdp in . according to the imf, an increase in consumer demand and a reduced dependence on exports and investment are keys to achieving stable long-term economic expansion. china's th five-year plan (covering - ) aims to promote domestic consumption and to support innovation and entrepreneurship within a framework of balanced and sustainable development. efforts to promote domestic consumption have seen exports' share of gdp falling from % in to Á % in and a lower investment contribution to gdp. trade frictions are predicted to disproportionately affect smaller firms that are less able to squeeze profit margins to accommodate tariff hikes, as well as those geographical regions most reliant on exports. the continued decline in commodity prices coupled with china's economic slowdown has had knock-on effects for commodity-exporting nations, such as brazil, indonesia and argentina, given that china consumes about half of the world's steel, aluminium and nickel. inefficient production and outmoded equipment have meanwhile led to significant environmental problems, especially in the north of the country. air pollution, soil erosion and a declining water table are of particular concern. china has become the world's largest consumer of coal and second largest consumer of oil after the usa. the government aims to diversify its energy sources, relying less on coal and more on nuclear and alternative energy sources. there has been heavy investment in hydro-power, including the three gorges dam. since , m. people have been lifted out of poverty, yet china still has the second largest number of poor in the world after india. the world bank estimates that Á m. people lived below the national poverty line at the end of (equivalent to income less than us$ per day), located mainly in remote and resource-poor regions and particularly in the west and the interior. nonetheless, some progress has been made, with Á % of the rural population living below the poverty line in compared to Á % in . a large gap remains between living standards of the urban and rural communities, between urban zones on the chinese coast and the interior and western parts of the country, and between the urban middle classes and those who have not been able to profit from the growth of recent decades. china also faces the growing burden of an ageing population. those aged and over accounted for Á % of the total population in , up from Á % in . the currency is called renminbi (i.e. people's currency). the unit of currency is the yuan (cny) which is divided into ten jiao, the jiao being divided into ten fen. the yuan was floated to reflect market forces on jan. while remaining state-controlled. for years the people's bank of china maintained the yuan at about Á to the us dollar, allowing it to fluctuate but only by a fraction of % in closely supervised trading. in july it was revalued and pegged against a 'market basket' of currencies the central parities of which were determined every night. in july , after three years of sharp appreciation, it was repegged at around Á yuan to the dollar, leading to claims from some international observers that it was being kept unfairly low to boost exports. in june the government announced that the yuan would be allowed to move freely against the dollar as long as a rise or fall does not exceed Á % within a single day. in aug. the yuan was devalued by a total of Á % on three consecutive days. in aug. total money supply was , Á bn. yuan, gold reserves were Á m. troy oz and foreign exchange reserves us$ , Á bn. (us$ Á bn. in ). china's reserves are the highest of any country, having overtaken those of japan in . inflation rates (based on imf statistics): Á % - Á % Á % Á % Á % Á % Á % Á % Á % Á % china's economy overheated in the early s, leading to inflation rates of Á % in , Á % in and Á % in of the total revenues in central government accounted for , Á bn. yuan and local governments , Á bn. yuan. tax revenues came to , Á bn. yuan in (including domestic vat , Á bn. yuan and corporate income tax , Á bn. yuan) and non-tax revenues , Á bn. yuan. of the total expenditure in central government accounted for , Á bn. yuan and local governments , Á bn. yuan. the leading items of expenditure in were education ( , Á bn. yuan) and social safety net and employment effort ( , Á bn. yuan). the standard rate of vat is %. performance gdp totalled us$ , Á bn. in , the second highest behind the usa. china's share of world gdp has risen from % in to % in . it replaced japan as the second largest economy in . it is forecast that around china will overtake the usa to become the world's largest economy. as recently as the us economy was around eight times larger than china's. real gdp growth rates (based on imf statistics): supervising the country's banks and other deposit-taking financial institutions from the central bank. legislation in permitted the establishment of commercial banks; credit co-operatives may be transformed into banks, mainly to provide credit to small businesses. there were , rural credit co-operatives at the end of . insurance is handled by the people's insurance company. the industrial and commercial bank of china is the world's largest bank by assets (us$ , bn. as at dec. ). savings deposits in various forms in all banking institutions totalled , Á bn. yuan in ; loans amounted to , Á bn. yuan. there are stock exchanges in the shenzhen special economic zone and in shanghai. a securities trading system linking six cities (securities automated quotations system) was inaugurated in for trading in government bonds. china received a record us$ Á bn. worth of foreign direct investment in , up from us$ Á bn. in . external debt totalled us$ , m. in (up from us$ , m. in ) and represented Á % of gni. china's carbon dioxide emissions from the consumption of energy in accounted for Á % of the world total (making it the biggest emissions producer, having overtaken the usa in ) and were equivalent to Á tonnes per capita (up from Á tonnes per capita in ). carbon dioxide emissions have more than doubled since . an environmental performance index compiled in ranked china th of countries, with Á %. the index examined various factors in nine areas-agriculture, air quality, biodiversity and habitat, climate and energy, fisheries, forests, health impacts, water and sanitation, and water resources. pollution is estimated to cost china about % of gdp annually. installed generating capacity in was an estimated , m. kw, compared with m. kw in . in electricity output was , , gwh, up from , , gwh in . consumption per capita was , kwh in . rapidly increasing demand has meant that more than half of china's provinces have had to ration power. sources of electricity in as percentage of total production: thermal, Á %; hydro-electric power, Á %; wind. Á % (china is one of the world's largest producers of wind power); and nuclear, Á %. in there were nuclear reactors in use and under construction. generating electricity is not centralized; local units range between and mw of output. in dec. china formally broke up its state power monopoly, creating instead five generating and two transmission firms. the three gorges dam project on the yangtze river was launched in and is intended to produce abundant hydro-electricity (as well as helping flood control). the first three , -kw generators in service at the project's hydro-power station began commercial operation in july . the original specification was completed in oct. , although six more generators have been added in the meantime (bringing the total to ). the final two generators become operational in july , giving the dam an overall capacity of Á gw. china surpassed germany in terms of solar generating capacity in , with Á gw at the end of the year. on-shore oil reserves are found mainly in the northeast (particularly the daqing and liaohe fields) and northwest. there are off-shore fields in the continental shelves of east china. oil production was a record Á m. tonnes in and was Á m. tonnes in . china is the second largest consumer of oil after the usa. ever-growing demand has meant that increasing amounts of oil are having to be imported. a -km pipeline from skovorodino in russia to daqing in the northeast of china was inaugurated in jan. , allowing china to increase significantly its imports of oil from the world's second largest producer. the , -km turkmenistan-china gas pipeline, bringing natural gas to xinjiang in china via kazakhstan and uzbekistan, was inaugurated in dec. . this connects with china's second west-east gas pipeline. only the usa imports more oil. domestic production now accounts for only % of consumption, compared to nearly % in . proven reserves in were Á bn. bbls. the largest natural gas reserves are located in the western and northcentral regions. production was a record Á bn. cu. metres in -up from Á bn. cu. metres in -with proven reserves of Á trn. cu. metres in . china is the second largest producer of wind power after the usa, with Á bn. kwh in . in total installed capacity amounted to , mw, the highest of any country and Á % of the world total. china is one of the world's leading mineral producing and consuming countries. recoverable deposits of coal in totalled Á bn. tonnes, mainly distributed in north china (particularly shanxi province and the inner mongolia autonomous region). coal production was , m. tonnes in . annual coal production has increased every year since . growing domestic demand nonetheless meant that china became a net importer of coal in . iron ore reserves were Á bn. tonnes in . deposits are abundant in the anthracite field of shanxi, in hebei and in shandong, and are found in conjunction with coal and worked in the northeast. production in was , m. tonnes, making china the world's largest iron ore producer. it is also the largest consumer, at around % of the global total in . tin ore is plentiful in yunnan, where the tin-mining industry has long existed. tin production was , tonnes in . china is a major producer of wolfram (tungsten ore). there is mining of wolfram in hunan, guangdong and yunnan. output of other minerals (in , tonnes) in : salt, , ; bauxite, , ; aluminium, , ; zinc, , ; lead, , ; copper, , . there are also reserves of diamond, nickel, barite, bismuth, graphite, gypsum, mercury, molybdenum, silver, salt, phosphate ore and sylvite. gold production, : tonnes. china surpassed south africa as the world's leading gold producer in , since when its output has increased every year. agriculture accounted for approximately % of gdp in , compared to over % in at the time of the birth of the people's republic of china and over % in . in sown areas for major crops were (in m. ha.): corn, Á ; rice, Á ; wheat, Á ; soybeans, Á ; tubers, Á ; rapeseed, Á . intensive agriculture and horticulture have been practised for millennia. present-day policy aims to avert the traditional threats from floods and droughts by soil conservancy, afforestation, irrigation and drainage projects, and to increase the 'high stable yields' areas by introducing fertilizers, pesticides and improved crops. in aug. more than m. ha., notably in the yangtze valley, were under water as china experienced its worst flooding since the s. the flood season claimed over , lives. 'township and village enterprises' in agriculture comprise enterprises previously run by the communes of the maoist era, co-operatives run by rural labourers and individual firms of a certain size. there were , state farms in with Á m. employees. net per capita annual income of rural households, : , yuan. in there were an estimated Á m. ha. of arable land and Á m. ha. of permanent cropland; Á m. ha. were equipped for irrigation. there were Á m. large/medium-sized tractors in and Á m. small tractors. china is the world's leading producer of a number of agricultural crops. production of major products (in m. tonnes), (unless otherwise indicated): corn, Á ; rice, Á ; wheat, Á ; sugarcane, Á ; potatoes ( estimate livestock, (unless otherwise indicated): pigs, , , ; sheep, , , ; goats, , , ; cattle and buffaloes, , , ; horses, , , ; chickens ( estimate), Á bn.; ducks ( estimate), m. china has more pigs, goats, sheep, horses and chickens than any other country. it is also home to nearly two-thirds of the world's ducks. meat production in was estimated at Á m. tonnes; milk, Á m. tonnes; eggs, Á m. tonnes; honey, , tonnes. china is the world's leading producer of meat, eggs and honey. gale, fred, (ed.) china's food and agriculture: issues for the st century. powell, s. g., agricultural reform in china: from communes to commodity economy, - . forestry in the area under forests was Á m. ha., or % of the total land area. the average annual increase in forest cover of , , ha. between and was the highest of any country in the world. total roundwood production in was Á m. cu. metres, making china the world's third largest timber producer ( Á % of the world total in ). it is the highest consumer of roundwood; timber consumption in totalled Á m. cu. metres. it is also the world's leading importer of roundwood, accounting for Á % of world timber imports in . total catch, : , , tonnes, of which , , tonnes were from marine waters. china's annual catch is the largest in the world, and currently accounts for approximately % of the world total. in the annual catch had been just Á m. tonnes. china's aquaculture production is also the largest in the world, at , , tonnes in . imports of fishery commodities in were valued at us$ , m. (the third highest behind japan and the usa); exports were the most of any country, at us$ , m. china's fishery commodities exports in represented approximately % of the global total. in , the first phase of the south-to-north water diversion project opened, with a second phase opening a year later. the scheme, which by provided beijing with a third of its total supply, was estimated to have cost almost us$ bn., with a third phase still to be completed. the leading companies by market capitalization in china in march were alibaba, an e-commerce and data company (us$ Á bn.); tencent holdings, an investment holding company (us$ Á bn.); and icbc, the world's largest commercial bank (us$ Á bn.). in nov. petrochina was briefly the world's largest company after its flotation on the shanghai stock market, with a market capitalization in excess of us$ trn., although its rank has since fallen considerably. industry accounted for Á % of gdp in . cottage industries persist into the st century. industrial output grew by Á % in . modern industrial development began with the manufacture of cotton textiles and the establishment of silk filatures, steel plants, flour mills and match factories. in there were , industrial enterprises with an annual revenue of more than m. yuan. of these enterprises, , were domestically funded, , were foreign funded and , were dependent on funds from hong kong, macao and taiwan. there were , state-owned industrial enterprises in total. output of major products, unless otherwise indicated (in tonnes): cement, , Á m.; rolled steel, , Á m.; crude steel, Á m.; pig iron, Á m.; gas oil and diesel oil ( ), Á m.; gasoline, Á m.; paper and paperboard, Á m.; sulphuric acid, Á m.; chemical fertilizers, Á m.; fuel oil ( ), Á m.; yarn, Á m.; refined sugar, Á m. also produced in : cloth, , m. metres; beer, , Á m. litres; , Á m. mobile phones; Á m. notebook pcs; Á m. colour tv sets; Á m. air conditioners; Á m. home refrigerators; Á m. washing machines; Á m. bicycles; Á m. cameras; Á m. motorcycles. china is the world's leading cement, steel and pig iron manufacturer; since output of cement has trebled, and production of crude steel has increased sixfold and of pig iron fivefold (although in pig iron production fell for the first time in more than years, as did crude steel production in ). china overtook japan as the world's largest producer of motor vehicles in , and in produced Á m. cars and Á m. commercial vehicles. the employed population at the census was Á m. ( Á m. female). by it had risen to Á m. ( Á m. more than in ), of whom Á m. worked in rural areas ( Á m. fewer than in ) and Á m. in urban areas ( Á m. more than in ). in china's registered urban jobless was Á %, with Á m. registered unemployed in the country's cities. with china's fast-growing ageing population, according to the united nations the working-age population began to decline in . in china had , private industrial enterprises. it was not until the late s that the private sector even came into existence in china. the average annual wage of people working in urban units in was , yuan. china's labour law stipulates a five-day working week with no more than eight hours a day and no more than hours a week. minimum working age was fixed at in . strikes over pay have become ever more frequent in china, particularly at foreign-owned facilities. china had Á m. people living in slavery according to the walk free foundation's global slavery index, the second highest total of any country. there are five special economic zones at shenzhen, xiamen, zhuhai, shantou and hainan in which concessions are made to foreign businessmen. the pudong new area in shanghai is also designated a special development area. since joint ventures with foreign firms have been permitted. a law of april reduced taxation on joint ventures to %. there is no maximum limit on the foreign share of the holdings; the minimum limit is %. in china is the second largest trading nation in the world, accounting for Á % of global merchandise imports by value in and Á % of global merchandise exports (up from Á % when it joined the wto in ). it was the second largest importer in behind the usa and the largest exporter. as recently as the usa's total trade in goods was more than twice that of china. it overtook germany as the largest exporter of goods in . its trade surplus in goods is the highest of any country. however, it has the world's highest trade deficit in services. in imports of services totalled us$ bn. but exports only us$ bn. main imports in (in us$ bn.): machinery and transport equipment, Á ; non-edible raw materials, Á ; mineral fuels, lubricants and related materials, Á ; chemicals, Á . major exports in (in us$ bn.): machinery and transport equipment, , Á ; miscellaneous manufactured goods, Á ; light textile industrial products, rubber products, minerals and metallurgical products, Á ; chemicals, Á . the main trading partners were as follows in (in us$ m.): the total road length in was , , km, including , km of expressways (of which there had not been any as recently as the mid- s); , m. tonnes of freight and , m. persons were transported by road that year. the number of civilian motor vehicles was Á m. in , including Á m. passenger vehicles and Á m. trucks (more than double the number in , when there were Á m. civilian vehicles overall including Á m. passenger vehicles and Á m. trucks). china is the world's fastest-growing car market. there were , traffic accidents in , with , fatalities. in in jan. there were , ships of gt or over registered, totalling Á m. gt. of the , vessels registered, were bulk carriers, general cargo ships, oil tankers, container ships, passenger ships and liquid gas tankers. mainland china's busiest port in was ningbo-zhoushan (handling Á m. tonnes of cargo), followed by shanghai ( Á m. tonnes), tianjin ( Á tonnes), guangzhou (canton) ( Á m. tonnes) and qingdao ( Á m. tonnes). shanghai overtook singapore to become the world's busiest container port in and handled Á m. teus (twenty-foot equivalent units) in . shenzhen, mainland china's second busiest port for container traffic and the world's fourth busiest in , handled Á m. teus. hong kong handled Á m. teus in . in jan. the first legal direct shipping links between the chinese mainland and taiwanese islands in more than years were inaugurated. inland waterways totalled , km in ; , Á m. tonnes of freight and Á m. passengers were carried. in june the three gorges reservoir on the chang jiang river, the largest water control project in the world, reached sufficient depth to support the resumption of passenger and cargo shipping. in out of countries analysed in the fragile states index-a list published jointly by the fund for peace and foreign policy magazine-china was ranked the th most vulnerable to conflict or collapse. the index is based on indicators of state vulnerability across social, political and economic categories. six new codes of law (including criminal and electoral) came into force in , to regularize the legal unorthodoxy of previous years. there is no provision for habeas corpus. as well as treason and murder the death penalty may be used for rape, embezzlement, smuggling, fraud, theft, drug-dealing, bribery and robbery with violence. amendments to the criminal law in and reduced the number of capital crimes-which include both violent and non-violent offences-from to and further to . china does not divulge figures on its use of the death penalty, but amnesty international reports that china executes thousands of people annually and is the world's top executioner. nevertheless, western analysts believe that the number of executions now is around a fifth of the yearly total in the s. 'people's courts' are divided into some higher, intermediate and , basiclevel courts, and headed by the supreme people's court. the latter, the highest state judicial organ, tries cases, hears appeals and supervises the people's courts. it is responsible to the national people's congress and its standing committee. people's courts are composed of a president, vicepresidents, judges and 'people's assessors' who are the equivalent of jurors. 'people's conciliation committees' are charged with settling minor disputes. there are also special military courts. procuratorial powers and functions are exercised by the supreme people's procuracy and local procuracies. in march the national people's congress passed legislation developing aspects of the general principles of civil law, with effect from oct. . among its provisions was the extension of legitimate rights and interests from chinese citizens only to anyone conducting civil activities in the country. in addition, the statute of limitation was increased from two to three years. the number of sentenced prisoners in mid- was , , ( per , of national population). china was ranked th of countries for criminal justice and th for civil justice in the world justice project rule of law index, which provides data on how the rule of law is experienced by the general public across eight categories. an educational reform of brought in compulsory nine-year education consisting of six years of primary schooling and three years of secondary schooling, to replace a previous five-year system. in mainland china the population census revealed the following levels of educational attainment: Á m. people had finished university education; Á m. had received senior secondary education; Á m. had received junior secondary education; and Á m. had had primary education. Á m. people over years of age or Á % of the population were illiterate, although this compared favourably with a Á % rate of illiteracy in the census and a Á % rate in . in adult literacy was estimated at Á %; youth literacy in was Á %. in there were , kindergartens with Á m. children and Á m. full-time teachers; , regular primary schools with Á m. pupils and Á m. full-time teachers; , secondary schools (including: , senior secondary; , junior secondary; , specialized; , vocational; and , technical) with Á m. pupils and Á m. full-time teachers. there were also , pupils at , special education schools. institutes of higher education, including universities, numbered , in , with Á m. undergraduates and Á m. postgraduate level students, and Á m. full-time teaching staff. china has more than private universities, almost all of which have been established since the mid- s. a national system of student loans was established in . the number of chinese students studying abroad went up from , in to , in ; it rose above , in and , in , and by exceeded , , making china the largest source of overseas students in the world. chinese students account for a fifth of all international students in tertiary education in the oecd, but fewer than half return to china after finishing their studies. the number of chinese undergraduate students in american universities in - was times as many as in - , rising from , to , in the space of seven years. there is an academy of sciences with provincial branches. an academy of social sciences was established in . in national government expenditure on education came to , , m. yuan and accounted for Á % of national government spending. medical treatment is free only for certain groups of employees, but where costs are incurred they are partly borne by the patient's employing organization. in there were , health institutions throughout china, including , hospitals, , local health centres, , centres for disease control and prevention, and , specialized prevention and treatment centres. china's first aids case was reported in . at the end of there were , reported cases of people living with hiv/aids. the number of deaths of people who had been living with hiv/aids in was , . in the first half of china was struck by an epidemic of a pneumoniatype virus identified as sars (severe acute respiratory syndrome). the virus was first detected in southern china and was subsequently reported in over other countries. according to the ministry of health, by the time the outbreak had been contained a total of , cases had been reported on the chinese mainland; , patients were cured and discharged from hospital, and died. in water: at what cost? the state of the world's water , wateraid reported that Á % of the population does not have access to safe water. china ranked as the country with the second largest number of people living without access to safe water ( Á m. in ). in an estimated Á % of adult males and Á % of adult females smoked in china. a study from the same year estimated that chinese males smoke one-third of all the world's cigarettes. in there were , social welfare enterprises with Á m. beds. numbers (in , ) of beneficiaries of relief funds in : urban residents receiving minimum living allowance, , ; rural residents receiving minimum living allowance, , ; persons receiving traditional relief, ; persons in rural households entitled to the 'five guarantees' (food, clothing, medical care, housing and burial expenses), , . the official retirement age for men is and for women (or in the case of civil servants and professionals). the government accords legality to five religions only: buddhism, islam, protestantism, roman catholicism and taoism. confucianism, buddhism and taoism have long been practised. confucianism has no ecclesiastical organization and appears rather as a philosophy of ethics and government. taoism-of chinese origin-copied buddhist ceremonial soon after the arrival of buddhism two millennia ago. buddhism in return adopted many taoist beliefs and practices. a more tolerant attitude towards religion had emerged by , and the government's bureau of religious affairs (since renamed the state administration for religious affairs) was reactivated. ceremonies of reverence to ancestors have been observed by the whole population regardless of philosophical or religious beliefs. a new quasi-religious movement, falun gong, was founded in , but has since been banned by the authorities. the movement has claimed some m. adherents, although the chinese government has disputed this. muslims are found in every province of china, being most numerous in the ningxia-hui autonomous region, yunnan, shaanxi, gansu, hebei, henan, shandong, sichuan, xinjiang and shanxi. roman catholicism has had a footing in china for more than three centuries. two christian organizations-the chinese patriotic catholic association, which declared its independence from rome in , and the protestant three-self patriotic movement-are sanctioned by the chinese government. according to estimates (by the state-approved xinhua news agency, the chinese academy of social sciences and the state administration for religious affairs) there were m. buddhists (more than in any other country), m. christians and more than m. muslims in the country in . other official figures indicate that there are Á m. catholics, although unofficial estimates are much higher. the number of christians in china is generally thought to be far higher than official numbers indicate, with so-called 'house churches' becoming ever more popular. some analysts estimate that there are as many as m. christians overall. legislation of prohibits foreign nationals from setting up religious organizations. johnson, ian, the souls of china: the return of religion after mao. china and provides habitat for a number of rare animal species, kulangsu, a historic international settlement ( ), a tiny island located on the estuary of the chiu-lung river, qinghai hoh xil ( ), the largest and highest plateau in the world, and fanjingshan ( ), an island of metamorphic rock in guizhou province. shared with kazakhstan and kyrgyzstan, silk roads: the routes network of chang'an-tianshan corridor ( ) is a , -km section of the extensive silk roads network stretching from chang'an/ luoyang to the zhetysu region in present-day kazakhstan. china has two news agencies: xinhua (new china) news agency (the nation's official agency) and china news service. in there were , newspapers and , magazines; , m. copies of newspapers and , m. copies of magazines were published. in there were fewer than newspapers. the communist party newspaper, renmin ribao (people's daily), had an average daily circulation of Á m. in . the most widely read newspaper is cankao xiaoxi, with an average daily circulation of Á m. in . china has the second highest circulation of daily newspapers after india, with an estimated average daily total of Á m. in . as of sept. it was also home to the world's two most visited online news sites: xinhua news agency ( Á m. unique desktop users per month) and people's daily online ( Á m.). in the world press freedom index compiled by reporters without borders, china ranked rd out of countries. in , , m. volumes of books were produced. in tourist numbers totalled Á m. china was the fourth most visited destination in after france, the usa and spain. income from tourists in was us$ Á bn., ranking it third behind the usa and spain. expenditure by chinese travellers outside of mainland china for was us$ Á bn., the most of any country and more than double the next largest expenditure (that of us tourists). in both german and us travellers abroad had spent more than those from china. the lunar new year, also known as the 'spring festival', is a time of great excitement for the chinese people. the climate is sub-tropical, tending towards temperate for nearly half the year, the winter being cool and dry and the summer hot and humid, may to sept. being the wettest months. normal temperatures are jan. f ( Á c), july f ( Á c). annual rainfall " ( , Á mm). hong kong used to be administered by the hong kong government. the governor was the head of government and presided over the executive council, which advised the governor on all important matters. the last british governor was chris patten. in oct. the executive council consisted of three ex officio members and ten appointed members, of whom one was an official member. the chief functions of the legislative council were to enact laws, control public expenditure and put questions to the administration on matters of public interest. the legislative council elected in sept. was, for the first time, constituted solely by election. it comprised members, of whom were elected from geographical constituencies, from functional constituencies encompassing all eligible persons in a workforce of Á m., and ten from an election committee formed by members of district boards. a president was elected from and by the members. at the elections on sept. turnout for the geographical seats was Á %, and for the functional seats ( of which were contested), Á %. the democratic party and its allies gained seats, the liberal party and the pro-beijing democratic alliance . the remaining seats went to independents. on dec. the selection committee selected a provisional legislature which began its activities in jan. while the legislative council was still functioning. in jan. the provisional legislature started its work by enacting legislation which would be applicable to the hong kong special administrative region and compatible with the basic law. constitutionally hong kong is a special administrative region of the people's republic of china. the basic law enables hong kong to retain a high degree of autonomy. it provides that the legislative, judicial and administrative systems which were previously in operation are to remain in place. the special administrative region government is also empowered to decide on hong kong's monetary and economic policies independent of china. in july the first-past-the-post system of returning members from geographical constituencies to the legislative council was replaced by proportional representation. there were directly elected seats out of for the first elections to the legislative council following hong kong's return to chinese sovereignty, increasing in accordance with the basic law to for the election with indirectly elected. in the sept. legislative council election (and that of sept. ) of the seats were directly elected. for the election in sept. the number of seats was increased to , with directly elected and indirectly elected by functional constituencies. there were also five new functional constituency seats nominated by elected district council members. the chief executive is chosen by a beijing-backed , -member election committee ( prior to the march election), although it has been stated that universal suffrage is the ultimate aim. in a timetable was announced for hong kong to directly elect its chief executive in and its legislative council in . however, beijing insisted that only approved candidates would be allowed to stand in , prompting mass pro-democracy rallies in the territory in and formal rejection of the plan by the legislative council in june . beijing nevertheless refused to countenance amendments. in july a new accountability or 'ministerial' system was introduced, under which the chief executive nominates for appointment policy secretaries, who report directly to the chief executive. the chief executive is aided by the executive council, consisting of the three senior secretaries of department (the chief secretary, the financial secretary and the secretary for justice) and eleven other secretaries plus five non-officials. hong kong used to be administered by the hong kong government. the governor was the head of government and presided over the executive council, which advised the governor on all important matters. the last british governor was chris patten. in oct. the executive council consisted of three ex officio members and ten appointed members, of whom one was an official member. the chief functions of the legislative council were to enact laws, control public expenditure and put questions to the administration on matters of public interest. the legislative council elected in sept. was, for the first time, constituted solely by election. it comprised members, of whom were elected from geographical constituencies, from functional constituencies encompassing all eligible persons in a workforce of Á m., and ten from an election committee formed by members of district boards. a president was elected from and by the members. at the elections on sept. turnout for the geographical seats was Á %, and for the functional seats ( of which were contested), Á %. the democratic party and its allies gained seats, the liberal party and the pro-beijing democratic alliance . the remaining seats went to independents. overview hong kong has one of the world's most open economies and is an internationally important financial centre. the territory's economic rise was founded on its role as an international trade emporium, acting as a conduit for china's burgeoning exports. mainland china, the usa and japan are hong kong's major export partners, accounting for Á %, Á % and Á % of exports respectively in . the island is dependent on imports of food and other resources. in it imported % of goods from mainland china, % from taiwan and % from japan. in and the economy grew strongly on the back of a rise in chinese tourism, healthy global demand for exports and improving domestic consumer confidence. however, the global financial crisis saw the economy shrink by Á % in before rebounding with a Á % increase the following year. between and annual growth averaged Á %, supported by strong external demand. student-led pro-democracy protests in the latter months of caused major disruption in several key business districts and threatened to weaken the local economy in the short term. foreign direct investment levels have been high, averaging % of gdp between and according to world bank data, and the world economic forum ranked hong kong as the ninth most competitive economy in the world in its report. the government aims to tackle a housing shortage by providing , new housing units by the mid- s. the unit of currency is the hong kong dollar (hkd) of cents. it has been pegged since at a rate of hk$ Á to the us dollar. banknotes are issued by the hongkong and shanghai banking corporation and the standard chartered bank, and, from may , the bank of china. total money supply was hk$ , m. in july . in aug. gold reserves were , troy oz and foreign exchange reserves were us$ , m. inflation rates (based on imf statistics): environment hong kong's carbon dioxide emissions from the consumption of energy in were the equivalent of Á tonnes per capita. installed capacity was Á m. kw in . production in was Á bn. kwh. hong kong is a net importer of electricity. consumption in was Á bn. kwh. the local agricultural industry is directed towards the production of high quality fresh food through intensive land use and modern farming techniques. out of the territory's total land area of , sq. km, only sq. km is currently farmed. in local production accounted for % of live poultry consumed, % of live pigs and % of fresh vegetables. the gross value of local agricultural production totalled hk$ , m. in , with pig production valued at hk$ m., poultry production (including eggs) at hk$ m., and vegetable and flower production at hk$ m. in the total catch was , tonnes, exclusively from marine waters. the leading companies by market capitalization in hong kong in march were: china mobile, a telecommunications company (us$ Á bn.); aia group, a life insurance company (us$ Á bn.); and cnooc, an integrated oil company (us$ Á bn.). industry is mainly service-oriented. in june there were , establishments employing , , persons in service industries and , establishments employing , persons in manufacturing industries. establishment statistics by service type (and persons engaged) were mainly: import/export trade and wholesale, , ( , ); retail, , ( , ); social and personal services, , ( , ) ; professional and business services, , ( , ); financing and insurance, , ( , ); accommodation and food services, , ( , ); real estate, , ( , ) . in the size of the labour force (synonymous with the economically active population) was , , ( , , females). the persons engaged in june included , , people in wholesale, retail and import/ export trades, accommodation and food services, , in finance, insurance, real estate, professional and business services, , in the civil service, , in manufacturing and , in construction sites (manual workers only). a minimum wage of hk$ per hour was introduced for the first time on may . unemployment stood at Á % in the period sept.-dec. . in the total value of imports was hk$ , , m. and total exports hk$ , , m. the main suppliers of imports in were mainland china ( Á %), japan ( Á %), taiwan ( Á %), singapore ( Á %) and usa ( Á %). in , Á % of total exports went to mainland china, Á % to the usa, Á % to japan, Á % to germany and Á % to the united kingdom. the chief import items in were: electrical machinery, apparatus and appliances, etc. ( Á %); telecommunications, sound recording and reproducing equipment ( Á %); office machines and automatic data processing machines ( Á %); articles of apparel and clothing accessories ( Á %). the main exports in were: electrical machinery, apparatus and appliances, etc. ( Á %); telecommunications, sound recording and reproducing equipment ( Á %); office machines and automatic data processing machines ( Á %); articles of apparel and clothing accessories ( Á %). in there were , km of roads, over % of which were in the new territories. there are road tunnels, including three under victoria harbour. in there were , private cars, , goods vehicles, , buses and coaches, and , motorcycles and mopeds. there were , road accidents in , of which were fatal. a total of Á m. tonnes of cargo were transported by road in . a km bridge (the world's longest sea bridge) linking hong kong, zhuhai in guangdong province in mainland china and macao opened in oct. following a number of delays. hong kong was ranked fourth for its road infrastructure in the world economic forum's global competitiveness report - . hong kong's railways are run by the mtr corporation limited (mtrcl), a public listed company of which the government is the majority shareholder. the mtr system comprises nine railway lines serving hong kong island, kowloon and the new territories. its km network has stations and carries an average of Á m. passengers each day. mtr lines carried , m. passengers in . in addition, a light rail network ( Á km and stops) serves the local communities of tuen mun, yuen long and tin shui wai in the new territories; , passengers travel daily on the system. a high speed rail service between hong kong and guangzhou on the mainland opened in sept. . the electric tramway on the northern state of hong kong island commenced operating in and has a total track length of km. the peak tram, a funicular railway connecting the peak district with the lower levels in victoria, has a track length of Á km and two tramcars (each with a capacity of passengers per trip). it carries an average of , passengers daily. the airport express line ( Á km) opened in and is also operated by the mtrcl. it carried Á m. passengers in . in june it was estimated that Á m. passenger journeys were made daily on public transport (including local railways, buses, etc.). in the world economic forum's global competitiveness report - hong kong ranked third for quality of rail infrastructure. the new hong kong international airport (generally known as chek lap kok), built on reclaimed land off lantau island to the west of hong kong, was opened on july to replace the old hong kong international airport at kai tak, which was situated on the north shore of kowloon bay. more than airlines now operate scheduled services to and from hong kong. in cathay pacific airways, the largest hong kong-based airline, operated approximately , passenger and cargo services to destinations in countries and territories around the world. cathay pacific carried , , passengers and Á m. tonnes of cargo in . dragonair, a cathay pacific subsidiary, provided scheduled services to cities in mainland china and asia in . in air hong kong, an all-cargo operator, provided scheduled services to bangkok, beijing, ho chi minh city, manila, nagoya, osaka, penang (via bangkok), seoul, shanghai, singapore, taipei and tokyo. hong kong international airport handled more international freight in than any other airport. in , , aircraft arrived and departed and m. passengers and Á m. tonnes of freight were carried on aircraft. hong kong was second, behind only singapore, in the rankings for air transport infrastructure in the world economic forum's global competitiveness report - . the port of hong kong handled Á m. teus (twenty-foot equivalent units) in , making it the world's third busiest container port after shanghai and singapore. the kwai chung container port has berths with , metres of quay backed by ha. of cargo handling area. at the end of there were , ships ( , ocean-going) of , , gt registered in hong kong. in , , ocean-going vessels, , river cargo vessels and , river passenger vessels arrived at the port of hong kong. a total of m. tonnes of freight were handled in . hong kong was ranked third in the world economic forum's global competitiveness report - for the quality of its port facilities. in there were , , main (fixed) telephone lines (equivalent to Á per , population). the local fixed telecommunications network services (ftns) market in hong kong was liberalized in . there were , , mobile phone subscriptions in (equivalent to , Á per , population), up from , , in ( , Á per , population). the number of subscriptions doubled between and . the internet market has also seen huge growth. in there were , , wireless broadband subscriptions ( Á per , population) and , , fixed broadband subscriptions ( Á per , population). the number of fixed broadband subscriptions has been declining since as more people have wireless subscriptions instead. in march there were Á m. facebook users. the external telecommunications services market has been fully liberalized since jan. , and the external telecommunications facilities market was also liberalized starting from jan. . in the adult literacy rate was Á % ( Á % in ). universal basic education is available to all children aged from six to years. in around three-quarters of the ordinary secondary day schools teaching has been in cantonese since - , with about a quarter of ordinary secondary day schools still using english. in there were , pupils in kindergartens, , in primary schools (including international schools) and , in secondary schools (including international schools). the estimated total government expenditure on education in - was hk$ Á bn. ( Á % of total government spending and Á % of gdp). in - : Á % of total government spending and Á % of gdp. according to the oecd's pisa (programme for international student assessment) study, -year-olds in hong kong rank second among oecd and other major countries and cities in mathematics and reading, and ninth in science. the three-yearly study compares educational achievement of pupils in over countries. the department of health (dh) is the government's health adviser and regulatory authority. the hospital authority (ha) is an independent body responsible for the management of all public hospitals. in there were , registered doctors, equivalent to Á doctors per , population. in there were , dentists, , nurses and , midwives. the total number of hospital beds in was , , including , beds in public hospitals under the ha and , beds in private hospitals. the bed-population ratio was Á beds per thousand population. the chinese medicine ordinance was passed by the legislative council in july to establish a statutory framework to accord a professional status for chinese medicine practitioners and ensure safety, quality and efficacy of chinese medicine. in there were , registered chinese medicine practitioners. total expenditure on health in - amounted to hk$ , m., an increase of Á % over that in - . the hong kong act of provided for hong kong ordinances to replace english laws in specified fields. the courts of justice comprise the court of final appeal (inaugurated july ), which hears appeals on civil and criminal matters from the high court; the high court (consisting of the court of appeal and the court of first instance); the lands tribunal, which determines on statutory claims for compensation over land and certain landlord and tenant matters; the district court (which includes the family court); the magistracies (including the juvenile court); the coroner's court; the labour tribunal, which provides a quick and inexpensive method of settling disputes between employers and employees; the small claims tribunal, which deals with monetary claims involving amounts not exceeding hk$ , ; and the obscene articles tribunal. while the high court has unlimited jurisdiction in both civil and criminal matters, the district court has limited jurisdiction. the maximum term of imprisonment it may impose is seven years. magistracies exercise criminal jurisdiction over a wide range of offences, and the powers of punishment are generally restricted to a maximum of two years' imprisonment or a fine of hk$ , . after being in abeyance for years, the death penalty was abolished in . , crimes were reported in , of which , were violent crimes. , people were arrested in , of whom , were for violent crimes. the population in penal institutions was , at dec. ( per , population). social welfare programmes include social security, family services, child care, services for the elderly, medical social services, youth and community work, probation, and corrections and rehabilitation. non-governmental organizations are subsidized by public funds. the government gives non-contributory cash assistance to needy families, unemployed able-bodied adults, the severely disabled and the elderly. caseload as at aug. totalled , . victims of natural disasters, crimes of violence and traffic accidents are financially assisted. estimated recurrent government expenditure on social welfare for - was hk$ Á bn. in there were daily newspapers, of which were paid-for and four free. the newspapers with the highest circulation figures are all chinese-language papers-oriental daily news, apple daily and the sun. the english-language paper with the highest circulation is the south china morning post. circulation of dailies (including free papers) in was Á m. ( Á m. paid-for and Á m. free). there were a record , , visitor arrivals in . expenditure associated to inbound tourism totalled hk$ , Á m. in . the macao special administrative region, which lies at the mouth of the pearl river, comprises a peninsula ( Á sq. km) connected by a narrow isthmus to the people's republic of china, on which is built the city of santa nome de deus de macao, the islands of taipa ( Á sq. km), linked to macao by three bridges, colôane ( Á sq. km) linked to taipa by a -km causeway, and cotai, a strip of reclaimed land between colôane and taipa ( Á km). the total area of macao in was Á sq. km. additional land continues to be reclaimed from the sea. the population at the census was , ( , females); density, , people per sq. km. according to un estimates, the entire population lived in urban areas in . the official languages are chinese and portuguese, with the majority speaking the cantonese dialect. only about , people speak portuguese as their first language. the un gives a projected population for of , . in , , foreigners were legally registered for residency in macao. there were , legal immigrants from mainland china. social statistics : births, , ( Á per , population); deaths, , ( Á ); marriages, , ( Á ); divorces, , ( Á ). infant mortality, , Á per , live births. life expectancy at birth , Á years. sub-tropical tending towards temperate, with an average temperature of Á c. the number of rainy days is around a third of the year. average annual rainfall varies from - " ( , - , mm) . it is very humid from may to sept. macao's constitution is the 'basic law', promulgated by china's national people's congress on march and in effect since dec. . it is a special administrative region (sar) of the people's republic of china, and is directly under the central people's government while enjoying a high degree of autonomy. the legislative assembly has seats of which are directly elected, indirectly elected by functional constituencies and seven appointed by the chief executive. at the elections held on sept. the macau-guangdong union won two of elected seats with Á % of votes cast and the union for development two with Á %. ten other parties won a single seat each. turnout was Á %. fernando chui sai-on was re-elected chief executive for a second term on aug. , receiving out of votes in the election committee. chief executive: fernando chui sai-on; b. (sworn in dec. and re-elected in aug. . government website: http://www.gov.mo the gaming sector is of major importance to the economy of macao. it accounted for Á % of total gdp in and provides billions of dollars in taxes. in , Á % of the workforce was employed in gaming. in gross gaming revenue totalled us$ , m. (nearly double the figure) . however, revenues were down slightly on the total. macao overtook nevada as the world's largest gaming market in . macao's traditional manufacturing industries virtually disappeared following the transfer of much of the textile industry to the chinese mainland and, in , the termination of the multifibre arrangement, which had governed international textile trade flows for three decades. the unit of currency is the pataca (mop) of avos, which is tied to the hong kong dollar at parity. inflation was Á % in and Á % in . foreign exchange reserves were us$ , m. in . total money supply was , m. patacas in . in revenues totalled , m. patacas; expenditures, , m. patacas. revenues from gaming tax accounted for Á % of total revenue in ; current expenditure accounted for Á % of expenditure. real gdp growth was just Á % in but then rose to Á % in and Á % in . more recently the economy contracted by Á % in before growing by Á % in . total gdp in was us$ Á bn. environment macao's carbon dioxide emissions from the consumption of energy in were the equivalent of Á tonnes per capita. installed capacity was Á m. kw in ; production, Á bn. kwh. macao imported , m. kwh of electricity in . oil and gas , , litres of fuel oil were imported in . the catch in was estimated at , tonnes. although the economy is based on gaming and tourism there is a light industrial base of textiles and garments. in the number of manufacturing establishments was (food products and beverages, ; textiles and wearing apparel, ; publishing, printing and reproduction of recorded media, ). in a total of , people were in employment, including , ( Á %) in gaming and junket activities (up from , in ); , ( Á %), hotels, restaurants and similar activities; , ( Á %), construction; , ( Á %), wholesale and retail trade, repair of motor vehicles, motorcycles and personal and household goods; , ( Á %), real estate and business activities; , ( Á %), public administration and social security. employment in was Á % of the labour force; unemployment rate stood at Á %. in imports (c.i.f.) were valued at us$ , Á m., of which the main products were telecommunications, sound recording and reproducing equipment; petroleum and petroleum products; and gold, silverware, jewellery and articles of precious materials. in the chief import sources (in us$ m.) were: mainland china ( , Á ); hong kong ( Á ); japan ( Á ). exports (f.o.b.) were valued at us$ Á m., of which the leading products were articles of apparel and clothing accessories; gold, silverware, jewellery and articles of precious materials; and petroleum oils and oils obtained from bituminous minerals. in the main export markets (in us$ m.) were: hong kong ( Á ); usa ( Á ); mainland china ( Á ). in there were km of roads. in there were , passenger cars in use ( cars per , inhabitants), , buses and coaches, , trucks and , motorcycles. there were fatalities in road accidents in . a km bridge (the world's longest sea bridge) linking macao, zhuhai in guangdong province in mainland china and hong kong opened in oct. following a number of delays. an international airport opened in dec. . in macau international airport handled , , passengers and , tonnes of freight (including transit cargo). in air macau flew to bangkok, beijing, changsha, chengdu, chongqing, da nang, hangzhou, hefei, kaohsiung, nanjing, nanning, ningbo, osaka, quanzhou, seoul, shanghai, shenyang, taipei, taiyuan, tokyo, wenzhou, xiamen and zhengzhou. regular services connect macao with hong kong, km to the northeast. in there were , landline telephone subscriptions (equivalent to Á per , inhabitants) and , , mobile phone subscriptions (or , Á per , inhabitants). in , Á % of households had internet access. in march there were , facebook users. there are a judicial district court, a criminal court and an administrative court with magistrates in all. in there were , crimes, of which , were against property. there were persons in prison in dec. . there are both public and private schools. in - there were schools and colleges. number of students in the - academic year (with number of teachers): pre-primary, , ( ); primary, , ( , ); secondary, , ( , ). in - there were four special education schools with pupils and teachers. there were ten higher education institutions with student enrolment of , . in there were institutions offering vocational training courses, in which participants totalled , . expenditure on education came to Á % of gdp in and Á % of total government spending in . in there were doctors, dentists and nurses working in primary health care, and doctors, dentists and , nurses working in hospitals. in there were , hospital beds; there were Á doctors per , population. in there were an estimated , folk religionists and , buddhists according to the pew research center's forum on religion & public life. a further , people were religiously unaffiliated. there are also small numbers of catholics. the historic centre of macao was inscribed on the unesco world heritage list in . in there were daily newspapers (nine in chinese, three in portuguese and two in english) and weekly newspapers (ten in chinese and one in portuguese). tourism is one of the mainstays of the economy. in there were Á m. tourists (of which Á m. were from mainland china, Á m. from hong kong and Á m. from taiwan), up from Á m. in and Á m. in . visitor spending in totalled , m. patacas. the government-run macao international music festival featuring a wide range of chinese and western music takes place in oct.-nov. in july president lee teng-hui repudiated taiwan's -year-old 'one china' policy-the pretence of a common goal of unification-arguing that taiwan and china should maintain equal 'state to state' relations. this was a rejection of beijing's view that taiwan is no more than a renegade chinese province which must be reunited with the mainland, by force if necessary. in the presidential election of march chen shui-bian, leader of the democratic progressive party, was elected, together with annette lu hsiu-lien as his vice president. both supported independence although chen shui-bian made friendly gestures towards china and distanced himself from colleagues who wanted an immediate declaration of independence. following his wife's indictment on embezzlement charges in nov. , president chen survived three parliamentary attempts to impeach him. he was succeeded as president in by ma ying-jeou of the nationalist party. in sept. chen shui-bian received a life sentence (later reduced to a -year term) after being found guilty of multiple counts of corruption. china and taiwan signed a free trade agreement in june , which was considered a significant thawing of relations. nonetheless, tensions remained, particularly in relation to disputed sovereignty over several islands in the east china sea. in jan. ma ying-jeou was re-elected to the presidency but the election in jan. was won by tsai ing-wen, whose democratic progressive party won the most seats in legislative polls at the same timethe first occasion that the nationalist party has not been the largest party in government since . the climate is subtropical in the north and tropical in the south. the typhoon season extends from july to sept. the average monthly temperatures of jan. and july in taipei are Á f ( Á c) and Á f ( Á c) respectively, and average annual rainfall is Á " ( , Á mm). kaohsiung's average monthly temperatures of jan. and july are Á f ( Á c) and Á f ( Á c) respectively, and average annual rainfall is Á " ( , Á mm). the roc constitution is based on the principles of nationalism, democracy and social wellbeing formulated by dr sun yat-sen, the founding father of the republic of china. the roc government is divided into three main levels: central, provincial/municipal and county/city, each of which has welldefined powers. the central government consists of the office of the president, the national assembly, which is specially elected only for constitutional amendment, and five governing branches called 'yuan', namely the executive yuan, the legislative yuan, the judicial yuan, the examination yuan and the control yuan. beginning with the elections to the seventh legislative yuan held on jan. the legislative yuan has members (formerly ). of the members are elected under the first-past-the-post system in singlemember constituencies, are filled by proportional representation in accordance with a nationwide party vote and six are reserved for aboriginal candidates. since the president has been directly elected. since a resolution on the impeachment of the president or vice president is no longer to be instituted by the control yuan but rather by the legislative yuan. the legislative yuan has the power to pass a no-confidence vote against the premier of the executive yuan, while the president of the republic has the power to dissolve the legislative yuan. the premier of the executive yuan is directly appointed by the president of the republic. in dec. a law came into effect allowing for referendums to be held. professional force-a process that was originally scheduled to start in and end in but has been delayed owing to low recruitment levels. defence expenditure in totalled us$ , m. (us$ per capita), representing Á % of gdp. the republic of china army conducts ground combat missions as well as air support and airborne special operations. it was estimated to number about , personnel in , with reserves numbering Á m. its principal role is to defend against a possible amphibious assault from the chinese mainland by the people's liberation army. in addition there are paramilitary forces totalling , personnel. navy personnel in totalled , , with , reservists. the forces consist of four submarines, four cruisers and frigates. there are also missile craft for patrol and coastal defence, mine-laying vehicles and amphibious landing craft. in the air force numbered , personnel with , reservists. there were combat-capable aircraft in the same year including f- es, f- s and mirage - s. taiwan has made a successful transition from an agricultural economy to one based on high-tech electronics. economic growth averaged % per year over three decades from the s, driven primarily by high value-added manufacturing and exports, especially in electronics and computers. government-owned enterprises, including banks, have been privatized. though largely escaping the impact of the asian financial crisis, the economy went into recession in with the first year of negative growth ever recorded and unemployment reaching record highs. strong export performance stimulated a recovery, with annual gdp growth above % from - . inflation has been consistently low and unemployment, which fell below % in , has averaged between and % since the turn of the century. owing to its heavy dependence on exports, taiwan suffered a severe downturn as a result of the global financial crisis in . major export industries such as semiconductors and memory chips declined, unemployment reached its highest levels since and, in , the economy again went into recession. a us$ Á bn. stimulus package boosted recovery and in the economy recorded its highest growth rate for nearly three decades, at Á %. however, growth subsequently cooled owing to lower demand from developed nations, averaging Á % per year between and . tourism has grown in importance, with over Á m. visitors in constituting taiwan's highest annual number to date. an ageing population and high savings rates threaten to constrain domestic demand in the future. the unit of currency is the new taiwan dollar (twd) of cents. gold reserves were Á m. oz in dec. . there was inflation of Á % in and Á % in . foreign exchange reserves were us$ Á bn. in dec. . in general government revenues totalled nt$ , , m. and expenditures nt$ , , m. tax revenue accounted for Á % of revenues in ; education, science and culture accounted for Á % of expenditures, economic development Á % and general administration Á %. vat is %. taiwan sustained rapid economic growth at an annual rate of Á % from up to . the rate slipped to Á % in the s and Á % in ; taiwan suffered from the asian financial crisis, though less than its neighbours. in global economic sluggishness and the events of sept. in the usa severely affected taiwan's economy, which contracted by Á %. subsequent economic recovery led to growth of Á % in and Á % in . there was negative growth of Á % in but again the economy bounced back, and grew by Á % in and Á % in . the central bank of the republic of china (taiwan), reactivated in , regulates the money supply, manages foreign exchange and issues currency. the governor is yang chin-long. the bank of taiwan is the largest commercial bank and the fiscal agent of the government. there are seven domestic banks, commercial banks and foreign banks. there are two stock exchanges in taipei. taiwan's carbon dioxide emissions from the consumption of energy in were the equivalent of Á tonnes per capita. output of electricity in was Á m. mwh; total installed capacity was , mw. there were six units in three nuclear power stations in . crude oil production in was , bbls; natural gas, m. cu. metres. taiwan imports most of the oil and natural gas that it consumes. in the cultivated area was , ha., of which , ha. were paddy fields. rice production totalled , , tonnes. livestock production was valued at nt$ , m., accounting for % of taiwan's total agricultural production value. forest area, : , , ha. forest reserves: trees, , , cu. metres; bamboo, , m. poles. timber production, , cu. metres. the catch in was , tonnes, almost exclusively from sea fishing. the largest companies in taiwan by market capitalization in march were: taiwan semiconductor manufacturing (us$ Á bn.); hon hai precision industry, an electronics manufacturer (us$ Á bn.); and chunghwa telecom (us$ Á bn.). output (in tonnes) in : crude steel; Á m.; cement, Á m.; cotton fabrics, Á m. sq. metres; integrated circuit packages, Á trn. units; global positioning system (gps) sets, Á bn. units. in the average total labour force was Á m., of whom Á m. were employed. of the employed population, Á % worked in manufacturing; Á % in wholesale and retail trade; Á % in construction; Á % in accommodation and food services; Á % in education; Á % in agriculture, forestry and fisheries. the unemployment rate was Á %. in there were , km of roads. in , Á m. passenger cars, , buses and coaches, Á m. lorries and vans, and Á m. motorcycles and mopeds were in use. , m. passengers and m. tonnes of freight were transported in . there were , fatalities in road accidents in . in freight traffic amounted to Á m. tonnes and passenger traffic to m. total route length was , km. there are metro systems in taipei (opened in ) , kaohsiung (opened in ) and taoyuan (opened in ). there are currently two international airports: taiwan taoyuan international airport at taoyuan near taipei, maritime transportation is vital to the trade-oriented economy of taiwan. in jan. there were ships of gt or over registered, totalling Á m. gt. of the vessels registered, were general cargo ships, bulk carriers, container ships, oil tankers and nine passenger ships. there are six international ports: kaohsiung, keelung, taichung, hualien, anping and suao. the first three are container centres, kaohsiung handling Á m. -ft equivalent units in , making it the world's th busiest container port in terms of number of containers handled. suao port is an auxiliary port to keelung. in jan. the first legal direct shipping links between taiwanese islands and the chinese mainland in more than years were inaugurated. in there were , , landline telephone subscribers ( Á per , inhabitants). taiwan's biggest telecommunications firm, the stateowned chunghwa telecom, lost its fixed-line monopoly in aug. . in there were , , mobile phone subscriptions, equivalent to , Á per , persons. in there were Á mobile broadband subscriptions per inhabitants and Á fixed broadband subscriptions per inhabitants. in march there were Á m. facebook users. the judicial yuan is the supreme judicial organ of state. comprising grand justices, since these have been nominated and, with the consent of the legislative yuan, appointed by the president of the republic. the grand justices hold meetings to interpret the constitution and unify the interpretation of laws and orders. there are three levels of judiciary: district courts and their branches deal with civil and criminal cases in the first instance; high courts and their branches deal with appeals against judgments of district courts; the supreme court reviews judgments by the lower courts. there is also the supreme administrative court, high administrative courts and a commission on the disciplinary sanctions of public functionaries. criminal cases relating to rebellion, treason and offences against friendly relations with foreign states are handled by high courts as the courts of first instance. the death penalty is still in force. there were no executions in but there was one in . the population in penal institutions in april was , ( per , of national population). since there has been compulsory education for six to -year-olds with free tuition. the illiteracy rate dropped from Á % in to Á % by . there were , primary schools, , secondary schools and vocational schools in ; and universities, colleges and junior colleges. in - there were , , pupils with , teaching staff at elementary schools; , pupils and , teaching staff at junior high schools; , pupils and , teaching staff at senior high schools; and , students and , teaching staff at senior vocational schools. there were , , students in universities and colleges in - with , academic staff. in there were , physicians (one for every persons), , doctors of chinese medicine, , nurses, , dentists and assistants, and , pharmacists and assistants. in there were , medical facilities serving , persons per facility; there were , beds and Á beds per , persons. in cancers, heart diseases, cerebrovascular diseases, diabetes and accidents were the first five leading causes of death. a universal health insurance scheme came into force in as an extension to social insurance plans that cover only % of taiwan's population. premium shares among the government, employer and insured are varied according to the insured statuses. by the end of , Á m. people or % of the population were covered by the national health insurance programme. according to estimates by the pew research center's forum on religion & public life, Á % of the population in were folk religionists, Á % were buddhists and Á % christians. the remainder of the population was either religiously unaffiliated or followed other religions, including taoism. there were daily newspapers in with a circulation of Á m. and non-dailies with a circulation of Á m. the biggest circulation dailies are the liberty times and apple daily. in there were , , international visitors. receipts totalled us$ , m. the pop festival, spring scream, is held in april in kenting. xinjiang tianshan ( ), a mountainous site comprising four components covering , ha. and an important habitat for endemic and relic flora species, the grand canal ( ), a vast waterway system running from beijing to zhejiang, tusi sites ( ), the remains of tribal domains whose leaders were appointed by the central government as 'tusi', hereditary rulers of their regions from the th to the early th century, located in southwest china prime minister and president of the executive yuan: su tseng-chang vice premier: chen chi-mai. there are ministries under the executive yuan: culture; economic affairs; education; finance; foreign affairs; health and welfare; interior; justice; labour; national defence; science and technology minister of culture: cheng li-chiun examples include the mongolian and tibetan affairs commission; the mainland affairs council; the fair trade commission; the public construction commission; and the financial supervisory commission. some of these are headed by ministers without portfolio (see above). other commissions, councils and agencies are headed by: council of agriculture: chen chi-chung mainland affairs council: chen ming-tong. national communications commission: chan ting-i. ocean affairs council: lee chung-wei. overseas community affairs council: wu hsin-hsing. directorate general of personnel administration: shih ning-jye. transitional justice commission (acting): yang tsui. veterans' affairs council: chiu kuo-cheng china in world history chinese politics in the age of deng xiaoping china and the global political economy china: the rise of xi jinping the cambridge encyclopaedia of china the cambridge history of china. vols the politics of hong kong's reversion to china the european union and china the chinese economy under transition china this century the tragedy of liberation: a history of the chinese revolution china: a modern history china's deep reform: domestic politics in transition chinese capitalism deng xiaoping and the making of modern china the great chinese revolution - the politics of eu-china economic relations china's second continent: how a million migrants are building a new empire in africa china in transition: communism, capitalism and democracy sowing the seeds of democracy in china: political reform in the deng xiaoping era historical dictionary of the chinese cultural revolution how the chinese economy works the rise of modern china china: a macro history tombstone: the untold story of mao's great famine china's economy: what everyone needs to know all under heaven: a complete history of china chinese politics in the hu jintao era: new leaders, new challenges the people's republic of amnesia: tiananmen revisited chinese foreign policy in a changing world chinese economy in the s the politics of china: sixty years of the people's republic of china the party: the secret world of china's communist rulers. .-asia's reckoning: china, japan and the fate of us power in the pacific century china's war with japan, - : the struggle for survival social and political development in post-reform china age of ambition: chasing fortune, truth and faith in the new china a revolutionary life at the crossroads of post-communist modernisation: russia and china in comparative perspective a history of china wealth and power: china's long march to the twenty-first century mao's road to power: revolutionary writings - . vols china goes global: the partial power the chinese century: the rising chinese economy and its impact on the global economy, the balance of power, and your job the china-pakistan axis: asia's new geopolitics the chan's great continent: china in western minds eldest son, zhou enlai and the making of modern china china in the xi jinping era india's and china's recent experience with reform and growth critical issues in contemporary china making china strong tide players: the movers and shakers of a rising china other more specialized titles are listed under territory and popula-tion; tibet; agriculture . commissioner: ning jizhe information: the census and statistics department is responsible for the preparation and collation of government statistics. these statistics are published mainly in the hong kong monthly digest of statistics. the department also publishes monthly trade statistics, economic indicators and an annual review of overseas trade hong kong's transitions the politics of hong kong's reversion to china the end of hong kong: the secret diplomacy of imperial retreat the hong kong story the final years of british hong kong: the discourse of colonial withdrawal last post: the end of empire in the far east the politics of democratization in hong kong historical dictionary of hong kong and macau china: a political history of the british crown colony's transfer to chinese rule managing china's sovereignty in hong kong and taiwan macau, the imaginary city: culture and society, to the present taiwan statistical yearbook of the republic of china. annual. the republic of china yearbook. annual. taiwan statistical data book. annual. annual review of government administration the other taiwan: to the present day historical dictionary of taiwan national identity and status in international society taiwan's political re-alignment and diplomatic challenges managing china's sovereignty in hong kong and taiwan the shadow of china: political developments in taiwan since . national library: national central library key: cord- - ayjej authors: zaki, jamil title: catastrophe compassion: understanding and extending prosociality under crisis date: - - journal: trends cogn sci doi: . /j.tics. . . sha: doc_id: cord_uid: ayjej abstract how do people behave when disasters strike? popular media accounts depict panic and cruelty, but in fact, individuals often cooperate with and care for one another during crises. i summarize evidence for such “catastrophe compassion,” discuss its roots, and consider how it might be cultivated in more mundane times. in the aftermath of hurricane katrina, news reports suggested the natural disaster had quickly been followed by a human one. unchecked by law enforcement, new orleanians had apparently committed countless brazen crimes [ ] . the new york times described the city as a "snake pit of anarchy, death, looting, raping, marauding thugs." i these harrowing stories shaped authorities' reaction to the crisis-for instance, deploying the national guard to "take control" of the city, rather than focusing on humanitarian relief. the stories were also inaccurate. though crime did occur in new orleans following katrina, victims by and large remained peaceful, and many helped one another [ , ] . for decades, social scientists have documented two narratives about human behavior during crises. the first holds that following disasters, individuals (i) panic, (ii) ignore social order, and (iii) act selfishly. this cluster of beliefs characterizes popular media accounts of disaster, as well as lay forecasts. in one study, members of the public generally agreed with statements including "when there is an emergency, crowd members act selfishly," and "when there is an emergency, social order breaks down." agreement further tracked support for "coercive" handling of disaster by authorities, such as keeping the public uninformed. interestingly, police officers-who presumably have more experience with people in crisiswere significantly less likely to agree with these statements [ ] (please see supplementary materials for additional references). the second narrative comes from historical records. far from rendering people antisocial and savage, disasters produce groundswells of prosocial behavior and feelings of community. in their wake, survivors develop communities of mutual aid, engage in widespread acts of altruism, and report a heightened sense of solidarity with one another [ , , ] . unaffected people, too, j o u r n a l p r e -p r o o f descend on scenes of disasters to volunteer, as well as flood them with donations and volunteers, a phenomenon known as "disaster convergence" [ ] . i will refer to positive social behaviors in the face of negative circumstances as catastrophe compassion. catastrophe compassion is widespread and consistent; it follows earthquakes, war, terrorist attacks, hurricanes, and tsunamis, and-now-a pandemic. as covid- spreads, communities around the world have created "mutual aid spreadsheets" to help vulnerable neighbors [ ] and billions of people have engaged in physical distancing to protect public health-perhaps the most populous act of cooperation in history. consistent with its prosocial nature, one recent study found that people expressed greater intent to follow distancing when it was framed as a way to help others, rather than protect themselves [ ] . in addition to being prevalent, catastrophe compassion appears beneficial. prosocial behavior exerts positive effects on helpers-including increases in happiness and decreases in stress and loneliness. following disasters, mutual aid also tracks increases in positive collective outcomes, such as social connection, solidarity, and shared resilience [ ] . psychologists have pinpointed a number of mechanisms that might underlie catastrophe compassion. one pertains to the powerful nature of social identity. each of us identifies with multiple groups, for instance based on our generation, ideology, and profession, and commonly expresses loyalty, care, and prosociality towards members of our own groups. social identity is also malleable. you might be an ohioan and a tuba player, but those identities will vary in salience depending on whether you're at band practice or a buckeyes game. even new identities created in a lab can take on importance, and shift one's tendency to j o u r n a l p r e -p r o o f act prosocially towards people in novel groups. identities also tend to matter most when they contain certain characteristics, including shared goals and shared outcomes. when disasters strike, victims might suddenly be linked in the most important de novo groups to which they've ever belonged. strangers on a bus that is bombed might experience a visceral, existential sense of shared fate, and might thus quickly not be strangers any longer-but rather collaborators in a fight for their lives. as described by drury [ ] , an elevated sense of shared identity is indeed common to disaster survivors, and a potent source of cooperative behavior. a second source of catastrophe compassion is emotional connection. empathy-sharing, understanding, and caring for others' emotional experiences-predicts prosocial behavior across a range of settings. consistent with this connection, a recent study found that individuals' empathy for those affected by the covid- pandemic tracked their willingness to engage in physical distancing and related protective behaviors, and that inducing empathy for vulnerable people increased intention to socially distance [ ] . emotional connection can also comprise mutual sharing of affect across people. after disclosing emotional experiences with each other, individuals tend to feel more strongly affiliated to one another. such disclosures are also a powerful way to recruit supportive behavior in during difficult times and thus buffer individuals against stress [ ] . however, individuals often avoid disclosing negative experiences-for instance because they imagine others will judge or stigmatize them-and thus miss out on the benefits of affect sharing [ ] . disasters thrust people into a situation where their suffering is obviously shared with others. this could in turn lower psychological barriers to disclosure, thus creating opportunities for deeper connection, mutual help, and community. consistent with this idea, in the wake of the j o u r n a l p r e -p r o o f loma prieta earthquake, individuals frequently talked about the disaster and its effects on them for about two weeks [ ] . a similar elevation in emotional conversations was found among spaniards following a terrorist bombing in madrid [ ] . researchers further found that that sharing one week after the attacks predicted increases in solidarity, social support, as well as decreases in loneliness, seven weeks later. as solnit [ ] observes, although few people would want a disaster to befall them, many survivors look back on disasters with a surprising amount of nostalgia. floods, bombings, and earthquakes are horrific, but in their aftermath individuals glimpse levels of community, interdependence, and altruism that are difficult to find during normal times. then, normal times return, and often so do the boundaries that typically separate people. might catastrophe compassion outlast catastrophes themselves, and if so, how? some suggestive evidence emerges from the study of individuals who endure personal forms of disaster-adverse events such as severe illness, family loss, and victimization by crime. such adversity often generates increases in prosocial behavior, which staub and vollhardt [ ] have termed "altruism born of suffering." positive effects of adversity appear to extend in time. for instance, individuals' experience of lifetime adversity reportedly tracks their willingness to help strangers and their ability to avoid "compassion collapse," by maintaining empathy even in the face of numerous victims [ ] . interestingly, this latter effect is partially explained by an increased sense of efficacy (i.e., the belief one can make a difference) among people who have endured high levels of adversity. further, experimentally inducing people to believe in their own efficacy to make a difference for j o u r n a l p r e -p r o o f others increases their compassion in the face of mass suffering [ ] . though speculative, it is possible that during disasters, people witness their own prosocial efficacy firsthand, because the others they help are highly visible-neighbors, friends, victims on whom a spotlight has been shone. as such, highlighting prosocial efficacy in non-disastrous times, by making the targets and effects of helping more visible, could extend individuals' willingness to help beyond disaster contexts. one way to do this is to reify and formalize communities of disaster survivors, so that they can remain visible to each other, and salient to survivors' identity. many such communities already exist-for instance in peer counseling associations that connect and support people who have endured addiction, or lost loved ones to war, or been victims of assault. broader groups, too, often emphasize remembrance of disasters, for instance when cultural rituals and practices commemorate a culture's experience of hardship as a way of bonding individuals and generations. another way to extend catastrophe compassion is to simply remember it, and what it reveals about human social behavior. when people believe others will "go rogue" following disasters, they are expressing one flavor of a more general, dim view of their fellow citizens. individuals tend to be unduly cynical about human nature, for instance demonstrably overestimating the extent that people are driven by self-interest [ ] . cynicism tracks decreases in psychological well being, and can also become self-fulfilling, for instance when people conform to a selfish norm, they erroneously believe others are following. metaphors matter: disaster myths, media frames, and their consequences in hurricane katrina a paradise built in hell: the extraordinary communities that arise in disaster psychological disaster myths in the perception and management of mass emergencies can war foster cooperation social sharing, participation in demonstrations, emotional climate, and coping with collective violence after the march th madrid bombings how to help people during the pandemic, one google spreadsheet at a time don't get it or don't spread it? comparing selfinterested versus prosocially framed covid- prevention messaging the role of social identity processes in mass emergency behaviour: an integrative review the emotional path to action: empathy promotes physical distancing during the covid- pandemic interpersonal emotion regulation: implications for affiliation, perceived support, relationships, and well-being beautiful mess effect: self-other differences in evaluation of showing vulnerability a social stage model of collective coping: the loma prieta earthquake and the persian gulf war altruism born of suffering and prosocial behavior following adverse life events: a review and conceptualization the norm of self-interest key: cord- - cl jll authors: stanley, phiona title: problematizing “activism”: medical volunteer tourism in central america, local resistance, and academic activism date: - - journal: int rev qual res doi: . / sha: doc_id: cord_uid: cl jll this paper critically examines epistemological, ontological, and axiological tensions of activism in three related contexts. these are, first, (primarily medical) volunteer tourism ideologies and practices in central america, including u.s.-american teenagers volunteering in medical centers where, entirely untrained, they do sutures and injections, deliver babies, and help with amputations. second, the paper considers and critiques local norms (e.g., widespread homophobia) and materials (e.g., the use of short-handled agricultural hoes) that may be discursively constructed as resistance to western imperialism. finally, the critique turns back on the researcher gaze itself, problematizing the notion of academic activism in spaces, like these, where criticality itself is an imported—arguably luxurious—folly. local people, it is apparent, do not want convoluted theorizing or western hand-wringing; they want proper medical care. the paper therefore considers the extent to which academic work in such spaces can call itself activism at all. three years of ethnographic research inform the paper ( – , predominantly in guatemala and nicaragua), including hundreds of hours of interviews and participant observational fieldwork, in spanish and english, with local stakeholders (e.g., teachers and homestay hosts) and western volunteer tourists. the paper is theorized with reference to postcolonial theory, critical medical ethics, and liberation theology. when can a film be considered obscene? and/or when is banning that film an infringement of people's rights? this matters in the unites states, as the first amendment explicitly protects the freedom of speech. but if these rights are to be upheld, a semantic boundary needs to be drawn around obscenity, determining precisely which freedoms are, and are not, protected. it was for this reason, in , that the supreme court ruled on the jacobellis vs. ohio case. nico jacobellis, a cinema manager, had been fined for showing the louis malle film les amants; the state of ohio had deemed the film obscene. but was it? and, if so, how was "obscenity" to be defined? previously, the supreme court had upheld a deductive ruling (in the , roth vs. united states case), defining obscenity as material where the "dominant theme, taken as a whole, appeals to the prurient interest" of the "average person, applying contemporary community standards." (and later, in miller vs. california , it would overturn the jacobellis vs. ohio ruling with another deductive definition.) but the case was different-and intellectually of great interest-as it relied on inductive (or, arguably, abductive; mingers, ) rather than deductive reasoning. in the case, justice potter stewart ruled: [u] nder the first and fourteenth amendments, criminal laws in this area are constitutionally limited to hard-core pornography. i shall not today attempt further to define the kinds of material i understand to be embraced within that shorthand description, and perhaps i could never succeed in intelligibly doing so. but i know it when i see it, and the motion picture [les amants] involved in this case is not that. (justia, ) stewart's line, now famous, "i know it when i see it," applied in this case to pornography. but might it equally apply to activism as used in both popular and academic discourses. what is activism? can we define it? or is it just that we "know it when we see it"? in problematizing the definition of activism, this paper presents three linked cases in which self-professed activists each claim to be doing activism. at issue is the fact that their activisms are contradictory in both their goals and their effects. logically, then, not all can be doing activism, if activism is definable by its aims and/or its effects. but perhaps it is not. perhaps it is enough to have goodwill-to be "helping"-however vaguely conceptualized. (although, see tilley-lubbs [ ] ) for a critique of well-intentioned activism that had deleterious effects.) the three cases described in this article thus present a quandary. if all are examples of activism, it is necessary to trouble the notion of what activism actually is. can it be defined by its aims? its effects? and/or a vague sense of goodwill? or is it necessary to rely on an inductive definition: that we know it when we see it? this is how the term seems to be used in both popular discourse and also in scholarly accounts. for example, mendes ( ) studied feminist activism, boykoff ( ) studied olympics-protest activism, kirshner ( ) studied youth activism, carter ( ) studied environmental activism, and reynolds and cohen ( ) studied urban farming as activism, and yet none troubled the construct of activism itself. but if we rely on an inductive construction-the assumption that we know activism when we see it-it is also necessary to trouble the "we" that is doing the perceiving. does activism necessarily invoke a progressive politics, and, if so, how is this to be defined? or is it still "activism" if it is the alt-right that perceives the objective as desirable social change? can we, for example, call it "activism" when swedish farright organizations spread hate on youtube (e.g., farmer, ) ? can we describe as "activists" those who participate in ku klux klan and neo-nazi groups in the united states, including an anti-jewish movement called "ss warriors" (blee, ) ? and how might we describe the english defense league, an organization mobilized "around a core narrative of the threat posed by 'militant islam' to the uk and more generally the west" (busher, ) ? in each of the scholarly accounts, these groups are termed "activists." but if any and all social-change goals are the legitimate target of "activism," does the term retreat from usefulness, becoming a catch-all for any and all impassioned or vaguely "helpful" activities-per the paradigm of the in-group itselfthat can be wrapped up in "activism" to confer legitimacy? this paper teases out these theoretical issues through the following examples. first, i examine foreign volunteer workers in central america. second, i consider local people's resistencia [resistance] to what they perceive as foreigners ignorantly interfering in local practices. in particular, i focus on untrained "nonmedics" (section titled "nonmedics"), contested values (section titled "values"), and the short-handled agricultural hoe (section titled "el cortito"). these are contested spaces offering rich conceptual pickings. against a potent, recent, and very bloody history of u.s. cultural imperialism in guatemala, western sojourners and their local hosts array themselves along a continuum of positions, from wishing to invite/impose u.s. norms and practices (under rubrics of "helping" and "expertise") to subscribing to (agri)cultural relativism and not wishing to exacerbate axiological violence through the adoption/ imposition of foreign ways. finally, i briefly consider academic activism (section titled "academia"), and the capacity-or otherwise-of academic work to effect change. before this is possible though, it is necessary to examine the postcolonial historical context (in the following section) and volunteer tourism-sometimes referred to in its portmanteau form, voluntourism-both as a phenomenon and as a discourse community (section titled "volunteers"). it is also worth noting that this conceptual paper is not intended as an ethnography in its own right. instead, it draws upon interpretive data already presented and analyzed in a book-length study (stanley, ) for the purpose of problematizing tensions and issues within activism. for this reason, a complete methodological account is not repeated here. in brief, though, the study from which the data excerpts are drawn was based on weeks of participant research over a -year period ( - ) among western sojourners engaging in volunteer projects, learning spanish, and/or staying in host families in guatemala and nicaragua. one hundred and twenty people participated directly in the study-in interviews and focus groups-including ngo directors, teachers, homestay hosts, spanish-language students, and volunteer workers. the nationality breakdown of the interviewees was as follows: u.s.-americans, guatemalans, europeans (from the uk, netherlands, denmark, italy, germany, and switzerland), eight nicaraguans, five canadians, and three australians. in total, the study was based on hr of interview recordings and pages of field notes. its data were coded and analyzed inductively, following the principles of constructivist grounded theory (charmaz, ) . everything in latin america starts with history and politics. and ancient and modern, these are histories covered in blood: latin america is the region of open veins. everything, from discovery until our times, has always been transmuted into european-or later united states-capital, and as such has accumulated in distant centers of power. everything: the soil, its fruits and its mineralrich depths, the people and their capacity to work and to consume, natural resources and human resources. production methods and class structure have been successively determined from outside…always for the benefit of the foreign metropolis of the moment. (galeano, , p. ) five hundred years after the sinking of european teeth into indigenous throats, latin america still lives the open veins of colonization. so much blood. so much death. first, there was the spanish conquest, and then, for hundreds of years, there was exploitation. independence came, but by the s, all that had changed was the master (booth et al., ) . by , the united fruit company was the largest employer in central america and the biggest landowner in guatemala. from , years of "springtime" came under land-reforming presidents arévalo and Árbenz. unused united fruit company lands were nationalized, and workers gained a few rights. but the united fruit company, friends with the u.s. government, felt aggrieved. and to the united states, this looked way too much like a worker's revolution. so, the cia overthrew Árbenz and installed a military dictator. and over the next years, , people were massacred, the majority of them indigenous, mayan civilians killed by government paramilitaries. more blood. more death (grandin et al., ) . nicaragua's story is slightly different, but it starts the same: the conquista [conquest] and foreign exploitation. but then, in the s and again in , the people's protests worked, to some extent. again, they rose up against a u.s.-funded puppet and even though the sandinistas-the nicaraguan revolutionaries-celebrated victory in , the civil war dragged on through the s, killing about , people. more blood. more death (wade & walker, ) . but even through the civil war, the sandinista government improved literacy, health care, workers' rights, and education, and they did this, in part, thanks to the brigadas internacionalistas, the international brigades. foreign doctors, teachers, engineers, and agriculturalists came, this time to help. they came from europe, the united states, and elsewhere in latin america: che guavara was an internacionalista, a medical doctor from argentina who helped the revolution in guatemala in before moving on to cuba, the congo, and (finally, fatally) bolivia. so, there's a history, here, of international helpers (wade & walker, ) . western volunteers still come. nowadays, they talk about "doing development" or "aid work" rather than social justice or overthrowing tyrants. they don't talk about liberation theology (e.g., gutiérrez, ) or structural violence (after galtung, ) in the gringo bars of central america, like they did in the s (e.g., unferth, ) . now, they channel angelina jolie and the white-savior optics of instagram, blaming bad luck and corrupt local politicians, blind to their own complicity in an international system of greed. the volunteers describe "helping out," as if their presence-a few crumbs from their table-can change a global economic system designed and perfected in their favor. let us not forget: [t]he poor person does not exist as an inescapable fact of destiny. his or her existence is not politically neutral and is not ethically innocent. the poor are a by-product of the system in which we live and for which we are responsible. they are marginalized by our social and cultural world. they are the oppressed, exploited proletariat, robbed of the fruit of their labor and despoiled of their humanity. hence the poverty of the poor is not a call to generous relief action, but a demand that we go and build a different social order. (gutiérrez, , p. ) but the westerners don't call themselves brigadistas anymore. now, they are voluntourists, or just tourists, often backpackers, and sometimes students of spanish, usually staying in homestays, and sometimes learning local crafts. and just as central america provided bananas, because that's what the international system wanted, now it provides voluntourism. in developing-world playgrounds, young westerners play identity games, reinscribing old colonial relationships. instead of extracting cotton, sugar, and slaves, the colonizer now extracts character-building challenges on which young people might cut their teeth. otherwise, little has changed. whole industries have sprung up in central america selling formative experiences to young gringos. goudge ( , p. ) writes: [volunteer work provides] a chance to improve one's career prospects by cutting one's teeth on 'unusual' challenges.…this is a continuation in a different guise of the old colonial relationship whereby colonies were regarded as essential providers of what the 'mother country' needed and desired. only in those days it was slaves, sugar and cotton rather than character-building safari adventures. the volunteers are still changing lives, but now it's mainly their own. this is to say that a codependent relationship still exists, in which central american tourism accommodates longer-term sojourners engaged in various activities that, arguably, serve the needs of the sojourners more than they do the local people. but the tourism industry matters enormously to local economies, too. tourism contributes . % of nicaraguan gross national product, for example, and provides almost , people's livelihoods (world travel and tourism council, ) . this codependency is thus still one in which power is tilted heavily in favor of those from outside, and as galeano argues (above), latin america is (still) a region of open veins, its resources transmuted into, determined from, and accumulated in distant centers of power for the benefit of the foreign metropolis of the moment. but this is not the discourse within which volunteer tourism is undertaken. instead, social imaginaries of "helping," "authenticity," and "fun" permeate volunteers' own descriptions of their activities and also the advertising that allows them to find opportunities. all over the gringo press in central america, you see ads in english for volunteer jobs. here's one: "weekend staff at black cat hostel. free food, cheap drinks. months minimum commitment. … evening and weekend bar staff needed at the old school bar. guaranteed fun. give josé a call" (xela who magazine, june ). here is another: "put your education to use by teaching at the community center! … support education [for] over kids in need in the community" (kamalbe poster, shown in stanley, , p. ) . other ads offer volunteer projects in coffee farms, kindergartens, and even a domestic violence shelter. why, i ask the gringos working here, why do they think people hire them, the gringos rather than the locals? and one tells me: i got a job as a waitress. i joined a band. like, either one i wasn't qualified to do in the us.… here, i literally just walk up to people and [i'll] be like, 'hey i think you need a waitress', 'alright', 'good, that's me'.…i'm also very go getter, yeah, and i'm very active and have a lot of ideas. so maybe that's partially just me. i think, yeah, there's just a lot of opportunities to start working on projects [here] .…i think [local people] could [do the same] if they wanted to, yeah. (a participant-pseudonym "amber"-cited by stanley, , p. ) let us be clear. this volunteer cannot do what che guevara did; she's not a doctor. but she is go-getting and active, and she has lots of good ideas. local people could do this too, if they wanted to. if they wanted to. the problem is, seemingly, that they don't have good ideas and they're not go-getter enough. and also: they can't afford to work for free. and perhaps volunteer tourists' whiteness confers on a bar or a band the cachet of gringo approval. but is this participant uniquely blind to her own positioning? should we blame her? i don't think so. along with so many others, this participant is part of a wider discourse in which "helping" irreducibly constructs the "helped" as rather helpless. this is well documented in critiques of "development" (e.g., farmer, ) and is a position that permeated the narratives of almost all the volunteers interviewed for this study. am i therefore shooting fish in a barrel by citing and then critiquing these participants, embedded as they are in a paradigm of which i am critical? do i seduce and betray them, building trust and then breaking it down as i re-present them as nasty imperialists? i hope not. my view is that they are not to blame. instead, they are part of a system that is to blame, and also one in which we are all complicit, particularly those of us who work in center-west education. as long as our medical schools value prequalification experience of dubious ethical standing, premed students will seek out opportunities to practice on human beings in the majority world (stanley, , pp. - ) . and as long as employers and colleges value (and in some cases, even promote and even give credit for) volunteer tourism, it will thrive. so, when their quotes are read from outside the volunteer-tourism discourse community (as i and presumably some readers are doing), the participants sound naïve (at best) and actively harmful and neoimperialist (at worst). but then does critiquing their discourses fall into precisely the trap of "academic activism" described in the "academia" section? is there a risk, here, of axiological and epistemological imperialism of our own, in which our morally superior, more "woke" discourses trump those of naïve volunteer tourists who are gamely trying to "help"? herein is part of the paradox that even this paper itself may problematically be part of academic activism. this discussion continues in the "academia" section. but some voluntourism is even more harmful and here-i'm sorry-we come back to blood: i was talking to someone who was in the process of applying to medical school, and he was like, 'you're going on an international volunteer trip for medicine?' i said, 'yeah, i'm really excited'. he was like, 'yeah, i helped deliver a baby my first day [in guatemala]. i literally landed and i went to the clinic and i did that. then i performed a pap smear, too'. a man, an american male, doing that to …a guatemalan woman. there's just so many different …lines that are crossed and a lack of understanding between those two parties. (nadia, early twenties, usa, cited by stanley, , p. ) the first week [in the clinic in masaya, nicaragua] was even more intimidating because spanish was so difficult because they talk so fast, and it's all so chaotic.…they assumed that we were doctors. so, i guess they thought we were stupid.…to work there you had to put in a donation [of us$ /month]. so, i'm not really burdening anyone because i'm, i already helped. so, it's not a big deal if i'm an idiot.…some of the nurses are a lot more welcoming, and they let me do some injections.…[as] a volunteer, i guess, you do whatever you can to help. and i think i've helped. (george, early twenties, usa, cited by stanley, , p. ) all the medics around the table…describe the [nicaraguan] clinic/hospital as shocking, insufficient,etc. blood all over the floor, gloves/instruments reused between patients. [one of the ngo coordinators] danny told me [earlier that day] about scissors so blunt that to cut suture thread you have to pull at the stitches a bit, and the wound sometimes then reopens. in this case, they got the scissors from the clinic [and] 'no, no way. nica is way too sketchy', candace says. nicaragua as 'sketchy' is based on her experiences at the clinic.…having come thinking she was helping a terribly poor country, so very poor that it needed her as a medic, has she now had this confirmed? nicaragua is so very poor, so 'sketchy' that it cannot do anything 'properly', whether skydiving or suturing. (field notes on a focus group, stanley, , pp. - ) this is the dark side of what ibarra and petriglieri ( , p. ) call "identity play," defined as engagement in the provisional but active trial of possible future selves. while candace, amber, george, and others try out future identities in majority-world playgrounds, the experience is far from playful for their patients, whose lives and dignity are at stake. instead of learning from central americans, the voluntourists are practicing on them. there's another problem with voluntourism, and it's one of positionality and the reinscribing of colonial-type power relations. goudge ( , p. ) says: [t]he constant flow of development visitors from the materially better off countries… [may] unwittingly transmit a message that [practices] in the west are superior to those in [the south]…the message of superiority and corresponding inferiority, repeated endlessly in relation to all aspects of life, contributes to people believing the idea that everything in the west is superior [.] this is why candace and george are able to perform as doctors, because local people expect the gringos to know better, even when-as in this case-they don't. but what happens when gringos do know better? what happens if the west is getting something right? one issue that came up often in the data is that of deeply entrenched homophobia and transphobia in central america: there are instances [in my spanish class, in xela, guatemala]…where i'm like, 'i do not believe that'. for instance, talking with a teacher who…was talking about [her] view on gay people. that's something that i found really hard to deal with.…it's just something where her core belief…was that people who are homosexual were incorrect, like there was something wrong with them, that there's a disorder, when i know that's not true. they say that…homosexuals will go to hell … she was explaining that she thinks there's a spirit, like a demon-ish spirit controlling them. that just contradicts what i know. (amy, early twenties, usa, cited by stanley, , p. ) i've had experiences with some of my [local, spanish-language] teachers [in the western highlands of guatemala]…when they've asked about my romantic life, and i am [a woman] married to a woman.…on monday i actually had to ask to change teachers because [my teacher's] reaction was so awful.…he said, 'i'm fine with that', and then went on to equate homosexuality with prostitution, to say that transvestites were members of gangs and that people were right to be scared of them because they were like these big tattooed men in women's clothes. (alice, mid-twenties, uk, cited by stanley, , p. ) there is a tension here. on the one hand, there are-or should be-certain universal values, such as a respect for all human beings, and therefore an acceptance of lgbtiqa+ identities. i went to a small but vocal pride parade in xela, guatemala, in and waved a rainbow flag. but i also ducked a confrontation when my homestay host in antigua, guatemala, was openly homophobic: i was staying with a host family and [my host mother], over a few drinks on the friday night, was really homophobic. like wildly homophobic, equating people who are gay with child molesting and pedophilia and stuff. i was like, 'um, some of my best friends -' but she wouldn't hear it. so, i made an excuse and went to bed early because i thought, 'i don't want to sit and drink with this woman, but also i don't want to rock this boat, and i've got to stay here'. but i felt so guilty afterwards for not saying anything. … should i be standing up for people [for example, my close friends who are gay] who aren't there? i was just hiding behind [seeming] straight privilege. i had talked about my ex-novio [ex-boyfriend] .…then someone said, 'oh no, no. choose your battles. you're not going to change that woman's mind. you can't go in being all colonial. it's not your place'. (stanley, , p. ) i wonder about my own activism: was i an activist (or an imperialist?) when i attended the pride parade? and was a cop-out (or was i decolonizing tourism?) when i chose not to engage with my host's homophobia? it is easy to frame either course of action as activism, or not. i might ask: who am i to tell guatemalans what to think? but i might equally ask: where was my calling out of social injustices? neither question can be adequately resolved within the vague rubric of "activism." some interviewees grappled with the same issue: [the danish volunteers, in granada, nicaragua] did a sexual education class a couple of weeks ago.…for the [high-school] kids to be in our program, the nica[raguan] parents have to be accepting of what we're teaching them.…when we're teaching tolerance for homosexuality…because there is a deeply, deeply embedded homophobic culture [in nicaragua].…i think [ours] is just a very progressive approach to education. in a lot of our home universities, our schools, it wouldn't be seen that way, but compared to the culture here, it is. (sally, mid-twenties, usa, cited by stanley, , p. ) to sally, the power dynamics of these competing values are simple: tolerance is the trojan horse invited in with the free, after-school program run by westerners. but to sam, the issue is more nuanced, especially in light of the bloody history of imperialist meddling, not least by the united states, in central america: i don't feel like you can go into a place [in sam's case, quetzaltenango, guatemala] that's not yours, where you're a foreigner and where your passport gives you incredible privilege…and your country has a terrible legacy-i really don't feel like you can go into a place and lecture people. even though i feel uncomfortable, after a while [of] my [host] family [saying] , 'you need a novia' [girlfriend]…at the same time, i still don't feel like i'm in a position where i can be like, 'okay, you need to shape up'. …as much as i would love to see a flowering of lgbt acceptance in central america…i think it's kind of the white man's burden, and is it the gay white man's burden if i come in and lecture…the people i interact with on a daily basis to say, 'okay, this is my identity and my identity's getting accepted in my country and you need to accept it'? (sam, early twenties, usa, cited by stanley, , p. ) the medical voluntourists say they are doing activism, the danish volunteers say they are doing activism, i say i am doing activism. are we all activists? none of us? some of us? defined how? i tried resolving this swirl of questions by asking local people. chatting about my research with cab drivers and homestay hosts and other strangers-i told them about the nonmedics and the problematics of power, explaining it simply, in spanish, as something i was curious about, and asking what they thought-most shrugged and said, "pues, nos ayudan" [well, they're helping us]. implicitly, they mimicked the internacionalistas' [international brigades'] discourses of the s, seemingly grateful for the table crumbs however inadequate. and then i asked myself: was my shiny criticality a form of imperialism, too? then a guatemalan teacher, critical and forthright, told me about local resistance to the voluntourist antics of the gringos, especially those instigating projects of their own devising. framing local people as opportunistic but ultimately savvier than the gringos, who "didn't know any better," barbara inverts the trope of foreign aid workers leading hapless peasants out of ignorance. her voice is gleeful as she recounts: gringos came to the countryside [in the western highlands of guatemala, near lake atitlán] and said, 'oh my god, they will ruin their backs weeding with those shorthandled hoes! don't they realize?' so, they went back to the usa and raised money for the poor, ignorant guatemalans. and, proudly, they brought back their long-handled hoes, showed people how to use them, and handed them over. the local people were very happy. lots of nice, smiley photos were taken. these were really good hoes with heads made from single piece of reinforced steel. they were much better than the cheap, chinese-made ones from the local ferretería [ironmonger] , which tended to break where the two pieces had been welded together. when the gringos left, the people cut the handles down to the length they were used to, because that's what they were used to and what they knew how to use. no one thought anything much of it. the gringos just didn't know any better. (barbara, early fifties, guatemala, [translated from spanish], in stanley, , p. ) in good faith, i cited her story when i wrote the book. see, i mused: not all "activism" is activism. but then barbara's own implied activism began to unravel, too. is this local agency resisting foreign meddling? or is this a victory for the oppression and injury of workers? after reading more about the short-handled hoe, i have come to understand this story differently from how i first saw it. the short-handled hoe-el cortito (the "shorty")-was banned in california in , after a series of industrial safety board hearings. in these, evidence was sought from employers, union leaders, farm workers (most of whom were central american migrants) and the physicians treating the back injuries caused by their bending double to use the short-handled hoe. evidence against el cortito included medical: when i used the short-handled hoe my head would ache, and my eyes hurt because of the pressure of bending down so long. my back would hurt whenever i stood up or bent over. i moved down the row [of crops] as fast as i could so i could get to the end and rest my back for a moment. (farm worker, cited by murray, , p. ) i can unequivocally say that the use of this hoe will cause tissue injury and severe back pain, and late may result in degeneration of the intervertebral discs and other supporting elements of the spine, thereby causing pain, limitation of motion, increased vulnerability to severe injury, and in many cases complete physical disability. (physician, cited by murray, , p. ) but el cortito's effect was not just catastrophic for individuals. its capacity to injure also caused a rapid turnover of workers, which, in turn, made it difficult to organize trade unions (murray, , p. ) . why, then, was el cortito ever used at all? employers' testimonies cite a clear advantage: surveillance: "with the long-handled hoe i can't tell whether they are working or just leaning on their hoes. with the short-handled hoe, i know when they are not working by how often they stand up" (agricultural supervisor, cited by murray, , p. ) . so, were the gringos who brought the high-quality, long-handled hoes as naïve as barbara suggests? i don't think so. i do wonder who, precisely, cut down the handles: was it the workers themselves or was it perhaps their supervisors? this detail was elided from the story, but it is important. the central american workers themselves, in the california case, certainly did not prefer el cortito. a central american agricultural worker from that case, is recorded as saying: the message was clear: if i didn't like working with the short-handled hoe, i could quit. there were others to do the work. the contractor didn't have to deal with what the farm workers wanted, so we continued to use el cortito. … they didn't want the farm worker to stand up. psychologically, that gives us some dignity. …when you are bent over, it's showing humility. … it was time for us to overcome these things. (cited by murray, , p. ) instead of being a local preference, is el cortito more a symbol of laborers' lowly position and a tool of surveillance by their supervisors? if so, can el cortito be located as conceptually adjacent to homophobia, as a local phenomenon for which there is no justification in a universalist model of social justice but as something that can, perhaps, be turned into a local symbol of resistance against what appears to be neocolonial gringo meddling? there is no easy answer. pitted against one another are, on the one hand, an ethical universalism and its potential for the reinscribing of neocolonial power relations, versus, on the other hand, cultural relativism and the risk that phenomena like homophobia and el cortito will thrive thanks to a (misplaced?) postcolonial resistance. decolonization, on the one hand, and calling out social injustice, on the other, may thus be contradictory. either may be the purpose of activism, which is why, as a construct, activism is rather empty. related, how are we to define activism in an academic setting? farmer ( ) , researching structural violence and medical ethics in "developing world" contexts, writes: "there have been few attempts to ground medical ethics in political economy, history, anthropology, sociology, and the other contextualizing disciplines." (p. )…"the quandary ethics of the individual constitute most of the discussion of medical ethics.… might positively influence candace or george? all believe they are "doing activism." few will ever read my esoteric, academic papers. what good did i do? here is what i cling to. after freire ( ) , my activism is conscientização, a "consciousness raising" and, i hope, a seed of conscientização for others, too. i teach in higher education and it may be that some of my hard-won conscientização will leak out into my classes. perhaps, instead of medical volunteering in central america (practicing on local people, and implicitly holding them in low esteem), my students might choose, instead, to learn spanish, or weaving, or art, or mayan cosmology-anything, really-in central america (thus learning from local people, and explicitly holding their culture in much higher esteem). this is my hope. but i do despair that comedians, such as frankie boyle, are the center of cultural gravity in a way that even the most successful academics are not. if my activism is not about improving nicaraguan clinics and i must rely on those i can influence, would i not be better placed as an influencer outside of academia? i wonder. "activism," explored here, is difficult to define and thus to measure, and the actions of all the "activists" in this article would be easy to reframe in other ways. putting untrained u.s.-american teenagers in positions of power, in which they pretend to be doctors for those who cannot afford proper medical care-this could equally well be called human experimentation. similarly, is barbara's resistance false consciousness? and is my own academic activism wishful thinking? or even axiological violence? this paper has asked at least as many questions as it has answered. i wish it were otherwise, but as i hope to have conveyed, there is a need for complexity here, and the rush toward facile answers is part of the problem. decolonization, on the one hand, and addressing social injustice, on the other, are sometimes contradictory, and "activism" needs to address this. this paper has explored some of the issues inherent in who gets to claim they are doing activism and why. it has suggested a framework of structural violence, much bigger than activism itself, that acknowledges intersectional power relations. this draws, perhaps improbably, from the idealism and liberation theology of the original internacionalistas: those who went to help the green shoots of the people's revolutions in central america in the s, before "helping" was subsumed, a generation later, into the neoliberal voluntourism industry. the author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author received no financial support for the research, authorship, and/or publication of this article. phiona stanley https:// orcid. org/ - - - personal effects from far-right activism understanding central america: global forces, rebellion, and change activism and the olympics: dissent at the games in vancouver and london britain's criminally stupid attitudes to race and immigration are beyond parody. the guardian english defence league: discourse and public (dis)order the politics of the environment: ideas, activism, policy constructing grounded theory pathologies of power: health, human rights, and the new war on the poor pedagogy of the oppressed las venas abiertas de america latina violence, peace, and peace research the power of whiteness: racism in third world development and aid guatemala reader: history, culture, politics teología de la liberación: perspectivas the power of the poor in history identity work and play jacobellis versus ohio ( , us ) youth activism in an era of education inequality the academichunger games abduction: the missing link between deduction and induction the abolition of el cortito, the short-handled hoe: a case study in social conflict and state policy in california agriculture beyond the kale: urban agriculture and social justice activism in a critical auto/ethnography of learning spanish: intercultural competence on the gringo trail good intentions pave the road to hierarchy revolution: the year i fell in love and went to join the sandinistas nicaragua: living in the shadow of the eagle the countless people whose life course is shortened by unequal access to health care are not topics of discussion." (p. ) there is a need, therefore, to go beyond the individualist ethics of medical (mal)practice, which tend to be the focus of academic medical ethics. instead, we must consider structural violence, including questions of who does, or does not, get to become a patient in the first place. this is a critical medical ethics that concerns itself less with whatever candace or george are doing to their central american patients and more with larger-scale social justice.farmer's reframing of medical ethics is an example of theorizing as activism. his thinking goes beyond the immediate "case" and into underlying constructs to understand what is happening at a generalizable level (in the conceptual sense rather than the brutalist generalizability of sample-to-population positivism). similarly, i critique as structurally violent the existence of "volunteer tourism" within a postcolonial power relationship; this is another example of theorizing as activism.but as posited above, is there a risk that those of us engaged with academic activism are guilty of precisely the same imperialisms of which we are so roundly critical elsewhere, trammeling young volunteers' attempts at "helping" within our own critical discourses of systemic change? perhaps it is necessary for everyone to start somewhere. perhaps it is even necessary, sometimes, for us to not jump to critiquing, but instead to listen to and to hear where others are coming from. perhaps this text, itself, is paradoxically part of the problem it is critiquing: by roundly critiquing george and candace, am i perpetuating my own kind of axiological violence? this is another way in which we need to problematize "activism" much more than we already do. (as i hope i am conveying, this is not as simple as it looks.)then, in academic activism, there is also the question of reach. are all my academic words-and yours-subsumed into the white noise of neoliberal productivity in which we churn out more and more to appease the small administrative gods who value less and less (e.g., mewburn, ) ? does any of what we do in the name of academic activism actually change anything? scottish comedian frankie boyle ( ) writes:give a man a fish and he can eat for a day. give him a fishing rod and he can feed himself. alternatively, don't poison the fishing waters, abduct his great-grandparents into slavery, then turn up years later on your gap year talking a lot of shite about fish.reading this, i crumble. even as i write academic publications and tell myself i am "doing activism," a popular entertainer makes a comment that, in four short lines, conveys precisely the point that i am trying, in hundreds of thousands of words, to make. and people hear him. in contrast, farmer ( , p. ) writes that his team "conducted work and published it" but that "research did not figure on the wish list of the people we were trying to serve. services were what they asked for" farmer ( ) . if even farmer's work is not particularly valued by the people on the ground, then what chance is there that i phiona stanley is associate professor in intercultural business communications at edinburgh napier university in scotland. her work is critical, qualitative, and primarily ethnographic. she has published around thirty papers as well as four books: two monographs (one on western teachers in china and one on backpacker/volunteer tourisms in latin america) and two edited collections (one on issues of 'culture' in the writing of the self and the other on decolonizing intercultural education). key: cord- -f bn o authors: jassi, amita; shahriyarmolki, khodayar; taylor, tracey; peile, lauren; challacombe, fiona; clark, bruce; veale, david title: ocd and covid- : a new frontier date: - - journal: cogn behav therap doi: . /s x sha: doc_id: cord_uid: f bn o people with obsessive compulsive disorder (ocd) are likely to be more susceptible to the mental health impact of covid- . this paper shares the perspectives of expert clinicians working with ocd considering how to identify ocd in the context of covid- , changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (cbt) for ocd in the current climate. the expert consensus is that although the presentation of ocd and treatment may have become more difficult, cbt should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. the authors highlight some of the considerations to take in cbt in light of our current understanding of covid- , including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with ocd after the pandemic is over. key learning aims: ( ).. to learn how to identify ocd in the context of covid- and consider the differences between following government guidelines and ocd. ( ).. to consider the presentation of ocd in context of covid- , with regard to cognitive and behavioural processes. ( ).. review factors to be considered when embarking on cbt for ocd during the pandemic. ( ).. considerations in cbt for ocd, including weighing up costs and benefits of behavioural experiments or exposure tasks in light of our current understanding of the risks associated with covid- . coronavirus disease (covid- ) is a new and rapidly evolving pandemic. the physical consequences are well documented but mental health challenges have been less well considered (world health organization, ) . whilst covid- will create problems for mental health more broadly, there are groups that are potentially more vulnerable to the impact of this pandemic; these include those with obsessive compulsive disorder (ocd). this paper walks through the main clinical considerations when working with ocd in the context of covid- , including what to consider in the delivery of cognitive behaviour therapy (cbt). it is written by clinicians working with young people and adults across both in-patient and out-patient national specialist ocd services in the uk. it offers practical advice and clinical reflections, including case examples, to support others working with this client group. identifying ocd in the context of covid- ocd is a common disorder affecting around . % of adults (kessler et al., ) and - % of children and adolescents (heyman et al., ; valleni-basile et al., ) . ocd can centre on recurrent or persistent obsessions or pre-occupation around a fear of contracting/suffering from an illness or fear of contamination, which drives sufferers to engage in repetitive behaviours or avoidance to reduce the risk of developing the illness. obsessions/pre-occupation or compulsions/behaviours in these disorders are time consuming (e.g. take more than hour per day) and cause clinically significant distress or impairment in social, occupational or other important areas of functioning (american psychiatric association, ; world health organization, ) . stringent following of uk government guidelines to reduce the risk of contracting covid- to an observer may mimic the presentation of some of the most publicly perceived symptoms of ocd, for example repetitive handwashing/antibacterial gel use, avoidance of potential contaminants, or socially isolating. an understandable consequence of covid- is heightened anxiety due to the increased likelihood and awfulness of the threat. however, it is important to consider what the differences are between those who are following government guidelines to those with ocd to inform clinical practice. these centre on a different set of beliefs and motivations driving the behaviours, and their cessation (see table ). people without ocd are more likely to follow the guidelines in the way set out by the government (i.e. thorough handwashing for seconds), whereas those with ocd may be likely to wash until meeting an 'internally referenced criterion' such as 'feeling comfortable' or 'just right', resulting in prolonged and repetitive behaviour that is likely to be longer than seconds. they may wash their hands more frequently than those who are following covid- guidance and may do so in response to an obsession (i.e. intrusive thought, doubt or sensation), an idiosyncratic trigger (e.g. after a shower) or in response to the preoccupation with or fear that they may be at risk of contracting covid- , rather than a time when they may need to, such as coming home from a public place. it is likely that sufferers will clean or hand wash in a rigid or ritualised way. they may have developed methods for cleaning shopping with anti-bacterial gel, or quarantining parcels and shopping delivered for a set period of time before they can be opened. these behaviours are clearly idiosyncratic, excessive and not recommended by government guidelines. in addition to this, people with ocd may report a heightened moral responsibility for spreading covid- and may engage in other behaviours such as excessive checking of covid- -related information and reassurance seeking. finally, there may also be repeated consultation with medical professionals or advice lines, without lasting reassurance. the next section will consider in more detail the presentation of ocd in the context of covid- . it is likely that as the current pandemic took hold and awareness increased, most individuals without ocd will have experienced some increased distress and safety-seeking behaviours. these understandable, ego-syntonic responses to an objective increase in threat should not be pathologised and, as time has passed, most of these behaviours will have reduced. clinicians should, however, be alert for those who may start to exceed the diagnostic threshold for ocd, whose obsessions and compulsions are becoming excessive, time consuming, distressing and interfering with their lives (see box for an example). there is no evidence to suggest increased rates of ocd during or immediately after other major health scares, such as hiv, swine flu, etc. nevertheless, if people do start to exhibit more enduring symptoms in line with ocd, this may warrant a referral for cbt (see 'what to consider in cbt' section below). presentations of ocd can be very idiosyncratic; some people may be relatively unscathed by the current virus, others may experience elevated and devastating degrees of distress. some have even described that the societal restrictions in place to manage covid- have led to perceived shortterm benefits. for example, the 'lockdown' may facilitate some compulsive behaviours, such as reassurance seeking (e.g. by ensuring that household members are close by at all times) and avoidance (e.g. by reducing contact with children for those with paedophilic obsessions). some have stated other 'positive' aspects such as a perceived validation of beliefs about the harmfulness of contamination, and relief and reassurance in government-mandated hygiene practices and safe distancing. lockdown may also be preferred as it allows one to avoid the uncertainty of appropriate levels of precaution-taking. some sufferers have reported that the content of obsessions/pre-occupations has changed since the pandemic; those with other contamination/illness concerns are now more focused on covid- . others have reported a worsening of their symptoms, which may be due to many direct and indirect factors related to covid- . without doubt there is an increase in threat/ risk and information about that threat; ocd sufferers are likely to have attentional biases towards threat information. furthermore, there is a surfeit of information from multiple sources which is rolling and instant in the digital age (freeston et al., in press). unfiltered information may be perplexing, a -year-old married man was fearful of himself and his family catching covid- . his children had been kept in the house for the previous weeks during 'lockdown'. he reported that parcels delivered to his home were kept in quarantine in the garden for days. the garden patio would be washed down with boiled water and dettol. all non-perishable food is sterilised by boiling in water before it can be eaten. he went out for the odd run but kept a metre distance. he sprayed his door handles and bell daily with alcohol. he avoided touching taps, window locks and door handles in the house. he washed his hands about times a day. his wife had to accommodate his anxiety-driven behaviours. contradictory, untrustworthy or even misinformation. the -hour news cycle and widely accessible information online about covid- can exacerbate checking behaviours and reassurance seeking. the constant checking of information will undoubtedly create further fear and uncertainity. a worsening of symptoms can occur as people engage in a cycle of triggered excessive threat perception, anxiety and excessive compulsions, such as showering for hours after arrivals of post and food shopping, handling everything with gloves and wiping every item down. some have reported that despite taking recommended precautions, they still 'feel' that covid- has contaminated their homes and they experience urges to decontaminate it entirely, even to an extreme of removing wallpaper and flooring. intolerance of uncertainty (iou) is a well-documented feature of ocd (tolin et al., ; boelen and carleton, ) . various sources of uncertainty to do with the pandemic may be relevant to people with ocd. uncertainty around whether individuals have covid- or not, about the 'right' level of necessary precaution, receiving inconsistent or even conflicting messages from different institutions, as well as 'the new normal', where even people without ocd are trying to avoid potential contamination in a variety of ways, may make sufferers uncertain about whether they are taking the right approach or whether what they are doing is excessive. additionally, with the government guidelines around washing and social distancing, some ocd sufferers are reporting difficulty in identifying which behaviours are acceptable and recommended versus what is driven by their anxiety. iou may mainfest in a variety of responses, including repeated researching and analysing of information related to the virus and precautionary measures, reviewing whether one has carried out actions properly, or altogether avoiding tasks where the associated uncertainty is deemed unacceptably high. inflated responsibility, the belief 'that one has power that is pivotal to bring about or prevent subjectively crucial negative outcomes' which therefore obliges action (salkovskis et al., ) , is another key concept in cognitive models of ocd. when faced with the uncertainty associated with covid- , those with ocd may feel driven to take what they perceive as responsible action, with no upper limit to this definition. responsibility beliefs may encompass perceptions of others as insufficiently careful, and therefore drive attempts to compensate for this by taking excessive actions to prevent harm to self or others, including checking that others have followed routines properly. for sufferers who are parents, this may extend to imposing excessive (and potentially harmful) routines on children, which may need to be factored into risk assessment. a case example of inflated responsibility is presented in box . individual patterns of safety-seeking behaviour and avoidance will be meaningfully linked to cognitive themes. those with iou appraisals may seek absolute certainty that they have taken proper precautions, leading to repetitive actions. they may adopt subjective termination criteria for when to stop handwashing, such as feeling 'just right', timing or otherwise closely monitoring actions. decision-making about how to behave may be impacted by conflicting messages about the correct levels of precaution, with the highest levels sought and adhered to. a young autistic woman aged became distressed when her mother developed moderate symptoms of covid- , necessitating brief hospitalisation. she became pre-occupied with the thought that she had infected her mother (without objective evidence of this) and driven to carry out increasingly timeconsuming rituals. in addition to excessive handwashing, cleaning of objects, avoidance of anything associated with her mother and frequent reassurance seeking, she also spent hours each day praying. these behaviours had been present to varying degrees previously but had responded well to cbt, so this marked a sudden deterioration. she expressed a belief that not carrying out compulsions would lead to her mother's death and this would be entirely her fault. attempts to remove contamination may become extreme, perhaps involving use of specialised products, repeated cleaning, etc. those whose main fear is that they will spread the virus to others might engage in repeated checking (e.g. self-monitoring for possible symptoms, mentally retracing their steps and reviewing who may have had contact with), and reassurance-seeking/confessing. extreme levels of agoraphobic avoidance may be seen as the only way to achieve certainty about one's likelihood of causing harm and/or having acted responsibly. in summary, while the content of this threat is new, the mechanisms of response within ocd remain consistent with other well-documented stimuli. finally, the circumstances of lockdown including severe disruption of routine, financial and interpersonal stress and limited access to external protective factors, may lead to a vacuum that ocd can fill. disruptions to routine and activity can contribute to low mood, which in turn increases the accessibility of intrusive thoughts and reinforces their credibility. an additional consequence of lockdown is the impact on families and partners, who are relentlessly exposed to their loved one's difficulties and may have to accommodate symptoms to a greater degree, e.g. giving reassurance, changing routines and cleaning items on behalf of the sufferer. this is likely to increase anxiety, tension and conflict in the home environment. the changes in presentation and processes described above are important to consider in formulation and treatment (see 'what to consider in cbt' section below). cbt or not cbt? that is the question cbt is the recommended and evidence-based psychological treatment for adults and children with ocd (national institute for health and clinical excellence, ) . during the lockdown, services may offer treatment remotely via video-conferencing and telephone. studies have shown this is a viable treatment option for many, and outcomes are equivalent to face-to-face cbt (e.g. wootton, ) . it is important to consider a range of factors before embarking on this work. there are practical considerations such as whether someone can access remote treatment, e.g. availability of personal computers or devices, use of a quiet and confidential space for sessions and access to session materials. clinicians have noted some advantages of remote cbt, for example people using their telephones in sessions and the ability for them to move around in areas where their ocd is triggered, making the work more ecologically valid. some groups may struggle with remote cbt, such as young people with autism spectrum disorder (asd) or attention deficit hyperactivity disorder (adhd). in such cases, some services are offering face-to-face treatment in clinic with service users and therapists both wearing personal protective equipment (ppe) such as masks. ppe may impact on rapport building or undermine some in-session work, e.g. coming into contact with contaminants. additionally, there may be travel restrictions such as not being able to use public transport, which may make accessing cbt in clinic difficult. overall, the pros and cons of the mode of delivery (remote vs in clinic) need to be discussed with the client before deciding which approach to take. given the context of likely heightening of general anxiety and uncertainty, a discussion with the client is needed about whether they feel able to commit to therapy and try to overcome their difficulties in the context of covid- . it is important to consider whether commencing cbt in the current climate has the potential to increase risk (e.g. self-harm), and if so, whether a risk management plan can effectively be put in place in current circumstances, so that the individual has access to the support they need (veale et al., ) . clinicians need also to consider whether government guidelines will restrict the feasibility of undertaking specific behavioural experiments or exposure tasks, without which treatment would be substandard. for example, a client with olfactory reference disorder needed to be able to be close to strangers in busy areas to test out their fears that others will be disgusted by their perceived smell, which is not possible to do with social distancing government guidelines, and as such treatment therefore was put on hold. where it is agreed that it is not the time to embark on cbt, individuals may benefit from accessing support through regular clinician contact to review and monitor how they are managing. having said this, in our experience, the majority of people are managing to engage in cbt at this time. what to consider in cbt at present there are no empirical data on the cognitive processes and behaviours that may underlie covid- -related ocd. future research may reveal similarities and differences in these factors; however, our impression is that the processes are the same. based on our early clinical observations, there are likely to be several key cognitive factors to consider in cbt. people with ocd who are high in iou will struggle to tolerate the uncertainty associated with covid- , which may include not knowing whether surfaces, other people, etc. may be contaminated; whether one may have the disease oneself (and be contagious); what the appropriate level of precaution is to be taking; or whether one may have unknowingly spread the virus to others. an inflated level of responsibility for harm, where one has an exaggerated perception of one's degree of influence over feared outcomes, will motivate excessive attempts to prevent harm. beliefs about others (e.g. members of the public) being insufficiently careful may in turn contribute to the perception that one has to take an even greater level of precaution to compensate for others' negligence. closely related to inflated responsibility is the concept of 'agency', which is the belief that having an intrusion makes one responsible for the outcome by just having the thought (e.g. 'having a thought about someone contracting covid- makes me responsible for preventing it'). ocd sufferers' perceptions of risk are also likely to be over-estimations and characterised by 'all-or-nothing' thinking, for example perceiving relatively low-risk situations (e.g. walking outside while observing social distancing guidelines) as equivalently risky to high-risk scenarios. there are other manifestations of ocd where the nature of the fears are more qualitatively distinct from those of non-ocd sufferers, but where the content has now become focused on covid- . these include, for example, 'thought-event fusion' or magical thinking, where there is a fear that one has the power to cause covid- -related harm just by thinking about it (e.g. 'if i picture a loved one contracting the virus, i will make it happen'), or 'foretelling', where the belief is that having an intrusion about covid- represents an omen and means that it will happen in the future. fears of 'transfer' may take the form of believing that having an intrusion about covid- can transfer properties onto another object or person, by just having the thought (e.g. 'if i think my hands are contaminated, then i can transfer the contamination onto objects through my thoughts'). treatment should begin with the development of an individualised formulation, which highlights the idiosyncratic cognitive processes and behaviours. as part of this, introducing an alternative perspective (theory a/b) and highlighting this as a problem of excessive pre-occupations and concern about covid- is important. it is likely to be important at this stage to discuss what is deemed excessive, i.e. going beyond government guidelines, significant impact on functioning, increase in distress. for clients whose ocd predated the pandemic (perhaps sub-clinically), it could be useful to consider with them whether the cognitive themes and patterns of responding may be the same. cognitive interventions are likely to include normalisation of the uncertainty surrounding the virus and the correct levels of precaution. iou can be introduced as a concept with reference to various metaphors, with the message that individuals in the general population will vary in their ability to tolerate the uncertainty inherent in the virus. an implication for treatment will therefore be to help increase one's tolerance of the uncertainty. responsibility beliefs can be evaluated using the standard methods. these include continua methods to show that responsibly behaviour in relation to the virus is not all-or-nothing but on a spectrum; adopting maximum levels of responsibility has unintended costs and reducing one's level of responsibility does not equate with becoming negligent. responsibility pie charts may be useful for clients whose attributions for preventing harm are excessively focused on themselves. cost-benefit analyses will invariably form part of these conversations, drawing attention to the unintended consequences of continuing with the existing strategy. all-or-nothing styles can be addressed through continua methods and guiding the client to consider the grey area and sharing with them that we are living in this area together. behavioural interventions should be set up to test an emerging, alternative cognitive account of the problem (theory b) as one of excessive worry and pre-occupation about covid- . processes such as iou, excessive responsibility, all-or-nothing thinking and over-estimation of risk may also be targeted in behavioural tasks. the underlying principles of behavioural interventions in this context will therefore be to carry out exposure to uncertainty/perceived responsibility for harm, within the bounds of the current context. the aims are to develop tolerance of uncertainty and widen the bandwidth of behaviour in line with a more functional level of responsibility. on the surface, behavioural tasks usually associated with the treatment of ocd may appear to be contraindicated by public health advice and common-sense precaution-taking. when collaboratively developing tasks with clients, it is important to tailor tasks considering new emerging evidence about covid- , including information on viral loading and vulnerability groups (e.g. elderly, ethnic minorities, pregnant women). considering environments where there may be low viral loading (e.g. open outdoor spaces) and working up to higher viral loading environments (e.g. small indoor spaces) can be one way to increase the difficulty of tasks. most people are in the low vulnerability group, therefore tasks collaboratively developed with the client should include higher risk, e.g. go outside for a walk, touch a handrail and not handwash when they get home. if working with someone in a vulnerable group, tasks may need to be tailored to consider this, e.g. go outside for a walk, touch handrail and do a second handwash when they get home. as therapists we help our clients to weigh up their choices and to help them to choose to begin to bravely take risks which are either not present in reality or are exaggerated. this may be a more anxiety-provoking time for therapists too, as we work out our new limits in doing behavioural experiments or exposure tasks; we will have to be safe and within ethical codes, whilst also enabling our clients to take the necessary 'risks' to overcome their ocd. each task would need to be developed considering the cost-benefit of task, calculating the risk (viral loading plus vulnerability factors) against the potential benefit of challenging the ocd. specific exposure tasks will be guided by personalised therapy goals that are meaningful to the client and enable them to live as functionally as possible during the crisis. tasks may therefore include activities that are outside the client's current bandwidth but which many people without ocd are still willing to engage in. there is growing awareness of the potential emotional and developmental impact of covid- restrictions on children and young people (e.g. lee, ) , with substantial changes to their daily structure, environments and learning opportunities. for young people with neurodevelopmental conditions such as asd (where predictability and routine may be key to emotional coping), adhd (who are often reliant on regulation from physical activity) or where parenting capacity is reduced by other difficulties within the family, this impact may be increased. it is through this lens that formulation and interventions for young people experiencing ocd in the context of covid- should be understood. although some provision remains in place for vulnerable children and young people, many parents have reduced access to support and respite. this unfortunately has the potential for spiralling distress and family burn-out. therapists should consider whether cbt-informed work with parents to contain and reduce their accommodation of ocd symptoms, for example, may have greater benefits in such situations than individual cbt. as with adults, there are many young people who are able to make use of remote cbt for ocd (lenhard et al., ; turner et al., ) . for those already familiar with online communication, the switch to this way of working may prove a smoother transition than for their adult counterparts or indeed therapists. the age and developmental profile of a young person, the availability of a quiet and calm space (alongside a parent if appropriate) in which to conduct therapy sessions, the ability to tolerate sustained screen time in a focused way and the opportunities for meaningful exposure will all influence the decision to undertake cbt. for a young person out of school, with no direct contact with peers or indeed no time spent independently from their parents, some ingenuity may be required to identify exposure tasks that tap into the individual's core ocd fears. this may be the time to adopt creative imagery-based tasks, to recruit grandparents and friends as online 'stooges' or to exploit the growing number of platforms available for exploring virtual worlds. helpful modifications to sessions may include the use of sensory objects or materials to improve concentration and attention, drawing facilities to help them to make their ideas more concrete, use of interfaces with shared screen capabilities to enable visual aids, shorter and more frequent sessions or greater reliance on recording and recapping of session information throughout the week. anxiety disorders affect approximately % of perinatal women (dennis et al., ) , and ocd affects approximately - % of women in the perinatal period, usually defined as pregnancy to months postpartum (fairbrother et al., a) . the combination of prolonged uncertainty regarding the outcome (the baby's health and wellbeing), a myriad of potential threats and high responsibility for a vulnerable infant are particularly pertinent to the context of pregnancy and the postpartum period. there are often new incident ocd disorders during the perinatal period, in particular if there are additional risks and complications within pregnancy (fairbrother et al., b) . the additional concern caused by the risk of contracting covid- is likely to be causing perinatal women with ocd more distress and may trigger new anxiety disorders in some. cbt is always adapted to the person's context, with the aim of achieving behaviour relative to someone in a similar position, i.e. an expectant parent without ocd. for pregnant and postnatal women with ocd, experiments involving exposure might be less extreme than experiments outside this context, and this is further modified within the bounds of current restrictions, for example additional caution in late pregnancy. intrusive thoughts of deliberately harming the infant are very common in perinatal women and distress may be exacerbated by the constant close proximity and lack of normative information available, intensified by lockdown. gaining a sense of the range of normal parenting and infant behaviour is key to working with perinatal ocd, and encouraging women to access general online peer support and antenatal groups is an important part of treatment during social distancing. it may also help with symptoms of low mood which are a likely consequence of current limitations, and often play a role in maintaining perinatal ocd (challacombe et al., ) . additionally, the need to visit hospitals for some (albeit pared back) antenatal appointments as well as to give birth in hospital is a source of understandable worry, and women may need support in thinking through the best ways to manage these situations and problem solving any issues that may present in the context of their particular fears. what happens when it is all over? it might be predicted that a return to more normal levels of activity, and a decrease in the need to adopt such stringent and hypervigilant efforts to fight covid- will be celebrated by the public generally. however, it seems almost certain that we will be doing so in an atmosphere of ongoing uncertainty, at least until a vaccine is developed. we are going to have to learn to live with the virus, and some people may find it hard to leave the 'enhanced/emergency covid- rules' behind. there is likely to be a general level of anxiety, and it is probably true that we are all going to have to take 'calculated risks' in order to regain a more fulfilling and enjoyable way of life. there may have to be cost-benefit analyses for us all as we calculate the level of risk we are individually prepared to take in order to get our lives back to our 'new normal'. some people, perhaps those with co-morbid health problems, may choose or be advised to remain living in a fairly restricted way, as the risk for them will be much higher. others will happily adopt a much more relaxed approach. there is nothing at this point to say there will be an increase in rates of ocd in the general population. however, it may be that this level of threat has been traumatic for many people, and this may be an opportunity to pick up those people who are at risk of further exacerbation of anxiety and worsening of symptoms over time. people do not usually present with ocd until an average years after onset (stobie et al., ) , despite ocd symptom severity increasing over this time. this could be a good opportunity to help this population identify early warning signs of ocd, such as excessive fear and pre-occupation with covid- , inability to resume regular activities or inability to drop safety behaviours that were functional during the pandemic, when the advice is that these are no longer necessary. awareness and knowledge of ocd and its development have generally increased, and it might be hoped that we can use covid- as an opportunity to educate people to identify symptoms at an early stage and seek help. people with ocd are likely to be more susceptible to the mental health impact of covid- . the presentation of ocd in the context of the pandemic, in terms of the cognitive and behavioural processes, are likely to be broadly similar to presentations before the pandemic, but the content of the fear will have changed. government guidance on covid- will have an impact on the delivery of cbt; however, in our experience effective treatment can still be carried out for a majority of people. when therapists and clients are developing behavioural experiments and exposure tasks which involve contact with potential covid- contaminants, they need to consider the current understanding of covid- , such as viral loading and individual vulnerability factors. the costs and benefits of such tasks need to be weighed up with regard to the risk of contracting covid- against the benefits of overcoming ocd. whilst there is no evidence to suggest there will be an increase in ocd in the aftermath of the pandemic, there still may be opportunities to help this population identify early warning signs of ocd and access support sooner. covid- may change the content of the threat for those with ocd, but the cognitive and behavioural processes involved are similar current government guidance on managing covid- may make aspects of treatment delivery and content more difficult, but for the vast majority of people with ocd, cbt can be delivered effectively when undertaking cbt for ocd, attention must be given to how best to set up behavioural experiments and exposure tasks in light of current understanding of covid- , i.e. 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coronavirus (covid- ). the cognitive behaviour therapist prevalence of obsessive-compulsive disorder in the british nationwide survey of child mental health lifetime prevalence and age-ofonset distributions of dsm-iv disorders in the national comorbidity survey replication mental health effects of school closures during covid- therapist-guided, internet-delivered cognitive-behavioural therapy for adolescents with obsessive-compulsive disorder: a randomized controlled trial obsessive compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (bdd). nice clinical guideline the relationship between obsessional problems and intrusive thoughts contents may vary': a pilot study of treatment histories of ocd patients intolerance of uncertainty in obsessive-compulsive disorder telephone cognitivebehavioural therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial family and psychosocial predictors of obsessive compulsive disorder in a community sample of young adolescents risk assessment and management in obsessivecompulsive disorder remote cognitive-behavior therapy for obsessive-compulsive symptoms: a meta-analysis international statistical classification of diseases and related health problems the cognitive behaviour therapist acknowledgements. none. conflicts of interest. the authors have no conflicts of interest. key: cord- -o biwypo authors: asai, atsushi; okita, taketoshi; ohnishi, motoki; bito, seiji title: should we aim to create a perfect healthy utopia? discussions of ethical issues surrounding the world of project itoh’s harmony date: - - journal: sci eng ethics doi: . /s - - - sha: doc_id: cord_uid: o biwypo to consider whether or not we should aim to create a perfect healthy utopia on earth, we focus on the sf novel harmony ( ), written by japanese writer project ito, and analyze various issues in the world established in the novel from a bioethical standpoint. in the world depicted in harmony, preserving health and life is a top priority. super-medicine is realized through highly advanced medical technologies. citizens in harmony are required to strictly control themselves to achieve perfect health and must always disclose their health information to the public and continuously prove their health. from a bioethical standpoint, the world in harmony is governed by a “healthy longevity supremacy” principle, with being healthy equated to being good and right. privacy no longer exists, as it is perceived ethical for citizens to openly communicate health-related information to establish one’s credibility. moreover, there is no room for self-determination concerning healthcare because medical interventions and care are completely routinized, automated, centralized, and instantly provided. this is a situation where the community exhibits extremely powerful and effective paternalism. one can argue that healthy longevity is highly preferred. but is it right to aim for a perfectly healthy society at all costs? should we sacrifice freedom, privacy, vivid feelings, and personal dignity to achieve such a world? in our view, the answer is no, as this would require the loss of many essential values. we conclude by proposing an alternative governing principle for future healthcare, and refer to it as the “do-everything-in-moderation” principle. tuan kirie, a -year-old woman, is the main character of harmony. this work is told in the first person of tuan. it is the year , and tuan is a world health organization (who) monitoring officer who protects people's right to life. her job is to ensure that society guarantees healthy and humane lives for its members and to intervene when necessary. tuan describes her mission as follows: we are basically a flag-waving troop of diplomats-cum-peacekeepers charged with the protection of life everywhere… [t] o check whether they were ensuring their populace a lifestyle that was sufficiently healthy and human. (p. ). she was ordered to temporarily return to japan by her boss after a certain incident. shortly afterwards, more than people around the world attempted suicide simultaneously, and people, including one of tuan's best friends from high school, were successful in the attempt. an unidentified criminal declares to all citizens in the world: within the next week, i want you each to kill at least one other person… those who are unable or unwilling to perform this small task will die. (p. ). the main story in harmony concerns tuan kirie's investigation into the cause of the multiple suicides and identification of the person who issued the one-man-one-kill order. harmony's world is governed by an ideology referred to as lifeism (project itoh's coinage). lifeism is explained as being a politically enacted policy or tendency to view the preservation of health as the community's highest responsibility (p. ). harmony's world consists of communities which include people who have reached a consensus on a particular medical system and these medical conclaves are referred to as administrations (project itoh's coinage) (p. ). the medical conclaves (or administrations) have successfully realized super-medicine that uses advanced medical technologies including ai, ict, and nanotechnology. based on the welfare societies of the twenty-first century, this means the inclusion at adulthood of a constant internal monitoring network through a device called watchme, the establishment of a high-volume medical consumer system with affordable medicine and medical activities, and the provision of proper nutrition and lifestyle advice designed to mitigate predicted lifestyle-related illnesses. these activities are seen as the basic minimum conditions for human dignity (p. ). community groups cover % of the world (p. ), but some areas do not belong to a medical consensus community. for these %, super-medicine has nothing to do with citizens' lives. those who live outside medical conclaves are just like usthey catch colds, get headaches, get cancer, and die around the age of sixty or seventy (p. ). on the other hand, in medical conclaves, all people install watchme by injection into their bodies when the body finishes growing, i.e., when they become adults. watchme constantly monitors the level of rna transcription errors and immunological consistency in human blood at the molecular level. based on data sent from watchme, a little pharmaceutical factory in every household called medicare (personal medical drug purification system) synthesizes substances called medicule (project itoh's coinage) needed to eliminate pathogenic substances in the blood, and sends medicule, in a matter of milliseconds, to the area where the abnormality occurred at pinpoint and eliminates substances harmful to the human body. medicule can also issue a warning via measuring homeostasis in the body (p. ). as a result, swarms of medicines have essentially eliminated most diseases off the face of the planet (p. ). medicare performs autonomous, automatic, and instant medical interventions. medical treatments are nearly perfect and citizens' health management is almost completely realized. interestingly, healthcare professionals do not appear in the novel at all. a healthy longevity world has been established where no one is ill, the elderly are extremely active and healthy, and no one dies except in accidents or due to senility. in addition, each person's life is designed together with a health consultant. it is the extreme health-conscious society (p. ). in harmony's world, there are no interventions based on scientific technologies such as nanotechnology, let alone devices for monitoring the brains of community members. watchme is not designed to directly monitor mental activities, nor is medicule able to pass through the blood-brain barrier. behavior modification is attempted by request for self-restraint via traditional educational methods and social pressure. promotion of healthy behavior, and improvement of the environment by eliminating factors that could adversely affect mental and physical health, also lead people to live a healthy life. good health and health efforts are awarded high social assessment points, further motivating people to make efforts toward self-restraint. watchme warns people when a disturbance in the autonomic nervous system is detected and blocks harmful information, which also helps maintain peace of mind. children and young adults who cannot tolerate health education or the demand to live a public life attempt suicide or self-harm, as discussed later in sect. , unrelated to the aforementioned incident by the unidentified criminal. suicide that occurs frequently in this society is interpreted as a rebellion against controlled mental health by individuals who suffer from feelings of disillusionment and despair toward society, as well as hopeless, disconsolate feelings and a sense of entrapment. the above-mentioned medical conclaves were born after reflecting on a frightening history. in , a riot in the united states led to ethnic slaughter, and nuclear warheads spread around the world during the ensuing turmoil. this led to frequent nuclear terrorism, and radiation led to the development of cancer in many people. in addition, an unknown virus was generated due to the radiation, and many people succumbed to it and fell ill. this event is referred to as "maelstrom," meaning "the great disaster." the world in the face of an imminent health crisis established medical conclaves overnight. now, most parts of the world are free from chaos, savage, and slaughter, and a utopian world of peace, healthy longevity, and love has been realized (p. ). as it becomes apparent during the course of the story, harmony's world adopts an oligarchy political system; % of humans are basically under the watchful eye of a select group of people (p. ). this group refers to itself as the next-generation human behavior monitoring group. group members (i.e., leading senior citizens of medical conclaves, highest authorities of the medical industrial complex, and some scholars and scientists) have no intention of exploiting members of medical conclaves and created the healthy longevity society purely based on good intentions. they are solely dedicated to preventing the return of "maelstrom," and have the noble intentions of ensuring healthy longevity and world peace. no malice exits and the rulers remain concerned that all it would take is one mishap for cancers and viruses to return (p. ). we present here a brief overview of the history of medicine and medical development which are relevant to harmony's world. progress in medicine has provided solutions to various diseases including infectious diseases, genetic disorders, malignant tumors, and cerebrovascular disorders, and brought about mental stability to many people. all of these medical advances are cornerstones of the medical technologies used in harmony's world. in fact, a comparison between modern-day medical care that has evolved over the past years to that of harmony's world reveals a number of similarities. for example, wearable wireless devices that measure and display vital signs, steps, calorie consumption, and other variables have been in widespread use, with smartphones providing health guidance. continuous blood glucose monitoring devices have also been put into practical use. the use of "digital pills" started, in which a patient's medication status and physical condition are monitored by a sensor patch and ingestible sensor and sent to a central server and physicians, and improvement in medication adherence is attempted via guidance feedback. digital medicine includes a wide range of devices, such as temperature-monitoring foot mats capable of automatically detecting diabetic foot ulcers or clinically validated smartphone apps for smoking cessation combined with video tutorials and nicotine replacement therapy (ohta ; martani et al. ; biesen et al. ) . behaviors of members of the public are monitored, recorded, and aggregated for the purpose of preventing the spread of infectious diseases using smartphone location information and surveillance cameras. anti-cancer therapy with a drug delivery system using nanomolecules created by nanotechnology, micro-sample diagnosis, medical treatment by nano-robots, diagnosis/drug selection/prediction of disease onset based on genome analysis, gene manipulation by crispr/cas genome editing in fertilized eggs, and organ regeneration by regenerative medicine technology have also begun (sekai-cyoukan ; kanaya and ichikawa ; kobayashi ; johnston et al. ; sunshine and paller ; king and bishop ; itai ); medicule and genetic-level repairs of abnormalities described in harmony' world are beginning to be realized. the development of diagnostic systems using ai deep learning which had made a substantial breakthrough in the past decade is another active area of research. medical ai is used to carry out pathological diagnosis, diagnostic imaging, endoscopic diagnosis, diagnosis of and critical care for rare and intractable diseases, prediction of patient prognosis, and big data management. ai robots also provide nursing care. direct-to-consumer medicine using a digital healthcare application has also been put into motion (susskind and susskind ; kirinuki-sokuho ) . many countries guarantee affordable healthcare and good access to medical care through universal health care systems. in japan, the health promotion act ( ) states that citizens are responsible for health promotion, as well as local governments and the state, thereby setting the stage to support healthy lifestyles and promote behavior modifications. simultaneously, the act prescribes environmental maintenance to prevent passive smoking in society ). thus, we would argue that harmony's world is an sf story depicting a "brave healthy world" and can also be regarded as a speculative fiction about a health promoting society. as mentioned above, medical conclaves in harmony's world covers % of the world population and exclusively aim to promote healthy longevity and life retention. harmony's world devotes itself to realizing the health-supremacy principle and healthism, and this leads to various problematic issues, which are discussed in detail below (table ) . we can gain insight into important lessons about ethical, social, and psychological issues of our future world with strong health orientation by analyzing harmony's world in detail. first, the extreme healthoriented and health-conscious society has given rise to health worship. in this world, healthy longevity is considered more important than anything else. health the value we call health is trampling us over everything else. it means that the flood is coming. we are about to drown. (p. ). another one of tuan's colleagues, who is critical of the excessive health-oriented society, mentions: since we are both here on business, we don't have to worry about oil or cholesterol or any moral concerns. let's eat! (p. ). here, we note that cholesterol and ethical concerns are referred to in the same dimension. taking cholesterol would be considered unethical in the context of a non-work situation. also, a goody-goody woman in the community who claims that coffee addiction is a serious problem and should be banned mentions: i was just wondering if there isn't a moral problem with the taking of caffeine. (p. ). tuan describes harmony's world as follows: plague, booze, and smokes -loot too good to pass up. you could not find any of these things in japan, a nation obsessed with health, or anywhere else under admedistration rule, for that matter. all these vices, things which had gone more or less ignored in the past, had been carved in a list of sins by the all-powerful hand of medicine, and one by one, they had been purged form a society. (p. ). she also mentions: the invention of medicines had put the human body and moral precept side by side on the same lab table… the program took care of the signal sent form the body and transmitted morals in return. the moral code over percent of the people in the world had taken for their own. (p. ). substance intake that leads to poor health is a sin in harmony's world. issues surrounding alcohol, smoking, and coffee suggest that health-related perfectionism is an endless slippery slope. in harmony's world, medicine is the subject of people's faith. in this regard, tuan states: our gods, asklepios and hippocrates, watched closely over us, the 'medicine people' and in their name we built temples to clinical medicine and shock down nearly every disease ever known. our faith was such that we would continue striking them down, and so the medicine people who would never be abandoned by their gods. (p. ). the propensity to avoid caffeine and animal fats, and taking only healthy food, can be considered orthorexia nervosa, an obsession with eating only healthily or an obsessional adherence to a clean, pure, and healthy diet (mccartney ). one commentator argues that individuals with orthorexia consider their eating styles to be virtuous and wholesome, citing ethical reasons for their eating practices, and they may even proudly discuss their dietary practices because they believe their eating behaviors symbolize moral superiority (donini et al. ) . the healthy life is the good life and striving for health is one of the most important goals in life. therefore, a healthy life equates to a good life (komduur et al. ). medical conclaves do their best to help members eliminate health risks. for example, life pattern designers instill in people the notion that they should do as the medical doctor says, i.e., a type of health counseling. life pattern designers determine a lifestyle pattern to optimize both their client's health and their social assessment score by looking at information supplied by watchme (pp. - ). interestingly, emergency rooms in harmony's world are referred to as emergency morality centers (pp. - ). we argue that all aspects of life protection, medical care, and ethics are inseparable, and that healthy longevity equates to goodness in this world. beyond maintaining complete health and extending life to the extent possible, there exists a desire for immortality. in harmony's world, citizens are required to live as resources to the community. tuan explains this as follows: resource awareness. that was how people defined their obligation to society. that and the concept of a communal body. always be aware that you are an irreplaceable resource, they would tell us. (p. ). with the population so dramatically reduced, our bodies are considered public property, valuable resources to society, and as such they were something to be protected, or so went the publicly correct thinking. (p. ). medical conclaves obligate their members to live healthily as long as possible in order to maintain the community. this may be an inevitable consequence of the major disaster which happened half a century ago. but to live for society rather than oneself renders people merely a means to an end-they are objectified. nonetheless, the majority of citizens are willing to fulfill their duty of being healthy and live as long as possible for the sake of their medical conclaves. in harmony's world, one's body no longer belongs to oneself. some people, especially children and adolescents, disagree with this awareness. for example, miach as a high school student wanted a world where one's body was one's own. tuan recalled that this was what miach wanted. miach wanted a body that was hers, not beholden to a society or its rules (p. ). given that citizens are a public existence in harmony's world, individual privacy no longer exists. members of medical conclaves are required not only to keep themselves healthy at all costs, but also to continuously prove their own health to other members of the community. private information such as name, age, occupation, and social assessment score, as well as current health status, must be discussed with other members of society (p. ). in this lifeist society, where it was considered a moral obligation to reveal personal information, especially that concerning one's health, the very word "private" had the illicit stench of secrecy to it. the regional ethics committee ("administration moral consortium") tracks members' assessment scores and discloses them to the public. citizens are constantly evaluated and ranked based on their health. according to tuan: the augmented reality (ar) in my contacts kicks in. ar public metadata: everything in our world had a user review attached to it. even people had little social assessment stars stuck on them. (p. ). it can be argued that a healthy person is a person that you can trust and those who are not healthy seem to be the person who cannot be trusted. however, miach suggests her friends that people are getting tired of this telling-everyone-whothey-are-all-the-time business. what a drag it is to have you to show you are healthy and you are taking care of yourself all the time (p. ). finally, by fully pursuing health and longevity, as well as a medically optimal body, physical diversity is lost in society and the delusion of a "standardized" human body has become reality. the myth of a normalized human body was elevated to a high public standard (p. ). under the constant monitoring of watchme and advice from health consultants, obesity and emaciation were both driven out of the human experience (p. ). all citizens live within the prescribed margins of a healthy adult. regarding this, tuan states: they were all the same. everyone. i realized how bizarre a sight the medically standardized japanese populace presented. (p. ). deviations from standard physique really stood out when everyone was listening so attentively to their health consultant's advice and following their perfectly designed lifestyle plans to the letter. the range of acceptable body types grew narrower every year. (p. ). the atmosphere of conformity that the society generated was too hard to break free of. (p. ). it is clear to us that harmony's world would be intolerant of those who deviate from social standards in any respect. in addition, because of the similarity of harmony's world we would like to refer to, one of the famous english utopian novels, samuel butler's erewhon or over the range. this novel presents a society that values health above all else and punishes citizens who fall sick, blaming them for a moral failing. it seems that erewhon's society is much more unsparing against unhealthy people than harmony world (butler ) . in erewhon, sick people are treated like criminals and they are stigmatized, fined, and imprisoned for a condition they could not help, whereas criminals are treated like sick people and they are helped, attended, and given decent treatments (butler ; osborn ; jenkins ) . in other words, the law of erewhon outlaws physical rather than moral deviations, punishing disease and physical disability while treating acts of dishonesty and theft in the way that we would treat illnesses (parrinder ) . for an example a man in the last stage of tuberculosis being sentenced to life imprisonment. the rationale is that if harsh measures were not taken against disease, a time of universal dephysicalisation would ensue (parrinder ; bulter ). the judge who assumes that the sick are responsible for their acts said to the patient in chronic respiratory failure with severe tuberculosis, "you may say that it is not your fault…if you tell me that you had no hand in your parentage and education and that it is therefore unjust to lay these things to your charge. you may say that it is your misfortune to be criminal; i answer that it is your crime to be unfortunate… infliction of pain upon the weak and sicky was the only means of preventing weakness and sickness from spreading… you are a terrible and perilous character, and stand branded in the eyes of your fellow-countrymen with one of the maximum heinous recognized offences." the underlying rationale for self-responsibility for sickness seems to be based on the erewhonians strange belief that an unborn child in erewhon voluntarily choose to be born according to self-determination, even knowing very bad things could happen in their life. therefore, individuals in the society are completely responsible for their health regardless of its causes or circumstances. many ill individuals attempt to hide their disease in the society (bulter ). in the previous sections, we introduced harmony's world and brought to light various issues pertaining to health worship and the healthy longevity supreme principle, including the strong faith in medicine and healthcare, moralization of health issues, identification of health and good, people's obligation to be healthy, objectification of citizens, loss of privacy and diversity, and one's life designed by others ( table ) . all of these would be problematic from an ethical standpoint. this is because individual freedom would be deprived on many fronts. moreover, harmony's world is value-monistic, perfectionistic, and intolerant of lifestyles that are not perfectly healthy and diverse ways of thinking about healthcare. there are also other issues in this world. below we discuss some of the ethically dubious means and policies that are used in harmony's world to achieve health and longevity. the first means by which harmony's world achieves a perfect healthy utopia is the routinization and automation of healthcare delivery. the combination of watchme, medicare, and medicule have enabled the provision of instant, matter-ofmilliseconds, diagnosis and therapy, as well as prevention. naturally there exists no room for self-determination and the concept of treatment refusal or informed refusal has disappeared completely. every medical intervention has become a matter of course. all medical care procedures are quick and completely routinized. regarding issues with routinization, japanese philosopher kenji hattori rightfully noted that routine examinations are often conducted implicitly without a sufficient explanation or with little expectation that they will be refused, and everyday medical care is being provided with such routine examinations as a matter of course. he also argued that the word "routine" or routinized healthcare system would deprive patients of their initiative in medical decision making by suggesting that all other people or patients would usually do the same thing. he concluded his criticism against routinization by noting that, whenever an action or intervention is intended to be routinized, we should ethically scrutinize potential problems caused by the routinization (hattori ) . in harmony's world, which effortlessly provides citizens with adequate and affordable medical care, the pressure to use it is stronger because no financial barrier exists. in our opinion, there likely is no option not to install watchme, not to set medicare in one's house, or not to receive a diagnosis, prevention, and interventions through medicule in medical conclaves. harmony tells us that the medical conclaves are a gathering of people who have reached a consensus on a particular medical system (p. ), but it is unclear to us the extent to which the consensus is voluntary or what members have actually consented to. the second means by which harmony's world achieves a perfect healthy utopia is through cryptic and clever techniques and covert interventions, including educating individuals to voluntarily internalize social norms, incentives tied to social assessment scores, domination by the atmosphere of society, and kind watching supported by affirmative paternalism. in this world, there is no unilateral and forced order to become healthy-no enforcement exists. rather, people are skillfully driven toward the direction of health promotion. from childhood, they are repeatedly instructed and guided to suppress human instincts and impulsive desires which could result in an unhealthy state through polite education. the world has made them think that they themselves should voluntarily try to be and stay healthy. society requires citizens to voluntarily internalize morality consistent with social norms (p. ). such a framework creates a contradiction within the individual; since it is not simple or high-pressure coercion, face-to-face rebellion and rejection are psychologically difficult. miach notes: i knew how barbaric people could be. and i knew how broken they could become when they tried to repress that nature. i thought that this society, admedistrative society, this lifeist system was all wrong. a society that wanted me to regulate myself internally, even while people were killing themselves all around me. it was just bizarre. (p. ). in our view, if you failed to internalize social norms which are long taught to be self-evidently good and right, you may feel guilty or have reduced self-esteem. you may also feel alienated from others who have naturally accepted these social norms. freedom inside would be lost because you are expected to monitor yourself on your own initiative. to this, miach further notes: a society where rigid self-monitoring was the only path to peace and harmony. (p. ). one commentator states: the everyday practices involved in improving or maintaining our own health -eating, exercising, feeling emotions, managing time, sleep, and so on -do not merely constitute our health; they also constitute our identities. the combination of obligations to internalize and act in accordance with shared moral norms and a focus on individual achievement seems likely to limit human freedoms. (carter et al. ). not only educating people about social norms, but social assessment would also be an incentive to become healthy in harmony's world. careers and medical records are used to award social assessment points. in a world where you must always keep others informed of your health efforts and health condition, the majority of people may want to get as high a score as possible. families and supervisors would also pressure people to do so. there is also psychological control by "the air" or atmosphere, rather than written laws or rules. the atmosphere of harmony's world decides almost everything. invisible rules that reflect common sense and "the air" are conceptually very japanese. regarding impressions about buildings in japanese cities, tuan mentions: there weren't any laws against painting a building something more exciting, and yet here they were, an endless line of houses, all cast in bland, nondescript shades. none of them stood out against others. (p. ). in fact, there are no laws that prohibit drinking in most medical conclaves. one of tian's who colleagues noted: funny thing is, it turns out that out of all the thousands of admedistrations in the world, only twenty-six have laws on the books actually prohibiting alcohol. just twenty-six that forbid their members to imbibe. in all the rest, it's just not done. i am sure that that social assessment analysis has something to do with that. that is how the social assessment points work. as long as enough people agree about something, it starts being reflected in your points, and before you know it, you had better behave or else. and enforcement is built in. (pp. - ). good intentions and kindness make it difficult for people to counter or refute the world's health interventions. harmony's world is not malicious. it is not a cold and cruel surveillance society, but rather a warm and kind watching society. it attempts to connect all people to its server from good will and kindness. importantly, some citizens, like miach's adoptive mother, are thankful. she mentions the following to tuan: my watchme (the public correctness monitoring module in it) just warned me my emotional state was beyond acceptance parameters for interfacing with others. it is a real lifesaver, having another pair of eyes inside me to help me through these things. (p. ). but tuan felt that mankind was trapped in an endless hospital. (p. ). informational regulation as an additional kindness is also notable. it serves as a paternalistic block on harmful information. tuan notes that parts of their history have been censored, images in particular, such as horribly disfigured corpses, and that people need special clearance to see those. even what had probably been considered tame content by the standards of yesteryear was teeming with violence by the peaceful, elegant standards of society (p. ). novels are no exception. tuan indicates that any novel or essay people are about to read would be scanned in advance and cross-referenced with their therapy records (p. ). in the middle of the story, the perpetrator of a massive simultaneous suicide attempt sent a tv station a one-man-one-kill order. the newscaster who read the statement was killed on the air by the mysterious perpetrator. this killing scene was instantly censored by the ai censor. the image cut out and was replaced by other thing (p. ). but how is the ai programmed? perhaps information other than that which protects the individual is also censored, for example, the problems of medical conclaves. information can be fabricated and falsified. delivered contents could be biased in favor of the community. information critical against authorities will probably be cut off. totalitarian control of information is a substantial barrier to autonomous thought and independent decision-making. the third means by which harmony's world achieves a perfect healthy utopia is through inappropriate responses to issues. in harmony's world, there are many suicide attempts and acts of self-harm, particularly among children and young people. yuki keita, an -year-old university professor who does brain research, told tuan that the statistical rise in suicides is troubling and that pharmaceuticals and novel therapeutic treatments, as well as legal support for such treatments, would likely eventually bring these under control. he also noted that those who would want to destroy the safe and stable cycle of life are anathema to the rest of us (pp. - ) . tuan also pointed out that even without the mass simultaneous suicides, administration reports showed an increasing trend in suicide rates among youngsters. more kids were cutting their wrists, hanging themselves, and jumping off buildings (p. ). however, the cause of suicides among youngsters resides exactly in the very system of medical conclaves. in harmony's world, many cannot bear to fit into the molds society stamps for them and, according to tuan, the breakpoint of an over-considerate society is nearing (pp. - ). souls in danger of being crushed by society were, in turn, gnawing away at its underbelly. there are souls that just did not fit, soul of children yearning for disease, for damage, for pain are predominant (p. ). with wickedness in their hearts, they tried to ruin their own precious lives, and they knew what they were doing. tuan thought that something had to be wrong with this picture and even in her brainwashed society people had begun to realize it (pp. - ). a boy who committed suicide said he hated this world and did not belong to the world (p. ). we argue that the high suicide rate in harmony's world is clearly a serious side effect brought about by its social institutions, healthism, super-medicine, and lack of freedom and diversity. one could argue that it is in fact medical conclaves that require emergent intervention and correction, rather than the young wouldbe-suicidal. nevertheless, the leaders of the next-generation human behavior monitoring group carried out the "harmony project" without resolving the true causes. tuan's father, who is a brain scientist, explains the "harmony project" as follows (p. ): in controlling the feedback web in the midbrain with medicules, we found we were able to influence human decisions, emotions, and thoughts. the control of human will was a hot topic with upper leader at who and some of the admedistrations. (p. ). in those days, we picked up a lot of kids like her (miach) and put them into treatment. we gathered the ones that wanted to kill themselves, especially the ones who overate or refuses to eat, the ones who wanted to watch themselves grow weak and die. our goal was to create a harmonized will inside the human brain. we call it the "harmony program." there were plenty of kids back then who had attempted suicide more than once, just as there were plenty of them now. (p. ). because their system of values is fashioned to be in perfect harmony with society, there are far fewer suicides, and the kinds of stress we find in our admedistrative society disappear completely. (p. ). to tuan, it appeared as though her father and his colleagues of the next-generation human behavior monitoring group were trying to create a self-evident person, perfectly adapted to the stresses of the administrative society (p. ). because the correctness of society is self-evident to the leaders, they attempted to alter the values of young people by manipulating their brains. in our view, this is unilateral brainwashing and cannot be ethically justified-the "harmony project" is a typical example of an unethical human experiment. as mentioned above, harmony's world makes it self-evident that health longevity has the highest value and that all members have an ethical obligation to maintain healthy longevity and world peace. the rightness of the object of strong faith would of course be self-evident and an absolute right to believers. those who believe there is self-evident truth would rarely reflect on the justification of the very truth. there is no room for doubt or reflection on the truth. for the sake of respecting self-evident truth, self-evident persons may consider it justified to physically manipulate the brain and alter the consciousness and thoughts of young individuals who cannot accept social norms. we argue that the "harmony program" is a future-world lobotomy. instead of dealing with the real cause that is disturbing and confusing the mind, lobotomy destroys the brains of the mentally ill. before concluding our paper, we present four sf works that are deeply relevant to our discussion of harmony's world, and touch on their contemporary significance in comparison with that of harmony's world. since it is beyond the scope of this paper to introduce in detail the contents of these works, we will mainly focus on backgrounds and events described in each work. these include mental therapy by means of nanotechnology, environmental manipulation, and ultimate harm to japanese society. the first two of the four is a duology, queen of angels ( ) and slant ( ) , written by american sf writer greg bear (bear (bear , . in the world of queen of angels and slant, nanotechnology has been perfected, and humans are given the ability to change their environment and themselves at a cellular level, as well as to achieve perfect mental health. in los angels, the setting of queen of angels, % of people are receiving psychiatric treatment by 'nano therapy,' a literal brain reconstruction in which tiny surgical prochines are used to alter neural pathways. nano therapy is performed to repair genetic defects and improve work, sociality, and human relationships, and to correct the behavior of criminals. in other words, the society has reached a point where effective therapy is a necessity. people are even subjected to permanent mood adjustment. the world depicted in these books is fundamentally different from harmony's world, in that no direct interventions to the mind or brain are generally performed in the latter. nanotechnology is used not only in psychotherapy but also to transform, heal, and strengthen the body. with this technology, police officers can regenerate their severely damaged bodies many times. at the same time, their wounds and diseases are instantly fixed from inside the body using medical monitors and stabilizer infusions. indeed, nanotechnology has realized an 'in-body hospital,' and in this aspect, similarities can be found with harmony's world. murderers are given 'enforced deep therapy,' a therapy that fixes and changes them. personality correction is mandatory for all criminals, resulting in a sharp decline in crime with almost zero murder cases. this therapy is similar to the harmony project in harmony's world. the latter, however, is only used as a last resort for social survival due to its side effects (i.e., deprivation of consciousness). in the world of queen of angels and slant, discrimination and economic disparities emerge between those who receive nano therapy and those who do not. contrarily, harmony's world is free of conflict and disparities. in slant, it becomes apparent that mental therapy based on nanotechnology is ineffective, and difficult-to-treat cases in which individuals repeat anti-social behaviors ("core therapy reject," often with a long criminal history) or experience relapse and worsening of conditions ("fall-out") start to appear. the harmony project in harmony's world would have been implemented to treat suicidal people as planned, had it been successful, and perhaps, its use would have been extended to people with mild mental ailments and mood disorders. if no one followed the one-man-one-kill order in harmony's world, and had the harmony project been successful as mental therapy with no side effects, a peaceful, equal 'slant' might have been realized. as described above, nanotechnology depicted in the duology has been used in the real world for treating various physical illnesses. in the near future, it may be applied to the brain, leading to the establishment of nextgeneration psychiatric surgery. the third story we introduce, from the perspective of quasi-forced environmental manipulation for the purpose of health promotion, is "ai no seikatsu (life of love) (hayashi ) ." it is a part of a collection of short stories on the theme of "creating the future," published by the japanese society for artificial intelligence with the cooperation of science fiction and fantasy writers of japan. the main character is an obese, diabetic male writer. his cohabitating girlfriend left him, as she ran out of patience due to his sloppy and irregular lifestyle. he ended up renting a furnished apartment with home appliances in a brand-new building. however, strange things start to happen in this apartment: in the morning, the curtains open automatically and coffee is made; at pm, room lights automatically turn off. when he tries to have a bowl of rice with curry and pork cutlet for breakfast at a restaurant, his smartphone all of a sudden sends a message, "stop!" he can only buy healthy food with his smartphone payment app. the writer loses weight without even knowing it, and his physical condition improves. he begins to lead a regular life. the story ends with his illness getting better, and his work being a success. as it turns out, a woman had built a self-learning system that combines ai, iot, and ict in order to improve her former roommate's lifestyle habits. this system was manipulating the furniture and household electronics, as well as the writer's smartphone. the main character of this story loses weight and becomes successful and happy. the theme here is how ai embedded in our living environment can change our lives and values without us knowing. it is a world in which people are manipulated into selecting a healthy choice unknowingly. people are constantly monitored, warned if their health condition is poor, and are restricted in terms of access to unhealthy food and products. it is a miniature version of harmony's world, in which the healthier people are, the higher their social assessment score. all is well and good, but we are left with a complex feeling about the clever manipulation, as in the case of harmony's world. the manipulation toward a healthy lifestyle depicted in this story has already begun around the world, as with the above-mentioned japanese health promotion act ( ) (okita, enzo, asai ) . lastly, "ai houkai (ai collapse)" by rintaro hamaguchi depicts the collapse of japanese society, i.e., a crisis of ultimate harm, caused by the malfunctioning of medical ai (hamaguchi ). in , japanese society is completely reliant on a medical ai called nozomi ('hope' in japanese), which has deep learning and self-learning abilities, to carry out medical examination, vital sign monitoring, data management, and physical condition management. roughly % of all japanese medical institutions have introduced nozomi in inpatient practice. patients who visit these institutions send their physical data to nozomi from their wearable devices on a regular basis, and nozomi administers insulin, provides instructions on medication, or controls cardiac pacemakers. moreover, infrastructures related to everyday life such as finance, security, and transportation are also single-handedly managed by this ai. one day, a terrorist hacks nozomi, and nozomi suddenly starts killing patients. the medical ai with the power to decide life and death, now running out of control, brings about a crisis of collapse in japanese society. the terrorist attempts to kill all incompetent people, those who cannot work, and those with low productivity-i.e., the sick, disabled, and elderly-with the aim of rejuvenating japan's super-aged society and creating a society with high economic power and no poverty via the selection of life. this story portrays the horror of ai malfunctioning, and the crisis of ultimate harm brought about by one individual. it would not be strange for something similar to happen in the future. whatever the cause, if watchme's sensor, its network, or medicare which synthesizes medicule falls out of order, a similar crisis would easily fall upon harmony's world. harmony's world aimed to establish a perfect healthy utopia and nearly completely realized this goal. we believe the creation of the world depicted in harmony to be a great work when considered solely from the standpoints of medical science and healthcare. intuitively, the healthier we are and the longer we live, the better. however, from an ethical standpoint, it is clear that there are serious issues with the medical conclave system and unacceptable measures taken to maintain it (table ) . we argue that the existence of harmony's world cannot be accepted as is. we oppose the basic idea of creating a super-healthy society at the expense of all other worthy things, in particular, our freedom, diversity, and privacy. we need to remain a free and diverse existence with the ability to make decisions about one's own life without interference. we do not want to be monitored by a watchful society, even if the intentions are good and ultimately would make us healthier. in harmony's world, even decisions about lifestyle are outsourced. any decision must always be made together with others, and thus it is no longer possible to live according to one's idiosyncratic ways. tuan says, we are expected to always keep personal information on display, to participate in admedistration discussions on morality sessions, and to make decisions only after receiving advice from the appropriate expert. (p. ). she feels that people in administrations prefer that other people decide things for them (p. ). however, in the real world, there are things which we cannot help but decide by ourselves. in harmony, a perfect example of this is the response to the one-man-one-kill declaration. regarding this order, tuan was disgusted with the society that calls for people to gather and talk about the situation. most admedistrations had called immediate sessions to discuss the declaration, but hardly anyone had shown up. what was there to discuss? this was not something you could discuss in public. this was a decision everyone had to make on their own. (p. ). thinking alone and deciding alone is sometimes important, and we should not lose the ability and will to make decisions on our own without support from others, even if it is difficult to do so. we need not be perfect. there is no end to the pursuit of perfection concerning health and longevity in our life because there is no such thing as an objectively "long enough" life-span, and because the occurrence of diseases and disorders is best kept as close to zero as possible. the higher the quality of life, the better. the lower the individual out-of-pocket payments, the better. healthcare is the subject of infinite craving. health needs and desires are virtually limitless beauchamp and childress ) . thus, the pursuit of medical perfection will inevitably end in vain and ruin our satisfaction, acceptance, and peace of mind. social solidarity is important and good, but we argue it is not something we should aim for from the beginning. on the contrary, it is something we achieve naturally and unintentionally as a result of our activities and relations with others. medicine and ethics are different, and health and good are not identical. there is no self-evident truth in our lives. although being healthy is obviously good, health should not be regarded as the only good in our lives. the monistic claim that health has the sole highest value is unacceptable to us pluralists. we consider the infinite craving for health and healthcare problematic, but survival is a more powerful craving by human nature. naturally, some people think they are better off staying alive even in poor health rather than having to face ultimate harm, i.e., the extinction of mankind. however, the validity of this claim depends on the context of poor health. for example, persson & savulescu argued the following in their discussion of ultimate harm: "something could be ultimately harmful by forever extinguishing sentient life, or by damaging its conditions so drastically that, in general, life will not henceforth be worth living (persson and savulescu ) ." therefore, we need to consider what an acceptable condition would be in which we would want to keep living. would people want to live even if in a vegetative state, or as perhaps even a robot or zombie? the answer will be different for each individual. some may not want to keep living if their condition is such that it meets the requirements for euthanasia (e.g., unbearable pain with no prospect to recover), which is practiced in the netherlands and elsewhere. however, others might not feel the same way. with the presence of a loving family, a purpose in life, and valuable memories, some people may wish to live under any physical condition. yet, for those of us who live outside the religious culture of a monotheistic personal god, it is somewhat unrealistic to think that life in any condition is a gift of god and should thus be better lived than lost. we do not understand, frankly, the meaning of "reason for being" in a state of the eternal absence of "self," self-consciousness, and free will, which is realized in the ending of harmony. it can be argued that quality of life studies, by shifting away from ends-oriented criteria such as survival rate and life expectancy and towards subjective psychometrics including our purpose and meaning of life, they propose that a patient's quality of life must be determined in relation to his or her affective preferences and would agree with our position. they translate both the medical condition affecting survival and the affective response to that condition into a common register of temporal progression: qalys. however, the body's physical well-being, i.e. survival or length of life, is taken into account only to the extent that it impacts the patient's affective experience of the time period under consideration (eatough ) . we would argue that our perception concerning our life strongly rely on the purpose and meaning of our lives to provide us with a sense of self-worth and that our sense of self-worth would naturally have a tremendous impact on our subjective estimation of quality of life, which is sometime more important than the length of life. we do not deny the great value of a healthy longevity society. naturally, we do not want to live in a world ridden with disease, disability, pain, premature death, and separation. what is needed is a world where people are adequately healthy, while avoiding harmful health worship and healthism. how can we achieve this? in our view, the answer is provided early on in harmony. the answer is "do everything in moderation." a warrior of the tuareg, one of the characters in the tribe that does not belong to any medical conclave, suggests this. he referred to tuan and her colleagues as "medicine people." below is a conversation between the warrior and tuan. you think we bow too deeply to our gods, then? warrior in a word, yes. 'all things in moderation' you say, but you do not practice it. you are so filled with your faith that you must push it upon us as well. tuan we moderates are in the minority. (pp. - ). finally, in harmony, the top leaders of the next-gen human behavior monitoring group faced a chaotic situation in which murders and suicides among citizens became frequent after the perpetrator's declaration. they were frightened of chaos, frightened of people losing their rational minds, and frightened of riots that would lead to genocide and nukes going off all over the world again. (p. ) as a consequence, they destroyed the consciousness of all members of medical conclaves, including themselves and tuan, in order to conserve the medical conclaves. in a nutshell, harmony tells us a story in which individual consciousness was deprived forever for the sake of preserving the healthy longevity society. to us, the ending suggests that we human beings should not have individual consciousness, self-consciousness, or "i" if we hope to maintain a healthy and peaceful society. we are ambivalent about the story's ending. certainly, if unhealthy foods have disappeared and a medically ideal life plan is presented and exactly followed, then we would be healthier as a group and live longer. those who are self-aware and think freely with different interests and value systems are likely to have conflicts with others and disobey medically appropriate health advice. we are also willing to admit that there are many unhealthy people who are "prematurely dead" from inappropriate lifestyles and addictions to smoking or alcohol. if this is the case, we should not simply dismiss harmony's message as completely nonsensical or fictional. nonetheless, we cannot accept harmony's ending, because a free and autonomous agent must not be used solely for any purpose. harmony's world wrongly defines good, or being ethical, as being healthy in a very monistic way. we argue that it is ethically sufficient for us to live moderately healthily and happily, so long as we remain self-aware, self-conscious, and unique. even if society needs to preserve its values, it is wrong to destroy individual consciousness. a commentator who discusses aldous huxley's two novels argued the danger of forgetting that, in our world, complete control is impossible and that it is even more dangerous to forget why we should be happy that this is so. he added that our world is pluralistic and people hold vastly different views on what a good life entails and that a peaceful pluralism is impossible (schermer ) . in conclusion, we argue that we can lead a reasonably healthy and long life in a peaceful world, so long as everything is done in moderation, we pay some attention to our health, and we are considerate to others in accordance with the no harm principle. however, our self-awareness and consciousness could lead to an unhealthy life and premature death, which otherwise could be preventable. we would rather accept the consequences than lose our free will and self-aware consciousness. another point to note is that the extent to which social control over individuals is considered acceptable changes depending on whether or not the actions of individuals have the potential to harm others. naturally, enhanced social interventions are justified if an act causes direct harm to others, or relates to murder or terrorism. but as argued above, if people have compassion for others and act in accordance with the no harm principle, the potential for ultimate harm could be reduced. our argument is not directed at nuclear weapons or bioterrorism; it is primarily a criticism of excessive health management. just because a certain number of people are unhealthy, it does not mean the whole world would collapse (although healthcare costs would be high). those who follow their own life philosophy and avoid strict health management would have to take responsibility for the consequences of their behavior. healthcare systems could be modified in such a way that, if those individuals get sick due to their own carelessness, they can get treated at their own expense. however, it should be noted that to take a stance that all diseases are to be considered an individual's responsibility overlooks one's upbringing, peer pressure, genetic predisposition, and luck as significant influencing factors. on the other hand, people with highly pathogenic infectious diseases, such as covid- , have the potential to harm others. thus, their isolation is warranted, and the restriction and monitoring of their behaviors as long as they remain infectious cannot be avoided. yet, such requirements must be kept to the necessary minimum, and human rights and social defense must always be balanced. that said, we are not advocating that each person is free to do anythig in any way they desire. we maintain that everything should be done in moderation, and that we should pay attention to our health and be considerate to others in accordance with the no harm principle. we value 'moderation,' which we consider a moral virtue. if many people embodied this virtue, our world would be a better place. we anticipate also that the likelihood of ultimate harm would decrease. according to the analects of confucius, a classic of eastern philosophy, "there is little to choose between overshooting the mark and falling short," and "supreme indeed is the mean as a moral virtue. it has been rare among the common people for quite a long time." these ideas are the basis of the 'everything-in-moderation' principle we advocate (confucius ) . some argue that human beings lack sufficient altruism, empathy for the suffering of others, and a sense of justice, and that it is difficult to cultivate those with conventional methods of education (persson and savulescu ) . unfortunately, we cannot completely deny that assertion. perhaps humans are morally imperfect and our brains cannot stop us from harming others. that said, is it permissible to perform a lobotomy on a person's brain or perform medical interventions aimed at improving morals? or, as in the case of harmony's world, to take away self-consciousness permanently from people? at this time, we cannot agree with these. furthermore, we think that the rights and wrongs of permanently depriving consciousness from people should be determined at least by democratic means, and not by a handful of people. hope for the best and prepare for the worst: ethical concerns related to the introduction of healthcare 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jurisdictional claims in published maps and institutional affiliations acknowledgements our paper has been writing under the support of human information technology ecosystem (hite). hite is a research and development (r&d) focus area delivered by the research institute of science and technology for society (ristex), japan science and technology agency (jst). conflict of interest the authors declare that they have no conflict of interest. key: cord- -y w xo authors: neto, modesto leite rolim; de souza, ricardo inácio; quezado, rosa magda martins; mendonça, elayne cristina santos; de araújo, tallys iury; luz, dayse christina rodrigues pereira; de santana, willma josé; sampaio, juliana ribeiro francelino; carvalho, poliana moreira de medeiros; arrais, tereza maria siqueira nascimento; landim, josé marcondes macedo; da silva, claúdio gleideston lima title: when basic supplies are missing, what to do? specific demands of the local street population in times of coronavirus – a concern of social psychiatry date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: y w xo background: homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. in terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. in this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? method: the studies were identified using large-sized newspapers with international circulation results: with more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop covid- (global news, ). these people face lack of sleep, malnutrition, and “extreme stress levels just to meet their daily needs”, all of which weakens the immune system. along with mental illness or substance abuse disorders, they are “incredibly vulnerable to this virus”. conclusions: health organizations are well aware of the risks involved in mental health. a large population of homeless people experience their pain and psychological distress intermittently. for low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. this is a serious concern when linked to the pandemic. severe acute respiratory syndrome coronavirus (sars-cov- ) is infecting people around the world. coronavirus disease will probably be transmitted to people experiencing homelessness. this will become a major problem, especially in north america, where there are sizable populations of people experiencing homelessness in nearly every metropolitan city in the usa and canada. in the usa, more than , people were reported to be experiencing homelessness on any given night over the past decade ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) (the council of economic advisers, ) . homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. housing advocates say they fear an outbreak could occur in large homeless encampments, where thousands of people live on the streets and lack the ability to self-quarantine, receive medical attention or access cleaning facilities (the washington post, ). the idea of police arresting homeless people, many with complex health and addiction issues, without proper testing, and placing them in detention centers, just does not sit right (bbc, ) . in terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. in this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? (sky news, ) . the plans in each country differ in scope, pace, and ambition and reflect the specific demands of the local homeless population, which has yet to report a case of covid- . whether these approaches will be effective in the long-term remains unclear. for those living in encampments scattered throughout cities or bedding down in crowded shelters, containment or mitigation might prove elusive (los angeles time, ). people experiencing homelessness not only have a set of challenges that make it really hard to do what has been asked -stay home when you are sick, wash your hands frequently, talk to your medical provider if you are feeling ill -, but also their health condition is worse than of many other people. although the coronavirus is affecting people around the world, it is imperative that we have a lens focused on the potential to endanger those living on streets (usa today, ) . but what happens when you do not have a home? how do you practice social distancing when, at best, the only barrier between you and your neighbor is a nylon tent wall? that is the question facing the homeless individuals, and one that is vexing lawmakers and public health workers as they try to prevent the spread of covid- among a particularly vulnerable segment of the population (fox news, ) . with more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop covid- (global news, ) . these people face lack of sleep, malnutrition and "extreme stress levels just to meet their daily needs", all of which weakens the immune system. along with mental illness or substance abuse disorders, they are "incredibly vulnerable to this virus. and the more obvious: they may have trouble accessing hand sanitizers and hand-washing facilities" (abc news, ). public health agencies at all levels of government have a role to play in mitigating the coronavirus effects. if public health agencies from local governments to the centers of disease control (cdc) do not have the capacity because of budget cuts or a lack of commitment, local jurisdictions will not have the tools necessary to reach out to those at risk that will be necessary to contain the virus and mitigate its effects on our most vulnerable groups (the conversation, ). in the state of washington, the number of schoolchildren on the streets increased dramatically in the past decade, now reaching about , students. a fifth of them are in seattle and king county. this is worrying and alarming for decision-making in the spaces of social psychiatry. as a whole, the homeless are disproportionately young. in the usa, in general, % are aged or older, but among those who stayed in a shelter at some point during , only . % were or older. in san francisco, % of the homeless are aged or older. in new york, % of sheltered single adults are over years old. los angeles county reports that . % of its street population is aged or older. the relative youth of the homeless is likely a macabre testament to their low life expectancy and poor health (city journal, ). spreading information, providing easier access to washing facilities and monitoring health would be a start. however, on a wider scale, this situation seems to shine a light on the ways in which, as a society, we forget about people among us who have nothing. perhaps it is time to reconsider the ethical basis of our communities and our social system. what moral nation can allow its citizens to live without shelter, safety or dignity? (the guardian, ). health organizations are well aware of the risks involved in mental health. a large population of homeless people experience their pain and psychological distress intermittently. for low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. this is a serious concern when linked to the pandemic. mlrn, dcrpl, wjs, and jmml designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript. mmm, ris, rmmq, ecsm, tia, pwgf, and jlsm reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript. mlrn, jmml, cgls and tmsna reviewed the study protocol. mmm read and screened articles for inclusion. all authors critically reviewed drafts and approved the final manuscript. the research group: suicidology -universidade federal do ceará (ufc) and brazilian national council for scientific and technological development (cnpq) -institution linked to the brazilian department of science, technology and innovation to encourage research in brazil. the authors declare that they have no competing interests. coronavirus and the homeless: why they're especially at risk, ways to stop a spread 'like wildfire coronavirus: 'safe spaces' needed for homeless to self-isolate another vulnerable population -the homeless present special challenges in the current crisis california moving homeless to hotels, in scramble to prevent coronavirus explosion on the streets coronavirus: homeless canadians need help from governments, advocates say an unexpected side effect of the coronavirus? a new urgency about helping homeless people coronavirus: how do you self-isolate if you are homeless? coronavirus could hit homeless hard, and that could hit everyone hard the state of homelessness in america the guardian, . coronavirus and the risk to the homeless fears mount about impact of coronavirus on homeless why the homeless, 'surviving the best way they can the authors would like to thank the research group: suicidology -universidade federal do ceará (ufc) and brazilian national council for scientific and technological development (cnpq) -institution linked to the brazilian department of science, technology and scientific writing lab, medicine school -universidade federal of cariri (ufca). key: cord- -o noe t authors: hurst, tom; nigam, amit title: ten minutes with tom hurst, medical director, london’s air ambulance date: - - journal: nan doi: . /leader- - sha: doc_id: cord_uid: o noe t nan i think something that has served me well is the idea of positive regard, the assumption of positive intent. this particularly holds during a difficult period where people are under significant stress and strain and we don't always know what's going on for people in the other facet of their lives. this involves looking at behaviours or issues that are raised and asking yourself 'what's the most positive possible explanation for this?' and then assuming that's the case. then you can explore it with them if you need to, rather than thinking 'they're a problem and they need to do what they're told.' that is something that has been useful for me during this…because it's all very easy to say 'don't overreact and keep calm,' but actually, what's the intellectual underpinning for that? one intellectual underpinning is you can't possibly know all of the what's going on in someone's head. you can't possibly know all the things that are relevant for that person. everyone sees this as a major challenge we're all trying to do what we think is the right thing. let's work with that as an assumption, that this makes sense for that person and that they think this is a helpful and positive contribution that they're making. i started a new leadership role as the medical director for the air ambulance in january. i had a couple of months in the early phases of the role and i was busy doing the initial engaging and meeting people and building a team. then in march the pandemic started to raise its head and it became increasingly clear we were going to have to respond to that. by mid-march i was heavily involved in working out what we were going to do. although we've been quieter in terms of volumes of patients, we've still had very sick trauma patients. there's definitely been a requirement for the service to be there, and the leadership and management workload has gone up because of the need to respond to changing requirements coming up. these were principally around ppe and working practices, risk assessments, or decision-making about how we manage different groups of patients. for example, we've had to stop flying patients in the helicopters. we're using the helicopter just to take the team to the scene, which is mainly what we do anyway in london, but it's been an impediment not be able to fly patients. i've also been managing the team in terms of people's views on what we should be doing, what we shouldn't be doing, what the right balance is on different topics. in my other role as an intensive care consultant at kings, it has been very busy. kings is one of the biggest centres in south london, and south london has been one of the highest covid- regions in the uk. kings pretty much doubled its bed base over a few weeks. my role there was very different. i basically did my clinical shifts, and then i did some additional clinical shifts as we were all doing to support the service. but i realised because i have these air ambulance leadership responsibilities, i couldn't really dip in and out of leadership stuff at kings. i very consciously decided to try and just be a follower there. i tried to just keep up to speed by reading emails and the daily bulletins, but otherwise just go in, do my shift, keep my head down, and not try and contribute too much to the tactical and strategic decision-making that was happening because there are colleagues there who are excellent, and have that as their sole focus during the pandemic. there's elements of the crisis that are like a more standard major incident, like a bomb or a big train crash. the timescale is very, very, different but the same principles apply. for example you have to put in place a command structure or a decision-making structure, and then you have to put in place a communication structure. the earlier you established that, and the earlier you established the tempo and get the tempo roughly right for the incident, then the sooner you're going to have a sense of control, accepting that the initial phase is always semichaotic. that's what i tried to do with the air ambulance. we put in place a daily whatsapp group catch-up for the leadership team and we classified a level of strain from green to amber, red and black. we had a daily four o'clock whatsapp message from the chief pilot, the chief paramedic, and so on, just to say what the services were up to. i then sent a daily email out to the whole service saying, 'right, we are green here, but amber here, and these are some key points.' we tried to get into the rhythm of doing that, and maintained it for about the first month. then a few weeks ago we stepped that down when we noted that actually the situation was much more stable. we're clearly on the downslope. people need to get some rest and recuperation. we don't all need to be whatsapping each other on a saturday afternoon if we're not otherwise at work. we stepped down to exception reporting, and then i or the clinical lead or the chief exec sends a weekly status update just say, 'this is where we are, and thanks very much. here's what we think is going to happen next week.' tom is a consultant in prehospital care at bart's health and consultant in intensive care medicine at king's college hospital. he trained predominantly in greater manchester before undertaking a secondment to london's air ambulance in . he is the medical director of london's air ambulance. we've largely stepped our decision-making command structure back to normal. we normally have a weekly ops meeting and that's seems to be an adequate tempo now. so my previous experience of attending major incidents and learning about how major incidents are managed was applicable there. one of the big leadership challenges that i've had as the medical director of the air ambulance has been that we've been less busy. major trauma's fallen by about % during the lockdown. we've got a team of people who are passionate about what they do and who are used to responding to major incidents for whom my message has been 'we can't do anything really on covid- . but we have to keep the day-to-day service running.' i think if the answer to the pandemic would have been, ' we're all going to work super hard for a week, and we're going to put every single team out that we can, and for a week we'll absolutely beast ourselves with back-to-back shifts treating covid- patients,' then everyone would have been happy. sadly there will still be interpersonal violence and there will still be road accidents, so we can't decommission the service for the duration and release the doctors and paramedics back to other roles. but for a number of people, there was a period where they were clearly desperate to do something that was directly contributory to the covid- response, but there just wasn't anything that could be done. you have to convey 'we're one service.' we treat about six people a day. there were emergency calls to the london ambulance service in a single hours' period. if our teams are busy continuously, we can probably treat patients in a hours' period. but it's super hard for some people to not to be part of this response. it's been really difficult, without sounding slightly nihilistic, to convey the message that we actually need to focus on our core job, which is looking after trauma patients. they're still there. we're quieter and it's not busy and it doesn't feel super productive, but they're still there. they still need our help. i was slightly surprised at how many people took a while to accept that the scale of the problem was such that we, as an air ambulance service, didn't have a prominent role to play that was directly focused on the pandemic. also, we've had some arguments between a couple of the team. there's this book called an astronaut's guide to life on earth. in it there's this wonderful phrase, 'expeditionary behaviours'-the sort of behaviours that keep people together in a team when they're on an expedition. it's actually really simple stuff. it's just that ability to recognise when someone's having a bad min and make them a cup of tea, and to recognise that when you thrust a whole lot of people together for a protracted period of time, really little things will become areas of tension. you need to find ways to manage yourself and manage other people and resolve it. while in most cases on our team this has been the case, there have been some exceptions. there has been lots of really good stuff. we are doing a review to think about our recovery, and recognising that there are lots and lots of things which are good. we're using a × matrix of good things and bad things that have started or stopped. for example, there are some bad things that we've stop doing, and we should resist restarting them. there are things that we have started that we should reinforce or try and make routine. as a service, we've got people that come and do our ambulance shifts from different places. a lot of our paramedics live outside of the m , so they come for that shift, but coming in for meetings or for debriefs is harder for them. using things like zoom has been good. we did a clinical governance day meeting for the whole team last week on zoom-it works really well. we're getting better attendance at some of those meetings than we did before. so that's been really good. the fact that people are in the main resilient and adaptive and finding ways around problems is really positive. the fact that we're able to identify some of the good things and say, 'we want to keep that' or 'let's do more of that' has been good. the crisis has actually brought the operational and the charity and fundraising side of the service closer together because, again, they used to operate on separate sites and now that we're doing zoom stand-up meetings there's a bit more integration. there's just a general sense of the adaptability or indomitability of the human spirit… that there has been a huge amount of stuff going, but life goes on. the things that make us human and the bonds that connect us and the basic needs that people have are still there and find expression. one of the things i said to the team was how positive i thought it was that we kept, and in some ways almost enhanced our ways of actively reaching out to people after difficult jobs and making sure that people were okay, and were debriefed and supported. in some ways when you know that you're not going to run into them incidentally, it almost gives people permission to be a bit more formal about it and to say, 'i heard there was a really bad job yesterday, do you want me to debrief it with you?' i think the positive intent stuff that i spoke about at the beginning has helped. that's been really helpful for me to just remind myself that everyone is trying to make their own way through this and that how it looks to each individual will be different. it helps me remind myself that the main thing is that we just need to be kind to each other through this difficult time and how we come out the other side of it will be largely down to how we've treated each other during it. compassion for other people starts with compassion for yourself. last year i read quite a lot of stuff by brene brown. she's written a lot on vulnerability and bravery and the impossibility of having compassion for people if you don't have compassion for yourself. she writes about the impossibility of having compassion if your response to threat is to develop armour. she's got this lovely metaphor about the extent to which people armour up to protect themselves because they think it will make life easier. then every time they get hurt they add an extra bit of armour until the point where they're just carrying so much armour that just walking through life is exhausting. brene brown is brilliant. she's an academic social worker and started out wanting to research connectedness, but couldn't really find a cohesive theory. she then started working around shame, which she defines as the pain of feeling unworthy of connection. she built from there this very compelling narrative about how fundamentally, if we're unacceptable to ourselves and we fear disconnection from other people, then that drives a whole host of addictive and pathological and dysfunctional behaviours. it is a different in the two roles. in my kings role, i've found it relatively straightforward. i've got a clear to job to do being the icu consultant on call, and more than ever i just need to run my unit and when someone rings me up and says there's a patient coming i just say, 'yes, fine. tell me what i need to know about them and what you want me to do.' what i want from operational leaders is basic, timely, concise, helpful communication. stepping into the medical director role has been really interesting because i have a chief executive and a board chairman and then other trustees on the board. what i'm looking for there is very different. that's really about development and an opportunity to flourish in that role. i want to have quite a lot of autonomy, and to be able to lead the service and evolve the strategy, and for the interactions with my leaders there to be supportive and formative. i want to be able to benefit from their experience but not in a way that's directive or didactic contributors th, the interviewee, was responsible for the main content that was written up. an interviewed th, and used his words to craft the written interview. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. an astronaut's guide to life on earth. toronto: random house daring greatly: how the courage to be vulnerable transforms the way we live, love, parent, and lead braving the wilderness: the quest for true belonging and the courage to stand alone patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. key: cord- -oyfx ij authors: thunstrÖm, linda; ashworth, madison; shogren, jason f.; newbold, stephen; finnoff, david title: testing for covid- : willful ignorance or selfless behavior? date: - - journal: nan doi: . /bpp. . sha: doc_id: cord_uid: oyfx ij widespread testing is key to controlling the spread of covid- . but should we worry about self-selection bias in the testing? the recent literature on willful ignorance says we should – people often avoid health information. in the context of covid- , such willful ignorance can bias testing data. furthermore, willful ignorance often arises when selfish wants conflict with social benefits, which might be particularly likely for potential ‘super-spreaders’ – people with many social interactions – given people who test positive are urged to self-isolate for two weeks. we design a survey in which participants (n = ) choose whether to take a costless covid- test. we find that % would take a test. surprisingly, the people most likely to widely spread covid- – the extraverts, others who meet more people in their daily lives and younger people – are the most willing to take a test. people's ability to financially or emotionally sustain self-isolation does not matter to their decision. we conclude that people are selfless in their decision to test for covid- . our results are encouraging – they imply that covod- testing may succeed in targeting those who generate the largest social benefits from self-isolation if infected, which strengthens the case for widespread testing. covid- rapidly developed into a pandemic, and by march , the usa had the highest reported number of infected people in the world. a general message from public health experts is that effective control of the spread of covid- requires widespread medical testing (who, ) . the testing will serve to determine whether people are infected or not, and ideally also if they have been infected and have reached immunity status. three reasons motivate widespread testing. first, if a person learns that they are infected, they can take appropriate measures to reduce the probability of infecting others, such as the recommended -day self-isolation (harvard medical school, ) . second, the data provided by widespread testing will better inform the need for the current social distancing policies (e.g., sheltering at home, avoiding gatherings of or more people, keeping at least feet away from other people and temporarily closing schools, universities, daycare centers, major sports leagues, cultural events and public spaces) (stock, ) . third, testing provides data about the asymptomatic rate in the usa (the share of infected people who show no or very mild symptoms) and insight into how close americans are to developing herd immunity to covid- . this information is useful in order to determine when and where it makes sense to relax these costly social distancing measures. while the usa has increased its capacity to conduct more testing, around . % of the population had been tested by april (covid tracking project, ) . the effectiveness of testing in controlling covid- depends largely on how the tests are conducted. the ideal scenario is to test everyone, but that is infeasible. a second-best scenario is random sample testing (stock, ) . but for random testing to be effective, all sampled people would either need to voluntarily agree to be tested (which is unlikely, as we explain) or be forced to do so (which is illegal in the usa). the third-best (and first-best feasible) strategy is voluntary random testing. this strategy, however, could lead to a systematic selection biaswe will only test those individuals who prefer to learn their health status regarding covid- ; a significant fraction of people might not want to know. these individuals might find that their private costs outweigh any social benefits from not infecting others. this implies that they might want to avoid testing. if their private costs include above-average opportunity costs of social interactions, then individuals who decline to be tested may also be disproportionately likely to become superspreaders. to understand why this might happen, consider the ongoing literature on willful ignorance of health information (also called strategic ignorance). while standard economic theory suggests people never ignore information that enables them to adjust behavior (stigler, ) , many new studies find that people willfully ignore medical diagnoses, even when such knowledge would enable them to adjust behavior to better accommodate their health condition (sharot & sunstein, ) . for example, we see willful ignorance in many people at risk for breast cancer (thompson et al., ) , alzheimer's disease (cutler & hodgson, ) , hiv (hightow et al., ) and huntington's disease (oster et al., ) . the study by ganguly and tasoff ( ) is particularly relevant: they observe people will avoid a costless test for herpesa disease for which there is currently no cure, but for which information is useful in that it helps adjust behavior. people have also been found to willfully ignore health risk information, such as calories in food (thunström et al., ; woolley & risen, ; sunstein, ; thunström, ; nordström et al., ) . willful ignorance of health outcomes is likely to arise when people are torn between what they think they should do and what they want to do (thunström, ; woolley & risen, ) , or when ignorance allows them to form optimal expectations (downplay the probability of a bad health outcome; oster et al., ; nordström et al., ) . for instance, a person may think she should eat healthy, but want to indulge in ice-cream-she might then choose to avoid learning about the exact amount of calories in the ice-cream in order to avoid either her inner pressure to reduce the ice-cream consumption or the guilt from consuming it despite being aware of the calorie content. in this paper, we explore self-selection in covid- testing in the usa. we examine if people willfully avoid getting tested for covid- , and, if so, what individual or household characteristics and circumstances are associated with testing avoidance. given that random voluntary testing is not yet available in the usa, there are no observational data to rely on for our analysis. we therefore design a hypothetical randomized controlled trial (rct). we recruit a nationally representative sample of participants. the study entails two treatments, across which we vary information about the potential emotional cost of testing before asking if participants would agree or disagree to a financially costless covid- test. in the baseline treatment, we inform participants that if they are found to be infected, they are urged to self-isolate at home for days. in the high-cost treatment, we tell participants that those who test positive are strongly urged to self-isolate, which may be in a self-quarantine site away from home. we assume the test itself is costless and that the only cost incurred from a covid- test is the recommended self-isolation for days should the test come back positive. if people are concerned only with their private benefits and costs from taking a covid- test, those with large private benefits and low private costs from knowing that they are infected will be the most likely to get tested. private benefits are significant for people at elevated risk for severe health consequences if they contract the virus or with family members at higher risk, while private costs are low for those who generally live a solitary life, professionally and in private. we expect elderly and those who haveor have a family member that haspre-existing conditions to be more willing to test. furthermore, we expect those at the lowest risk of losing out financially (e.g., risk to labor income or health care costs) or emotionally from self-isolating (i.e., if they are introverts who attach a low value to social interactions) to be the most willing to get tested for covid- . in contrast, if people are concerned only with social benefits and costs, we would expect those most at risk of exposing others to be the most likely to get tested (e.g., potential 'super-spreaders'; i.e., people with jobs that entail mixing with other people, people living in urban areas, young people and people who are extroverts and attach a high value to social interactions). people with the potential to be super-spreaders might be torn about learning whether they are infected by covid- . both private costs and social benefits from being urged to self-isolate for the next days (harvard medical school, ) might be high for this group, and so influence their testing decision in opposite directions. for example, consider the behavior of an extrovert who values social interactions highly. if unsure of being infected, the extrovert behaves just as if she is not infected (e.g., as found for huntington's disease, by oster et al., ) . self-isolation means this person needs to give up highly valued social interactionsa factor that might deter them from a voluntary test for covid- . at the same time, their self-isolation provides particularly meaningful private and social health benefits from reduction in exposure to, and spread of, the disease. these benefits to learning whether they are infected might encourage them to voluntarily test. it is an open question if the benefits outweigh the costs, causing the extrovert to take a costless covid- test. similarly, imagine a store clerk who risks losing income if self-isolating for days. the potential private loss of income would deter them from testing, while the social benefits from reducing disease spread would encourage taking the test. again, the decision to test becomes an open question. previous studies show that willful ignorance arises when prosocial behavior is privately costly (dana et al., ; conrads & irlenbusch, ; onwezen & van der weele, ; gigerenzer & garcia-retamero, ; grossman & van der weele, ) . in this study, we find that around % of people want to take a costless covid- test. as might be expected, people who worry more about their health are particularly likely to want to take the test. we also find that those most likely to want to take the test are those most likely to spread the virus if unaware of their infection, including young people and extroverts with a preference for socializing. extroverts might also be at the highest risk for being infected, but even when we control for personal risks (amount of social interactions and worry about own health), we find they are more willing to test. the ability to afford to self-isolate for days does not seem to affect the willingness to test. our results suggest that there is a significant amount of selflessness in the decision to test; people appear to be highly concerned about the social benefits from testing for covid- and little concerned about private costs. in addition, we do not find the expected treatment effect of our experimental manipulation of the private cost to testing (i.e., the location of self-isolation (at home or in a facility away from home) does not seem to matter to the testing decision). our expectation was that willful ignorance would be higher if selfisolation might take place away from home, since we assume self-isolation away from home is perceived as more costly. one interpretation of the lack of expected treatment effect is that it lends further support to the idea that private costs play a negligible role in the decision to test for covid- . our results matter because they underscore the value of widespread covid- testing, even if such testing cannot be done randomly. our findings suggest that widely available and costless voluntary testing will target rather than scare off those most likely to be 'super-spreaders'. to test people's willingness to take a financially costless covid- test, we designed a hypothetical field experiment. the experiment is a rct with a between-subjects design, consisting of two treatments. in the first treatment (treatment baseline), participants were told they would be urged to selfisolate at home, if having tested positive. in the second treatment (treatment high cost), they were told they might be urged to self-isolate at a special site away from home. participants (n = ) were recruited by the research firm qualtrics, and the sample was required to be nationally representative along the dimensions of gender, age, education, race, income and residential region (east, west, north or south). while the recruitment costs from qualtrics are higher than when recruiting from amazon mechanical turk or turk prime, qualtrics continuously quality checks participants, which enabled us to avoid many issues that may otherwise contaminate online panels (e.g., see chandler & paolacci, ; sharpe wessling et al., ) . participants received standard qualtrics compensation to participate in a survey. testing for the sequence of the experimental study was as follows: step : all participants were asked screening questions at the front end of the survey about their gender, age, education, race, income and region in order to ensure the sample met us national quotas for those characteristics. step : participants were asked whether they had already been tested for the covid- . if 'yes', they were asked why they got tested, the outcome of the test, how many days prior to survey participation they had taken the test and if the test was costly. if 'no', they were randomized into one of the two treatments and asked about their willingness to take a test. specifically, if in treatment baseline, they received the following information: currently, us authorities are working to test more people for the coronavirus. legislators are urging people who test positive, i.e., are found to be infected by the virus, to self-isolate at home for days. if in treatment high cost, they were instead told: currently, us authorities are working to test more people for the coronavirus. legislators are urging people who test positive, i.e., are found to be infected by the virus, to self-isolate for days. some states have started building self-quarantine sitessites where people who have the virus would be isolated for days. if people stay at those sites, it is easier to ensure they comply with the guidelines to self-isolate. thereafter, participants in both treatments were asked: if you were given the opportunity to take a coronavirus test for free within the next days, would you take the test? default alternatives to get or not get information have been shown to affect observed choices of ignorance (grossman, ) . to avoid nudging participants toward any particular answer, there was no default alternative; participants needed to choose either "yes, i would take the test," or "no, i would not take the test." step : all participants were asked about their current level of social distancing (how many people outside their household they had been within feet of in the last days; how many gatherings with more than people they had participated in; and self-assessed level of compliance with social distancing). they were also asked whether they supported the public recommendations for social distancing in general. step : participants were asked questions about factors that might affect the perceived cost of a positive covid- test (implying social isolation for days), as well as the perceived benefits from being able to make behavioral adjustments. they were asked about their job situation, job security and possibility of the main income provider in the household taking sick leave; risk factors for contracting the virus (e.g., living in a urban area, working in a health care facility, working in a grocery store or pharmacy); risk factors (for self or any children) for suffering severe health consequences if contracting the virus (e.g., underlying health conditions that increases the risk, such as cancer, obesity, diabetes, etc.); level of extraversion (francis et al., ) ; and social lifestyle. step : participants were asked about religious belonging, religiosity, political affiliation and social and fiscal conservatism (everett, ) . the full survey can be found in the online supplementary material. of our total sample, participants stated that they had already been tested, while stated that they had not already been tested. we asked those who had been tested for the primary reason they had taken the covid- test. table shows their answers. as expected, given the current prevailing strategy in the usa of focusing the limited testing on people who are symptomatic, most people got tested because they themselves showed symptoms (almost %) or because someone close to them either showed symptoms or was diagnosed with covid- (around %). summary statistics for the participants who had been tested before participating in our study are shown in the online supplementary material. our analysis focuses on the participants who stated that they had not been tested for covid- . due to a coding error in the survey at the beginning of the data collection, seven participants did not respond to the question on whether they were a business owner, employed or unemployed. we dropped these seven participants from our analysis, and we were left with observations. table presents the summary statistics for these participants. unless otherwise stated, all of the remaining analysis focuses on the results for this group of participants. table shows that % of participants who had not yet been tested for covid- are female. the variable age describes a participant's age in years, and the mean age in our sample is years. the variable high-risk age is a dummy variable that takes the value if a person is aged years or older. table shows that % of our participants are aged years or older. the variable rural area takes a value if participants stated that they live in a rural area and if they live in an urban area. table shows that % of our participants live in a rural area. the variables emotional tolerance and financial tolerance are dummy variables that take the value if the participant answered that the maximum time (from the time of taking the survey) he/she would be able to emotionally or financially sustain social distancing was days or longer, given the -day recommended time to self-isolate if you test positive for covid- . these variables take the value if their stated maximum time was days or less. table shows that % of participants stated that they can afford to continue their testing for covid- current level of social distancing for days or more, while % stated that they can emotionally tolerate another days or more of their current level of social distancing. the variable lifestyle impacthealthy is an index that measures the extent to which social distancing has changed participants' behavior in a healthier direction. participants were assigned a value for each of the following: if they stated that social distancing had (a) increased consumption of vegetables, (b) decreased in-between-meals snacking (excluding fruits and vegetables), (c) increased time spent in green spaces, (d) increased time spent doing strenuous or (e) moderate exercising and (f) reduced stress. this variable could take a value between and , where higher values represent healthier changes. the variable lifestyle impactunhealthy is an index that measures the extent to which social distancing has changed behavior in an unhealthy direction. participants were assigned a value for each of the following: if they stated that social distancing had (a) decreased consumption of vegetables, (b) increased in-between-meals snacking (excluding fruits and vegetables), (c) decreased time spent in green spaces, (d) decreased time spent doing strenuous or (e) moderate exercising and (f) increased stress. this variable could also take a value between and , where higher values represent a higher number of unhealthy changes. the summary statistics in table suggest that social distancing has led to more unhealthy behavior than it has healthy behavior, as implied by the lower mean value of lifestyle impacthealthy. we note, however, that these variables are crude measures of the lifestyle impact from social distancing, where each change is given equal weight, although some changes might have a more important health effect than others. the variable business impact takes a value if a participant is a business owner whose business has experienced negative impacts due to covid- , such as their operation losing income, going out of business or being at risk of going out of business. the variable employer impact takes a value if a participant is an employee and his/her employer has experienced a negative impact due to covid- , such as their employer losing income or being at risk for going out of business, if they had experienced pay cuts, reduced working hours or were on unpaid leave as a result of the virus. table shows that of participants who are business owners, or where until a month ago (n = ), % had experienced a negative impact on their business from covid- . of participants who are employees, or were until a month ago (n = ), % had experienced a negative impact on their job security, payment or employer revenues. the variable social distant compliant - feet measures how many people a participant has been close to in the last days. participants could state 'none', person, - people, - people, - people, - people, - people, - people or 'more than people'. we assigned participants the midpoint of the range they picked. for those in the highest range ( and more), we assumed the same size interval as the second to highest interval (i.e., we assumed an endpoint of the last interval equal to people). table shows that the average number of people that participants had been close to during the last days, besides their household members, was . . although not reported in the table , the median was . . the variable social distant compliantgroups measures how many times during the last days a participant has been in a room with or more people. participants could state a value anywhere between zero and ' or more times'. the median of this variable is . table shows that participants on average had been in a room with or more people around . times during the last days. the variable self health risk measures the sum of underlying health conditions that would put the participant at higher risk for developing severe health consequences if becoming infected with covid- . these health conditions include chronic respiratory conditions, heart disease, neurological conditions, diabetes and obesity (cdc, ). the variable child health risk measures the same sum of underlying health conditions for a child in the household. the variable worry about own health is based on the stated extent to which participants worry about their own health due to covid- , where the value indicates 'not at all' and the value indicates 'a lot'. the dummy variable insurance takes a value if a participant states that he/she has private health insurance or is covered by medicare or medicaid and if the participant stated not having any coverage. table shows that % of participants have insurance or medicare or medicaid coverage. the dummy variables republican, democrat and other political party take a value if a participant identifies as republican, democrat or neither, and otherwise. about % of participants identify as republican, % as democrat and % as other. that they had been placed on unpaid leave; and % of workers said that they had had their pay reduced. the variable extrovert is based on the extraversion scale developed by francis et al. ( ) and includes participants' answers to questions such as "are you a talkative person?" and "can you easily get some life into a rather dull party?" in addition to the extraversion scale, we also asked participants to indicate their level of agreement with statements about their general social lifestyle, such as "my social life is very important to me," and "in my spare time, my favorite thing to do is to spend time with friends." if the participant answered yes to three or more of these questions, they were assigned a for the extrovert dummy variable. the answers to these statements were, however, highly correlated with the extraversion scale, so they were excluded from our analysis because they provided little or no additional information. when we pool participants from both treatments who had not been tested prior to participating in our study (n = ), we find that % of participants would be willing to take a costless covid- test. we find no difference in shares of participants willing to test across treatments (pearson χ ( . ); p = . ), suggesting that the location of self-isolation (at home or in a facility away from home), in the event the test comes back positive, is not an important determinant of people's willingness to test for covid- . not only is the treatment effect small, it is also of the unexpected signthe share of people willing to test if self-isolation would happen at home is smaller ( %) than the share of people willing to test if self-isolation might happen at a facility away from home ( %). if anything, people might be slightly more inclined to test if a positive result could lead to isolation away from home (potentially due to this also signaling the greater severity of the covid- situation), but the size of the effect is too small for us to detect with our sample size. we have ruled out participants who stated that they would prefer not to take the test ( / ) were asked for their reasons not to want to take the test. they were given the following alternatives and were asked to mark all that apply: "i would not change my behavior if i learned i had the virus" ( %); "i do not want to self-isolate for days" ( %); "my job prevents me from self-isolating for days" ( %); "i think i have already had the virus" ( %); "it would cause me emotional discomfort if i knew i had the virus" ( %); "it doesn't matter to me if i get tested or not" ( %); other ( %). the numbers in parentheses show the shares of participants who agreed with the statement. as shown, a large share of participants stated that the test would not matter, and that they would not change their behavior anyway. a potential reason for the prominence of these reasons could be that they are already highly complying with social distancing. (table shows that the more people comply with social distancing, the less likely they are to want to take a covid- test.) however, a large share also states 'other', suggesting that the alternatives presented to our participants did not cover the full range of reasons as to why people may refrain from testing. we encourage future research to further explore these reasons. that this absence of identifiable average effect masks any potentially 'rational' heterogeneity in the population (i.e., we have explored whether there exists a treatment effect for subgroups of the population, such as those with children, higher-quality homes (as measured by income) or health anxiety (as measured by underlying health conditions)). one interpretation of the absence of treatment effect is that people assign little weight to the personal cost associated with the location of self-isolating when they decide on whether to take a covid- test. we pool participants from both treatments and examine the determinants of willingness to test. we estimate a probit model. table shows the resulting average marginal effects. concerns about own health are captured by the variable worry about own health. the results in table imply that the more a person worries about their health due to covid- , the more likely they are to take a test. the inclusion of this variable in our model also renders the coefficient for the variable that measures underlying health conditions (i.e., self health risk) small and statistically insignificant (if worry about own health is excluded from the regression, self health risk has the expected positive, and statistically significant, effect on willingness to test). we do not find that people with children who have underlying health conditions are more likely to take the test, perhaps due to the expectation that people of young age are less affected. this result remains robust if we recode the variable child health risk into a dummy variable that takes the value if any child in the household has one or more underlying health conditions. variables that affect a person's financial situation do not seem to matter to the willingness to take a covid- test. in particular, we do not find an effect from business impact or employer impact. we examine the robustness of these findings to alternative measures of business and employer impact. first, we instead include the multitude of variables underlying business impact and employer impact in the regression model (see footnote ), but we do not find an effect from any of those variables that is close to statistically significant at even the % level. furthermore, we do not find an effect on willingness to test from financial tolerance. second, we recode the variables such that they range from little impact to severe impact (ranging from if a business owner or employee has experienced no adverse effects from covid- , to one or multiple effects). again, we find no statistically significant effects from these variables on the willingness to test. taken together, these results suggest that people do not consider their own private costs from a positive test when deciding on taking a covid- test. similarly, we find no effect on the willingness to test from emotional tolerance, implying that the private emotional cost from social isolation in the event of a positive test might not affect the decision to take a covid- test. we find that healthy younger people are more likely to take a test than healthy older people, as implied by the negative parameter estimate for high-risk age. this age effect is consistent with findings in other studies that standard errors in parentheses. *p < . , **p < . , ***p < . . observe older people avoid health-related information more than younger people (thunström et al., ; gigerenzer & garcia-retamero, ) . while this result could imply that older people are more likely to be willfully ignorant, it is also in line with the idea that those with more social interactions (younger people) are more likely to get tested. studies find that people below years old have more social contacts, and therefore are more likely to transmit infectious diseases (mossong et al., ) . furthermore, we find that those who have met more people during the last days are more willing to take the test, as suggested by the negative parameter estimate for social distance compliant - feet. furthermore, the potential 'super-spreaders'the extrovertsare more likely (by %) to take a test compared to the introverts. taken together, this suggests that social benefits weight heavily in people's decisions to test; those most at risk to spread covid- are the most willing to get tested. we find that republicans are % less likely than democrats to get tested. we speculate that this might be due to different information sources and because the risks of covid- might be portrayed differently in liberal and conservative popular and social media. we examined the robustness of this result by including a conservatism scale (everett, ) in the probit regression, and the result remains the same: people who are more conservative are less likely to want to take a covid- test. the conservatism scale is, however, not included in the final model, given its high correlation with the political dummy variables. finally, we find that people with health insurance, or coverage from medicare or medicaid, are around % more likely to take the test. this result might suggest that people who lack health care coverage use willful ignorance as a means to reduce anxiety about how to deal with a diagnosis. this would be in line with previous studies that suggest willful ignorance of health diagnoses may be motivated by the drive to reduce anxiety about the future (e.g., oster et al., ) . our results are robust to the inclusion of other explanatory variables, such as race, education, income and profession with high exposure to infected people (health care worker, store clerk, etc.). but these variables lack explanatory power or are highly correlated with other explanatory variables included in table . the tests conducted prior to participating in our study were neither randomly offered to people (so far, testing for covid- in the usa has been primarily of individuals who showed symptoms), nor costless ( % of those who had tested prior to participating in our study stated the tests were financially costly and % said testing was time consuming). the value of data on observed testing is limited when it comes to helping us understand whether people might purposefully ignore such tests. while acknowledging that, we still compare our identified determinants of testing in table to the determinants of having taken a test before participating in our study (see online supplementary material). while the levels of statistical significance vary, all coefficients are of the same sign as those in table , except for four variables. having taken a test before participating in our study seems to be positively affected by having spent more time in groups with or more people (i.e., social distance compliantgroups), as well as by a child having underlying health conditions (i.e., child health risk). employer impact has a (weakly) statistically significant positive effect on testing prior to participating in our study, while it is not statistically significant in table . insurance is not a statistically significant determinant of having been tested prior to participating in our study, while it does have an effect in table . widespread testing is one of the most important actions that us governments at any level can undertake to help slow down the spread of covid- . given budget and testing supply constraints, it is likely that random, but voluntary, testing will be the most effective policy. we design a survey to examine the risks from self-selection into taking a covid- test. overall, we observe that around % of people would agree to a costless covid- test. we find that people who are more worried about their own health due to covid- are more likely to test, as are young healthy people, relative to older healthy people. ability to afford self-isolation for days does not seem to affect the decision to test. furthermore, people who worry more about their health, and people with health insurance or health coverage through medicare or medicaid, are more likely to take the test, as are people identifying as democrats compared to republicans. contrary to our expectation, we also find that potential 'super-spreaders' are more likely than other individuals to agree to a costless covid- . it could be that extroverts are more willing than expected to take a covid- test because their private cost of doing so is unusually low due to the broadly implemented social distancing at the time of data collection for this study. if extroverts are already relatively isolated (i.e., due to a stay-athome order and mandated closures by the state governor of public spaces, such as gyms, restaurants and bars), the personal cost of testing might be low. furthermore, extroverts might be more likely to get infected if they socialize more, which could be a 'selfish' motivation to get tested. however, we control for the current level of compliance with social distancing, which should address both of these private motivations for increased probability of testing, and we find that people who comply more are less motivated to take the test. we also control for their worry about own health due to covid- . even so, the positive effect on willingness to test from being an extrovert persists. we therefore conclude that the positive effect of being an extrovert on willingness to test for covid- is likely due to social health benefits weighing more heavily in their decision than their private costs from potential self-isolation for days, should the test come back positive. the importance of the prosocial motive in determining covid- testing is consistent with the results of the study by jordan et al. ( ) , who find that prosocial messages are more effective than self-interested messages in promoting behavior that prevent the spread of covid- (e.g., hand washing, hand shaking, hugging). our results suggest that the risks of adverse selection (in terms of failing to target the people most likely to spread the virus) in testing for covid- might be fairly low. this underscores the value of widespread testing, even if it cannot be truly random, and the importance of making such testing available nationwide in the usa as soon as possible. an important shortcoming of our analysis is that it builds on hypothetical survey data. it is well documented that survey answers may be affected by a 'hypothetical bias', meaning that people answer one way in a survey and behave in a different way when faced with real, incentivized decisions. this risk pertains to our study as well, and the hypothetical bias might be particularly pronounced if the choice to test for covid- is regarded as prosocial. several studies suggest that a hypothetical bias is particularly likely when measuring prosocial behaviorpeople often exaggerate the extent to which they engage in such behavior (e.g., murphy et al., ; vossler et al., ; jacquemet et al., ) . furthermore, it is possible that personal costs to the testing decision are less salient in a hypothetical context. once testing is more widespread in the usa, it will be important to examine who actually chooses to get tested, and the extent to which they deviate from the general population. that said, hypothetical and incentivized behavior generally correlate, such that an analysis like ours can provide important insights into the potential pitfalls of voluntary testing, prior to the actual testing. this is useful information to have on hand when designing an efficient and costeffective testing strategy. to view supplementary material for this article, please visit https://doi.org/ . /bpp. . l i n d a t h u n s t r Ö m e t a l . what you can do if you are at higher risk of severe illness from covid- lie for a dime: when most prescreening responses are honest but most study participants are impostors strategic ignorance in ultimatum bargaining most recent data to test or not to test: interest in genetic testing for alzheimer's disease among middle-aged adults exploiting moral wiggle room: experiments demonstrating an illusory preference for fairness the item social and economic conservatism scale (secs)', plos one the development of an abbreviated form of the revised eysenck personality questionnaire (epqr-a): its use among students in england, canada, the usa and australia fantasy and dread: the demand for information and the consumption utility of the future cassandra's regret: the psychology of not wanting to know strategic ignorance and the robustness of social preferences self-image and willful ignorance in social decisions coronavirus resource center failure to return for hiv posttest counseling in an std clinic population preference elicitation under oath don't get it or don't spread it? comparing self-interested versus prosocially framed covid- prevention messaging social contacts and mixing patterns relevant to the spread of infectious diseases a meta-analysis of hypothetical bias in stated preference valuation strategic ignorance of health risk: its causes and policy consequences when indifference is ambivalence: strategic ignorance about meat consumption optimal expectations and limited medical testing: evidence from huntington disease how people decide what they want to know mturk character misrepresentation: assessment and solutions the economics of information random testing is urgently needed ruining popcorn? the welfare effects of information psychosocial predictors of brca counseling and testing decisions among urban african-american women strategic selfignorance welfare effects of nudges: the emotional tax of calorie menu labeling truth in consequentiality: theory and field evidence on discrete choice experiments closing your eyes to follow your heart: avoiding information to protect a strong intuitive preference report of the who-china joint mission on coronavirus disease we thank the stroock fund for financial support. this study was approved by the irb at university of wyoming and was pre-registered in the aea rct registry (rct id: aearctr- ). key: cord- - jolt r authors: joensen, l. e.; madsen, k. p.; holm, l.; nielsen, k. a.; rod, m. h.; petersen, a. a.; rod, n. h.; willaing, i. title: diabetes and covid‐ : psychosocial consequences of the covid‐ pandemic in people with diabetes in denmark—what characterizes people with high levels of covid‐ ‐related worries? date: - - journal: diabet med doi: . /dme. sha: doc_id: cord_uid: jolt r aim: to map covid‐ ‐specific worries and overall psychosocial health among people with diabetes in the initial phase of the covid‐ pandemic in denmark, and to explore characteristics of people with diabetes and high levels of worries related to the covid‐ pandemic. methods: a cross‐sectional survey was conducted by distributing online questionnaires to adult members (> years) of two user panels consisting of people with diabetes who have volunteered to share information about their life with diabetes. the questionnaire included items on covid‐ ‐specific worries as well as such worries related to diabetes, sociodemographic and health status, social relations, diabetes‐specific social support, diabetes distress and changes in diabetes‐specific behaviours. responses were analysed with descriptive statistics and logistic regressions. results: people with diabetes have covid‐ ‐specific worries related to their diabetes. more than half were worried about being overly affected due to diabetes if infected with covid‐ , about one‐third about being characterized as a risk group due to diabetes and not being able to manage diabetes if infected. logistic regressions showed that being female, having type diabetes, diabetes complications and diabetes distress, feeling isolated and lonely, and having changed diabetes behaviours were associated with being more worried about covid‐ and diabetes. conclusion: people with diabetes have covid‐ ‐specific worries related to their diabetes which is associated with poorer psychosocial health. these worries should be addressed through support targeting specific questions and needs of individuals with diabetes as well as frequent updates on new knowledge regarding covid‐ and diabetes. spread of coronavirus disease (covid- ) was declared a global pandemic by the world health organization (who) on march [ ] . for most people, covid- will cause only mild symptoms similar to a common cold, but it can also cause severe respiratory infections and multi-organ failure [ ] . the covid- outbreak started in in the hubei province, china in december . since then, the virus has spread rapidly to multiple countries across the globe within a very short space of time. in denmark, all schools and childcare services were closed on march, employees in the public sector with non-critical roles were sent home and a ban on gatherings of more than people was issued. care services were adapted to handle the covid- pandemic not only by increasing capacity to treat people with covid- , but also by avoiding spread of the virus between healthcare professionals and patients [ ] . the covid- outbreak and associated mass media coverage about the course of the pandemic worldwide and the frightening mortality levels in some countries are expected to increase the prevalence and change the character of psychological problems, including anxiety, depression and stress among citizens in affected countries [ ] [ ] [ ] . previous studies have highlighted the psychological impact of quarantine, which can cause post-traumatic stress symptoms, confusion and anger [ , ] . stressors related to quarantine include fear of infection, frustration, boredom, inadequate supplies, inadequate information, financial loss and stigma [ ] . during the covid- outbreak in china, a survey of respondents found that half rated the psychological impact of the outbreak as moderate or severe; % reported moderate to severe depressive symptoms; % reported moderate to severe anxiety symptoms; and % reported moderate to severe stress levels [ , ] . the study showed that people with chronic illness experienced greater stress, anxiety and depression compared with people without chronic illness [ ] . an increase in generalized fear has also been documented during other outbreaks such as sars in and spread of the ebola virus in [ ] . the psychological responses were particularly high among high-risk persons [ ] . it is well-established that diabetes under 'normal' conditions can have a significant and negative effect on quality of life. around % of people with diabetes experience diabetes distress as well as an increased prevalence of a range of psychosocial problems, including depression, anxiety, eating disorders and general stress compared with the general population [ , ] . the psychosocial consequences of the covid- pandemic may add to the burden of psychosocial problems of people with diabetes. the aim of this paper is: ( ) to map overall psychosocial health and covid- -specific worries among people with diabetes in the initial phase of the covid- pandemic in denmark; and ( ) to explore characteristics of people with high levels of worries related to the covid- pandemic. a cross-sectional survey was conducted by distributing online questionnaires to adult (> years) members of two user panels at steno diabetes center copenhagen and the danish diabetes association, respectively. the user panels consist of people with diabetes, who have volunteered to share information about their lives with diabetes. panels comprise people from all parts of denmark with type and type diabetes, latent autoimmune diabetes of adulthood (lada), gestational diabetes (gdm) and other rarer types of diabetes. thus, the panels represent people with diabetes who are treated in different primary and/or secondary care settings across denmark. invitations containing a link to the online questionnaire and written informed consent were sent to all members of the user panels via e-mail. the questionnaire was open for response seven days from the distribution date and a reminder was sent out if a response had not been recorded within the first three days. the study was approved by the danish data protection agency (p- - ). the questionnaire was developed in close collaboration with a person with diabetes and professional communication people working with patient involvement in diabetes care. this was done to ensure appropriate wording of normative items in the questionnaire to avoid inducing unnecessary worry or anxiety in the surveyed population. alongside with items on covid- -specific worries, the questionnaire included items on sociodemographic and health status, social relations, diabetes-specific social support, diabetes distress as well as changes in diabetes-specific behaviours. the generic mental health questions were developed as part of a larger danish data collection initiative 'standing together-at a distance: how danes are living with the corona crisis' (https://coronaminds.ku.dk/). the specific questions used in this study are listed in table s . items on covid- -specific worries included one question measuring general worries due to the covid- pandemic :'how worried are you about the corona-crisis on a scale from to ?', and a yes/no list of ten potential diabetesrelated worries due to the covid- pandemic. sociodemographic and health status items included age, gender, type of diabetes, complication status and latest hba c measurement as well as questions about whether the respondent had other chronic or mental illnesses. items regarding whether relatives or respondents themselves had experienced covid- symptoms or been diagnosed with covid- with or without hospitalization were also included. measures of social relations included general and diabetesspecific loneliness and diabetes-specific social support. general loneliness was measured with the three-item ucla loneliness scale [ , ] with response categories 'never/rarely', 'sometimes' what's new? • little is known about how worldwide pandemics affect the psychosocial health of people with diabetes. • this study showed a high prevalence of diabetesspecific worries related to covid- , especially fear of being overly affected by the virus, labelling of people with diabetes as a high-risk group, and inability to manage diabetes if infected. • female gender, type diabetes, diabetes complications, isolation, loneliness, high diabetes distress and behaviour changes were associated with being more worried about covid- and diabetes. • when providing information and support to people with diabetes in time of crisis, attention should be payed to crisis-specific worries in specific groups. and 'often', providing a total score from to . diabetes-related loneliness was measured with two questions developed for a previous qualitative pilot study [ ] and took the same format as the ucla loneliness scale. the questions measured: ( ) if the respondents missed someone to talk to about diabetes; and ( ) whether they felt alone with diabetes. the questions on loneliness were accompanied by a -to -point scale about the degree of feelings of isolation. diabetes-related social support from family, friends, people at work, healthcare professionals, other people in the community and people on social media was measured with questions inspired by the diabetes attitudes, wishes and needs (dawn) support for diabetes self-management profile [ ] . the original scale measures how supportive potential support providers are, with the response categories 'not supportive', 'somewhat supportive' and 'very supportive'. we also included social media as potential support which is not included in the original scale. the social support questions were analysed separately as single items in this study and not as a total score. diabetes distress was measured by the brief two-item diabetes distress scale (dds ) [ ] : 'feeling overwhelmed by the demands of living with diabetes' and 'feeling that i am often failing with my diabetes routine'. possible scores on each item range from (not a problem) to (a very serious problem). the dds score is derived as the average of the two items. a score > indicates moderate to high diabetes distress. changes in diabetes-related behaviours as a result of the covid- pandemic were measured with a yes/no list of potential behaviour changes related to diet, physical activity, medication taking and measurement of blood glucose. multivariate logistic regression models were used to examine the likelihood of experiencing: ( ) diabetes-related worries related to the covid- pandemic by sociodemographic factors and health status; and ( ) diabetes-related worries related to the covid- pandemic by sociodemographic factors, health status and psychosocial and behavioural factors. for each diabetes-related worry, the same base model consisting of age, gender, education, diabetes type and number of diabetes complications was used. in each regression, a specific explanatory psychosocial variable of interest was included. all coefficients were estimated using maximum likelihood and all coefficients are reported as odds ratios (or) with % confidence intervals (ci) and standard errors (se). p-values ≤ . were considered statistically significant. all analyses were performed in stata . (statacorp, college station, tx, usa) table shows sociodemographic and health status characteristics of the study population. half of the participants were women; age ranged from to years with a mean of years; almost half of the population had medium to higher tertiary education; % were employed; around one-third had type diabetes; % had diabetes complications; over covid- -specific diabetes worries figure shows that participants were most frequently worried about 'being overly affected due to diabetes if infected with covid- ' ( %), about 'people with diabetes being characterized as a risk group' ( %) and 'not being able to manage diabetes if infected with covid- ( %). in all, % were worried about 'possible lack of diabetes medications' and - % were worried about 'possible lack of diabetes equipment', 'reduced quality of professional health care during the covid- crisis' and 'insufficient access to health care professionals if needed'. in the later analyses, we focus on the three most prevalent worries. psychosocial health table presents levels of different psychosocial factors. mean rating of overall covid- -specific worries was . and mean rating of feeling socially isolated was . . one-quarter of participants had moderate to high diabetes distress (dds score > ). around %, % and % often or sometimes felt lonely, isolated from others and starved for company, respectively. the average loneliness score was . . roughly % often or sometimes felt alone with their diabetes, while % felt that they often or sometimes missed someone to talk to about diabetes. regarding diabetesspecific social support, most respondents ( %) received moderate to high levels of support from family, friends and people close to them. moderate to high support from people at work or school, diabetes care team, other people in the community and other people with diabetes, and people on social media ranged from~ % (people at work or school) to % (diabetes care team). characteristics of people with worries related to the covid- sociodemographic and health status were also more likely to be worried than those participants who did not experience diabetes loneliness. feelings of isolation also predicted being worried. participants who felt a stronger sense of isolation were more likely to experience worries (or . to . , % ci . to . ). changes in diabetes management due to the covid- pandemic participants who were more likely to have diabetes-related worries about the covid- pandemic were more likely to check blood glucose more often (or . to . , % ci . to . ), were more aware of medication taking (or . to . , % ci . to . ) and exercised more than usual (or . to . , % ci . to . ) ( table ) . eating more or less than usual were both associated with being worried about people with diabetes being characterized as a risk group compared with people eating as usual (or . , % ci . to . and . , . to . ). this study of people with diabetes showed that worries related to the covid- pandemic were highly prevalent. participants most frequently worried about 'being overly affected due to diabetes if infected with covid- ' ( %), that 'people with diabetes are characterized as a risk group' ( %) and 'not being able to manage diabetes if infected with covid- ' ( %). people with diabetes have been informed of the necessity to be acutely aware of the advice and restrictions imposed by the health authorities [ ] because they are expected to be at higher risk of being infected and to experience more severe symptoms of covid- if infected. the information from, for example, the danish health authorities varied in the initial phase of the pandemic: at first, people with diabetes were said to be at [ ] . the high morbidity and mortality in people with diabetes was made clear as well as the lack of knowledge about reasons for this. this information may potentially increase worries among people with diabetes and is likely to create a demand for more information. the question regarding worries about being labelled as a risk group was intended to measure experiences of stigma associated with this labelling. however, respondents may have interpreted this as being worried about the actual risk associated with diabetes. living with diabetes and managing the condition on a dayto-day basis are associated with heightened levels of anxiety and distress [ , ] . likewise, a range of different factors, such as sex, diabetes type and presence of complications, moderate the levels at which distress and anxiety are experienced [ , ] . in our population, % experienced diabetes distress at the beginning of the covid pandemic, which corresponds to what is found under normal circumstances [ ] [ ] [ ] . our findings also showed that experiencing high diabetes distress and feeling lonely were related to experiencing covid- specific worries. women, people with type diabetes and people with diabetes complications were more likely to express covid- worries than men, people with type diabetes and people without complications, respectively. this corresponds to previous findings of predictors for diabetes distress. [ , ] . we did not find an association between level of social support and covid- -specific worries, although previous studies have shown that a lack of social network and social support was associated with higher diabetes distress [ , ] . thus 'corona worries' seem to have resemblances to as well as differences from worries under normal circumstances. in , a survey of~ members of the danish diabetes association showed that loneliness is more frequent among people with diabetes and their relatives compared with the general danish population [ ] . in this population, % often or sometimes felt left out, % often or sometimes felt isolated from others, and % often or sometimes felt starved for company [ ] . in our study, the corresponding figures were, respectively, %, % and %. this indicates that a larger proportion of people with diabetes feel left out and starved for company during the covid- pandemic than during normal circumstances, but the proportion of people feeling isolated does not differ. people with diabetes are supposedly even more alone at home than the general population, which may lead to feelings of being left out and starved for company. the feeling of being left out may refer to not being able to, for example, take up what is allowed for the general population such as gathering up to people, which might not seem appropriate for people with diabetes, either by themselves or their friends and relatives. people feeling alone with or having no one to talk to about their diabetes were more than twice as likely to worry about covid- . qualitative studies show that people with diabetes under usual conditions experience a burden of feeling lonely with their diabetes [ ] . the present study showed that % often or sometimes felt alone with their diabetes, while % felt that they often or sometimes missed someone to talk to about diabetes. these are high numbers per se, and although we have not found valid information about usual conditions related to feeling lonely with diabetes, the frequency is expected to be higher under the covid- pandemic and the related isolation. our study indicates that people who report being more worried are more likely to check their blood glucose levels, are more aware of taking their medication and exercise more. this appears to be an upside and may be an adaptive response to the current situation. this behaviour may even relieve feelings of worry as exercise is associated with lower levels of, for example, stress, anxiety and depression [ ] . our results emphasize the need to communicate all new information regarding diabetes and covid- , as well as to provide support and guidance associated with specific and individual worries related to diabetes and covid- . more knowledge about how to provide this support systematically is needed. even under normal circumstances, it is often not possible for people with diabetes to get access to emotional support, but in the case of the covid- pandemic this might be even more important [ ] . peer support, social media and telephone support may be part of the solution [ , , ] . strengths of our study include the timeliness of the survey, which was initiated very shortly after substantial lockdown in denmark due to the covid- pandemic. the response rate of > % is considered relatively large under the circumstances, with a relatively short response time and only one reminder. also, the study included both people with type diabetes ( %) and type diabetes ( %). limitations include the convenience sample of participants, who may generally be healthier than the average person with diabetes. this is evinced by the relatively low prevalence of diabetes complications, for example retinopathy, with % in our study population reporting retinopathy compared with % in the danish diabetes registry [ ] . however, one could argue that our estimates are conservative given the fact that psychosocial issues are less pronounced in healthier individuals with diabetes, further emphasizing the gravity of the situation. furthermore, more than half of the population has at least one comorbid condition. all measures are selfreported, which may introduce uncertainties about prevalence of diabetes complications, comorbidity and glycaemic levels. validation of the questionnaire was somewhat compromised by time constraints imposed by the need to administer the survey as and when concerns about covid- were emerging. however, relevant actors from the danish diabetes association, the user-involvement programme at steno diabetes center copenhagen and a person with type diabetes contributed to and piloted the questionnaire through several iterations. very few respondents commented negatively about the questionnaire. this study highlights a high prevalence of worry among people with diabetes during the covid- pandemic related to being part of a high-risk group, as well as several other significant worries due to diabetes. further studies are needed to explore if and how covid- worries change during the pandemic. our study will be continued, and the future longitudinal study will contribute to this understanding. our findings are expected to be relevant in settings other than the danish, depending on the local course of the covid- pandemic and local restrictions. thus, our findings could be helpful in the effort to improve support for people with diabetes to manage their anxieties, particularly for those at greater risk of worries. providing peer support and support help lines may be helpful in mediating feelings of loneliness. none. none declared. who declares covid- a pandemic the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak diagnosis and clinical management of severe acute respiratory syndrome coronavirus (sars-cov- ) infection: an operational recommendation of peking union medical college hospital (v . ) -ncov epidemic: address mental health care to empower society the emotional impact of coronavirus -ncov (new 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flexible and participatory intervention diabetes attitudes, wishes and needs second study (dawn ): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes development of a brief diabetes distress screening instrument sundhedsstyrelsen: alle med diabetes er i risikogruppen [danish health authority: all people with diabetes are at risk addressing diabetes distress in clinical care: a practical guide the prevalence of diabetes-specific emotional distress in people with type diabetes: a systematic review and meta-analysis the detection and management of diabetes distress in people with type diabetes diabetes distress in type diabetes-a new measurement fit for purpose understanding the sources of diabetes distress in adults with type diabetes social support and self-management behaviour among patients with type diabetes en undersøgelse om ensomhed -ensomhed blandt mennesker med diabetes og p arørende til mennesker med diabetes [an investigation of loneliness -loneliness among people with diabetes and relatives to people with diabetes patient perspectives on peer support for adults with type diabetes: a need for diabetes-specific social capital diabetes prevention program research group. psychological predictors of physical activity in the diabetes prevention program if it does not significantly change hba c levels why should we waste time on it? a plea for the prioritization of psychological well-being in people with diabetes out-of-office hours nurse-driven acute telephone counselling service in a large diabetes outpatient clinic: a mixed methods evaluation the tinkering m-patient: co-constructing knowledge on how to live with type diabetes through facebook searching and sharing and offline tinkering with self-care dansk diabetes database we extend our sincere gratitude to the participants of this study for their invaluable responses to our questionnaire in a time of crisis, and to phd student astrid andrea schultz, dr tanja thybo and dr bryan cleal for valuable input to this study and paper. we would also like to acknowledge the entire 'standing togetherat a distance' team of researchers at the university of copenhagen for their cooperation in the conception of this study. additional supporting information may be found online in the supporting information section at the end of the article. table s . questionnaire content doc. s . english translation of the online article 'sundhedsstyrelsen: alle med diabetes er i risikogruppen' published on the website of the danish diabetes association, april . key: cord- -khjo j u authors: davern, melanie; winterton, rachel; brasher, kathleen; woolcock, geoff title: how can the lived environment support healthy ageing? a spatial indicators framework for the assessment of age-friendly communities date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: khjo j u the age-friendly cities and communities guide was released by the world health organization over a decade ago with the aim of creating environments that support healthy ageing. the comprehensive framework includes the domains of outdoor spaces and buildings, transportation, housing, social participation, respect and inclusion, civic participation and employment, communication and information, and community and health services. a major critique of the age-friendly community movement has argued for a more clearly defined scope of actions, the need to measure or quantify results and increase the connections to policy and funding levers. this paper provides a quantifiable spatial indicators framework to assess local lived environments according to each age-friendly cities and communities (afc) domain. the selection of these afc spatial indicators can be applied within local neighbourhoods, census tracts, suburbs, municipalities, or cities with minimal resource requirements other than applied spatial analysis, which addresses past critiques of the age-friendly community movement. the framework has great potential for applications within local, national, and international policy and planning contexts in the future. research has long recognized that environmental factors play a significant role in determining health and wellbeing in older age [ ] , and there are rising proportions of older people in the populations across the world. consequently, the recently released united nations decade of healthy ageing - calls for sustained global action to generate transformative change in four priority areas: addressing ageism; creating age-friendly communities; delivering integrated and person centered care; and providing long-term care [ , ] . increased urbanization and policy discourses supporting ageing in place add to the urgency to create and plan for age-friendly environments. on a global scale, life expectancy has increased from years in the mid- th century to an expected years by the mid- st century [ ] and % of the world's population is predicted to be aged over years by [ ] . the world health organization (who) world report on ageing and health [ ] documented how age-friendly environments play a which often includes transportation systems, land development patterns, and microscale urban design (e.g., footpaths) [ , ] . a lived environment reflects the importance of locality and access to good urban design, as well as human-made and natural environments to support health and wellbeing in the local neighbourhoods where people live. this is consistent with the argument regarding the narrow application of the term "built environment" where both human made and natural worlds are conceived as though there is no separation between them [ ] . spatial indicators provide a quantitative measurement of local lived environments using geocoded data (defined by x and y co-ordinates) developed using geographic information systems (gis). data linked to a street address can be mapped using gis and calculated as spatial indicators, providing aggregated measures across a range of geographic areas, including neighbourhoods or census tracts, suburbs, municipalities, regions, or states. aggregated geocoded data can be drawn from a range of existing administrative data sources that assess the lived environment and a range of social, economic, and environmental issues. spatial afc indicators consequently provide objective and cost-effective assessments of age-friendliness that are easily replicated across large geographic areas using desktop spatial analysis. these indicators can also be made readily accessible to local governments using online digital planning portals and liveability indicator systems for cities, like the australian urban observatory (auo.org.au) [ ] . the development of quantifiable spatial indicators of afc addresses the major critiques of the afc initiative-that it is too descriptive in approach [ ] , not measured or monitored by indicators [ ] , and without a clear understanding of an indicator framework [ ] . this paper proposes spatial indicator tools that can be applied for the assessment of afc in local lived environments using a gis methodology. these afc spatial indicators can also be applied in a variety of international contexts with direct relevance to the healthy cities movement [ ] , the new urban agenda, and the agenda for sustainable development [ ] . the agenda provides a global framework for sustainable urban development up until signed by all members states with specific targets. these include sustainable development goals (sdgs) with specific mention of older people in targets for goal reduced inequalities, goal sustainable cities and communities, and goal partnerships for the goals. in addition, the decade of healthy ageing [ ] calls for disaggregated data in twenty-eight indicators across eleven goals. spatial indicators measuring afc in lived environments are noted by the united nations as being necessary for the measurement and monitoring of any actions contributing to sustainable development (goal ) and multi-stakeholder partnership development and policy and institutional coherence. they have been developed to address segregation or siloed approaches in the current planning approaches and to encourage discussion and action that can promote integrated policy, planning, and practice across urban planning and public health. often the outcome of afc remains the sole responsibility of health or social planning with little integration across important portfolios, such as transport or statutory or strategic planning. the implementation of afc principles must extend beyond practitioners with interest in ageing and should ideally be integrated across policy portfolios with budget and legislative support. this paper aims to introduce a new set of afc spatial indicators that can be used to quantify and assess the age-friendliness of local lived environments and monitor changes in age-friendliness over time consistent with the sdgs and agenda. these indicators seek to support the decade of healthy ageing, which includes a commitment to action in the development of age-friendly environments and improved measurement, monitoring, and research [ ] as well as tools to support planners and practitioners working within government settings. these spatial indicators of afc also identify the importance of older people and their lived environments in sustainable urban development and the agenda. eight interconnected domains are included in afc ( figure ). the selection of specific spatial indicators to assess the lived environment of each afc domain was made following a workshop held with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. potential indicators were then judged against the key criteria recommended by the who (box ) as well as other best practice principles for indicator application [ ] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [ ] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box . the criteria suggested for defining local afc indicators [ ] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table ). potential indicators were then judged against the key criteria recommended by the who (box ) as well as other best practice principles for indicator application [ ] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [ ] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box . the criteria suggested for defining local afc indicators [ ] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table ) . additional contextual factors for consideration include: the estimated resident population; proportion of population aged more than years; population age distribution including proportions of older and younger populations in area; ethnicity; education; homeownership; residential density; remoteness e.g., accessibility/remoteness indices or the distance between towns in rural settings; the risk of natural disasters; climatic conditions; and the impact of climate change. * recommended as priority indicators for inclusion. the suggested spatial indicators for each afc domain are presented in table with the priority indicators notated with asterisks. this provides flexibility for practitioners in identifying the key spatial indicators of importance to afc or additional optional indicators where resources are available. additional information is provided below explaining why these indicators are recommended for each afc domain with detailed explanations of the supporting research evidence. the indicators recommended in the following section were identified in accordance with indicators acting as icebergs and highlighting issues of major importance [ ] . only after the major factors have been quantitively assessed should further qualitative assessment be completed, similar to a hierarchy of need. for example, if there are no public open spaces available there is little point in assessing the maintenance, shelter, or facilities available in public open spaces within an area. additional qualitative assessment could also include local consultation with older residents and relevant stakeholders. the priority indicators identified for this domain are walkability for transport [ , ] and access to public open space within m [ ] . these indicators are directly related to walking [ ] [ ] [ ] , specifically in older people [ ] , and associated with physical health benefits [ ] and mental health benefits [ ] . walkable neighbourhoods are important for older people because, along with the fact that they enable people to reach destinations with commercial and social opportunities [ , ] , walking is also associated with maintaining functional independence [ ] and better cognitive function [ ] . similarly, public open spaces that are easy to visit with walkable access are important for older people and important in reducing social isolation and increasing physical activity [ ] . data required to create indicators of walkability are commonly available within municipal and planning contexts. road network analysis (a way to walk), land use mix (destinations to walk to), and housing density (people to service the destinations) are common key components of walkability assessments. similarly, public open space location data are also regularly held by most municipal governments. footpaths are an important infrastructure supporting walking in older people [ , ] , and walkability can also be refined by superimposing footpath access where spatial data are available. an example of a walkability for transport assessment for the regional city of launceston in tasmania, australia was calculated and is provided in figure to demonstrate the value of neighbourhood level walkability assessments. the results clearly suggest that the inner neighbourhoods of the city of launceston have good walkability while the outer neighbourhoods are less supportive of walking for transport, particularly those on the eastern side of town. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [ , ] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [ ] and should also be included within high quality public open spaces. accessible buildings are italicised in table due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [ ] . post occupancy evaluations are generally more common in sustainability assessments [ ] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [ , ] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [ ] and should also be included within high quality public open spaces. accessible buildings are italicised in table due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [ ] . post occupancy evaluations are generally more common in sustainability assessments [ ] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. there is a growing body of evidence showing a positive association between healthy ageing and blue space [ ] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [ ] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [ ] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [ ] , while, in ireland, older people had a lower risk of depression in those with more sea views [ ] . in addition, nature-based solutions, there is a growing body of evidence showing a positive association between healthy ageing and blue space [ ] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [ ] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [ ] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [ ] , while, in ireland, older people had a lower risk of depression in those with more sea views [ ] . in addition, nature-based solutions, through green and blue space urban management planning, can mitigate the health impacts of climate change while addressing the need for climate resilience in local communities [ ] . future revisions of the afc principles could consider the inclusion of more detailed measures of green and blue spaces in the domain of outdoor spaces and buildings to address changing climates around the globe. these could include access to local blue spaces, public and private tree canopy coverage, public street tree canopy coverage and the associated shade capability, in combination with the currently recommended measures of walkability and accessibility to public open space. these measures are very worthy of consideration but bring their own challenges in terms of data access and spatial capability making them harder to produce. consequently, they are suggested as potential expanded, not essential, measures of the afc lived environment assessment. transport is an important determinant of health [ , ] influencing access to local services, engagement in paid and non-paid productive activities (such as employment or volunteering), maintaining and developing social networks and supports, and engaging in social and recreational activities. public transport has also been identified as a critical influence of liveability in a community [ ] and active transport important to older people [ ] . policy-relevant spatial public transport indicators are typically based on m access or a -min walk [ , ] . another important factor that influences the use of public transport is service frequency. consequently, access to any public transport stop provides a high-level assessment while access to frequent public transport provides a more refined assessment. similar measures are also included in the australian government's national cities performance framework (https://www.bitre.gov.au/national-cities-performance-framework). for older people, mobility is essential for social participation and wellbeing [ ] . public transport is particularly important for older people who might have a reduced ability to drive. older people tend to use public transport more frequently if there is easy access to public transport in neighbourhoods at a distance less than min away [ ] . this is also consistent with existing research that found that the frequency of public transport and wait time affected older people's willingness to travel [ ] and that a high proportion of older people are no longer driving [ ] . data for these indicators can most often be sourced from public access data portals, open street map or general transit feed specification (gtfs) where public transport data are provided by transport agencies into a computer readable format for web developers [ ] . gaining access to more detailed data describing public transport that meets disability standards is another very valid indicator and has been associated with increased satisfaction and perceived useability in older people [ ] . similarly, access to a bus stop with an accompanying shelter and seat is also important for older people's mobility, as well as dropped curves, footpaths, and pedestrian signals [ ] . housing is central to living a productive, meaningful, and healthy life, and housing quality is an important influence on self-reported health [ ] . unaffordable housing is detrimental to mental health in low to moderate income households [ ] . unaffordable housing has also been associated with an increased risk of poor self-rated health, hypertension, and arthritis, and renting, rather than owing a home, increases associations between unaffordable housing and self-rated health [ ] . consequently, housing costs and gentrification [ ] are particularly important to consider, with housing stress in lower income households being a particularly important indicator for the assessment of age-friendly cities. housing needs, sizes, and types can change as people age. older people might consider downsizing to smaller homes with reduced maintenance needs or to be closer to extended family for support to age in place [ ] . in rural and regional areas, older people might need to move from larger farms and back into towns where services are more readily available. alternatively, frail older residents might require the support of aged care providers to support high care needs. addressing these issues means that communities need to understand the available housing diversity options (e.g., larger houses, smaller houses, units, and apartments to serve broad community needs) as well as access to services for residents. afc supports multiple housing options that are beneficial to all residents with many municipalities thinking primarily about formal aged-care accommodation when addressing housing needs for older people. even more concerning in australia, it is common for aged care facilities to be built on the outskirts of cities and towns where there is an abundance of inexpensive and undeveloped land. this isolates older people from the rest of the community, makes it harder for people to access and visit, decreases access to other community services, and decreases intergenerational contact within communities. the / housing affordability indicator is recommended and describes the proportion of households in the bottom % of household incomes spending more than % of their income on housing costs [ ] . this measure is also referred to as the ontario measure where the interest in housing affordability first identified the disproportionate impact of housing costs on lower income households [ , ] . understanding community demographic profiles, particularly age, in combination with the high incidence of / housing affordability issues should raise concerns for any community wanting to support age-friendliness. specifically, older adults on an aged pension within the private rental market will face significant challenges in housing affordability [ ] . the indicator of access to services for older people was developed with older people themselves [ ] and includes hospitals, general practitioners, aged care facilities, public transport stops, supermarkets, community centres, libraries, and universities of the rd age, and could also include places of worship and parks. this indicator also provides a useful assessment for the afc domain of community support and health services but is included in the housing domain to reinforce the importance of urban planning that supports the co-locations of services and housing options. the proportion of government owned dwellings could also be investigated as an additional support measure of afc, particularly in lower income areas. meaningful social relationships and participation are essential for good health, with health defined as a social phenomenon in the social determinants of health [ ] . social participation has been associated with physical activity [ ] , mental health [ ] , reduced psychological distress [ ] , reduced risk of myocardial infarction [ ] , and up to a % increased likelihood of survival in people with strong social relationships compared to lifestyle risk factors [ ] . for older people, social participation provides greater life satisfaction [ ] , is protective against cognitive decline [ ] , and contributes to resilience in older people [ ] , especially in rural communities [ ] . social participation is also being taken seriously internationally, and the united kingdom appointed a new minister for loneliness and a national government action plan on loneliness [ ] . the recommended spatial indicators supporting social participation connect to the access to services for older people [ ] that are included in the housing domain. two indicators are recommended: access to community centres and neighbourhood houses; and access to recreational services that cater to the needs of older people. shared or 'third spaces' such as these are critical social infrastructure [ ] and essential in supporting social participation for older adults [ ] . recreational services also support physical and mental health through opportunities for physical activity designed for older people and supporting community connections. another indicator recommended for inclusion is access to a local library, which also supports the afc domains of respect and social isolation, communications and information, and community support and health services. libraries provide multiple community benefits beyond simply lending books [ , ] , including multimedia borrowing, technology training, community classes, lectures, and opportunities for intergenerational and community connections. libraries also support the need for learning opportunities across the course of life with universities of the third age (u as) providing social and learning benefits to older people [ , ] . this is associated with better physical health and activity levels [ ] . places of worship are also considered an important facilitator of social connections and social capital [ ] , particularly in humanitarian arrivals [ ] and different cultures [ , ] . respect and social inclusion are essential to ensure social participation for older people. there is much debate on the definition of social inclusion, though most studies refer to an objective participation in society and a more subjective assessment of whether the actual participation meets an individual's preferences [ ] . most definitions of social exclusion emphasise the importance of social activities as a core component [ ] . however, the effects of cumulative disadvantage, decreasing social networks, and age discrimination magnify the negative health and wellbeing impacts of social exclusion in later life [ ] . a local or lived environment must provide accessible buildings, housing and transport, along with opportunities for social activities to occur if social inclusion and social participation are supported and encouraged. previous research on the services deemed important for older people has emphasised the importance of local services, such as shops [ , ] , and this is supported by the use of new spatial indicators that can access formal and informal places to meet. these include recommended indicators of access to social clubs/senior citizens clubs or participation in international clubs, like rotary or probus, that are more formally organised by older people themselves. alternatively, informal opportunities for social inclusion include an indicator of distance-based access to local cafes that support broader intergenerational social opportunities. older people need a range of venues to create opportunities for social activities as a foundation for community respect and social inclusion. empowerment, autonomy and control [ , ] , and employment conditions [ ] were all found to be important influences of actual and self-reported health. control over one's own destiny has also been proposed [ ] , consistent with an understanding of health being simultaneously influenced at the individual (micro/personal), place and community context (meso/community) as well as the larger societal context (macro/societal level) [ ] . civic participation and employment are important influences of agency and autonomy in a society. consequently, it is important to understand how many older people are engaged in paid and unpaid productive activity in the community. this is best measured through the proportion of people who remain employed past the official retirement age ( years in australia noting there is no official retirement age and eligibility for the aged pension is currently years increasing to years by ) or people aged years or more who are engaged in regular volunteering. these indicators of paid and unpaid productive activity are also important measures of social engagement and civic participation and could be separated into additional age brackets or deciles (e.g., - years) for more detailed information. it is important to note that employment is also not defined according to hours worked, acknowledging both the civic connections and benefits that come from any level of paid employment and that retirement is not a single event and includes a diverse range of retirement patterns [ ] . there has been criticism regarding the dominance of volunteering in measures of collective civic social participation in older people [ ] with voting participation argued as a better measure of civic participation [ ] . however, voting participation is less relevant in countries like australia where electoral voting is compulsory and volunteering activities are measured every years. volunteering is also particularly important in regional areas of australia where third sector or non-profit organisations rely on older people volunteering [ ] with increasing proportions of older people residing in rural locations [ ] . in countries where voting is not compulsory (e.g., the usa), then voting participation could be considered as an additional measure of civic engagement. in , approximately % of australian households had access to the internet [ ] . this proportion decreased to % in remote areas where it is common to have a high proportion of older people within populations, with entertainment, social networking, and banking the most commonly supported activities supported by internet connection. internet access is also becoming more necessary to access information about the government, health, banking, and community services as well as to maintain contact with friends and family. finding information on services like these is also critical for older people to age in place and is necessary to support independent living and the connection to communities [ ] . th information provision also extends beyond essential services and includes services provided by local libraries, which includes online books, audio, audio-visual, and educational resources that can be made available online for people with physical or geographical mobility restrictions. online streaming (e.g., netflix) is another more recent example of recreational activities supporting social connection and information provision. however, all these online resources require household internet access. access to a national radio service is another important source of information and becomes particularly important in emergency management, including preparation and recovery from natural disasters, such as floods, droughts, and bushfires, which are becoming increasingly more commonplace in australia. emergency sms messaging systems are also deployed during emergency situations to inform residents of impending safety risks but are worthless without adequate mobile phone reception. climate change is predicted to increase the likelihood of these emergency situations making telecommunications assessment essential in the support of afc. it is also necessary for developing technologies, including passive surveillance of movement monitoring within the home, personal alarm devices, and telehealth [ ] , which have become increasingly accessible and necessary during the coronaviruses (covid- ) pandemic. communication is an important influence on the wellbeing of older people [ ] , and both household internet and mobile phone reception provide essential telecommunication systems that support both intergenerational communication with family and friends, the communication of essential information [ ] , and the ongoing adoption of new technologies [ ] , as well as influence the quality of life [ ] . currently, there is a paucity of references or inclusion of technological solutions offered to support afc and healthy ageing and technology, and icts have recently been suggested as a new smart age-friendly ecosystem framework [ ] . suggestions included in this new framework to assist afc include: the development of smart housing; the inclusion of ageing in smart cities and engagement with the internet of things (iot); the better use of digital assistants (e.g., alexa) in the home; the use of digital robots for deliveries; electronic camera enabled doorbells; and motion sensors to detect mobility. technological features like these require inclusion during new housing development and have benefits across multiple afc domains beyond communication. they also require a rethink and interdisciplinary collaboration between planners, architects, developers, computer science, industry, and the government. while the opportunities are waiting for action, they also require engagement with older people themselves and their families using qualitative and ethnographic research methods [ ] . this is an important area of growth and future development in afc and requires further research. access to primary health support services is essential and necessary for people to age in place. it is also the preferred option for most older people to maximise their health and wellbeing [ ] . within the local community, access to general practitioners has been identified by older people themselves as essential community support services [ , , ] and the key access point for primary health care. consequently, access to general practitioners was identified as an indicator of primary importance within community support and health services. these practitioners also provide gateway services and referrals to any other medical specialists, including geriatricians, who specialise in treating conditions that affect older people, including dementia. additional indicators that should be included relate to housing support either as in-home support packages or residential aged-care accommodation. all of these services are also included within a complete definition of social infrastructure, which has an important influence on subjective wellbeing [ ] and are important components of liveability [ ] . the approaches and spatial measures described above were applied in a case study in a regional context and rural centre in north-eastern victoria, australia. the regional town is located over km north-east of the capital city of melbourne in the centre of the state of victoria, south-eastern australia. the major industries are agriculture and manufacturing, with a population of over people. both the state government department of health and the local municipality/council were interested in analysing and understanding afc and broader liveability given an increasingly ageing rural population. the spatial measures used to assess this included: walkability (with and without footpaths); access to public open space; access to public transport; housing affordability; housing diversity; government owned dwellings (social housing); access to services for older people; libraries; universities of the rd age; places of worship; volunteering; households with internet access; aged care facilities; and access to general practitioners. the results were presented to the local health department officials, the local municipality, and as a community presentation to residents at the local library. many of the challenges and barriers to afc planning were identified in the spatial measures and were confirmed by the lived experiences of residents from the local community. these included: poor walkability on the outer areas of town; difficulty getting to doctors and medical services located at the regional hospital located on the outer town boundary with limited public transport and poor walkability; disconnection between the older people, families, and younger people in the town due to the location of residential aged care on the town boundary next to the hospital; the importance of cafes and social spaces in the centre of town to support community and social connections; the value of the town's library, art facilities, and public open spaces; and inequity in the disadvantaged areas of the town that had reduced access to public transport and lower levels of household internet connections. the use of mapped spatial measures of afc was hugely beneficial for inter-agency conversations and planning initiatives as well as community conversations, engagement, and validation of the spatial analyses. the results also highlight the future negative impact of the age-friendliness of the town if future residential aged care development is supported in the outer areas of the town. the original who global age-friendly cities guide was developed in response to the rapid population ageing and urbanisation across the world and was informed by interviews conducted with older people themselves in over different countries [ , ] . the ultimate aim of afc is to create environments that support healthy ageing. this paper provided detailed, objective, and functional spatial measures of age-friendliness across lived environments that can be used to assess, monitor, evaluate, and communicate age-friendliness refined to the neighbourhood level. objective spatial measures of the lived environment are critical for the following reasons: to simplify assessments of afc; to provide a foundation level of knowledge about the age-friendliness of an environment; to assist local and state government planning by informing and monitoring future actions and interventions needed to promote healthy ageing in communities; and to include older people into targets of the sustainable development goals and the new urban agenda. the movement has previously been criticised for a lack of objective measurements and the need to connect these ideals into functional measures connected to policy, planning, and financial levers [ ] . previous attempts at developing indicators of age-friendliness have been non-specific, non-coordinated, and reliant on survey-based responses (e.g., world health organization [ ] ). such assessments are also beyond the budget, resources, capabilities, and motivation of local planning agencies and municipalities. the proposed spatial measures of age-friendliness across lived environments is relevant to planners, policymakers, advocacy organisations, governments, architects, industry, citizens and research audiences. the suggested indicators are provided to guide and inform discussions and interventions to promote healthy ageing. the measures can also be adopted and customised to local environments ranging in geographic and population sizes, rurality, climate conditions, and resource limitations. the proposed spatial indicators of afc address these issues through the application of gis technology to produce an objective assessment of the age-friendliness of local lived environments, drawing on indicators from the liveability literature that are specifically relevant to the values, preferences, and needs of older adults. these indicators provide measurement and quantification of afc domains consistent with the idea that value comes with measurement and leads to knowledge production as argued by lord kelvin over hundred years ago [ ] . the more simplistic interpretation of this, is that what is measured, is valued, and consequently is done. one of the critical issues raised in the recommended afc spatial indicators is the connection of all indicators within existing policy and planning contexts [ ] . all the recommended indicators can be linked to existing policy and planning environments regardless of whether these have a local/municipal, state, or national focus. the connection of indicators to policy has been long identified within social indicator research [ , ] . these indicators can assist governments in meeting their commitments to the sustainable development goals in a way that is meaningful for a growing segment of their populations. there is also an increasing interest and development in public health digital observatories. for example, relevant liveability indicators for the largest cities of australia are available in the australian urban observatory (auo.org.au) launched in . there is an opportunity to make spatial indicators available through novel data visualisation and ease of communication providing an influence on the policies required for healthy ageing across communities. the spatial indicators recommended for assessing afc domains can all be influenced and improved through policy levers. this includes the indicators suggested for outdoor spaces, transport, housing, social participation, respect and social inclusion, civic participation and employment, communications and information, community support, and health services. the indicator results can be influenced though local and immediate strategies or applied in advocacy with the responsible higher government agencies. this can include reviewing afc assessments within the context of current policy contexts, existing public health planning, liveability planning, transport planning, strategic planning, land use, and statutory planning it is also important to acknowledge the limitations of afc spatial indicators and understanding that these aggregated area-based results effectively act as icebergs of knowledge [ ] providing a tip of the iceberg assessment of what is occurring, with additional information required to understand why the result is happening and how it can be addressed. consequently, the objective afc spatial indicators should also be combined with additional sources of knowledge. these include consultation and engagement with local older people themselves to expand understanding, prioritise actions, and support the greatest social and economic benefits and returns on investments that support improved health and quality of life for older people. given the diversity of cities, communities, and places, it is recognised that the achievement of all suggested indicators might not be feasible across all geographic settings. this is particularly relevant to rural and regional locales, which often have a lower population density and reduced levels of physical or social infrastructure. consultations with older people and combining subjective understandings with more objective afc spatial indicators will also help to inform the understanding of unique community contexts, including regional and remote areas. for example, high levels of walkability might not be possible across an entire town in a rural area with a small population. alternatively, signaled pedestrian crossings might not be necessary. however, a walkability assessment using the recommended walkability indicator could identify walking and transport barriers (e.g., a major road or bridge across a rail line) or identify the best location for new community services. alternatively, the distances and measures of accessibility listed within indicators may vary across diverse rural and regional settings, but as noted above, these definitions of access within indicators must be determined through consultation with the older adults and communities to a reach consensus on what can be reasonably expected within this locale. consequently, in certain settings, these proposed indicators should act as a tool to prompt place-specific discussions around what is important in terms of measurement indicators, and what is achievable (particularly in relation to what should constitute reasonable access). a notable challenge of afc planning is the absence of the relevant climate change implications in the current afc principles and domains and inclusion of ict and new technology. we recommend that future revision of afc should expand and account for the challenges associated with climate change given the implications on the health and wellbeing of older people [ ] and the ultimate afc goal of healthy ageing. the relationship between older people's physical health and mental health with the environment, urban design, architecture, and afc could also be considered in the development of future indicators [ ] . understanding and expanding afc spatial indicators for unique contexts and environments is needed in the future and this current foundation of recommended indicators can be applied and tested across a range of different locations. this could include localities with climatic extremes (e.g., heat, cold, and snow), regional and rural locations, international comparisons, and cultural differences to explore how communities differ and what additional indicators should be included. the major aim of this research was to propose a foundational set of objective afc spatial indicators that can be applied in any location with minimal resources and are directly aligned for policy intervention. this is particularly relevant to planning and policymakers working in government and was neither previously available nor consistently applied within afc locations. further research should investigate how this proposed suite of afc spatial indicators can be added to, refined, or customized to address the needs of many different locations, including the relevant subjective indicators to enhance knowledge. the inclusion of new technology and ict and addressing climate change are also increasing areas of interest in the future. environmental gerontology: making meaningful places in old age how 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insights from an international, multi-site study connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities effects of technology use on ageing in place: the izi pilots who doesn't think about technology when designing urban environments for older people? primary health care and older people the ideal neighbourhood for ageing in place as perceived by frail and non-frail community-dwelling older people oxford essential quotations lessons learned from the history of social indicators; redefining progress disappointments and legacies of social indicators climate change in an ageing world. helpage international knowledge synthesis for environmental decisions: an evaluation of existing methods, and guidance for their selection, use and development: a report from the eklipse project the authors declare no conflict of interest. key: cord- - by r authors: khalifa, shaden a. m.; mohamed, briksam s.; elashal, mohamed h.; du, ming; guo, zhiming; zhao, chao; musharraf, syed ghulam; boskabady, mohammad h.; el-seedi, haged h. r.; efferth, thomas; el-seedi, hesham r. title: comprehensive overview on multiple strategies fighting covid- date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: by r lately, myriad of novel viruses have emerged causing epidemics such as sars, mers, and sars-cov- , leading to high mortality rates worldwide. thus, these viruses represented a challenging threat to mankind, especially considering the miniscule data available at our disposal regarding these novel viruses. the entire world established coordinative relations in research projects regarding drug and vaccine development on the external range, whereas on the internal range, all countries declared it an emergency case through imposing different restrictions related to their border control, large gatherings, school attendance, and most social activities. pandemic combating plans prioritized all sectors including normal people, medical staff politicians, and scientists collectively shouldered the burden. through planning and learning the previous lessons from sars and mers, healthcare systems could succeed in combating the viral spread and implications of these new pandemics. different management strategies including social distance, social awareness and isolation represented successful ways to slow down the spread of the pandemic. furthermore, pre-preparedness of some countries for emergencies is crucial to minimize the consequences of the crisis. . comparison between total deaths and confirmed cases in some countries with different population from jan till april [ ] . most countries were forced to announce emergency measures to protect vulnerable people and block ways of transmission due to the continuous increase in confirmed cases by time as reported in figure [ ] [ ] [ ] [ ] [ ] [ ] . with regard to this escalating situation, governments have begun to develop strategies to resolve the pandemic cooperatively with international health agencies, i.e., centers of disease control (cdc) and world health organization (who) that declared many precautions based on previous lessons from mers and sars diseases, as will be outlined in this section. our review aims to evaluate strategies of the most affected countries from different continents all over the world (china, italy, germany, france, spain, america, canada, brazil, uk, india, japan, singapore, iran, korea, and australia) for confronting the epidemic as it explains the best practices that could help other countries to overcome current or any upcoming pandemic. most countries were forced to announce emergency measures to protect vulnerable people and block ways of transmission due to the continuous increase in confirmed cases by time as reported in figure [ ] [ ] [ ] [ ] [ ] [ ] . with regard to this escalating situation, governments have begun to develop strategies to resolve the pandemic cooperatively with international health agencies, i.e., centers of disease control (cdc) and world health organization (who) that declared many precautions based on previous lessons from mers and sars diseases, as will be outlined in this section. figure . change in numbers of confirmed cases over time [ ] [ ] [ ] [ ] [ ] [ ] . the chinese lunar new year holiday, which synchronized with the outbreak of covid- , is the most celebrative time of year in china. usually, a large global migration takes place, as individuals travel back to their homes. around five million people had left wuhan [ ] . around a third of those people travelled outside the province of hubei. restricting people's social contacts was critical to covid- regulation. key elements of such social distancing initiatives included that the chinese government promoted people to stay home, dissuaded mass gathering, postponed or the chinese lunar new year holiday, which synchronized with the outbreak of covid- , is the most celebrative time of year in china. usually, a large global migration takes place, as individuals travel back to their homes. around five million people had left wuhan [ ] . around a third of those people travelled outside the province of hubei. restricting people's social contacts was critical to covid- regulation. key elements of such social distancing initiatives included that the chinese government promoted people to stay home, dissuaded mass gathering, postponed or cancelled major events, and closed universities, factories, museums, libraries, schools, and governmental offices. chinese people began to take steps to shield themselves from covid- , i.e., wearing protective masks, if they had to commute in public. social distancing has been successful in limiting human to human transmission and cutting morbidity and mortality. more stringent steps are introduced such as isolation and quarantine. the lunar new year holiday was expanded by chinese government. the holiday deadline was shifted to march for hubei province and feb for other provinces, so that the holiday duration was long enough to cover the alleged covid- incubation time. diagnosed people were segregated in hospitals. in wuhan, in which a large number of infected people resided, people with mild or asymptomatic infections were quarantined at shelters called fang cang hospitals, which were public open areas, i.e., stadiums and convention centers that had been retooled for medical treatment. the chinese government promoted and funded grassroots screening for contact tracking and early detection and encouraged hand-washing and surface sanitization. home-based quarantine of people who were at the epicenters of epidemic and travelled to other places in china to curb the spread of virus to boarder populations. the government avoided panic amongst people by providing the updated information through media. free medical care was introduced by the state to motivate patients to visit doctors as soon as possible and in good time to prevent further deterioration of the condition. the state guaranteed people's daily needs [ ] . the state with the second highest numbers of viral deaths worldwide. the government declared a state of emergency lockdown that began in northern italy and spread throughout the world. the fatality rate ( . ) was much higher than that of china ( . ). all italian regions were known as "red zones" with extreme limits imposed on every public event. italy responded to the situation with screening even for those without symptoms. italy faced a persistent shortage of health care staff. the government announced a proposal to recruit , new doctors, nurses, and health workers to meet demand. retired doctors and students who had finished their medical degree and are in the final year of specialist training, were called upon [ ] . coordinated intensive care units were equipped for covid- positive patients. continuous training for health care staff was crucial with applying dedicated protocols and full isolation [ ] . the rules initially laid down approximately one month for schools' closures and restrictions on people's right to leave homes and two weeks for the suspension of business activities. the italian government proposed an extension of lockdown steps [ ] . to curb viral transmission, air travels were banned from china and italian passengers were quarantined in china. suspected cases were moved to pre-defined hospitals where the check for sars-cov- was available and infectious disease divisions were willing to isolate confirmed cases. emergency medical system of milan metropolitan area formed covid- response team with main goal of resolving the viral pandemic without encumbering regular emergency medical system activities. the response team examined the health and clinical conditions of persons being screened to evaluate the need for hospitalization or home testing and subsequent isolation. this response team designed algorithm to identify covid- suspected cases. the algorithm is continuously modified to comply with the regional directives [ ] . in a speech about the coronavirus pandemic, german chancellor angela merkel approached the citizens directly. she explained the situation this way "it is serious. take it seriously too!". "since world war ii, there has been no other challenge to the country, where national solidarity was as important as right now", she said. the german chancellor announced stricter steps and declared standards/rules for germany. the main objective was to "reduce public life to the extent warranted". this included restriction of the bare minimum connections, maintenance of a minimum distance to the public of at least . m, permission for people to go to work, doctors, shops, and play outdoor sports individually. however, gatherings in groups or meeting were no longer permitted [ ] . france, like other nations formed their pandemic influenza plan (pip) based on the recommendations for the contagion management by who. president macron clarified that only collective national campaign can prevent the spread of infection, restrict deaths, and avoid the submergence of health service. french pip aimed to alleviate pandemic by minimizing the number of civilian casualties and preserving machinations in particular economic activities. pip included stages: the st stage was to impede the introduction of outbreak to the world, nd stage to restrict viral growth and distribution in france, rd stage to attenuate the potential outbreak to minimum and th stage was returning to normalcy. first reported cases were chinese nationals visiting france, so steps were rapidly taken to keep these cases in isolation. contact tracing was held to identify people at risk of infection. the government cancelled all sporting events and schools were also closed. authorities have repeatedly pronounced individual habits and requested protective masks for those who show signs of infections and for health workers so, public and private sectors were mustered to produce masks and disinfectants. to prevent viral transmission, france pressured the european union to close the schengen treaty zone for all non-european citizens. despite the strategy's economic impacts, france scarified the entire society to combat covid- [ ] . on march, the spanish government started the applications of safety measures, in order to flatten the curve days after the exponential rate of virus start (r < ); the day in which new cases were registered for the first time. all people were forced to stay home through announcing the lockdown. spain has adopted some measures to control spread: social distance, closure of most activities, e.g., cinemas, clubs and schools to avoid crowding [ ] . under supervision of the president of the government, pedro sánchez, who described the crisis as: "unprecedented challenge", "a global threat that recognizes no borders, colors or languages", and an "extraordinary challenge that forces us to take exceptional measures". he assured the importance of application of distance learning as much as possible to slow down viral spread. they reduced non-essential work to conserve support to different sectors including the vulnerable categories, the elderly, families with the lowest resources, and small business owners. their strategy included increasing the awareness that each person in the community has a role in combating the virus; elderly people receive intensive care and the young follow the safety measures and social distancing. everyone had to care of others and the sense of social responsibility was increased. moreover, they had a continuously announced transparent data from the beginning beside their steps to prevent infection through following the guidelines and health monitoring protocol [ ] . the director-general of the world health organization (who) announced that the covid- pandemic had triggered an international public health emergency. the united states department of health and human service secretary announced on january a u.s public health emergency, and the u.s. president legitimated a "proclamation on suspension of entry as immigrants and non-immigrants of persons that pose a risk of transmitting novel coronavirus". this regulation restricts the entrance of american citizens and those with legal permanent residents and their families, especially those who have travelled to mainland china. the centers of disease control and prevention (cdc) and other governmental agencies, as well as state and local health centers, introduced proactive steps to limit covid- propagation in the u.s. [ ] . such steps included the recognition of cases and their contacts, and the suitable care of travelers coming from china to the u.s. the correct actions were taken to ( ) slow down virus spread; ( ) prepare health care systems and encourage public willingness for pervasive transmission; and ( ) clearly define infection and directly report to public health centers in order to make decisions and improve medical safeguards involving diagnosis, therapy, and vaccines [ ] . despite the fact that these initiatives were being enforced in anticipation of the virus in the u.s., the continued widespread dissemination of the virus was devastating. usa holds a negative record in regard to the pandemic, with the highest number of infections and deaths recorded worldwide. public health and disease prevention programs in canada were refashioned around guidelines and recommendations of naylor and his group that were used before against sars and entitled "learning from sars". experience with sars affected positively canada's response to the covid- outbreak. most notably, correspondence concerning public health was greatly improved and digital media was progressed. there were some technological gaps like contrasting directives on the use of personal protective equipment but this has been mainly resolved. in airports, procurement were organized and rolling tests became faster [ ] . previous preparedness before incidence of infection was phenomenal in brazil. on january , the health surveillance secretariat together with the ministry of health activated an emergency health operation center with low alerting level, which was raised later on january when the first suspected corona virus case appeared. national contingency plan (ncp) for the covid- and guidelines; based on information received from who were announced to be applied in all states. quarantine law was imposed for protecting people. isolation and exceptional restrictions on travelling was applied even before the appearance of the first case. currently, there is a rapid growth in cases in brazil; cases and deaths were registered only one month after the first confirmed case [ ] . trials to reduce cases were implemented and huge attention was paid towards availability of intensive care units (icus), diagnostic tests and ventilators needed for patients with covid- [ ] . brazil suffered from political flounder, which constituted distraction in the middle of crisis. the government restricted the use of rt-pcr examinations to people with more severe symptoms leading to higher mortality rates. this was due to high cost of materials and shortage in qualified people and labs able to do the rt-pcr test and the needed transportation for samples to places, where tests are performed. thus, people with mild symptoms or the asymptomatic caused the transmission of infection. dense populations on favelas made it impossible to follow the social distance. moreover, illegal mining and logging in amazon forests may have brought infections to remote areas. scientific organizations, such as the brazilian academy of sciences opposed bolsonaro due to the decreased science budget, general security, and shortage of public services. currently, there is increased production of personal protective equipment, ventilators, and diagnostic kits [ , ] . the united kingdom (u.k.) government followed health's department direct recommendations for travelling abroad with respiratory infections, especially travelling to wuhan [ ] . the u.k. national health service emphasized the importance of using personal protective equipment, obtaining a detailed history of travelling, and rapidly escalating suspicious cases with a dedication to isolate patients. any confirmed cases of covid- should be moved to an airborne high impact infectious disease center such as the two major centers in england (royal free hospital in london and newcastle royal victoria infirmary). u.k. chief medical officers told individuals who had toured wuhan or hubei province over the past days to stay at home and call national health service number . such recommendations were also applied to people, who have visited japan, thailand, hong kong, singapore, taiwan, macau, and malaysia [ ] . the world's second most densely-populated country after china made the situation worse, since population density beside some other factors contributed to the wide viral transmission [ ] . poverty and money-related problems complicated combating strategies. if the government imposed social distance ( m distance), many categories opposed the actions, especially craftsmen. ignorance from indians at first increased the number of infected people [ ] . then, the government imposed a strict lockdown for days except for some services such as fire departments, police, and hospitals. diagnostic kits were increased every day and in every state. train coaches were turned to mobile wards for isolation. a phone application was launched called aarogya setu (health bridge) aiming to track people's health [ ] . check points were built at borders to check people entering the country, and all borders were shut. the ministry of health and family welfare (mohfw), india, increased awareness, took actions to control covid- and guidelines on management; prevention and sample collection were announced. also a hotline was created with a h/ days-a-week service to help people [ ] . a huge budget of about us $ . billion was endowed for health sector to combat covid- . the department of science and technology, government of india tried to promote research in university institutes and started working in various directions to control the virus during the country's lockdown. the indian council of medical research (icmr) launched private labs with suitable safety regulations to test covid- samples. icmr reported that about , tests (as of april ) were performed in india. blood plasma therapy using the plasma of recovered patients with immunity against covid- was applied to infected individuals. the indian strategies paid the most attention for medical care requirements. thus, the number of infected people is less than other countries due to exerted efforts by authorities to impose the strict lockdown. yet even after lockdown removal (fully or partially) on may , the threats amplified [ ] . on june , the ministry of health and family welfare (mohfw) announced that , confirmed covid- cases and deaths from states especially the states of maharashtra, tamil nadu, delhi, and gujarat. hence, the case-fatality rate became . % [ ] . it is not the first time for japanese people to face a national crisis, as they previously experienced two atomic bombings in , the sarin gas in , and the h n epidemic in . thus, fear and anxiety was dominating. images, headlines, rumors and confirmation of human-to-human transmission in nara prefecture played a role. anxiety-related behaviors appeared significantly in shortage of masks and sanitizers in drug stores, social rejection, discrimination against affected people [ ] . however, preparedness and learning from previous lessons was effective. japan reported low numbers of covid- -related deaths due to the following measures. to prevent infection, emergency state was declared on april and continued for a month. people were asked to stay home and stop un-essential activities. japanese customs suited for social distancing, as they exclude handshaking, hugging, or kissing in greetings [ ] . usage of long-term care areas with the most vulnerable residents was temporarily suspended. japanese people were asked to avoid crowded places with bad ventilation and conservation of physical distances according to recommendations of an expert committee [ ] . travels were restricted from and to wuhan, and japanese citizens were asked to evacuate china. subsequently, three flights transported them back home. healthy individuals were isolated, prevented to move around and kept under medical observation at designated hotels, while others with disease symptoms upon arrival in japan were admitted to hospitals [ ] . singapore, the regional travel center in southeast asia, was one of the first places to be impacted by covid- . the singapore strategies were based on back experience with sars outbreak. an important lesson was to ensure cohesive response across all sectors, consistent leadership and guidance was crucial. therefore, a multi-ministerial task force was established to provide central leadership for all government crisis management, before singapore had its first covid- incident. an intensified surveillance system was developed to monitor covid- cases between hospital and primary care pneumonia patients. to promote this system, covid- rt-pcr laboratory tests were rapidly expanded to all singapore hospitals with tests per day for . million persons. suspected and confirmed cases were isolated in hospitals immediately to avoid further transmission. contact tracing was also started to determine their past locomotion before isolation to identify potential sources of infections. more than public health preparedness clinics has been set up to facilitate the control of primary care of respiratory diseases. incoming travelers were subjected to temperature and health checks at all airports and suspicious cases sent immediately to hospitals. singapore's community approach focused on social responsibilities while precautionary life kept going as usual. social education was a key empowerment strategy and carried out through print, broadcast, and social media. workers are empowered to continuously monitoring temperature and health and organizations are motivated to step forward their business plans. schools remained opened with precautions. even though these precautions were enforced, singapore retained normality of daily life [ ] . by march , the viral spread increased, and all provinces were affected. then, by april the number of confirmed cases reached , with deaths in iran. the government prohibited many activities: sale and export of face masks to legal entities were limited, commercial movements with china were prevented, and travel was banned. cancelation of all public gatherings, including cinemas, concerts, theaters, postponement of weddings, parties, conferences, seminars, camps and collective sports, school closure, and establishing e-learning, reduced office hours for h/day [ ] . people were guided for hand-washing and wearing masks. suspected and infected people with covid- were isolated for days [ ] . poor people were severely affected by quarantine; hence, the government financially supported them. the supreme council for health and food security together with a special council for covid- confessed essential deficiencies in policies regarding food security including delays in bills such as electricity, payment of bank loans. however, reductions in oil prices and oil selling due to sanctions significantly affected the ability of governmental support [ ] . the iranian ministry of health and medical education (mohme) compiled the who guidelines for covid- prevention and announced them through different platforms. hotlines to answer questions and give advice on nutrition and mental health were available. national campaigns for increasing awareness and information were held to improve public knowledge. a website was launched (salamat.gov.ir) to help people and answer their questions [ ] . the political situation in iran impacted the economic infrastructure, which indirectly affected the health sector and the first-line defense against the virus. thus, the burden scaled up. in addition, the weakness of the medical infrastructure, inadequate personal protective equipment and difficulties in importing them are all key factors. quarantining cities was rather ineffective due to viral distribution throughout the country [ ] . korea's infection alerting system has four levels: ( ) attention to the epidemic as the government began tracking, ( ) caution if an epidemic reached the country and the government maintained a program of cooperation, ( ) activation of response system that could be alerted regarding to spread of infection, and ( ) development of a national response program, as the outbreak progressed and became serious. four days after announcement of new cases in china, korea began screening and enforced quarantine program at the airports. everyone who had visited wuhan during the past days was asked to complete health questionnaire and to have days of self-quarantine. if there was fever or respiratory ailments, they should call korea cdc. early recognition helped korea remove the community infection and limit it to medical facilities which was an integral part of outbreak response. a -h rapid test was distributed in all health centers around the country. korea cdc started recording the crisis to provide reliable data. such reports included number and history of suspected cases with public guidance for prevention. travel to china was cancelled. korea goals were accomplished through key strategies: st outbreak based on suppression and mitigation, nd risk awareness to encourage community involvement, and rd science-based and reality driven behavior [ ] . australia built its response to covid- on the basis of its powerful healthcare system. australia realized that people involved in primary care, elderly care, home care, and disability care need the same degree of support and safety as people working in hospitals in attempt to preserve both public and vital health care system to sustain the workplace of services. good, coherent contact with the primary care staff and general public was very critical for the needed steps. borders were shut down, non-essential facilities were closed, precautionary measures were in the places with infection risk, stringent social distancing were enforced together with quarantining of individuals with suspected infection or confirmed infection. the prime minister of australia stated the implementation of the novel coronavirus emergency response program for australian medical sector. the four strategic goals of the targeted plan were: protecting people from covid- effects, maintain health care functional capacity, facilitate the most appropriate treatment of people with symptoms, manage, and control personal protective equipment. the australian government introduced . billion primary care packages to safeguard all australians. primary care approach has main components: telemedicine services, online infection control training provided to all caregivers, institution of general practice-led primary healthcare respiratory clinics ( clinic) to transfer affected people away from other general practices [ ] . most governmental strategies are summarized in figure . collectively, demographic diversity, standard of living of each country's citizens, political state and health systems in addition to other factors led to various strategies being implemented across the globe trying to cope with the crisis. however, the collaboration and sharing of responsibility for controlling the pandemic through exchange of information between countries was the most important step. taken together, countries facing covid- or any other pandemic should consider control or closure periods and whether required or compulsory closure of unneeded workplaces and public entities as a first line of social distance measures can reduce transmission rate. the closure times should be adapted to the unique characteristics of the novel disease, i.e., the incubation duration and transmission routes, and the nature of these outbreaks. the main purpose of the pandemic control closure phase is to avoid the spread of disease by people with asymptomatic infections. governments should use closure times to optimize effect, promotions, group screening, active communication, monitoring, isolation, and quarantine. some countries have promoted their people's consciousness across many channels, e.g., television, newspapers, and conferences. they have been resorting to the use of more modern health and education technologies i.e., e-learning and telemedicine to reduce the urge to go outside. such a hybrid strategy is also backed up by analyses of responses to previous pandemics, which have shown that average attack rate reductions were more noticeable if social distance policies and other disease prevention steps were combined to prevent transmission. sars-cov- spreads at an astonishing speed across the globe. on january , who collectively, demographic diversity, standard of living of each country's citizens, political state and health systems in addition to other factors led to various strategies being implemented across the globe trying to cope with the crisis. however, the collaboration and sharing of responsibility for controlling the pandemic through exchange of information between countries was the most important step. taken together, countries facing covid- or any other pandemic should consider control or closure periods and whether required or compulsory closure of unneeded workplaces and public entities as a first line of social distance measures can reduce transmission rate. the closure times should be adapted to the unique characteristics of the novel disease, i.e., the incubation duration and transmission routes, and the nature of these outbreaks. the main purpose of the pandemic control closure phase is to avoid the spread of disease by people with asymptomatic infections. governments should use closure times to optimize effect, promotions, group screening, active communication, monitoring, isolation, and quarantine. some countries have promoted their people's consciousness across many channels, e.g., television, newspapers, and conferences. they have been resorting to the use of more modern health and education technologies i.e., e-learning and telemedicine to reduce the urge to go outside. such a hybrid strategy is also backed up by analyses of responses to previous pandemics, which have shown that average attack rate reductions were more noticeable if social distance policies and other disease prevention steps were combined to prevent transmission. sars-cov- spreads at an astonishing speed across the globe. on january , who announced the outbreak of covid- an international public health emergency which impacted countries (status: march ) [ ] . the speed and extent of pandemic detection, particularly early diagnosis and notification of new cases, is an important measure to monitor this infectious disease. countries that have previous experience with viral infectious diseases (most commonly sars), powerful primary care systems with helpful infrastructures, guidance rules and instructions, and community awareness with social responsibilities prove to be more effective in controlling the spread of infection and reducing its deleterious impacts. numerous countries endeavor to construct an info-structure of national digital health in order to improve disease surveillance and link public health and clinical intelligence programs. clear and open contact between governments and healthcare staff would be pivotal. it was the time for hospitals or agencies that engage in healthcare delivery to audit its protocols and consumables for all selected patients. heads of state, global health leaders, private sector partners, and other stakeholders have accelerated global partnership to speed up the production of covid- diagnostic and preventive tools. all governments should prepare the public for a second wave or another outbreak. national policy discussions about the future of the respective society should be initiated. covid- is a tragedy for us all collectively, but it is also an opportunity to ask ourselves what kind of society we want after the pandemic fades away. reproduction numbers of infectious disease models molecular mechanisms of coronavirus rna capping 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of novel coronavirus ( -ncov) infection: estimation using japanese passengers data on evacuation flights interrupting transmission of covid- : lessons from containment efforts in singapore covid- pandemic and comparative health policy learning in iran the challenges and considerations of community-based preparedness at the onset of covid- outbreak in iran ensuring adequate health financing to prevent and control the covid- in iran ir of iran national mobilization against covid- epidemic coronavirus disease (covid- ) outbreak in iran: actions and problems lessons learned from korea: covid- pandemic crossref] . world health organization. responding to community spread of covid- : interim guidance the authors declare no conflict of interest. key: cord- - s e authors: sun, mei; xu, ningze; li, chengyue; wu, dan; zou, jiatong; wang, ying; luo, li; yu, mingzhu; zhang, yu; wang, hua; shi, peiwu; chen, zheng; wang, jian; lu, yueliang; li, qi; wang, xinhua; bi, zhenqiang; fan, ming; fu, liping; yu, jingjin; hao, mo title: the public health emergency management system in china: trends from to date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: s e background: public health emergencies have challenged the public health emergency management systems (phemss) of many countries critically and frequently since this century. as the world’s most populated country and the second biggest economy in the world, china used to have a fragile phems; however, the government took forceful actions to build phems after the sars outbreak. after more than one decade’s efforts, we tried to assess the improvements and problems of china’s phems between and . methods: we conducted two rounds of national surveys and collected the data of the year and , including all provincial, municipal, and county cdcs. the municipal and county cdcs were selected by systematic random sampling. twenty-one indicators of four stages (preparation, readiness, response and recovery) from the national assessment criteria for cdc performance were chosen to assess the ten-year trends. results: at the preparation stage, organization, mechanisms, workforce, and stockpile across all levels and regions were significantly improved after one decade’s efforts. at the readiness stage, the capability for formulating an emergency plan was also significantly improved during the same period. at the response stage, internet-based direct reporting was . %, and coping scores were nearly full points of ten in . at the recovery stage, the capabilities were generally lower than expected. conclusions: due to forceful leadership, sounder regulations, and intensive resources, china’s phems has been improved at the preparation, readiness, and response stages; however, the recovery stage was still weak and could not meet the requirements of crisis management and preventive governance. in addition, cdcs in the western region and counties lagged behind in performance on most indicators. future priorities should include developing the recovery stage, establishing a closed feedback loop, and strengthening the capabilities of cdcs in western region and counties. since the early twenty-first century, frequently appearing public health emergencies such as severe acute respiratory syndrome (sars), middle eastern respiratory syndrome, and ebola have threatened population health and social stability [ ] . this has critically challenged the public health emergency management systems (phemss) of many countries [ ] , especially developing countries. the global community quickly reached a consensus on the development of the phemss [ ] . in , the th world health assembly (wha) adopted the revised international health regulations, which instructed the world health organization (who) member states to collaboratively confront public health emergencies of global concern. a world health report in also focused on global public health security in the twenty-first century. the ebola outbreak in - has pushed the process of who reform into high gear [ ] , giving top priority to changes in the who's emergency operations and a need to build resilient health systems that can withstand epidemics. china has the largest population and the second biggest economy in the world. china has played an increasingly important role in preventing and controlling the global spread of epidemics in recent years and gradually changed from aid recipient to aid donor [ ] . china used to have a fragile phems; however, the sars outbreak exposed many weaknesses and problems [ ] , such as an ineffective response system, lagging epidemiological field investigation and laboratory testing skills, and inaccurate and untimely information communication. these aroused the public's horror and international community's blame. the central government urged governments at different levels to make political commitments and take forceful actions to build the phems. after more than one decade's efforts, what are the trends of china's phems? what are the improvements and remaining problems? what are the implications for china and global health security? in recent years, the development of phems has received increased attention in the literatures. some researchers expressed the importance of phems and the progress after sars qualitatively [ , ] . others quantitatively accessed the trends using regional data, usually at a certain level or within a certain province or city [ ] [ ] [ ] [ ] . time spans were restricted to early-phase usually around [ ] . to our knowledge, little evidence could tell the differences that happened in china's phems in this decade. based on two national surveys in and , we previously reported that resource allocation of cdcs increased and the general completeness of phems improved between and [ ] . however, what measures phems carried out and how it changed still remained unclear. this paper will attempt to answer these questions specifically. this article consists of the follows. the next section provides details on methodology,including sampling, indicator selection and measurements, data collection, and data analysis methods. the third section shows the results, followed by discussion corresponding to the results. the final section is about conclusion and policy implications. the survey methods have previously been published [ ] . briefly, we conducted two rounds of cross-sectional surveys in and . the two surveys were retrospective and selected the same agencies in the two rounds. the survey of collected the data from to , and the survey of collected data of . we conducted a multistage sampling to select cdcs at different administration levels, selected all provincial cdcs and used systematic random sampling to select municipal and county cdcs. as governmental funding is the most critical control point of public health emergency management for the cdcs [ ] ,we used "governmental funding to cdcs per thousand people" as a basis to determine sample size [ ] . a sample size of municipal and county cdcs was calculated based on the following formula [ ] . where n is the number of the minimal sample size; αis the probability of type i error, and β is the probability of type ii error, here α = . ,β = . ; u α and u β are standard normal distribution values corresponding to α and β respectively;σis the population standard deviation, hereσ = . yuan; δ is the allowable error. for municipal cdcs, δ = . yuan, σ = . yuan. for county-level cdcs, δ = . yuan, σ = . yuan ( u.s. dollar = . yuan). the municipal and county level cdcs were all selected through random sampling. the sampling process was conducted based on the national standard coding (gb coding, the corresponding administrative regional code which is unique for each city or county [ ] ). we used a computergenerated random number to identify the first institution, and then selected every third municipal cdc and every sixth county level cdc. finally, we selected provincial cdcs, municipal cdcs, and county cdcs. the study was approved by the former ministry of health (moh) in china and reviewed by the medical research ethics committee at the school of public health of fudan university. we selected twenty-one indicators associated with the phems from the national assessment criteria for cdc performance. based on the crisis management theory which was commonly used in the field of public emergency management [ , ] , the whole process was divided into four stages including preparation, readiness, response and recovery [ ] . according to the framework, we grouped the indicators into stages and capabilities. table showed the features, units and measurements of these indicators. according to the national regulations on public health emergency management [ ] , each sampled cdc graded five public health emergencies handled in the year before the survey with the full mark of points for each indicator; at cdcs where the total numbers of handled public health emergencies were fewer than five, all public health emergencies were graded instead. the bureau of disease prevention and control of the former moh approved and organized two rounds of field surveys, and provincial health departments coordinated data collection. a pilot survey was conducted to ensure validity and reliability. after receiving uniform training from the moh, the provincial quality supervisors trained investigators from sampled cdcs in their corresponding provinces. the investigators collected relevant data from sampled cdcs and submitted the completed questionnaires to their provincial quality supervisors via e-mail or cd-rom. simultaneously, paper copies with official stamps were submitted. the second round of survey data were obtained from national disease control and prevention performance evaluation platform. the quality control process was set up and carried out by the platform with backend logic judgments and audit procedures. as the final step of quality control in both surveys, research group rechecked data and contacted cdcs with abnormal or absent values via email or phone. finally, the overall response rate was . % in and . % in . we established a dataset using excel (microsoft redmond wa). we only used the data of the year and for analysis. after data cleaning and sorting, descriptive analysis and statistical tests were performed using spss . (ibm spss, chicago, il, usa). we used establishing organization comprised building an emergency response office and forming a leadership group and an expert panel. table ). the capability for building mechanisms in terms of information sharing and on-site treatment increased by . % and . %, respectively. increasing by . %, response-material deployment mechanism gained the highest growth rate. municipal cdcs had the highest percentages, followed by provincial and county cdcs. the central region not only had the highest percentages, but also experienced the highest growth rate. average number of emergency response personnel per cdc increased from in to in , which was significant. in , provincial cdcs had the highest number of personnel (n = ), followed by municipal (n = ) and county (n = ) cdcs. moreover, the average number decreased from eastern (n = ) to western regions (n = ) ( table ). the percentage of fully stockpiling emergency resources significantly increased from . % in to . % in . provincial cdcs had the highest percentage ( . %) in and increased by . %, whereas county cdcs had the lowest percentage ( . %) in and increased by . %. nevertheless, the average percentage at each administrative level did not meet the corresponding performance assessment criteria. average percentages of fully stockpiling emergency resources decreased from eastern ( . %) to western ( . %) regions. the mean percentage of formulating emergency plan increased from . % in to . % in , statistically significantly increasing by . %. provincial cdcs had the highest percentage ( . %) in , and the difference between municipal ( . %) and county cdcs ( . %) was not significant. cdcs in central region had the highest percentage ( . %), followed by western ( . %) and eastern ( . %) regions ( table ). the average length of emergency response training increased from . days per person in to . days per person in ; however, this . % increase was not statistically significant. provincial cdcs had the highest average length of response training ( . days per person), followed by municipal and county cdcs (table ) . comparing the statistics in and , the average times of exercises did not change with statistical significance. in , county cdcs had higher average times of exercises than did municipal ( . ) and provincial ( . ) cdcs; nevertheless, only provincial cdcs had increased average times of exercises during the past decade. from regional perspective, the average times of exercises decreased from western ( . ) to eastern ( . ) regions (table ). there were . % and . % of disease surveillances conducted per month and per week in , respectively. compared with statistics in , frequencies of daily, weekly, and monthly surveillance analysis increased, among which weekly surveillance analysis increased with statistical significance. meanwhile, the frequencies of disease surveillance analysis per ten days, quarter, and year decreased with statistical significance ( table ). according to "contingency rules of paroxysmal public health events", public health emergency events are classified into four levels (i, ii, iii and iv), with severity decreasing from level i to level iv. in , there were public health emergencies directly reported via the disease surveillance information management system, which accounted for . %.the percentage of timely reporting by county cdcs emergency levels in was presented in table . moreover, the average scores for indicators of coping capability were high in (table ). the average scores for capabilities at recovery stage were lower than those for capabilities at response stage. the average score for data archiving was . , then followed by those for data analyzing ( . ) and concluding ( . ) ( table ). the main findings indicated that china had made significant progress in the four stages after a decade's efforts, especially in preparation, readiness, and response stages. this has been demonstrated by other researches [ , ] . the average percentages of cdcs with an emergency response office, a leadership group and an expert panel were . %, . % and . % in , respectively. this suggests that a phpm system with better leadership has been established in china. soon after the sars outbreak, chinese governments at different levels were urged to establish a sars headquarters at cdcs to shoulder the responsibilities of unified leadership and command during public health emergencies. the emergency response law of the people's republic of china issued in formally and strongly stipulated the establishment of the emergency management system that urged unified leadership, comprehensive coordination, categorized management, graded responsibility, and territorial management. the capability for building mechanisms comprised of information sharing, on-site treatment and response-material deployment increased to more than % in . boosted by the sars outbreak in , various authorities consecutively issued a series of regulations that standardized the phems in terms of macro-level management, professional categories, disposal processes, etc. from the perspective of macro-level management, regulations included emergency management [ ] , organizational establishment [ ] , coordination mechanisms [ ] , etc. from the perspective of professional categories, regulations standardized the responses to nuclear accidents [ ] , infectious disease outbreaks [ ] , etc. from the perspective of disposal processes, regulations clearly guided emergency response plans [ ] , exercising [ ] , information reporting [ ] , etc. another notable foundation is that the growth of resources including workforce and stockpile was . % and . %, respectively. since , intensive investments by governments have contributed to the improvements on the following aspects. first, funding for cdcs across different levels changed from balanced allocation to full fiscal funding after . total income governmental funding increased from . % in to . % in [ ] . second, cdcs' staff were overall more educated. the percentage of staff with bachelor degree or higher increased from . % in to . % in [ ] . last, the total value of fixed assets of all cdcs increased from . billion cn ¥ in to . billion cn¥ in [ ] . available research showed that the quantity and quality of emergency staff, governmental-funding level, and fixed assets played important roles in improving the implementation of cdcs' capabilities in the phems [ ] . a firm leadership, a favorable mechanism and sufficient resources are the key elements of a well-developed phpms [ ] . it is undeniable that the phems' achievements in the past decade are remarkable. china's active and constructive contributions have been highly valued by the global community; for example, china's response to h n in was recognized as "exemplary" by the who [ ] . the three leading guarantees of china could be referenced by developing and other underdeveloped countries. however, to cope with future challenges in global health security, the following aspects require strengthening. first, preventive governance is necessary. the recovery stage capabilities were the weakest, which is far from achieving the standard of full recovery including sustainability, resilience after crisis and feedback to preparationstage. the prediction, communication, and social services during and after emergencies require improvement. second, balanced development at different regions and levels is very important. county cdcs in the front lines [ ] had the weakest capabilities. one possible reason was that the relevant policies including contingency plan, work specifications, and guidelines were not instructive and operable enough for county cdcs [ ] . another reason was an inequitable distribution of personnel in urban and rural areas [ ] . available data showed that compared with county cdcs, a greater number of personnel with degree higher than bachelor worked at provincial and municipal cdcs [ ] . additionally, the governmental funding per staff for county cdcs in was . million cn¥, which was much lower than the funding at municipal and provincial cdcs ( . and . million cn¥, respectively) [ ] . from the perspective of regional disparity, cdcs in western region were the weakest. reasons include that it had the poorest fiscal capacity to fund cdcs; a limited personnel size; and an inadequate stockpile in terms of working budget, timely reserves, and prompt delivery [ ] . third, the application of new technologies should keep pace with science and technology development. for example, the disease surveillance systems need to be integrated with the use of standard data formats and allow the public health community to respond more quickly to public health threats [ ] . a stockpile management and tracking system could also be designed and used to manage stockpiles across different levels and regions [ ] . the available assessment indicators are relatively narrower in comparison with those such as the capability nearly half the indicators were binary ("yes" or "no"), so the quality of policy implementation and accountability could not be judged. although logic judgments and audit procedures were conducted, recall bias may still exist. despite these limitations, the main contribution of this paper are the findings based on the data from two rounds of national field surveys conducted in to in china. we believe that this contribution is theoretically and practically relevant because the lessons china's government learned from the sars outbreak provide an emergency response framework that can be employed by developing countries. since the sars outbreak, china has built an effective phems and achieved comprehensive progress and improvements at preparation, readiness, response, and recovery. nevertheless, lacks of conceptual crisis management and preventive governance, disparities across regions and levels, and insufficient application of new technologies remain. future priorities should be to develop the recovery stage, establish a closed-feedback loop between recovery and preparation stages, and strengthen capability-building cdcs in western areas through increasing governmental funding and improving the quality of response personnel. the guarantees of leadership, regulations, and resources provide useful references for other developing countries. this survey was administered in the collaboration with national health commission of the people's republic of china (the former ministry of health), and the data ownership belongs to former moh. we just got the admission of certain data fields to analyze, so we are sorry that we cannot provide basic data. authors' contributions ms participated in study design and conception, data acquisition, data analysis, manuscript drafting, and funding acquisition. nx participated in data analysis and manuscript drafting. cl, yw and ll participated in data acquisition. dw participated in data analysis. jz participated in discussion and manuscript revision. my, yz, hw, ps, zc and jy participated in the design and conceptualization of the study, acquisition of data, and data interpretation. jw, yl, ql, xw, zb, mf, and lf participated in the interpretation and acquisition of data. mh participated in the design and conceptualization of study, acquisition of data, revising of the manuscript, acquisition of funding, and supervision. all authors read and approved the final manuscript. the study was approved by the medical research ethics committee at the school of public health of fudan university. the access to the survey data used in this study was approved by the national health commission of the people's republic of china (the former ministry of health). this study didn't involve human participants and there was no data collected from humans or animals. consent to participate for patients were not applicable. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with 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family planning commission of the people's republic of china. statistical yearbook of china's health and family planning emergency capability construction of institution of disease prevention and control updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group development of the inventory management and tracking system (imats) to track the availability of public health department medical countermeasures during public health emergencies key: cord- - qvvkvk authors: shammi, mashura; bodrud-doza, md.; islam, abu reza md. towfiqul; rahman, md. mostafizur title: strategic assessment of covid- pandemic in bangladesh: comparative lockdown scenario analysis, public perception, and management for sustainability date: - - journal: environ dev sustain doi: . /s - - -y sha: doc_id: cord_uid: qvvkvk abstract: community transmission of covid- is happening in bangladesh—the country which did not have a noteworthy health policy and legislative structures to combat a pandemic like covid- . early strategic planning and groundwork for evolving and established challenges are crucial to assemble resources and react in an appropriate timely manner. this article, therefore, focuses on the public perception of comparative lockdown scenario analysis and how they may affect the sustainable development goals (sdgs) and the strategic management regime of covid- pandemic in bangladesh socio-economically as well as the implications of the withdrawal of partial lockdown plan. scenario-based public perceptions were collected via a purposive sampling survey method through a questionnaire. datasets were analysed through a set of statistical techniques including classical test theory, principal component analysis, hierarchical cluster analysis, pearson’s correlation matrix and linear regression analysis. there were good associations among the lockdown scenarios and response strategies to be formulated. scenario describes how the death and infection rate will increase if the bangladesh government withdraws the existing partial lockdown. scenario outlines that limited people’s movement will enable low-level community transmission of covid- with the infection and death rate will increase slowly (r = . , p < . ). moreover, there will be less supply of necessities of daily use with a price hike (r = . , p < . ). in scenario , full lockdown will reduce community transmission and death from covid- (r = . , p < . ). however, along with the other problems gender discrimination and gender-based violence will increase rapidly (r = . , p < . ). due to full lockdown, the formal and informal business, economy, and education sector will be hampered severely (r = . ). subsequently, there was a strong association between the loss of livelihood and the unemployment rate which will increase due to business shutdown (p < . ). this will lead to the severe sufferings of poor and vulnerable communities in both urban and rural areas (p < . ). all these will further aggravate the humanitarian needs of the most vulnerable groups in the country in the coming months to be followed which will undoubtedly affect the bangladesh targets to achieve the sdgs of and other development plans that need to be adjusted. from our analysis, it was apparent that maintaining partial lockdown with business and economic activities with social distancing and public health guidelines is the best strategy to maintain. however, as the government withdrew the partial lockdown, inclusive and transparent risk communication towards the public should be followed. recovery and strengthening of the health sector, economy, industry, agriculture, and food security should be focused on under the “new normal standard of life” following health guidelines and social distancing. proper response plans and strategic management are necessary for the sustainability of the nation. graphic abstract: [image: see text] electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. performed is , which is tests/ million (iecdr ; worldometer ) . the number is one of the lowest in the world (table ) . it is predictable that during a pandemic, a humanitarian crisis may arise in a developing country like bangladesh. in most incidents, it will be the combined effects of a variety of shortages that will likely culminate in the worst outcomes (truog et al. ). this can lead to a shortage of basic needs including foods, goods, and services such as job loss, economic and financial loss, food insecurity, famine, social conflicts, and deaths. besides, an impact on the psychosocial and socio-economic and health and well-being of the citizens may be affected which we had shown in our previous study . while predicting all the subsequent impact of the covid- pandemic is challenging, early strategic planning and groundwork for the evolving and established challenges will be crucial to assemble resources and react in an appropriate timely manner. moreover, as the gob has lifted the lockdown without flattening the curve of the pandemic what should be the socio-economic management strategy for the government at this stage. this article, therefore, focuses on the public perception of comparative lockdown scenario analysis and the strategic management regime of covid- pandemic in bangladesh. as there is no such prediction on how long the situation prevails, the absence/lack of management strategy for an epidemiological and socio-economic emergency response might be a tool to assess the forthcoming situation under a set of specific scenarios. therefore, the objective of this study is to analyse long-term strategic management of the pandemic in three different lengths of scenarios in a resource-limited setting of the so-called lockdown of the country. the outcome can play a crucial role to formulate emergency response strategy to tackle the covid- considering the impact of current socio-economic lockdown for flattening the curve of covid- infection in bangladesh, this study identifies three scenarios of lockdown based on literature review, the lockdown situation in bangladesh, and the global lockdown practices in different countries. a total of statements were used to develop the questionnaire to understand the scenario-based impact assessment and management of covid- outbreak in bangladesh. we had taken expert suggestions, consultations, and cross-validation of statements for getting perceptions from a different group of people. we have used google form to prepare the questionnaire and conduct the survey online. an online database of target bangladeshi participants was prepared by reviewing different online social platforms of different expert groups in bangladesh, considering their current activities, responsibilities, and engagement related to covid- response in socio-economic sectors, planning, and policymaking. the prepared questionnaire with an introductory paragraph outlining the objective of the study was then shared through email, facebook, messenger, linkedin, and whatsapp with selective and relevant people considering the purposive sampling method. the questionnaire survey was conducted from april to april . a five-point ( - ) scenario-based likert scale was employed to test whether each respondent understands the statements described ranging from strongly disagree to strongly agree. the target population was general bangladeshi citizens age years and older. the inclusion of the respondents was different social groups like university faculty and scholars, government officials, non-government officials, development workers or practitioners, doctors, engineers and technologists, youth leaders and students, businessmen and industry officials, banking and finance corporates, researchers, and others. the answers to the survey questionnaires were the voluntary basis. a total of responses were recorded during the survey. according to the survey findings, the ratio of male to female participants was (n = ): (n = ). the composition of age groups was % ( - years old), % ( - years old), and % ( - years old), respectively. however, the average age of the respondents (n = ) was . years (sd ± . ). % of the youth leader was mostly students as they are the dynamic group in the society, also involved in covid- response, volunteer social works, job seeking, research and reporting activities. rest of the % participants belonged to various professions of doctors, civil service officials, development practitioners, non-government officials, expert panels, and university scholars. the descriptive statistics (e.g. frequencies, percentages, and student t test) were used to understand the participant's characteristics. applying the statistical package for the social science (spss) v. . , datasets were analysed via a set of statistical tools such as principal component analysis (pca), hierarchical cluster analysis (hca), pearson's correlation coefficient (pcc), multiple regression analysis (mra), and classical test theory (ctt) analysis. pca is one of the population data reduction techniques that indicate each potentiality of variables and their significance level in a huge sample size. before conducting the pca, kaiser-maier-olkin (kmo) and bartlett's sphericity tests were applied to confirm the necessity of this analysis. the results of the kmo > . (the kmo value was . in this research) and the significance of bartlett's sphericity test at p < . verified our datasets to be fitted for the pca ). the number of factors chosen was based on the kaiser's normalization principle, where the only factors with eigenvalues > . were regarded. from ctt analysis, cronbach's alpha was employed to test the consistency and reliability of the factor loadings in this study. cronbach's alpha validation values ranged from . to . (the cronbach's alpha reliability value was . indicating that these statements are appropriate in social science study (table ) (devellis ). the hierarchical cluster analysis (hca) is a crucial means of identifying relationships among all socioenvironmental variables. the hca assists to classify a population into different groups based on the similar characteristics of a set of the dataset that may show causes, effects, and or the source of any undetected socio-environmental crisis. furthermore, hierarchical clustering was adopted to determine the possible number of clusters. the one-way anova test was conducted to confirm the significant differences in the variance at p < . . participants were informed of the specific purpose of the study. participants' consent was taken before the survey and they remained anonymous. the survey was completed only once, and the survey could be completed/terminated whenever they wished. the survey content and procedure were reviewed and approved by the department of public health and informatics, jahangirnagar university. reductions of covid- pandemic have been linked with the cessation of public transport, educational institutions, the closing of entertainment and business centres, and the prohibition of public meetings. averagely, cities that carried out control measures of lockdown within the first week of the outbreak reported fewer cases compared to the cities which started control later (tian et al. ) . vietnam, the communist country bordering china with a population of million, has been an under-reported low-cost success story of the pandemic, which has had just coronavirus cases and no deaths due to strong public health systems, good governance and transparent communication, strict quarantine approach, and contact tracing. from the first-known international cases on january , vietnam quarantined anyone who arrived from the high-risk area and closed its porous -km border with china to all but essential trade and travel. in february, it quarantined more than , people in the son loi village due to infections. it also closed all schools, colleges, universities, and all other educational institutions beginning in february. on march , the vietnamese government suspended all foreign entries (wef a). it also decided early on to impose a -day quarantine on anyone arriving in vietnam from a high-risk area. on april , vietnam eased its lockdown effort. unfortunately, in the european region such as worst-affected italy, france, and uk, the region in the americas such as the usa and now brazil experienced most deaths due to the failure to understand the disease and keep continuing their activities such as travelling and tourism which spiked the death rates, or delayed lockdown efforts (table ). the case of new zealand is interesting in the sense that it pursued an eradication tactic historically based on a mitigation model and focused on slower arrival of the virus, followed by a range of measures to flatten the curve of cases and deaths (cousins ) . the measures include increased testing, screening, strict quarantine of the infected person, contact tracing, and surveillance. the same measures have been adopted by south korea, taiwan, and many successful countries. luo ( ) , of singapore university of technology and design (http://www.sutd.edu. sg) forecasted using a data-driven model that by may , % of the infection case will end, while % will end by july for bangladesh. however, the forecast does not seem to be valid considering the present context in bangladesh. at this background, a scenario-based assessment under different assumptive situation considering the socio-economic and cultural attitude of the country could better identify the impacts. the later section of the article mainly focused on the different scenario and their possible management and their way forwards. in our study, we have considered global lockdown practice, country situation analysis, and expert suggestions to set three scenarios for impact analysis and possible management strategies which are: lockdown scenario : withdraw the existing partial lockdown (ls ) lockdown scenario : continue the existing partial lockdown (ls ) lockdown scenario : full lockdown/shutdown with an exit plan (ls ) a total of scenario-based statements were set, and perception-based statistical analysis was performed. the descriptive statistics are presented in table , which exhibits the percentage, mean, and standard deviation (sd), describing the responses of participants to the related scenarios for all statements from each of the respondents and the direction of each statement in the studied survey datasets. sect. . - . discusses the impacts of different lockdown scenarios. considering the withdrawal of existing partial lockdown, the results of ctt analysis and the corrected inter-item correlation analysis reveal that eight statements have low corrected item-total correlation values (< . ). this includes, people will start moving towards table (continued) table (continued) regular life (ls s : . ); massive movement and a mass gathering of people will be started again (ls s : . ); community transmission of covid- will increase due to people's movement and mass gathering (ls s : . ); and the number of infected populations will increase (ls s : . ). bangladesh is entering into this scenario without having any signs of flattening the infection curve. from pearson correlation analysis, a strong significant positive relationship was observed between people will start moving towards regular life (ls s ) and the formal and informal economic activities will be started (ls s ) (r = . , p < . ) ( table ) . linear regression analysis reveals that the community transmission of covid- will increase due to people's movement and mass gathering (ls s ) as people will start moving towards regular life (ls s , p < . ), and crime will rise and more people will die (ls s , p < . ) exhibited a statistically significant high correlation with the number of infected populations will increase (ls s ) ( table ). in addition, more unemployment and loss of livelihood (ls s ) and more people will die (ls s ) statistically pose a significant positive impact on an irreversible loss to the economy (p < . ) of bangladesh. from ctt analysis, continue the existing partial lockdown (ls m : . ); limited people's movement will enable low-level community transmission of covid- (ls s : . ); infection and death rate will increase slowly (ls s : . ); increased facilities to the healthcare system for covid- treatment will be able to provide health services to the infected peoples (ls s : . ). from pearson correlation (table ) , a significant positive relationship was found between the limited people's movement will enable low-level community transmission of covid- (ls s ) with the infection, and the death rate will increase slowly (ls s ) (r = . , p < . ). also, there will be less supply of basic products for daily use (ls s ) which posed a significant relationship with the price of most of the basic products will be higher than usual (ls s ) (r = . , p < . ). from the linear regression model (table ) , the association between dependent statements limited people's movement will enable low-level community transmission of covid- (ls s , r = . , p < . ) with poor people will suffer from food and the nutritional deficiency (ls s ), and gender-based violence will increase (ls s ). based on management scenario , massive awareness and enforcement of proper lockdown and quarantine initiatives were strongly associated with limited people movement will enable low-level community transmission of covid- (ls s , p < . ). from the ctt analysis, among statements, the corrected inter-item correlation analysis showed that only one statement has low corrected item-total correlation values (< . ). this adds existing with increased facilities for covid- in the health system will be able to provide health services to the infected people (ls s : . ). the highest interitem correlated value is the loss of livelihood and the unemployment rate will increase due to business shutdown (ls s : . ), while the lowest value is the number of infections and death will be limited (ls s : . ). in the case of management of scenario , inter-item correlated values are more than . . the high inter-item correlation was observed in the synergy with government, law enforcement agencies, and private sector initiatives (ls m : . ) and long-term planning and implementation of policies regarding covid- , psychosocial, and socio-economic loss (ls m : . ). according to the results of the pearson correlation, there was a statistically significant correlation among scenario where gender discrimination will increase due to covid- outbreak with gender-based violence will increase rapidly (r = . , p < . ). besides, extremely limited people's movement will reduce the risk of community transmission of covid- with the number of infection and death will be limited (r = . , p < . ). for management purposes, synergy with government, law enforcement agencies, and private sector initiatives with coordinated emergency relief support (r = . , p < . ). also, microfinance support to small and medium enterprises is required for recovery (ls m , p < . ). for management strategies of scenario , deep analysis of the situation should be carried out and go for full lockdown with relief support to the poor and most vulnerable are urgently needed for decision-making in the county due to the rapid community transmission of covid- (p < . ). first of all, the government should come up with a comprehensive strategic plan accompanied by non-governmental and social organizations and law enforcement to analyse the spread of the virus, identifying the most vulnerable hosts, properly tracked the movement of general people, precise estimation of economic losses from different financial and industrial sectors, educational diminutions and professional and informal employment disruption to picture an integrated scenario of the current situation and future predictions by which the revival of the negative aspects of the country could be managed. there must be two types of the strategic plan on under the category of the emergency response plan (short-term) by ensuring basic supplies to all citizens who are in real needs, motivate and/or force the people to abide by the covid- guidelines by the gob and who, prepare a complete but robust list of vulnerable population in terms of covid- spreading, co-morbidities, and economic stress, activate all the local wings of the gob such as local government representatives at the village level, and construct a covid- response task force to monitor and handle the country situation through application of information and communication technologies (ict). the government should implement those plans with proper timing, transparency, and resources. the gob has already been taking a lot of initiatives to tackle covid- pandemic, but there seems lacking proper risk assessment and weak coordination among stakeholders from medical to social welfare. another plan must be focused on the reconstruction or rebuild (long-term) and must follow the guidelines of the sendai framework. the sendai framework for disaster risk reduction - recognizes health at the heart of disaster risk management (drm) at the global policy level (wright et al. ). this sendai framework has given the rise of the health-emergency disaster risk management (health-edrm) framework an umbrella term used by who ( ). health-edrm thus refers to the "systematic analysis and management of health risks, posed by emergencies and disasters, through a combination of ( ) hazard and vulnerability reduction to prevent and mitigate risks, ( ) preparedness, ( ) response and ( ) recovery measures" (djalante et al. ). this also includes build back the healthcare sector, industrial sector, education, agriculture, research, environment, and finance. however, deep research complied with massive surveillance could help in making decisions whether the lockdown must be further carried on or not and this must have to be based on evidence. miscommunication and miscalculation of the strategy may trigger worsen the situation. communicating the disease risk in the local language is also necessary to increase awareness about the diseases. moreover, in sects. ( . . - . . ) we have analysed emergency management issues including short to medium-term measures as well as long-term management strategies of covid- pandemic lockdown scenarios in bangladesh based on our research outcomes. "lockdown" is an unfamiliar word or term to the people of bangladesh. according to scenario , a partial lockdown is a hoax. people recommended to use a more familiar term "curfew" (legal section ) to maintain strict and there is no alternative to reduce covid- transmission. in bangladesh, section of the penal code prohibits assembly of five or more people, holding of public meetings, and carrying of firearms and this law can be invoked for up to two months (minlaw/gob ). this law could have been a much more effective strategy to contain the infection. in total, . % of the participants agreed that community transmission of covid- will increase due to the people's movement and mass gathering, . % agreed to continue the existing partial lockdown, whereas approximately % of respondents agreed that deep analysis of the situation is required and go for full lockdown with the relief support to the poor and the most vulnerable. overall, the participants had a positive view about lockdown scenario to possibly spread out of covid- at the community level. many people expressed their disappointment towards the extreme corruption of the healthcare sector and that it has collapsed before the covid- pandemic. respondents advocated the government to consider biomedical waste management for reducing further environmental transmission and that efficient incinerator to be built for hospital waste management. however, the responders also suggested the government to sustain the retail and wholesale kitchen market/bazaar of any area maintaining the health guideline and social distancing. this approach could have positive feedback as already experience in different upazilas in bangladesh with the help of local administrative authorities, magistrates, and police forces. after the days of the partial lockdown, the federation of bangladesh chambers of commerce and industries recommended the opening of the industrial sectors with some guidelines (fbcci ). moreover, the fbcci taskforce demanded the covid- incentive financial package in a more gettable way from the gob. it could be a very crucial decision to be taken considering the covid- contagions and the business development to protect the exports. to maintain livelihood, industrial workers resumed their work from april . however, the gob weakened the lockdown and resumed the industrial activities without proper guidelines or the scientific basis for such a risky decision. the question is why the gob was in hurry to weakening the lockdown and withdraw it without eradicating the disease? predictably, there might be a strong business/financial association to withdraw the lockdown when life and livelihood matters for the poor and middle-class people and to run the country's economy. although gob provided healthcare guidelines and social distancing during work, the infection rates surged significantly among the workers in the industrial zones. most of the covid- clusters are majorly distributed in dhaka city, chittagong city, narayanganj, cumilla, gazipur, and the peripheral cities (iedcr ; tbs news b). finally, this study confirms that the withdrawal of the partial lockdown will not become positive in terms of covid- management in bangladesh, because still, we do not have enough evidence even after the days of lockdown that the transmission is reducing from the peak. overall, the participants had a positive view about lockdown scenario to stop/slow down the spreading out of covid- pandemic in bangladesh. in total, . % of respondents in this study agreed that existing health facilities will not be able to provide adequate services to the number of covid- patients due to limited community transmission, while . % strongly agreed that there will be a need for emergency food and financial support to the poor communities. about . % strongly agreed that emergency relief to the poor communities in both urban and rural areas should be provided ensuring transparency. around million people, or . % of the population, live below the poverty line and based on the current rate of poverty reduction, bangladesh is projected to eliminate extreme poverty by (chaudhury ). yet, as covid- pandemic hit the country within weeks poverty rate in bangladesh rose to . % as % of family incomes fell (the financial express a). so, it was the choice between life versus livelihood (hussain ) . the poor community always lacks food and nutrition due to the injustice and corruption by the local or regional level of political stakeholders in bangladesh. by nature, people of bangladesh are quite unaware and kind of ignorant or does not like to abide by rules. moreover, the public is not confident somehow with the administrative decisions, policies, and their implementation of covid- emergency response such as lockdown on their livelihoods. there was also a lack of coordination among the different government stakeholders to tackle emergency healthcare and crisis management in the field. for instance, people usually made different excuses to go outside and a regular crowd was common in the kitchen market, streets, and small bazaars. only the government, semi-government, autonomous institutes/organizations, and educational institutions were maintaining the rules/guidelines. this situation is well visualized in different mass media that people are in movement for relief, road blockage, corruption by the government representatives, mismanagement in relief distribution, biases to party supporters, bureaucratic administrators to look after the response activities, and so on. likewise, the potential danger of covid- pandemic from the very beginning has been overlooked by the people due to the presence of misinformation in the social and mass media that it was general flue, and that the virus cannot infect in a humid country like bangladesh. so, the government should try to implement a stringent policy of risk communication and media communication during this emergency to the most vulnerable communities. the vulnerable groups such as disable and disadvantaged persons, young children and orphans, and aged citizens should be taken under protection for their well-being (undp a). right now, doctors, bankers, grocers, police, and armed forces are the most vulnerable profession to the covid- infection. until may , % doctors, % nurse and % frontline healthcare workers were covid- -infected. of the infected, police personnel had so far died, while more than others are in either isolation or in quarantine (the daily star ). although the extension of partial lockdown was not a solution in bangladesh, it could have been an effective option continued to slower the infection rate. the lockdown should have been partially continued with necessary financial support for the vulnerable. it would have been a crisis for a short time, but it would be a saviour for the future (shammi and bodrud-doza ). however, to run the economy, the hotspots of the infection and the cluster areas could remain lockdown, while economic activities could have maintained by strongly abiding public health guidelines and social distancing. moreover, for the next couple of years, it will be extremely hard for the country especially as far as the financial issues are concerned to achieve the current development as well as sdg targets and reaching to middle-income countries (undp a). gob should declare the delayed beginning of its th five-year national plan due to the covid- pandemic as a large part of it seems to be irrelevant at this stage, according to his proposals (the financial express b). increasing surveillance as well as the reallocation of the budget, the distribution of direct cash, and private sector engagement could be some of the options to alleviate the crisis. in total, . % of the respondents in this study agreed that due to full lockdown, the formal and informal business, economic and education sector will be hampered severely. . % agreed that the poor and vulnerable communities both in urban and rural areas will be affected severely. for management purposes, % of the respondents thought that coordinated emergency relief support is required. overall, the respondents had a positive viewpoint about lockdown scenario due to the covid- outbreak in bangladesh. if we have no other options, a strategic plan and policy should be taken for the revival of the health sector, economy, and education. it is speculative that a full lockdown might end up with famine and starvation. according to the world bank report ( ) prolonged and broad national lockdowns will bring a negative growth rate of the economy in bangladesh and other south asian countries in due to the covid- pandemic. this negative growth rate will continue in with growth projected to hover between . and . %, down from the previous . % estimate. a more serious issue that will arise due to the progress of the pandemic is the rate of suicide as a long-term effect on the vulnerable population due to fear and economic hardships (mamun and griffiths ) . preventing suicide and counselling mental health issues are therefore be considered by the authority (gunnell et al. ) . moreover, the authority should take proper steps to meet the basic emergency services and maintain the basic supply-demand of the daily needs of urban and rural people by transporting the crops and vegetable production from the farms. due to the lockdown, the farmers should not face any crop loss and they should be also brought under the financial and other stimulus plans so they can continue their productions for the future. if the needed government should give them free seeds, fertilizers, electricity for irrigations, and water and other incentives such as no-interest agricultural loans for future food security. the government already declared a financial recovery package with a clear disparity towards the agricultural sector. the financial stimulus package mainly focused on large and export-oriented businesses such as the readymade garment sector (rmg). it seems that this package has arrived a little earlier without any participatory strategic assessment. a strong collaborative need-based assessment is required to tackle the short-term and long-term needs to properly distribute the stimulus package. in this emergency response, the local government must have to come forward with full strength and capacities to implement the work plan for the gob. for overall relationship assessment for effective management of policy implications, governance, and developmental effects, pca (fig. ) , cluster analysis (fig. ) , and pearson correlation (table and supplementary table ) significantly show the relationships. pca showed a significant level of controlling factors in bangladesh covid- pandemic and how these statements are associated with the various scenarios (table ) . nine principal components (pcs) were originated based on standard eigenvalues (surpassed ) that extracted . % of the total variance as outlined in table . however, before pca applying in the tested data, the kaiser-meyer-olkin (kmo) and bartlett's tests of sphericity were conducted to appropriateness for this study. the findings of the kmo value in this research were . (> . ), the confidence level of bartlett's sphericity (bs) test was zero at p < . , suggesting the tested data were fit for pca analysis. the scree plot was used to identify the number of pcs to be retained to the understanding of the inherent variable structure (fig. ) . the loading scores were classified into three groups of weak ( . - . ), moderate ( . - . ), and strong (> . ), respectively (liu et al. ; islam et al. ) . the pc (first) explained . % of the variance as it covered a significance level of strong positive loading of the lockdown scenarios and management in bangladesh (ls s : . and ls s : . ). similarly, moderate positively loaded of the lockdown scenarios in bangladesh (ls s : . ls s -s : . - . ). the pc (second) explained . % of the total variance and was loaded with moderate positive loading of lock drown scenarios (ls s - : - . and ls s : . ). the pc (third) elucidated . % of the variance and was strong positively loaded of massive awareness and enforcement of proper lockdown and quarantine initiatives (ls m : . ) and provide emergency relief to the poor communities both in urban and rural areas ensuring transparency (ls m : . ). furthermore, management scenario and scenario were observed moderate positive loading of pc (ls m : . ; ls m : . , ls m : . and ls m : . ). the pc (four) accounted for . % of the total variance and was strong positively loaded of poor people who will suffer food and the nutritional deficiency (ls s : . ) and moderately loaded in scenario (ls s -s : . - . and ls s : . ). the pc (five) explained . % of the variance and was strong positively loaded of deep analysis of the situation and continue this existing partial lockdown (ls m : . ) and with moderately loaded in the management scenario (ls m : . and ls m : . ). pc (six) accounted for . of the total variances and were strong positive loading of existing with increased facilities for covid- in the health system will be able to provide health services to the infected peoples and number of infection and death will be limited (ls s : . and ls s : . ) and with moderately loaded of very limited peoples movement will reduce the risk of community transmission of covid- (ls s : . ). pc (seven) explained for . % of the variance and was strong positively loaded with gender-based violence will increase (ls s : . ) and gender discrimination will increase (ls s : . ). pc (eight) was responsible for . % of the variance and was strong positively loaded with people will start moving towards regular life and formal (ls s : . ) and informal economical activities will be started (ls s : . ) and moderate positively loaded of massive movement and a mass gathering of people will be started again (ls s : . ). cluster analysis (ca) further recognized the total status of scenario variations and how these scenarios influence the socio-economic and development impacts (fig. ) . all the statements were categorized into five major classes: cluster (c ), cluster (c ), cluster (c ), cluster (c ), and cluster (c ). c consisted of five sub-clusters of c -a, b, and c; c -a composed of an irreversible loss to the economy and more people will die (ls s -ls s ) c -b comprised of community transmission of covid- will increase due to people's movement and mass gathering and panic will rise in the mass communities (ls s -s ). c -c is comprised of the possibility of the full lockdown of the whole system again and no basic services will be available (ls s and ls s ). c consisted of three sub-clusters of c -a, and b. c -a consists of continue the existing partial lockdown and deep analysis of the situation and go for full lockdown with relief support to the poor and most vulnerable (ls m -m ) c -b consists of people will start moving towards regular life and massive movement and a mass gathering of people will be started again (ls s -ls s ). c consisted of three sub-clusters of c -a, b, and c. c -a contained an existing increase in the health facilities involving private sectors and implement inclusive sustainable quick plan and policies to revive the economy and employment (ls m -m ). c -b consisted of lack of support and improper management will lead to the psychosocial and socio-economic crisis and long-term planning and implementation of policies regarding covid- , psychosocial, and socio-economic loss (ls s and ls m ), while c -c composed of continuous situation analysis of disease outbreak and implement the full lockdown with relief and basic support for human survival and loan support for business and economic recovery (ls m -m ). cluster consisted of three sub-clusters of c -a due to full lockdown, the formal and informal business, economic, and education sector will be hampered severely, loss of livelihood and unemployment rate will increase due to business shutdown, and poor communities in both urban and rural areas will be affected severely (ls s - ); c -b supply and access to basic daily products in urban areas will be reduced drastically, the extreme need for relief and financial support in the urban and rural communities will increase, and people will be involved with conflict and crime to access the basic needs (ls s - ); and c -c there will be less supply of basic products for daily use and price of most of the basic products will be higher than usual (ls s -s ). c -d indicates poor people living from hand to mouth will be severely affected and the formal education system will be hampered. c consisted of two sub-clusters of c -a, b, and c. c -a contained gender-based violence will increase and gender discrimination and violence will increase ls s and ls s . c -b comprised of limited people's movement will enable low-level community transmission of covid- and infection and death rate will increase slowly (ls s -s ). c -c contained limited people movement will reduce the risk of community transmission of covid- and the number of infections will be limited ls s -s . the covid- pandemic has the most effects on vulnerable populations, ranging from good health and well-being (sdg ) to quality education (sdg ) worldwide. disruptions in the routine health care, poverty, and access to food and nutrition will culminate into unavoidable shocks and health system collapse which will increase child mortality and maternal deaths as well as many unwanted deaths (roberton et al. ) . the crises in achieving clean water and sanitation targets (sdg ), weak economic development and the absence of decent jobs (sdg ), overall inequality (sdg ), and above all, no poverty (sdg ), and food insecurity (sdg ) will be aggravated in many developing countries. the world bank reports that about million people will be forced into poverty by the crisis (wef b). according to undp ( b), revenue losses in developing countries are estimated to reach $ billion. the losses would be consequences of the education, human rights, and, in the most extreme cases, fundamental food security and nutrition, with an estimated % of the global population not having access to social protection. wider socio-economic effects will likely continue for several months to years across the world which will also significantly impact the economy of bangladesh. global food security will be hampered as one-third of the world's population is in lockdown (galanakis ) . both the import of important goods and exports related to the readymade garment sector and others likely will be affected for income and employment. financial protection during outbreak matters. at the initial stage of the covid- epidemic, out-of-pocket expenditure posed a substantial financial burden for the poor populations with severe symptoms, even for those under coverage by the social health insurance scheme (wang and tang ) . people marginally above the poverty level particularly low-income families, daily and informal low wedge earners, ethnic community groups, people with disabilities, and returnee migrant workers are already started falling below the poverty line due to loss of income and employment. brac an international bangladeshi ngo survey report confirmed to increase a % rise in poverty amidst the covid- pandemic (brac ). the intake of foods, vegetables, and herbs can boost the immune system against the infection disease, while it can stimulate the transmission through the food chain (galanakis ) . again, the lack of food will rise to malnutrition, hunger, and famine. approximately , million people worldwide will be suffering from acute hunger projected by the un world food programme (wef c). ready-made garment (rmg) sector is going to suffer a serious shortfall as until march , orders of rmg products from garment factories worth us$ . billion was cancelled. this is the sector where almost million low-income people-of whom over % are women-work and another similar number of people indirectly depend on the downstream and upstream services required by the rmg value chain (dhaka tribune a). as the lockdown continues to ensure public health and safety, many rmg workers already lost their jobs and did not receive their salary of the previous months, some of them have been sacked already. food security and social and economic recovery package of the government should focus on immediate response during the lockdown period and outbreak and post-lockdown support mechanisms. in this condition, middle-income families are relying on their savings available. the negative coping mechanism includes skipping meals and nutrition and distressing the whole family. in the prolonged lockdown scenario, they need government and other support measures to continue their lives under lockdown. due to lockdown, the agricultural products in the urban areas are selling at a high price, while the farmers are not getting the fair price of the product in agricultural districts. it was due to the proper decisions and policy of the gob that aman paddy was timely harvested ensuring the safety of migrant workers. otherwise, it would have likely imposed a bigger social and economic implications such as heavy rainfall triggering natural flash flooding. moreover, due to the lockdown transport of animal, poultry and fish feed are hampered. likewise, due to the closure of local restaurants and hotels, the market demand for eggs and chicken had lowered. all this will likely impose further impacts on food production and crop supply chains. to protect the country from famine, the bangladesh government should consider the stimulus package for the farmers with % agricultural loan to continue cropping and agricultural production. receiving education has stopped for most of the students in bangladesh. the government of bangladesh postponed all academic and public exams until the indefinite period, considering the growing public concern. distance learning education of the national curriculum through air transmission in the national tv had started though. while urban children can attend virtual classes through the internet, rural and marginalized children are deprived due to limited resources. students from marginalized backgrounds particularly with disabilities will lose out more on their education. considering this, gob should prepare special educational package including counselling for marginalized and disadvantaged students. the severe infection of covid- pandemic has devastated the healthcare systems across the globe from a shortage of n masks, and personal protective equipment (ppes) for the healthcare workers and putting occupational health risk, allocations of ventilators, icus, and hospital beds to a patient who can benefit most from treatment while letting the older persons to death. the peaked disparity between supply and demand for healthcare properties raised a normative query of equitable resource allocation during the covid- pandemic (emanuel et al. ). thousands of healthcare workers have already been infected worldwide (gan et al. ) , and the administrative and managerial departments are likely to place increased burdens and stresses on the frontline healthcare workers (willan et al. ). bangladesh has no exceptional scenario. on may , gob lifted its partial lockdown after days of general holidays. the gob claimed the withdrawal of lockdown as a test for next days from may to june , but it was decided without having the designated committees' opinion rather only considering the economic considerations. the gob is planning to divide areas around the country that are affected by the covid- into three zones based on colour as red, yellow, and green indicating the severity of cluster infections and to prevent the disease spread (the daily star ). at present bangladesh is at number considering the infections and mortality from covid- (worldometer ) . the overall attack rate among the bangladeshi population is . / million and more than % positive cases have been identified in the recent days reported in the who situation report on th may (who c). among the countries of india, pakistan, nepal, bhutan, sri lanka, thailand and vietnam, bangladesh is at the bottom in terms of the number of covid- tests done per million population (newage ) . the maldives and bhutan are on the top of the list with each conducting , tests per millions of people (tbs news c). the testing laboratories are situated in the urban metropolitan areas and often due to fear and social stigma the patients do not want to test. moreover, the incidences of a false negative in one laboratory while positive in another laboratory had been reported in mass media. in addition, the mortality rate from covid- infection remains a puzzle which just cannot be explained by the gdp of the country, strength of healthcare governance and availability of equipment like icu or ventilators. the trend of screening and testing ( / million population) and contact tracing the covid- patients in bangladesh is not quite enough to conclude that the curve is flattening, or the peak of the curve has reached. thus, at this point, the database does not seems to be robust and it could be chaotic from the epidemiological point of view. after the lockdown is withdrawn, it was speculated that the number of infections will increase as the life and livelihood needed to sustain. on st may , bangladesh recorded deaths from covid- and new infections (iedcr ). at this stage, gob should increase the icu numbers and strengthen the healthcare departments by recruiting more doctors, nurses, and technicians. rapid testing, screening and diagnosis should be increased which was the advice of who from the beginning. along with isolation, clinical management, and infection prevention and risk communication should be continued to the public. the gob should engage public and private hospital authorities for the treatment of covid- infected patients and resume treatment of other critical-care patients who are being deprived of any treatment at present. moreover, as the infection from dengue is also rising government should take special emphasis for dengue treatment and management also. in fig. we have outlined the overall impact and management analysis of the three scenarios: scenario , scenario , and the scenario after the withdrawn of partial lockdown. community health workers can support pandemic preparation earlier to the epidemics by increasing access to the healthcare services and the healthcare products within the communities. they can communicate disease risks and increase awareness in the comparative lockdown scenarios with impact and management analysis for bangladesh due to covid- pandemic respected area in cultural language whereas reducing the weights of the formal healthcare systems. community healthcare workers can also contribute to pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps (boyce and katz ) . it is critical to detect cluster surveillance of covid- to better allocate resources and improve decision-making as the outbreaks continue to grow in different districts of bangladesh to improve resource allocation, faster testing stations, stricter quarantines and city/block lockdowns as well as travel bans (desjardins et al. ) . it is predictable that environmentally the decrease in air pollution reduces preventable communicable and non-communicable diseases such as covid- (dutheil et al. ) . likewise, ma et al. ( ) mentioned that the warmer season and lockdown activities were the keys to reduce exposure to novel coronavirus on humans in china. although the relationship between the infection rate and climatic variables is not confirmed in bangladesh, as the partial lockdown failed and continued, the number of infections over the past days indicates that gob should have ensured proper implementation of the lockdown scenario with limited public movement in the hotspots, resulting in lower community transmission of the virus and a slower death rate, while continuing economic activity with strict guidelines. gob was looking forward to exiting from partial lockdown beginning of may, yet no specific exit plans were executed by the government which should be scientifically rational and practically achieved. the exit plans from the lockdown should have been well communicated to the public ensuring transparency. without ensuring safety and security the partial lockdown was withdrawn. public transportation started on may without maintaining any health guideline (tbs news d). coordination among the different stakeholders of the government is necessary, along with increased surveillance and resource allocation to the needy ones, to ensure supply of daily necessities, control price hikes, and reduce the loss of livelihood and unemployment. moreover, very recently cyclone amphan hit bangladesh on may , living the coastal districts flooded and in the mayhem. preliminary losses were estimated to be worth bdt , crores (dhaka tribune b). at this stage detection of covid- hotspots by increased testing facilities all over the country must be ensured. the poor and vulnerable communities always lack food and nutrition due to injustice and corruption by local political stakeholders. the vulnerable groups, such as disabled and disadvantaged persons, young children and orphans, and elderly citizens, should be taken under protection for their well-being. they should be provided with food and nutrition for the time being. covid- pandemics cause environmental, economic, and social attributes which have only partially been described in bangladesh. to fight this pandemic, it requires remarkable tasks and partnership development in the local and global level. the world must prepare for the likelihood that mitigation measures might fail because lockdown periods in different countries took different times to prevent or suspend the spread of covid- (gautam and hens ) . collective responsibility is required from the public as well to protect themselves by abiding general health guideline, maintaining hygiene and social distancing, and avoiding going to crowded places and meetings. extremely coordinated and effective planning and strategies for both the ongoing and afterwards response are required from the gob to manage this pandemic and take it as a new "standard of normal". considering the global hard-hit economy, depression, unemployment, job loss, shortfall of rmg export and incoming remittances, the socio-economic and development impacts along with the food insecurity as well as rising poverty due to covid- at the community level need to be coordinated in bangladesh. at present, as the lockdown is withdrawn, both lives and livelihoods are in danger which is a long-debate that is going on. along with the pandemic disease, the upcoming seasons of natural disasters from cyclones, tidal floods, flash floods, and landslides of monsoon seasons should be considered to prepare for the emergencies. all these will further aggravate the humanitarian needs of the most vulnerable groups in the country in the coming months to be followed. as the health sector is the most strained at present, it will affect the targets of sustainable development goals of . in addition, quality education will be hampered in the country. the government of bangladesh has already mobilized a noteworthy stimulus package to support the affected industries and community which needs to be coordinated over a longer period of - months and may be incorporated in the upcoming th -year plans with substantial revising. however, this package should also include research and innovation, recovery of education. there is no alternative to strengthen the health care facilities and preparedness for the potential humanitarian crisis. moreover, humanitarian support should reach the most vulnerable communities which need to be targeted, outlined, and delivered. finally, economic implications should be subjected to the spatial and geographical locations based on the vulnerabilities. hotspots identified in the delta plan can be considered here. the long-term strategic plan can be integrated into perspective plan and bangladesh delta plans , for better strategic management. whatever will be the lockdown scenario, the basic supports to the mass people must be ensured and that is not so easy without strong strategic planning and multisectoral collaboration for sustainability including 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health equity matters strengths, weaknesses, opportunities and threats (swot) analysis of china's prevention and control strategy for the covid- epidemic viet nam shows how you can contain covid- with limited resources why we cannot lose sight of the sustainable development goals during coronavirus doubl e-acute -hunge r-un-warns ?fbcli d=iwar jlhk fiove fpyf jwcdv qqovv j qsa xwx t gqv-iwnmy cri d ydidr o health emergency and disaster risk management framework who coronavirus disease (covid- ) dashboard who bangladesh covid- situation report no who bangladesh covid- situation report no challenges for nhs hospitals during covid- epidemic bangladesh must ramp up covid- action to protect its people, revive economy covid- coronavirus pandemic health emergency and disaster risk management: five years into implementation of the sendai framework covid- containment: china provides important lessons for global response publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge all the frontline doctors, healthcare workers, emergency responders, security, and armed forces fighting this pandemic.funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- - pychvxi authors: thao, nguyen cong title: life in hanoi during the coronavirus pandemic date: - - journal: city soc (wash) doi: . /ciso. sha: doc_id: cord_uid: pychvxi nan course, the key to understanding the city's success lies in understanding people's implementation of social distancing measures, which people in hanoi have followed with surprising commitment. the willingness of residents to stay indoors was quite interesting to see in hanoi, which during normal times is an extroverted city, where people often spend most of their time outdoors. how might we explain why people have been so quick to follow orders? one reason is fear. over the centuries, vietnamese in general, and hanoi residents in particular, have had a range of experiences with various infectious diseases, but some of them have historically been linked to cultural expression of fear and discrimination, especially leprosy, tuberculosis, and, more recently hiv. from a cultural perspective, it is important to recognize that these afflictions are not only understood as diseases in the medical sense but are also commonly understood by people as signs of death that are entangled with ideas about morality and fate. for example, for much of the th century, leprosy patients suffered from discrimination, were isolated into leprosy villages, and were generally viewed with disgust by the wider population. in the vietnamese language, the word leprosy has become a metaphor referring to those who are dirty both physically and mentally. in many cases, it was not only leprosy patients but their entire families who suffered discrimination in their community, even though there was clear evidence that the affliction was not genetic. instead, their disease was believed to be a kind of price paid for mistakes or bad deeds the family members had committed in previous lifetimes. this way of associating personal diseases with family history, culture and morality remains and then shared such information to the public without any concern that doing so would violate their privacy. the case of "patient number " illustrates how this also took on moral tones. patient number was a well-known woman from a well-to-do hanoi family who was found positive on march after returning from italy on march following a period of european travel. after returning to vietnam, she experienced symptoms but did not initially inform health officials until after having spent several days interaction with other including some high-ranking government officials who were on the same flight as her. some of those officials, were also found positive a bit later, and the revelation of the case sparked mass © by the american anthropological association. all rights reserved. doi: . /ciso. fear and anger. she was widely criticized for putting her own self-interests above the cause of public safety. discovery of her case was followed by the lockdown of the entire street where she lived, and thousands of people, not only hanoi, but also in other provinces, were isolated as they were either f or f of the patients on this flight. this case not only marked the beginning of the pandemic in hanoi in the second week of march, but also set the tone for moral outrage towards those exhibiting symptoms. in those cases when an entire building or a village was isolated for public health reasons, the f or f families were seen as perpetrators, subjected to the full hatred of other residents who had to close their businesses completely and had to stay at home for at least days. this attitude made f and f families feel like they were prisoners, as if their houses had become jails placed under the surveillance of their own neighbors. they had to face hatred, though they had done nothing wrong. living under this atmosphere, fear of the disease increased. one f case even said on her facebook account that "we would possibly die because of rumor and discrimination faster than because of the virus." this atmosphere of fear made most people stay at home and avoid contact with others. people accepted and abided by the social distancing policy not only because they cared about their health, but because they wanted to protect their names, their reputations. within the cramped spaces of such establishments, averaging about square meters in size, it is common for dozens of people to sit next together enjoying various types of noodles, bread or sticky rice. when the pandemic arrived, all restaurants were ordered closed and the only alternative was for people to eat breakfast at home. this turned out to be quite a challenge for the people, who had grown accustomed to being served breakfast instead of serving themselves (and other family members). schools also closed during this period, and parents had to start cooking, which took a great deal of time to prepare, as people prefer cooked hot meals. this new task consumed at least two hours for parents, especially mothers. in most cases, parents would have to wake up quite early in the morning to prepare breakfast and clean up afterward. breakfast during this period would often not be finished until am (about hours later than normal in hanoi), leaving parents just about two hours to prepare lunch. in vietnamese cuisine, it is expected that even a very frugal lunch or dinner will include a bowl of soup, a dish of vegetable, and a dish of either fish or meat. during normal times, this complex combination can be readily obtained in even the most inexpensive street side vendor, but for those forced to cook at home, it dramatically increased the time spent on food preparation and clean up. despite the labor involved, many adult household members found themselves feeling less bored than expected during social distancing because they were so busy trying to prepare three meals a day. the official response to the pandemic was to mobilize the city as if it was fighting a battle. community surveillance teams were established at every building, village, and population cluster. body temperatures were tested at checkpoints located at every entry point. people were asked to wear face masks and to wash their hand with alcohol frequently. written notices announcing these regulations, and including telephone hotlines, were placed at all public places, including offices, banks, entryways and in elevators. official public health teams would show up whenever a suspect was reported and administer a quick test and record the results. during march and april, the pandemic was viewed as an "enemy" (giặc) and this approach was overly proclaimed by the government through a slogan "chống dịch như chống giặc!" ("fighting the pandemic is like fighting the enemy"). public megaphones, which had not been used in hanoi for many years, were once again used on a daily basis to deliver updated information on the pandemic and to provide prevention instructions to public at the commune level. the city was like it was organized for a time of war, with sirens from ambulance and police cars sounding throughout day and night. all these elements made people stay alert and intensify their precautionary measures against the pandemic. fortunately, life was not only grey. the silver lining during the pandemic was the way collective values were revived, not only by being broadcast on the mass media, but also through social networks. rice atms and free food distribution stalls were placed in many places in the city so that the poor could come and received food. the prime minister's call, "don't let anyone be left behind" ("không để ai bị bỏ lại phía sau"), was well heeded by the public. donation's started increasing to provide as much support to the poor as possible. food, masks, alcohol and other necessary supplies were not only provided at public stalls, but also delivered to straight to the doors of the poor and the vulnerable by local government or volunteer groups. a warm human sensibility and the spirit of the collective spread in waves to every corner of the city. this brought people together and united them on one side to fight against the pandemic on the other the side. differences of social status were removed, and many people felt a sense of responsibility towards helping others as much as they could. the activities of motorbike delivery people, who normally receive online orders and deliver all kind of goods door-to-door was another factor that made people's lives possible. during march and april, those who wore the green grab uniform designating them as motorbike delivery people, were perhaps the most popular people on the street. at every entryway to the city's apartment buildings, one could see lines of motorbike delivery people waiting to pickup and deliver goods. this mode of transportation and delivery provided quite fast, cheap and convenient solutions for people who could buy everything they needed without having to go outside. the persistence of the city's cash-based economy also facilitated an easy response to the lockdown. most people in vietnam, including hanoi, often keep a reserve of cash at home, typically enough to use in at least two months. this allowed them to safely and conveniently buy necessary goods which were sold at small, local neighborhood stalls, where credit cards are typically not accepted. after days without any local infections, city life has gradually returned to its pre- haunting images: a cultural account of selective reproduction in vietnam after aggressive mass testing, vietnam says it contains coronavirus outbreak thanks to erik harms for comments and editorial suggestions on this essay. the average density for the entire city is , persons per square kilometer, but this figure includes numerous rural districts. the average living area for the city is . m per person, but this includes rural districts. (gammeltoft , , ) a reuters article cites a range of foreign public health experts working with vietnamese authorities, noting that they say "these public health experts say vietnam was successful because it made early, decisive moves to restrict travel into the country, put tens of thousands of people into quarantine and quickly scaled up the use of tests and a system to track down people who might have been exposed to the virus." (khanh vu, phuong nguyen, and pearson ). on official mass media channels, numbers were used instead of real names to protect privacy https://tuoitre.vn/ha-noi-co- -ca-duong-tinh-ncov-la-ca-thu- -o-viet-nam- key: cord- -r n g authors: núñez, ana; madison, maria; schiavo, renata; elk, ronit; prigerson, holly g. title: responding to healthcare disparities and challenges with access to care during covid- date: - - journal: health equity doi: . /heq. . .rtl sha: doc_id: cord_uid: r n g nan viruses know no boundaries, but the impact of pandemics highlight faulty health systems and at-risk individuals. the novel coronavirus of - pandemic has hit certain groups of people within the united states more severely than others. those living in underserved areas, often with financial hardship, and black and brown individuals, are more prone to experience sickness and death from the virus. this roundtable discussion brings together several experts from various fields related to health equity to address these disparities and recommend actions needed to attain equity. dr. ana nÚ Ñ ez: i recognize that identifying one top ranking priority is a challenge, as there are many. that said, what is your top-ranking priority during this current covid pandemic? what item most needs to be realized or addressed? dr. ronit elk: my number one priority is how culture influences and fundamentally shapes how people make meaning out of illness, suffering, dying, and death are, and how culture strongly influences people's response to getting a diagnosis to an illness, as well as treatment preferences. and the problem is that we have a lack of appreciation in the u.s. for the cultural differences that may and in fact do compromise care for seriously ill minority-i call them patients, but people. and that is my number one priority. dr. maria madison: thank you so much, dr. elk, for your comments, because my number one priority is fairness. when i think of fairness, i am thinking of investing in equitable access to prevention, mitigation, and treatment for covid. that includes looking out for the most vulnerable populations and their needs for basic things, including clean water. when we say prevention is easy, that we should wash our hands for seconds, it is easy to forget that a large proportion of the population in the u.s., if not the world, does not have access to clean water, or the internet access to learn about best practices or threats to our food supply, but even more importantly, in order to assure that we try to protect our frontline workers, personal protective equipment (ppe) supply chain, investing in vaccines, or even investing in evidence-based treatments. so for me, the number one answer has to focus on promoting equity for all the reasons dr. elk just described. right now, we are seeing that a disproportionate number of people who are suffering and dying from covid- are black and brown folks. we can dig deeper into why that is when we get to the other questions, but it really draws attention to the inequity in our society that allows us to continue to oppress populations that are already at risk for all aspects of inequity. dr. renata schiavo: my number one priority is to protect marginalized and vulnerable populations from this pandemic and beyond. i feel pandemics have this very strong way of showing us how widespread social and health inequalities are, and how in the day-to-day they prevent people not only from protecting themselves, but also from leading healthy and productive lives. within the realm of vulnerable and marginalized populations, there are three main groups that come to mind as examples. first, there are children who live in poverty who may not be directly affected by the serious health consequences of covid- , but in many cases depend on being in school for their only meals. the pandemic has shown that in addition to school-based nutrition, we need to think of additional systems to deliver child nutrition to the + million children who live in poverty in the united states, especially in communities of color that have been marginalized and discriminated against for centuries, and experience high rates of poverty. the family first coronavirus act has tried to address these issues, but it is just a drop in the bucket compared to the needs we are facing. the second group is the homeless population. we talk about social distancing and washing hands. these are very difficult behaviors for people who live in shelters or in the street. we have seen communities coming together and trying to install temporary sinks. but again, we need more comprehensive interventions. and third, of course, the communities of color who are more significantly impacted. we are already seeing that the highest mortality is within black and brown communities. this has to do with a history of lack of investment in communities of color, poverty, racismplease let's use that word, and a variety of other issues that have determined a higher burden of health and social inequities. i will stop it here, but again, it was very difficult to talk about one priority, so i decided to make an example of populations within the ones that we need to protect. dr. nÚ Ñ ez: thank you. dr. holly prigerson: i direct the center for research on end-of-life care at weill cornell medicine. although my focus is on disparities, i have concentrated my research mostly on psychosocial influences on the poor or inadequate care at the end of life. my focus has been on mental health issues and how patients and families might feel abandoned, as well as how poor communication and lack of resources to attend to psychosocial needs are often overlooked in life-threatening illness, especially for marginalized patient populations and families. i look more at the intersection of how psychosocial influences might be affected and impact access to care, receipt of care, feelings of injustice that some people might have gotten a ventilator whereas other people may have been denied a ventilator. we are trying to leverage the available resources that we know exist to try to remove barriers to better care for everyone, but by targeting a lot of the psychosocial issues that we think really account for who gets what. augmenting much of what you all said, the area that i see and feel that is the priority from my perspective is something that sounds sort of simple: process. there is not a coordinated, integrated, thoughtful process right now. instead, we have this patchwork of competition where every institution and individual has to figure it out independently. the fact that there is not a coordinated and integrated approach that oversees this pandemic speaks to the fact that we only have a public health finance structure. we do not actually have a functional, robust public health infrastructure. this void increases adverse health risk for vulnerable, marginalized populations and stresses these populations and the system. it's very difficult to ignore this impact now because we are seeing the exposure of vulnerabilityrisking mortality rates is just one marker-which really speaks to the pressing issues of need for integration and coordination of public health and prevention. ultimately, it will affect everybody. the question is, is this our opportunity to take this challenge as an opportunity to do things differently, or do we go from here and not make the needed changes that can put us all in a better position? dr. prigerson: by saying ''process,'' that sounds more macro, conceptual, zoomed-out kind of approach. and i think related to zooming out, i would say communication is important as well. by ''communication,'' i am referring to barriers to effective communication to decision-making, to getting care, to receiving care, to working with families at home to connecting families with work and employment. it is communications about medical decisions but also more mundane responsibilities such as going to shop for food and pick up cleaning supplies and all the sort of ways in which this covid- has affected our lives. communication, and in particular, telecommunication appears to have become a normal part in the way of life for many of us. right now, this is how we are all communicating with each other, but it is important to bear in mind that access to telecommunications for certain communities might not be available. maybe health literacy might affect communication and understanding of medical choices before making decisions. i think communication is a key aspect in how this pandemic has adversely affected different communities. dr. madison: yes to ''process'' but it must be fair process. as of the time we are having this discussion, we are seeing states like alabama and washington creating triages that some are calling ruthless utilitarianism, because they are singlehandedly creating hospital practices with a process that may be likely to inhibit treatment and care for certain groups, again, including our most vulnerable populations. that is why we are seeing high rates of morbidity and mortality for black and brown folks. dr. elk: so most of us have defined the problem in terms of what is happening. i would like to discuss, when we get best practices, what happens in the hospital, because this is where the physicians and nurses and ethicists and so on, have to do. i will talk about how to make advance care planning decisions and how to incorporate leaders. my expertise is with african american communities. you must incorporate pastors in your ethics committees. if you do not do that, you could be doing something morally wrong. in the united states, they do not give sufficient respect to the pastors, who are not only leaders in terms of faith and spirituality, but in terms of everything else. dr. schiavo: i want to add something to what dr. prigerson was saying about the importance of communication in this moment. some of the main principles of communication, and especially risk communication, are trust, transparency, and community engagement. a lot of communication has not been meeting these principles because it has been conflicting. it has not included community leaders who actually have the real understanding of the communities for which this communication is intended, who are trusted sources. often these are the individuals who really know best about the needs, preferences, and priorities of specific communities, such as communities of color, children, and other populations. we need really to think of risk communication not as the rem-edy when things go wrong, but something we should be prepared for in advance, during inter-pandemic times. dr. nÚ Ñ ez: currently we are overwhelmed by news and social media activity. an important question for me is, how do vulnerable populations identify trusted sources of communication? dr. prigerson: we are actually trying to develop what we call a ''divine intervention'' that capitalizes on the trust that we have found that healthcare chaplains and hospital chaplains have, particularly among our black patients with advanced-stage cancer. in our studies, what we have found is that for whatever reason -we do not know the mechanisms -but when very sick, dying patients seek a hospital chaplain, they are more likely to sign a do not resuscitate order. they are less likely to die in an icu. they are more likely to enroll earlier in hospice. we have been trying to understand this, but we suspect it has to do with feelings of trust that may lead to an enhanced ability to communicate. leveraging the power and influence that healthcare chaplains have in this crisis might be effective. we think this may be a missed opportunity, because healthcare chaplains have the ability to understand where people in their communities are coming from, as well as talk the talk to physicians. dr. elk: there are two things i think are key and that may be promising aspects. one is in terms of transparency and reaching out to the community. at the university of alabama, birmingham, i have been involved with the school of public health, where we have reached out to the black pastors, housing authority and the dean of the medical school, who himself is black, and have set up a series of webinars. the first webinar was on saturday, april , . there were , people on the webinar. many of the people were from the housing authority, just regular people. many others were black people from the community. the whole point was to discuss all these issues. there were specific goals with this webinar: one was to help people in the community understand how this illness progresses and so on, and our dean did speak about that. a little bit too much jargon, but okay. and then, the other goal of the webinar was to educate participants on how to protect themselves. i am hoping that i can partner with the housing authorities and we can create culture-based messaging, because creating messaging that the white man and the white middle-class has developed for the large audience does not work. we know that. so i wish we would stop doing that. and so we did create culture-based messaging, and we are going to continue to do that. what i am begging hospitals to do is to include leaders who are black, alongside other ethnic groups, on ethics board before making decisions on protocol for care allocation. failing to do that is failing to care about the black population and can lead to lawsuits, which is discussed heavily if bottom dollar is what the institution cares about. i do not care if you have already got a policy. change it. revise it. the other thing is, there is a lot of pressure in the united states for having a written advance care directive. that is not going to work in the black community, particularly in the south. if i sign something saying, ''do not resuscitate my mother, you will do nothing. as it is, you do nothing for our people. why should i sign a piece of paper?'' so do not pressure people. and if i say that culture influences how you make decisions, in the black community in the south, it has been shown that millions of people have held belief in the concept of, ''there could be a miracle. god can make a miracle happen.'' i do not know why people have such difficulty with this, since so many people read the old testament, where the word ''miracle'' is everywhere. but it is very, very difficult for physicians to understand this concept. if a miracle can happen, then you have to do everything that you can for the patient until they decide. another thing is that nobody dies alone in the black community. there will always be a pastor or somebody who will sit with them. in this time of covid- , we have people sitting alone. there are a couple of practices that i have seen that could be used. one thing that can be done is to have someone sit with the patient, remembering that this is somebody's loved one. yes, it may take hours, and yes, there are other patients to care for. but there is always someone who can sit there and be with the person and pray with them and maybe sing a church song with them. that act can be tremendously meaningful. the other thing is funerals. we know what happens at funerals. it is not only blacks. in israel, they have had the ultra-orthodox, who went to funerals where there were thousands of people. the percentage of the virus in that community is very, very high. what can we do? one way is to have the funeral through facebook, where singing and praying can be facilitated through a virtual platform. i also heard from a pastor who was talking about his grandfather who passed away from covid- . his grandfather was a very, very senior, very respected black pastor. thousands would have come to his funeral, but could not because of the virus. instead, they had five people go into the church and record music. five people somewhere else recorded the sermons. then they put it all together and people from the church drove up and were able to see the whole video they created this way. dr. madison: i want to prevent the deaths. i want us to think about why % of covid- deaths in places like chicago are black folks. i want the country to take a public health approach, which starts with prevention. in terms of prevention, the reason why we are seeing these rates of morbidity and mortality is because of rationing. the reason we are seeing rationing is because of the lack of planning on the national level, the lack of taking lessons not just previous pandemics and plagues, but also from other countries that have already determined and discovered. for example, cordon sanitaire does not work, so we need to do physical distancing. we need to promote social connections so we can promote sociobehavioral health and well-being. when we do not put ourselves into a situation where we have to ration, we should see fewer deaths, and we should see much less suffering, particularly in vulnerable populations. i think the fundamental problem is that we have gotten into a situation where we have to ration. so why are black and brown folks dying more? is it because of rationing of ventilators? is it because of rationing and not providing an environment where there is equitable access to treatment, equitable access to screening? we have to look at the entire chain of events that happens. it begins with prevention, and making sure we do not have to get into a situation of rationing. rationing is one of the root causes of why we are seeing this demographic differential in morbidity and mortality. when it comes to states determining who is the most worthy, who should be the first in line to have access to screening, treatment, ventilators, it is not our black and brown folks who are already immunocompromised, who are already in high-risk groups from obesity, diabetes, and hypertension. we need to do whatever we can to reduce this pandemic of rationing. we need to promote case finding in all populations. we need to promote contact tracing. we need to promote screening. we need to learn the lessons, not using cordon sanitaire. it reduces trust. it does not promote communication. we need to increase fact-checking and transparency in reporting on who is most infected versus affected. there is so much we could go into related to the cares act and joblessness and the relationship between joblessness and comorbidities, for example. but i saw this one data point that described how for every % increase in unemployment, it leads to a . % increase in opioid addiction. the pandemic's economic effects alone will exacerbate our drug and mental health problems down the road. we are developing a lot of psychosocial interventions that deal with the opioid epidemic and how people are responding to this pandemic psychologically, especially when they are unemployed and at home and life looks hopeless. alcohol sales have skyrocketed. people are going to self-soothe, and that is going to cascade to a whole bunch of problems down the road. but that is not what i wanted to react to. what i was wondering, in terms of process and in terms of equity and thinking down the road, is what happens when people feel that there was an unfair distribution of who got saved, who got the ventilator? what could be done now to have more transparency in the icu to support decision-making? there was recently an editorial by daniella lamas in the new york times about the decisions and the criteria for deciding which patients would benefit from getting a ventilator and which would not. ironically, or paradoxically, in end-of-life care, there are always recommendations like, ''do not put an advanced cancer patient on a ventilator anyway. it is futile. you are wasting valuable resources, and it is burdensome, and they are not going to survive.'' so that is not a good use of a very scarce resource. how can those rules about who should live and who is going to be put on a ventilator be made more equitable so to address the concern down the road, so there are not lawsuits saying, ''you discriminated against equally needy patients who would benefit from scarce resources but denied care for other reasons.'' a real quick answer goes back to what dr. elk had said before. your triage committees need guidance documents, and those should be written by ethics committees that are representative of the community. so you should have black ministers involved. you should have every demographic and profession included in your ethics committees to collaborate in creating these guideposts so that it is not left up to an individual, implicitly biased practitioner. dr. elk: and having just one black person is not enough. that is insufficient. dr. nÚ Ñ ez: at least from what i am hearing from other physicians, they are desperate for these equitable protocols. in the absence of protocols, clinicians are having to make the decision in the moment with so many things happening in terms of the trauma, lack of ppe, and so on and so forth. healthcare providers are desperate for these equitable protocols. and i will just remind you that we know data that say, if you have a committee, and % of that committee is not representative of the population, you do not have voice. so it is important when we are looking at these committees that it really is that percentage of the committee to bring that voice into the equation. but i will tell you that equitable protocols are desperately sought by healthcare providers who are in the trenches having to make these decisions, and with no time, on top of being under-resourced and potentially unsafe. dr. elk: there is a hashtag on twitter, #pallicovid, used by the palliative care community, linking to all kinds of resources that can help. the reality is, probably only the palliative care physicians or clinicians are looking at it, but others need to as well, because this is the group that has the expertise. now, unfortunately, even though palliative care is the group that has this expertise, they do not and have not been trained in determining cultural aspects of care. that is why a paper on cultural aspects of care, especially at end of life, is so, so key. health equity just published my article and in it we include a table with information about the differences in approach for how to talk to southern black and white patients. and who determined that? the community members, both black and white. everything that is in there is a cultural guide for clinicians. now, this was done in the rural south. i have no idea if it works up north. dr. prigerson and i are going to be collaborating on another study to see to what extent that works up north. but at least, if you respect what the community has asked, then you will go a very long way in showing respect, which, in turn enhances trust. and those additional suggestions of having somebody there with a black person, when they are ill, using facetime so the family can sing and pray with the patient as they are dying. how difficult is that? it is not difficult. it can easily be done. you want to build trust? do that. and by the way, i do not believe that it is a waste of resources, particularly for people whose culture believes god can create a miracle, and if that is what the family wants and believes, then we should respect the patient and/or family's values and act according to their established goals of care. it does not matter if medically it seems like, ''oh, this person will live and this person will die.'' you have to be equitable, as dr. nunez says. the issue of preparedness is of the utmost importance. we definitely need more preparedness for a variety of different issues. for example, i published with co-authors a systematic review, which perhaps is still the only review on communicating risk in epidemics in low-and middle-income countries, and also includes eligible studies on marginalized and at-risk populations here in the united states. some of the things we have been discussing resonate with the findings of the review, which point to the importance of communities and community engagement. as supported by several studies included in the review, when community members and families were involved, communities or patients were also more likely to adopt and embrace mitigation measures. another lesson that we learned from ebola: we cannot go into communities and tell them to suspend traditions for burials and funerals during a time of crisis. we need to think about culturally sensitive rituals to substitute for existing traditions during the preparedness phase. so again, the preparedness process is really key. i'd like to change the topic. in addition to engaging community leaders in finding solutions for issues related to the rationing of scarce resources (for example, the use of ventilators or protective equipment) so that we prioritize vulnerable and underserved populations, especially communities of color, professional associations representing the black and latino communities should also become involved. these associations should consider issuing guidelines that physicians and nurses desperately need to treat and prioritize patients who most need these resources, especially in disparity settings. finally, i had prepared something on paid leave, because among the most promising changes that i see happening-that, again, is not sufficient to meet the actual need-is the family first coronavirus response act, as related to the provision of paid leave for at least some of the workers. i am not an economist, but unfortunately, this provision is really a drop in the sea, because we know that up to million people will be excluded from this provision. on the other hand, people need to stay home as a way of protecting themselves. but we know that a lot of people are excluded from the paid leave provision, and would need to choose between protecting themselves or paying rent and putting food on the table. and this happens primarily within the food service industry and other industries where the people are really on the front line of the epidemic, and/or where workers are from communities of color, or women, or from other vulnerable populations. although the family first coronavirus response act is a step forward, we need to engage communities to make it more of a reality for all americans, because paid sick leave is something that is important not only during this pandemic, but it actually is a human right to be able to take care of one's health and the health of others during times of crisis and beyond. so, it is a step forward, but it is a fraction of what we need. we talked about isolation, opioid use, and issues related to mental health. i think it also bears mentioning that issues of intimate partner violence go hand in hand with alcohol use and gun sales. it is also worth recognizing that both morbidity and mortality, for women, is also likely to explode during this pandemic. many of the places that are being serviced that support victims of intimate partner violence are not-for-profits that receive federal funding, and these are going to be places with incredible need, especially in a time where there is isolation, alcohol, unemployment, et cetera. it bears mention. the most uncertainty in terms of the future of preserved food supply, ways of moving forward to continue living, are all on the backs of populations that are predominantly the ones that have been most discriminated against, or who suffer and bear the burdens in terms of inequities. these are not necessarily the ones who have free access to be able to get on the internet to find information. and even if they do, to other people's points, it is in such a high level of jargon, or written in english language when the individual maybe doesn't speak english. we need much more profound translations of that content to support health literacy as a way to get messages out for everybody, from pastors to communities, because one of the challenges that i see as a physician is that suddenly everybody is interested in science. science is not perceived as being irrelevant anymore. science is not a ridiculous thing. science is not something that people do not need to know about, and suddenly people are wondering, ''what do you mean by immunity?'' i think this is fabulous, but i am not sure that those messages are effectively reaching the communities of need. we need to be able to make those connections and parlay into building trust. currently, there are too many mixed messages. dr. elk: one of the things that you said about community is key. one of the research methods that is very, very appropriate, however extremely difficult to do in a very tight timeline, is community-based participatory research, where you could partner with the community. to reach the communities, we have to work in partnership with them. we can do a community-based research project where we can develop prevention guidelines in words the community will understand and according to the community's values. even if we can only determine feasibility, the goal will be to help save some lives. but if we can determine that this is a method that we can do when the next crisis comes, we will be ready to have such studies. and to add to what dr. schiavo said, i would like to stress, we have to learn from what happened in the ebola epidemic, when whites were attempting to provide aid, they did so without paying respect to the culture. they did not listen to the people experiencing the health crisis. they did not incorporate the culture of the people into it. if you fail to incorporate the culture of the local people, you are doomed to failure, and more people will die. it is a matter of cultural humility that people have to learn, and especially physicians, who unfortunately do not effectively receive this as part of their training. it is part of the nurses' training, but it is not part of the physician's training. dr.nÚ Ñ ez: i agree with you. i think that with the ''do to'' rather than the ''do with,'' mentality, especially with the scarcity of key equipment right now, there is a propensity to say ''let us do something.'' this results in, ''here is the shortcut that lets us something.'' and i think that the best thing to do, even though it may take a bit more time, is actually reaching out and including community networks to create a better outcome in the end if there is a matter of trust. dr. schiavo: actually there is evidence also from the ebola crisis such as for example some interesting case studies on sierra leone and liberia from unicef showcasing that when communities finally got involved, not only in research and intervention design, but also in the implementation and the evaluation of solutions, and in building trust in the community about the recommendations for protection, finally, the ebola epidemic subsided. , and i think this is a very important lesson, especially because in the united states, i feel we do not integrate enough community engagement in intervention design, implementation and evaluation. we have imported to a certain extent the community health worker model, but for the most part this model is being implemented in a very limited way because we primarily train people to disseminate information that experts designed. it is not really the same as the kind of community consultative process we need, especially in moments of crisis when we really need to empower communities, giving them ownership of solutions. there is a long list of steps that countries such as taiwan, singapore, and others took that both flattened the curve faster, and reduced the prevalence of disease and mortality. in that long, wonderful list is the item that they addressed the issue of disease stigma and compassion. i do not know where that exists in our state-by-state plans. we do not really have a national plan. but that was listed as a policy in taiwan and it made considerations for those affected by providing food and frequent health checks. it also included encouragement for those under quarantine. and the rapid response included hundreds of action items in their supplement. but just imagine including disease stigma and compassion as a part of the process. dr. elk: andy slavitt is one person who has shown unbelievable compassion and action. he was the head of president obama's medicare and medicaid cms, and helped develop the affordable care act. he is very knowledgeable and very connected. he has taken it upon himself to develop an organization called the united states of care. andy slavitt has put together so many initiatives. for example, he set up a site where ventilators can be shipped from one place to another, even before there were other initiatives. his group also set up a step-by-step guide for bringing resources to underserved communities. (see appendix s ; ª united states of care campaign and reprinted with permission.) so you can take it into your state, and all you need is the governor of that state, for example, to follow this step-by-step guide. now, let us see how many states use this incredible model. in terms of resources, i do not want to plug too much of what we are doing, but we are developing online resources to aid communication between families, between families and medical professionals, particularly in the life-threatening icu situation. but also we are developing tools to prevent people from dying alone and funerals not being able to happen in accordance with and culturally specific cremation and burial practices. we are developing an app that actually is a virtual memorial. we have developed something called the living memory home to help families in that time-it is not going to be a substitute for actually convening and having face-to-face ceremonies at some point, but the idea is, i think people are really struggling with this forced separation and lack of communication as everyone-everyone is essentially a shut-in right now. we are all shut-ins. and when your loved one is dying in the hospital, and you are shut in, regardless of your race or ethnicity, you are upset, you are frustrated, and you need tools to help you communicate better and more effectively. the other point i wanted to make in listening to everyone's' great suggestions, is that all our suggestions are essentially top down. community-based participatory research is great in that a lot of voices are heard. what should recommendations to actual families do? what should be some of the simple patient prompts or family caregivers' checklists for things that they should do to help them protect themselves and ensure their interests? we are always thinking about how we can help other people through being very instrumental and telling them what to do or treating people differently. what can they do themselves to have their rights and interests and values respected? dr. nÚ Ñ ez: i certainly read that in some places patients actually got an ipad that is covered in plastic so that they are not alone, they can connect with some-body and so on and so forth. and if we are talking about best practices, whether it is a phone or any other kind of device, to support that connection when someone is critically ill or at the end of life, that is as instrumental as having an iv. now, granted, i would submit to you that in terms of dying in a hospital, dying alone is a very frequent thing and very culturally devoid thing outside of that hospital. and so perhaps this is a practice we need to bring in that, just like the iv, there is this digital access to music, to a spiritual advisor, to family, to singing, whatever that is, that as a person surrounded by all the illness in a hospital, they do not necessarily feel alone. as long as you attach it to something, it is not like you are mandating that another person necessarily be there, but if an iv is essential, then perhaps we are saying this as well, because we need to pay attention to the humanity of individuals as they go through this struggle. dr. madison: i think that what communities also need to do, particularly my community and black communities and international communities, is to destigmatize accessing mental health services. by destigmatizing access to mental health services, society also has to provide free services, right? so let's promote access to free telehealth, promote access to paid sick time if you are fortunate to have a job, and promote access to free testing and treatment. we should promote destigmatizing access, whether it is for behavioral health or clinical health care. but right now, some of the barriers to access are both inside and outside of the community, so we should somehow support bridging that. in massachusetts, the department of public health, through the massachusetts public health association, highlighted four action items. and i believe that the fourth one is the one we have not mentioned yet, is so important because it adds to an increase in prevalence and incidence of this pandemic, of covid- pandemic, and it is to enact a moratorium on evictions, foreclosures and termination of public benefits. what can the individual do about that? not much. if you lost your job and you call up unemployment assistance, you are not even able to get off the waitlist on that phone. people are waiting two, three weeks to get a response in order to get unemployment insurance. i want to also stress that people finding themselves unable to get through to a representative at the unemployment office should document their every try. and so in the process, you are getting someone telling you have to be evicted from your housing, and foreclosures, and losing your public benefits. so it is ecosocial theory. it is all around the lifespan of what is happening to our most vulnerable populations. some of what we can do within our group, within our community is to destigmatize access and promote lobbying and advocacy. but it really is oppression working through ideological, institutional, interpersonal, and internalized mechanisms. dr. elk: one of the things that dr. prigerson had raised was, what about doing something for the patient? there is a tool that was developed at uab in which the palliative care doctors said, ''we will sit with your patient. tell us.''-they have developed a little questionnaire. the patient's loved ones fill in the answers. ''what does he love talking about? what is important to him? what is the name of.?'' this is meant to help the practitioners get to know their loved one, the patient, intimately, and can help to represent the loved one in a very unique, individual way. there is also a tool for providers on how to communicate at this time, developed specifically for covid. all of that is both on twitter under #pallicovid, and also on facebook, which is much easier, and is covid- palliative care providers. it is open for anybody. i saw that , people are already on the facebook group as of the time of this discussion. it has all these tools. if the physicians and others are looking for tools, the palliative care people have the perfect tools. one of them deals with how to communicate and what to say. they use a lot of acronyms to help clinicians remember them. dr. schiavo: i want to highlight something that has not yet emerged from the last discussion, which is the digital divide. we all talk a lot about digital health, we talk about those apps. but these media approaches are not necessarily going to reach the vulnerable populations we need to protect, where word of mouth, community gatherings, churches, and similar channels and venues are still the preferred ways of communicating. we are already seeing that when school went online, some schools in disadvantaged neighborhoods were left scrambling to figure out how to provide online instruction. in addition to this, we are in the middle of an infodemic, and there is a lot of information and misinformation out there. easy and widespread access to social media, which we did not need to care about during h n , really have a prominent role in disseminating this misinformation. and although some of the vulnerable populations may not use social media as their preferred media of choice, they hear from other people who have read things on social media. so we need to be aware of these challenges and prepared to equip the public health infrastructure to react to hoaxes and misinformation. i was reading the other day that there were some hoaxes in africa saying that blacks were not susceptible to covid- . we need to be prepared to counteract misinformation, and the only way to do this is having, again, governments and public health agencies to work with community leaders, so that those leaders become our rock stars on social media and within other information settings. let's give them social media accounts. train them to use social media. let's do something that actually brings their trusted voices to the communities they reach, because whether these communities are on social media or not, they hear from others who are on social media. this is also another important aspect that may have an impact on training of the public health workforce and on the overall infrastructure. dr. nÚ Ñ ez: i want to agree with you. i mean, i will share with you that in terms of our community participatory research project, philadelphia ujima, we brought in the radio celebrities, because the radio celebrities are important from a cultural perspective with lower-income residents in the city. some of these radio celebrities had profound credibility, and whatever they said was viewed as true. unfortunately it is the case that right now there is no way to certify what is actually credible information. dr. prigerson raised the point that we have talked about a top-down approach, and dr. madison eloquently talked about how there is so much in terms of the infrastructure that does not exist, and topdown is important. but i think that some of the bottom-up is, how do we attend to the legitimate disenfranchisement of our at-risk populations, many of whom are saying, ''you do not really care about me. i am expendable. i can clean. i can pick in the fields for your food, but i am not going to have time off, and if i am a casualty of this pandemic, well, then, you do not really care. somehow i am supposed to continue to be engaged, maybe vote, and to be part of this process. how does it make sense when it seems that you all do not really care about me?'' and so i think that there is a component that we have to reach to address that legitimate disenfranchisement as well as figure out through culturally competent sort of communication about how can they have some agency in this, how do they recruit help for when their loved one is sick, identify who were all the individuals that need to be in the loop on that conversation? negotiating the health access process is difficult for most of us, even in better times. how can we streamline the process, provide navigation help during this global pandemic? i think that disenfranchisement linked with health, health literacy, and misinformation, or ''the infodemic,'' is an important part of the storm, and if we do not address that, no matter what happens top down, the disenfranchisement may very well explode. it is important to mention that disenfranchisement is a useful way to control the populace, because if everybody is looking at everybody else, the problem is always going to be that other person. it is us and them. the community affords strength, innovation, and cohesiveness in coming together to find and promote solutions. that being said, we are hearing in the media lots of amazing examples where people are coming together to form community. this is too often drowned out by the sensational stories of hoarding and price gouging. we do not hear the common acts of checking on the elderly neighbor and sort of going grocery shopping. we do not hear about that, because, again, that does not sell eyeball time for the evening news. it is important that we think about how to best use community-focused, inclusion-promoting messages as one of the antidotes to the infodemic. in response to all this, and the infodemic, we are developing some tools. we call them gist, ''giving information simply and transparently,'' so that when oncologists talk with advanced-stage cancer patients, you are disenfranchising patients if you talk about millimeters of tumor growth, or you talk about drugs for which they do not understand the mechanisms of action. we are developing this intervention to both address the infodemic, to simplify and clarify main talking points, and insist that physicians have patients leave a clinic visit doing what in psychology they call cognitive interviewing, ensuring that patients have enough information to make an informed choice-they do not need to know every single fact, but maybe the physicians or the medical community needs to decide what are the main kernels of medical information that, without which, anyone, regardless of race or ethnicity or language or education level, needs to know to make a choice that will resonate with them, that will be consistent with their values, and consistent with informed values. so we are trying to reduce disparities, but through education and information, both on the parts of having physicians communicate to empower patients to have the information they need, to insist on the care that might be consistent with what they would want. it dr. schiavo: i would like to say that pandemics have a way of showing us how much we are interconnected. taking care of everyone in our communities and being our brothers' and sisters' keeper is not only an important human rights issue but also benefits the health of everyone. i hope that this lesson is not going to be forgotten too quickly, as we have seen so many lessons be forgotten in the past. as dr. madison said, we really need to address all the social and political determinants of health so that we can advance health equity and racial equity in the years to come and protect people during this pandemic. in the meantime, i would like to ask for everyone to take the time to thank the people who are on the frontline. yes, the healthcare workers, but also the food and pharmacy cashiers, the sanitation workers, the hospital housekeepers and cleaners, and everyone who puts their life at stake every day, so that so many of us can stay safe. i think it is important to say thank you, because a lot of them are making huge sacrifices for the common good, and we need to do our share and at the minimum to thank them. dr. elk: in terms of prevention, please, work on partnering with communities to develop prevention messaging that is not as complicated as what's on the cdc or other health care sites, but is instead very simple, and not only that, takes cultural differences into consideration. just a photograph or a picture of a native american person or somebody in some tribal dress is absolutely insufficient. a lot of nurses already have training in cultural competency, but sometimes physicians don't have quite as much competency in this area. it is important for all practitioners to show cultural humility and to not talk down to patients, but to ask what their cultural values and preferences are. and then once you know them, respect them. and if you do not know, there are tools and guidelines to improve cultural competency. look at the article that we have just published in health equity. dr. prigerson: one thing that struck me as a way to synthesize what we have been talking about is the huge importance of communication in making sure that families are connected, that health professionals are connected, that people get adequate information, that people's preferences and needs are heard. it all depends on facilitating and improving communication between patients, families, communities, and the medical team. there is hope, but we also know that a lot of work needs to be done to improve not just access to care, but also to strengthen communication, and improve relationships between communities and healthcare institutions, between the federal government and constituents, and between practitioners and patients. communication needs to be facilitated so that people's needs are heard and respected. dr. madison: i have three nieces in the healthcare field. one is a black female physician, chicago. another black nurse in the la area, managing nurses. and the third, black female social worker. they all agreed on their answer to this question, and what they said was, ''let us work towards disease prevention and health promotion instead of a curative model for health care delivery.'' dr. nÚ Ñ ez: one of my favorite acronyms is pdq, which stands for partner-defined quality. if we can start with the pdq straight away, then hopefully we can take advantage of this opportunity for good. there is an asian proverb that says, ''the best part of my house burning down is i have a good view of the moon.'' in crisis, there is opportunity. we are awash with opportunity. the question, as has been mentioned so eloquently by many of you, is, do we then leverage this opportunity for the better in terms of efforts of equity, relationships, communication, infrastructure, to roll it back resulting in a robust, effective prevention model? we will be able to say, ''yeah, this is not just. we've learned from the spanish flu. covid- was the tipping point where we changed things up.'' i really, really appreciate all of your time. this was a fabulous conversation. it was just really a wonderful opportunity, and thanks so much for all your insights. ana núñez, md, is a professor of medicine and professor of obstetrics and gynecology, dean of diversity, equity & inclusion at drexel university college of medicine. her expertise includes sex/gender cbr and health and workforce enhancement for underrepresented populations. ''the first step is recognizing, acknowledging, and respecting the inequity, disrespect, and disregard our african american patients have experienced.'' holly g. prigerson is the irving sherwood wright endowed chair of medicine, co-director, cornell center for research on end-of-life care, and professor of sociology in medicine at weill cornell medicine. her research has been continuously funded for over years by the national institutes of health to examine issues of health care disparities at the end-of-life and psychosocial influences on and outcomes of those disparities. renata schiavo, phd, ma, ccl, is a senior lecturer at columbia university mailman school of public health, department of sociomedical sciences, and the founder and board president of health equity initiative, a nonprofit membership organization. she is a passionate advocate for health equity and a committed voice on the importance of addressing and removing barriers that prevent people from leading healthy and productive lives. she has significant experience with and has written on communicating risk and promoting disease mitigation measures in epidemics and emerging disease outbreak settings. dr. maria madison has built her career, since , around evidence-based research methods. this has included conducting and supervising significant public health projects with multicultural communities, often in resource constrained settings. she began her career as a peace corps volunteer in the democratic republic of the congo, (i.e., zaire), and continued working through the private and public sector. dr. madison is currently the associate dean for equity, inclusion and diversity at the heller school for social policy and management at brandeis university. she teaches on subjects such as intersectionality and bioethics. families first coronavirus response act: employee paid leave rights covid- 's impact on the black community: a conversation with health experts and faith leaders fee de db aa e b aad eb ce c afe e dd bc f ca ad c c ae b a cf d accessed one hundred sixteenth congress of the united states of america mental health in the age of the coronavirus. the new york times online alcohol sales jump % during coronavirus pandemic c. death toll tops , as cuomo warns on ventilators developing and testing the feasibility of a culturally based tele-palliative care consult based on the cultural values and preferences of southern, rural african american and white community members: a program by and for the community communicating risk and promoting disease mitigation measures in epidemics and emerging disease settings what the coronavirus law means for paid sick leave, family leave community care centers, community dialogue and engagement: key ingredients in sierra leone county: communities took the matter in their own hands response to covid- in taiwan: big data analytics, new technology, and proactive testing united states of care center for palliative and supportive care. covid- resources coronavirus: what misinformation has spread in africa? supplementary appendix s key: cord- -kenstpja authors: nan title: china date: journal: the statesman&#x ;s yearbook doi: . / - - - - _ sha: doc_id: cord_uid: kenstpja nan yuan dynasty in , swept into southern china. the mongol yuan dynasty adopted chinese ways but was overthrown by a nationalist uprising in , led by hongwu ( - ), a former beggar who established the ming dynasty. the ming empire collapsed in a peasants' revolt in . the capital, beijing (peking), was only km from the great wall and vulnerable to attack from the north. within months the peasants' leader was swept aside by the manchus, whose qing dynasty ruled china until . preoccupied with threats from the north, china neglected its southern coastal frontier. the portuguese, who landed on the chinese coast in , were followed by the dutch in and the english in . the qing empire expanded into mongolia, tibet, vietnam and kazakhstan. but by the th century, under pressure from rural revolts ignited by crippling taxation and poverty, the qing dynasty was crumbling. two opium wars ( - ; - ) forced china to allow the import of opium from india into china, while britain, france, germany and other european states gained concessions in 'treaty ports' that virtually came under foreign rule. the taiping rebellion ( - ) set up a revolutionary egalitarian state in southern china. the european powers intervened to crush the rebellion and in british and french forces invaded beijing and burnt the imperial palace. further trading concessions were demanded. a weakened china was defeated by japan in and lost both taiwan and korea. the xenophobic boxer rebellion, led by a secret society called the fists of righteous harmony, broke out in . the guangxu emperor attempted modernization in the hundred days reform, but was taken captive by the conservative dowager empress cixi who harnessed the boxer rebellion to her own ends. the rebellion was put down by european troops in . china was then divided into zones of influence between the major european states and japan. with imperial authority weakened, much of the country was ripe for rebellion. in the kuomintang (guomintang or nationalist movement) of sun yet-sen (sun zhong shan; - ) overthrew the imperial system. the authoritarian yuan shih-kai ruled as president from to . following the overthrow of yuan, china disintegrated into warlord anarchy. in sun founded a republic in southern china but the north remained beyond his control. reorganizing the nationalist party on soviet lines, sun co-operated with the communists to re-establish national unity. but rivalry between the two parties increased, particularly after the death of sun in . after sun's death the nationalist movement was taken over by his ally chiang kai-shek (jiang jie shi; - . as commander in chief of the nationalist army from , chiang's power grew. in april his campaign to suppress the chinese communist party saw thousands of communists slaughtered. the survivors fled to the far western province of jiangxi. in chiang's army entered beijing. with the greater part of the country under chiang's rule, he made nanjing the capital. in the communists were forced to retreat from jiangxi province. led by mao zedong (mao tse-tung; - they trekked for more than a year on the , -mile long march, eventually taking refuge in shaanxi province. in the japanese invaded manchuria. by they had seized beijing and most of coastal china. the nationalists and communists finally co-operated against the invader but struggled against the superior japanese forces. during the second world war , a nationalist government ruled unoccupied china ineffectually from a temporary capital in chongqing. at the end of the war, nationalist-communist co-operation was short-lived. the soviet union sponsored the communist party, which marched into manchuria in , beginning a civil war that lasted until . although the nationalist forces of chiang kai-shek received support from some western countries, particularly the united states, the communists were victorious. on oct. mao declared the people's republic of china in beijing. chiang fled with the remains of his nationalist forces to taiwan, where he established a government that claimed to be a continuation of the republic of china. at first recognized as the government of china by most western countries, taiwan kept china's security council seat at the united nations until . chiang's authoritarian regime was periodically challenged by red china, which bombed taiwan's small offshore islands near the mainland. in the s and s, taiwan gradually lost recognition as the legitimate government and in the usa recognized the people's republic of china. in china invaded tibet, independent since . chinese rule quickly alienated the tibetans who rebelled in . the tibetan religious leader, the dalai lama, was forced to flee to india. since then, the settlement of large numbers of ethnic chinese in the main cities of tibet has threatened to swamp tibetan culture. during the s and s china was involved in a number of border disputes and wars in neighbouring states. the communists posted 'volunteers' to fight alongside communist north korea during the korean war . there were clashes on the soviet border in the s and the indian border in the s, when china occupied some indian territory. from the establishment of the people's republic of china, communist china and the soviet union were allies. communist china initially depended upon soviet assistance for economic development. a soviet-style five-year plan was put into action in , but the relationship with moscow was already showing signs of strain. by the end of the s the soviet union and china were rivals, spurring the chinese arms race. chinese research into atomic weapons culminated in the testing of the first chinese atomic bomb in . mao introduced rapid collectivization of farms in . the plan was not met with universal approval in the communist party but its implementation demonstrated mao's authority over the fortunes of the nation. in he launched the doctrine of letting a 'hundred flowers bloom', encouraging intellectual debate. however, the new freedoms took a turn mao did not expect and led to the questioning of the role of the party. strict controls were reimposed and free-thinkers were sent to work in the countryside to be 're-educated'. in may mao launched another ill-fated policy, the great leap forward. to promote rapid industrialization and socialism, the collectives were reorganized into larger units. neither the resources nor trained personnel were available for this huge task. backyard blast furnaces were set up to increase production of iron and steel. the great leap forward was a disaster. it is believed that m. died from famine. soviet advice against the project was ignored and a breakdown in relations with moscow came in , when soviet assistance was withdrawn. a rapprochement with the united states was achieved in the early s. having published his 'thoughts' in the 'little red book' in , mao set the cultural revolution in motion. militant students were organized into groups of red guards to attack the party hierarchy. anyone perceived to lack enthusiasm for mao zedong thought was denounced. thousands died as the students lost control and the army was eventually called in to restore order. after mao's death in the gang of four, led by mao's widow jiang qing, attempted to seize power. these hard-liners were denounced and arrested. china effectively came under the control of deng xiaoping. deng pursued economic reform. the country was opened to western investment. special economic zones and 'open cities' were designated and private enterprise gradually returned. improved standards of living and a thriving economy increased expectations for civil liberties. the demand for political change climaxed in demonstrations by workers and students in april , following the funeral of communist party leader hu yaobang. in beijing where demonstrators peacefully occupied tiananmen square, they were evicted by the military who opened fire, killing more than , . hard-liners took control of the government, and martial law was imposed from may to jan. . since the leadership has concentrated on economic development. hong kong was returned to china from british rule in (for the background, see page ) and macao from portuguese rule in . the late s saw a cautious extension of civil liberties but chinese citizens are still denied most basic political rights. beijing was chosen for the olympic games. china's treatment of tibet came under the international spotlight in the build-up to the games, following violent protests in tibet's capital city, lhasa. the arrest by japan of a chinese trawler in disputed waters in marked the beginning of heightened tensions between the two nations in the east and south china seas. in china became the world's second largest national economy. in nov. the communist party congress selected xi jinping to succeed hu jintao as president from march . in sept. that year, former leadership hopeful bo xilai received a life sentence for corruption in one of china's highest-profile trials in decades. in oct. the government announced the end of the country's one-child policy. a month later, the presidents of china and taiwan met for talks-the first time that leaders from the respective territories had met since . on the economic front, gdp growth in was at its lowest level for a quarter of a century. china is bounded in the north by russia and mongolia; east by north korea, the yellow sea and the east china sea, with hong kong and macao as enclaves on the southeast coast; south by vietnam, laos, myanmar, india, bhutan and nepal; west by india, pakistan, afghanistan, tajikistan, kyrgyzstan and kazakhstan. the total area (including taiwan, hong kong and macao) is estimated at , , sq. km ( , , sq. miles). a law of feb. claimed the spratly, paracel and diaoyutasi islands. an agreement of sept. at prime ministerial level settled sino-indian border disputes which had first emerged in the war of . china's sixth national census was held on nov. . the total population of the provinces, autonomous regions and municipalities and of servicemen on the mainland was , , , ( , , females, representing · %); density, per sq. km. china's population in represented % of the world's total population. the population rose by , , (or · %) since the census in . there were , , urban residents, accounting for · % of the population; compared to the census, the proportion of urban residents rose by · % (reflecting the increasing migration from the countryside to towns and cities since the economy was opened up in the late s). population estimate, dec. : , , , . china has a fast-growing ageing population. whereas in only · % of the population was aged or over and by this had increased to · %, by it is expected to rise to · %. long-term projections suggest that in as much as · % of the population will be or older. the population is expected to peak at · m. around and then begin to decline to such an extent that by around it will be back to the level. china is set to lose its status as the world's most populous country to india in about . the un gives a projected population for of , · m. regulations restricting married couples to a single child, a policy enforced by compulsory abortions and economic sanctions, were widely ignored, and it was admitted in that the population target of , m. by would have to be revised to , m. from peasant couples were permitted a second child after four years if the first born was a girl, a measure to combat infanticide. in china started to implement a more widespread gradual relaxation of the one-child policy. in dec. the standing committee of the national people's congress (npc) approved a resolution allowing couples to have two children if either parent was an only child. the one-child policy was formally abandoned altogether from jan. . an estimated m. persons of chinese origin lived abroad in . a number of widely divergent varieties of chinese are spoken. the official 'modern standard chinese' is based on the dialect of north china. mandarin in one form or another is spoken by m. people in china, or around % of the population of mainland china. the wu language and its dialects has some m. native speakers and cantonese m. around m. people in china cannot speak mandarin. the ideographic writing system of 'characters' is uniform throughout the country, and has undergone systematic simplification. in a phonetic alphabet (pinyin) was devised to transcribe the characters, and in this was officially adopted for use in all texts in the roman alphabet. the previous transcription scheme (wade) is still used in taiwan and hong kong. mainland china is administratively divided into provinces, five autonomous regions (originally entirely or largely inhabited by ethnic minorities, though in some regions now outnumbered by han immigrants) and four government-controlled municipalities. these are in turn divided into prefectures, cities (of which are at prefecture level and at county level), , counties and urban districts. tianjin, · m.; dongguan, · m.; wuhan, · m.; foshan, · m.; chengdu, · m.; chongqing, · m.; nanjing, · m.; shenyang, · m.; xian, · m.; hangzhou, · m.; haerbin, · m.; suzhou, · m.; dalian, · m.; zhengzhou, · m.; shantou, · m.; jinan, · m.; qingdao, · m.; changchun, · m.; kunming, · m.; changsha, · m.; taiyuan, · m.; xiamen, · m.; hefei, · m.; urumqi (wulumuqi), · m.; fuzhou, · m.; shijiazhuang, · m.; wuxi, · m.; zhongshan, · m.; wenzhou, · m.; nanning, · m.; ningbo, · m.; guiyang, · m.; lanzhou, · m.; zibo, · m.; changzhou, · m.; nanchang, · m.; xuzhou, · m about % of the population is engaged in the dominant industries of farming and animal husbandry. in the total sown area was , ha. output in : total grain crops, , tonnes; vegetables, , tonnes. in there were · m. sheep and goats and · m. cattle and yaks. tibet has over , mineral ore fields. mining, particularly of copper and gold, has expanded rapidly since when the railway came to tibet. cement production, : · m. tonnes. electricity consumption totalled · bn. kwh in . in there were , km of roads ( , km in ) . there are airports at lhasa, bangda and nyingchi providing external links. in , , foreign tourists visited tibet. in july a , -km railway linking lhasa with the town of golmud opened. it is the highest railway in the world. direct services have subsequently been introduced between lhasa and a number of major chinese cities, including beijing and shanghai. an extension from lhasa to shigatse, tibet's second largest city, became operational in aug. . in tibet had primary schools (with , pupils) and secondary schools of which were senior secondary schools (with , pupils), junior secondary schools (with , pupils) and eight whole secondary schools. there were also six vocational secondary schools in ( , pupils). tibet has six higher education institutes (the largest of which is tibet university), with , enrolled students in total in . the illiteracy rate of people aged and above was · % in . in there were , medical personnel (including , doctors) and , medical institutions, with a total of , beds. births, , , , ; deaths, , , . birth rate (per , population), · ; death rate, · . in the birth rate rose for the first time since . there were , , marriages and , , divorces in . in the marriage rate was · per , population and the divorce rate a record high · per , . the divorce rate has doubled since . in april parliament passed revisions to the marriage law prohibiting bigamy and cohabitation outside marriage. the suicide rate in china in was · per , population. life expectancy at birth, , was · years for men and · years for women. infant mortality, , per , live births. china has made some of the best progress in recent years in reducing child mortality. the number of deaths per , live births among children under five was reduced from in to in . fertility rate, , · births per woman (compared to over in the mid- s). annual population growth rate, - , · %. according to the world bank, the number of people living in poverty (less than us$ · a day) at purchasing power parity declined from m. in to m. in . most of china has a temperate climate but, with such a large country, extending far inland and embracing a wide range of latitude as well as containing large areas at high altitude, many parts experience extremes of climate, especially in winter. most rain falls during the summer, from may to sept., though amounts decrease inland. monthly average temperatures and annual rainfall ( ): beijing (peking), jan. · °f (- · °c), july · °f ( · °c). annual rainfall · " ( mm). chongqing, jan. · °f ( · °c), july · °f ( · °c). annual rainfall · " ( , mm). shanghai, jan. · °f ( · °c), july · °f ( · °c). annual rainfall · " ( , mm). tianjin, jan. · °f (- · °c), july · °f ( · °c). annual rainfall · " ( mm). on sept. the chinese people's political consultative conference met in beijing, convened by the chinese communist party. the conference adopted a 'common programme' of articles and the 'organic law of the central people's government' ( articles). both became the basis of the constitution adopted on sept. by the st national people's congress, the supreme legislative body. the consultative conference continued to exist after as an advisory body. three further constitutions have been promulgated under communist rule-in communist rule-in , communist rule-in and . the latter was partially amended in , , and , endorsing the principles of a socialist market economy and of private ownership. the unicameral national people's congress is the highest organ of state power. usually meeting for one session a year, it can amend the constitution and nominally elects and has power to remove from office the highest officers of state. there are a maximum of , members of the congress, who are elected to serve five-year terms by municipal, regional and provincial people's congresses. , xi pursued a strong style of authoritarian rule at home and a proactive and muscular foreign policy in his first term. in oct. the ccp gave him the title of 'core' leader, a significant honorific bracketing him with mao zedong and deng xiaoping among previous party figures although conferring no absolute powers. then, at its five-yearly congress in oct. , the party voted to enshrine his name and ideology in the chinese state constitution. he was subsequently re-elected in march and parliament also voted to abolish presidential term limits in a major shift from precedent. xi jinping was born on june in beijing, the son of one of the first generation of communist leaders. he joined the ccp in and, after graduating from tsinghua university in with a degree in chemical engineering, he became secretary to the vice-premier and secretary-general of the central military commission. xi became the zhengding county committee deputy secretary in hebei province in and the following year was promoted to secretary. in he was made deputy mayor of xiamen city, fujian province. having undertaken various party roles in the province, he became deputy governor of fujian in and governor a year later. in he moved to zhejiang province and made his first inroads into national politics when he was named a member of the th central committee. from - he was party secretary of fujian, overseeing economic growth averaging % a year and earning a reputation as an opponent of corruption. in march xi transferred to shanghai to take the role of party secretary following the dismissal of the incumbent on corruption charges. his appointment to such an important regional post was seen as a vote of confidence from the central government and he became a member of the politburo standing committee at the th party congress in oct. . he was also made a high-ranking member of the central secretariat. on march he was elected vice-president at the th national people's congress and took on a number of high profile portfolios including the presidency of the central party school. he was also beijing's senior representative for hong kong and ahead of his presidency, xi said little about his policy ambitions. there was hope abroad and at home that he would champion political and social reform and attempt to deal with corruption and a widening wealth gap between rich and poor and between urban and rural communities. he also faced the conundrum of how to provide adequate healthcare to a rapidly ageing population. in jan. the prospect of greater transparency and accountability under his leadership was undermined when the authorities began criminal proceedings against anti-corruption campaigners calling for public disclosure of officials' assets. this coincided with a report by a us investigative organization claiming that relatives of some of china's top political and military figures, including xi's brother-in-law, held secret offshore financial holdings. in other social and political affairs the ccp announced plans in nov. to ease china's one-child policy (which was subsequently abandoned following an announcement in oct. , with effect from ) and to abolish the system of 'reeducation through labour' camps, while a party plenum calledfor the first time-for markets to play a 'decisive' role in the allocation of resources. meanwhile, in xi was confronted by domestic political opposition in the form of militant attacks by ethnic uighur separatists from xinjiang region and, from sept. that year, by widespread pro-democracy and autonomy protests in hong kong. on the economic front, china's previously frenetic annual rate of growth slowed markedly in , reflecting a slump in factory production and concerns over depressed oil prices, and again in to its lowest since . it also heralded severe stock market turbulence into despite emergency government measures, which had negative reverberations throughout the world economy. nevertheless, recognizing china's rise as a global economic power, the imf in nov. voted to add the yuan as the fifth member of its special drawing rights (sdr) currency basket alongside the us dollar, japanese yen, british pound and the euro. in foreign affairs, regional concerns over china's territorial and military intentions were raised in nov. by the government's declaration of a new 'air defence identification zone' over a swathe of the east china sea including disputed islands claimed by japan and south korea. there has also been friction, regionally and with the usa, over china's sovereignty claims and land reclamation operations on islands in the south china sea, although in july an international legal tribunal ruled in favour of a challenge by the philippines to china's sovereignty assertions-a verdict beijing vowed to ignore. further afield, xi has meanwhile undertaken numerous official visits abroad, as well as attending multilateral forums, for diplomatic, trading and investment purposes. and, while in singapore in nov. , xi and president ma ying-jeou of taiwan held the first direct talks between leaders of the two estranged governments since their split in . most recently, xi urged greater trade co-operation with the usa during his first encounter with the new us president, donald trump, in april , while also increasing economic and military cooperation with russia. li keqiang took office as premier of the state council, a role equivalent to prime minister, in march , succeeding wen jiabao. he was re-elected in march . li keqiang was born on july in dingyuan county, anhui province. following graduation from high school in , he joined the ccp and in he graduated in law from peking university, serving as head of the students' federation from - . he went on to earn a master's degree and doctorate in economics and headed the university's communist youth league of china (cylc) committee. over the following two decades he rose through the cylc ranks, joining the secretariat of its central committee in the s and serving as its first secretary in the s. at this time he built up his power base and forged close ties with hu jintao, a fellow cylc committee member and future chinese president. in li became deputy party secretary for henan province and a year later was appointed henan's governor. in dec. he was named party secretary for liaoning province where he spearheaded a major coastal infrastructure project, the ' points and one line' highway development. in this template was adopted at the national level to rejuvenate industrial northeast china. he also oversaw the rehousing of · m. shanty-town residents into new apartment blocks over a three-year period. li advanced to national level politics when he was elected to the politburo standing committee in oct. . he was appointed vice-premier of the state council in march , leading a medical reform programme aimed at creating an accessible public healthcare service. he also chaired an affordable housing programme and introduced tax reform plans. in nov. li was re-elected as a member of the politburo standing committee and on march became premier of the state council at the th national people's congress. regarded as the steward of the chinese economy, li was expected to focus on securing china's long-term expansion and on the further provision of basic national healthcare, affordable housing, employment growth, regional development and cleaner energy. however, global confidence in china's economy has been shaken since as the country's growth momentum has slowed amid apparent policy differences and blunders, prompting rumours that li was being increasingly sidelined in the governing hierarchy. he was nevertheless re-elected to the politburo standing committee in oct. and to the premiership in march . the chinese president is chairman of the state and party's military commissions. china is divided into seven military regions. the military commander also commands the air, naval and civilian militia forces assigned to each region. china's armed forces (pla: 'people's liberation army'), totalling nearly · m. in including the paramilitary people's armed police (pap) and · m. excluding the pap, are the largest of any country. however, active armed personnel numbers have halved since . moreover, in president xi laid out plans to reform the army structure-replacing an organization based on seven regions with one based on five 'theatre commands'-and reduce the number of military personnel by a further , . conscription is compulsory, but for organizational reasons, is selective: only some % of potential recruits are called up. service is for two years. a military academy to train senior officers in modern warfare was established in . defence expenditure in was us$ , m. (equivalent to us$ per capita). china's military spending more than trebled during the s. defence spending in represented · % of gdp. only the usa spent more on defence in , but china's defence expenditure totalled around a fifth of that of the usa. in march it was announced that the defence budget would rise by · % to us$ bn. following increases of · %, · % and · % in the previous three years. china is the world's third largest exporter of arms after the usa and russia, with · % of the global major weapons total over the period - . in the period - it had only been the eighth largest exporter. as at may china had , personnel serving in un peacekeeping operations (the largest contingent of any of the five permanent members of the un security council and more than the other four combined). having carried out its first test in , there have been tests in all at lop nur, in xinjiang (the last in ). the nuclear arsenal consisted of approximately operational warheads in jan. according to the stockholm international peace research institute. china has been helping pakistan with its nuclear efforts. the army (pla: 'people's liberation army') is divided into main and local forces. main forces, administered by the seven military regions in which they are stationed, but commanded by the ministry of defence, are available for operation anywhere and are better equipped. local forces concentrate on the defence of their own regions. ground forces are divided into infantry, armour, artillery, air defence, aviation, engineering, chemical defence and communications service arms. there are also specialized units for electronic counter-measures, reconnaissance and mapping. in there were group armies covering seven military regions. they included: armoured divisions and brigades; mechanized infantry divisions, brigades and regiments; motorized infantry divisions and brigades; nine special operations units; artillery divisions and brigades; amphibious brigades and divisions; two mountain brigades; aviation brigades and regiments; and two guard divisions. total strength in was · m. including some , conscripts. reserve forces are undergoing major reorganization on a provincial basis but are estimated to number some , . there is a paramilitary people's armed police force estimated at , under pla command. in nov. the naval arm of the pla included submarines, of which three were strategic (two jin-class and one xia-class) and tactical. by mid- two more jin-class nuclear-powered ballistic missile submarines had entered service. surface combatant forces in nov. included destroyers and frigates. sea trials of china's first aircraft carrier, liaoning (a former soviet warship purchased from ukraine), began in aug. . it entered service in sept. and was initially only used for training before being declared 'combat ready' in nov. . work on china's first domestically-built aircraft carrier began in . it was launched in april and is expected to be operational by . there is a land-based naval air force of about combatcapable aircraft, primarily for defensive and anti-submarine service. the force includes h- strategic bombers and jh- fighters. the naval arm is split into a north sea fleet, an east sea fleet and a south sea fleet. in naval personnel were estimated at , , including , in the naval air force and , conscripts. the people's liberation army air force organizes its command through seven military region air forces. the air force has an estimated , combat-capable aircraft. equipment includes j- (mig- ) interceptors (known in the west as 'fishbed'), h- chinese-built copies of tu- strategic bombers, q- fighterbombers (evolved from the mig- and known in the west as 'fantan'), su- fighters supplied by russia (known in the west as 'flanker'), j- chinese-designed and produced fighters (known in the west as 'firebird') and j- locally-developed fighters (known in the west as 'finback'). total strength ( ) was , . in agriculture accounted for · % of gdp, industry · % and services · %. industry was the largest contributor until , while services only overtook agriculture as the second largest sector in . in the late s agriculture was the largest contributor towards gdp. china's economic performance has been marked by high rates of growth for over three decades. annual gdp increases in the early s consistently exceeded % until the global financial crisis. china also holds the world's largest foreign exchange reserves, at more than us$ · trn. in april , although they have been falling since as the central bank strives to boost the currency in the face of large capital outflows. it is among the top recipients of foreign direct investment (fdi) and is the world's largest producer and consumer of coal. in china made the transition from net receiver of foreign aid to net donor and has established itself as a key player in africa's economic development, becoming the largest export partner of sub-saharan africa in . according to the world bank, china's cumulative fdi stock in africa totalled nearly us$ · bn. in , up from us$ · bn. in . in china overtook japan to become the world's second largest economy after the usa. the first steps from a centrally-planned towards a more market-oriented economy were taken by deng xiaoping in the late s. he opened the economy to foreign trade and investment, decentralized industrial management and allowed private sector development. in china became a member of the world trade organization, establishing trade relations with many countries. private entrepreneurs and foreign investors have played an important role in developing the manufacturing sector, china's principal growth engine. even before the economy was heavily skewed towards manufacturing, but following the market-oriented transition output increased significantly. during this period there was a structural shift away from large state-owned enterprises (soes), although these still remain an important part of the economy. between and the government oversaw reform of soes, with many poorly performing businesses privatized or liquidated. stronger firms were restructured and often listed on the stock market. many more recent enterprises are labourintensive as distinct from the capital-intensive soes. growth has been fuelled by low added value and labour-intensive exports. however, chinese firms are predicted to become increasingly competitive with higher added value producers, such as south korea. although the global financial crisis reduced the rate of growth and inbound fdi, china's recovery was among the earliest. gdp growth averaged · % in the second quarter of , up from a two-decade low of · % in the first quarter of that year. fdi also recovered rapidly, averaging · % of gdp annually between and . growth was rooted in a stimulus package of trn. yuan (us$ bn. or % of gdp), including fiscal spending and interest rate cuts, as well as an expansionary monetary policy. central government committed · trn. yuan, with the rest coming from local government, banks and soes. although exports declined by around % in , other countries fared worse and china's share of world exports increased to nearly · % in (up from % in ), making it the world's largest merchandise provider. gdp growth in stood at more than % but moderated between and , reflecting the global economic slowdown and diminishing dividends from past reforms. in aug. a devaluation of the yuan sent the shanghai stock exchange plummeting by nearly %, which was swiftly followed by a surge in capital outflows. the stock market meltdown lasted until feb. , with trading halted altogether for two days in jan. that year. nonetheless, the shanghai exchange subsequently began a recovery and had stabilized (at around , points) by feb. . despite stock market turbulence, the property market, which constitutes a quarter of china's gdp and is vital to the banking sector (as it accounts for a substantial amount of its collateral), remained buoyant. gdp growth declined to · % in (the slowest rate in years) and fell again to · % in as china attempted to reduce its reliance on exports, increase domestic consumption and develop its service sector. the economy then grew by · % in . rapid economic advance has brought with it a number of challenges that threaten future growth. notably, china's cost advantage has been undermined in recent years by rising wages and transportation costs, as well as weak global demand. other concerns include rising property costs, high levels of local government debt, lack of enforcement of intellectual property rights, endemic corruption at government level and credit and investment dependence, while total social financing-a broad measure of total credit-increased by % of gdp between and early . the stimulus package implemented by the government to boost growth increased total debt levels to more than double the value of gdp in . according to the imf, an increase in consumer demand and a reduced dependence on exports and investment are keys to achieving stable long-term economic expansion. china's th five-year plan (covering - ) aims to promote domestic consumption and to support innovation and entrepreneurship within a framework of balanced and sustainable development. efforts to promote domestic consumption have seen exports' share of gdp falling from % in to · % in and a lower investment contribution to gdp. the continued decline in commodity prices coupled with china's economic slowdown has had knock-on effects for commodityexporting nations, such as brazil, indonesia and argentina, given that china consumes about half of the world's steel, aluminium and nickel. inefficient production and outmoded equipment have meanwhile led to significant environmental problems, especially in the north of the country. air pollution, soil erosion and a declining water table are of particular concern. china has become the world's largest consumer of coal and second largest consumer of oil after the usa. the government aims to diversify its energy sources, relying less on coal and more on nuclear and alternative energy sources. there has been heavy investment in hydro-power, including the three gorges dam. since , m. people have been lifted out of poverty, yet china still has the second largest number of poor in the world after india. the world bank estimates that · m. people lived below the national poverty line at the end of (equivalent to income less than us$ per day), located mainly in remote and resource-poor regions and particularly in the west and the interior. nonetheless, some progress has been made, with · % of the rural population living below the poverty line in compared to · % in . growing inequality between urban and rural regions, particularly in terms of educational opportunities, needs to be addressed, however. china also faces the growing burden of an ageing population. those aged and over accounted for · % of the total population in , up from · % in . the currency is called renminbi (i.e. people's currency). the unit of currency is the yuan (cny) which is divided into ten jiao, the jiao being divided into ten fen. the yuan was floated to reflect market forces on jan. while remaining state-controlled. for years the people's bank of china maintained the yuan at about · to the us dollar, allowing it to fluctuate but only by a fraction of % in closely supervised trading. in july it was revalued and pegged against a 'market basket' of currencies the central parities of which were determined every night. in july , after three years of sharp appreciation, it was repegged at around · yuan to the dollar, leading to claims from some international observers that it was being kept unfairly low to boost exports. in june the government announced that the yuan would be allowed to move freely against the dollar as long as a rise or fall does not exceed · % within a single day. in aug. the yuan was devalued by a total of · % on three consecutive days. in aug. total money supply was , · bn. yuan, gold reserves were · m. troy oz and foreign exchange reserves us$ , · bn. (us$ · bn. in of the total revenues in central government accounted for , · bn. yuan and local governments , · bn. yuan. tax revenues came to , · bn. yuan in (including domestic vat , · bn. yuan and corporate income tax , · bn. yuan) and non-tax revenues , · bn. yuan. of the total expenditure in central government accounted for , · bn. yuan and local governments , · bn. yuan. the leading items of expenditure in were education ( , · bn. yuan) and social safety net and employment effort ( , · bn. yuan). the standard rate of vat is %. savings deposits in various forms in all banking institutions totalled , · bn. yuan in ; loans amounted to , · bn. yuan. there are stock exchanges in the shenzhen special economic zone and in shanghai. a securities trading system linking six cities (securities automated quotations system) was inaugurated in for trading in government bonds. china received a record us$ · bn. worth of foreign direct investment in , up from us$ · bn. in . external debt totalled us$ , m. in (up from us$ , m. in ) and represented · % of gni. china's carbon dioxide emissions from the consumption and flaring of fossil fuels in accounted for · % of the world total (making it the biggest emissions producer, having overtaken the usa in ) and were equivalent to · tonnes per capita (up from · tonnes per capita in ). an environmental performance index compiled in ranked china th of countries, with · %. the index examined various factors in nine areas-agriculture, air quality, biodiversity and habitat, climate and energy, fisheries, forests, health impacts, water and sanitation, and water resources. pollution is estimated to cost china about % of gdp annually. installed generating capacity in was an estimated , m. kw, compared with m. kw in . in electricity output was , , gwh, up from , , gwh in . consumption per capita was , kwh in . rapidly increasing demand has meant that more than half of china's provinces have had to ration power. sources of electricity in as percentage of total production: thermal, · %; hydro-electric power, · %; wind. · % (china is one of the world's largest producers of wind power); and nuclear, · %. in there were nuclear reactors in use and under construction. generating electricity is not centralized; local units range between and mw of output. in dec. china formally broke up its state power monopoly, creating instead five generating and two transmission firms. the three gorges dam project on the yangtze river was launched in and is intended to produce abundant hydro-electricity (as well as helping flood control). the first three , -kw generators in service at the project's hydro-power station began commercial operation in july . the original specification was completed in oct. , although six more generators have been added in the meantime (bringing the total to ). the final two generators become operational in july , giving the dam an overall capacity of · gw. china surpassed germany in terms of solar generating capacity in , with · gw at the end of the year. on-shore oil reserves are found mainly in the northeast (particularly the daqing and liaohe fields) and northwest. there are off-shore fields in the continental shelves of east china. oil production was a record · m. tonnes in . china is the second largest consumer of oil after the usa. ever-growing demand has meant that increasing amounts of oil are having to be imported. a -km pipeline from skovorodino in russia to daqing in the northeast of china was inaugurated in jan. , allowing china to increase significantly its imports of oil from the world's second largest producer. the , -km turkmenistan-china gas pipeline, bringing natural gas to xinjiang in china via kazakhstan and uzbekistan, was inaugurated in dec. . this connects with china's second west-east gas pipeline. only the usa imports more oil. domestic production now accounts for only % of consumption, compared to nearly % in . proven reserves in were · bn. bbls. the largest natural gas reserves are located in the western and north-central regions. production was a record · bn. cu. metres in -up from · bn. cu. metres in -with proven reserves of · trn. cu. metres in . china is the second largest producer of wind power after the usa, with · bn. kwh in . in total installed capacity amounted to , mw, the highest of any country and · % of the world total. china is one of the world's leading mineral producing and consuming countries. recoverable deposits of coal in totalled · bn. tonnes, mainly distributed in north china (particularly shanxi province and the inner mongolia autonomous region). coal production was , m. tonnes in . annual coal production has increased every year since . growing domestic demand nonetheless meant that china became a net importer of coal in . iron ore reserves were · bn. tonnes in . deposits are abundant in the anthracite field of shanxi, in hebei and in shandong, and are found in conjunction with coal and worked in the northeast. production in was , m. tonnes, making china the world's largest iron ore producer. it is also the largest consumer, at around % of the global total in . tin ore is plentiful in yunnan, where the tin-mining industry has long existed. tin production was , tonnes in . china is a major producer of wolfram (tungsten ore). there is mining of wolfram in hunan, guangdong and yunnan. output of other minerals (in , tonnes) in : salt, , ; bauxite, , ; aluminium, , ; zinc, , ; lead, , ; copper, , . there are also reserves of diamond, nickel, barite, bismuth, graphite, gypsum, mercury, molybdenum, silver, salt, phosphate ore and sylvite. gold production, : tonnes. china surpassed south africa as the world's leading gold producer in , since when its output has increased every year. agriculture accounted for approximately % of gdp in , compared to over % in at the time of the birth of the people's republic of china and over % in . in sown areas for major crops were (in m. ha.): corn, · ; rice, · ; wheat, · ; soybeans, · ; tubers, · ; rapeseed, · . intensive agriculture and horticulture have been practised for millennia. present-day policy aims to avert the traditional threats from floods and droughts by soil conservancy, afforestation, irrigation and drainage projects, and to increase the 'high stable yields' areas by introducing fertilizers, pesticides and improved crops. in aug. more than m. ha., notably in the yangtze valley, were under water as china experienced its worst flooding since the s. the flood season claimed over , lives. 'township and village enterprises' in agriculture comprise enterprises previously run by the communes of the maoist era, cooperatives run by rural labourers and individual firms of a certain size. there were , state farms in with · m. employees. net per capita annual income of rural households, : , yuan. in there were an estimated · m. ha. of arable land and · m. ha. of permanent cropland; · m. ha. were equipped for irrigation. there were · m. large/medium-sized tractors in and · m. small tractors. china is the world's leading producer of a number of agricultural crops. production of major products (in m. , - . forestry in the area under forests was · m. ha., or % of the total land area. the average annual increase in forest cover of , , ha. between and was the highest of any country in the world. total roundwood production in was · m. cu. metres, making china the world's third largest timber producer ( · % of the world total in ). it is the highest consumer of roundwood; timber consumption in totalled · m. cu. metres. it is also the world's leading importer of roundwood, accounting for · % of world timber imports in . output of major products, unless otherwise indicated (in tonnes): cement, , · m.; rolled steel, , · m.; crude steel, · m.; pig iron, · m.; gas oil and diesel oil ( ), · m.; gasoline, · m.; paper and paperboard, · m.; sulphuric acid, · m.; chemical fertilizers, · m.; fuel oil ( ), · m.; yarn, · m.; refined sugar, · m. also produced in : cloth, , m. metres; beer, , · m. litres; , · m. mobile phones; · m. notebook pcs; · m. colour tv sets; · m. air conditioners; · m. home refrigerators; · m. washing machines; · m. bicycles; · m. cameras; · m. motorcycles. china is the world's leading cement, steel and pig iron manufacturer; since output of cement has doubled and production of crude steel and pig iron has quadrupled (although in both crude steel and pig iron production fell for the first time in years). china overtook japan as the world's largest producer of motor vehicles in , and in produced · m. cars and · m. commercial vehicles. the employed population at the census was · m. ( · m. female). by it had risen to · m. ( · m. more than in ), of whom · m. worked in rural areas ( · m. fewer than in ) and · m. in urban areas ( · m. more than in ). in china's registered urban jobless was · %, with · m. registered unemployed in the country's cities. with china's fast-growing ageing population, according to the united nations the working-age population began to decline in . in china had , private industrial enterprises. it was not until the late s that the private sector even came into existence in china. the average annual wage of people working in urban units in was , yuan. china's labour law stipulates a five-day working week with no more than eight hours a day and no more than hours a week. minimum working age was fixed at in . strikes over pay have become ever more frequent in china, particularly at foreign-owned facilities. china had · m. people living in slavery according to the walk free foundation's global slavery index, the second highest total of any country. there are five special economic zones at shenzhen, xiamen, zhuhai, shantou and hainan in which concessions are made to foreign businessmen. the pudong new area in shanghai is also designated a special development area. since joint ventures with foreign firms have been permitted. a law of april reduced taxation on joint ventures to %. there is no maximum limit on the foreign share of the holdings; the minimum limit is %. in china is the second largest trading nation in the world, accounting for · % of global merchandise imports by value in and · % of global merchandise exports (up from · % when it joined the wto in ). it was the second largest importer in behind the usa and the largest exporter. as recently as the usa's total trade in goods was more than twice that of china. it overtook germany as the largest exporter of goods in . its trade surplus in goods is the highest of any country. however, it has the world's highest trade deficit in services. in imports of services totalled us$ bn. but exports only us$ bn. main imports in (in us$ bn.): machinery and transport equipment, · ; non-edible raw materials, · ; mineral fuels, lubricants and related materials, · ; chemicals, · . major exports in (in us$ bn.): machinery and transport equipment, , · ; miscellaneous manufactured goods, · ; light textile industrial products, rubber products, minerals and metallurgical products, · ; chemicals, · . the main trading partners were as follows in (in us$ m.): the total road length in was , , km, including , km of expressways (of which there had not been any as recently as the mid- s); , m. tonnes of freight and , m. persons were transported by road that year. the number of civilian motor vehicles was · m. in , including · m. passenger vehicles and · m. trucks (more than double the number in , when there were · m. civilian vehicles overall including · m. passenger vehicles and · m. trucks). china is the world's fastest-growing car market. there were , traffic accidents in , with , fatalities. in in jan. there were , ships of gt or over registered, totalling · m. gt. of the , vessels registered, were bulk carriers, general cargo ships, oil tankers, container ships, passenger ships and liquid gas tankers. mainland china's busiest port in was ningbo-zhoushan (handling · m. tonnes of cargo), followed by shanghai ( · m. tonnes), tianjin ( · tonnes), guangzhou (canton) ( · m. tonnes) and qingdao ( · m. tonnes). shanghai overtook singapore to become the world's busiest container port in and handled · m. teus (twenty-foot equivalent units) in . shenzhen, mainland china's second busiest port for container traffic and the world's fourth busiest in , handled · m. teus. hong kong handled · m. teus in . in jan. the first legal direct shipping links between the chinese mainland and taiwanese islands in more than years were inaugurated. inland waterways totalled , km in ; , · m. tonnes of freight and · m. passengers were carried. in june the three gorges reservoir on the chang jiang river, the largest water control project in the world, reached sufficient depth to support the resumption of passenger and cargo shipping. out of countries analysed in the fragile states index-a list published jointly by the fund for peace and foreign policy magazine-china was ranked the th most vulnerable to conflict or collapse. the index is based on indicators of state vulnerability across social, political and economic categories. six new codes of law (including criminal and electoral) came into force in , to regularize the legal unorthodoxy of previous years. there is no provision for habeas corpus. as well as treason and murder the death penalty may be used for rape, embezzlement, smuggling, fraud, theft, drug-dealing, bribery and robbery with violence. amendments to the criminal law in and reduced the number of capital crimes-which include both violent and non-violent offences-from to and further to . china does not divulge figures on its use of the death penalty, but amnesty international reported that in china executed thousands of people and was the world's top executioner. nevertheless, western analysts believe that the number of executions now is around a fifth of the yearly total in the s. 'people's courts' are divided into some higher, intermediate and , basic-level courts, and headed by the supreme people's court. the latter, the highest state judicial organ, tries cases, hears appeals and supervises the people's courts. it is responsible to the national people's congress and its standing committee. people's courts are composed of a president, vice-presidents, judges and 'people's assessors' who are the equivalent of jurors. 'people's conciliation committees' are charged with settling minor disputes. there are also special military courts. procuratorial powers and functions are exercised by the supreme people's procuracy and local procuracies. in march the national people's congress passed legislation developing aspects of the general principles of civil law, with effect from oct. . among its provisions was the extension of legitimate rights and interests from chinese citizens only to anyone conducting civil activities in the country. in addition, the statute of limitation was increased from two to three years. the number of sentenced prisoners in mid- was , , ( per , of national population). china was ranked th of countries for criminal justice and th for civil justice in the world justice project rule of law index, which provides data on how the rule of law is experienced by the general public across eight categories. an educational reform of brought in compulsory nine-year education consisting of six years of primary schooling and three years of secondary schooling, to replace a previous five-year system. in mainland china the population census revealed the following levels of educational attainment: · m. people had finished university education; · m. had received senior secondary education; · m. had received junior secondary education; and · m. had had primary education. · m. people over years of age or · % of the population were illiterate, although this compared favourably with a · % rate of illiteracy in the census and a · % rate in . in adult literacy was estimated at · %; youth literacy in was · %. in there were , kindergartens with · m. children and · m. full-time teachers; , regular primary schools with · m. pupils and · m. full-time teachers; , secondary schools (including: , senior secondary; , junior secondary; , specialized; , vocational; and , technical) with · m. pupils and · m. full-time teachers. there were also , pupils at , special education schools. institutes of higher education, including universities, numbered , in , with · m. undergraduates and · m. postgraduate level students, and · m. full-time teaching staff. china has more than private universities, almost all of which have been established since the mid- s. a national system of student loans was established in . the number of chinese students studying abroad went up from , in to , in ; it rose above , in and , in , and by exceeded , , making china the largest source of overseas students in the world. chinese students account for a fifth of all international students in tertiary education in the oecd, but fewer than half return to china after finishing their studies. the number of chinese undergraduate students in american universities in - was times as many as in - , rising from , to , in the space of seven years. there is an academy of sciences with provincial branches. an academy of social sciences was established in . in national government expenditure on education came to , , m. yuan and accounted for · % of national government spending. medical treatment is free only for certain groups of employees, but where costs are incurred they are partly borne by the patient's employing organization. in there were , health institutions throughout china, including , hospitals, , local health centres, , centres for disease control and prevention, and , specialized prevention and treatment centres. china's first aids case was reported in . at the end of there were , reported cases of people living with hiv/ aids. the number of deaths of people who had been living with hiv/aids in was , . in the first half of china was struck by an epidemic of a pneumonia-type virus identified as sars (severe acute respiratory syndrome). the virus was first detected in southern china and was subsequently reported in over other countries. according to the ministry of health, by the time the outbreak had been contained a total of , cases had been reported on the chinese mainland; , patients were cured and discharged from hospital, and died. in water: at what cost? the state of the world's water , wateraid reported that · % of the population does not have access to safe water. china ranked as the country with the second largest number of people living without access to safe water ( · m. in ). in an estimated · % of adult males and · % of adult females smoked in china. a study from the same year estimated that chinese males smoke one-third of all the world's cigarettes. in there were , social welfare enterprises with · m. beds. numbers (in , ) of beneficiaries of relief funds in : urban residents receiving minimum living allowance, , ; rural residents receiving minimum living allowance, , ; persons receiving traditional relief, ; persons in rural households entitled to the 'five guarantees' (food, clothing, medical care, housing and burial expenses), , . the official retirement age for men is and for women (or in the case of civil servants and professionals). the government accords legality to five religions only: buddhism, islam, protestantism, roman catholicism and taoism. confucianism, buddhism and taoism have long been practised. confucianism has no ecclesiastical organization and appears rather as a philosophy of ethics and government. taoism-of chinese origin-copied buddhist ceremonial soon after the arrival of buddhism two millennia ago. buddhism in return adopted many taoist beliefs and practices. a more tolerant attitude towards religion had emerged by , and the government's bureau of religious affairs (since renamed the state administration for religious affairs) was reactivated. ceremonies of reverence to ancestors have been observed by the whole population regardless of philosophical or religious beliefs. a new quasi-religious movement, falun gong, was founded in , but has since been banned by the authorities. the movement has claimed some m. adherents, although the chinese government has disputed this. muslims are found in every province of china, being most numerous in the ningxia-hui autonomous region, yunnan, shaanxi, gansu, hebei, henan, shandong, sichuan, xinjiang and shanxi. roman catholicism has had a footing in china for more than three centuries. two christian organizations-the chinese patriotic catholic association, which declared its independence from rome in , and the protestant three-self patriotic movement-are sanctioned by the chinese government. according to estimates (by the state-approved xinhua news agency, the chinese academy of social sciences and the state administration for religious affairs) there were m. buddhists (more than in any other country), m. christians and more than m. muslims in the country in . other official figures indicate that there are · m. catholics, although unofficial estimates are much higher. the number of christians in china is generally thought to be far higher than official numbers indicate, with socalled 'house churches' becoming ever more popular. some analysts estimate that there are as many as m. christians overall. legislation of prohibits foreign nationals from setting up religious organizations. in , , m. volumes of books were produced. in tourist numbers totalled · m. the world tourism organization predicts that china will overtake france as the world's most visited destination by . it was the third most visited destination in after france and the usa. income from tourists in was us$ · bn., ranking it fourth behind the usa, spain and france. expenditure by chinese travellers outside of mainland china for was us$ · bn., the most of any country. in both german and us travellers abroad had spent more than those from china. the lunar new year, also known as the 'spring festival', is a time of great excitement for the chinese people. constituencies encompassing all eligible persons in a workforce of · m., and ten from an election committee formed by members of district boards. a president was elected from and by the members. at the elections on sept. turnout for the geographical seats was · %, and for the functional seats ( of which were contested), · %. the democratic party and its allies gained seats, the liberal party and the pro-beijing democratic alliance . the remaining seats went to independents. on dec. the selection committee selected a provisional legislature which began its activities in jan. while the legislative council was still functioning. in jan. the provisional legislature started its work by enacting legislation which would be applicable to the hong kong special administrative region and compatible with the basic law. constitutionally hong kong is a special administrative region of the people's republic of china. the basic law enables hong kong to retain a high degree of autonomy. it provides that the legislative, judicial and administrative systems which were previously in operation are to remain in place. the special administrative region government is also empowered to decide on hong kong's monetary and economic policies independent of china. in july the first-past-the-post system of returning members from geographical constituencies to the legislative council was replaced by proportional representation. there were directly elected seats out of for the first elections to the legislative council following hong kong's return to chinese sovereignty, increasing in accordance with the basic law to for the election with indirectly elected. in the sept. legislative council election (and that of sept. ) of the seats were directly elected. for the election in sept. the number of seats was increased to , with directly elected and indirectly elected by functional constituencies. there were also five new functional constituency seats nominated by elected district council members. the chief executive is chosen by a beijing-backed , -member election committee ( prior to the march election), although it has been stated that universal suffrage is the ultimate aim. in a timetable was announced for hong kong to directly elect its chief executive in and its legislative council in . however, beijing insisted that only approved candidates would be allowed to stand in , prompting mass pro-democracy rallies in the territory in and formal rejection of the plan by the legislative council in june . beijing nevertheless refused to countenance amendments. in july a new accountability or 'ministerial' system was introduced, under which the chief executive nominates for appointment policy secretaries, who report directly to the chief executive. the chief executive is aided by the executive council, consisting of the three senior secretaries of department (the chief secretary, the financial secretary and the secretary for justice) and eleven other secretaries plus five non-officials. according to the anti-corruption organization transparency international, hong kong ranked equal th in the world in a survey of the countries and regions with the least corruption in business and government. it received out of in the annual index. overview hong kong has one of the world's most open economies and is an internationally important financial centre. the territory's economic rise was founded on its role as an international trade emporium, acting as a conduit for china's burgeoning exports. mainland china, the usa and japan are hong kong's major export partners, accounting for · %, · % and · % of exports respectively in . the island is dependent on imports of food and other resources. in it imported % of goods from mainland china, % from taiwan and % from japan. in and the economy grew strongly on the back of a rise in chinese tourism, healthy global demand for exports and improving domestic consumer confidence. however, the global financial crisis saw the economy shrink by · % in before rebounding with a · % increase the following year. between and annual growth averaged · %, supported by strong external demand. student-led pro-democracy protests in the latter months of caused major disruption in several key business districts and threatened to weaken the local economy in the short term. foreign direct investment levels have been high, averaging % of gdp between and according to world bank data, and the world economic forum ranked hong kong as the ninth most competitive economy in the world in its report. the government aims to tackle a housing shortage by providing , new housing units by the mid- s. the unit of currency is the hong kong dollar (hkd) of cents. it has been pegged since at a rate of hk$ · to the us dollar. banknotes are issued by the hongkong and shanghai banking corporation and the standard chartered bank, and, from may , the bank of china. total money supply was hk$ , m. in july . in aug. gold reserves were , troy oz and foreign exchange reserves were us$ , m. inflation rates (based on imf statistics): in - revenue totalled hk$ · bn. and expenditure hk$ · bn. earnings and profits taxes accounted for · % of revenues in - and indirect taxes · %; education accounted for · % of expenditures and social welfare · %. hong kong's carbon dioxide emissions from the consumption of energy in were the equivalent of · tonnes per capita. installed capacity was · m. kw in . production in was · bn. kwh. hong kong is a net importer of electricity. consumption in was · bn. kwh. the local agricultural industry is directed towards the production of high quality fresh food through intensive land use and modern farming techniques. out of the territory's total land area of , sq. km, only sq. km is currently farmed. in local production accounted for % of live poultry consumed, % of live pigs and % of fresh vegetables. the gross value of local agricultural production totalled hk$ , m. in , with pig production valued at hk$ m., poultry production (including eggs) at hk$ m., and vegetable and flower production at hk$ m. in the total catch was , tonnes, exclusively from marine waters. the leading companies by market capitalization in hong kong in may were: china mobile, a telecommunications company (us$ · bn.); aia group, a life insurance company (us$ · bn.); and cnooc, an integrated oil company (us$ · bn.). industry is mainly service-oriented. in june there were , establishments employing , , persons in service industries and , establishments employing , persons in manufacturing industries. establishment statistics by service type (and persons engaged) were mainly: import/export trade and wholesale, , ( , ); retail, , ( , ) ; social and personal services, , ( , ) ; professional and business services, , ( , ); financing and insurance, , ( , ); accommodation and food services, , ( , ); real estate, , ( , ) . in the size of the labour force (synonymous with the economically active population) was , , ( , , females). the persons engaged in june included , , people in wholesale, retail and import/export trades, accommodation and food services, , in finance, insurance, real estate, professional and business services, , in the civil service, , in manufacturing and , in construction sites (manual workers only). a minimum wage of hk$ per hour was introduced for the first time on may . unemployment stood at · % in the period sept.-dec. . in the total value of imports was hk$ , , m. and total exports hk$ , , m. the main suppliers of imports in were mainland china ( · %), japan ( · %), taiwan ( · %), singapore ( · %) and usa ( · %). in , · % of total exports went to mainland china, · % to the usa, · % to japan, · % to germany and · % to the united kingdom. the chief import items in were: electrical machinery, apparatus and appliances, etc. ( · %); telecommunications, sound recording and reproducing equipment ( · %); office machines and automatic data processing machines ( · %); articles of apparel and clothing accessories ( · %). the main exports in were: electrical machinery, apparatus and appliances, etc. ( · %); telecommunications, sound recording and reproducing equipment ( · %); office machines and automatic data processing machines ( · %); articles of apparel and clothing accessories ( · %). in there were , km of roads, over % of which were in the new territories. there are road tunnels, including three under victoria harbour. in there were , private cars, , goods vehicles, , buses and coaches, and , motorcycles and mopeds. there were , road accidents in , of which were fatal. a total of · m. tonnes of cargo were transported by road in . a -km bridge linking hong kong, zhuhai in guangdong province in mainland china and macao has been built and was scheduled to open in july following a number of delays. hong kong was ranked fourth for its road infrastructure in the world economic forum's global competitiveness report - . hong kong's railways are run by the mtr corporation limited (mtrcl), a public listed company of which the government is the majority shareholder. the mtr system comprises nine railway lines serving hong kong island, kowloon and the new territories. its -km network has stations and carries an average of · m. passengers each day. mtr lines carried , m. passengers in . in addition, a light rail network ( · km and stops) serves the local communities of tuen mun, yuen long and tin shui wai in the new territories; , passengers travel daily on the system. a high speed rail service between hong kong and guangzhou on the mainland is scheduled to open in late . the electric tramway on the northern state of hong kong island commenced operating in and has a total track length of km. the peak tram, a funicular railway connecting the peak district with the lower levels in victoria, has a track length of · km and two tramcars (each with a capacity of passengers per trip). it carries an average of , passengers daily. the airport express line ( · km) opened in and is also operated by the mtrcl. it carried · m. passengers in . in june it was estimated that · m. passenger journeys were made daily on public transport (including local railways, buses, etc.). in the world economic forum's global competitiveness report - hong kong ranked third for quality of rail infrastructure. the new hong kong international airport (generally known as chek lap kok), built on reclaimed land off lantau island to the west of hong kong, was opened on july to replace the old hong kong international airport at kai tak, which was situated on the north shore of kowloon bay. more than airlines now operate scheduled services to and from hong kong. in cathay pacific airways, the largest hong kong-based airline, operated approximately , passenger and cargo services to destinations in countries and territories around the world. cathay pacific carried , , passengers and · m. tonnes of cargo in . dragonair, a cathay pacific subsidiary, provided scheduled services to cities in mainland china and asia in . in air hong kong, an all-cargo operator, provided scheduled services to bangkok, beijing, ho chi minh city, manila, nagoya, osaka, penang (via bangkok), seoul, shanghai, singapore, taipei and tokyo. hong kong international airport handled more international freight in than any other airport. in , , aircraft arrived and departed and m. passengers and · m. tonnes of freight were carried on aircraft. hong kong was second, behind only singapore, in the rankings for air transport infrastructure in the world economic forum's global competitiveness report - . the port of hong kong handled · m. teus (twenty-foot equivalent units) in , making it the world's third busiest container port after shanghai and singapore. the kwai chung container port has berths with , metres of quay backed by ha. of cargo handling area. at the end of there were , ships ( , ocean-going) of , , gt registered in hong kong. in , , ocean-going vessels, , river cargo vessels and , river passenger vessels arrived at the port of hong kong. a total of m. tonnes of freight were handled in . hong kong was ranked third in the world economic forum's global competitiveness report - for the quality of its port facilities. in there were , , main (fixed) telephone lines (equivalent to · per , population). the local fixed telecommunications network services (ftns) market in hong kong was liberalized in . there were , , mobile phone subscriptions in (equivalent to , · per , population), up from , , in ( , · per , population). the number of subscriptions doubled between and . the internet market has also seen huge growth. in there were , , wireless broadband subscriptions ( · per , population) and , , fixed broadband subscriptions ( · per , population). the number of fixed broadband subscriptions has been declining since as more people have wireless subscriptions instead. in march there were · m. facebook users. the external telecommunications services market has been fully liberalized since jan. , and the external telecommunications facilities market was also liberalized starting from jan. . the hong kong act of provided for hong kong ordinances to replace english laws in specified fields. the courts of justice comprise the court of final appeal (inaugurated july ), which hears appeals on civil and criminal matters from the high court; the high court (consisting of the court of appeal and the court of first instance); the lands tribunal, which determines on statutory claims for compensation over land and certain landlord and tenant matters; the district court (which includes the family court); the magistracies (including the juvenile court); the coroner's court; the labour tribunal, which provides a quick and inexpensive method of settling disputes between employers and employees; the small claims tribunal, which deals with monetary claims involving amounts not exceeding hk$ , ; and the obscene articles tribunal. while the high court has unlimited jurisdiction in both civil and criminal matters, the district court has limited jurisdiction. the maximum term of imprisonment it may impose is seven years. magistracies exercise criminal jurisdiction over a wide range of offences, and the powers of punishment are generally restricted to a maximum of two years' imprisonment or a fine of hk$ , . after being in abeyance for years, the death penalty was abolished in . , crimes were reported in , of which , were violent crimes. , people were arrested in , of whom , were for violent crimes. the population in penal institutions was , at dec. ( per , population). in the adult literacy rate was · % ( · % in ). universal basic education is available to all children aged from six to years. in around three-quarters of the ordinary secondary day schools teaching has been in cantonese since - , with about a quarter of ordinary secondary day schools still using english. in there were , pupils in kindergartens, , in primary schools (including international schools) and , in secondary schools (including international schools). the estimated total government expenditure on education in - was hk$ · bn. ( · % of total government spending and · % of gdp). in - : · % of total government spending and · % of gdp. according to the oecd's pisa (programme for international student assessment) study, -year-olds in hong kong rank second among oecd and other major countries and cities in mathematics and reading, and ninth in science. the three-yearly study compares educational achievement of pupils in over countries. the department of health (dh) is the government's health adviser and regulatory authority. the hospital authority (ha) is an independent body responsible for the management of all public hospitals. in there were , registered doctors, equivalent to · doctors per , population. in there were , dentists, , nurses and , midwives. the total number of hospital beds in was , , including , beds in public hospitals under the ha and , beds in private hospitals. the bed-population ratio was · beds per thousand population. the chinese medicine ordinance was passed by the legislative council in july to establish a statutory framework to accord a professional status for chinese medicine practitioners and ensure safety, quality and efficacy of chinese medicine. in there were , registered chinese medicine practitioners. total expenditure on health in - amounted to hk$ , m., an increase of · % over that in - . social welfare programmes include social security, family services, child care, services for the elderly, medical social services, youth and community work, probation, and corrections and rehabilitation. non-governmental organizations are subsidized by public funds. the government gives non-contributory cash assistance to needy families, unemployed able-bodied adults, the severely disabled and the elderly. caseload as at aug. totalled , . victims of natural disasters, crimes of violence and traffic accidents are financially assisted. estimated recurrent government expenditure on social welfare for - was hk$ · bn. sub-tropical tending towards temperate, with an average temperature of · °c. the number of rainy days is around a third of the year. average annual rainfall varies from - " ( , - , mm) . it is very humid from may to sept. macao's constitution is the 'basic law', promulgated by china's national people's congress on march and in effect since dec. . it is a special administrative region (sar) of the people's republic of china, and is directly under the central people's government while enjoying a high degree of autonomy. the legislative assembly has seats of which are directly elected, indirectly elected by functional constituencies and seven appointed by the chief executive. at the elections held on sept. the macau-guangdong union won two of elected seats with · % of votes cast and the union for development two with · %. ten other parties won a single seat each. turnout was · %. fernando chui sai-on was re-elected chief executive for a second term on aug. , receiving out of votes in the election committee. the economy grew by an average · % per year from - , driven mainly by the gaming sector and the ongoing construction of a number of casino resorts. however, it went into recession from following china's crackdown on government corruption. macao's traditional manufacturing industries virtually disappeared following the transfer of much of the textile industry to the chinese mainland and, in , the termination of the multifibre arrangement, which had governed international textile trade flows for three decades. the unit of currency is the pataca (mop) of avos, which is tied to the hong kong dollar at parity. inflation was · % in and · % in . foreign exchange reserves were us$ , m. in . total money supply was , m. patacas in . in revenues totalled , m. patacas; expenditures, , m. patacas. revenues from gaming tax accounted for · % of total revenue in ; current expenditure accounted for · % of expenditure. real gdp growth was just · % in but then rose to · % in and · % in . more recently the economy contracted by · % in and then by · % in -the lowest rate for any advanced economy that year-owing to a decline in tourism and gaming revenues. total gdp in was us$ · bn. there are two note-issuing banks in macao-the macao branch of the bank of china and the macao branch of the banco nacional ultramarino. the monetary authority of macao functions as a central bank (chairman, teng lin seng). commercial business is handled ( ) by banks, nine of which are local and foreign. total deposits, (including non-resident deposits), , · m. patacas. there are no foreign exchange controls within macao. macao's carbon dioxide emissions from the consumption of energy in were the equivalent of · tonnes per capita. installed capacity was · m. kw in ; production, · bn. kwh. macao imported , m. kwh of electricity in . oil and gas , , litres of fuel oil were imported in . the catch in was estimated at , tonnes. although the economy is based on gaming and tourism there is a light industrial base of textiles and garments. in the number of manufacturing establishments was (food products and beverages, ; textiles and wearing apparel, ; publishing, printing and reproduction of recorded media, ). in a total of , people were in employment, including , ( · %) in gaming and junket activities (up from , in ); , ( · %), hotels, restaurants and similar activities; , ( · %), construction; , ( · %), wholesale and retail trade, repair of motor vehicles, motorcycles and personal and household goods; , ( · %), real estate and business activities; , ( · %), public administration and social security. employment in was · % of the labour force; unemployment rate stood at · %. in imports (c.i.f.) were valued at us$ , · m., of which the main products were telecommunications, sound recording and reproducing equipment; petroleum and petroleum products; and gold, silverware, jewellery and articles of precious materials. in the chief import sources (in us$ m.) were: mainland china ( , · ); hong kong ( · ); japan ( · ). exports (f.o.b.) were valued at us$ · m., of which the leading products were articles of apparel and clothing accessories; gold, silverware, jewellery and articles of precious materials; and petroleum oils and oils obtained from bituminous minerals. in the main export markets (in us$ m.) were: hong kong ( · ); usa ( · ); mainland china ( · ). in there were km of roads. in there were , landline telephone subscriptions (equivalent to · per , inhabitants) and , , mobile phone subscriptions (or , · per , inhabitants). in , · % of households had internet access. in march there were , facebook users. there are a judicial district court, a criminal court and an administrative court with magistrates in all. in there were , crimes, of which , were against property. there were persons in prison in dec. . there are both public and private schools. in - there were schools and colleges. number of students in the - academic year (with number of teachers): pre-primary, , ( ); primary, , ( , ); secondary, , ( , ). in - there were four special education schools with pupils and teachers. there were ten higher education institutions with student enrolment of , . in there were institutions offering vocational training courses, in which participants totalled , . expenditure on education came to · % of gdp in and · % of total government spending in . in there were doctors, dentists and nurses working in primary health care, and doctors, dentists and , nurses working in hospitals. in there were , hospital beds; there were · doctors per , population. in there were an estimated , folk religionists and , buddhists according to the pew research center's forum on religion & public life. a further , people were religiously unaffiliated. there are also small numbers of catholics. the historic centre of macao was inscribed on the unesco world heritage list in . in there were daily newspapers (nine in chinese, three in portuguese and two in english) and weekly newspapers (ten in chinese and one in portuguese). tourism is one of the mainstays of the economy. in there were · m. tourists (of which · m. were from mainland china, · m. from hong kong and · m. from taiwan), up from · m. in and · m. in . visitor spending in totalled , m. patacas. the government-run macao international music festival featuring a wide range of chinese and western music takes place in oct.-nov. in sept. chen shui-bian received a life sentence (later reduced to a -year term) after being found guilty of multiple counts of corruption. china and taiwan signed a free trade agreement in june , which was considered a significant thawing of relations. nonetheless, tensions remained, particularly in relation to disputed sovereignty over several islands in the east china sea. in jan. ma ying-jeou was re-elected to the presidency but the election in jan. was won by tsai ing-wen, whose democratic progressive party won the most seats in legislative polls at the same time-the first occasion that the nationalist party has not been the largest party in government since . beginning with the elections to the seventh legislative yuan held on jan. the legislative yuan has members (formerly ). of the members are elected under the first-past-thepost system in single-member constituencies, are filled by proportional representation in accordance with a nationwide party vote and six are reserved for aboriginal candidates. since the president has been directly elected. since a resolution on the impeachment of the president or vice president is no longer to be instituted by the control yuan but rather by the legislative yuan. the legislative yuan has the power to pass a no-confidence vote against the premier of the executive yuan, while the president of the republic has the power to dissolve the legislative yuan. the premier of the executive yuan is directly appointed by the president of the republic. in dec. a law came into effect allowing for referendums to be held. national anthem 'san min chu i' ('the three principles of the people'); words by dr sun yat-sen, tune by cheng mao-yun. conscription was reduced from months to months in . the government has announced its intention to move towards a volunteer professional force-a process that was originally scheduled to start in and end in but was delayed owing to low recruitment levels. in dec. the defence minister announced that conscription would officially cease in . defence expenditure in totalled us$ , m. (us$ per capita), representing · % of gdp. the republic of china army conducts ground combat missions as well as air support and airborne special operations. it was estimated to number about , personnel in , with reserves numbering · m. its principal role is to defend against a possible amphibious assault from the chinese mainland by the people's liberation army. in addition there are paramilitary forces totalling , personnel. navy personnel in totalled , , with , reservists. the forces consist of four submarines, four cruisers and frigates. there are also missile craft for patrol and coastal defence, mine-laying vehicles and amphibious landing craft. in the air force numbered , personnel with , reservists. there were combat-capable aircraft in the same year including f- es, f- s and mirage - s. by a treaty of dec. the usa pledged to defend taiwan, but this treaty lapsed one year after the usa established diplomatic relations with the people's republic of china on jan. . in april the taiwan relations act was passed by the us congress to maintain commercial, cultural and other relations between usa and taiwan through the american institute in taiwan and its taiwan counterpart, the co-ordination council for north american affairs in the usa, which were accorded quasi-diplomatic status in . the people's republic took over the china seat in the un from taiwan on oct. . in may taiwan ended its formal state of war with the people's republic. taiwan became a member of the world trade organization on jan. . in feb. taiwan had formal diplomatic ties with countries. in aug. , of the diplomatic allies sponsored an unsuccessful proposal for taiwan to join the un. taiwan has made a successful transition from an agricultural economy to one based on high-tech electronics. economic growth averaged % per year over three decades from the s, driven primarily by high value-added manufacturing and exports, especially in electronics and computers. government-owned enterprises, including banks, have been privatized. though largely escaping the impact of the asian financial crisis, the economy went into recession in with the first year of negative growth ever recorded and unemployment reaching record highs. strong export performance stimulated a recovery, with annual gdp growth above % from - . inflation has been consistently low and unemployment, which fell below % in , has averaged between and % since the turn of the century. owing to its heavy dependence on exports, taiwan suffered a severe downturn as a result of the global financial crisis in . major export industries such as semiconductors and memory chips declined, unemployment reached its highest levels since and, in , the economy again went into recession. a us$ · bn. stimulus package boosted recovery and in the economy recorded its highest growth rate for nearly three decades, at · %. however, growth subsequently cooled owing to lower demand from developed nations, averaging · % per year between and . tourism has grown in importance, with over · m. visitors in constituting taiwan's highest annual number to date. an ageing population and high savings rates threaten to constrain domestic demand in the future. the unit of currency is the new taiwan dollar (twd) of cents. gold reserves were · m. oz in dec. . there was inflation of · % in but deflation of · % in . foreign exchange reserves were us$ · bn. in dec. . in general government revenues totalled nt$ , , m. and expenditures nt$ , , m. tax revenue accounted for · % of revenues in ; education, science and culture accounted for · % of expenditures, economic development · % and general administration · %. taiwan sustained rapid economic growth at an annual rate of · % from up to . the rate slipped to · % in the s and · % in ; taiwan suffered from the asian financial crisis, though less than its neighbours. in global economic sluggishness and the events of sept. in the usa severely affected taiwan's economy, which contracted by · %. subsequent economic recovery led to growth of · % in and · % in . there was negative growth of · % in but again the economy bounced back, and grew by · % in , · % in and · % in . the central bank of the republic of china (taiwan), reactivated in , regulates the money supply, manages foreign exchange and issues currency. the governor is yang chin-long. the bank of taiwan is the largest commercial bank and the fiscal agent of the government. there are seven domestic banks, commercial banks and foreign banks. there are two stock exchanges in taipei. taiwan's carbon dioxide emissions from the consumption of energy in were the equivalent of · tonnes per capita. output of electricity in was · m. mwh; total installed capacity was , mw. there were six units in three nuclear power stations in . crude oil production in was , bbls; natural gas, m. cu. metres. taiwan imports most of the oil and natural gas that it consumes. in the cultivated area was , ha., of which , ha. were paddy fields. rice production totalled , , tonnes. livestock production was valued at nt$ , m., accounting for % of taiwan's total agricultural production value. forest area, : , , ha. forest reserves: trees, , , cu. metres; bamboo, , m. poles. timber production, , cu. metres. the catch in was , tonnes, almost exclusively from sea fishing. the first three are container centres, kaohsiung handling · m. -ft equivalent units in , making it the world's th busiest container port in terms of number of containers handled. suao port is an auxiliary port to keelung. in jan. the first legal direct shipping links between taiwanese islands and the chinese mainland in more than years were inaugurated. in there were , , landline telephone subscribers ( · per , inhabitants). taiwan's biggest telecommunications firm, the state-owned chunghwa telecom, lost its fixed-line monopoly in aug. . in there were , , mobile phone subscriptions, equivalent to , · per , persons. in there were · mobile broadband subscriptions per inhabitants and · fixed broadband subscriptions per inhabitants. in march there were · m. facebook users. the judicial yuan is the supreme judicial organ of state. comprising grand justices, since these have been nominated and, with the consent of the legislative yuan, appointed by the president of the republic. the grand justices hold meetings to interpret the constitution and unify the interpretation of laws and orders. there are three levels of judiciary: district courts and their branches deal with civil and criminal cases in the first instance; high courts and their branches deal with appeals against judgments of district courts; the supreme court reviews judgments by the lower courts. there is also the supreme administrative court, high administrative courts and a commission on the disciplinary sanctions of public functionaries. criminal cases relating to rebellion, treason and offences against friendly relations with foreign states are handled by high courts as the courts of first instance. the death penalty is still in force. there was one execution in but none in . the population in penal institutions in april was , ( per , of national population). since there has been compulsory education for six to year-olds with free tuition. the illiteracy rate dropped from · % in to · % by . there were , primary schools, , secondary schools and vocational schools in ; and universities, colleges and junior colleges. in - there were , , pupils with , teaching staff at elementary schools; , pupils and , teaching staff at junior high schools; , pupils and , teaching staff at senior high schools; and , students and , teaching staff at senior vocational schools. there were , , students in universities and colleges in - with , academic staff. in there were , physicians (one for every persons), , doctors of chinese medicine, , nurses, , dentists and assistants, and , pharmacists and assistants. in there were , medical facilities serving , persons per facility; there were , beds and · beds per , persons. in cancers, heart diseases, cerebrovascular diseases, diabetes and accidents were the first five leading causes of death. a universal health insurance scheme came into force in as an extension to social insurance plans that cover only % of taiwan's population. premium shares among the government, employer and insured are varied according to the insured statuses. by the end of , · m. people or % of the population were covered by the national health insurance programme. according to estimates by the pew research center's forum on religion & public life, · % of the population in were folk religionists, · % were buddhists and · % christians. the remainder of the population was either religiously unaffiliated or followed other religions, including taoism. there were daily newspapers in with a circulation of · m. and non-dailies with a circulation of · m. the biggest circulation dailies are the liberty times and apple daily. in there were , , international visitors. receipts totalled us$ , m. the pop festival, spring scream, is held in april in kenting. china in world history chinese politics in the age of deng xiaoping china and the global political economy china: the rise of xi jinping the cambridge encyclopaedia of china the cambridge history of china. vols the politics of hong kong's reversion to china the chinese economy under transition china this century the tragedy of liberation: a history of the chinese revolution china: a modern history china's deep reform: domestic politics in transition chinese capitalism deng xiaoping and the making of modern china the great chinese revolution - the politics of eu-china economic relations china's second continent: how a million migrants are building a new empire in africa china in transition: communism, capitalism and democracy sowing the seeds of democracy in china: political reform in the deng xiaoping era historical dictionary of the chinese cultural revolution the rise of modern china china: a macro history tombstone: the untold story of mao's great famine china's economy: what everyone needs to know all under heaven: a complete history of china chinese politics in the hu jintao era: new leaders, new challenges the people's republic of amnesia: tiananmen revisited chinese foreign policy in a changing world chinese economy in the s the politics of china: sixty years of the people's republic of china the party: the secret world of china's communist rulers. .-asia's reckoning: china, japan and the fate of us power in the pacific century china's war with japan, - : the struggle for survival social and political development in post-reform china age of ambition: chasing fortune, truth and faith in the new china a revolutionary life at the crossroads of post-communist modernisation: russia and china in comparative perspective a history of china wealth and power: china's long march to the twenty-first century mao's road to power: revolutionary writings - . vols china goes global: the partial power the chinese century: the rising chinese economy and its impact on the global economy, the balance of power, and your job the china-pakistan axis: asia's new geopolitics the chan's great continent: china in western minds eldest son, zhou enlai and the making of modern china india's and china's recent experience with reform and growth critical issues in contemporary china making china strong other more specialized titles are listed under territory and population; tibet; agriculture further reading statistical information: the census and statistics department is responsible for the preparation and collation of government statistics. these statistics are published mainly in the hong kong monthly digest of statistics. the department also publishes monthly trade statistics, economic indicators and an annual review of overseas trade hong kong's transitions the politics of hong kong's reversion to china the end of hong kong: the secret diplomacy of imperial retreat the hong kong story the final years of british hong kong: the discourse of colonial withdrawal last post: the end of empire in the far east the politics of democratization in hong kong historical dictionary of hong kong and macau china: a political history of the british crown colony's transfer to chinese rule managing china's sovereignty in hong kong and taiwan the democratic progressive party won seats ( constituency and proportional); the nationalist party, ( constituency and proportional); the new power party, ; the people first party, ; the non-partisan solidarity union, ; ind., . current government president: tsai ing-wen; b. (nationalist party/kuomintang foreign affairs; health and welfare; interior; justice; labour; national defence; science and technology national defence: yen de-fa. science and technology: chen liang-gee. transportation and communications: ho chen-tan tang feng; lo ping-cheng coast guard administration: lee chung-wei. environmental protection administration: lee ying-yuan. fair trade commission: huang mei-ying. financial supervisory commission: koo lihsiung. hakka affairs council: lee yung-te. council of indigenous peoples: icyang parod. mainland affairs council: chen ming-tong. national communications commission: chan ting-i. overseas community affairs council: wu hsin-hsing. directorate general of personnel administration: shih ning-jye. veterans' affairs council: lee shying-jow hon hai precision industry, an electronics manufacturer (us$ · bn.); and chunghwa telecom (us$ · bn metres; integrated circuit packages, · trn. units; global positioning system (gps) sets, · bn. units. labour in the average total labour force was · m., of whom · m. were employed. of the employed population, · % worked in manufacturing · % in construction; · % in accommodation and food services buses and coaches, · m. lorries and vans, and · m. motorcycles and mopeds were in use. , m. passengers and m. tonnes of freight were transported in . there were , fatalities in road accidents in . rail in freight traffic amounted to · m. tonnes and passenger traffic to m. total route length was , km. there are metro systems in taipei civil aviation there are currently two international airports: taiwan taoyuan international airport at taoyuan near taipei, and kaohsiung international in the south there were ships of gt or over registered, totalling · m. gt. of the vessels registered, were general cargo ships, bulk carriers, container ships, oil tankers and nine passenger ships. there are six international ports statistical yearbook of the republic of china. annual. the republic of china yearbook. annual. taiwan statistical data book. annual. annual review of government administration the other taiwan: to the present day historical dictionary of taiwan national identity and status in international society managing china's sovereignty in hong kong and taiwan the shadow of china: political developments in taiwan since national statistics website the climate is subtropical in the north and tropical in the south. the typhoon season extends from july to sept. the average monthly temperatures of jan. and july in taipei are · °f ( · °c) and · °f ( · °c) respectively, and average annual rainfall is · " ( , · mm). kaohsiung's average monthly temperatures of jan. and july are · °f ( · °c) and · °f ( · °c) respectively, and average annual rainfall is · " ( , · mm). the roc constitution is based on the principles of nationalism, democracy and social wellbeing formulated by dr sun yat-sen, the founding father of the republic of china. the roc government is divided into three main levels: central, provincial/ municipal and county/city, each of which has well-defined powers.the central government consists of the office of the president, the national assembly, which is specially elected only for constitutional amendment, and five governing branches called 'yuan', namely the executive yuan, the legislative yuan, the judicial yuan, the examination yuan and the control yuan. key: cord- -uheb cvg authors: prior, lindsay; evans, meirion r.; prout, hayley title: talking about colds and flu: the lay diagnosis of two common illnesses among older british people date: - - journal: soc sci med doi: . /j.socscimed. . . sha: doc_id: cord_uid: uheb cvg this paper reports on a study of the ways in which older people in south wales (uk) talk about the symptoms and causes of cold and influenza (flu). the study was designed to understand why older people might reject or accept the offer of seasonal flu vaccine, and in the course of the interviews respondents were also asked to express their views about the nature and causes of the two key illnesses. the latter are among the most common infections in human beings. in terms of the biomedical paradigm the common cold is caused by numerous respiratory viruses, whilst flu is caused by the influenza virus. medical diagnosis is usually made on clinical grounds without laboratory confirmation. symptoms of flu include sudden onset of fever and cough, and colds are characterized by sneezing, sore throat, and runny nose, but in practice the symptoms often overlap. in this study we examine the degree by which the views of lay people with respect to both diagnosis and epidemiology diverge with that which is evident in biomedical discourse. our results indicate that whilst most of the identified symptoms are common to lay and professional people, the former integrate symptoms into a markedly different observational frame from the latter. and as far as causation is concerned it is clear that lay people emphasize the role of ‘resistance’ and ‘immunity’ at least as much as ‘infection’ in accounting for the onset of colds and flu. the data are analyzed using novel methods that focus on the co-occurrence of concepts and are displayed as semantic networks. as well as reporting on its findings the authors draw out some implications of the study for social scientific and policy discussions concerning lay diagnosis, lay expertise and the concept of an expert patient. the lay diagnosis of colds and flu colds and flu, collectively referred to in biomedical terms as upper respiratory tract infections or urtis, are the most common infections in human beings. adults may have between two and five episodes of the cold in a year, and schoolchildren from five to seven episodes (eccles, ) . during the twentieth century biomedical understanding of urtis was primarily focused on the identification of the viral agents that are regarded by medical professionals as their main cause. influenza virus was first identified during the s, and during the s and s numerous viruses including rhinovirus, coronavirus and adenovirus were associated with the common cold (heikkinen & järvinen, ) . by the beginning of the current century over serologically different virus types had been implicated in the aetiology of the cold (mcchlery, ramage, & bagg, , p. ) . in parallel with the identification of viral agents, the public health effort from the latter part of the twentieth century was concentrated on delivering effective vaccines to reduce the prevalence of seasonal and pandemic flu variants e the most recent global attempt relating to the winter of e . however, despite the fact that urti's have been progressively taken into the laboratory and systematically 'jennerized' (c.f. latour, ) , the main site for their diagnosis is in the community or the world of everyday life. and in that world the understanding of respiratory infections is mediated through a web of concerns e about the origins and interconnection of symptoms, the maintenance of personal health and the distribution of illness among relatives, friends, and neighbours. this paper focuses on such concerns and in particular how colds and flu are spoken about and diagnosed by lay people in ordinary, everyday, non-clinical settings. the data are drawn from a qualitative interview based study (n ¼ ) of older people's understanding and acceptance of seasonal flu vaccine that was undertaken in south wales during the earlier part of the current decade. from the work of stimson and webb ( ) onward there has been an increasing recognition of the role played by lay people (as patients) in the diagnostic process (see, for example, beach, ; frankel, ; gill & maynard, ; gill, pomerantz, & denvir, ; heath, ; peräkylä, ) . however, the overwhelming majority of relevant studies look at doctorepatient activity in clinical settings e mostly using techniques of conversation analysis. interestingly, some of those who research into lay engagement with the diagnostic process argue that the word diagnosis should be reserved solely for categorizations of disease by doctors (e.g., gill et al., , p. ) . the research reported on here is somewhat different from the work just referred to in that it examines how lay people identify and categorize groups of symptoms in the 'lifeworld' (mishler, , p. ) , or the world 'grounded' in everyday life, rather than the world of the clinic or the consulting room. in the context of common respiratory symptoms, it is also worth noting that there has been a long tradition of looking at the ways in which lay people understand the symptomatology of urti's, and especially 'colds' (see, for example, ; baer, weller, garcia, ; baer, weller, pachter et al, ; helman, ; mccombie, ) . however, most of that work examines the range of symptoms lay people associate with cold e and to a lesser extent flu -and how they explain respiratory illness. such studies are not overly concerned with how lay people differentiate between or how they diagnose colds and flu e a topic that is the focus of this paper. the study of lay diagnoses of illness and infection is important for a number of reasons and not least because the manner in which ordinary people understand infection and its origins is directly relevant to the spread and control of disease in populations -the health of the public (mccombie, ) . it is also a topic directly relevant to discussions concerning the display of expertise by lay people in matters of health and illness more generally (fox, ward, & o'rourke, ; prior, ) . while in policy terms, the topic connects to a growing 'acknowledgment'e especially with regard to chronic conditions e of patient expertise in health care and the ways in which such expertise can be drawn upon in the delivery of services to the public at large (donaldson, ; lindsay & vrijhoef, ; rogers, bury, & kennedy, ; wilson, ) . in an age of threatened pandemics these discussions acquire an unusually clear resonance. the data in this paper are drawn from a qualitative study on the views of primary care staff and older people concerning the uptake of the seasonal flu vaccine in rural, urban, and semi-urban areas of south wales. the study was carried out during - and the main objectives were to understand why a large percentage of individuals in high risk groups failed to seek or accept vaccination and what could be done to improve immunization rates among older people. respondents were selected from a previous agestratified random postal survey of people in the area aged over who had reported on their immunization status. in light of those reports we chose to sample across a range of status groups. eighteen people who had refused immunization, who had previously accepted immunization but had since 'relapsed', people who claimed that they had never been offered immunization and people who had accepted the vaccine (including 'first timers') were eventually included in the study. the work was funded by nhs wales office of r&d, and ethical approval granted by the local (bro taf) research ethics committee. findings relating to the original objectives were published in evans, prout and prior ( ) . data were gathered using a semi-structured interview schedule that contained a list of key topics for discussion. as well as focusing on the reasons why people might accept or reject the offer of a flu vaccine, the interview schedule contained questions asking: 'what do you think are the symptoms of colds and flu'? 'what do you think is the difference between cold and flu? 'how do you think people catch flu?' qualitative interviews of this kind have previously been categorized as a genre of conversation (kvale, , p. ) in which respondents tend to reply to questions in a free-flowing style. in our case, for example, that style led the research participants to talk about the causes of upper respiratory tract infections in general and not merely the causes of flu. the current paper is based on an analysis of that talk, and in that context the exercise might be seen as constituting a secondary analysis of an existing data set. for the purposes of this paper the interview transcripts were initially analyzed using 'text-mining for clementine . ' (spss, ) . there are various advantages of using such automated text-mining techniques for data analysis. one offshoot is that the data set can be trawled for instances of co-occurrence between two concepts (such as flu jab and side-effects). the programme in use is capable of calculating a coefficient for all such co-occurring concepts and can display the results of such connections diagrammatically. following the exclusion of terms with fewer than citations, the programme identified some concepts (flu, flu jab, side-effects, colds, etc) in our data set. the coefficients of cooccurrence between these concepts naturally varied in strength. in some cases the strength of the links was unsurprising (e.g. the cooccurrence coefficient for the link between cold and flu was unity since the two terms occurred in all interviews); in other cases the link was considerably weaker (e.g. the link between 'virus' and flu was only . ). text-mining results provide a visible means of checking the veracity of interview analysis. for example, the number of instances a concept appears is given, as well as a visual representation as to how that term links to related concepts. using the text-mining results it is also possible to identify exactly which of the respondents associated the various concepts together and how they combined them. these data form the basis for the information displayed in figs. and . unfortunately, text-mining software uses the document (interview) as the basis for all its calculations and so it is not immediately clear whether the interviewer or the interviewee makes the connections between concepts. in our case we have restricted ourselves to looking at explicit links made only by the respondents, and for that reason we have extracted the textmining results and re-incorporated them into semantic networks using social network software (de nooy, mrvar, & batagelj, ) rather than the original text-mining software. our focus is of course more on the concept networks than on social networks, and the figures provide a graphic indication of the nature and strength of the co-occurrence relationships between the basic terms and concepts in the interviews. colds and flu: a view from the clinic "cold. a contagious viral infection of the upper respiratory tract usually caused by a strain of rhinovirus. it is characterized by rhinitis, tearing, low-grade fever and malaise and is treated symptomatically". "influenza; a highly contagious infection of the respiratory tract caused by the orthomyxovirus and transmitted by airborne droplet infection. symptoms include sore throat, cough, fever, muscular pains and weakness . onset is usually sudden, with chills, fever, respiratory symptoms, headache, myalgia and extreme fatigue." (mosby's dictionary of medicine, nursing, and health professions, ). the view from the laboratory would suggest that colds and flu are viral infections, and indeed over different virus types have been associated with the common cold. around e % of all colds are said to be caused by rhinoviruses, followed by coronaviruses ( e % of all colds), and influenza viruses ( e %) (heikkinen & järvinen, ; mcchlery et al., ). it is not surprising perhaps that in biomedical literature cold and flu are regarded as syndromes rather than as clear cut ontological categories, and the preferred contemporary biomedical designation is 'urti' or upper respiratory tract infection. as is also implied above, colds and flu are diagnosed clinically, though laboratory findings are regarded as necessary for the confirmation of any diagnosis. studies that compare the two forms of diagnosis highlight disjunction in a high proportion of cases (call, vollenweider, hornung et al, ) . the symptom pattern for colds and flu is far from agreed upon. sudden onset of fever and cough are regarded as good predictors of influenza being present, but in general there is a variable list of symptoms associated with the two syndromes in the medical literature. eccles ( ) for example, lists sore throat, sneezing, rhinorrhoea, nasal congestion, sinus pain, cough, headache, chilliness (for cold) and fever (for flu), anorexia, psychological effects and muscle aches and pains. during the recent ( ) pandemic alert the uk department of health information (http://www.direct.gov.uk/ swineflu) stated that, "the symptoms of swine flu are a fever or a high temperature ( c) and two of the following symptoms: unusual tiredness, headache, runny nose, sore throat, shortness of breath or cough, loss of appetite, aching muscles, diarrhoea or vomiting. the same symptoms were listed by the cdc in the usa (http:// www.cdc.gov/flu/about/disease/symptoms.htm) with an added remark that diarrhoea or vomiting were more likely in children than in adults. eccles ( ) makes no mention of either diarrhoea or vomiting, and nor do call, vollenweider, hornung et al, ( ) . diagnosis of flu, in particular, is not therefore a straightforward or clear-cut business. clinicians, if necessary, can combine reported symptoms, information derived from clinical examination, together with laboratory and radiograph evidence, and data about current circulating strains from flu disease surveillance systems so as to arrive at a firm diagnosis. lay people generally have access to only the first of these. as stated in our introduction, lay talk about colds and flu is set within a mesh of concerns e about causes, symptoms and consequences. such talk comprises the base elements of what has at times been referred to as the 'explanatory model' of an illness (kleinman, eisenberg, & good, ) . in this section we will focus almost entirely on the identification of symptoms and views concerning the causes of colds and flu. we do so by relating such views to a wider rhetoric of complaint in which the understanding of colds and flu is embedded. the diagnosis of colds and flu in the lay population concentrates, as one would expect, on the symptom pattern. in that respect the procedure differs little from that of clinicians. for diagnostic purposes, of course, clinicians have ultimate recourse to a laboratory identification of a causative agent e though that is rarely used in routine consultations. lay people have no recourse to such data and one might guess that even if they did they would interpret findings in a distinctly colloquial manner. indeed, from our data set it is clear that lay people understand symptoms in a markedly different frame from that of medical professionals. in particular they report not only on symptoms relating to the body (especially the head), but also on behavioural correlates e and to a lesser extent on some psychological factors. in addition, lay people mention symptoms that are not ordinarily associated with flu in the medical literature, and they also connect the body itself to colds and flu in ways that can run counter to a prevailing western medical cosmology that seeks to connect pathology to specific anatomical sites. fig. shows in diagrammatic form the key symptoms that lay people associate with colds and flu respectively. the thickness of the lines between the concept nodes express the value of a coefficient of co-occurrence between a reference to any given symptom (in interviews), and any other symptom mentioned. the diagram also displays links between the symptoms and the two key entities of 'cold' and 'flu'. the calculation of the coefficient is based on that used in text-mining software (spss: , p. ) , except that here the links are confined to those that are explicitly made by the respondent between the various concepts in the course of the interview (rather than the words merely appearing anywhere in the document). the size of a node is proportional to the total number of references to each concept in the transcripts. looking at fig. , we can see that there are a range of entities deployed for the purpose of diagnosis. these include parts of the body affected (nose, throat, eyes); physiological processes (coughing, eating, sneezing, vomiting, and fever); behavioral processes (being bedridden); and to a lesser extent psychological processes (feeling down). note that most (but not all) of the symptoms are common to both conditions. lay people naturally weave these entities into their accounts in idiosyncratic ways, but this diagram contains all of the elements that our respondents required to distinguish between a cold and the flu e in short, all that is required to make a differential diagnosis. essentially, the diagnosis of a cold focuses on symptoms in the head and colds are associated almost entirely with the head (headache, however, is viewed primarily as a symptom of flu e as is evident from the detail in fig. ). so when respondents were asked to distinguish between colds and flu they would say such things as: 'well i think colds is (sic) just in the head and runny nose and stuffy nose.' (respondent (r): ), or refer simply to "a head cold" (r: ). unsurprisingly, and as is also evident in fig. , the nose (and sneezing) is particularly prominent in the symptom pattern for cold, though associated sites such as the sinus, the throat and the eyes also figure in the diagnostic frame. this is in marked contrast to flu which is invariably viewed as a whole body illness e characterized by whole 'bodyache' (fig. ) . interestingly, a number of respondents also referred (usually in a dismissive manner) to a third category of illness 'the sniffles' e which seemed to relate to very mild forms of rhinorrhea and associated nasal symptoms. the following data extracts illustrate some of the key ways in which lay people differentiate colds from flu. (r: ) "well, flu, you get all your aches and pains. you feel lethargic, that type of thing, but with a cold, it's usually a head cold and plenty of coughs, sneezes and such like that you don't always get with the flu. i feel the flu is more in the whole of the body." (r: ) "always the question is, i mean my daughters about but i said, um, is your body aching all over? yes, or no? 'yes'. you've got flu then. if it's not, you've got a heavy cold and that's it." (r: ) "well, i think with flu you're aching all over aren't you, you go, you get hot and then you get cold and you're aching all over whereas if it's a cold you're sneezing. you have a sort of a heady cold. i think it's a big difference isn't there?" (r: ) "well. well the influenza usually affects your stomach. it usually affects aching all over the body. and, you usually have a higher temperature. you feel a lot worse with flu, obviously". as is suggested by r above, flu is strongly associated with fever. in addition, it is predominantly associated with myalgia, and exclusively related to being bedridden or to an inability to undertake routine and normal duties. it is sometimes associated with vomiting and co-related stomach pain (r: ). above all, to have flu is to be 'really ill' (r: ); flu is 'more of an illness than a cough or a cold', (r: ). and, 'when you've got the flu, you're really ill. when you've got a cold you can manage you know' (r: ). indeed, it is possible to 'shake off a cold' (r: ), but not the flu; flu 'knocks you for six' (r: ). "well, a cold you can really master" (r: ), but the flu, 'puts you right off your feet' (r: ). it is often the severity of the discomfort that enables a person to diagnose the one from the other. so, 'flu is woof, bang wallop, out, you're gone' (r: ). in short the flu necessitates withdrawal from normal and routine social intercourse. respondents also made clear that, on occasion, colds can develop into flu e which is why the behavioural features can be so crucial in diagnosing one from the other. and perhaps it is this unique capacity of flu to remove an individual from everyday affairs that warrants the invariable use of the definite article in discussions of the one (the flu) -as compared to the more probable use of the indefinite article (a cold) in discussions concerning the other. in any event, the possibility of a cold metamorphosing into flu serves to highlight the dynamic, 'wait-and-see' and emergent aspects of lay diagnosis with respects to both urti's and l(ower)rti's such as pneumonia. in sum, then, flu is not 'just in the head', but rather affects the entire human frame. as such, and as well as having corporeal symptoms e in the head, stomach, or muscles -flu affects one's routine activities and especially the capacity to function in daily affairs. flu in that sense is more 'serious'. we return to examine some of the implications of the analysis in the discussion section of the paper. for now we turn to an exploration of causation. fig. is based on the talk that our respondents made in response to the question, "how do you think people catch flu?" as we have already stated, semi-structured interviews of the kind used for this study are often characterized as akin to 'a conversation with a purpose' (kahn & cannell, , p. ); as such they are designed to generate data rather than just to collect data. in our case and even though our focus was on the causes of flu, our respondents spoke extensively about the causes of both cold and flu and even of pneumonia (see extracts below). their responses led to the identification of a wide range of factors associated with the onset of the two key conditions; we can see virtually all of these referenced in fig. . therein are mentioned items such as 'bugs' (and 'germs') as well as viruses; but the most commonly referred to causes invoked 'the air' and 'atmosphere'. the interview data also pointed toward means of transmission as 'cause' e so coughs and sneezes and mixing in crowds figure in the causal mix. most interesting perhaps is that lay people make a nascent distinction between facilitating factors (such as bugs and viruses) and inhibiting factors (such as being resistant, immune, or healthy), so that in the presence of the latter, the former are seen to have very little effect. in general, it is not easy to unravel the web of talk about causation that occurs in the interview data. causal agents, inhibiting agents and means of transmission are very often conflated by the respondents e as will be evident in the quotes that follow. in addition, a large proportion of our respondents pointed to the 'flu jab' as a cause of flu. we have not included inoculation as a causal agent in fig. because it was rejection (or acceptance) of a flu jab that formed the focal point of the interviews -and therefore given undue attention. (r: ) "how do you catch it [the flu]? well, i take it its through ingesting and inhaling bugs from the atmosphere. not from sort of contact or touching things. sort of airborne bugs. is that right?" indeed 'the air' (and atmosphere) in particular were spoken of both as a cause of infection in its own right and as the key means of transmission between one person and another. thus; (r: ) "i suppose it's [the cause of flu] in the air. i think i get more diseases going to the surgery than if i stayed home. sometimes the waiting room is packed and you've got little kids coughing and spluttering and people sneezing, and air conditioning i think is a killer by and large i think air conditioning in lots of these offices. i know in the last years of when i was working, we had air conditioning in offices and i had more coughs and colds more during that period than i ever had". (r: ) "i think you catch flu from other people. you know in enclosed environments in air conditioning which in my opinion is the biggest cause of transferring diseases is air conditioning. worse thing that was ever invented that was. i think so, you know. it happens on aircraft exactly the same you know." while, the following respondent connects the air to flu's 'own little germs': (r: ) "i think it's [the flu] in the air with people who've got it. i don't really know. i know the old saying goes, coughs and sneezes spread diseases, but whether it's the flu or not or whether that's just colds or coughs. i don't think you catch it off someone else, i think you do it all by yourself. quite clever. i don't really know. i think it probably does come with the environment if you're working in an office and everybody's snuffly and .i think possibly flu can be more dangerous than people think. it's not just a cold plus. it has it's own little germs". as previously stated, being, cold, wet, or damp can also be viewed as a direct cause of flu. interviewer: "ok, good. how do you think you catch the flu?" r: "ah. the dollar question. well, i would catch it if i was out in the rain and i got soaked through. then i would get the flu. i mean my neighbour up here was soaked through and he got pneumonia and he died. he was younger than me: well, . and he stayed in his wet clothes and that's fatal. got pneumonia and died, but like i said, if i get wet, especially if i get my head wet, then i can get a nasty head cold and it could develop into flu later." despite the presence of bugs and germs, viruses, the air and wetness or dampness, 'catching' the flu is not a matter of simple exposure to causative agents. for within each person there is a measure of immunity or resistance or healthiness that comes into play and is capable of counteracting the effects of external agents. for example being 'hardened' (r: ) to germs and harsh weather can prevent a person getting colds and flu. being 'healthy' (r: ) can itself negate the effects of any causative agents, and healthiness is often linked to aspects of 'good' nutrition and diet (r: , r: ), and not smoking cigarettes. these mitigating and inhibiting factors can either mollify the effects of infection or prevent a person 'catching' the flu entirely. thus, (r: ) argued that it was almost impossible for him to catch flu or cold "cos i got all this resistance".interestingly respondents often used possessive pronouns in their discussion of immunity and resistance ('my immunity', and 'my resistance') e and tended to view them as personal assets (or capital) that might be compromised by mixing with crowds (see r: below). (r: ) "because i'm fairly healthy. as a matter of fact, i nearly said to you now, no, i don't want [the flu jab] now because i had shingles two years ago and i think i'm protected against the plague even. i have the full range of antibodies having recovered from shingles." (r: ) "because you and i can do exactly the same thing and be in exactly the same place, and you can have flu and i won't. your immune system you know plays a tremendous part in all this isn't it, so i think you know, if you're immune to it then you'll sail through it". equally, having a weak immune system (r: ) can sharpen the risk of contracting cold and flu and might therefore spur one on to take preventive measures such as accepting a flu jab. there are some, of course, who believe that it is the flu 'jab' that can cause the flu and other illnesses. the three extracts below illustrate the general idea, and we cite them not so much for what might be called their lay 'epidemiology' (davison, davey-smith & frankel; ) , but to illustrate the operation of what might be called a lay surveillance system -a system that is more often than not based on information derived from intimate knowledge of 'small worlds'. (r: ) "well, now it's coincidental you know that [my brother] died after the jab, but another friend of mine, about years ago, the same happened to her. she had the jab and about six months later, she died, so i know they're both coincidental, but to me there's a pattern". (r: ) "i told him. i was awful poorly last week. i had that bloody flu injection. and next to me in the butchers. was a husband and wife, my age group, near enough. and she said oh, we're not having it any more either. yes, she said, we had a terrible time last year . there's a lot of people complaining". (r: ) "i'm nearly . i've had flu four times in my life. and i think i've developed a sort of immunity. and i don't want to spoil that immunity. and that is why i don't have an injection. int: right. so you think that because you've had flu four times, you probably won't have it again? r: well, it's a good record, isn't it and i'll be in july. plus, i've got two other reasons why. i know somebody that's had gbs from it. int: gbs? (r: ) guillain-barré syndrome. you're paralyzed. he was paralyzed from there down. int: really! (r: ) yes, and i've got a friend, up grange road, here, who has flu every days for years because of a flu jab. yes. she has flu symptoms every days. she's one, the doctors have told her. she's one in i don't know how many million. so that's another reason." what we can see in fig. , then, is not so much an 'explanatory model' for either cold of flu, but the ingredients out of which a variety of explanations can be built. naturally, specific individuals weave these common elements into their own web of causation in distinctive ways. thus r: (above), for example, wove 'resistance'; 'immunity' and good health as well as the flu jab into his explanatory model; while r: placed emphasis on viruses, coughs and sneezes and 'resistance' in addition to the inoculation. indeed, people who refused inoculation proved highly likely to assert that the 'flu jab' caused the flu (which is partly why they avoided it). in the following section we highlight and discuss some of the implications of these observations. lay or 'folk' understandings of cold and flu have constituted the topic of investigation for a number of studies e especially crosscultural studies. however, the attention of such studies has normally been on the symptomatology of either cold or flu, rather than on the ways in which lay people differentially diagnose cold from flu (e.g. baer, weller, pachter et al, ; baer, weller, de alba garcia, & salcedo rocha, ) . in health service research literature also, there are numerous symptom surveys that concentrate on the reporting of symptoms for 'the cold' in particular (e.g. barrett, brown, mundt et al, ) . again, none of the latter looks explicitly at the process of lay diagnosis, or the ways in which lay people integrate observations of individual symptoms of cold into diagnostic procedures. in this paper, however, we have intentionally focused on describing the ways in which older lay people e as nonmedical professionals -assign clusters of symptoms to one of the two common disease categories (the views of younger people and of parents of young children may be different). it is relatively clear that while lay and professional knowledge of colds and flu intersect at various points, they diverge significantly when assessed as a whole. for even where there is apparent agreement on symptoms e and most of the symptoms mentioned by our sample also appear in the biomedical literature -it is evident that lay people assess such symptoms in a different frame from that used by clinicians. we know from cross-cultural studies that the symptoms for cold appear to be similar in many different linguistic and social cultures (baer, weller, pachter et al, ) and most, if not all, social groups seem to draw a distinction between cold and flu as separate illnesses. however, there are important differences to note. for example, members of the sample reported on here associated 'fever' with cold as well as with flu, and a number of people associated vomiting with flu (though not with cold). other populations e such as latin american populations -do not seemingly associate gastric symptoms with respiratory disease. more importantly, perhaps, it seems that the ways in which members of our sample integrated the symptom pattern into an understanding of cold and flu is quite different from that which appears in professional medical discourse. in particular, lay people place a heavy emphasis on behavioural correlates as distinguishing features of flu e being bedridden and therefore unable to function normally is exclusively associated with flu and constitutes a defining feature of flu. there is no consistent reference to causative agents here as a means of demarcating cold from flu. furthermore it is clear that flu is interpreted as a whole body illness characterized by an aching body (rather than just aching muscles) while colds are mainly confined to the head e head cold. it is not merely that in cases of flu people suffer with aching muscles (and of course they do), but that they, as homo totus, are ill. in medical anthropology the concept of a whole body illness is far from unknown. however, such illnesses are usually spoken of in the context of culture-bound syndromes and disorders with psychiatric symptoms. they are also reported on almost exclusively in studies of people living in countries outside of the advanced industrial world -see, for example, oths ( ) study of 'debilidad'. yet from the talk of informants in our study it seems plausible to suggest that, among this group of older white english speaking people at least, 'the flu' is essentially regarded as a whole body illness in which psychological symptoms (feeling low or down) play a very minor role (none of the respondents associated feeling low or feeling down with colds). in the discussion section of their paper, baer, weller, pachter et al, argued that in english speaking populations in the usa there was common reference to a 'folk flu' that differed in its symptomatology from the biomedical version; the key difference being an emphasis in folk flu on gastrointestinal symptoms, especially vomiting. the concept of 'folk flu' was a particular focus for mccombie ( ) , who placed a heavy emphasis on references to vomiting and diarrhea as symptoms of folk flu, and argued that such beliefs hampered the investigation of outbreaks of food-borne diseases. it is clear from our data that an association between flu and vomiting exists among some of our informants. in addition we have noted that it appears as a symptom of 'swine flu' in both uk and us health information sites. our respondents pointed to a wide range of causative agents e especially in their discussions concerning flu, but also in their talk about colds. extraneous causes of the flu can involve viruses, bugs and germs; the environment in general and 'stuffy' air in particular; being wet and wearing damp clothes; the flu jab; and coughs and sneezes of other people. however, any systematic understanding of the role of these factors has to take into account a series of countervailing factors such as a person's robustness, immunity, resilience and healthiness (attributes that, in turn, are often related to a regime involving 'good' nutrition and diet). colds and flu are 'caught', and the predominant notion of causation is one involving an infectious agent -usually referred to as a 'bug' or a 'germ', a 'virus' or merely 'it' -transmitted via coughs and sneezes through the air and 'atmosphere'. it's, "a germ that's floating around in the air" (r. ); it's 'airborne' (r. ); "you breath it in" (r. ), it's "a spray" (r. ); "germs in the atmosphere, that go through people" (r. ). there is no apparent recognition of transmission of infection via contact with infected surfaces (see, for example, the extract from r: in the previous section) e consequently hand washing does not figure at all in the armoury of preventive measures. more significantly, for a large proportion of people, 'bugs' and germs are believed to be capable of producing little more than the 'sniffles' in the presence of individual (bodily) 'resistance' or 'immunity'; a resistance that can be built up over a lifetime e rather like financial capital -through conscious self-care and a 'good' diet. there is, of course a parallel and alternative theory of causation that emphasizes factors such as getting wet, keeping warm and staying dry. in this frame, wearing damp clothes, getting wet feet, or simply getting chilled or cold, can in itself cause flu (and lead into pneumonia). thus, people catch flu by "getting wet, damp and neglecting themselves" (r: ); wearing "light clothes" (r: ); "staying damp too long" (r: ), while " a wind chill can kill as good as anything" (r: ). these notions of catching cold and flu' from getting wet have been observed in uk populations previously (helman, ) . baer, weller, & de alba garcia ( ) , noted their existence across all their lay (and some of their spanish speaking professional) populations, and refer to it as the hot-cold classification system. helman ( ) examined it in the frame of a 'hotcold', 'wet-dry' matrix. interestingly, according to our informants, the potential for the hot-cold causation mechanism to bring about illness is often neutralized by a healthy constitution and is readily over-powered by the natural resilience of immune and resistant individuals. finally it is useful to note that lay people as well as professionals can call upon a nascent surveillance system. in the case of the former group it is a surveillance system reliant on anecdotal evidence and anchored in knowledge of small worlds e worlds composed of near neighbours, friends and close relatives. one implication of living in small worlds is that one (or two) reports of an adverse reaction to medication or vaccination can carry enormous weight in deciding, for example, whether to accept or reject the offer of immunization. the status of 'layperson' or 'expert' is dynamic and situated a one. to be an expert is to be positioned as an expert e via, say, an expert patient programme (eep) for chronic disorders, or by virtue of holding professional 'license'. according to rogers et al. ( ) , the expert patient is one who can, among many other things, recognise, monitor and respond to symptoms in terms of an effective programme of self-management, and they note how the eep as described in uk policy documents extends to encompass ' e per cent of patients'. in that context it is clear that our informants are expert e especially in the management of colds and flu. yet the ways in which the lay people in our study integrate their recognition and monitoring into an explanatory model suggests a different kind of comprehension from that contained in professional text-book discussions of such infections. in the case of flu, as we have seen, there is more emphasis on it as a whole body illness than there would be in professional discourse, and there is much more emphasis on 'the air' and the 'atmosphere' as a causative factor than one might find in professional epidemiological discussions of the flu. in this paper, we have explored such points of emphasis and pointed to such contrasts using relatively novel methods of data analysis and display. most interesting perhaps is the fact that lay people seem to assess information about disease and illness in the context of small worlds of family, friends and neighbours. we have pointed to that context by reference only to lay discussions concerning inoculation, wherein it certainly seems to be the case that, using popperian logic, a sighting of one sick but vaccinated 'swan' can be sufficient to reject the hypothesis that all vaccinated swans are healthy (c.f. popper, , p. ) e or that all vaccines are benign for all people. such reliance on small 'n' and anecdotal evidence about associations between specific causes and particular effects is apparent in relation to the public understanding of many medical debates (moore & stilgoe, ). in some circumstances it can prompt new lines of research and investigation about the causes of illness (brown, ) . under other circumstances it can hamper efforts to eradicate disease or establish 'herd' immunity (petts & niemeyer, ) . how lay knowledge is acquired, structured and deployed is seemingly central to public health efforts whichever direction we approach it from. one of our aims has been to demonstrate how a study of lay diagnosis and lay epidemiology can play a part in such a project. cross cultural perspectives on the common cold. data from five populations crosscultural perspectives on physician and lay models of the common cold popular epidemiology: community responses to toxic wasteinduced disease does this patient have influenza? lay epidemiology and the prevention paradox exploratory social network analysis with pajek expert patients usher in a new era of opportunity for the nhs understanding the symptoms of the common cold and influenza a qualitative study of lay beliefs about influenza immunisation in older people the 'expert patient': empowerment or medical dominance? the case of weight loss, pharmaceutical drugs and the internet clinical care and conversational contingencies. the role of patients' self-diagnosis in medical encounters explaining illness: patients' proposals and physicians' responses pre-emptive resistance: patients' participation in diagnostic sense making activities. sociology of health and illness the delivery and reception of diagnosis in the general practice consultation feed a cold, starve a fever' e folk models of infection in an english suburban community, and their relation to medical treatment the dynamics of interviewing. theory, technique and cases interviews. an introduction to qualitative research interviewing culture, illness & care, clinical lessons from anthropologic and cross-cultural research the pasteurization of france introduction. a sociological focus on 'expert patients respiratory tract infections and pneumonia folk flu and viral syndrome. an epidemiological perspective the discourse of medicine. dialectics of medical interviews experts and anecdotes. the role of 'anecdotal evidence' in public scientific controversies. science, technology and human values mosby's dictionary of medicine, nursing, and health professions. london. (online version accessed debilidad: a biocultural assessment of an embodied andean illness health risk communication and amplification: learning from the mmr vaccination controversy communicating and responding to diagnosis belief, knowledge, and expertise: the emergence of the lay expert in medical sociology rationality, rhetoric and religiosity in health care: the case of england's expert patient programme going to see the doctor e the consultation process in general practice text mining for clementine. . . user's guide. chicago: ill: spss acknowledging the expertise of patients and their organizations the empirical work on which this paper was based was funded by the wales office of research and development; grant r / / . the analysis of the data was facilitated by the resources of the northern ireland centre of excellence in public health at qub. the authors wish to record their appreciation for the funding and the support. key: cord- -yjn sja authors: o'connor, daryl b.; aggleton, john p.; chakrabarti, bhismadev; cooper, cary l.; creswell, cathy; dunsmuir, sandra; fiske, susan t.; gathercole, susan; gough, brendan; ireland, jane l.; jones, marc v.; jowett, adam; kagan, carolyn; karanika‐murray, maria; kaye, linda k.; kumari, veena; lewandowsky, stephan; lightman, stafford; malpass, debra; meins, elizabeth; morgan, b. paul; morrison coulthard, lisa j.; reicher, stephen d.; schacter, daniel l.; sherman, susan m.; simms, victoria; williams, antony; wykes, til; armitage, christopher j. title: research priorities for the covid‐ pandemic and beyond: a call to action for psychological science date: - - journal: br j psychol doi: . /bjop. sha: doc_id: cord_uid: yjn sja the severe acute respiratory syndrome coronavirus‐ (sars‐cov‐ ) that has caused the coronavirus disease (covid‐ ) pandemic represents the greatest international biopsychosocial emergency the world has faced for a century, and psychological science has an integral role to offer in helping societies recover. the aim of this paper is to set out the shorter‐ and longer‐term priorities for research in psychological science that will (a) frame the breadth and scope of potential contributions from across the discipline; (b) enable researchers to focus their resources on gaps in knowledge; and (c) help funders and policymakers make informed decisions about future research priorities in order to best meet the needs of societies as they emerge from the acute phase of the pandemic. the research priorities were informed by an expert panel convened by the british psychological society that reflects the breadth of the discipline; a wider advisory panel with international input; and a survey of psychological scientists conducted early in may . the most pressing need is to research the negative biopsychosocial impacts of the covid‐ pandemic to facilitate immediate and longer‐term recovery, not only in relation to mental health, but also in relation to behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we call on psychological scientists to work collaboratively with other scientists and stakeholders, establish consortia, and develop innovative research methods while maintaining high‐quality, open, and rigorous research standards. the global impact of the coronavirus disease (covid- ) is unprecedented. by the june , in excess of million cases of covid- worldwide had been confirmed and covid- -related deaths were close to half a million. however, its impact should not only be measured in terms of biological outcomes, but also in terms of its economic, health, psychological, and social consequences. the covid- pandemic is unique with respect to the ongoing risks associated with the large numbers of infected people who remain asymptomatic, the impacts of the countermeasures on societies, the likelihood of second or third waves, and the attention it has received due to its global reach (particularly in high-income countries). the effects of the covid- pandemic will likely shape human behaviour in perpetuity. psychological science is uniquely placed to help mitigate the many shorter-and longer-term consequences of the pandemic and to help with recovery and adjustment to daily life. the immediate research response to covid- was rightly to focus resources on the transmission of covid- , identify biologics with which to treat those infected with the virus, and develop vaccines to protect populations. however, biomedical science can only go so far in mitigating the severe negative health, economic, psychological, and social impacts of covid- . the future availability of a vaccine currently remains uncertain; therefore, the primary weapons to mitigate the pandemic are behavioural, such as encouraging people to observe government instructions, self-isolation, quarantining, and physical distancing. even if a vaccine becomes available, we will still require changes in behaviour to ensure its effective delivery and universal uptake, so we need to prioritize research that will make the greatest contributions to our understanding of the effects of, and recovery from, the pandemic. the important contributions made by psychological scientists to understanding the impact of previous pandemics, including the ebola disease outbreak, severe acute respiratory syndrome (sars), and the middle east respiratory syndrome (mers), are welldocumented and mean we knew already a lot about public messaging and stress among frontline workers when the covid- outbreak began (e.g., brooks et al., , holmes et al., rubin, potts, & michie, ; tam, pang, lam, & chiu, ; thompson, garfin, holman, & silver, ; wu et al., ) . however, the unique features of covid- , including its virulence, the large proportions of people who remain asymptomatic but may still spread the virus (centre for evidence-based medicine, ), the stringent lockdown procedures imposed at pace on whole societies, and its global reach mean there is an urgent and ongoing need for social science research (world health organisation, ) . the collective and individual responses to severe acute respiratory syndrome coronavirus- (sars-cov- ) and to the introduction of measures to counter it have fundamentally changed how societies function, affecting how we work, educate, parent, socialize, shop, communicate, and travel. it has led to bereavements at scale, as well as frontline workers being exposed to alarming levels of stress (e.g., british medical association, ; greenberg, docherty, gnanapragasam, & wessely, ) . there have additionally been nationwide 'lockdowns' comprising physical distancing, quarantines, and isolation with the associated effects on loneliness, forced remote working, and homeschooling (e.g., hoffart, johnson, & ebrahimi, ; holmes et al., ; lee, ) . however, as well as having adverse psychological effects, the measures introduced to fight the pandemic may have led to positive social and behavioural changes. most obvious are the remarkable levels of compassion and support that have developed among neighbours and within communities as well as positive changes in behaviours such as hand hygiene, homeschooling, and physical activity. therefore, in addition to mitigating the negative effects of the pandemic, it is important to understand how any positive effects can be maintained as restrictions ease. there are, and will undoubtedly continue to be, inequalities in the effects of the pandemic and its aftermath; recognizing these vulnerability and resilience factors will be key to understanding how the current situation can inform and prepare us for dealing with future crises. of course, while we, as psychological scientists, are interested in the general effects of the pandemic, we are acutely aware of the fact that these effects disproportionately impact on different groups (box ). the issue of inequality is of central importance and runs through the research priorities that we describe below and it is a picture is emerging of covid- not as a single pandemic, but multiple parallel pandemics with some people facing numerous severe challenges and others experiencing few or none (williamson et al., ) . for those most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. a clear priority for psychological scientists is to understand how best to help those in need and to consider the following factors in their research efforts. in western europe and the united states, the death rate among people with black, asian, and minority ethnic backgrounds is substantially higher than that of the general population. it is not known what is causing the disproportionate impact nor how it can be mitigated. psychological science is in a good position to explore the biopsychosocial antecedents and consequences of having a black, asian, or minority ethnic background in the context of covid- . individuals living in poverty face disproportionate challenges in relation to education, work, income, housing, and physical and mental health. for these most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. moreover, an impending financial crisis means that people who have never before experienced hardships may suddenly find themselves in precarious circumstances. a quarter of people in the uk experience mental health problems every year, with particularly high levels in young people (mental health foundation, ) . the changed social conditions of the pandemic may increase the severity of mental health challenges, particularly when standard (face-toface) treatment and support are difficult to access. at the same time, pregnant women and those with existing long-term conditions such as transplant patients, cancer patients, and chronic obstructive pulmonary disease patients have been designated 'extremely vulnerable' and asked to self-isolate for long periods of time with uncertainties over access to support. those individuals who have recovered from covid- might also have new biological vulnerabilities, uncertainty over immunity post-covid- , and risk stigma arising from infection. individuals with disabilities, learning disabilities, special educational needs, and developmental disorders may also be more vulnerable due to the increased psychological challenges associated with shielding and self-isolation. the challenges generated by the pandemic vary markedly across the lifespan and will influence the nature of current and future psychological needs of different groups. many young people have struggled with reductions in direct social contact, decreased motivation, and uncertainty caused by disrupted training and education. adults have experienced multiple stresses as a consequence of intensified caring responsibilities, financial concerns, job uncertainty, and health conditions. for many older people, the greatest challenges have been social isolation, disruptions in access to health and social care, and coping with bereavement. in addition to the challenges surrounding age, there are emerging data to suggest that the effects of covid- may exacerbate existing inequalities for women. for example, women are more likely to be key workers and primary caregivers, thereby being exposed to higher levels of psychological and financial stress (fawcett society, ). the covid- pandemic is likely to have had a disproportionate impact on groups with low levels of social inclusion and/or those who traditionally have declined support services, such as people living in poverty, traveller communities, and people who are homeless. being separated from wider support networks may also be particularly difficult for those living in hostile households such as victims of domestic abuse and lgbt people living with family members who are unaccepting of their identity. many of those detained in secure settings have been exposed to marked changes in service delivery and reduced social contact, increasing their vulnerability to the psychological effects of the pandemic. surely not a coincidence that the murder of george floyd during a global pandemic prompted a global civil rights movement drawing attention to inequalities. in this position paper, informed by a group of experts and a survey (box ), we highlight the many ways in which psychological science, its methods, approaches, and interventions can be harnessed to help governments, policymakers, national health services, education sectors, and economies recover from covid- (box ) and other future pandemics (if they occur). specifically, we have identified the shorter-and longerterm priorities around mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness in order to ( ) frame the breadth and scope of potential contributions from across the discipline, ( ) assist psychological scientists in focusing their resources on gaps in the literature, and ( ) help funders and policymakers make informed decisions about the shorter-and longer-term covid- research priorities to meet the needs of societies as they emerge from the acute phase of the crisis. the methodology we employed to develop the main research priority domains is described in box , and the seven priority domains are outlined below and summarized in table . how does collective identification impact on social responsibility and adherence to anti-pandemic measures? one of the most striking aspects of the covid- pandemic has been the importance of social psychology to the outcomes. given the highly differentiated nature of susceptibility to the virus (box ), one might have expected many (especially the young and fit) to conclude that they have more to lose than gain by observing the rigours of lockdown and other preventative measures. if they had acted on such an individualistic calculus, then far more people would get infected and far more (especially the old and infirm) would die. however, on the whole, people did not act on the basis of such narrow self-interest, and the vast majority supported the lockdown (e.g., duffy & allington, ) . what is more, conversely, well-functioning social support is likely to confer resilience against the negative psychological impacts of the pandemic. finally, it is important that psychological scientists consider the interconnectedness of the above factors. for example, individuals who are young and from a bame background who are also from a less affluent socio-economic background may be disproportionately impacted by the educational, economic, and other consequences of the measures taken to contain and recover from the pandemic. similarly, many of the solutions to the problems posed by the pandemic involve the use of new technologies that assume the requisite skills, access to devices, and internet connectivity meaning that the 'digital divide' will likely have been exacerbated by the pandemic (ons, ). this paper outlines research priorities for psychological science for the covid- pandemic. in april , the british psychological society convened a core group of nine experts who met regularly for weeks in order to develop the research priorities. the nine experts represent broad areas of the discipline, namely biological, clinical, cognitive, developmental, educational, health, occupational, and social, and were assisted by a wider advisory group of psychological scientists (n = ) drawn from a range of uk higher education institutions and areas of research expertise. we also received input from two international experts. briefly, we used an iterative expert consensus procedure (e.g., merry, cooper, soyannwo, wilson, & eichhorn, ) to elicit and distil the judgments of experts on the research priorities for psychological science. unlike other consensus methods, which typically start with a list of priorities that are then ranked over the course of or meetings (e.g., fitch, bernstein, aguilar, burnand, & lacalle, ; mcmillan, king, & tully, ) , the present approach both generated and judged the priorities over hour long face-to-face meetings of the core group. consensus was achieved through discussion, and the experts were encouraged to discuss with the wider advisory group and their professional networks in between meetings. given the need to establish the priorities rapidly, a lengthy consultation process or an extensive review of all relevant scientific literatures was not possible. however, a brief online survey of psychological scientists was launched early in may with the aim of ensuring that the core and advisory groups had not missed any key research priorities, and to identify the highest ranked priorities in each of the broad areas of psychology to help inform the final wider-ranging research priority domains. the online survey had two components: first, participants were asked the open-ended question, 'please can you tell us what are your priorities for psychological science research in response to the covid- pandemic?' second, participants were asked to rank order the top five research priorities identified by the core group in each of the eight broad areas of the discipline (i.e., biological, clinical, cognitive, developmental, educational, health, occupational, social). the survey was distributed to psychologists via heads of uk psychology department email lists, the social media outlets of professional psychology networks (including the british psychological society), and snowball email methods by the expert and advisory group members. we received replies from psychological scientists representing all of the main areas of the discipline. respondents were . % female, . % were aged between and years, and . % self-identified as being from a minority group. the highest ranked research priorities in each of the broad areas are presented in table (see appendix for the full list of priorities). as a result of the time constraints, a detailed qualitative analysis was not possible for inclusion in this paper; nevertheless, the core group gave consideration to all of the free responses provided. overall, there were differing degrees of specificity, and respondents provided numerous, additional, and wellspecified research questions. however, at the broadest level, respondents' priorities coalesced around the question of how do we address the negative biopsychosocial effects of the covid- pandemic? the degrees of specificity related to population (e.g., people with black, asian, and minority ethnic backgrounds, children, people with low socio-economic status, people living with long-term conditions), type of intervention (e.g., service provision, environmental/social planning), methodology (e.g., qualitative, online, survey, laboratory-based), and setting (e.g., workplace, school, prison), but there was broad agreement. perceived personal risk bears no relation to whether people adhere to government instructions: whether or not one identifies with the broader community and hence acts on the basis of the risks to the community as a whole is the key driver (jackson et al., ) . so, getting people to think in collective rather than personal terms is critical to controlling the pandemic (reicher & drury, ) . or, in the rather more forceful terms of new york governor andrew cuomo: 'yeah it's your life do whatever you want, but you are now responsible for my life. you have a responsibility to me. it's not just about you . . . we started saying, "it's not about me it's about we." get your head around the we concept. it's not all about you. it's about me too. it's about we'. how can we nurture the development and persistence of mutual aid and pro-social behaviour? the significance of such 'we-thinking' is not limited to issues of adherence and social responsibility. the literature on behaviour in disasters and emergencies (drury, ) suggests that the experience of common fate in such events leads to a sense of shared social identity that in turn underpins solidarity and cohesiveness between peopleeven strangers. we have seen numerous examples of 'we-thinking' in the time of pandemic, which have played a key role in sustaining people through difficult circumstances. these range from neighbours knocking on doors to see whether people need help to over three million people contributing to more than four thousand mutual aid groups across the uk (butler, ) . so, how can we nurture such we-thinking in order to build mutual aid in communities and ensure it endures even after the acute phase of the covid- pandemic is over? what is the relationship between group membership, connectedness, and well-being? there is growing evidence of the role of group membership in sustaining both physical and mental health (haslam, jetten, cruwys, dingle, & haslam, ) . in addition to asking in general terms about how group identities are created, sustained, or else undermined in times of crises, we also need to investigate further the interface between group processes and health during and after periods of crisis. in other words: how can we keep people psychologically together even when they are physically apart and what is the relationship between face-to-face and virtual groups in terms of their health effects? more generally, that is not to say that all research priorities were covered in the original survey. two issues in particular stood out from the comments we received. the first was the importance of dealing with inequalities and differences between groups in the experience of the pandemic. the second was the need to address the positive as well as the negative developments coming out of the response to covid- . these were both incorporated into revisions of the paper and now occupy a much more central place than before. we are thankful to all those anonymous respondents whose comments helped improve our argument. a more rigorous, thematic analysis of these data is now available (see bps, c). the picture was very similar when respondents were asked to place research priorities identified by the expert group into rank orders. that is, broadly speaking, the priorities that received the highest rankings, irrespective of area of subdiscipline, were related to the need to address the negative biopsychosocial effects of the covid- pandemic. box : psychological science: methods, approaches, and interventions to help meet the immediate and longer-term covid- research priorities the future research landscape will be challenging due to the ongoing physical distancing requirements; however, psychological scientists are equipped with a broad range of methods, approaches, and interventions that will allow these research priorities to be met. some examples are as follows: internet-mediated research will be an important approach utilized by psychological scientists to collect data in the immediate post-pandemic phase and at longer-term follow-ups. internet-mediated research can be reactive (e.g., online surveys, online interviews) and non-reactive (e.g., data mining, observations from screen-time apps) and can be integrated with objective assessments of behaviour as well as with biological and social markers of physical and mental health. internet-mediated research can also be used to run experiments with online software available such as gorilla, psychopy, and e-prime. recent work has summarized the range of software for building behavioural tasks, and their efficacy in being used online (sauter, draschkow, & mack, ) . changes in the use of research methodologies may provide a catalyst for the formation of new collaborations and training to develop research skills in the psychological science community. at the same time, trust around data security and confidentiality will need to be built between researchers and the general public from whom we sample. however, in , more than an estimated million people aged - years in the european union reported they had not used the internet in the preceding months (eurostat, ) , and researchers will need to think creatively about conducting research projects remotely. for example, participants can have study materials delivered by post (e.g., salivettes for cortisol sampling or asking participants to self-sample), replacing face-to-face communication with telephone and/or video calls, and the use of personal protective equipment when collecting data. psychological therapies and behaviour change interventions can already be delivered remotely and evidence suggests that remote delivery does not necessarily mean inferior delivery (e.g., irvine et al., ) . urgent research is needed to translate interventions that are typically delivered in-person to telephone and online delivery modalities. psychologists are well-positioned to collect valuable qualitative data concerning people's relevant experiences, perspectives, and practices associated with covid- , which could inform psychologybased interventions to improve well-being and social cohesion. multiple participant-centred qualitative research methods can be rapidly deployed to elicit first-hand accounts from members of different communities, including (online) interviews, focus groups, and qualitative questionnaires, focusing on the psychological and social impact (jowett, ) . beyond the immediate term, qualitative data can be gathered longitudinally so that insights can be generated into the experiences of diverse groups over time, identifying salient crisis points and effective resolutions. implementation science is a branch of psychological science that is dedicated to the uptake and use of research into clinical, educational, health care, organizational, and policy settings. principles of implementation science can be used to help stakeholders navigate the extensive and unwieldy psychological science research literature. to inform policymakers and support professional decisionmaking about implementation, psychological research needs to be disseminated in an accessible format. one example of a well-regarded translational system is the us institute of education sciences what works clearinghouse (https://ies.ed.gov/ncee/wwc/), which provides reviews and recommendations about evidence-based practices for professionals working in educational settings. can we learn from this in order to improve the plight of socially isolated people as we emerge from the acute phase of the pandemic? under what conditions does unity and social solidarity give way to intergroup division and social conflict? finally, in addressing the positive potential of social psychological processes, we must not forget their darker side. 'we' thinking can all too easily slip into 'we and they' thinking, where particular groups are excluded from the community and then blamedeven an important feature of the covid- pandemic has been requested by government to provide psychological science expertise at pace. the inclination of many psychological scientists is to begin designing a new study or conducting a systematic review following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, but this does not meet the needs of policymakers. it would be valuable for psychological scientists providing expert advice to acquaint themselves with the terminology and procedures that are familiar to civil servants who are more likely to have use for a quick scoping review or rapid evidence assessment (collins, coughlin, miller, & kirk, ) rather than embarking on a time-consuming systematic review of systematic reviews (keyworth, epton, goldthorpe, calam, & armitage, ) . there are many challenges involved with conducting covid- -related research including dealing with vulnerable groups, giving due consideration to ethical concerns, as well as issues around running studies in the light of physical distancing requirements. therefore, having relevant patient and public involvement and including individuals with lived experience (as appropriate) in designing studies will be of paramount importance. psychological science has been leading the way in promoting and adopting open science principles and practices. nevertheless, psychological scientists need to ensure they balance the urgency of conducting covid-related research (during and in the recovery period) with ensuring research quality and open research practices. therefore, in order to help maintain quality, openness, and rigour, we urge researchers to endeavour to use registered reports, where possible (e.g., https://osf.io/rr/), or preregister their research hypotheses and analysis plans (e.g., https://aspredicted.org/) and make their data findable, accessible, interoperable, reusable (fair) recognizing the principle of 'as open as possible; as closed as necessary' (bps, a (bps, , b norris & o'connor, ) . moreover, we urge researchers to utilize pre-print servers, such as psyarxiv, in order to ensure their latest research findings are made publicly available rapidly and at no cost. we hope that openness will drive quality, but as yet there is no substitute for articles being peer-reviewed prior to wider acceptance by the scientific community. psychological science has responded swiftly to the covid- pandemic, but there is a danger of duplication of efforts and participant fatigue in the proliferation of online surveys, experiments, and focus groups that have arisen. we need to harness the ongoing efforts of psychological scientists worldwide in a coordinated effort on the scale of the large hadron collider (cern, ) to deliver truly evidence-based interventions to help societies emerge from the covid- pandemic. this will include cross-cultural research to understand why mortality rates, mitigation measures, and adherence to government instructions have differed so markedly between countries. finally, we urge researchers to register their research studies and findings on international repositories (https://osf. io/collections/coronavirus/discover). attackedfor the crisis. thus, un head antonio guterres has warned of a 'tsunami of hate' unleashed by the pandemic (davidson, ) . this hate and violence can take different forms: of anti-authority riots as in france (willsher & harrap, ) , or of racist violence against minorities as in india (mazumdaru, ) . in sum, insights from social psychology can be a valuable resource in a crisis; it can bring people together and generate constructive social power. but equally, it can set people apart and create problems that endure well beyond the crisis itself. it is evidently of the greatest importance to understand the processes that determine whether people unite or divide in hard timesand notably to understand the role of leadership, which has been so significant and so diverse in different countries during covid- . work environment and working arrangements consistent with previous pandemics (e.g., rubin et al., ) , the work-related challenges of the pandemic have been particularly high and widely recognized for health and social what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? how will the covid- pandemic affect children's development? how will the covid- pandemic affect family functioning? how do school closures influence children's educational progress and well-being? what kinds of support improve long-term outcomes for children and young people? how can support services be effectively delivered to vulnerable children and young people, families, and schools? what are the immediate and longer-term consequences of covid- for mental health outcomes? what changes in approaches resulting from the pandemic need to be harnessed for the future? . physical health and the brain does covid- have neurological effects on the brain with consequences for mental health? what are the psychobiological impacts of the covid- pandemic on physical and mental health? how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? how do we develop new theories and tools to promote sustained behaviour change? care workers in direct contact with patients suffering the effects of covid- , leaving them vulnerable to trauma, fatigue, and other manifestations of chronic stress. what is unique about covid- is that changed working conditions and anxiety about infection have affected almost all employees, with particular challenges being faced by delivery workers, shop assistants, teachers, emergency services personnel, care home staff, transport staff, and social workers. the full economic severity of the covid-related restrictions is uncertain, although up to two million people could lose their employment in the uk alone (wilson, cockett, papoutsaki, & takala, ) . for those people still working, and those about to return to work, there are notable changes that will likely affect working practices in the foreseeable future. therefore, understanding the impact of the covid- pandemic on the work environment and new working arrangements is paramount to kick starting the economy and adjusting to daily life. what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? for many workers, particularly those in white-collar occupations, work took place entirely from home during the lockdown. it is possible that the lockdown will accelerate the general increase observed in home working practices (ons, ). a move to greater levels of remote working has clear economic benefits for employers (e.g., reduced estates costs). the flexibility to balance work and family life is also attractive to many employees (cf. strategic review of health inequalities in england, ). overall, the evidence points to positive benefits of remote working in terms of well-being (charalampous, grant, tramontano, & michailidis, ) , although these effects are not consistent. for example, it may lead to greater levels of professional isolation (golden, veiga, & dino, ). an increase in remote working will likely occur with a concomitant increase in the use of online technology to support communication and aspects of collaborative working. this has the potential to blur boundaries between work and home domains, resulting in negative impacts on well-being and productivity from work-home interference (van hoof, geurts, kompier, & taris, ) . greater use of technology may also be associated with different perceptual and cognitive demands that may affect productivity and wellbeing including social connections with work colleagues (e.g., mark et al., ) . what is the impact of physical distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? until an effective vaccine is available, physical distancing rules will need to continue to be in place in work environments and we may experience multiple stay-at-home versus return-towork cycles. there is very little research exploring physical distancing and its effect on the general workplace, but returning to work will likely be both a welcome change and a potential stressor. while we have research from teams working in difficult and extreme environments (power, ; smith, kinnafick, & saunders, ) and research on professional isolation (golden et al., ) , this is an unprecedented opportunity to study adaptation across a breadth of individuals and organizational settings. how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? the unprecedented demands that the pandemic has placed on organizations also offer a unique opportunity to understand how organizational resilience and preparedness for dealing with disruptions and emergencies can be developed. while a pandemic of this nature is rare, we can anticipate increasing periods of disruption due to covid- flareups and additionally, for example, in response to climate-induced events (e.g., recent australian fires, uk flooding), which are predicted to occur more frequently (banholzer, kossin, & donner, ) . although we know a lot about individual resilience, we know relatively little about organizational resilience, especially in the context of well-being and performance (taylor, dollard, clark, dormann, & bakker, ; fasey, sarkar, wagstaff & johnston, under review) and the ingredients such as the structures, processes, culture, and leadership that are essential for developing organizational resilience. parenting can be a challenging and anxiety-provoking experience at any time, but the covid- pandemic has brought these challenges and anxieties into sharp focus. for most families, the lockdown will represent the longest period of parenting they have experienced without ( ) the support of extended family members, friends, and childcare professionals; ( ) the routine of school and out-of-school activities; and ( ) any face-to-face social life outside the home. these changes in the social environment may have both negative and positive impacts on children and their families. at the most extreme end of the spectrum, the restrictions in place to combat the spread of the virus have been associated with worrying increases in domestic violence and child abuse. however, all families are likely to have experienced greater levels of stress (social care institute for excellence, ). the majority of carers with school-age children are dealing with homeschooling for the first time, and many carers are having to adapt to working from home while also looking after their children and older relatives. these pressures will be particularly acute for single-carer families. of course, such multi-tasking concerns apply only to carers fortunate enough to have maintained employment. it is important to support families during the current crisis, but also to understand the implications of these unprecedented changes in family life for family functioning and children's development as we emerge from the pandemic. how will the covid- pandemic affect family functioning? many effects of the pandemic on children's development are likely to be indirect, functioning through its impact on caregiving and family functioning. it is crucial for this research to include family members such as grandparents and non-resident parents and siblings. children in families who are already vulnerable due to domestic violence or abuse, social or economic disadvantage, or physical or mental ill health are likely to be most adversely affected. there is an urgent need for research to examine how these vulnerabilities moderate changes in family functioning post-pandemic and their impacts on the child. the ability to regulate behaviour and emotional responses is a key aspect of successful social interaction in individuals of all ages (e.g., baumeister & heatherton, ; kochanska, murray, & harlan, ) . family members may develop new self-regulation strategies as a result of having extended contact with the same restricted group of people. while such strategies may be adaptive, individuals facing extreme social or financial challenges may cope by psychologically distancing themselves from family members, ruminating on negative events, or engaging in behaviours that are harmful. understanding how adaptive and maladaptive self-regulation strategies change post-pandemic may prove useful in identifying individuals who need additional psychological support. school closures and social restrictions may provide a unique opportunity for family members to gain insight into each other's lives, potentially reducing disagreements and improving family functioning. research should investigate whether reporting such improvement during the crisis is associated with lower caregiving stress and better mental health. it is also important to study how families can maintain any positive aspects of functioning that have resulted from the pandemic as restrictions are eased. how will the covid- pandemic affect children's development? the effects of the pandemic will undoubtedly vary as a function of the child's age. while carers with young infants may have concerns about the negative impact of the lockdown on their babies' development, the infants themselves will be unaware of the abnormal nature of their social environment. optimal later development is predicted by caregivers' ability in the first year of life to see the world from the infant's point of view and respond appropriately to their cues (e.g., fraley, roisman, & haltigan, ; zeegers, colonnesi, stams, & meins, ) . the social restrictions do not obviously impede this type of infantcaregiver engagement, and young infants may therefore be least affected by the pandemic. older children who recognize the drastic changes in social contact may find transitioning back to pre-pandemic social behaviour difficult. it is therefore important to study how children and young people manage this transition and investigate whether the lockdown has raised the incidence of emotional and behavioural difficulties. studying the effects of the pandemic and its aftermath on particular groups that are known to be vulnerable to educational and health disadvantage (e.g., looked after children or children with developmental disorders) should be prioritized. positive effects of the pandemic on children's behaviour and social interaction are also anticipated. many children and young people will have found new ways to communicate with friends, entertain themselves, and keep themselves physically active. time away from school may have been spent learning new skills, developing new hobbies, or helping or supporting others. investigating changes in children and young people's empathy, altruism, theory of mind, creativity, innovation, problem-solving, and cognitive flexibility post-pandemic will help shed light on potential positive outcomes of the social restrictions associated with the pandemic. the challenges posed by the covid- pandemic have never been more evident than for the education and well-being of children and young people. in april , a third of the world's population were experiencing extended periods of lockdown with closure of schools and nurseries. parents, many of whom had work and other family responsibilities had to adopt the additional role of educator in home environments not set up for formalized learning. ad hoc arrangements were put in place at speed by schools with limited opportunities to develop clear definitions of learning activities, provide access to learning resources, and establish effective home-school communication. early surveys have shown wide variation in homeschooling arrangements, including stark differences between state and private schools in access to online learning and pupil-teacher communication (sutton trust, ) . there is a wealth of evidence about the factors that facilitate effective learning in schools, such as curricula and teaching strategies (hattie, ) . other studies have established that children's academic attainment and adjustment are predicted by higher caregiver education (erola, janolen, & lehti, ) and engagement in schooling (harris & goodall, ) . however, little is known on how to set up and deliver home education effectively under the unique conditions of the pandemic. while for some children the extended period at home is likely to have distinct positive benefits, research prior to covid- on substantial externally driven disruptions in schooling has shown adverse effects on child achievement and well-being (meyers & thomasson, ; sunderman & payne, ). the outcomes for the individual child are likely to depend on the capacity of families to step in and effectively support curriculum delivery at home. studies of other severe unplanned disruptions to schooling and family lives such as long-running strikes and natural disasters have shown greatest impacts on long-term educational and emotional outcomes for the most disadvantaged children (jaume & will en, ; masten & osofsky, ) . at particular risk of disproportionate adverse outcomes are children from families living in poverty, those receiving social care support, individuals with special educational needs and disabilities, and young people with mental health problems. there are high levels of concern that the recognized attainment gap for children from disadvantaged families (education in england: annual report . education policy institute) could be magnified by the pandemic conditions. there is an urgent need to identify and understand both the positive and negative factors that influence children's educational outcomes during and after the pandemic, and to use this knowledge to target support to those who need it most. the unanticipated consequences of the pandemic pose challenges for conventional designs depending on pre-intervention assessments. understanding its impacts on children's lives will require a robust body of research that draws on the diverse research methods of psychological science. this will require large-scale multidisciplinary data collection in addition to smaller-scale quantitative and qualitative approaches that will be vital for understanding the experiences of children, families, and professionals. some key questions to be addressed by this research are outlined below. in addition to collecting data on home-based support for learning, detailed contextual data are needed about social and environmental factors that are likely to interact in determining positive educational outcomes at particular educational phases (e.g., reading, writing, and maths in primary schools), as well as a range of mental health outcomes (e.g., anxiety, depression, self-harm, resilience). this will include research into the effect of social distancing on a range of social outcomes in children and young people (e.g., inclusion/ exclusion, friendships). what kinds of support improve long-term outcomes for children and young people? knowledge about the impacts of school disruptions on all children and young people will allow evidence-based interventions and resources to be targeted at those with greatest need. robust evaluations are required to scrutinize how interventions are accessed, by whom and with what degree of success. how can support services be effectively delivered to vulnerable children and young people, families, and schools? with reduced resources and restricted movement, professionals (such as practitioner psychologists) have had to adapt and develop new ways of delivering services. researchers in psychological science have a key role to play in working with practitioners and service providers to evaluate systems put in place for monitoring and delivering professional support during and in the aftermath of the pandemic. what are the immediate and longer-term consequences of covid- for mental health outcomes? there is expected to be an increase in mental health problems as a result of the covid- pandemic and the measures used to counter it. we already have evidence for the long-term mental health effects of previous pandemics and disasters (e.g., tam et al., ; thompson et al., ; wu et al., ) and an emerging literature on the near-term effects of covid- (e.g., ahmad & rathore, ; williamson et al., ) . but previous pandemics have been more localized and circumscribed making covid- different. social distancing, school closures, self-isolation, and quarantine have lasted longer than anything previously experienced. we know that these factors, together with financial uncertainty and concerns about health, are predictive of mental health difficulties, particularly anxiety. the current pandemic amplifies these factors and not only exacerbates problems in those with pre-existing mental health difficulties, but also increases the chance of new onset in those with no previous contact with mental health services. concerns about mental health effects may be particularly heightened for children, who have experienced high levels of disruption to normative developmental opportunities (including opportunities for social and outdoor play) and education, and potentially high levels of family stress (https://emergingminds.org.uk/cospace-study- ndupdate/). various poor mental health outcomes are also potentially associated with the disease itself. information about the long-term consequences comes from similar viruses such as sars and the mers. for example, many people who suffered from sars seemed to experience detrimental psychological effects even a year later (rogers et al., ; tam et al., ; thompson et al., ; wu et al., ) . therefore, we need to establish the immediate and long-term consequences of covid- on mental health outcomes in the population generally, but also in vulnerable, shielding, and self-isolating groups (box ). we urgently need to understand how all these factors interact and whether these consequences will require psychological interventions and supports not currently available. what changes in approaches resulting from the pandemic need to be harnessed for the future? even if the mental health consequences of this pandemic are not as predicted, we still expect increases in mental health problems. we know that mental health accounts for an increasing proportion of sick leave and that one in eight children and young people experience a diagnosable mental health problem (nhs digital, ) . childhood mental health problems often recur in adulthood (kessler et al., ) and are associated with physical health difficulties, poor academic, and occupational functioning, and are the primary predictor of low adult life satisfaction (layard, clark, cornaglia, powdthavee, & vernoit, ) . the increased prevalence will place a further burden on a mental health system that was already stretched and will increase waiting times and accentuate gaps in care. during the pandemic, mental health services rapidly changed. inpatients were discharged, even if they were detained in hospital because they were a risk to themselves or others. some people benefited, but we do not know how this reduction in bed use was managed. was it because the right supports and accommodation were provided? the move to remote contact in mental health services had been slow and of varied quality prior to covid- with challenges for both staff and service users. but the shift during the pandemic was swift, and although undoubtedly nhs staff felt pressure during the changeover, there now seems to be a steadier state. again, some service users may have benefited from this change with reductions in travel and, for some, better access to care and treatment. however, although the digital divide is reducing (robotham, satkunanathan, doughty, & wykes, ) , it remains highest in those who already have high unmet needs, including people in rural areas, those on lower incomes, people with lower levels of formal education, and older people. if remote working is tobe abeneficial part of an evolved mental health service, then we need to understand how to provide that 'webside' manner that will increase adherence and promote a therapeutic alliance. we also urgently need to evaluate the effectiveness of remotely delivered, digital interventions in the immediate and longer term. future interventions will need to be deliverable remotely, depending on local resources. for example, from an international perspective, many low-to-middle-income countries do not have high broadband penetration; hence, optimizing digital delivery that depends strongly on good internet connections will further widen the welfare gap. physical health and the brain the effects of covid- on health outcomes will be far-reaching and complex. for those falling ill, there are the direct consequences of the disease symptoms, such as respiratory failure in severe cases, alongside potentially direct viral effects on the brain. there are also more indirect population-wide effects of covid- pandemic-related stress and anxiety on physical and mental health, not only from the disease itself but also from changes in lifestyle including delayed treatment and screening for other known or suspected conditions. moreover, it is also likely that from an international perspective, in many lowto-middle-income countries, the pandemic will result in greater hunger/starvation, which will have severe impacts upon health. does covid- have neurological effects on the brain with consequences for mental health? at one level, covid- might alter mental health by the direct actions of the specific virus (severe acute respiratory syndrome coronavirus- ; sars-cov- ) on the brain. while neurological dysfunction is often described in covid- , including dizziness, and loss of taste and smell, these conditions are common to other respiratory tract infections and need not reflect a neurological disease per se (needham, chou, coles, & menon, ) . data from cerebrospinal fluid and post-mortem analyses will help resolve issues over the penetrance of sars-cov- . it is, however, known that the target receptor for sars-cov- is the angiotensin-converting enzyme- receptor (ace ). disruption of the blood-brain barrier during illness might enable entry of the virus, potentially aided by the presence of ace receptors in glial cells and brain endothelium. other potential routes of entry include the cribriform plate and olfactory epithelium, as well as via peripheral nerve terminals, permitting entry to the cns through synapse connected routes (ahmad & rathore, ) . at the same time, there is an array of immunological responses, including the cytokine 'storm' in severe cases, alongside non-immunological insults to the central nervous system provoked by covid- . the latter include hypoxia, hypotension, kidney failure, and thrombotic and homeostatic changes involving neuroendocrine function (needham et al., ) . together and separately, they may contribute to brain dysfunction in ways that vary with the severity of the infection, other underlying conditions (needham et al., ) , and the treatment for those other conditions (south, diz, & chappell, ) . largescale studies help confirm differential clinical risk factors for death following infection (williamson et al., ) , prompting genotype analyses, while noting that covid- might also induce epigenetic changes, including ace demethylation (sawalha, zhao, coit, & lu, ) . additional health concerns include post-viral fatigue and whether it might provoke a long-lasting syndrome. research consortia are initiating comparisons between populations that have or have not contracted covid- . challenges for psychological scientists include how to assess impacts on cognition and mental health, both in the short term and long term. a part of this challenge is how to deliver effective, online psychological testing (e.g., for 'shielded' populations), or to help follow-up large population cohorts, while not biasing the sample away from those least likely to use these platforms. an integral part of some investigations will be the inclusion of multiple neuroimaging methods, despite the era of distancing. just one of many questions would be the impact of covid- on mild cognitive impairment and its conversion to dementia. there is a premium on studying pre-existing cohorts (e.g., uk biobank, alspac), where retrospective, baseline data exist. such data are especially precious in the present landscape where everyone is, to some degree, affected by the pandemic. the power of these pre-existing cohorts will, however, be heavily influenced by the proportion of the population who contract covid- . what are the psychobiological impacts of the covid- pandemic on physical and mental health? despite the umbrella term 'stress' covering many different things, there is agreement that in its different forms, stress can lead to physiological changes (e.g., neuroendocrine, cardiovascular), with negative consequences for health (o'connor, thayer & vedhara, in press). three principal research questions can be identified: ( ) to what extent does pandemic-related stress, anxiety, and worry impact on biological mechanisms that influence health (i.e., hypothalamic-pituitary-adrenal axis regulation and cortisol dynamics, the autonomic nervous system, and gene expression) as well as on health behaviours (e.g., eating, sleep, alcohol consumption)? ( ) how best to counter their adverse effects? and ( ) how might such stress exacerbate existing medical and mental health conditions, and for how long? for all three questions, there will be considerable variations between groups and individuals (box ). one challenge will be to collate and verify relevant information, including that from 'smart' devices that can provide daily physiological data, activity information, and other measures of diurnal patterns, including sleep. one of the groups most likely to be negatively affected by stress is health care professionals. the pandemic may exacerbate the already high prevalence of secondary traumatic stress, burnout, and physical exhaustion among health care professionals, as well as impact on patient safety and medical error (e.g., dar & iqbal, ; figley, ; hall, johnson, watt, tsipa, & o'connor, ) , due to excessive workload and workplace trauma (e.g., itzhaki et al., ) . while resources such as support from managers and colleagues can help protect health care professionals against traumatic stress, the longerterm impact is likely to be substantial on individuals, their families, on the national health services and the wider care industry. amongst other groups of concern (box ) are those caring for a vulnerable relative or partner at home. one novel feature of daily life in the wake of the covid- pandemic in countries around the world are near-daily government briefings. one focus of these briefings is government instructions to the public as to how to behave. adherence to these and future instructions will be key to dealing with future crises. moreover, many sections above share in common the requirement that people adhere to instructions, whether it is practitioners delivering psychological therapies effectively over the telephone or employees continuing to maintain physical distancing at work. in the initial response to the pandemic, many governments instructed people to ( ) stay inside as much as possible; ( ) stay > m away from other people at all times; and ( ) maintain hand hygiene, among other measures such as wearing face coverings. the evidence suggests that public adherence to government covid- -related instructions worldwide has been high (ons, ), but it is not clear for how long people will continue to adhere to instructions that impinge on personal freedoms. what is clear is that there is a dearth of workers sufficiently trained to advise policymakers and to implement behaviour change interventions rapidly and at scale. the british psychological society's guidance on behaviour change is a good starting point for ensuring that instructions and messaging is clear (british psychological society, a). appointing chief behavioural science advisers to governments would ensure that cuttingedge psychological science advice is placed at the heart of policymaking. as people begin to emerge from the acute phase of the pandemic and the changes that were made to tackle it, it is important that psychological science is at the heart of ensuring that health-enhancing behaviours are sustained and that health-damaging behaviours are changed or prevented. there are numerous approaches to developing such interventions, including the behaviour change wheel (michie, atkins, & west, ) and intervention mapping (bartholomew eldrigde et al., ) , but they require the expertise of psychological scientists to deliver and to evaluate them (west, michie, rubin, & amlôt, ) . one of the main challenges now, and in the future, will be to ensure there is a workforce equipped with the competencies to develop behaviour change theory and tools that will bring about sustained changes in behaviour. taught post-graduate courses exist that could be scaled up and/or adapted to continuing professional development qualifications to meet this demand and help ensure that the changes in behaviour that will be required for the foreseeable future are sustained. how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? we sometimes forget that we have the theories and evidence for solutions that can be applied at pace to address novel problems. although we have never seen a lockdown before and so cannot predict what the outcomes will be directly, we do know what processes underpin adherence to instructions, and so can advise on the levers that can sustain adherence. in unprecedented and uncertain times now and in whatever the future might bring, the nature of psychological science allows us to make unique and invaluable contributions. if the covid- pandemic teaches us one thing, it is on the need to accelerate the translation of evidence from psychological science into practice. how do we develop new theories and tools to promote sustained behaviour change? at the same time, we should not forget the 'slow' approach to research (armitage, ) that involves addressing key research questions with multiple perspectives and methodologies, and accumulating such knowledge in prisma-guided systematic reviews. it is vital that continued investment is made into behaviour change research. only with this can we refine and develop the theories that best explain human behaviour (e.g., michie et al., ) . key research priorities include identifying which behaviour change techniques work best, for whom, in which contexts, and delivered by what means (e.g., epton, currie, & armitage, ) as well as how to counter the conspiracy theories and misinformation that arise during crises that seem to be aimed at derailing the very behaviours required to keep us safe and to reduce risk. in this position paper, we have set out seven research priority domains in which psychological science, its methods, approaches, and interventions can be harnessed in order to help governments, policymakers, national health services, education sectors, economies, individuals, and families recover from covid- . these are mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we have also highlighted that a clear overarching research priority relates to understanding the inequalities in the effects of the pandemic and recovery; recognizing the vulnerability and resilience factors that will be key to understanding how the current pandemic can inform and prepare us for dealing with future crises. we call on psychological scientists to work collaboratively with other scientists in order to address the research questions outlined, refine them and to adopt multidisciplinary working practices that combine different disciplinary approaches. an important next step will be to engage with wider stakeholders, potential users, individuals with lived experience, and beneficiaries of the research. addressing each of the research priority domains will benefit enormously from larger scale working and coordinated data collection techniques and the establishment of research consortia with their associated economies of scale. we also call on psychological scientists to further develop and adapt innovative research methodologies (e.g., remote testing and intervention delivery, online data collection techniques), while maintaining high-quality, open, and rigorous research and ethical standards in order to help with the recovery as we emerge from the acute phase of the crisis. how can we use biological markers to facilitate people's return to work? how do we link covid- -related biomarkers to existing population cohort databases? how do we address the negative biological impacts of the covid- virus on mental health? what are the impacts of covid- infection, treatment, and recovery on the brain? how do school closures influence educational progress, and physical and mental health outcomes for all children and young people? what 'homeschooling' practices are associated with positive educational and psychological outcomes? what is the effect of social distancing on a range of social outcomes in children and young people? what methods are used to track, monitor, and deliver local authority support services to vulnerable children and young people, families, and schools during lockdown, at transition back to school, and after return to school? how are educational and psychological interventions allocated, structured, delivered, and evaluated for children and young people in need, after schools have reopened? what is the impact of remote and flexible working arrangements on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what managerial behaviours are most effective to manage remote working, possible mental health issues, job 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(covid- ) the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perfection, and altruistic acceptance of risk mind matters: a three-level meta-analysis on parental mentalization and sensitivity as predictors of infant-parent attachment christopher armitage's contribution is supported by the nihr manchester biomedical research centre and the nihr greater manchester patient safety translational research centre. the views expressed in this publication are those of the authors and not necessarily those of nihr. armitage would like to thank professors madelynne arden and alison wearden for their support in writing. til wykes would like to acknowledge the support of her nihr senior investigator award. the set of priorities utilized for the survey of the psychological community.how do we increase adherence (and ability to adhere) to uk government covid- related instructions? how do we promote maintenance of positive behaviour changes and reverse negative behaviour changes resulting from covid- -related lockdown? how do we address the negative psychological impacts of the covid- pandemic? how do we maximize recovery from covid- for those infected with the virus? what is the impact of covid- -related stress on biological processes and health outcomes? what makes people adhere to anti-covid measures? what are the bases of anti-social behaviours such as stockpiling? how do mutual aid groups form and what makes them endure? when does social cohesion give way to scapegoating, prejudice, and intergroup conflict? what creates (or prevents) the potential for protests and collective disorder in the crisis? what are the long-term mental health effects of covid- ? what coping mechanisms are useful in reducing mental health problems during a pandemic? how do we provide beneficial remote psychological therapy and maintain therapeutic alliance? has discussion of mental health during the pandemic reduced stigma and discrimination in the community? people detained in hospital under the mental health act were discharged to free up bedshow was this possible? what are the impacts of covid- infection, treatment, and recovery on cognition, behaviour, and the brain? what are the drivers of covid- -related stress and its cognitive, neural, and physiological mechanisms and consequences? what are the perceptual and cognitive demands of digital and other alternative forms of communication and how do they impact on work and social connectivity? what factors influence the effectiveness of communication of scientific evidence and national guidance, and how do they influence behaviour? how do restrictions of movement, communication, and social support influence the cognitive, physical, and mental health of older individuals, and what factors lead to improved outcomes? how has the covid- pandemic affected parenting? how has the covid- pandemic affected children's development? how has the covid- pandemic affected family functioning? which factors moderate family members' response to the covid- pandemic? what support is most effective for families during the covid- pandemic? how do we assess biological markers of health and well-being remotely?continued key: cord- -lgee ers authors: liddle, jennifer; pitcher, nicole; montague, kyle; hanratty, barbara; standing, holly; scharf, thomas title: connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: lgee ers social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. in contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. we present findings from interviews with older adults and a linked ideation workshop. our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. however, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. by uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. we introduce an amended definition—‘underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community’s physical, social and digital environments and its supporting infrastructure’—to conceptualise our approach. we conclude by suggesting areas for future work in developing digitally connected age-friendly communities. social connectedness in later life is important for health and wellbeing. consequently, making it easy for people to develop and maintain social relationships is a fundamental ambition of 'age-friendly' communities. this local, place-based, policy approach recognises that physical and social environments are key determinants of whether people remain independent, autonomous and healthy in later life. human-computer interaction (hci) researchers are directing increasing attention towards the role of technology in shaping and supporting social relationships in later life. much of this work focuses on online communities or connecting across geographical or generational distances, where digital technology is the interface or infrastructure for connection. in addition, approaches commonly place emphasis on addressing technological inexperience, or on physical or cognitive impairment and decline. in this paper, we are interested in considering technology and connectedness in later life within a specific local context, and exploring how innovation in social connection can be age-friendly and embedded within such physical community settings. we consider older adults as a heterogeneous group, rather than a group marked by singular identities of health, cognitive status, or technological proficiency. nevertheless, our place-based approach aims to identify common values and experiences shared by people living in the same geographical area. life events such as retirement, along with experiences of building and maintaining social connections over the life course, will also have implications for how and why older adults wish to develop and sustain proximate relationships in particular ways. we suggest that considering these topics enables a deeper understanding of how to design for a digitally connected age-friendly neighbourhood, where both the design process and its outputs are age-friendly. our paper presents findings from a study comprising two phases: qualitative interviews with older adults; and a linked workshop ideation process to engage interviewees in beginning to consider how connections within their local area might be enhanced over time. the contributions of our paper centre around a context-specific and bottom-up approach to designing for increased local connectedness in later life. the importance of this topic has since been emphasised by the covid- pandemic, heightening awareness of the need to consider ways to maintain and create social connectedness, particularly at a local level. our aim is not to design a technological output. instead, we see our approach as prioritising a crucial, and often neglected, stage in technology design, which provides important insights that would be required for any future stage of a design process that aimed to design or create an actual technology. themes that emerged from our interviews suggest that participants viewed technology as acceptable when it filled a 'gap' and did not have too many negative impacts on everyday life. our starting point for the linked workshop was to consider some of these 'gaps' in local connectedness that interview participants had described. the workshop activities were used to facilitate participants in thinking creatively about addressing specific local challenges, or 'gaps' in connectedness. in drawing together participants' ideas about spaces, processes and mechanisms that might address these local challenges, we conclude the paper with implications that offer scope for further exploration and consideration in terms of how technology might support the operationalisation of local people's ideas for improving face-to-face connections in age-friendly community settings. growing interest in what makes places 'good' to grow old in has led to an increasing focus on the 'age-friendliness' of different types of environments [ ] . despite variation in emphasis between models of age-friendly environments, most approaches promote consideration of how policies, services and structures can integrate physical and social environments, supporting social engagement and connection [ ] . our work adopts the following conceptual definition, with its emphasis on age-friendliness as commitment to a process rather than a standard to be reached: 'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical and social environments and its supporting infrastructure' [ ] . the adopted definition of age-friendliness shapes our research design and methods, with its emphasis on community engagement and the participation of older people in processes to optimise the environment to support social connections. we also draw on concepts from environmental gerontology, such as 'ageing in place' to understand the importance of the local area in older people's lives. an overarching premise of an age-friendly community is that it is 'friendly for all ages and not just "elder-friendly"' [ ] . even so, the argument that older people are 'able to remain more independent by, and benefit from, ageing in environments to which they are accustomed' [ ] makes it all the more important to consider how environments can support people 'ageing in place' to optimise their social connectedness within their local area. this has become even more apparent during the covid- pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, even with people in proximate locations, has become a greater priority. there has also been a strong emphasis on tackling the counterparts of social connectednessloneliness and isolation. warnings of the 'loneliness epidemic' and its associated public health implications are prevalent in media discourse [ ] [ ] [ ] , and the uk government appointed the world's first minister for loneliness in [ ] . accordingly, responses to the drive for increased social connection have often focused on mitigating unpleasant experiences, risks and deficits at an individual level [ ] . efforts along these lines reflect and uphold persistent ageist stereotypes that fail to acknowledge the roles that older people (can) play in communities, or their potential to contribute innovative ideas or create a voice for themselves [ ] [ ] [ ] . indeed, technology is often presented as the ideal way of solving these 'problems' faced by older adults [ ] . ten bruggencate et al. draw our attention to the predominant focus on loneliness and/or isolation in studies about social technology, ageing and relationships [ ] . in contrast, a growing body of work on social connectedness in later life challenges the image of older people as lonely and isolated. population ageing is leading to increasing numbers of older people, thereby increasing the number of older people in society who experience loneliness. however, loneliness affects only the minority of older people, including the oldest old [ ] [ ] [ ] . the likelihood of reporting feeling lonely decreases with age, with younger adults ( - years) reporting loneliness more often than those in older age groups [ ] . while older adults may have smaller social networks, they are often more involved in the community than younger adults-socialising with neighbours, participating in religious organisations and volunteering [ ] . however, even if social reciprocity and meaningful interactions are desired and enacted by older people, infrastructural barriers can, and do, impede the quantity and quality of such connectedness [ ] . technology offers the potential for scalable and cost-effective interventions to address barriers to connectedness. the design, or adoption, of digital technology to support social relationships in later life often results in technology being the core interface for connection between people, rather than a route to facilitating face-to-face connections by overcoming barriers. for example, online communities are promoted as presenting opportunities for older people to meet and interact with peers [ ] [ ] [ ] [ ] . in this interfacing role, technology is a bridge across distances. lindley et al. comment that much hci research related to relationships focuses on ways to maintain feelings of connectedness or express intimacy at a distance [ ] . distances being bridged may be geographical, for individuals living in remote areas or wanting to connect with people with whom they share interests, friendship or familial bonds. distances may also be generational, where, despite intentions to the contrary, technology replicates asymmetrical family interactions [ , , ] . growing proportions of older people are now using digital technologies. in the uk, % of adults aged - , and % of adults aged and over use the internet [ ] . thus, the majority rather than a minority of older people are technologically connected, suggesting a need to understand more about how this diverse population uses, and feels about, technology for connecting with others. the few studies that have explored older people's attitudes towards, and perceptions about, communication and connection suggest that rich interactions are valued above lightweight connections offered by newer technologies [ , , ] . again, this work primarily considers the capacity of digital technology to bridge geographical or generational distances, where more traditional technologies such as telephone and email are often preferred. thoughtful and meaningful interactions are the goal, and technology provides the interface. research methods centre around questions about how older adults use, or would choose to use, technology in their social relationships. for instance, sayago et al. report on research with older people (across six studies) that examined situated technology use and the reasons why participants did, or did not, incorporate particular forms into their everyday lives [ ] . in this way, technological interfaces are often in-built as fundamental foundations for designing for connection, diminishing considerations of technology in non-interfacing roles. research that has explored ways to improve geographically proximate connections has also tended to concentrate on a prominent role for technology, often studying online community networks. these include bespoke online communities for older adults, or those formed on more widely used social networking platforms. righi et al. focussed on how older people's use of social networking sites could be used to promote their involvement in both online and offline local communities [ ] . while participants used, for example, facebook to find out information about the local area, most did not post or share information or send messages to others. instead, these interactions took the form of face-to-face conversations. on this basis, the authors conclude that proximity and face-to-face contacts should be kept in mind when designing online community networks. we would extend this argument further, to suggest reversing the design process. such a process would design for proximity and face-to-face contact in offline communities, with technology kept in mind in a background, less visible, role. the research described above concentrates on technology as the interface for connection between people. while the potential of technology to foster involvement in local communities has been explored, less attention has been paid to understanding and drawing on context-specific factors to develop approaches to promote connection in local areas with, rather than for, older people. this would be a fundamental approach for any community engaged in the ongoing process becoming (more) age-friendly. an effective strategy in one community will not necessarily translate to a community with different geographical, social or structural features. likewise, the attitudes of older people towards technology will vary individually and across communities and countries. in their 'manifesto for change' in age-friendly cities and communities, buffel et al. emphasise the necessity of ensuring the empowerment and recognition of older residents in order to achieve age-friendliness [ ] . for these reasons, we adopted a bottom-up, place-based approach that can be responsive to local needs, preferences and resources. we recognise community as an inclusive concept, with the participation and empowerment of members (particularly older people) being fundamental to its creation and functioning [ , , ] . the following sections present the methods and findings of our study. our research design (in-depth interviews followed by an ideation workshop) draws on key concepts, theories, gaps and definitions in the literature outlined above. it is a bottom-up place-based approach that focuses on local needs, preferences and resources. it prioritises the participation of older people in exploring context-specific routes to local connection that present opportunities for future design of technology. we see our participants as crucial to developing ideas to increase or improve connection. as residents within the local area, they have a wealth of knowledge and experience and are best placed to identify resources, ideas and options that can lead to context-specific routes to connection. our overall aim within this study is to begin exploring context-specific routes to local connection that do not start the design process with attempts to design technological interfaces. discovering issues or opportunities for increased connection at a community level is the first step in this process. these opportunities and 'gaps' also need to be considered alongside insights into the current practices and perceptions of older people regarding technology in their social lives. once opportunities for increasing connection have been identified, ways to address these can then be explored by older people with local expertise and knowledge. therefore, in practice, the workshop methods were designed after analysis of our interview data so that we could draw on the interview findings as the starting point for workshop activities and discussions. however, for structural clarity, the methods for both the interviews and workshop are presented first in this paper, followed by the findings from our analyses. the first phase of our study aimed to explore opportunities for designing to improve proximate social connections for older people living within a geographically identified 'community'. we also wanted to know more about how and why research participants were using technology, or not, in their social lives. qualitative interviews were an appropriate method for exploring these two topics, with their potential to elicit personal accounts that help people to 'make explicit things that have hitherto been implicit-to articulate their tacit perceptions, feelings and understandings' about their social lives and technology [ ] . the study setting was an electoral ward (district) within a city in the north of england, uk, chosen for its proximity to the research team's institutional location. just over % of the around , people living in this geographical area are aged or over (compared to % overall in england and wales). it is also one of the most ethnically diverse and socially deprived wards in the region [ ] . following institutional ethical approval (ref. ), we recruited older adults ( women, men) to take part in audio-recorded interviews. sixteen interviews were with individual participants and three interviews were with couples living in the same household who chose to be interviewed together. our only inclusion criterion was that participants were aged or over. however, we also sought to achieve a diverse sample in terms of age, gender, ethnicity, social connectedness and living arrangements. table summarises participant characteristics. participants were aged between and and had been living in the area for between seven months and years. one participant was asian and the remaining participants were white. eight participants were living alone, and the others lived with at least one other person (a spouse/partner ± extended family). with the exception of one participant who was working part-time, all participants were retired. recruitment was via face-to-face conversations at community events and locations (such as a weekly café held in a local church) and contact details shared by community groups and organisations based in the area. we made substantial efforts to achieve a sample with greater ethnic diversity, including seeking assistance from individuals running local organisations and groups for people from non-white backgrounds, and posters in local culturally diverse food and clothing shops. we also made provisions for language translation in interviews. however, in the time available, we were unable to identify additional people from different ethnic groups who were willing to take part in an interview. longer-term development of relationships within the community would likely be needed to increase interest and trust, which was not possible in a study of this scale. all potential participants were given an information sheet about the study and a copy of the consent form to read. interviews were arranged at times to suit participants, and they were offered a choice of location. one participant chose to meet for their interview in a community building and all other interviews were conducted in people's own homes. after completing the consent form and giving an opportunity for the interviewee to ask any questions, we audio-recorded the interview with the participant's agreement. interviews were conducted by jl, hs or np. we initiated the interviews with a narrative approach, asking individuals to tell the story of their social lives since they had been living in the area. this facilitated the exploration of each individual's own concerns, meanings and priorities related to their social lives, rather than these being imposed by predetermined questions [ ] . the same question was asked at the beginning of each interview: 'can you please tell me the story of your social life while you've been living in [this area]; your relationships with family, friends, neighbours and other people?'. participants were asked to talk about any events and experiences that were important for them, and invited to take as long as long as they needed to tell their story. this narrative section of the interview was followed by supplementary probing questions to explore areas of particular interest, including the role of technology in their social lives. these questions were not pre-defined in order that interviewers were free to explore anything that they felt was of interest and relevant to the overall aims of the study, maintaining a natural and spontaneous flow within the interview. brief reflective field notes were made by interviewers after each interview. electronic data files were stored in password-protected folders in the university filestore. interview recordings were transcribed and names were anonymised. we then completed initial inductive coding [ ] of the data to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. codes were organised under themes, following the process outlined by braun and clarke [ ] . for example, codes such as 'places people used to socialise no longer exist', 'many buildings are not accessible', and 'there are few facilities' were grouped together under the theme 'few local places to socialise'. coding and theme development were completed independently by two researchers (j.l., n.p.) and then discussed and refined with all members of the research team. while all names used in this paper are pseudonyms, participants in photographs gave consent for their images to be included in research outputs. the second phase of the study comprised an ideation workshop. we drew on the following conclusions from our interview analysis when designing the workshop: • there were concerns and perceptions about local community connections and characteristics that offered opportunities for design; • our participants predominantly used technology to connect with family, or friends at a distance; existing local technological connections in their social lives were less obvious; • many participants were actively using a variety of technologies, but their willingness to do so depended on perceptions of unmet needs and balancing the negative aspects (additional work, potential contribution to face-to-face disconnection) in their everyday lives. we designed the workshop to explore and generate ideas to improve and optimise social connections in the local area, focusing on four of the opportunities we identified in our interview analysis. based on the in-depth understanding about participants' use and perceptions of technology that we gained from the interviews, we designed 'playful' workshop activities that deliberately did not ask participants explicitly to consider how technology could address issues in local social connections. instead, we wanted to begin by eliciting participants' thoughts about the best ways to tackle these issues before considering any technological needs that arose from these suggestions. this approach avoids the tendency of previous research to foreground technology at the start of the design process. by deliberately not seeking to design a technology or technological interface in this study, we could instead reflect on the potential needs or roles for technology once we knew what type of interventions our participants had suggested. our approach also fitted well with our desire to draw on participants' knowledge, experience and capacity for creative thinking, and was in keeping with our aim of developing approaches to promote connection with, not for, older people, prioritising their participation in a bottom-up design process. all interview participants were sent a postal invitation to the workshop. eleven individuals initially confirmed their availability and nine attended on the day ( women, men). these individuals were aged between and and had been living in the area for between and years. the workshop was held in a church hall in the local area and refreshments were provided. participants were asked to read and complete the consent form on arrival. consent to being photographed was optional. the workshop was structured around four opportunities to improve local social connections that we identified as themes through our interview analysis. each theme represented shared concerns and negative perceptions about local relationships, connections and characteristics of the area that participants had talked about. the four themes were 'few local places to socialise', 'not knowing neighbours well', 'absence of a shared community feeling', and 'activities on offer not always conducive to socialising or making new friends'. these themes were chosen to take forward in the workshop based on their content being both appealing and generic enough for all participants to engage with, regardless of their individual circumstances and experiences. in line with age-friendly models, our aim was for a bottom-up approach in which workshop attendees' participation and contributions were fundamental to the resulting design ideas [ ] . confronting ageist stereotypes, we also wanted to capitalise on participants' creative abilities and ingenuity along with their knowledge and experience as residents within the local area. in line with these priorities and our aim to explore participants' thoughts about how to improve connections at a local level without a specific focus on technology, we designed a range of playful ideation (idea-generating) activities to scaffold workshop discussions. choosing activities to maintain a 'playful mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [ ] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [ ] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. data collection in the workshop comprised ideas written by participants on the templates provided (see figure for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and sub-themes that captured the overall range, content and types of ideas [ ] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table outlines the four themes, along with linked examples from the interview data. data collection in the workshop comprised ideas written by participants on the templates provided (see figure for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and sub-themes that captured the overall range, content and types of ideas [ ] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table outlines the four themes, along with linked examples from the interview data. beginning with the first of the four themes, most participants reported that there were few places in the immediate local area that they could use for socialising beyond their own homes. they described how there was no central community centre in the area, and no clearly distinguishable main high street. perceptions about the lack of local options contrasted with participants' opinions about the venues, centres and cafés available in other areas where they felt that community spaces and cafés were prominent and actively used and adopted by people living there. some participants were happy to socialise at home, but others saw this as too much of a burden or did not feel comfortable inviting people into their home. a noteworthy and unique characteristic of the local area highlighted by participants was the historic covenant on the land in the vicinity, preventing any licensed premises or pubs from operating. in the face of limited options in terms of usable spaces, local churches often hosted (or were booked to host) activities and events. however, this itself was a deterrent to some participants who felt uncomfortable attending events that had a religious connection-even if religion was not intended to be part of the event, such as a community café. overall, the perspective was that the community's physical features and built environment did not facilitate face-to-face social activities and interactions. the second theme (not knowing neighbours well) did not apply to all interview participants. in fact, some participants described their neighbours as good friends. these interviewees lived in quieter, more spacious streets, accommodating larger houses with gardens. other interview participants felt very disconnected from their neighbours. those living in particularly 'neighbourly' streets were aware that their situations were unusual in the wider local area where different road and housing types and tenures were more dominant, and fewer longstanding residents were living alongside the same neighbours for extended time periods. population churn, the movement of people in and out of streets, was perceived as a factor influencing the extent to which participants knew their neighbours. growing families and the number of properties available to rent in the area were cited as reasons behind this movement. streets were often busy with traffic-a factor that participants identified as not being conducive to unplanned meetings or chats with neighbours. while the physical proximity of neighbours potentially offered the most geographically close opportunities for social interaction, this had not translated into actual interactions for many participants. in particular, participants indicated that local issues of population mobility and transport routes contributed to the under-development of these relationships. the essence of the third theme (a lack of shared community feeling) was expressed by many participants. some attributed the absence of community to the area's geographical characteristics and location within the wider city, including the proximity of a motorway and the absence of a central focal point, or main high street, in the area. interview participants also commented on the lack of interaction between people of different ethnic and cultural backgrounds, despite the fact that the area was home to a diverse population. some talked about how this had been a longstanding issue, first noticed when their children were at school. together, both the physical environment and the population makeup of the area appeared to contribute to participants feeling that there were physical and cultural divisions within the geographical community. the fourth theme illustrates the complexity of developing new connections and relationships that extend beyond acquaintanceship: activities on offer are not always conducive to socialising or making new friends. even when participants were meeting people and seeking new friendships, these interactions did not often translate into deeper relationships. some participants described attending regular or one-off activities where they felt that the type and format of sessions were not helpful for getting to know people. for example, the focus was on a particular activity so chatting was only possible during brief time periods while setting up or packing away. another barrier was that some participants were more passive than others, and did not initiate conversations or connections themselves. in addition, participants mentioned that the same volunteers or people were often involved in several different groups and activities, resulting in a smaller pool of people to form friendships with. in other instances, it was simply that occasional casual conversations participants had with others did not result in deeper friendships or relationships that were sustained or developed beyond interactions at the events themselves, and individuals, therefore, remained acquaintances. taken together, these themes demonstrate clear barriers in, and characteristics of, local community connections. the themes capture issues that were impacting on the quality and quantity of participants' relationships in the local area, offering opportunities for participatory design processes to address these. alongside identifying opportunities to improve connections at a local level, the other focus of our analysis of the interview data was on understanding more about participants' existing engagements with technology in relation to their social lives. this engagement ranged from minimal (i.e., landline telephone only) to extensive (including social media, real-time audio/video interactions and applications). we use eight central themes to capture participants' accounts of the existing roles that technology played, or did not, play in their social lives. these themes, and examples of the data that support them, are outlined in table . capturing and sharing images marie: "it's got an excellent camera. i use it as a camera because i'm useless at taking photographs otherwise." simon: "see, if marie uses a camera to take somebody's photograph, and eventually either cuts them in half or chops their head off, you know, which is-but, with this phone, it's absolutely brilliant." marie: "yes, yes." simon: "the pictures that she's taken when she's been on holiday and things, absolutely superb." "i get loads of photographs of the children when they're opening birthday presents. their mother takes a photograph and sends it with a comment on what they said when they were trying on things." (lynne) the first theme about the role of technology in interviewees' social lives focuses on its use to connect participants with people in geographically distant locations. in fact, many of the digitally mediated interactions described by participants bridged geographical distances. applications and platforms such as facetime, facebook and whatsapp (along with traditional landline phone calls) were commonly used to keep in touch with friends and family located in geographically separate locations. grandchildren were frequently mentioned as being a priority in seeking to connect face-to-face at a distance. while the financial savings of free long-distance technological connection were noted and appreciated by some, interviewees also reflected on the emotional value of being able to stay visually connected with loved ones. for claire, this connection even changed her perception of the duration of time passing between in-person interactions, making it feel like she had seen her son in person more recently than was the case in reality. in contrast to those using technology to bridge distances in order to maintain existing relationships, deborah was unusual among interviewees in that she had formed long-lasting friendships with people she met initially through the use of an online marketplace. as someone living alone in later life, she was using technology designed for one purpose (financial/accommodation transactions) to initiate and facilitate face-to-face interactions with strangers from geographically distant locations, offering the potential for developing new social relationships. our next theme encapsulates the role of technology in connecting family members and groups. family relationships were frequently discussed as examples of connections that were supported by technology, through informal chatting, sharing photographs or stories and news about day-to-day life events. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. whatsapp was often highlighted in this context, particularly for its usefulness in communicating with a group, and across generations. examples included whatsapp groups with interviewees, their children and partners, and grandchildren. these were sometimes longstanding groups for general communication, but at other times were set-up for a specific purpose, such as organising a birthday party. cross-generational interactions were also perceived as improving the connectedness of family members who had previously felt 'left out' of family communications. john described the example of his sister, who was previously less connected with other members of the family but could now see photographs and hear about what other members of the family were doing, without them needing to make a special effort to include her. technology was seen, in cases like this, as a solution to the barriers to instantaneous communication with family members with diverse and busy lives and routines. however, telephone calls were also important to participants as a way of keeping in touch, particularly with others who were nearer in age such as siblings or friends. in addition, paul expressed his unease at the invasive nature of commonly used apps and platforms which, for example, access lists of contacts from the device they are using or collect data to support targeted advertising. his use of whatsapp was 'reluctant' on this basis, but he acknowledged its usefulness in keeping in touch when his son was abroad, highlighting the trade-off he had to negotiate between privacy and connection. we did not ask participants explicitly about the ways in which they chose to record social interactions or events, but the use of in-built cameras in mobile phones featured in participants' accounts of the role of technology in their social lives. we have described this theme as 'capturing and sharing images'. the ease of taking photographs with a smartphone in comparison to using a camera was noted by some participants, facilitating them in documenting social occasions. moreover, despite his privacy concerns about the invasiveness of technology more generally, paul valued the fact that he was able to recover digital images from an automatic cloud backup after he accidentally deleted photos (documenting an international trip) from his mobile phone. photographs as mementos of experiences in participants' social lives, like paul's trip, were treasured. additionally, the act of sharing and receiving images was a central feature of participants' digital interactions, connecting participants with events and experiences when they were not physically present. after initially dismissing much technology (apart from facetime) as insignificant in her social life, claire later reflected that it did play a large role in how she organised and arranged social events and interactions. the theme of 'sharing information and making arrangements' draws on these organisational uses of technology described by interviewees. information was generally not necessarily shared on social networking sites or more visible platforms, but interactions commonly took place through instant messaging and other technological channels rather than solely in person. in fact, for marie, there were additional benefits to using technology as a tool for organising or making arrangements with people. she preferred the control that it gave her in contrast with the unpredictability and social awkwardness she experienced when talking on the phone. technology was mainly described by interviewees in terms of its role as a tool for connecting, or supporting connections between, people. conversely, several participants noted the ways in which technology itself was a dimension of their social life, offering an alternative to interactions with people. perhaps because of its dominant focus on portraying human lives and activities, jane felt that television was a more 'personal' type of technology. patricia and brenda watched television at times when other company or interaction was inaccessible. for patricia, this was at 'silly hours' of the day or night, whereas brenda described how she might watch television, dvds or listen to cds when she found herself alone or 'down'. there were particular times when others living in her housing development were more likely to be spending time with family, such as weekends, where she used music or television as a strategy to deal with loneliness. at the other end of the spectrum, simon tended to avoid face-to-face social activities and events with other people, preferring to spend time playing games or reading on his computer. there were two main ways that participants described technology as contributing to disconnection in terms of social interactions and events: its prevalence as a platform for information about events; and its disruptive potential during face-to-face interactions. sally used the internet but chose not to engage with social media for privacy and security reasons, but felt that this was increasingly disadvantaging her when it came to finding out about local events. she reflected on her reliance on other people to keep her informed, and the difficulties of being separate from the dominant route of information sharing via social media. for sally, information sharing was happening in a way that excluded her, meaning that she missed out on attending social activities and events that she would have chosen to go to otherwise. in contrast, liz highlighted the capacity of technology to disrupt social interactions themselves. she described both a friend's extensive use of a smartphone, and purely the presence of a phone (in use or not), as disrupting face-to-face interactions and impacting on their quality. sally's and liz's accounts indicated a reluctance to allow technology to become pervasive in everyday life, balanced against a recognition that there were places and circumstances where it could be beneficial. along with concerns about the potential for technology to disrupt relationships, the positive impacts of technology in participants' social lives were also, in some cases, accompanied by additional unwanted work. our penultimate theme, therefore, centres around experiences of technological interaction as an additional 'chore'. sally described being 'bombarded' by messages, and she and others found their perceived continual need to respond and interact electronically to be a burden. the perpetual nature of communicating using interactive technologies such as email, texts and instant messages was also unpopular with some interviewees because of the amount of time it consumed. responding was not perceived as an optional activity. even if emails contained welcome content, the task of checking, opening and reading them was viewed as a compulsory individual task and responsibility. catherine likened this to the responsibility to open letters that came through the post, rather than a choice or pleasurable activity. our final theme sums up participants' thoughts about not needing digital technologies. more traditional technologies such as the telephone or television were commonly accepted as integral to daily life. in fact, their deep-seated role in participants' social lives meant that they were often no longer considered or mentioned (by participants) when talking about technology. instead, participants tended to focus on newer digital technologies such as social media, applications and email. regarding these more modern technologies, there was a sense for some participants that they were unnecessary. for example, when talking about social media, liz explained that she did not 'think there's a gap that i need them.' christopher used the internet and email but did not consider it necessary to go online to find out about local social events as he was exposed to paper-based publicity, such as posters and flyers, as well as information via word-of-mouth. for judith, the whole idea of using a computer or the internet was superfluous when she could instead rely on her family for support, asking them for anything she needed. overall, technological connections were predominantly bridging distances, with existing local technological connections less obvious. technology was mainly seen as a tool to be used to make connecting easier where there were needs, barriers or 'gaps' (geographical or generational distances, difficulties sharing information, capturing images, avoiding uncomfortable face-to-face interactions), but not at the expense of disrupting desired face-to-face interactions or in situations where technology was seen as unnecessary (other strategies would suffice). in addition, the additional work required to use technology as an aid to connection was an unwanted consequence. willingness to use technology depended on balancing the positive and negative aspects. as described earlier, the workshop was designed to build on the findings from our interviews. an extensive list of ideas was generated through our ideation activities, which we combined and organised under themes and sub-themes. table summarises the themes and sub-themes identified in our analysis of the written workshop data. participants commented that the workshop had been enjoyable and thought-provoking-an outcome that supports us in challenging ageist stereotypes of older people as unable or unwilling to engage in creative, disruptive or wild thinking. the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up the three main themes we use to understand the workshop data are: social spaces and places; processes to promote social interactions; mechanisms to drive change. these themes capture different dimensions of participants' ideas for facilitating social interactions in the local area. ideas varied in both scale and scope (see table for examples). the first theme describes ideas that related to the physical environment and developing spaces and places to promote interactions. the proposed changes were either to directly provide locations for organised or informal activities to take place, or to change environmental factors to increase the likelihood of people meeting and connecting in their everyday lives. ideas for developing locations for activities included making better use of existing spaces as well as creating new spaces or places. residents suggested taking advantage of the large areas of green space that were nearby and using them in new ways. they also thought that new community premises, such as a community centre, would be helpful. ideas to change other environmental factors included improving the environment for pedestrians and improving security of tenure to increase the length of time that people are resident in the same location before moving home. while some ideas residents suggested were more generic, others were particularly context-specific. participants drew on their local knowledge to consider what resources in the local area could be used, and identified other resources that were lacking. table . themes from workshop data analysis. making better use of existing geographical features and spaces for social purposes, such as large areas of green space (e.g., figure ) longer opening hours e.g., library marquees/undercover spaces in parks etc., for rainy days make better use of open/green spaces for community activities e.g., exercise equipment, open a beach, more benches, ice cream vans to encourage use of parks new transport options to support travel in the immediate local area and into the city centre frequent, small scale local transport e.g., minibus every min extend the metro into the area to improve access to city focusing on proximate relationships i.e., at a street level or between those volunteering at the same events, as well as at the community level encourage greater walking in area e.g., parents taking children to school encourage volunteers to build friendships/relationships outside volunteering activities/context street level interventions e.g., street meetings/cups of tea, annual events community-driven/commissioned or cooperative initiatives around social spaces, information provision, transport and learning/training community/cooperative/volunteer-run hospitality venues buy a property on a co-operative basis and use as community resource/café/party venue community uber-style, tandems/sidecars or other forms of 'fun' transport, bike sharing, motorcycle lessons-teaching/learning/using transport cafes that also operate as training kitchen for cooking healthily, training in basic work skills by involvement in running community hub incentives to: sustain and attract small catering and hospitality businesses to the local area; encourage local people to participate in social activities increase incentives for small catering/hospitality businesses e.g., no rates/taxes for first years after opening happy hours in cafes etc., with free tea/coffee/cake, sponsored by local businesses credits for free attendance at social activities for residents e.g., swimming pool on particular days/times/a month, extra credits could be earned through volunteering dedicated time slots for social and/or physical activity/exercise time finding ways of improving the commitment and contributions of individuals to the local area to create and sustain a sense of community commitment of individuals to community e.g., minimum number of community work hours/community service and strategy to deal with those who do not contribute, volunteers to supervise weekend sporting activities for children, create sense of community between residents/students the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up component that precedes design of technological outputs. we begin our discussion of the findings from this study by considering the interview data, and their position in relation to wider debates and literature around technology and social interaction in later life. we then move on to discuss what the ideas generated by workshop participants offer in terms of implications, scope and challenges for future technology design around social connectedness, particularly when considered in the context of the interview findings. we use three sub-themes from the workshop (making better use of existing geographical places and spaces; focusing on proximate relationships; community driven/commissioned or cooperative initiatives) as examples to avoid our discussion of implications and challenges for future technology design being too generic, and to ensure that our focus remains on designing in the particular context of our research community and participants. within an age-friendly context, our analysis of interview data identifies a number of opportunities to design for increased social connectedness within local communities. participants felt that: there were few local places to socialise; they often did not know their neighbours well; there was an absence of shared community feeling; social activities on offer did not always lead to socialising or making new friends. in a policy and practice environment where technology-based initiatives are increasingly perceived as offering huge potential, our findings highlight the importance of age-friendly approaches that are grounded in the local context [ , ] . this has become even more apparent during the covid- pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, including with people in proximate locations, has become even more important in ways we did not anticipate when conducting this study. every community is unique, so designing to optimise social connectedness at a local level requires understanding and recognition of context-specific characteristics. in addition, taking account of the social and structural particularities of places gives insight into meanings and functions that are the result of cumulative experiences over time [ ] . in our study, the geographical layout of the community, restrictions on licensed premises and population churn were all factors that participants highlighted as playing a role in disconnection. however, these issues can also be seen as 'leverage points' where interventions could afford the greatest benefits within a specific local context [ ] . our interview data also contribute to understanding more about how older people use and perceive technology in their social lives. unlike dickinson and hill's findings in that older people did not engage with instant messaging or other forms of computer technology aside from email [ ] , participants connected using a range of methods and formations of communication. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. participants were not necessarily using social networking sites to share information, as righi et al. [ ] also found, but in our study these information-sharing interactions were commonly taking place through instant messaging and other technological channels rather than solely in person. these findings reflect changing levels of digital connection for older people in the uk [ ] and emphasise the need for hci to reconsider longstanding stereotypes of older people as digitally inexperienced or uninterested [ ] . the covid- pandemic has provided further evidence to counter these outdated stereotypes, with many older people embracing technology to facilitate connections with friends and family at a time when face-to-face meetings have been restricted. yet, while participants in our study made regular use of technology to support their connections with others, this use was carefully considered. technology was not, in itself, an attractive prospect unless it was perceived to fill a 'gap' and the 'chore' of using it did not overly impact on everyday life. similarly, lindley et al. reported that older people were cautious of the time commitments required to use technologies, although they also used technology as a way to manage levels of contact and control their own availability to other people [ ] . in addition, participants in our study were aware of the potential for technology to contribute to disconnection. waycott et al. [ ] reflect that the mismatching of values and assumptions guiding a technology-based social intervention with those of the older adults participating in the evaluation, noticeably contributed to individual decisions not to participate. in an increasingly digital society, our findings again indicate the importance of design processes that are in tune with the perceptions and values of older adults. marston and van hoof draw our attention to the fact that the world health organization's age-friendly cities model does not explicitly consider the role of technology [ , ] . by adopting a lens of age-friendliness, studies like ours can ensure that methods and processes are rooted in opportunities, concerns and 'gaps' that are relevant and engaging to participants. consequently, we put forward an amended definition that highlights the need for explicit and thoughtful consideration of the role of technology in an age-friendly setting: underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure. another contribution of our work comes from its findings about the potential for technology to contribute to building and strengthening connections in geographically-bounded communities. the combination of shared local concerns and opportunities for improving connections, combined with the knowledge that technology was infrequently used to sustain or support local connections, suggests this is a design space worth exploring. participants in this study were comfortable using digital technology to stay in touch with friends and family in geographically distant locations, particularly to maintain close family connections. kharicha et al. also found that engagement with the outside world by landline telephones and computers was an important strategy adopted by older people experiencing loneliness [ ] . for this reason, it would seem plausible that technology to facilitate local, proximate, connections and social lives would also be acceptable, should it fill perceived gaps and not lead to unacceptable levels of additional effort. the methods we used in the workshop were intended to encourage 'playful' creativity, and they were successful in their purpose of generating a wide range of ideas as well as being acceptable and enjoyable for participants. in future, we would consider adapting these methods to reduce their paper-based nature, further enhancing their potential for prompting creative thinking by participants. exploring options beyond face-to-face participation may also be important in the context of covid- and its aftermath. drawing the interview findings together with one sub-theme from each of the themes we used to organise the ideas generated by workshop participants, we suggest a number of ways in which technology might support greater face-to-face connection in local community contexts and operationalise local people's ideas. by deliberately not placing technology in the foreground in the workshop, we contend that participants' ideas (technological or otherwise) about how to tackle local issues are more likely to align with their own values and perceptions, meaning that any technological needs that arise from these suggestions will be filling 'gaps' rather than technology being introduced as the automatic interface in connection. we maintain that design processes and spaces should be context-specific and bottom-up, but summarise general implications that offer scope for further exploration and consideration in community settings. workshop participants expressed interest in re-purposing spaces in the local area that they felt were underused, or offered potential as social spaces. this ranged from using existing green spaces or buildings on a permanent or temporary basis, to creating new spaces and places for social activities and events. a real-life example of creative use of space by older people that challenges expectations and norms was the transformation (for one night only) of a nightclub in manchester, uk, into a night-time venue reserved for older people [ ] . in our study, there were suggestions that spaces could be acquired or managed by groups of local residents as cooperative initiatives. such work is ongoing in virtual spaces by older people in the uk creating a radio network [ ] . other adaptations to the built environment were also suggested by participants to improve suitability for pedestrians. however, operationalising these ideas and coordinating the input of the local community presents challenges at many levels. while online platforms to facilitate community commissioning of digital services exist [ ] , it is not immediately clear that these tools and processes would translate to local community commissioning of resources and events. moreover, it is unrealistic to expect the required intense interaction with such digital platforms, leading to the need for alternative situated means of participating and engaging in the processes. given the interest by study participants in leveraging local infrastructures and spaces, it is plausible to consider situated artefacts that would mediate between local, physical, and online engagements. for example, postervote is an innovative electronic polling system aiming to provide easy electronic voting for communities [ ] . a traditional poster is augmented with buttons that can be pressed by community members to register digital responses to questions on the poster. providing infrastructure for residents to have greater input and control over the provision of their immediate local environments would facilitate their participation in the process of age-friendliness at a community level. while our workshop focussed on connections at a local i.e., electoral ward level, some discussions were about connecting with people who were located very close nearby or even physically 'connected' by living on the same street. in fact, two participants expressed surprise on discovering that they had both been living in the area for many years a few houses apart on adjacent streets, yet they had never interacted before. concerns about safety, privacy and possible lack of interest by others were mentioned as barriers to interventions at a street level. in recent years, we have witnessed a surge in location-based and serendipitous dating/meet-up services and networks (i.e., tinder [ ] ). the core functionalities of these technologies are the abilities to discover similar individuals in your local area; privately extend an invitation to initiate a conversation; whilst maintaining a degree of privacy and safety through the network's services (not revealing personal details such as address or phone number). such solutions would have scope to support the hyper-local match-making of friendships within communities. however, our research showed that participants were not using existing online services designed to develop new relationships, indicating that these did not appeal. this is echoed by findings that older people who were lonely did not report using the internet to cultivate new friendships, despite using telephones and computers to engage with the outside world [ ] . in fact, one participant, deborah, had instead capitalised on the ability of an accommodation matching platform to facilitate face-to-face interactions in her home with strangers, who then had the potential to become friends. the opportunity for such encounters (through mutually beneficial financial, or other resource, transactions) to result in long-lasting friendships is an area for further exploration. in particular, it would be interesting to consider how these types of interaction could be translated into a purely local context, given that deborah's formation of new friendships contrasts with experiences of those in our study who attended regular local activities but did not find them conducive to making friends. the findings from our study indicate an opportunity for design around community or cooperative ways of addressing local transport gaps. a number of ideas generated by workshop participants related to improving transport in the immediate local area in order to facilitate connection to physical spaces and locations to meet other people. community or cooperative initiatives were suggested as one option, or mechanism, for driving new models of transport in the area. volunteer-run minibus and car transport did exist in the local area, but these prioritised 'essential' travel such as hospital appointments and did not have the flexibility that participants thought important. while existing schemes (e.g., streetbank [ ] -a website that facilitates possession sharing and borrowing between neighbours) have been successful in meeting other needs at a very local level, hyper-local journeys in suburban communities outside busy city centres are unlikely to offer sufficient cost/profit ratios to be attractive to existing sharing economy or peer-to-peer services such as uber. a small number of demand responsive transport (drt) schemes are running in the uk, and in theory sound promising. however, it is notable that a drt service actually operated in our study area in the past, but closed in [ , ] . similarly, existing bicycle sharing schemes rely on scale of use within large communities or cities to remain profitable, but in contrast, restricted access to a smaller population might reduce the risk of damage and loss experienced by larger scale operations. consideration of what a hyper-local transport system might look like would include questions about who might provide and use the service, and what their incentives would be. participants in this study also suggested teaching, learning and training opportunities as potentially playing a role. this is another avenue for exploration in future technology design which could serve the dual purposes of creating new connections between those learning and teaching, as well as the transport itself facilitating connections between people living in the area. our study adopted an age-friendly, bottom-up approach to explore opportunities for facilitating social connectedness for older adults in a local community context. we focused on specific community issues that could be addressed and considered the physical, social and structural mechanisms (potentially mediated or supported by technology) that might offer routes to tackling these. by understanding more about our participants' current use and perspectives on the role of technology in their social lives, we highlight a need for design work to reduce emphasis on technology as the interface between people. in contrast to previous work, we focus on connection between people in geographically close locations. we also demonstrate the importance of understanding the specific local context within which any technological interventions will take place. our findings reflect changing patterns of technology use among older adults in the uk, suggesting that adoption of new technology is acceptable when it fills gaps and does not create intrusive levels of additional work or contribute to disconnection. our modified definition of age-friendliness highlights a need for the explicit and thoughtful consideration of the role of technology. we identify topics for consideration by those seeking to design with local communities, and make the case for an age-friendly approach to designing (digital) interventions to address social connectedness in later life. world health organization. global age-friendly cities: a guide; world health organization what makes a community age-friendly: a review of international literature exploring the age-friendliness of purpose-built retirement communities: evidence from england evolving images of place in aging and 'aging-in-place how should we tackle the loneliness epidemic is loneliness a health epidemic lonely older people as a problem in society-construction in finnish media prime minister's office; office for civil society; the rt hon theresa may mp. pm commits to government-wide drive to tackle loneliness the firekeepers: aging considered as a resource never too old older voices: supporting community radio production for civic participation in later life researching age-friendly communities: stories from older people as co-investigators an age-old problem: examining the discourses of ageing in hci and strategies for future research friends or frenemies? the role of social technology in the lives of older people an investigation into the patterns of loneliness and loss in the oldest old-newcastle + study being alone in later life: loneliness, social isolation and living alone the high cost of isolation the social connectedness of older adults: a national profile the importance of social connectedness in building age-friendly communities assistive technology, computers and internet may decrease sense of isolation for homebound elderly and disabled persons ethnographic research on the experience of japanese elderly people online tales of the map of my mobile life: intergenerational computer-mediated communication between older people and fieldworkers in their early adulthood multimodal computer-mediated communication and social support among older chinese internet users desiring to be in touch in a changing communications landscape tsunagari-kan" communication: design of a new telecommunication environment and a field test with family members living apart keeping in touch: talking to older people about computers and communication older people's use of social network sites while participating in local online communities from an ethnographical perspective age-friendly cities and communities: a manifesto for change ageing in urban environments: developing 'age-friendly' cities the who global network of age-friendly cities and communities: origins, developments and challenges. in age-friendly cities and communities in international comparison interviewing for social scientists office for national statistics research interviewing: context and narrative using thematic analysis in psychology les villes amies des aînés au québec: un mouvement de changement à large échelle en faveur des aînés experiences of place and neighbourhood in later life: developing age-friendly communities not for me: older adults choosing not to participate in a social isolation intervention who doesn't think about technology when designing urban environments for older people? managing loneliness: a qualitative study of older people's views an alternative age-friendly handbook later life audio and radio network proceedings of the chi conference on human factors in computing systems good practice guide: transport and social inclusion we thank all participants who took part in this research. our appreciation also goes to cathrine degnen for her involvement in the design, planning and acquisition of funding for the study, and to drake long, meena nanduri and marlo owczarzak for their support in facilitating the workshop. the authors declare no conflict of interest. key: cord- -ppu idl authors: russo, daniel; hanel, paul h. p.; altnickel, seraphina; berkel, niels van title: predictors of well-being and productivity among software professionals during the covid- pandemic -- a longitudinal study date: - - journal: nan doi: nan sha: doc_id: cord_uid: ppu idl the covid- pandemic has forced governments worldwide to impose movement restrictions on their citizens. although critical to reducing the virus' reproduction rate, these restrictions come with far-reaching social and economic consequences. in this paper, we investigate the impact of these restrictions on an individual level among software engineers currently working from home. although software professionals are accustomed to working with digital tools, but not all of them remotely, in their day-to-day work, the abrupt and enforced work-from-home context has resulted in an unprecedented scenario for the software engineering community. in a two-wave longitudinal study ($n~=~ $), we covered over psychological, social, situational, and physiological factors that have previously been associated with well-being or productivity. examples include anxiety, distractions, psychological and physical needs, office set-up, stress, and work motivation. this design allowed us to identify those variables that explain unique variance in well-being and productivity. results include ( ) the quality of social contacts predicted positively, and stress predicted an individual's well-being negatively when controlling for other variables consistently across both waves; ( ) boredom and distractions predicted productivity negatively; ( ) productivity was less strongly associated with all predictor variables at time two compared to time one, suggesting that software engineers adapted to the lockdown situation over time; and ( ) the longitudinal study did not provide evidence that any predictor variable causal explained variance in well-being and productivity. our study can assess the effectiveness of current work-from-home and general well-being and productivity support guidelines and provide tailored insights for software professionals. the mobility restrictions imposed on billions of people during the covid- pandemic in the first half of successfully decreased the reproduction rate of the virus [ , ] . however, quarantine and isolation also come with tremendous costs on people's well-being [ ] and productivity [ ] . for example, the psychosocial consequences of covid- mitigation strategies have resulted in an estimated average loss of . years of life [ ] . while prior research [ ] has identified numerous factors either positively or negatively associated with people's well-being during disastrous events, most of this research was cross-sectional and included a limited set of predictors. further, whether productivity is affected by disastrous events and, if so, why precisely, has not yet been investigated in a peer-reviewed article to the best of our knowledge. this is especially relevant since many companies, including tech companies, have instructed their employees to work from home [ ] at an unprecedented scope. thus, it is unclear whether previous research on remote work [ ] still holds during a global pandemic while schools are closed, and professionals often have to work in non-work dedicated areas of their homes. it is particularly interesting to study the effect of quarantine on software engineers as they are often already experienced in working remotely, which might help mitigate the adverse effects of the lockdown on their well-being and productivity. therefore, there is a compelling need for longitudinal applied research that draws on theories and findings from various scientific fields to identify variables that uniquely predict the well-being and productivity of software professionals during the quarantine, for both the current and potential future lockdowns. the software engineering community has never before faced such a wide-scale lockdown and quarantine scenario during the global spread of the covid- virus. as a result, we can not build on pre-existing literature to provide tailored recommendations for software professionals. accordingly, in the present research, we integrate theories from the organizational [ ] and psychological [ , ] literature, as well as findings from research on remote work [ , , ] and recommendations by health [ , ] and work [ ] authorities targeted at the general population. this longitudinal investigation provides the following contributions: -first, by including a range of variables relevant to well-being and productivity, we are able to identify those variables that are uniquely associated with these two dependent variables for software professionals and thus help improve guidelines and tailor recommendations. -second, a longitudinal design allows us to explore which variables predict (rather than are predicted by) well-being and productivity of software professionals. -third, the current mobility restrictions imposed on billions of people provide a unique opportunity to study the effects of working remotely on people's well-being and productivity. our results are relevant to the software community because the number of knowledge workers who are at least partly working remotely is increasing [ ] , yet the impact of working remotely on people's health and productivity is not well understood yet [ ] . we focus on well-being and productivity as dependent variables because both are crucial for our way of living. well-being is a fundamental human right, according to the universal declaration of human rights, and productivity allows us to maintain a certain standard of living and thus also affects our overall well-being. thus, our research question is: research question: what are relevant predictors of well-being and productivity for software engineers who are working remotely during a pandemic? in the remainder of this paper, we describe the related work about wellbeing in quarantine and productivity in remote work in section , followed by a discussion about the research design of this longitudinal study in section . the analysis is described in section , and results discussed in section . implications and recommendations for software engineers, companies, and any remote-work interested parties is then outlined in section . finally, we conclude this study by outlying future research directions in section . to slow down the spread of pandemics, it is often necessary to quarantine a large number of people [ , ] and enforce social distancing to limit the spread of the infection [ ] . this typically implies that only people working in essential professions such as healthcare, police, pharmacies, or food chains, such as supermarkets, are allowed to leave their homes for work. if possible, people are asked to work remotely from home. however, such measures are perceived as drastic and can have severe consequences on people's well-being [ , ] . previous research has found that being quarantined can lead to anger, depression, emotional exhaustion, fear of infecting others or getting infected, insomnia, irritability, loneliness, low mood, post-traumatic stress disorders, and stress [ , , , , , ] . the fear of getting infected and infecting others, in turn, can become a substantial psychological burden [ , ] . also, a lack of necessary supplies such as food or water [ ] and insufficient information from public health authorities adds on to increased stress levels [ ] . the severity of the symptoms correlated positively with the duration of being quarantined and symptoms can still appear years after quarantine has ended [ ] . this makes it essential to understand what differentiates those whose mental health is more negatively affected by being quarantined from those who are less strongly affected. however, a recent review found that no demographic variable was conclusive in predicting whether someone would develop psychological issues while being quarantined [ ] . moreover, prior studies investigating such predictors focused solely on demographic factors (e.g., age or number of children [ , ] ). this suggests that additional research is needed to identify psychological and demographic predictors of well-being. for example, prior research suggested that a lack of autonomy, which is an innate psychology need [ ] , negatively affects people's well-being and motivation [ ] , yet evidence to support this claim in the context of a quarantine is missing. to ease the intense pressure on people while being quarantined or in isolation, research and guidelines from health authorities provide a range of solutions on how an individual's well-being can be improved. some of these factors lie outside of the control for individuals, such as the duration of the quarantine, or the information provided by public authorities [ ] . in this study, we therefor focus on those factors that are within the control of individuals. however, investigating such factors independently might make little sense since they are interlinked. for example, studying the relations between anxiety and stress with well-being in isolation is less informative, as both anxiety and stress are negatively associated with well-being [ , ] . however, knowing which of the two has a more substantial impact on people's well-being above and beyond the other is crucial, as it allows inter alia policymakers, employers, and mental health support organizations to provide more targeted information, create programs that are aimed to reduce people's anxiety or stress levels, and improve people's well-being, since anxiety and stress are conceptually independent constructs. thus, it is essential to study these variables together rather than separately. the containment measures not only come at a cost for people's well-being but they also negatively impact their productivity. for example, the international monetary fund (imf) estimated in june that the world gdp would drop by . % as a result of the containment measures taken to reduce the spread of covid- -with countries particularly hit by the virus, such as italy, would experience a drop of over % [ ] . this expected drop in gdp would be significantly larger if many people were unable to work remotely from home. however, previous research on the impact of quarantine typically focused on people's mental and physiological health, thus providing little evidence on the effect on productivity of those who are still working. luckily, the literature on remote work, also known as telework, allows us to get a broad understanding of the factors that improve and hinder people's productivity during quarantine. the number of people working remotely has been growing in most countries already before the covid- pandemic [ , ] . of those working remotely, % do so for all of their working time. the vast majority of remote workers, % would recommend others to do the same [ ] , suggesting that the advantages of remote work outweigh the disadvantages. the majority of people who work remotely do so from the location of their home [ ] . working remotely has been associated with a better work-life balance, increased creativity, positive affect, higher productivity, reduced stress, and fewer carbon emissions because remote workers commute less [ , , , , , , ] . however, working remotely also comes with its challenges. for example, challenges faced by remote workers include collaboration and communication (named by % of , surveyed remote workers), loneliness ( %), not being able to unplug after work ( %), distractions at home ( %), and staying motivated ( %) [ ] . while these findings are informative, it is unclear whether they can be generalized. for instance, if mainly those with a long commute or those who feel comfortable working from home might prefer to work remotely, it would not be possible to generalize to the general working population. a pandemic such as the one caused by covid- in forces many people to work remotely from home. being in a frameless and previously unknown work situation without preparation intensifies common difficulties in remote work. adapting to the new environment itself and dealing with additional challenges adds on to the difficulties already previously identified and experienced by remote workers, and could intensify an individual's stress and anxiety and negatively affect their working ability. the advantages of remote work might, therefore, be reduced or even omitted. substantial research is needed to understand further what enables people to work effectively from home while being quarantined [ ] . the current situation shows how important research in this field is already. forecasts indicate that remote work will grow on an even larger scale than it did over the past years [ , ], therefore research results on predictors of productivity while working remotely will increase in importance. some guidelines have been developed to improve people's productivity, such as the guidelines proposed by the chartered institute of personnel and development, an association of human resource management experts [ ] . examples include designating a specific work area, wearing working clothes, asking for support when needed, and taking breaks. however, while potentially intuitive, empirical support for those particular recommendations is still missing. adding to the complexity, the measurement of productivity, especially in software engineering, is a debated issue, with some authors suggesting not to consider it at all [ ] . nevertheless, individual developer's productivity has a long investigation tradition [ ] . prior work on developer productivity primarily focused on developing software tools to improve professionals' productivity [ ] or identifying the most relevant predictors, such as task-specific measurements and years of experience [ ] . similarly, understanding relevant skillsets of developers that are relevant for productivity has also been a typical line of research [ ] . eventually, as la toza et al. pointed out, measuring productivity in software engineering is not just about using tools; instead, it is about how they are used and what is measured [ ] . in the present research, we build on the literature discussed above to identify predictors of well-being and productivity. additionally, we also include variables that were identified as relevant by other lines of research. furthermore, we chose a different setting, sampling strategy, and research design than most of the prior literature. this is important for several reasons. first, many previous studies included only one or a few variables, thus masking whether other variables primarily drive the identified effects. for example, while boredom is negatively associated with well-being [ ] , it might be that this effect is mainly driven by loneliness, as lonely people report higher levels of boredom [ ] -or vice versa. only by including a range of relevant variables, it is possible to identify the primary variables, which can subsequently be used to write or update guidelines to maintain one's well-being and productivity while working from home. second, this approach simultaneously allows us to test whether models developed in an organizational context such as the two-factor theory [ ] can also predict people's well-being in general and whether variables that were associated with well-being for people being quarantined also explain productivity. third, while previous research on the (psychological) impact of being quarantined [ ] is relevant, it is unclear whether this research is generalizable and applicable to the covid- pandemic. in contrast to previous pandemics, during which only some people were quarantined or isolated, the covid- pandemic strongly impacted billions globally. for example, previous research found that people who were quarantined were stigmatized, shunned, and rejected [ ] ; this is unlikely to repeat as the majority of people are now quarantined. fourth, research suggests [ ] that pandemics become increasingly likely due to a range of factors (e.g., climate change, human population growth) which make it more likely that pathogens such as viruses are transmitted to humans. this implies that it would be beneficial to prepare ourselves for future pandemics that involve lockdowns. fifth, the trend to remote work has been accelerated through the covid- pandemic [ ] , which makes it timely to investigate which factors predict well-being and productivity while working from home. the possibility to study this under extreme conditions (i.e., during quarantine), is especially interesting as it allows us to include more potential stressors and distractors of productivity. this is critical. as outlined above, previous research on the advantages and challenges of remote work can presumably not be generalized to the population because mainly people from certain professions and specific living and working conditions might have chosen to work remotely. sixth and finally, a longitudinal design allowed us to test for causal inferences. specifically, in wave , we identified variables that explain unique variance in well-being and productivity, which we measured again in waves . this is important because it is possible that, for example, the amount of physical activity predicts well-being or that well-being predicts physical activity. additionally, we are able to test whether well-being predicts productivity or vice versa -previous research found that they are interrelated [ , ] . the variables we are planning to measure in the present longitudinal study are displayed in figure . to facilitate its interpretation, we categorized the variables in four broad sets of predictors, which are partly overlapping. we include all variables related to people's well-being and productivity that we discussed above and measured on an individual level. to summarize, while the initial selection of predictors is theory-driven, based on previous research, or recent guidelines, the selection of predictors included in the second wave is data-driven. during the covid- pandemic, many governments and organizations have called for volunteers to support self-isolation (see, for example, [ , ] ). while also relevant to the community at large, research suggests that acts of kindness have a positive effect on people's well-being [ ] . additionally, volunteering has the benefit of leaving one's home for a legitimate reason and reducing cabin fever. we therefore decided to include volunteering as a potential predictor for well-being. coping strategies such as making plans or reappraising the situation are, in general, effective for one's well-being [ , ] . for example, altruistic acceptance -accepting restrictions because it is serving a greater good -while being quarantined was negatively associated with depression rates three years later [ ] . conversely, believing that the quarantine measures are redundant because covid- is nothing but ordinary flu or was intentionally released by the chinese government (i.e., beliefs in conspiracy theories), will likely lead to dissatisfaction because of greater feelings of non-autonomy. indeed, beliefs in conspiracy theories are associated with lower well-being [ ] . we further propose that three needs are relevant to people's well-being and productivity [ , ] . specifically, we propose that the need for autonomy and competence are deprived of many people who are quarantined, which negatively affects well-being and motivation [ ] . further, we propose that the need for competence was deprived, especially for those people who cannot maintain their productivity-level. this might especially be the case for those living with their families. in contrast, the need for relatedness might be over satisfied for those living with their family. another important factor associated with one's well-being is the quality of one's social relationships [ ] . as people have fewer opportunities to engage with others they know less well, such as colleagues in the office or their sports teammates, the quality of existing relationships becomes more important, as having more good friends facilitates social interactions either in person (e.g., with their partner in the same household) or online (e.g., video chats with friends). moreover, we expect that extraversion is linked to well-being and productivity. for example, extraverted people prefer more sensory input than introverted people [ ] , which is why they might struggle more with being quarantined. extraversion correlated negatively with support for social distancing measures [ ] , which is a proxy of stimulation (e.g., being closer to other people, will more likely result in sensory stimulation). finally, research on predictors of productivity while working from home can be theoretically grounded in models of job satisfaction and productivity, such as herzberg's two-factor theory [ ] . this theory states that causes of job satisfaction can be clustered in motivators and hygiene factors. motivators are intrinsic and include advancement, recognition, work itself, growth, and responsibilities. hygiene factors are extrinsic and include the relationship with peers and supervisor, supervision, policy and administration, salary, working conditions, status, personal link, and job security. both factors are positively associated with productivity [ ] . as there are little differences between remote and on-site workers in terms of motivators and hygiene factors [ ] , the two-factor theory provides a good theoretical predictor of productivity of people working remotely. in our two-wave study, we are covering an extensive set of predictors, as identified above. based on the literature mentioned earlier, we expected the strength of the association between the predictors and the outcomes' well-being and productivity to vary between medium to large. therefore, we assumed for our power analysis a medium-to-large effect size of f = . and a power of . . power analysis with g*power . . . [ ] revealed that we would need a sample size of participants. to ensure data quality and consistency, and to account for potential dropout in participants between the two waves, we invited almost participants who were identified as software engineers in a previous study [ ] to participate in a screening study in april . to collect our responses, we used prolific, a data collection platform, commonly used in computer science (see e.g., [ ] ). we opted for this solution because of the high reliability, replicability, and data quality of dedicated platforms, especially compared with the use of mailing lists [ , ] . to administer the surveys, we used qualtrics and shared it on the prolific platform. the screening study was tailored for the covid- pandemic and was completed by professionals. here, we aimed to select only participants from countries where lockdown measures where put into place. countries with unclear, mixed policies or early reopening (e.g., denmark, germany, sweden) were excluded. similarly, our participants were supposed to actively work from home during the lockdown for more than h a week. in the first wave of data collection, which took place in the week of april - , participants completed the first survey. participation in the second wave (may - ) was high ( %), with completed surveys. participants have been uniquely identified through their prolific id, which was essential to run the longitudinal analysis while allowing participants to remain anonymous. in each survey, we included three test items (e.g., "please select response option 'slightly disagree"'). moreover, we controlled if the participants were still working from home in the reference week and if lockdown measures were still in place in their respective countries. as none of our participants failed at least two of the three test items, all participants reported working remotely and answered the survey in an appropriate time frame, and we did not exclude anyone. the mean age of the participants was . years (sd = . , range = ; women, men). participants were compensated in line with the current us minimum wage (average completion time seconds, sd = . ). we employed a longitudinal design, with two waves set two-weeks apart from each other towards the end of the lockdown, which allowed us to test for internal replication. also, running this study towards the end of the lockdowns in the vast majority of countries allowed participants to provide a more reliable interpretation of lockdown conditions. we chose a period of two weeks because we wanted to balance change in our variables over time with the end of a stricter lockdown that was discussed across many countries when we run wave . many of our variables are thought to be stable over time. that is, a person's scores on x at time is strongly predictive of a person's scores on x at time (indeed, the test-retest reliabilities we found support this assumption, see table ). the closer the temporal distance between wave and , the higher the stability of a variable. in other words, if we had measured the same variables again after only one or two days, there would not have been much variance that could have been explained by any other variable, because x measured at time already explains almost all variance of x measured at time . in contrast, we aimed to collect data for wave while people were still quarantined. if at time of the data collection people would still be in lockdown and at time the lockdown would have been eased, this would have included a major confounding factor. thus, to balance those two conflicting design requirements, we opted for a two weeks break in between the two waves. we describe the measures of the two dependent (or outcome) variables in subsection . . predictors (or independent variables) are explained in subsections . , . , . , and . . wherever possible, we relied on validated scales. if this was not possible (e.g., covid- specific conspiracy beliefs), we created a scale. all items are listed in the supplemental materials. additionally, we also explore whether there are any mean changes in the variables we measured at both times (e.g., has people's well-being changed?) well-being was measured with an adapted version of the -item satisfaction with life scale [ ] . we adapted the items to measure satisfaction with life in the past week. example items include "the conditions of my life in the past week were excellent" and "i was satisfied with my life in the past week". responses were given on a -point likert scale ranging from (strongly disagree) to (strongly agree, α time = . , α time = . ). productivity was measured relative to the expected productivity. we contrasted productivity in the past week with the participant's expected productivity (i.e., productivity level without the lockdown). as we recruited participants working in different positions, including freelancers, we can neither use objective measures of productivity nor supervisor assessments and rely on self-reports. we expect limited effects of socially desirable responses as the survey was anonymous. the general understanding and the widespread belief that many people could not be as productive as they usually are during the lockdown in (e.g., due to stress or caring responsibilities). we operationalized productivity as a function of time spent working and efficiency per hour, compared to a normal week. specifically, we asked participants: "how many hours have you been working approximately in the past week?" (item p ), "how many hours were you expecting to work over the past week assuming there would be no global pandemic and lockdown?" (item p )to measure perceived efficiency, "if you rate your productivity (i.e., outcome) per hour, has it been more or less over the past week compared to a normal week?" (item p ). responses to the last item were given on a bipolar slider measure ranging from ' % less productive' to ' %: as productive as normal' to '≥ % more productive' (coded as - , , and ). to compute an overall score of productivity for each participant, we used the following formula: productivity = (p /p ) × ((p + )/ ). values between and . would reflect that people were less productive than normal, and values above would indicate that they were more productive than usual. for example, if one person worked only % of their normal time in the past week but would be twice as efficient, the total productivity was considered the same compared to a normal week. we preferred this approach over the use of other self-report instruments, such as the who's health at work performance questionnaire [ ] , because we were interested in the change of productivity while being quarantined as compared to 'normal' conditions. the who's questionnaire, for example, assesses productivity also in comparison to other workers. we deemed this unfit for our purpose as it is unclear to what extent software engineers who work remotely are aware of other workers' productivity. also, our measure consists of only three items and showed good test-retest reliability (table ) . test-retest reliability is the agreement or stability of a measure across two or more time-points. a coefficient of would indicate that responses at time would not be linearly associated with those at time , which is typically undesired. higher coefficients are an additional indicator of the reliability of the measures, although they can be influenced by a range of factors such as the internal consistency of the measure itself and external factors. for example, the test-rest reliability for productivity is r = . lower than for most other variables such as needs or well-being, but this is because the latter constructs are operationalized as stable over time. in contrast, productivity can vary more extensively due to external factors such as the number of projects or the reliability of one's internet connection. self-discipline was measured with -items of the brief self-control scale [ ] . example items include "i am good at resisting temptation" and "i wish i had more self-discipline" (recoded). responses were registered on a -point scale ranging from (not at all) to (very; α = . ). coping strategies was measured using the -item brief cope scale, which measures coping dimensions [ ] . example items include "i've been trying to come up with a strategy about what to do" (planning) and "i've been making fun of the situation" (humor). responses were on a -point scale ranging from (i have not been doing this at all) to (i have been doing this a lot). the internal consistencies were satisfactory to very good for two-item scales: self-distraction (α = . ), active coping (α = . ), denial (α = . ), substance use (α = . ), use of emotional support (α = . ), use of instrumental support (α = . ), behavioral disengagement (α = . , α = . ), venting (α = . ), positive reframing (α = . ), planning (α = . ), humor (α = . ), acceptance (α = . ), religion (α = . ), and self-blame (α = . , α = . ). loneliness was measured using the -item version of the de jong gierveld loneliness scale [ ] . the items are equally distributed among two factors, emotional; α = . , α = . ) (e.g., "i often feel rejected") and social; α = . , α = . (e.g., "there are plenty of people i can rely on when i have problems"). participants indicated how lonely they felt during the past week. responses were given on a -point scale ranging from (not at all) to (every day). compliance with official recommendations was measured using three items of a compliance scale [ ] . the items are 'washing hands thoroughly with soap', 'staying at home (except for groceries and x exercise per day)' and 'keeping a m ( feet) distance to others when outside.' reponses were given on a -point scale ranging from (never complying to this guideline) to (always complying to this guideline, α = . ). anxiety was measured using an adapted version of the -item generalized anxiety disorder scale [ ] . participants indicate how often they have experienced anxiety over the past week to different situations. example questions are "feeling nervous, anxious, or on edge" and "not being able to stop or control worrying". responses were given on a -point scale ranging from (not at all) to (every day, α = . , α = . ). additionally, we measured specific covid- and future pandemic related concerns with two items "how concerned do you feel about covid- ?" and "how concerned to you about future pandemics?" responses on this were given by a -point scale ranging from (not at all concerned) to (extremely concerned; α = . ) [ ] . stress was measured using a four-item version of the perceived stress scale [ ] . participants indicate how often they experienced stressful situations in the past week. example items include "in the last month how often have you felt you were unable to control the important things in your life?" and "in the last month how often have you felt confident about your ability to handle your personal problems?". responses were registered on a -point scale ranging from (never) to (very often; α = . , α = . ). boredom was measured using the -item version [ ] of the boredom proneness scale [ ] . example items include "it is easy for me to concentrate on my activities" and "many things i have to do are repetitive and monotonous". responses were on a -point likert scale ranging from (strongly disagree) to (strongly agree; α = . , α = . ). daily routines was measured with five items: "i am planning a daily schedule and follow it", "i follow certain tasks regularly (such as meditating, going for walks, working in timeslots, etc.)", "i am getting up and going to bed roughly at the same time every day during the past week", "i am exercising roughly at the same time (e.g., going for a walk every day at noon)", and "i am eating roughly at the same time every day". responses were taken on a -point likert scale ranging from (does not apply at all) to (fully applies; α = . , α = . ). conspiracy beliefs was measured with a -item scale as designed by ourselves for this study. the first two items were adapted from the flexible inventory of conspiracy suspicions [ ] , whereas the latter three are based on more specific conspiracy beliefs: "the real truth about coronavirus is being kept from the public.", "the facts about coronavirus simply do not match what we have been told by 'experts' and the mainstream media", "coronavirus is a bioweapon designed by the chinese government because they are benefiting from the pandemic most", "coronavirus is a bio-weapon designed by environmental activists because the environment is benefiting from the virus most", and "coronavirus is just like a normal flu". responses were collected on a -point likert scale ranging from (totally disagree) to (totally agree, α = . ). extraversion was measured using the -item extraversion subscale of the brief hexaco inventory [ ] . responses were given on a -point likert scale ranging from (strongly disagree) to (strongly agree; α = . , α = . ). low scores on extraversion are an indication of introversion. since we found at wave that extraversion and well-being were positively correlated contrary to our hypothesis (see below), and, in our view, contrary to widespread expectations, we decided to measure in wave what participants' views are regarding the association between extraversion and well-being. we measured expectations with one item: "who do you think struggles more with the current pandemic, introverts or extraverts?" response options were 'introverts', 'both around the same', and 'extraverts'. autonomy, competence, and relatedness needs of the self-determination theory [ ] was measured using the -item balanced measure of psychological needs scale [ ] . example items include "i was free to do things my own way' (need for autonomy; α = . , α = . ), "i did well even at the hard things" (competence; α = . , α = . ), and "i felt unappreciated by one or more important people" (recoded; relatedness; α = . , α = . ). participants were asked to report how true each statement was for them in the past week. responses were given on a -point scale ranging from (no agreement) to (much agreement). extrinsic and intrinsic work motivation was measured with the item extrinsic regulation -item and intrinsic motivation subscales of the multidimensional work motivation scale [ ] . the extrinsic regulation subscale measures social and material regulations. specifically, participants were asked to answer some questions about why they put effort into their current job. example items include "to get others' approval (e.g., supervisor, colleagues, family, clients ...)" (social extrinsic regulation; α = . ), "because others will reward me nancially only if i put enough effort in my job (e.g., employer, supervisor...)" (material extrinsic regulation; α = . ) and "because i have fun doing my job" (intrinsic motivation; α = . ). responses were given on a -point scale ranging from (not at all) to (completely). mental exercise was measured with two items: "i did a lot to keep my brain active" and "i performed mental exercises (e.g., sudokus, riddles, crosswords)". participants indicated the extent to which the items were true for them in the past week on a -point scale ranging from (not at all) to (very; α = . ). technical skills was measured with one item: "how well do your technological skills equip you for working remotely from home?" responses were given on a -point scale ranging from (far too little) to (perfectly). diet was measured with two items [ ] : "how often do you eat fruit, excluding drinking juice?" and "how often do you eat vegetables or salad, excluding potatoes?". responses were given on a -point scale ranging from (never) to (three times or more a day; α = . ) quality of sleep was measured with one item: "how has the quality of your sleep overall been in the past week?" responses were given on a -point scale ranging from (very low) to (perfectly). physical activity was measured with an adapted version of the -item leisure time exercise questionnaire [ ] . participants were be asked to report how many hours in the past they have been mildly, moderately, and strenuously exercising. the overall score was computed as followed [ ] : × mild + × moderate + × strenuously. missing responses for one or more of the exercise types were be treated as . quality and quantity of social contacts outside of work were measured with three items. we adapted two items from the social relationship quality scale [ ] and added one item to measure the quantity: "i feel that the people with whom i have been in contact over the past week support me", "i feel that the people with whom i have been in contact over the past week believe in me", and "i am happy with the amount of social contact i had in the past week." responses were given on a -point likert scale ranging from (strongly disagree) to (strongly agree; α = . , α = . ). volunteering was measured with three items that measure people's behavior over the past week: "i have been volunteering in my community (e.g., supported elderly or other people in high-risk groups)", "i have been supporting my family (e.g., homeschooling my children)" and "i have been supporting friends, and family members (e.g., listened to the worries of my friends)". responses were given on a -point scale ranging from (not at all) to (very often; α = . ). quality and quantity of communication with colleagues and line managers was measured with three items: "i feel that my colleagues and line manager have been supporting me over the past week", "i feel that my colleagues and line manager believed in me over the past week", and "overall, i am happy with the interactions with my colleagues and line managers over the past week." responses were given on a -point likert scale ranging from (strongly disagree) to (strongly agree; α = . , α = . ). distractions at home was measured with two items: "i am often distracted from my work (e.g., noisy neighbors, children who need my attention)" and "i am able to focus on my work for longer time periods" (recoded). responses were given on a -point scale ranging from (not at all) to (very often; α = . , α = . ). the participants' living situation was reported in the following categories. living with (babies/infants), (toddlers), (children), (teenager), and (adults), and additionally, it was displayed with how many people the participant is currently living. financial security was measured with two items that reflect the current but also the expected financial situation [ ] : "using a scale from to where means 'the worst possible financial situation' and means 'the best possible financial situation', how would you rate your financial situation these days?" and "looking ahead six months into the future, what do you expect your financial situation will be like at that time?". responses were given on a -point scale ranging from (the worst possible financial situation) to (the best possible financial situation; α = . ). office set-up was measured with three items: "in my home office, i do have the technical equipment to do the work i need to do (e.g., appropriate pc, printer, stable and fast internet connection)", "on the computer or laptop i use while working from home i do have the software and access rights i need", and 'my office chair and desk are comfortable and designed to prevent back pain or other related issues". responses were given on a -point likert scale ranging from (strongly disagree) to (strongly agree; α = . ). demographic information were assessed with the following items: "what is your gender?", "how old are you?" "what type of organization do you work in" (public, private, unsure, other), "what is your yearly gross income?" (us< , , u s - , , us . − , , u s , - , , us , − , , > u s , ; converted to the participant's local currency), "in which country are you based?", "have you been working from home or remotely in general before february ?" (yes, no, unsure), "what percentage of your time have you been working remotely (i.e., not physically in your office) over the past months?", "in which region/state and country are you living?", "is there still a lockdown where you are living?". the data analysis consists of two parts. first, we used the data from time to identify the variables that explain variance in participant well-being and productivity beyond the other variables. second, we used the pearson productmoment correlation coefficient (r), to identify which variables were correlated with at least r = . with well-being and productivity, to test whether they predict our two outcomes over time. r is an effect size which expresses the strength of the linear relation between two variables. we used . as a threshold as we are interested in identifying variables that are correlated with at least a medium-sized magnitude [ ] with one or both of our outcome variables. also, a correlation of ≥ . indicates that the effect is among the top % in individual difference research [ ] . finally, selecting an effect size of this magnitude provides an effective type-i error control, as in total, we performed correlation tests at time alone ( independent variables correlated with the two dependent variables, which were also correlated among each other). given a sample size of , this effectively changes our alpha level to . , which is conservative. this means that it is very unlikely that we erroneously find an effect in our sample even though there is no effect in the population (i.e., commit the type-i or false-positive error) we did not transform the data for any analysis. unless otherwise indicated above, scales were formed by averaging the items. the collected dataset is publicly available to support other researchers in understanding the impact of enforced work-from-home policies. to test which of the variables listed in figure explains unique variance in well-being and productivity, we performed two multiple regression analyses with all variables that were correlated with the two outcome variables with ≥ . . in the first analysis, well-being is the dependent variable; in the second analysis, we use productivity as the dependent variable. this allows us to identify the variables that explain unique variance in the two dependent variables. however, one potential issue of including many partly correlated predictors is multicollinearity, which can lead to skewed results. if the variance inflation factor (vif) is larger than , multicollinearity is an issue [ ] . therefore, we tested whether the variance inflation factor would exceed before performing any multiple regression analysis. to analyze the data from both time-points, we performed a series of structural equation modeling analyses with one predictor variable and one outcome variable using the r-package lavaan [ ] . unlike many other types of analyses, structural equation modeling adjusts for reliability [ ] . specifically, models were designed with one predictor (e.g., stress), and one outcome (e.g., wellbeing) both as measured at time and at time . we allowed autocorrelations (e.g., between well-being at time and at time ) and cross-paths (e.g., between stress at time and well-being at time ). autocorrelations are essential because without them we might erroneously conclude that, for example, stress at time predicts well-being at time although it is the part of stress which overlaps with well-being, which predicts well-being at time [ ] . to put it simply, we can only conclude that x predicts y if we control for y . no items or errors were allowed to correlate. this is usually done to improve the model fit but has also been criticized as atheoretical: to determine which items and errors should be allowed to correlate to improve model fit can only be done after the initial model is computed and thus a data-driven approach which emphasizes too much on the model fit [ ] . the regression (or path) coefficients and associated p-values were not affected by the type of estimator. we compared in our analyses the standard maximum likelihood (ml), the robust maximum likelihood (mlr), and the multi-level (mlm) estimator. the pattern of correlations was overall consistent with the literature. at time , variables were correlated with well-being at r ≥ . (table ) . stress, r = −. , quality of social contacts, r = . , and need for autonomy, r = . were strongest associated with well-being (all p < . ). the pattern of results from the coping strategies were also in line with the literature [ ] : self-blame, r = − . , p < . , behavioral disengagement, r = − . , p < . , and venting r = − . , p < . were negatively correlated with well-being. interestingly, generalized anxiety was more strongly associated with well-being than covid- related anxiety (r = − . vs −. ) which might suggest that specific worries have a less negative impact on well-being . contrary to our the pearson's correlation coefficient (r) represents the strength of a linear association between two variables and can range between - (perfect negative linear association), (no linear association), to (perfect positive linear association). the regression coefficient b indicates how much the outcome changes if the predictor increases by one unit. for example, the b of stress predicting well-being is -. . this indicates that a person who has a well-being level of has a stress level that is of -. units lower than a person who has a well-being level of . a multiple regression with generalized anxiety and covid- related anxiety supports this interpretation: only generalized anxiety, b = − . , se = . , p < . , but not expectations, extraversion was positively correlated with well-being, both at waves and . the pattern of the associations was similar at time . a reason for participants' misinterpretation of the intensity to struggle with working from home for introverts could be explained by introverts usually having to avoid unwanted social interactions, and due to being quarantined, they now have to put effort into having social interactions actively. the added challenge to contribute more energy than usual to not being too lonely and changing their usual behavioral pattern demands much more from introverts than extraverts. at time , four variables were correlated with productivity at r ≥ . (table ) : need for competence, r = −. , distractions, r = −. , boredom, r = −. , and communication with colleagues and line-managers r = . . surprisingly, work motivations were uncorrelated with well-being at α = . . at time , only distraction was still correlated with productivity, r = − . , p < . . the strength of association of most variables with productivity dropped between time and , which means that those variables associated with productivity at wave were no longer or less strongly associated with productivity at wave . the strengths of correlations remained the same when we computed spearman's rank correlation coefficients rather than pearson's correlations (spearman's coefficient is a non-parametric version of pearson's r and ranges also between - and ). at time , we added additional questions to better understand the counterintuitive finding that well-being and extraversion are positively correlated. interestingly, the finding that extraversion is positively correlated with well-being during lockdown is contrary to the expectations of most participants. when asked whether introverts or extraverts struggle more with the covid- pandemic, only participants correctly predicted introverts, where stated extraverts, with participants believing that both groups struggle equally. this highlights the value of our research because people's intuition can be blatantly wrong. through an analysis of the participants' statements about the informant's (i) choice, the explanation became more articulated. we now report selected quotes from participants, including their level of extraversion, in wave . some informants reported their direct experience supporting the feeling that extraverts struggle more than introverts. "i'm introverted, and i don't feel the pandemic has affected me at all. rules aren't hard to follow and haven't feel bad. i feel for extraverts; they would struggle a bit with the rules." nonetheless, a minority of participants also provide alternative interpretations. according to those, both introverts and extraverts have difficulties in reaching out to people, although in different ways. the motivation for such answers is that both personality types struggle with different challenges. "both types need company, just that each needs company on their own terms. introverts prefer deeper contact with fewer people and extraverts less deep contact with a greater number of people." [i- , extraversion score = . ] "extraverts miss human contact; introverts find it even harder to mark their presence online (e.g., in meetings)." [i- , extraversion score = . ] interestingly, there is one informant which provide an insightful interpretation, aligned with our results. "introverts usually have more difficulty communicating with others, and confinement worsens the situation because they will not try to talk to others through video conferences." [i- , extraversion score = . ] the lack of a structured working setting, where introvert are routinely involved, causes further isolation. being 'forced' to work remotely significantly increased difficulty in engaging with social contacts. this means that introverts have to put much more effort into interacting with others instead of their typical behavior of reduced interaction in office-based environments. whereas extraverts have it easier to find some way to maintain their social contacts, introverts might struggle more. thus, the lockdown had a more negative impact on the well-being of introverts than of extraverts, as shown in table . to test which of the predictors had a unique influence on well-being and productivity, we included all variables that were correlated with either outcome with at least . at time . this is a conservative test because many predictors are correlated among each other and thus taking variance from each other. also, it allowed us to repeat the same analysis at time because all predictors which correlated with either well-being or productivity at time with r ≥ . were included at time . in a first step, we tested whether multicollinearity was an issue. this was not the case, with vif < . for all four regression models and thus clearly below the often-used threshold of [ ] . sixteen variables correlated with well-being r ≥ . (table ). together, they explained a substantial amount of variance in well-being at time , r = . , adj.r = . , f ( , ) = . , p < . , and at time note. r: correlations, b: unstandardized regression estimates, r it : test-rest correlation. signif. codes: * * * < . , * * < . , * < . , . < . , r = . , adj.r = . , f ( , ) = . , p < . . at time , stress (negatively), social contacts, and daily routines uniquely predicted well-being at α = . (see table , column , and table ) . at time , need for competence and autonomy, stress, quality of social contacts, and quality of sleep uniquely predicted well-being at α = . (see table , column , and table ). together, stress and quality of social contacts predicted at both time points significantly well-being. four variables correlated with productivity r ≥ . (table ) . together, they explained % of variance in productivity at time , r = . , adj.r = . , f ( , ) = . , p < . , and % at time , r = . , adj.r = . , f ( , ) = . , p = . . at both time points, none of the four variables explained variance in productivity beyond the other three variables, suggesting that they all are associated with productivity but we lack statistical power to disentangle the effects (tables and ). there is an ostensible discrepancy between some correlations and the estimates of the regression analyses which requires further explanations. an especially large discrepancy appeared for the variable need for competence, which correlated positively with well-being at time and , r = . with p < . , and r = . with p < . , but was negatively associated with well-being when controlling for other variables in both regression analyses, b = -. with p = . , and b = -. with p = . . this suggests that including a range of other variables, that serve as control variables, impact the results. indeed, exploratory analyses revealed that need for competence was no longer associated with well-being when we included need for autonomy. that is, when we performed a multiple regression with the needs for autonomy and competence as the only predictors, need for competence became non-significant. need for competence also includes an autonomy competent, which might explain this. it is easier to fulfill one's need for competence while being at least somewhat autonomous [ ] . further, including generalized anxiety and boredom reversed the sign of the association: need for competence became negatively associated with well-being. including those two variables remove the variance that is associated with enthusiasm (boredom reversed) and courage (generalized anxiety reversed), which might explain the shift to negative association with well-being. together, controlling for need for autonomy, generalized anxiety, and boredom, takes away positive aspects of need for competence, leaving a potentially cold side that might be closely related to materialism, which is negatively associated with well-being [ ] . test-retest reliabilities were good for all variables, supporting the quality of our data (last column of table , column ). in total, we performed structural equation modeling (sem) analyses to test whether well-being and productivity are predicted by or predict any of the independent variables for well-being, including one model in which we tested whether well-being predicts productivity or vice versa, and four models for productivity. since the probability of a false signif. codes: * * * < . , * * < . , * < . , . < . positive is very high, due to the high number of models analyzed, we used a conservative error rate of . . we are using a different threshold for the longitudinal analysis than for the correlation analyses since we did a different number of tests for the latter. one example of our sem analyses is presented in figure , where we looked at the predictive-causal relationship between stress and well-being in waves and . the boxes represent the items and the circles the variables (e.g., stress). the arrows between the items and the variables represent the loadings, that is how strongly each of the items contributes to the overall variable score (e.g., item of the stress scale contributes least and item most to the overall score at both time points). the circular arrows represent errors. the bidirectional arrows between the variables represent the covariances, which are comparable signif. codes: * * * < . , * * < . , * < . , . < . to correlations. the one-handed arrows show causal impacts over time. the arrows between the same variables (e.g., well-being and well-being ) show how strongly they impact each other and are comparable to the test-retest correlations. the most critical arrows are those between well-being and stress as well as between stress and well-being . they show whether one variable causally predicts the other. the most relevant values in figure are presented in table . columns - show that stress and well-being were significantly associated at time , b = - . , se = . , p < . . this association was mirrored at time , b = - . , se = . , p = . (columns - ). columns - show that stress at time did not significantly predict well-being at time , b = - . , se = . , p = . . columns - of the second part of table also show that well-being at time did not predict stress at time , b = . , se = . , p = . . columns - of the second part show the autocorrelation of well-being, that is how strongly well-being at time predicts well-being at time , b = . , se = . , p < . . autocorrelations can be broadly understood as the unstandardized version of the test-retest correlations (reliability) reported in table . finally, columns - of the second part show the autocorrelation of stress, which are also significant b = . , se = . , p < . . we conclude that no model revealed any significant associations at α = . . thus, no variable at time (e.g., stress) is able to explain a significant amount of variance in another variable (e.g., well-being) at time . we only found a negative tendency regarding distraction → p roductivity with b = -. , p = . . furthermore, table shows which variable is more likely to have a stronger impact on the other over time. for example, p roductivity → distraction has a b = . , p = . , suggesting that it is much more likely that distraction influence negatively productivity, rather than productivity influencing the level of distraction. additionally, we explored whether there are any mean changes between time and , separately for all variables. for example, has the well-being increased over time? this would suggest that people adapted further within a relatively short period of two weeks to the threat from covid- . table shows that the arithmetic mean (m ) of well-being has indeed slightly increased between time and , m = . vs m = . . a closer look revealed that participants reported higher well-being at time compared to time , reported the same level of well-being, and a lower level of well-being. further, on average people's score of behavioral disengagement and quality of social contacts increased, whereas emotional loneliness and the quality of communication with line managers and coworkers decreased. note. t: t-value of a paired sample t-test; higher: absolute number of people who scored higher on a variable at time compared to time ; lower: number of people who scored lower at time ; equal: people whose score has not changed over time. our finding that office-setup is not significantly related to well-being and productivity seems to contradict a recent cross-sectional study by ralph et al. [ ] that investigated how the fear of bioevents, disaster preparedness, and home office ergonomics predict well-being and productivity among software developers. in that study, ergonomics was positively related to both wellbeing and productivity. to measure ergonomics, the authors created six items concerning distractions, noise, lighting, temperature, chair comfort, and overall ergonomics. the first two items are closely related to our measure of distraction, which was negatively associated with well-being in wave of our sample, r = -. , and productivity, r= -. . in contrast, the following four items are more closely associated with office-setup in our survey, which was positive but not significantly associated with well-being, r = . , and productivity, r = . . to better understand such inconsistency with our result, we run a replication analysis using ralph et al.'s data. to test whether ergonomics' effect is mainly driven by distraction and noise, we combined the first two items into variable ergonomics-distractions (recoded, higher scores indicate less distraction) and the other four items into ergonomics-others. indeed, ergonomics distractions was more strongly correlated with well-being, r = . , and productivity, r = . , than was ergonomics-other, rs = . and . , respectively. this suggests that our findings replicate those of ralph et al. and emphasize the importance of distinguishing between distraction and office set-up. the covid- pandemic and the subsequent lockdown have had a definite impact on software professionals who were primarily forced to work from home. the first significant outcome of this research is that there are many variables that are associated with well-being and productivity. although we could not determine any causal relationship, the effect sizes for both waves are medium to large for several variables which have mainly shown high stability of the results over time. also, well-being and productivity were positively associated. in other words, neglecting well-being will likely also negatively impact productivity. therefore, we agree with ralph et al.'s [ ] recommendation that pressuring employees to keep the average productivity level without taking care of their well-being will lower productivity. however, we would also like to present an alternative interpretation that having productive employees will strengthen their sense of achievement and improve their well-being. in the following, we focus on practical recommendations based on the most reliable predictors of well-being and productivity that we identified in our study through our regression analysis: need for autonomy, stress, daily routines, social contacts, need for competence competence, extraversion, and quality of sleep as predictors of well-being, in table . distractions and boredom related to productivity are discussed in table . persistent high-stress levels are related to adverse outcomes in the workplace [ ] and people's well-being. to reduce stress, bazarko et al. [ ] recommend practicing mindfulness-based stress reduction training and practices that can be performed at home. participating in such a program can lead to lower levels of stress and a lower risk of work burnout. grossman et al. recommended other stress reduction methods. [ ] . moreover, naik et al. [ ] , who found that mindfulness meditation practices, slow breathing exercises, mindful awareness during yoga postures, and mindfulness during stressful situations and social interactions can reduce stress levels. together, the results of these studies suggest that mindfulness practices, even when performed at home, can reduce stress, which could also improve software engineers' well-being while being quarantined. the quality of social contacts as part of the overall quality of life has a significant impact on people's well-being, as discovered in this study. therefore, employers should be interested in enabling their employees to spend time with people they value and encourage them to build strong, meaningful relationships within their work environment. creating a virtual office, (e.g., using an online working environment such as 'wurkr') allows people to work with the impression of sharing a physical workspace online to communicate more comfortably and work together from anywhere. for example, in order to simplify conversations, the slack plugin 'donut' [ ] randomly connects employees for coffee breaks with the purpose to get to know each other better by spending some time chatting virtually. besides, our finding that quality of social contact, but not living alone is associated with well-being, is in line with the literature. quality of contact with one's partner and family independently predicted negatively depression, whereas the frequency of these contact did not [ ] . together, this suggests that findings from the literature can overall be generalized to people being quarantined. organizing the day in a structured way at home, appears to be beneficial for software professionals' well-being. people tend to overwork when working remotely [ ] . this could be further magnified during quarantine where usual daily routines are disrupted, and thus working might become the only meaningful activity to do. therefore, it is essential to develop new daily routines in order to not be completely absorbed by work and to prevent a burnout [ ] . therefore, scheduling meetings and designating time specifically for hobbies or spending time with family and friends is helpful while working from home and helps to satisfy employees' needs for social contacts. to fulfill people's need for autonomy, it is necessary to allow employees to act on their values and interests [ ] . while coordinating collaborative workflows and managing projects remotely comes with its challenges [ ] . for remote workers it is crucial to have flexibility in how they structure, organize, and perform their tasks [ ] . it is therefore helpful to delegate work packages instead of individual tasks. this makes it easier for individuals to work selfdirectedly and thus to fulfill their need for autonomy. to fulfill employees' need for competence, it is necessary to provide them with the opportunity to grow personally and advance their skill set [ ] . two of the mainly required and highly demanded skills in remote work environments are communication skills and the ability to use virtual tools, such as presentation tools or collaborative project planning tools [ ] . raising awareness for the unique requirements of virtual communication is crucial for a smooth working process. therefore, working remotely requires specific communication skills, such as mindful listening [ ] or asynchronous communication, which allows people to work more efficiently [ ] . collaborative tools such as github, trello, jira, google docs, klaxoon, mural, or slack can simplify work processes and enable interactive workflows. besides the training and development of employees' specific virtual skill set, it is also recommended to invest in employees' personal development within the company. taking action and offering employees the opportunity to grow will not only evolve their role but also strengthen their loyalty towards the employer and, therefore, employee retention [ ] . introverted software professionals seem to be more affected by the lockdown than their more extraverted peers. this finding is counter-intuitive since extraverted people prefer more direct contacts than introverted people [ ] . our interpretation of these results is that introverts have a much higher burden to reach out to colleagues than extraverted ones. also, being introverted does not mean that there is no need for social contacts at all. while in the office they had chances to be involved with colleagues both in a structured or unstructured fashion, at home it is much more difficult as they have to be more proactive to reach out to colleagues in a more formalized setting, such as online collaboration platform (e.g., ms teams). therefore, software organizations should regularly organize both formal and informal online meeting occasions, where introvert software engineers feel a lower entry barrier to participate. quality of sleep is also a relevant predictor for well-being. although it might sound obvious, there is a robust association between sleep, well-being, and mindfulness [ ] . in particular, howell et al. found that mindfulness predicts quality of sleep, and quality of sleep and mindfulness predict well-being. distractions at home are a challenging obstacle to overcome while working remotely. designating a specific work area in the home and communicating non-disturbing times with other household members are easy and quick first steps to minimize distractions at the workplace at home. another obstacle that distracts remote workers more frequently is cyberslacking, which is understood as spending time on the internet for non-work-related reasons during working hours [ ] . cyberslacking and its contribution to distractions at home for remote workers were not included in this study but would be worth exploring in future research. when people experience, boredom it makes them feel "...unchallenged while they think that the situation and their actions are meaningless" [ , p. ]. especially people who thrive in a social setting at work are in danger of being bored quickly while working in isolation from their homes. the enumerated recommendations above, such as assigning interesting, personally tailored, and challenging work packages, using collaborative tools to hold yourself accountable, and having social interactions while working remotely, also help reduce boredom at work. ideally, employees are intrinsically motivated and feel fulfilled by what they do. if this is not the case over a more extended period, and the experienced boredom is not a negative side effect of being overwhelmed while being quarantined, it might be reasonable to discuss a new field of action and area of responsibility with the employee. to conclude, working from home certainly comes with its challenges, of which we have addressed several in this study. however, at least software engineers appear to adapt to the lockdown over time, as people's well-being increased, and the perceived quality of their social contacts improved. similar results have also been confirmed by a survey study of , new zealanders' remote workers [ ] . walton et al. found that productivity was similar or higher than pre-lockdown, and % of professionals would like to continue to work from home, at least one day per month. this study also reveals that the most critical challenges were switching off, collaborating with colleagues, and setting up a home office. on the other hand, working from home led to a drastic saving of time otherwise allocated to daily commuting, a higher degree of flexibility, and increased savings. limitations are discussed using gren's five-facets framework [ ] . reliability. this study used a two-wave longitudinal study, where over % of the initial participants, identified through a multi-stage selection process, also participated in the second wave. further, the test-retest reliabilities were high, and the internal consistencies (cronbach's α) ranged from satisfactory to very good. construct validity. we identified variables, which were drawn from the literature, and a suitable measurement instrument measured each. where possible, we used validated instruments. otherwise, we developed and reported the instruments used. to measure the construct validity, we also reported the cronbach's alpha of all variables across both waves. however, we note that despite a large number of variables in our study, we still might have missed organizations should redesign employees goals by letting them choose tasks as much as possible and diversify activities. negative predictor in both waves (b w = −. , b w = −. ) organizations should support software engineers to set up a dedicate home office. routines and agreements with family members about working times also help to be more focused. one or more relevant variables, which would have been significantly turned out in our analysis. conclusion validity. to draw our conclusions, we used multiple statistical analyses such as correlations, paired t-tests, multiple linear regressions, and structural equation modeling. to ensure reliable conclusions, we used conservative thresholds to reduce the risk of false-positive results. the threshold depended on the number of comparisons for each test. additionally, we did not include covariates, nor did we stop the data collection based on the results, or performed any other practice that is associated with increasing the likelihood of finding a positive result and increasing the probability of false-positive results [ ] . however, we could not make any causal-predictive conclusion since all sem analyses provided non-significant results, using a threshold of significance that reduces the risk of false-positive findings. finally, we made both raw data and r analysis code openly available on zenodo. internal validity. this study did not lead to any causal-predictive conclusion, which was the main aim of the present study. we can not say that the analyzed variables influence well-being or productivity or vice versa. we are also aware that this study relies on self-reported values, limiting the study's validity. further, we adjusted some measures (i.e., productivity). participants were not supposed to report their perceived productivity but to make a comparison, which has been computed independently afterward in our analysis. we also underwent an extensive screening process, selecting over software engineers of the initial initial suitable subjects. typical problems related to longitudinal studies (e.g., attrition of the subjects over a long-term period) do not apply. the dropout rate between the two waves has been low (under %). we run this study towards the end of the lockdown of the covid- pandemic in spring . in this way, participants were able to report rooted judgments of their conditions. waves were set at two weeks distance, which ensured that lockdowns had not been lifted yet during the data collection of wave , but was also not close enough so that variability in each of the variables would already be sufficiently high between the two-time points. since this was a pandemic, the surveyed countries' lockdown conditions have been similar (due to standardized who's recommendations). however, we did not consider region-specific conditions (e.g., severity of virus spread) and recommendations. also, lockdown timing differed among countries. to control these potential differences, we asked participants at each of the two waves if lockdown measures were still in place, and if they were still working from home. since all our participants reported positively to both these conditions, we did not exclude anyone from the study. external validity. our sample size has been determined by an a priori power analysis, manageable for longitudinal analyses. however, this study was designed to maximize internal validity, focusing on finding significant effects, rather than working with a representative sample of the software engineering population (with n ≈ , such as russo and stol [ ] did, where the research goal focused on the generalizability of results). the covid- pandemic disrupted software engineers in several ways. abruptly, lockdown and quarantine measures changed the way of working and relating to other people. software engineers, in line with most knowledge workers, started to work from home with unprecedented challenges. most notably, our research shows that high-stress levels, the absence of daily routines, and social contacts are some of the variables most related to well-being. similarly, low productivity is related to boredom and distractions at home. we base our results on a longitudinal study, which involved software professionals. after identifying relevant variables related to well-being or productivity during a quarantine from literature, we run a correlation study based on the results gathered in our first wave. for the second wave, we selected only the variables correlated with at least a medium effect size with well-being or productivity. afterward, we run structural equation modeling analyses, testing for causal-predictive relations. we could not find any significant relation, concluding that we do not know if the dependent variables are caused by independent ones or vice versa. accordingly, we run several multiple regression analysis to identify unique predictors of well-being and productivity, where we found several significant results. this paper confirms that, on average, software engineers' well-being increased during the pandemic. also, there is a correlation between well-being and productivity. out of factors, nine were reliably associated with wellbeing and productivity. correspondingly, based on our findings, we proposed some actionable recommendations which might be useful to deal with potential future pandemics. software organizations might start to experimentally ascertain whether adopting these recommendations will increase professionals' productivity and well-being. our research findings indicate that granting a higher degree of autonomy to employees might be beneficial, on average. however, while ex-tended autonomy might be perceived positively experienced by those with a high need for autonomy, it might be perceived as stressful for those who prefer structure. it is unlikely that any intervention will have the same effect on all people (since there is a substantial variation for most variables), it is essential to have individual differences in mind when exploring the effects of any interventions. thus, adopting incremental intervention, based on our findings, where organizations can get feedback from their employees, is the recommended strategy. future work will explore several directions. cross-sectional studies with representative samples will be able to test whether our findings are generalizable and do get a better understanding of underlying mechanisms between the variables. we will also investigate the 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with feeling: a meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation statistically controlling for confounding constructs is harder than you think knowledge, attitudes, and practices among members of households actively monitored or quarantined to prevent transmission of ebola virus disease margibi county the importance of shared values in societal crises: compliance with covid- guidelines conspiracy suspicions as a proxy for beliefs in conspiracy theories: implications for theory and measurement world health organization: considerations for quarantine of individuals in the context of containment for coronavirus disease (covid- ): interim guidance we thank the editors-in-chief for fast-tracking our manuscript. the authors would also like to thank gabriel lins de holanda coelho for initial feedback on this project. key: cord- -ebh adi authors: flett, gordon l.; heisel, marnin j. title: aging and feeling valued versus expendable during the covid- pandemic and beyond: a review and commentary of why mattering is fundamental to the health and well-being of older adults date: - - journal: int j ment health addict doi: . /s - - - sha: doc_id: cord_uid: ebh adi the current commentary and review examines the potentially protective role of feelings of mattering among elderly people during typical times and the current atypical times associated with the covid- global pandemic. mattering is the feeling of being important to others in ways that give people the sense that they are valued and other people care about them. we contrast this feeling with messages of not mattering and being expendable and disposable due to ageism, gaps in the provision of care, and apparently economically focused positions taken during the pandemic that disrespect the value, worth, and merits of older persons. we provide a comprehensive review of past research on individual differences in mattering among older adults and illustrate the unique role of mattering in potentially protecting older adults from mental health problems. mattering is also discussed in terms of its links with loneliness and physical health. this article concludes with a discussion of initiatives and interventions that can be modified and enhanced to instill a sense of mattering among older adults. key directions for future research are also highlighted along with ways to expand the mattering concept to more fully understand and appreciate the relevance of mattering among older adults. this article is about the need to matter among older people. the quote above from nancy schlossberg from her seminal work on mattering versus marginalization reflects the fact that even though people can and do differ enormously, they share a need to feel valued and significant to other people who care about them. they also share a basic need to feel connected to other people and feel a sense of fit rather than feeling like a misfit. these common needs to matter to others and to belong fit well the general belief that people of all backgrounds are more similar than they are different, and that we should focus to a greater degree on commonalities and what brings us together than on apparent differences which can serve to divide us. the need to matter applies to people of all ages and of vastly different backgrounds and cultures. it is a feeling that is relevant from the cradle to the grave and it is a global and universal need. there is still room for individual differences, however; some people will always have a stronger need to matter than will others, just as some may be more sensitive to perceived social connections and support. moreover, at present, billions of people feel like they actually do matter, while billions of other people feel like they do not matter or they do not matter as much as they should. this sense of not mattering enough is especially common among people who feel marginalized and left behind for social, political, economic, or other reasons, rather than feeling cherished and valued as human beings. the current article is both a review and a commentary focused on mattering in older people. it is based on a thorough and systematic search using multiple search engines, including google scholar, to identify any relevant research conducted on mattering among older people. most of the review focuses on articles in refereed journals, but detailed empirical results found in two key chapters are also provided (see fazio ; pearlin and leblanc ) . our overarching goal was to be as contemporary and as up-to-date with both our review and our commentary as possible. in this regard, we also refer to national and international events pertaining to the treatment and care of older people that have quite recently occurred during the pandemic. so why our current focus on the need to matter among older adults? and why focus on this need now at this point in time? there are three interrelated reasons. first, in their work that introduced the mattering concept, rosenberg and mccullough ( ) observed astutely that mattering is particular relevant for two groups of people-young people and elderly people. specifically, they suggested that, "mattering may be relatively high among children and adults, among adolescents and old people. the young child feels that he matters because the world revolves around him, because he is the center of the universe. the adult matters because he runs the world" (p. ). regarding the relevance of mattering to older people, rosenberg and mccullough ( ) went on to note that mattering is tied closely with the transition to retirement. here they addressed the core fear that haunts many retirees by noting that, "it has been suggested that one problem of retirement is that one no longer matters; others no longer depend upon us" (p. ). second, the need for older people to feel like they matter and to wonder how much they actually do matter is a very salient theme right now as the covid- global pandemic continues. the messages from many political leaders are centered appropriately on urging people to engage in physical distancing, while awaiting development of vaccines and antibodies because this practice will help stop the spread of the virus and this is especially required to protect older and immunocompromised people who are more susceptible to the ravages of the coronavirus. this message is often wrapped around the theme that older people are cherished and we need to do whatever it takes to protect their health and well-being during this high-risk period. this focus includes the recognition that self-isolation practices implemented to counter covid- , albeit well-intentioned, disproportionately impact older adults and urgent action is needed to limit the mental health and physical health impacts among isolated older people (see armitage and nellums ) . finally, it is generally accepted that there are many challenges that have been brought about by the covid- global health crisis and the requirement that people engage in physical isolation. anxiety is heightened due to concerns about personal safety and the uncertainty of how and when the pandemic will be resolved. moreover, as noted above, physical distancing has led to the experience of social isolation among some people, especially those who are living alone and those who may lack web-enabled smartphones or other electronic devices that could help them remain in contact with friends and loved ones. loneliness is already a profound public health concern, especially among older people, and physical isolation is adding exponentially to the social isolation that is typified by loneliness. it was a grave concern in the usa before the pandemic; this was illustrated by the us senate special committee on aging chaired in by susan collins, united states senator from maine. this committee held hearings on the topic "aging without community: the consequences of isolation and loneliness." the disruption to daily routines and restriction of usually pleasurable activities as a result of the pandemic, including visiting with friends, children, and grandchildren, is also having a strong impact on people. given these changes, flett and zangeneh ( ) outlined how and why mattering is an essential resource for coping with and adapting to the pandemic. it was argued that everyone needs a sense of significance and being important to others in the best of times, but this is especially the case in challenging times and in anxiety-provoking crisis situations that entail being separated from others. this argument is particularly germane to the life experiences of older people coping with this global health crisis. older members of society have many reasons to be fearful and many have already been grappling with loneliness and mental health problems. unfortunately, expressions of concern about the health and welfare of older people and apparent steps taken to ensure their well-being are at variance with current realities. global statistics are mounting in ways that confirm that concerns about older people and their mortality are not overstated. there is growing evidence from various parts of the world of the disproportionate death and dying among older people (see onder et al. ; promislow ) . over % of deaths related to covid- were of individuals years or older, and more than % were over -an age group with a mortality rate times that of the global average. residential care homes, including long-term care (ltc) and assisted living (al) homes, have been hit especially hard and account for more than half of pandemic-related deaths worldwide (see comas-herrera et al. ) , posing a realistic source of existential anxiety and distress for older residents and their families. close-quarters living and limited access to personal protective equipment increase the risk of transmission, which, together with healthcare challenges associated with staffing shortages, results in multiple fatalities. the numbers of deaths are troubling but even more disconcerting are seemingly endless stories of neglect and mismanagement that have appear to be costing people their lives. key needs, both tangible and emotional, have been neglected and this is relevant to our premise because neglect is regarded as a primary precipitant of feelings of not mattering (see flett et al. a) . some of the more heinous incidents and situations involving apparent neglect of older adults in the context of the covid- pandemic are listed in table . this table contains a chronology of select occurrences. comparable events have already resulted in a litany of class action lawsuits by family members and urgent calls for public health inquiries to not only increase accountability but lead to necessary systemic change and better practices and procedures going forward. in addition to the incidents and situations in table , an exposé in the montreal gazette revealed one nursing home that apparently concealed the deaths of residents and many of these people died after most staff members abandoned the facility (see feith ) . some seniors did not have dignified deaths; indeed, the report indicated that they had gone for days without water, food, or a diaper change (derfel ) . more generally, actual occurrences include refusals of hospitals to provide treatment, improper treatment of deceased elders, and sending patients confirmed to have the virus to nursing homes, thereby increasing the risk for elderly residents. physical distancing requirements are having additional impacts on the ability of long-term care homes and assisted living residences to care for their older residents; prohibitions against large group meetings mean that residents cannot eat in cafeterias and common rooms, further limiting social connection, and overwhelming staff members who now must deliver food individually, limiting the amount of time and attention that they can pay to residents. these subtler impacts of the pandemic on the health and well-being of older adults are likely not being evaluated. a more recent exposé by the globe and mail of the situation in ontario, canada, also paints an exceptionally unfavorable picture. this article about this investigation is titled "systematic failings fuelled care-home outbreak" (see howlett ) . it is based on an extensive series of interviews and a review of documents filed with the ontario supreme court, as well as ontario ministry of labour inspection reports, and internal corporate records. key shortcomings included having home inspections conducted by telephone and the chief table chronology of select pandemic-related incidents and situations in connoting that older people do not matter or do not matter enough march , -spanish military finds corpses and seniors abandoned in care homes (benavides ) april , -italy's lombardy region wracked by exceptionally high number of deaths, totally about half of deaths in italy. deaths including thousands of elderly people described by one who official as a "massacre"; regional government makes decision on march th to place patients with covid- virus in nursing homes and staff in some homes instructed to not wear protective masks because masks will scare the residents (winfield ) may , -horrific deaths in an australian nursing home reported after an infected nurse works six shifts despite having mild virus symptoms. family members of residents express upset about inconsistent communication (zishuo ) may , -sweden's herd immunity strategy and failure to enact lockdown leads to mass deaths in swedish elder care homes; "terrible numbers" dramatically underestimated due to decision to only count deaths of persons who had covid- test (shilton ) may , -decision of new york to send recovering covid- virus patients to nursing homes characterized as "a fatal error" (mathews ) may , -elderly patients characterized as "sacrificial lambs" detected with coronavirus are released back to care homes in april; elderly people at st. nicholas care home in liverpool, england, die after hospital discharge (kelly and coen ) may , -hospitals in lima, peru, stop admitting elderly patients with coronavirus in part due to lower recuperation rates relative to younger patients (torres ) may , -nurses in care homes in sweden allege that people ill with the virus and or older are refused access to hospital and life-saving equipment despite potentially having many years to live (savage ) may , -report surfaces that older people in hamilton, ontario nursing home were transferred to st. joseph's healthcare but one male patient was forgotten and left entirely by himself in the evacuated nursing home (frketich ) medical officer of health waiting until april st to issue the decree that everyone in longterm care homes is to be tested for covid- . the deplorable conditions at sites in ontario were confirmed by a canadian military report that detailed conditions of severe neglect deemed to reflect "borderline abuse" or actual abuse in ontario care homes along with "blatant disregard" for basic infection control measures (see stephenson and bell ) . deplorable situations came to light in five residences once military personnel were deployed to assist in long-term care homes. ontario premier doug ford described these accounts as horrific and prime minister justin trudeau expressed his strong feelings, concluding that, "it is the elderly who are suffering the most in this pandemic." the stories that have emerged thus far underscore the lack of resources and planning that have left too many older people and staff members in vulnerable and potentially lifethreatening situations. for instance, in canada, the deaths continue to escalate across most provinces and this dovetails with years of concerned frontline people and academic scholars calling for improvements and more resources for the care system. these calls have been renewed and extended (see béland and marier ) . collectively, it has been estimated that four out of five covid- -related deaths in canada have been linked with senior homes (see brean ) . given these emerging realities in canada and elsewhere, it would be reasonable for older people in many countries to feel that professed concerns about their well-being either represent "lip service" or implemented safeguards simply add up to "too little" and "too late" given strong evidence of widespread system failure. the circumstances listed in table demonstrate some horrific situations in nursing homes and long-term care facilities in various parts of the world. second, some very troubling views about older people in general have been expressed during the pandemic. some views have come from political leaders, while others have come from members of the media and social media influencers. these views have led some authors to consider whether the pandemic will worsen the narrative about aging in terms of the proliferation of stereotypes. these are often signified by referring to the pandemic with harsh social media hashtags such as "#boomerremover" and "#grandmakiller" (see eisenberg ) . ironically, as many younger people are commenting that their grandparents' generation saved the world by fighting fascism and oppression, they are saving it by sitting around at home, and there is a lack of recognition that those same grandparents are now being sacrificed in panicked efforts to forestall an anticipated financial collapse. what is also being missed is the opportunity to learn and benefit from the survival resources and resiliency factors cultivated by older adults who have lived through times of war, oppression, discrimination, and financial collapse. as the statistics accumulate, it is natural for older people who are aware of these developments to become increasingly alarmed and demoralized not only about their health status prospects but also by the overarching question of whether they matter at all to other people. indeed, some older people have wondered openly about exactly when they became disposable (see socken ) . maria branyas, a -year old survivor of the spanish flu epidemic, stated that "the elderly are the forgotten ones of society" (the guardian ). this serves as a poignant counter-point to the quote attributed to gandhi that "the true measure of any society can be found in how it treats its most vulnerable members." older adults who have already felt marginalized and who have been subject to prejudice due to racism or classism may be particularly susceptible at present to feelings of not mattering to other people. unfortunately, some politicians have gone so far as to suggest that economic considerations must become the priority, even if it means the loss of lives. the argument here is that balance is needed and perhaps physical isolation and the shutdowns have gone too far or are now doing more harm than good from an economic perspective focused on costs versus benefits. it has been openly and crassly suggested by too many politicians that people who survive the pandemic will just have to live with the loss of other people, especially elderly people, because it is time to end social distancing in order to restart the economic engine as it is too dire to let it idle any longer. public calls to restart the economy, even if so doing confers health risks in vulnerable groups, can increase perceptions of lack of social worth among older adults, and this is especially among older adults who are sensitized to cues suggesting that they do not matter. another factor that has been identified as a factor during the pandemic that promotes the image of older people as being less important and contributes to ageism is that under certain circumstances, chronological age is listed as a deciding factor for determining which of two people in equal need are given a ventilator (for a discussion, see fraser et al. ) . they are also several instances of people being denied access to hospital treatment because of their age (see table ). it has been observed that older people are made to feel less significant as individuals by policies that characterize all older people as the same and fail to reflect the heterogeneity and varying levels of functioning and vitality among them. this too is regarded as a contributor to ageism (see fraser et al. ) . bob seger reminded us in one of his classic songs that it is easy for some people to "feel like a number." it is not difficult to take it personally when someone contends that it is just too bad, but some people may need to be sacrificed and needed medical equipment and supplies should be deployed to protect younger people. but how does it feel? one woman responded on twitter in early may by expressing her emotions in a clear and undeniable way in response to a televised segment she had watched. anne reminded us how it feels by saying, "that man you just had on said my life doesn't matter, that i am expendable, that i don't matter. i am a mother, wife, grandmother, community activist, community volunteer, i knit, i matter! i matter! i can't be sacrificed so he can go to walmart!" when it comes to lived experiences during the pandemic, this feeling of being expendable is, of course, not limited to older adults, but extends to others who are socially disadvantaged. findings are accumulating of the heightened risk of covid-related morbidity and mortality among hispanic and african americans. there have additionally been numerous reports from people of varying ages who are either refusing to go to work or who have quit their jobs given worry about their personal safety; however, it should be evident to any observer that the feeling of not being valued by the employer is also very salient and very strong among these workers. acts of defiance and disengagement should not be surprising; there is growing research evidence of how being made to feel unimportant and insignificant in the work setting is tied to turnover, work disengagement, and various negative emotions (jung ; jung and heppner ; richards et al. ) . the importance of mattering versus not mattering extends to healthcare workers. although some retired healthcare workers experience a sense of mattering when called back into service, one recent study found that nurses with lower levels of work mattering reported more burnout and less engagement (haizlip et al. ) . in contrast, workers thrive and flourish when they are valued and they know they matter. even small gestures and individualized inquiries about the personal life of the employee can have a huge positive impact. these are important themes for further consideration, but the current review article focuses on the need to matter among older adults. our analysis examines relational mattering (i.e., mattering to other people) as described by rosenberg and mccullough ( ) . statements about what should or should not happen at a broader level in institutions are more a reflection of the type of mattering known as societal mattering, which was a theme introduced by fromm ( ). people can be evaluated in terms of how much they feel they matter to others and to society. societal mattering is also quite important; indeed, many older people could feel like they are experiencing "double jeopardy." the person who does not feel significant to specific others and who does not feel significant to the broader community or society is someone who is at considerable risk in terms of both one's mental health status and physical health status. there is a third type of mattering known as "existential mattering" that is also distinct and involves assessments of whether one's life matters (see george and park ) ; this issue is also of relevance to many older adults and will be addressed in our discussion of meaningcentered research with older people. as suggested above, people know how it feels to them when they have been treated like they do not matter, so it should be easy to understand how many older people are feeling right now. our interest in the health and well-being of older people and their concerns are longstanding; we have conducted research over the past two decades on the risk and resilience factors associated with suicide and suicide ideation among older adults (heisel and flett , ; . this work has also resulted in the creation of the first measure of suicide ideation tailored specifically to the needs and lives of older people, the geriatric suicide ideation scale (heisel and flett ) , which assesses sociocultural and existential factors (i.e., its "loss of personal and social worth" and "perceived meaning in life" subscales) in addition to thoughts and wishes to die and for suicide. recently, concerns have been expressed about an anticipated spike in suicide behavior and deaths among older adults as a result of the pandemic (see wand et al. ) . the royal college of psychiatrists has just estimated that there could be a six-fold increase in suicide attempts among older adults (see hymas ) . suicide prevention researchers and public health experts have warned the public of a substantial increase in suicide rates among older adults, given covid-related increased fear and despair, restriction of physical access to social supports and mental healthcare programs, and financial anxiety due to the impact of stock market volatility on retirement savings. the spanish flu was associated with increased rates of suicide, and elevated suicide risk was reported for older adults in hong kong in the aftermath of the sars epidemic, due in part to the negative impact of physical distancing and isolation (see chan et al. ) . it is our contention that any increase will be fuelled not only by anxiety, stress, uncertainty, and isolation, but also the broader messages that convey to older people that perhaps they simply do not matter. one theme that has emerged from our research and from that of other investigators is that given the risks that face vulnerable older people, it is vitally important to promote positive protective factors and competencies that heighten their resilience and engagement and involvement. we agree with rosenberg and mccullough's ( ) contention that mattering is vital for everyone, but it may be especially vital for older people. however, mattering deserves much more focus among psychologists than it has received thus far; knowledge of whether an older person feels like she or he matters to others is fundamental to understanding this person and how life is going and how it is likely to go in the future. it is our hope that the current review and analysis will serve as a catalyst for a much greater emphasis on the role of mattering and its many potential benefits among scholars who conduct research with older adults and professionals who are in positions to implement practices and procedures to enhance their health and mental health. relevant research on mattering among older adults is summarized below. as is typically the case, these research investigations are mostly variable-centered studies that investigate levels of mattering and associations between mattering and other variables in large samples with participants who are either rapidly approaching or who have already reached the ages associated with being an older person. it is important to reiterate before launching into an overview about this research that mattering is about the individual person. that is, it is about the significance of the older person's individual story and life narrative. it is about whether the individual feels seen and heard and valued versus invisible and unheard and someone who does not count to the people in their lives and perhaps society as a whole. if mattering is as relevant as we claim it is, then it should be possible to identify themes related to feelings of not mattering or of feeling unimportant and expendable when the focus shifts to qualitative accounts of the experiences of individual people. this is clearly the case. for instance, a study of perceptions of preventive home visits yielded four categories including a mattering-based category centered around the theme "it made me visible and proved my human value" (see behm et al. ). berglund and narum ( ) interviewed women ranging in age from to years old. six categories emerged including a relationships category with content reflecting both belonging and mattering. specifically, one participant observed, "being in the company of my dear ones gives me a sense of belonging. it's nice to know that someone cares and they in turn can count on me when they need help or someone to talk to" (p. ). another analysis of long-term care environments by pope et al. ( ) resulted in residents identifying several things that made them feel significant (i.e., they mattered) versus insignificant (i.e., they did not matter). feelings of insignificance were trigged by events or treatment that evoked feelings of loss of control. feelings of insignificance are also rooted in insensitive treatment. an examination of factors contributing to loneliness included input from one longterm resident who said he was being shunned by his adult children (see roos and malan ) . his social pain is reflected in his statement that, "they don't want me anymore. i feel like i don't exist to them." other analyses point to feeling insignificant because of not being consulted about decisions that pertain directly to personal care and well-being (fetherstonhaugh et al. ) . a phenomenological analysis of suicidal tendencies among older adults by our colleague sharon moore identified themes of not mattering such as "no one cares" and "i am no longer needed" and the sorrow in the realization of "not being depended on anymore by other people" (see moore ) . these are commonly expressed themes among people who feeling insignificant and perhaps expendable. comments from participants in our study of meaning-centered men's groups (mcmg; see heisel and the meaning-centered men's group project team ) for men over the age of who were concerned about or struggling with the transition to retirement further underscore the central role of mattering in the mental health and well-being of middle-aged and older adults moving into their later years. qualitative findings from study exit interviews highlighted general themes relevant to mattering in enhancing participant satisfaction with the group experience, including being valued and respected, mutual camaraderie, fellowship, and belonging. a looming sense of missing each other was at the heart of requests to extend the sessions and find ways for group members to remain in contact. finally, the need to feel a sense of mattering was clearly evident in the responses that older people with mental health problems generated as part of a concept mapping exercise. this study by wilberforce et al. ( ) was conducted to inform the development of a new measure of quality of mental health services for older people. one category that emerged to characterize excellent services was labeled "personal qualities and relationships." this category included several references to the mattering construct such as care providers who are really interested and listen to and understand the older person (i.e., my care worker really listens to me). one elderly person made explicit reference to a worker who showed compassion and that they mattered. the essence of this concept category was a sense of humanity stemming from being treated as a real person by someone who is joining with the older person and is truly interested in spending time with her or him, and is not just passing through. collectively, these accounts underscore how mattering can be linked with joy and flourishing, but the feeling of not mattering can be associated with deep psychological pain. moreover, mattering needs to be embedded in therapy and counseling services. in general, the insights yielded from these accounts attest to the merits of future qualitative research that extensively examines the lived experience of feelings of mattering versus not mattering to others and perhaps to society. below, we describe the mattering construct in more detail and some elements that need to be added in order to more fully capture the relevance of mattering versus not mattering to older people. this description is then followed by a comprehensive overview of research conducted thus far that illustrates the benefits of mattering among older people. what is mattering? rosenberg and mccullough ( ) introduced mattering and the components that comprise this construct. mattering reflects our need to feel like we are significant and important to other people. rosenberg and mccullough ( ) focused on three components: ( ) the sense that other people depend on us; ( ) the perception that other people consider us to be important to them; and ( ) the understanding that other people are actively paying attention to us. rosenberg ( ) added a fourth component reflecting the sense that other people have expressed that they would miss us if we were no longer around. subsequently, schlossberg ( ) identified a fifth element-feeling appreciated by someone. this component emerged following interviews with adult caregivers who indicated what made them feel like they mattered to those people receiving their care. prilleltensky ( ) sees mattering as involving both the sense of having value to other people and giving value to other people; thus, mattering reflects both giving and receiving in ways that provide feelings of personal significance and importance. the notion of enhancing the self by becoming someone who matters to others was shown in a case excerpt described by karp ( ) in his book about people struggling with the sadness of chronic depression. marco struggled for years with profound depression but nevertheless had to assume the caregiver role when his mother suffered a prolonged illness and it became clear that she would never get better. when asked whether there was anything in it for him, marco replied, "it made me feel important" (p. ) and it forced him to put his own "stuff" aside for the time being. whereas a commonplace clinical response is to seek to alleviate stress from individuals struggling with depression, this example demonstrates the value in challenging clients to focus meaningfully on the needs of others rather than attending exclusively to their own emotional difficulty. most recently, killen and macaskill ( ) illustrated the relevance of giving value to others in a qualitative study of the positive life events reported by older adults. they conducted a revealing analysis of the diary entries of elderly people in order to arrive at a revised model of positive aging. one category that emerged from their analysis was being of value to others. this category involved doing something to help friends or family members or the broader community and receiving notes of appreciation from others. some entries reflected expressions of mattering. for instance, one woman noted in her diary that, "husband coming downstairs after going to bed specifically to give me a hug and kiss goodnight, what could be better to confirm that one matters!' (f ) (p. ). collectively, diary entries reflected the positive affect stemming from having value to other people. the components of mattering outlined above likely vary in their relevance according to an individual's current life stage, albeit with the caveat that all components are important to some degree. the need to feel that others depend on them is critical for older people. this observation accords with conclusions from sage scholars who point to the benefits that accrue when older people feel needed and wanted because other people are relying on them. findings of great longevity among older adults in japan who continue working into their th or th decades of life further demonstrate the very real health benefits that can accrue from feeling valued and that one has a purpose (see jenkins and germaine ). erik erikson proposed in his developmental theory that a key stage for middle-aged and older people is generativity versus stagnation. the positive resolution of this stage is care. although they did not discuss mattering per se, erikson et al. ( ) emphasized in their analysis of vital involvement that older people who show caring and engage in nurturing of younger people, especially younger family members (e.g., grandchildren), will spread feelings that clearly resemble feelings of mattering. similarly, george vaillant's ( ) classic analysis of the lives of older people who took part in the longitudinal harvard study of adult development also emphasized giving to others in ways that foster positive and mutually caring relationships in ways that benefit the self. these acts of caring can be focused on young family members but of course, in many instances, also involve caring for disabled relatives and friends. vaillant ( ) warned that it is possible for dedicated younger adults to become so engaged in providing care to aging parents that it can amount to too much sacrifice if such caregiving activities become all-consuming; he suggested that this can result in depleting the self by "giving the self away" to others. vaillant ( ) suggested that the benefits of giving to others are better and more evident when a person is older because caring for others is more self-determined and does not feel like an overwhelming obligation. similarly, erikson et al. ( ) suggested that generative acts from elderly people directed at younger family members are more beneficial when other people are shouldering the daily responsibility for younger people and older people can focus on being generative. how protective can it be to feel a sense of mattering to younger people who have come to depend on an older person? erikson et al. ( ) described an elderly woman who acknowledged during her interview that she actually refrained from taking her own life because she knew how much she was loved and admired by her grandchildren (i.e., she mattered). the feeling of mattering provides a sense of connection and comfort and a source of resilience that is a strong buffer of life problems and feelings of stress and distress (for discussions, see flett a; flett et al. ) , especially during the pandemic (see flett and zangeneh ) . we discuss this protective role in reducing suicide risk in more detail in a subsequent section of this article. we now turn to a discussion of ways to extend the mattering construct to more fully capture the relevance of mattering versus not mattering to older people. these additional ways of capturing individual differences in mattering are important from a conceptual perspective, but they also extend the potential focus of preventive interventions and open up additional directions for future research. the original conceptualization of mattering from rosenberg and mccullough ( ) focused on it as a feeling state and as a psychological need that is central to how people define themselves. a strong case can be made for the argument that the need to matter is just as important to people as are other key needs such as the need for autonomy, the need for competence, and the need for connection with others. rosenberg and mccullough ( ) discussed at length and demonstrated with their extensive data that mattering should not be equated with self-esteem. several researchers have confirmed that mattering goes beyond selfesteem when predicting key outcomes (e.g., flett and nepon ; flett et al. a flett et al. , b matera et al. ) . accordingly, any framework built around the notion that people need selfesteem should be modified to reflect that people need self-esteem but they also need to matter to other people. here it should be underscored that while the conceptual focus for the construct is on the need to matter, most existing measures of mattering such as the general mattering scale assess perceived levels of mattering to others and not the actual need to matter (for a discussion, see flett b). accordingly, research must focus jointly on the need to matter to other people and perceptions of achieved levels of mattering to other people. we contend that some other elements of the mattering construct are missing from the literature and clearly must be added in order to more fully capture what mattering and not mattering means to everyone, but especially older people. additional elements of the mattering construct are identified below. some of these elements have been discussed elsewhere, but they have not received much emphasis from a conceptual perspective until now. flett ( b) suggested originally that there is a key element of the mattering construct that has not been considered or measured thus far-the fear of not mattering to other people. flett ( b) proposed that people with a strong need to matter to others and who are also characterized by an insecure attachment style could become preoccupied with the fear of losing connections with the people whom they matter to and who matter to them. research on this facet of the mattering construct is in an early phase. casale and flett ( ) discussed at length how this fear of not mattering is especially relevant during the pandemic and how it is seemingly more germane at present than other fears such as the fear of missing out or the fear of negative evaluation. this element seems especially relevant to older people who have become isolated or socially disconnected or fearful of being forgotten as this global health crisis unfolds. elderly people who are cognizant of public statements about the expendability of whole segments of the population or the use of age as a key criterion to determine the allocation of scarce medical resources could have their general worries and levels of anxiety exacerbated by this particular fear. people who fear being alone may have also developed this fear of not mattering, and it could add to feelings of helplessness and hopelessness and perhaps resentment. this particular aspect of mattering may be especially relevant among some people who are in the process of dying. it is common to hear of people who just wanted to know that they have mattered to someone who cared about them and they have worries that this was not the case. it is not uncommon, among end-of-life care providers, to witness older adults at the end of life provide reassurance and comfort to family members who are struggling emotionally with the thought of the older person's impending death. a need for reassurance of having some significance to others should be especially salient among people who fear that they have not really mattered to anyone. a reasonable question to ask is, "what is worse-never having the sense of mattering to others or feeling a sense of mattering to others but then losing it?" a key element of the mattering construct that has received almost no attention thus far is the loss of mattering to others. elderly people who live long enough to outlive others and, as a result, experience loss of mattering via their losses can become very dejected if they have not found ways to maintain a sense of mattering or to still feel good about having mattering to the departed. there are many ways for older people to experience a loss of mattering to others. this may take the form of becoming a caregiver to young grandchildren who have parents employed full-time outside the home and then feeling no longer needed when these grandchildren are old enough to take care of themselves. complex family situations involving divorce and conflict may also result in a reduction in opportunities to matter for those older people who are no longer included in family activities. alternatively, a loss of mattering could take the form of losing physical mobility and no longer being able to fulfill an active volunteer role. and, of course, it could involve the loss of perceived mattering that results when an older person transitions to retirement and no longer feels important and significant to others, perhaps along with a loss of a sense of purpose. these transitions can be felt acutely by the older people who still very much need the sense of validation that is derived through mattering to other people. the loss of mattering can contribute to depressions that are due not only to loss of mattering but also a perceived loss of self. this observation fits with the many case examples of extremely depressed people who acknowledge that they no longer feel like their old selves and their first goal is to feel like themselves again. although they may not realize it, this translates into again having a feeling of mattering to others. as noted earlier, our geriatric suicide ideation scale contains a component subscale that assesses the perceived loss of personal and social worth. this factor is highly associated with a host of negative psychological factors, including depression, hopelessness, loneliness, and suicide ideation (e.g., heisel and flett . pearlin and leblanc ( ) stand alone as the only researchers thus far to focus extensively on the loss of mattering. their focus was on bereaved caregivers. their research showed that the death of a dependent relative (a spouse or parent with dementia) among caregivers resulted in a loss of mattering and contributed to depression, and the greater the loss of mattering among caregivers, the greater their level of depression year later (pearlin and leblanc ) . what is especially important about this finding is that it suggests that it is not simply a loss of activity or change in routine or sadness about having lost a loved one that is associated with depression, but rather the loss of connection, of feeling needed, and of mattering to others. we will conclude this segment by newly proposing another aspect of the mattering construct that applies universally but seems essential among older people. a fifth element of the mattering construct that is worth considering involves personal assessments of whether an individual who needs to matter sees herself or himself as someone who perhaps does not currently have a sense of mattering, but still feels that they are capable of engaging in behavior that will generate feelings of mattering to other people. this aspect of mattering can be regarded as a specific type of self-efficacy reflecting the perceived capacity to generate feelings of mattering by engaging with other people or contributing to the community in meaningful ways. this emphasis of a specific type of self-efficacy is suggested in general by research attesting to the protective role of other specific ways of framing self-efficacy among older adults (e.g., paggi and jopp ; stephan et al. ) . the concept of the capability to matter to others follows from a line of investigation in the personality field that began when wallace ( ) observed astutely that certain personality characteristics could be measured as abilities or capabilities. capabilities focus on what is possible or feasible versus what is typical, which is what personality traits tend to reflect. there has not been extensive research on personality capabilities despite their clear relevance to understanding people and the individual differences among them. one key exception is the work by martin ( , ) , who illustrated the usefulness of assessing personality capabilities in the interpersonal domain. they showed that capability and trait ratings of interpersonal characteristics are relatively orthogonal, and both capability and trait ratings are associated with low self-esteem and anxiety. the implications of these findings are clear: individual differences in trait ratings and capability ratings are quite different in their nature. similarly, just as it is possible to distinguish such things as a person's usual level of agreeableness and their capability of being agreeable, both subjectively and objectively, it should also be possible to distinguish a person's degree of mattering to others and their capability of being someone who could matter to others. it is likely that the perceived capability to matter to others overlaps to a substantial degree with feelings of loss of mattering. conceptually, it stands to reason that believing that one can still matter to others should moderate the negative impact of diminished feelings of mattering on depression and other negative psychological outcomes. some people will feel both a loss of mattering and a diminishment in their perceived capability to matter to others, perhaps as a consequence of having physical or cognitive declines that impact their ability to interact with other people. fazio ( ) has discussed how mattering to others can be impacted by personal circumstances and limitations that can also limit the frequency of positive social interactions. hopefully, such individuals will have people in their lives to whom they matter, and these people will be able to continue to demonstrate that they care about them and will take care of them. the next segment of this article consists of a review of existing research with an emphasis on mattering among older people. there are now enough articles on mattering among older people to get a clear sense of how mattering protects older people who have it and disadvantages those older people who do not feel like they matter to others. we then conclude with an analysis of applications in the form of preventive interventions and a discussion of directions for future research. our research review focuses on four topics. first, we examine the role of mattering in protecting against loneliness and social disconnection. next, we summarize research confirming that there is a negative association between mattering and depression. third, in keeping with a positive psychology orientation, we consider research illustrating the positive association between mattering and psychological well-being. finally, mattering is examined in terms of its role in positive physical health outcomes. results linking mattering with greater life satisfaction are also highlighted. most of the research investigations conducted on mattering in the elderly fit into these themes with the exception of some work examining the role of religiosity and mattering among older people (see lewis and taylor ; schieman et al. ) . loneliness is a serious problem facing many elderly people, and there are indications from extensive research that loneliness exacts both a devastating mental toll and a physical toll on older people. empirical research has supported the position that loneliness not only contributes to health problems, it may actually be a causal factor in early mortality (see holt-lunstad et al. ; luo et al. ) . fromm ( ) first discussed the association between being and feeling isolated and feelings of not mattering in his book escape from freedom. he proposed that individuals who achieve a sense of freedom from others also pay a price in terms of feeling both isolated and insignificant (see fromm ) . combined feelings of loneliness and of not mattering can be dangerous; this should especially be the case for exceptionally lonely older people who feel like they do not matter. this is just one of the many reasons why the situations brought about or exacerbated by the global health crisis may prove lethal for many older people. research on mattering and loneliness is quite limited. the most extensive study was conducted by flett et al. ( a, b) . this research with a sample of university students showed that lower scores on the general mattering scale (gms) were associated with loneliness and this association was quite robust (r = − . ). moreover, feelings of not mattering and loneliness were both associated with reports of various forms of childhood maltreatment. other analyses of this cross-sectional data yielded support for mattering as a mediator of the link between childhood maltreatment and loneliness. work is continuing in our lab on the link between feelings of not mattering and loneliness and the initial evidence continues to suggest a strong link between these interpersonally-based psychological factors. how are these factors associated among the elderly? initial evidence of a strong negative association between feelings of mattering and loneliness came from an investigation by kadylak ( ) of adult internet users years or older with a mean age of . years. the main focus of this work was to examine reactions to "phubbing" which is the tendency to focus on technology in a way that also involves ignoring someone else. low mattering would exist if an elderly person (or anyone) was being ignored by someone absorbed in technology. mattering was assessed by the -item mattering index by elliott et al. ( ) . the measures also included an eight-item loneliness scale and measures of self-reported health, depression, and the five-item satisfaction with life scale (diener et al. ) . the depression results from this study are reported in the next section. analyses established that mattering was linked robustly with lower levels of loneliness and higher levels of life satisfaction. interestingly, although it was not associated significantly with self-reported health status, levels of mattering were significantly lower among participants with lower levels of socioeconomic status and among those who were widows or widowers. lower mattering was also linked with more frequent family phubbing expectancy violations (i.e., attention of others was expected but not obtained). finally, mattering mediated the link between intergenerational family phubbing expectancy violations and loneliness. evidence of a link between low mattering with less social connection was provided in a study by francis et al. ( ) . they examined how the frequent use of informational communication technology (ict) can enhance the functioning of older adults in retirement communities. this was an extensive project that was part of a randomized control treatment study with five waves of data collection. the participants were older adults with a mean age of . years. mattering was assessed with the five-item gms (marcus and rosenberg ) . a negative link was found between mattering and assisted living, suggesting perhaps that mattering becomes diminished as a function of age-related declines in functioning. this interpretation seems consistent with the experience of older adults in residential care who are allowed to soil themselves before being assisted in toileting by on-site support workers; it is hard to conceive of a clearer message that one does not matter than to be subjected to this sort of indignity. the main analyses showed that higher levels of mattering were associated with more extensive ict use. it was also linked positively with a self-report measure of social network connectedness known as the lubben social network scale (see lubben and gironda ) . mediational analyses established further that social network connectedness mediated the association between ict use and mattering in this sample of elderly people. collectively, initial research with older people suggests that any links proposed between feelings of not mattering and feelings of isolation and social disconnection are well-founded. research with a lifespan perspective is now needed to examine mattering and loneliness from a longitudinal perspective. some complex associations likely exist, especially if mattering is studied with an extended scope that includes the fear of not mattering and the perceived loss of mattering. the predominant clinical research focus thus far in the mattering field has been on the negative association between mattering and depression. flett ( b) summarized numerous reasons why lower mattering to others should be associated with higher levels of depressive symptoms. an association would be expected given the negative self-worth judgments that are common to both. also, people with low levels of perceived mattering should have less perceived and actual social support which could have provided a buffer from depression. dixon ( ) conducted the initial study of mattering and depression in the elderly. a sample of older adults ( men, women) completed a -item measure of mattering developed by the author. the participants had a mean age of . years. dixon ( ) only reported the results for the overall score on this mattering measure even though it was comprehensive and assessed global mattering, but also mattering to significant others and friends and other family members, including any grandchildren. dixon ( ) found that mattering was linked robustly with less depression (r = − . ). other results from this study are reported in a subsequent segment of this article. chippendale ( ) also evaluated the link between mattering and depression on a smaller scale in a sample of older adults from four senior's residences in new york city. mattering was assessed with a single but highly face valid item (i.e., i feel valued and important). this item was taken from the duke social support index (koenig et al. ) . participants also completed a brief one-item measure of self-reported health status and the full version of the geriatric depression scale (gds: yesavage et al. ). the one-item measure of mattering (i.e., feeling valued and important) was associated negatively with depression (r = − . ). secondary analyses indicated that among those people who were severely depressed according to the gds cutoffs, it was the case that none of these people indicated any level or degree of agreement with the mattering item (i.e., no person with depression felt a sense of mattering). another study by wight et al. ( ) of gay identified men from the usa further illustrated the role of mattering in reduced levels of depression. the authors noted that their focus on mattering stemmed in part from reports found commonly among aging gay men of feeling invisible to other people. their participants had been part of a longitudinal study conducted over three decades, but wight et al. ( ) focused on data collected in and . the average age of participants was . years with an age range of to years. overall, % of the participants were hiv-negative. mattering was assessed with the gms (marcus and rosenberg ) . other measures in the study included a measure of internalized gay ageism with items such as "aging is especially hard for me because i am a gay man." depression was assessed with the ces-d depression scale (radloff ) . the ces-d was administered many times over three decades and this enabled the researchers to identify five depression trajectories. these trajectories were controlled for in subsequent statistical analyses. the results of a regression analysis predicting the most recent ced-d score found that elevated depression scores were uniquely and significantly associated with lower levels of mattering and higher levels of internalized gay ageism. other analyses pointed to mattering as a mediator of the link between internalized gay ageism and depression; that is, higher levels of gay ageism were associated with lower mattering which, in turn, was associated with higher levels of depression. no support was found for mattering as a moderator variable. another study of functional limitations by redmond and barrett ( ) included data on mattering and depression. this longitudinal study of over adults from miami-dade county in florida found that lower scores on an extended version of the general mattering scale were associated with depression and increases in depression over time. this study is relevant because it had a broad representative sample with participants from three age groups ( - years, - years, and - years) who had a mean overall age of . years. finally, the study by kadylak ( ) described above on reactions to phubbing among internet users also included a two-item depression scale. it was found once again that mattering was associated robustly with lower depression. as noted earlier, the study by dixon ( ) of elderly adults also included indices of wellness and purpose in life. wellness was examined only as a total score. the correlational analyses conducted by dixon ( ) found that mattering was linked with purpose in life (r = . ) and with overall wellness (r = . ). it is especially noteworthy that a regression analysis predicting overall wellness showed that mattering, purpose in life, and depression all were significant, unique predictors, suggesting that mattering is neither simply a synonym for purpose in life or wellness, nor the opposite of depression, but is an unique variable in its own right. myers and degges-white ( ) examined mattering and levels of wellness among older adults in a retirement community. the participants were residents ( men, women) who ranged in age from to years old and who had a mean age of years old. perceived stress was also assessed. mattering was assessed with the five-item gms (marcus and rosenberg ) . wellness was assessed with the five-factor wellness scale (myers and sweeney ) which taps domains of wellness and provides measures in total. correlational analyses found that mattering was not associated with perceived stress, but it was associated significantly with overall levels of wellness (p < . ). overall, mattering had significant positive links with of the individual measures of wellness. a third study by piliavin and siegl ( ) reported findings from the wisconsin longitudinal study. this long-term study began decades earlier. the report from piliavin and siegl ( ) examined a large sample of participants who were assessed in when they were approximately years old. the main focus of this work was to evaluate the potential benefits over time of volunteering. mattering was assessed with six items from the mattering index by elliott et al. ( ) . well-being was assessed with five-item or six-item subscale measure of ryff's ( ) well-being scale. it was a composite well-being measure comprised of four subscales tapping self-reported environmental mastery, purpose in life, personal growth, and self-acceptance. the results showed that even when controlling for levels of well-being when assessed in , it was the case that greater subsequent psychological well-being was predicted by mattering and a host of other factors, including social integration, years of education, and being female. other analyses suggested that social integration mediated the link between volunteering and well-being, and mattering mediated the link between volunteering and well-being. it was concluded that when someone does not have a high level of social connection, direct engagement in volunteering can boost well-being and this is underscored, at least in part, by an enhanced feeling of mattering to others. mattering should be protective in terms of physical health because it should act as a stress buffer, especially following interpersonal stressors that involve negative social exchanges (for a discussion, see fazio ). similarly, mattering should be associated with positive health behaviors and self-care to the extent that people who perceive that they matter to others have internalized this perception and so feel that they matter to themselves. the study by chippendale ( ) described above that was conducted with participants included a one-item assessment of self-reported health status. the one-item measure of mattering had a positive association with health status (r = . ), but this association did not achieve statistical significance. this could reflect the small sample size and the reliance on single-item measures. kadylak ( ) also did not find a link between mattering and a brief measure of health status. however, the study of ict frequency by francis et al. ( ) described earlier also included a one-item measure of self-reported health status; mattering was associated significantly with higher health status among these participants. fazio ( ) described the results of the first assessment point from the aging, stress, and health study (ash) in a published chapter on mattering. the initial assessment was based on adults who were years or older from washington and two counties in maryland. participants were categorized as young-old ( - ), old ( - ), and old-old ( or older). four items were used to measure mattering in terms of importance to other people and another four items assessed other people depending on and counting on the person. it was found that levels of mattering decreased significantly with age; both mattering components were significantly lower in the old-old group versus the young-old group. most noteworthy for our purposes was the finding that better self-reported physical health status was linked positively with the two facets of mattering. also, engagement in volunteer roles was also associated with higher levels of mattering. hence, remaining engaged in physical activities and in doing for others overcome the negative impact of aging on perceptions of mattering. the most relevant research conducted thus far suggests that mattering may help reduce the impact of "the wear and tear" on the body at a precise time when people are increasingly susceptible to the onset of disease and major illnesses. a key investigation by taylor et al. ( ) examined adults from tennessee. they ranged in age from to year olds. the sample included people between the ages of and years old and another people who were years old or older. they were evaluated on levels of allostatic load across physiological indicators. these indicators contained various objective measures (e.g., blood pressure, cholesterol, high-density lipids, etc.). participants also reported chronic health conditions. the mean level of chronic health conditions for the sample was . . the analyses found that age is associated with increased allostatic load, and this association is substantially greater among adults with low or moderate levels of mattering. these data suggest that a sense of not mattering plays an increasing role in poor physical health outcomes among older adults. ironically, with worsening health, the interpersonal others with whom older adults increasingly spend their time are healthcare providers; clinicians who work with older adults are thus strongly encouraged to be sensitive to, and seek to enhance, their older clients' feelings of mattering. analyses of chronic health conditions found that age was associated with more chronic health conditions, as would be expected, but mattering was associated with fewer reported chronic health conditions. however, levels of mattering did not interact with age to predict the number of chronic health conditions. while these findings need to be evaluated in future research to determine their replicability, employing multi-item measures and larger sample sizes, it does seem that mattering plays a protective role in health functioning, especially among older adults. taylor et al. ( ) went on to conclude that, "there is reason to believe that mattering may be a better predictor of health and well-being relative to other conceptualizations of social relationships" (p. ). in particular, they posited that mattering should outperform social support in terms of health and well-being. collectively, the results summarized above paint a positive image of the older person with a sense of mattering to others but a bleak image of the older person who feels insignificant, unimportant, or worthless to self and others. much more research is needed, but mattering is clearly protective in terms of being associated with less depression and greater well-being, and there are strong indications that mattering provides a platform for better health. also, initial data suggest that older people with a sense of mattering have lower loneliness and greater social connection. these findings combine to suggest that the older person who is able to maintain and extend a sense of mattering to others is someone who should cope reasonably well with the pandemic. once again, however, the situation is qualitatively different and untenable for elderly people who feel like they do not matter to others. these tendencies should be exacerbated if this is accompanied by the feeling of not mattering to the community or the broader society. flett et al. ( ) maintained that one of the key distinguishing features of mattering relative to other psychological constructs is that mattering translates well into actions and themes that can be incorporated into practical applications with a prevention and promotion focus. the potential relevance of mattering is considered below as part of a brief overview of some existing preventive interventions for older adults designed to enhance the sense of connection and relatedness to others and decrease social isolation and psychological distress. there now has been extensive research on the social isolation of older adults and the impact of loneliness and disconnection. the extent of this focus is reflected by there being at least two separate scoping reviews of research on isolation and social disconnection (see courtin and knapp ; o'rourke et al. ) . there is little doubt that anyone stands to gain from having more positive social interactions and a greater sense of interconnectedness with other people, but this is especially the case for older people who find themselves quite isolated. below we will provide a brief description of two interventions designed jointly to enhance social connections and improve mental health. mattering could be added as a key element in each instance. van orden et al. ( ) implemented a program in rochester, new york called the senior connection as a potential way of preventing suicide among elderly people. the essence of this program is that seniors who have expressed an interest in volunteering have that interest directed toward becoming a peer companion of another senior who is vulnerable and isolated, perhaps to the extent of becoming suicidal. the conceptual premise of this work is provided by the interpersonal theory of suicide by joiner and colleagues. this is a key element because ideally prevention attempts are guided by theory and conceptualization. two main themes are at the core of this interpersonal theory. people are suicidal because they feel like: ( ) they do not belong with others; and ( ) they have become a burden to other people. a program such as the senior connection will certainly address the sense of not belonging. moreover, the senior companion can openly discuss and refute the notion that their vulnerable partner is a burden to others. where could mattering enter this picture? there is a tendency to equate belongingness with mattering, but these two interpersonal constructs are distinct. someone can feel like they belong in a group yet still feel not valued or recognized within the group. flett ( b) has also described empirical findings showing that belonging and mattering are distinct concepts in various research investigations. these results suggest that the senior connection could be reframed to place a specific emphasis on how the actions and verbal interactions that take place between companions can emphasize that both are valued. one premise guiding work on mentors and mentees is that the mentor gives value to the mentee, but the mentor also receives value as a result of having a role that makes a difference in the life of someone else. mattering is also relevant to another program being led by the second author. this intervention has received the support of the movember foundation and it is geared toward lowering suicide risk and enhancing the psychological resilience of men transitioning to retirement. it is rooted in the work conducted by the authors on the role of meaning in life in promoting psychological well-being and reducing risk for suicide among older adults (see heisel and flett ) . this program and its initial effectiveness are summarized in heisel et al. ( ) . this new paper outlines the preliminary results for the mcmg (also see heisel and the meaning-centered men's group project team ). the mcmg is a -session existentially oriented, community-based, psychological group intervention. delivery of the mcmg sessions is in community settings. recruitment is based on promoting this opportunity as a "men's group dealing with adjustment to retirement" rather than as a "psychotherapy group" in an attempt to normalize any concerns about retirement. two male facilitators lead the groups. the groups are comprised typically of men who share the fact that are all facing the transition to retirement. a full description of positive initial findings is beyond the scope of this review article. it is worth noting, however, that heisel et al. ( ) made explicit reference to the potential role of mattering, and that the theme that each participant matters is implicit in the philosophy of this humanistic-existential group. our evaluation of the topics covered throughout the program identified many points where a more extensive focus on mattering could be implemented. for instance, of course, it is a simple matter when describing the purpose of the group in the initial meeting to emphasize the theme "you matter" as a reason for the existence of the program. mattering promotion can also be nonspecific in terms of providing opportunities to be seen and heard within a context where "everyone counts." some specific session themes fit naturally with the nature of the mattering construct and how to instill a feeling of mattering in a person facing retirement. for instance, one segment examines the benefits of volunteering and becoming a mentor for someone else; mattering through mentoring is quite viable. the role of mattering can also be highlighted in sessions seven and eight that collectively address meaning in relationships, friendships, business relations, and camaraderie, and meaning in love experiences with significant others, children, extended family, and even pets. one of the final sessions is focused on meaning in life and generativity. this session also represents a platform for the theme of giving a sense of mattering to the self by giving to others. the facilitators lead participants through the "clarence challenge"-named after the angel in the frank capra movie "it's a wonderful life"-asking them to imagine that an angel has materialized in front of them and shows them a movie reel of their life, specifically focusing on all of the contributions that they have made in life and the positive impact that they have had on others. after reflecting on these contributions, and listing them explicitly on paper, they are then asked to project themselves one decade into the future and imagine that clarence the angel reappears in years' time and reveals to them all of the good that they can still do. they are specifically invited to "focus on the lives you will have touched, the value you will have contributed to the lives of those around you, whether your family, friends, neighbors, community, or even strangers. then mark down (below) the impact that you can still make on the world around you over the coming decade." this highlights the facet of mattering that involves the perceived capability or capacity to matter to others, both now and in the future. it goes without saying that positive group experiences should foster the development of bonds among group members who come to matter to each other. this appears to be the case, as some former group members have continued socializing with one another following the end of the group, including one group that has been meeting on a monthly basis for nearly years following the end of their group; ironically, their most recent scheduled breakfast meeting was canceled due to covid-related prohibitions against group get-togethers. although it is beyond the scope of this review, the most recent mcmg group was temporarily halted due to covid; however, following receipt of research ethics approval, this group was reconvened online to positive effect. as suggested above, regardless of the specific content that comprises an intervention, we feel that there is much to be gained by highlighting the mattering theme prior to implementing an intervention so that participants understand that they are valued and their involvement is truly appreciated. it goes without saying that this value needs to be shown and lived rather than merely mentioned. this sense of being significant will resonate with those older people who have been feeling ignored or discounted. it should certainly be "music to the ears" of any older people who is troubled by messages and events during the pandemic that make them feel expendable and disposable rather than valued and cherished. numerous topics for future research have already been outlined in earlier segments of this article, so we will focus on only a few key themes that merit much more investigation. some of the work outlined below would benefit from a general approach that pits mattering versus other related constructs (e.g., belongingness, social support) in order to further establish the uniqueness and predictive utility of mattering. first, and foremost, the literature on the role of feelings of not mattering in suicide risk is beginning to build but, to our knowledge, there has not been research thus far focused on the potentially protective role of mattering among older people. research is imperative given growing concerns about suicidal tendencies among older people, especially during the pandemic. some studies have provided indirect evidence of the proposed association between mattering and lower suicidality, but programmatic research from a longitudinal perspective is urgently needed. regarding this indirect evidence, one study linked family connectedness with reduced suicide ideation among older adults (purcell et al. ) . measures of connectedness often include item content that assesses mattering (see flett b) . in this instance, family connectedness was assessed with a four-itembased measure of family-based reasons for living. our anlysis indicated that one of these items is directly relevant to mattering (e.g., my family depends on me and needs me), while two of three remaining items constitute indirect indicators of mattering (i.e., would be missed by others). another investigation established links between measures of belongingness and reduced suicide ideation among older adults (mclaren et al. ). once again, however, the two belongingness measures each had a small subset of items reflecting mattering to others (e.g., have felt valued in the past). thus, the results actually signify that lower suicide ideation is linked with both mattering and belongingness. the study above on family connectedness was based on a four-item measure comprised of items designed to tap reasons for living. this is noteworthy because one way to frame mattering is to consider it as a core reason for living, and research findings support reasons for living in promoting optimism and reducing risk for suicide among older adults (e.g., britton et al. ; edelstein et al. ; hirsch et al. ). accordingly, one possibility for future research is to incorporate mattering as a key theme in existing measures of reasons for living. this fits with the results of a qualitative analysis indicating that the feeling of not mattering was identified as an overarching theme among elderly people with a desire for a hastened death (see van wijngaarden et al. ) . finally, rosenberg and mccullough ( ) observed that mattering is especially important when people are facing a transition, and as such, it seems evident that more research is needed on the role played by mattering as people continue to age and they undergo a variety of impactful transitions. the focus thus far has been on mattering and retirement and there is a clear need for programmatic research on mattering and retirement; additional important moments of transition can include downsizing one's home or moving into a residential care home; experiencing health-related changes, widowhood, or other significant interpersonal losses; and anticipation of one's own mortality. schlossberg ( ) also proposed "the mattering recipe." it has four ingredients: ( ) getting involved and staying engaged, ( ) harnessing the power of invitations, ( ) taking initiative, and ( ) doing your best to make others feel like they matter. initial evidence attests to the benefits of mattering for retired workers. froidevaux et al. ( ) described a longitudinal investigation with retirees. gms scores were associated with positive affect, life satisfaction, and social support, and mattering was a mediator of the link between social support and positive affect. froidevaux et al. ( ) concluded that preventive efforts to enhance retirement adjustment should feature the mattering theme. in summary, the current article examined mattering and the need to feeling valued and significant and contrasted it with feelings of expendability among older people in usual times and in times of crisis such as the current global health pandemic. it has been mentioned often that the arrival of covid- has brought existing gaps and systemic problems into the light; we suggest that it has also illuminated a mattering gap. there is a clear need for older adults to be treated in ways that enhance their sense of mattering and enjoy the benefits of feeling significant and important rather than feeling expendable and disposable. this extends to the need to substantially increase the resources available to our older people, including training more mental health professionals to address the needs of older people who do not feel like they are priorities. humanistic approaches may be particularly consonant with such an approach, and we have outlined elsewhere the potential value of humanistically oriented interventions in enhancing well-being and reducing risk for suicide among older adults (heisel and duberstein ) . the facets of the mattering construct were described in this article and elements of the construct relevant to older people requiring much more attention were identified (e.g., the fear of not mattering and the loss of mattering). research was summarized which shows consistently the ways in which mattering is protective in terms of its links with higher levels of wellbeing and lower levels of depression and loneliness. mattering was also considered in terms of its link with physical health and its adaptive role as a buffer of the link between stress and physical health. the findings are generally in keeping with the premise advanced by rosenberg and mccullough ( ) that mattering is especially relevant among older people. it is vital for individuals, professionals, and communities to promote experiences of mattering among older adults so that our seniors can benefit fully from an enduring feeling of mattering to others and to society in general. it is our hope that this review and analysis will serve as a catalyst for a much greater emphasis on mattering as a way of promoting resilience among the elderly. we also hope it will serve as impetus for further research and applications that document how older people benefit enormously from chronic exposure to settings and situations that reinforce how much they matter and in which they know they are cherished. funding information gordon flett was supported by the canada research chairs program. this work was supported, in part, by funding from the movember foundation to the authors. covid- and the consequences of isolating the elderly. the lancet public health preventive home visits and health -experiences among very old people covid- and long-term care policy for older people in canada 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approach to support the development of a new quality measure many failures combined to unleash death on italy's lombardy development and validation of a geriatric depression screening scale: a preliminary report calls for inquiry into "horrific" covid- deaths at australian nursing home key: cord- -efv ovx authors: reicher, stephen; stott, clifford title: on order and disorder during the covid‐ pandemic date: - - journal: br j soc psychol doi: . /bjso. sha: doc_id: cord_uid: efv ovx in this paper, we analyse the conditions under which the covid‐ pandemic will lead either to social order (adherence to measures put in place by authorities to control the pandemic) or to social disorder (resistance to such measures and the emergence of open conflict). using examples from different countries (principally the united kingdom, the united states, and france), we first isolate three factors which determine whether people accept or reject control measures. these are the historical context of state‐public relations, the nature of leadership during the pandemic and procedural justice in the development and operation of these measures. second, we analyse the way the crisis is policed and how forms of policing determine whether dissent will escalate into open conflict. we conclude by considering the prospects for order/disorder as the pandemic unfolds. . for instance , snowden, ( ) documents how, during the cholera epidemic in italy, restrictions on burials led to attacks on health workers and the police. in general terms, then, we need to understand what determines whether a pandemic leads to greater social cohesion or greater social conflict? the question is equally pertinent when it comes to the current pandemic. we have seen high levels of adherence to lockdown measures and a remarkable flowering of mutual aid groupsin britain alone more than , groups involving some million people (butler, ) . we have also seen discord and overt conflict between the public and authoritiesin france, italy, brazil, and the united states, for example. so what determines why and when cohesion gives way to conflict, social order to social disorder? the origins of order let us turn first to the question of 'order'. more specifically, we focus here on whether the public accept without dissent the things that governments demand of them. in the context of covid- , why do people tolerate restrictions on their everyday lives, such as lockdown? the question of why people obey authorities is one of the most famous in the history of psychology. it is exemplified by the popularity and notoriety of milgram's yale obedience studies (milgram, ) . yet, milgram's work is more influential as a demonstration of how far some people will go in obeying an authority figure than as an explanation of this phenomenon. indeed, milgram's 'agentic state' account of obedience is little more than tautologysuggesting that we obey authority because we enter a state where we focus uniquely on obeying authority and hence automatically obey orders. our recent re-analyses suggest a very different story. obedient participants, we argue, should be understood as 'engaged followers' reicher et al., ) . far from being passive in the presence of an authority, they make an active ideological choice to work with the experimenter to advance the scientific enterprisesomething they see as a noble cause. moreover, we suggest this does not happen by accident. it is a result of active 'identity leadership' by the experimenter who actively seeks to bring about such shared identification between himself and the participant in the cause of science. this conclusion chimes with that from the work of tyler and colleagues on why people obey the law (tyler, )the so-called 'group engagement' model (tyler & blader, ) . they show that adherence depends upon whether people see themselves and authoritiesparticularly the policeas part of a common in-group. they too focus on the antecedents of such shared identity, but the emphasis is less on leadership than on procedural justice in the interactions between authorities and their publics. it is by giving people voice, by treating them fairly and with respect, that a sense of being part of a common group is created. this in turn legitimates laws and regulations and increases adherence to them (bradford, murphy & jackson, ) . more recent research suggests that the potency of procedural justice lies not simply in creating an in-group relationship between authorities and citizens but in establishing the authorities as prototypical in-group members acting for and serving the interests of the group (radburn & stott, ; radburn, stott, bradford & robinson, ; stott et al., ) . this work puts flesh on john turner's suggestion that the procedural justice framework 'points to a whole range of other factors relevant to identification with authorities and acceptance of their control as an ingroup norm (e.g. the ideology and goals of group members, the social comparative context, their history of success or failure for the group, the degree to which the authorities are perceived as more or less prototypical of the relevant identity) ' ( , p. ) . echoing turner, we suggest that, in addition to leadership and procedural justice, historical and structural context is a third antecedent of shared in-group identity and hence of adherence to authority. let us now briefly consider the significance of these three factors in the covid- pandemic. we use, as an example, the united kingdomwhere levels of adherence to restrictions have been consistently high. clearly, given that we are still in the midst of the pandemic and do not yet have the luxury of prolonged reflection or comprehensive data, our argument is more illustrative than definitive. but still, it is worth considering whether we can make sense of what we know thus far. first, regarding historical context, britain has a long tradition of treating state intervention as progressive and in the interests of the general populationwhich even if not a consistent reality, serves as a potent national myth (rollings, ) . politically, this is expressed in the idea that policing is not an imposition from the centre but rooted in local consent (channing, ) . economically, it is encapsulated in the idea of welfarism (page & silburn, ) . institutionally, it is exemplified by the nhs, invoked as a centrepiece in danny boyle's pageant of britishness for the opening ceremony of the london olympics and currently occupying an almost deified status. additionally, there are also powerful historical myths of state and society joining as one in times of national crisis as exemplified in the notion of a 'blitz spirit' and of the king and queen remaining in london to share the plight of the people during ww (calder, ) . these historical myths are potent sources for the ways contemporary social realities are broadly understood, and social relations are defined in the present. but they are not so much determining cultural presences as rhetorical resources that can be drawn uponand indeed need to be actively invokedif they are to influence our understanding of covid- , our relationship to authority during the pandemic and our responses to their policies. this takes us to the second antecedent of shared identity: leadership. there are already many controversies about the leadership of the uk government during this crisis and no doubt they will grow in time: did they tarry too long in declaring lockdown and have they shown sufficient diligence in developing testing and in securing protective equipment for frontline workers? nonetheless, government ministers and government information services have, increasingly over time, framed the crisis in inclusive national termsa 'we' thing that incorporates government and people in common cause . and indeed the queen, in her address to the nation on th april, invoked the myth of a 'blitz spirit' to ground her calls for national solidarity, notably by finishing with a reference to vera lynn's most famous of all ww songs: 'we will meet again'. but the rhetoric of 'togetherness' is of little use and may indeed be undermined when it is not matched by practices which make it possible for us to come together. otherwise, the words will be seen as hypocrisy and will only serve to undermine a sense of equity and trust in authority. at this point, we are back in the territory of procedural justicethe third antecedent of identification with authorityalbeit with a critical twist. that is, it is important that fairness is not just a matter of rhetoric and the process by which regulations are introduced but that it extends to the ways in which those regulations impact on people in practice (armaline, sanchez & correia, ; epp, maynard-moody & haider-markel, ) . once again, there is already criticism of government support to enable everyone to observe lockdown as too little and too late. and again, there will be more. there is little doubt that the poor and precarious are less able to stay at home, even if they are as motivated as the rich and secure to do so (atchison et al., ) . the evidence is clear that the poor (and bame people) are getting infected and dying at far higher rates than the affluent (pidd, barr & mohdin, ) . but first, the united kingdom does have a range of welfare provisions including free universal health care. second, even if insufficient, nonetheless unprecedented financial measures have been implemented to help people to stay off work during the pandemic: a boost in welfare payments, a state guarantee to replace % of lost wages and of lost income for the self-employed. this has been high enough to secure high levels of trust in government and support for lockdown even amongst those suffering from it (duffy & allington, ) . enough, for now at least (as we write at the start of may), to secure the social order. let us turn next to the question of 'disorder' and more specifically to protests against government social distancing measures and to anti-authority rioting in the context of the pandemic. if a facilitative historical context, inclusive leadership, and the legitimacy of authority (cf. bottoms & tankebe, ) are critical to creating shared identity and maintaining social order, what happens when these factors are absent? let us answer that question primarily by reference to the usa where (unlike in the united kingdom) there have been multiple protests against lockdownbut additionally by addressing the unrest that has occurred in various other countries such as italy, brazil, and france. the caveats we expressed concerning our analysis of the uk case obviously apply here as well. as before, we shall start with the historical relationship between state and people. gary wills starts his history of this relationship in the united states with a famous quotation: 'henry david thoreau put in extreme form what many americans want to believe: "i heartily accept the motto: 'the government is best which governs least'"' ( , p. ). the country, after all, was born in a revolution against what was seen as an alien and tyrannical state, and this attitude of suspicion remained attached to any state power. to this day, the right to bear arms (as articulated in the nd amendment to the constitution) is seen by many as a necessary counterbalance to such tyranny. in this context, any and all state intervention has the potential to be rejected as unacceptable and anti-american. once again, however, these beliefs do not exert a spontaneous influence. they have to be invoked, applied to the current context, and used to mobilize people against antipandemic measures such as lockdown. anti-state leadership is critical and, remarkably, it was provided by the right-wing populist head of state, us president donald trump. he directly referenced the anti-state principles on which 'this country' was built in order to criticize anti-pandemic measures. he praised protestors against lockdown as 'responsible', and he tweeted 'liberate minnesota!' followed by 'liberate michigan' and then 'liberate virginia and save your great nd amendment. it is under siege!' (embury-dennis, ). finally, the huge structural inequalities in the united states, the fact that less than half of poorer workers get any sick pay, that . million people have no health cover, and that % of americans could not find $ to cover an emergency (vesoulis, ) , combined with the fact million americans became unemployed in march and (santhanam, , have led to great hardship in the period of lockdown. this creates a context in which a sizeable pool of people is amenable to being mobilized by antilockdown leadership. in the poor south, for instance, % of people support trump on the pandemic over their own state governors (santhanam, ) . while, as yet, there are no systematic analyses of those who are protesting, anecdotal reportsalong with scrutiny of the chants and the placards displayed in protestssuggest a combination of 'liberty' and 'hardship' concernsa leadership and organization rooted in traditional antistate conservatism gaining some traction amongst those alienated from the authorities by economic suffering. as stocpol puts it: 'we've got a. . . combination of top-down influence from high-dollar organizations and some genuine energy at the grassroots level' (cited in illing, ) . in suggesting that all three factorsanti-state historical context, anti-state leadership, and inequitycontribute to the emergence of disorder, we do not suggest they are all equivalent or all necessary for protest to emerge. thus, events in america show how history and leadership can facilitate the emergence of an understanding that pandemic measures are unfair and unjustan illegitimate imposition by an alien authority that is acting against us rather than for and with us. however, events elsewherewe shall focus particularly on franceshow that such an understanding can arise directly from government measures that are experienced as inequitable and the ways that those who then challenge these measures are treated by the police. the lockdown in france took effect on march . this was in the context of the longstanding 'yellow vest' movement. as jetten et al. ( ) show, a sense of popular alienation from a state out of touch with the sufferings of ordinary people intertwined with the notoriously aggressive heavy handedness of french policing to drive the movement towards violent protest and sustain these protests across time and location. these features were then reproduced within the lockdown itself. as elsewhere, the lockdown exacerbated inequalities of class and 'race', making it particularly difficult for poor ethnic minority members to adhere to the regulations and stay at home (willsher & harrap, ) . the state responded with heavy-handed repression. anyone leaving their home has been required to carry a time-stamped certificate that has to be produced on demand. infringement carries penalties of heavy fines or even up to six-year imprisonment for the crime of 'endangerment'. by st april, just sixteen days after the control measures were introduced, the french police had already carried out . million controls and issued , fines (statista, ) compared to less than , across the one month following the imposition of control measures in the united kingdom. (npcc, ) . just one week into lockdown, french media began to report that the police were experiencing difficulties in enforcing such repressive measures especially in the poorer and ethnically mixed paris suburbs (keiger, ) , themselves historically areas of antipolice sentiment and rioting (body-gendrot, ) . then, early in the morning of th april, in the paris suburb of villeneuve-la-garenne, a local man of arab decent riding a motorcycle was injured when he collided with the open door of an unmarked police car. the incident was immediately interpreted by many as just another example of police brutality and rioting developed across the next four days, spreading into four suburbs across paris and with additional incidents reported across france (willsher, ) . what we see here is a classic pattern of crowd violence. a background of structural inequalities leading to alienation from authority, a pattern of antagonistic interactions with the police such that they become the concrete face of the 'other', a specific incident which is understood to exemplify the illegitimacy of the police, and then a spread of violence to other sites where locals share such a view of the police (ball et al, ; drury et al, ; stott et al, ) . the critical point is to understand how the distal determinants of conflict (which lie in the interaction of general structural inequalities and specific policies such as lockdown) interact with the proximal determinants (which lie in indiscriminate and repressive forms of policing, and in the spiral of negative interactions with particular sectors of the public that are initiated by such repression). it is only by developing such an understanding of how disorder occurs that we can learn how to preserve public order. we began this paper by asking what determines whether a pandemic brings people together with authorities so as to maintain order or else pushes them apart and creates disorder. our answer has been at two levels. on the one hand, we must look at the combination of historical context and contemporary leadership which determine whether people will mobilize around perceived inequities to challenge authority and disregard the regulations they seek to impose. on the other hand, we have pointed to the specific role of policingspecifically repressive policingin escalating dissent into open violence. both are key domains for further investigation. nonetheless, even if the details of our analysis are necessarily provisional at this stage of events, it is clear that disorder is a complex phenomenon which requires a combination of structural, political, and interactional factors to occur. consequently, lack of disorder might tell us that not all is bad, but it does not tell us that all is well either. nor does it allow us to be complacent. that is certainly true of the situation in the united kingdom. as we have indicated, there are major structural inequalities which are reflected in the disproportionate death rates of poor and bame people. equally the leadership and the political response to the pandemic may have done just enough to preserve cohesion, but there are more and more voices expressing concerns about the inefficiencies and inequities of current government policiesand these may grow as the situation develops. finally, the policing response may have largely concentrated on the three es of engaging, explaining, and encouraging the public to adhere to government measures (such as lockdown) before reverting to the fourth eenforcement (npcc, a). but the pattern has not been consistent across the country. all in all, we cannot rest on our laurels. unless we are clearly seen to do more in the longer term to make a priority of addressing the structural inequalities; unless more steps are taken to make it possible for those in precarious positions to cope with lockdown and other measures; unless the focus of the police and other agencies is more firmly focussed on enabling rather than enforcing coherence, then the precious and fragile social consensus that we have enjoyed thus far could always give way to social conflict. stephen reicher, phd (conceptualization; writingoriginal draft) clifford stott (conceptualization; writingreview & editing). the biggest gang in oakland': rethinking police legitimacy perceptions and behavioural responses of the general public during the covid- pandemic: a cross-sectional survey of uk adults who controls the city? a micro-historical case study of the spread of rioting across north london in public disorder and globalisation police legitimacy and the authority of the state officers as mirrors: policing, procedural justice and the (re) production of social identity nhs coronavirus volunteers frustrated at lack of tasks. the guardian, rd may the myth of the blitz the police and the expansion of public order law in britain the black death and the burning of the role of social identity processes in mass emergency behaviour: an integrative review social scaffolding: applying the lessons of contemporary social science to health, public mental health and healthcare a social identity model of riot diffusion: from injustice to empowerment in the london riots the accepting, the suffering and the resisting: the different reactions to life under lockdown coronavirus: trump doubles down on call for supporters to 'liberate' democratic states from lockdown. the independent. th april rethinking the nature of cruelty: the role of identity leadership in the stanford prison experiment there is no anti-lockdown protest movement. vox, nd april how economic inequality fuels the rise and persistence of the yellow vest movement france'sd downward spiral of coronavirus repression. the spectator obedience to authority police chiefs welcome positive start to recruitment drive engage, explain, encourage, enforce -applying the four 'e's. retrieved from https:// www.college.police.uk/what-we-do/covid- /documents/engage-explain-encourage-enf orce-guidance.pdf british social welfare in the twentieth century calls for health funding to be prioritised as poor bear brunt of covid- . the guardian, st may the social psychological processes of 'procedural justice': concepts, critiques and opportunities when is policing fair? groups, identity and judgements of the procedural justice of coercive crowd policing engaged followership and engaged fellowship working toward the experimenter: reconceptualizing obedience within the milgram paradigm as identification-based followership mad mobs and englishmen policing the coronavirus outbreak: processes and prospects for collective disorder butskellism, the postwar consensus and the managed economy despite economic hardship, most americans not ready to reopen, poll says. pbs the impact of plague in tudor and stuart england naples in the time of cholera number of controls carried out and fines issued during the containment linked to the coronavirus epidemic (covid- ) in france between the roots of evil the evolving normative dimensions of 'riot': towards an elaborated social identity explanation keeping the peace' social identity, procedural justice and the policing of football crowds explaining the nature of power: a three-process theory why people obey the law: procedural justice. legitimacy, and compliance the group engagement model: procedural justice, social identity, and cooperative behavior coronavirus may disproportionally hurt the poor -and that's bad for everyone a necessary evil disruption on streets of france as lockdown tensions rise. the guardian in a paris banlieue, coronavirus amplifies years of inequality. the guardian, th april all authors declare no conflict of interest. no data available. key: cord- -bis arbu authors: alexander, regi; ravi, ambiga; barclay, helene; sawhney, indermeet; chester, verity; malcolm, vicki; brolly, kate; mukherji, kamalika; zia, asif; tharian, reena; howell, andreana; lane, tadhgh; cooper, vivien; langdon, peter e. title: guidance for the treatment and management of covid‐ among people with intellectual disabilities date: - - journal: j policy pract intellect disabil doi: . /jppi. sha: doc_id: cord_uid: bis arbu the current covid‐ pandemic is a pressing world crisis and people with intellectual disabilities (ids) are vulnerable due to disparity in healthcare provision and physical and mental health multimorbidity. while most people will develop mild symptoms upon contracting severe acute respiratory syndrome coronavirus‐ (sars‐cov‐ ), some will develop serious complications. the aim of this study is to present guidelines for the care and treatment of people with ids during the covid‐ pandemic for both community teams providing care to people with ids and inpatient psychiatric settings. the guidelines cover specific issues associated with hospital passports, individual covid‐ care plans, the important role of families and carers, capacity to make decisions, issues associated with social distancing, ceiling of care/treatment escalation plans, mental health and challenging behavior, and caring for someone suspected of contracting or who has contracted sars‐cov‐ within community or inpatient psychiatric settings. we have proposed that the included conditions recommended by public health england to categorize someone as high risk of severe illness due to covid‐ should also include mental health and challenging behavior. there are specific issues associated with providing care to people with ids and appropriate action must be taken by care providers to ensure that disparity of healthcare is addressed during the covid‐ pandemic. we recognize that our guidance is focused upon healthcare delivery in england and invite others to augment our guidance for use in other jurisdictions. without a doubt, severe acute respiratory syndrome coronavirus- (sars-cov- ), and the development of coronavirus disease is the most pressing current world crisis. retrospective cohort studies from patients admitted to hospital who had contracted sars-cov- and developed covid- indicated that death was more likely among those who were older, had diabetes, coronary heart disease, hypertension, and an elevated sequential organ failure assessment (sofa) score or quick sofa score . together, there was evidence that having a higher sofa score, along with being of an older age, and having elevated fibrin degradation product (d-dimer) at admission significantly predicted death . evidence from other countries has indicated that those who were older, had cardiovascular disease, diabetes, cancer, or had smoked tobacco were at increased risk of death (remuzzi & remuzzi, ) . at the time of writing, the online interactive dashboard from the center for systems science and engineering at johns hopkins university reported worldwide are infected with sars-cov- , while lives have been lost (dong, du, & gardner, ) , and the numbers increase daily. the overall death rate has been reported to be . % based upon chinese data (wu & mcgoogan, ) . although there is some variability across studies, the estimated worldwide prevalence of intellectual disabilities (ids) is approximately % (maulik, mascarenhas, mathers, dua, & saxena, ; mckenzie, milton, smith, & ouellette-kuntz, ) , with higher rates within low-and middle-income countries, (maulik et al., ) where healthcare systems may not be as well developed as in the western world. people with ids have an increased rate of mental ill-health (cooper et al., ; cooper, smiley, morrison, allan, & williamson, ; emerson & hatton, ) , and physical health problems including a wide ranging list of organ-related disorders (e.g., hypothyroidism, congenital heart problems, difficulties with hearing and vision), specific conditions such as cerebral palsy, epilepsy, along with an increased incidence of pneumonia, as well as other issues such as dysphagia, gastroesophageal reflux, and feeding-related problems (evenhuis, henderson, beange, lennox, & chicione, ; haveman et al., ; krahn, hammond, & turner, ) , leading to an increased risk of admission to hospital (dunn, hughes-mccormack, & cooper, ) . furthermore, lifestyle factors among people with ids are known to contribute to disease burden, such as having a sedentary lifestyle, obesity, and difficulties with maintaining hygiene independently (evenhuis et al., ; haveman et al., ; krahn et al., ) . primary care data on a large sample of people with ids indicated that this group had substantial disease comorbidity (cooper et al., ) ; they were more likely to have epilepsy, visual impairment, constipation, hearing loss, parkinson's disease, but were less likely to have coronary heart disease and other-related disorders (e.g. hypertension), as well as being less likely to have cancer and chronic obstructive pulmonary disease (copd; cooper et al., ) . however, it was apparent that comorbidity increased with age (cooper et al., ) . a systematic review of the causes of death among people with ids revealed that mortality rates are substantially higher, with death coming, on average, years earlier for this population (o'leary, , and similar findings have been reported for other countries (mccarron, carroll, kelly, & mccallion, ) . conditions associated with an early death included having profound ids, epilepsy, difficulties with hearing, vision or mobility, increasing support needs, being female, and having some specific genetic syndromes. most notably, respiratory disease, including pneumonia, was a leading cause of death in people with ids, along with circulatory diseases, including heart disease and cardiac failure, cancer and congenital-related difficulties (o'leary et al., ) . strikingly, there are studies that have reported that people with ids have died from disease, such as aspiration pneumonia, urinary tract infections, and sepsis which could have been treated through the provision of good quality equitable healthcare (glover, williams, heslop, oyinlola, & grey, ; heslop et al., ; hosking et al., ; o'leary et al., ; the learning disability mortality review (leder) programme, ). furthermore, a number of people with ids will have difficulties with dysphagia (robertson, chadwick, baines, emerson, & hatton, ) , and this may in turn increase the risk of aspiration pneumonia. prompt and proactive identification of physical health concerns can be a challenge with people with ids because of diagnostic overshadowing (reiss, levitan, & szyszko, ) , which has an impact upon the correct recognition of both mental and physical health problems leading to difficulties with accessing high quality and appropriate healthcare within primary healthcare (beange, mcelduff, & baker, ; nocon, sayce, & nadirshaw, ) . the implications for people with ids during the current covid- pandemic are clear. there is, without a doubt, likely to be some apportioning of healthcare within some regions and people with ids will be disadvantaged. rebecca thomas ( ) in the health service journal wrote about general practitioners (gp) in england sending letters to care providers informing them that people with ids will not receive priority medical treatment in the event of sars-cov- infection. prior to this, the national institute for health and care excellence (nice, a published guidance for the care and treatment of people who have contracted sars-cov- , recommending use of the clinical frailty score (rockwood et al., ) within decision making about access to critical care treatment for complications arising from sars-cov- infection, including giving consideration to the "underlying pathologies, comorbidities, and severity of acute illness on the likelihood of critical care treatment achieving the desired outcome." the clinical frailty score was originally developed for use as an index of frailty among older people. individuals are assigned a score from to on a subjective scale that is meant to measure whether someone is dependent upon others in order to achieve and carry out tasks of daily living (rockwood et al., ) . considering that many people with ids are dependent upon others to help them carry out many tasks associated with daily living, and the subsequent concerns about the validity of the clinical frailty score when used with this group, nice ( b) quickly updated their guidance and stated that this score should not be used with people who have ids and/or autism, people with stable long term disabilities, nor younger people, and recommended the use of an individualized assessment of frailty and needs. there has also been concern raised about the issuing of do not attempt resuscitation (dnar) or cardiopulmonary resuscitation (dnacpr) orders within england because individuals may have ids or autism (british broadcasting corporation, ). on april , , nhs england ( b) made it clear to hospitals and primary care providers in england, quoting professor stephen powis, the national medical director of nhs england, who stated that ids or down syndrome "should never be a reason for issuing a dnacpr order or be used to describe the underlying, or only, cause of death…learning disabilities are not fatal conditions". while responsive changes to the guidance about the care and treatment of people who have developed covid- in england are welcomed, this population is likely to present with a series of healthcare challenges that will require specialist intervention across multiple health and social care systems. public health england ( d, f) have identified two groups that are most at risk, and include those at risk of severe illness who need stringent social distancing (table ) , and those who are extremely vulnerable and are at very high risk of severe illness and require shielding to prevent infection (table ). according to this guidance, many people with ids should be identified as being at risk or very high risk of severe illness from covid- , and a general practitioner may have already assigned them to this category. we recommend that tables and should be used to identify those with ids at high or very high risk of severe illness due to sars-cov- infection, and additional and appropriate action should be taken to protect their health and wellbeing. we have added three further categories of risk to table specifically including those with particular physical vulnerabilities, enduring, and severe mental illness and those who display challenging behavior which may become markedly exacerbated should they become infected with sars-cov- and action must be taken to guard against infection, noting the varying degrees of risk. however, and paradoxically for some in this group, stringent social distancing, and shielding may lead to an exacerbation of mental health symptoms and/or challenging behavior. those with ids are at higher risk than the general population from complications arising from contracting sars-cov- , and the purpose of this article is to present our guidelines for the care and treatment of people with ids during the covid- pandemic in an attempt to help address healthcare disparities within community, residential, and inpatient settings. the guidelines have been developed collaboratively by a group of health and social care professionals and carers who care for people with ids, who provide specialist medical, psychiatric, and social care within both community and inpatient psychiatric settings or in their own homes. throughout, we have attempted to focus upon the needs of people with ids, including those within this population, who are likely to be at most risk and they are meant to complement the initial guidance provided by nhs england ( a) about supporting people with ids during the covid- pandemic. these guidelines are subject to revision and the most recent versions can be downloaded by visiting http://radiant.nhs.uk. the aim of this study is to describe our guidelines which focus upon providing care and support before and after infection with sars-cov- and the development of covid- . these guidelines are meant for community teams, inclusive of social care providers, who provide care and treatment within communitybased settings and care teams working within hospital settings for people with ids. we have also included guidance about referral and admission to general hospital. community teams providing care to people with ids in england are referred to as community learning disabilities teams and we use this language in several places within this study. these teams provide a range of care and support to people with ids, while during the current pandemic there will be an increased focus upon providing table group at risk because they are clinically vulnerable due to severe acute respiratory syndrome coronavirus- (sars-cov- ) infection who need particularly stringent social distancing measures • aged or older (regardless of medical conditions) • under with an underlying health condition listed below (that is, anyone instructed to get a flu injection as an adult each year on medical grounds): • chronic (long-term) mild-to-moderate respiratory diseases, such as asthma, chronic obstructive pulmonary disease (copd), emphysema or bronchitis. • chronic heart disease, such as heart failure. • chronic kidney disease. • chronic liver disease, such as hepatitis. • chronic neurological conditions, such as parkinson's disease, motor neurone disease, multiple sclerosis, or cerebral palsy. • diabetes. • a weakened immune system as the result of conditions such as hiv and aids, or medicines such as steroid tablets. • being seriously overweight (a body mass index (bmi) of or above). • pregnant women. • people with intellectual or other developmental disabilities and one or more of the following conditions: • diagnosis of severe and enduring mental health problem or multiple mental health diagnoses within the acute phase or taking medication that requires close monitoring (e.g., clozapine). • increased likelihood of escalation or re-emergence of challenging behavior that will severely reduce quality of life. • coexisting physical vulnerabilities including epilepsy, dysphagia, bowel problems including constipation, gastroesophageal reflux disease (gord), sensory deficits, or other serious physical conditions not named in the lists above. healthcare. we recognize that healthcare systems for people with ids around the world vary, and while our focus is upon england, it is hoped that these guidelines will be applicable to health and social care settings for people with ids in other countries, and as appropriate, helpful for educational settings. we completely welcome and invite groups to adapt these guidelines to fit effectively within their own local, regional or national health and social care systems. for people with ids living in the community in england, physical healthcare is provided by primary care services, inclusive of their general practitioner. this also includes the vital and important role of carers working within shared residential settings where many people with ids live. the role of community learning disabilities teams is to provide input into healthcare about specific vulnerabilities, highlighting disparity, and helping to reduce the risk of infection. however, for community learning disabilities teams, if they make use of the ratings listed within tables and , many people with ids receiving care will be assigned to the at risk of severe illness from covid- category, and many will also be assigned to the very high risk of severe illness from covid- due to associated comorbidity. appropriate action should be taken to mitigate the risk of infection within community-based settings, inclusive of residential settings. staff working within psychiatric inpatient settings should also identify individuals with ids who are at risk as detailed in tables and . a summary of our guidance and associated risk mitigation strategies are found in figure . hospital passports. ensure that people with ids have an up to date hospital passport or equivalent, depending on the local, regional or national policy, which includes information from the person themselves, and all those who know them well, including their family and advocates. a hospital passport is a document that is meant to support the provision of appropriate healthcare to a person with an id. it includes essential information about the person inclusive of important medical information, their activities, and things the person prefers or does not identify those with intellectual disabilities who are at risk of severe illness and very high risk of severe illness (table a and b) and use appropriate risk mitigation strategies. (table ) . . include carers and family members at all stages, consulting and working effectively with the individual. make sure you have a good understanding of the mental capacity act ( ) ; best interest discussions and decisions will be needed for those who do not have capacity to make a specified decision. . make use of reasonable adjustments when sharing information to help increase understanding using helpful resources. . review and update positive behaviour support plans. . review and monitor medication. . take appropriate action to socially distance or isolate according to risk. balance decision making against risk of infection and risk of challenging behaviour and mental health symptoms. it may be appropriate for community access to continue which may be modified. . have appropriate do not attempt resuscitation or cardiopulmonary resuscitation discussions and make plans collaboratively. plan and share appropriately (table ) . . liaise with local palliative care teams for support when needed. . familiarise yourself with the gold standards framework. . adjust communication when using personal protective equipment (slow down, introduce yourself, use a positive tone, affix a photograph to your gown, avoid complex sentences). suspected or confirmed infection . isolate. assess in a single occupancy room and wear personal protective equipment. . monitor for red flags (table ) . follow wishes of individual, and/or family and carers. . further clinical decision making about transfer to hospital. . continue to make use of appropriate risk mitigation strategies. figure a summary of steps to take to mitigate risk and protect people who have intellectual disabilities during the covid- pandemic. prefer. ensure appropriate attention has been paid to the presence of physical health problems, including those which may increase the risk of more severe illness due to contracting sars-cov- (e.g., smoking history, history of heart disease, respiratory problems, body mass index (bmi) > ) and other conditions such as mental health problems, dysphagia, sensory problems, or communication needs. more information can be found about hospital passports by visiting the mencap website (https://www.mencap.org.uk/advice-and-support/health/healthguides). all people with disabilities are entitled to reasonable adjustments to the provision of healthcare under the equality act ( ), and a hospital passport is an example of a reasonable adjustment. further details about additional reasonable adjustments should be included within the hospital passport. covid- care plan. prepare a covid- care plan for each person with an id within your care and this should be developed collaboratively with the person. this should set out the specific risk factors and associated needs of each individual (table ) and community learning disabilities teams should work collaboratively with care providers within residential settings, bearing in mind that some people with ids live alone and may not have regular and consistent support beyond that provided by the community learning disabilities team. the care plan should include information from the person (if appropriate) and those who know the person well and refer to the hospital passport and incorporate relevant information. issues associated with diagnostic overshadowing, the views of parents, family members and carers, the required reasonable adjustments, communication needs, specialist mental health support, anticipatory care plans, any end-of-life or do not attempt cardiopulmonary resuscitation (dnacpr) discussions should be reported. associated strategies for managing hand hygiene, infection control, social distancing, and isolation when needed should be included. families and carers. carers and family members are vital to the health and security of people with ids (chester, james, rogers, grace, & alexander, ), and more so during the covid- pandemic and should be involved at all stages. clinicians should actively seek to explain the important precautions that need to be taken with handwashing, avoiding touching the face and eyes, use of tissues while coughing and sneezing and their appropriate disposal to carers and people with ids. it must be recognized that this is not likely to be straightforward with those who have severe and profound ids. limitations on access to the community need to be explained. for those living within residential settings, appropriate precautions and protocols need to be developed for isolation should someone contract covid- . there are a number of resources that can be used by carers and families to help explain these challenges to people with ids (e.g., beyond words, ) while emphasizing the need to monitor for signs and symptoms of covid- including a fever, new cough, fatigue, congestion, shortness of or difficulty breathing, chill, muscle pain, dizziness, sore throat, headache, vomiting, and diarrhea. many people with ids will have difficulties explaining how they are feeling, and it is important that family and carers remain vigilant to changes in presentation. for example, many people with ids may not be able to report that they have a headache, while other symptoms are observable to others (e.g., a new cough) and tools such as the distress and discomfort assessment tool (https://www.stoswaldsuk.org/ how-we-help/we-educate/education/resources/disabilitydistress-assessment-tool-disdat/) can be employed by carers to record symptoms of distress (regnard et al., ) . capacity and law. within england, where questions of capacity arise regarding an individual's ability to make a decision to isolate and take appropriate action to reduce risk (e.g., social distancing), this may trigger an assessment of capacity (the mental capacity act, ) for some individuals, bearing in mind that we will all make the assumption that all have capacity to make decisions unless there is information to the contrary. appropriate reasonable adjustments (e.g., sharing accessible information and providing clear explanations with opportunities for individuals to ask questions) should be made when sharing and discussing information. for those who have capacity, they are entitled to make their own decisions, and this may involve not following recommendations or advice which may cause them or others harm. for those who are judged not to have capacity, this will prompt a best interest discussion and may lead to an authorization of deprivation of liberty for some. for such to be authorized in relation to covid- , the person must lack capacity to consent to the arrangements, have an "impairment of their brain or mind" and the arrangements must be necessary to prevent harm and be proportionate to the likelihood and seriousness of the said harm. all of this would need to be balanced against a person's rights, autonomy, and well-being, and for many, this could be avoided with the provision of good communication and the involvement of carers and family members which is strongly recommended. related, and within england, the health protection (coronavirus, restrictions) (england) regulations (public health england, e) are relevant, which are statutory restrictions on every person which prevent people from leaving their homes without a "reasonable excuse." the police have been granted the powers of reasonable force to return someone to their home. furthermore, the coronavirus act ( ) has made it a criminal offense to fail to comply with the instructions of the police or a public health officer, and the police may use reasonable force to remove people or compel someone to remain at home. these laws are applicable to all citizens, but their interface and relationship with the mental capacity act ( ) is unclear. there are clear issues for many people who provide care to people with ids where routine and structure are exceptionally important. increasing isolation to protect people from infection is likely to have a negative impact upon the quality of life of people with ids and may lead to an increase or re-emergence of challenging behavior or the development of mental health problems. if individuals access the community, which will include opportunities to visit places to engage in exercise and activities, some individuals may require multiple support staff to be present. this may attract the attention of other members of the public and/or the police. avoiding these activities is likely to be detrimental to the health and well-being of many people with ids, disrupting their quality of life. protecting individuals from infection while maximizing quality of life is a tricky balancing act that must be navigated. community learning disabilities teams should work with families, and where necessary, consider issuing letters to families, and carers that can be shown to the police or public health officials as appropriate. social distancing. for all people with ids, stringent social distancing should be followed. this includes avoiding public transport, remaining at home, and of course, avoiding contact with those who have contracted sars-cov- , or those who are displaying symptoms of infection. for those who are judged to be at very high risk of illness, shielding measures must be adopted. this includes strictly avoiding contact with anyone displaying symptoms, remaining at home, never attending gatherings, avoiding going out to shops or taking part in leisure activities, arranging for food and medication to be delivered, and where possible, making use of technology for social contact as best as possible (public health england, f). for carers and those working in residential settings, public health england has issued separate guidance which includes reducing visits from family and friends. individuals should be risk assessed, and where possible, reasonable adjustments made. staff should wear personal protective equipment (ppe), and ensure proper hand and environment hygiene (public health england, b). changes to routine (e.g., canceling community trips) for people with ids may result in the development of, or an increase in challenging behavior, and care plans and associated risk assessment should be inclusive of these issues. in such instances, it is reasonable to facilitate and support community trips in order to reduce or escape a risk of harm, and in certain circumstances, with careful planning to mitigate risk of infection, it may be advantageous to facilitate some appropriate community trips for people with ids. this should be carefully considered, balancing risk, and should be fully discussed with family members and carers, as well as the community learning disabilities team. visits by community learning disabilities teams. as far as possible, community learning disabilities teams should make use of telephones and videoconferencing to contact carers, family members and people with ids. team members, when visits are necessary, should enquire as to whether anyone within a property is displaying symptoms of covid- , and make use of alternatives where such symptoms are present. if a visit is needed, appropriate risk mitigation strategies should be taken, and this may include wearing ppe during the visit. as a minimum, a fluid resistant surgical mask, disposable apron, and if blood or bodily fluid contamination is anticipated, gloves and eye protection should be worn (public health england, a). guidance changes rapidly and readers are directed to follow the advice from their own regional or national authority. community visits are unlikely to involve aerosol generation procedures, noting that spitting is not considered an aerosol generating procedure. if aerosol generation procedures are likely, then an appropriate respirator, longsleeved disposable fluid-repellent gown, gloves, and eye protection must be work. note that in situations where cardiopulmonary resuscitation attempts and the use of suction are likely, the continuous positive airway pressure and the use of high flow nasal oxygen are aerosol generating procedures. . mr ab is a -year-old caucasian male who is in supported living. . information about family and those who know the person well. . diagnosis (mental health): mild intellectual disability, autistic spectrum disorder, paranoid schizophrenia. . diagnosis (physical health): bronchial asthma and early chronic obstructive pulmonary disease (copd), no hospitalizations for that, not on regular inhalers. he is an ex-smoker who is off cigarettes for over years. he has obesity with a body mass index (bmi) of (he is not morbidly obese). . his current medication is depot olanzapine and tab procyclidine. he is on prn salbutamol inhalers that he usually does not like taking. . he is in supported living and has -hour staff support. at present, though not keen on exercise he has no active physical health symptoms. he carries out his daily activities with little help from others.actions: information shared with gp . mr ab is rated as a high-risk/vulnerable patient. this is firstly because he has a mild learning disability, bronchial asthma and early copd, all conditions that come within the category of the group at risk of severe illness from covid- . secondly, he is also considered to be vulnerable to having mental health distress and relapse of his mental illness. given him and the staff in his home the following support: a. mental health: medication advice and associated information. b. mental health: updated psychological formulation and behavior support plans. c. advice on a structured timetable of activities. d. advice on social distancing and other covid-related precautions (e.g., hand washing, infection control, isolation). e. advice from hospital passport (note legal requirement for reasonable adjustments). f. advice from communication passport (note legal requirement for reasonable adjustments). g. any other issues as relevant including information from the hospital passport, views of parents and carers, need for reasonable adjustments, behavioral responses to illness, and specialist mental health or behavioral support. h. capacity: he appears to have the capacity to understand this information. his capacity about treatment decisions, should he become physically unwell, will need to be taken by the treating clinician at that time. i. end of life: any end of life or do not attempt cardiopulmonary resuscitation (dnacpr) discussions or decisions that have happened. intellectual disabilities are not to be used as a reason for authorizing dnacpr.for any additional information from the cldt, contact "name, address, and telephone number." the above is a representative example and should be adapted as needed. do not attempt resuscitation or cardiopulmonary resuscitation. these discussion and decisions are difficult for all people, and the vast majority of people with ids known to community learning disabilities teams live full and rewarding lives. hence, end-of-life of dnar or dnacpr discussions and decisions are not necessary, but they may arise on some occasions. it is important to note that ids or down syndrome should never be used as a reason for issuing a dnacpr order (nhs england, b) . those who are ageing and have multimorbidity who may suffer a marked deterioration in adaptive behaviors may suffer a precipitous decline in their physical health if they develop a virulent infection (remuzzi & remuzzi, ; zhou et al., ) . in the context of the current pandemic, while such discussions and decisions are likely to be disturbing for many individuals, and families and carers, carefully formulated care plans for some are likely to be required. when used appropriately, such plans are intended to reduce suffering and promote a dignified death with those who are close to the end of their life (national end of life care programme, ). the role of the community learning disabilities team is not necessarily to oversee creating these plans, but to work closely with the individual, their family, carers, and those in primary care to help facilitate discussions as needed within the context of the covid- pandemic. the underlying principles for any such discussion are set out by the national end of life care programme ( ) and should ensure that care is client-centered and integrated, a circle of support is identified, people are treated with dignity and respect, their preferences are identified and respected, and appropriate care and support for families, carers, and staff are provided after death. timely and honest conversations about an individual's preferences and priorities, including any advance decisions to refuse treatment should be part of the care planning for anyone who has a progressive life-limiting illness. the care quality commission ( ) has reported that the barriers to effective palliative and end-of-life care include a nonrecognition of end-of-life, poor communication, inequalities in accessing good care, and difficulties with staff awareness and noncollaborative working. for most people with ids who contract sars-cov- , the priority will be treatment in line with national policies and guidance including referral to general hospital as needed, and clinical decision making should be the same as for members of the general population, drawing on the same parameters. however, for some, covid- may quickly exacerbate existing illness and create a situation where an individual may become very ill and unable to benefit from intrusive treatment (guan et al., ; huang et al., ; richardson et al., ) . considering this, honest conversations need to occur as early as practicable so that personalized care and support plans can be developed. these will need to be revisited if any situation changes, and families and those close to an individual should be involved in these discussions in line with a person's wishes where possible. there are several steps that services need to take which will vary according to national policy and legislation. first, within england, where there are concerns about capacity to make decisions about medical treatment, a best interest discussion and decision should happen, fully inclusive of family members and carers and any attorney appointed under a lasting power of attorney or enduring power of attorney if applicable, or personal welfare deputy. if a person has capacity to make decisions about their medical treatment, then it is their decision to refuse or accept treatment. second, a conversation should be started with and about those who are nearing the end of their life. this should include family members, carers, and others involved in the lives and care of individuals with ids. it should be recognized that this is an area fraught with difficulty for people with ids who may not be appropriately included within decision making (voss et al., ) . advance care planning is something that is used to help make decisions in the future, and this process is not just about palliative care, but for any planning. the process should help make clear a person's wishes and will usually take place within the context of an anticipated deterioration of a person's illness or condition in the future when they may have lost capacity to make decisions. it is important that these decisions are done sensitively and with empathy, and it is recommended that community learning disabilities teams (or inpatient teams) identify appropriate staff members for these conversations with both the individual and their family. staff should make use of resources to help structure and support any conversations with individuals (e.g., books beyond words) to help make sure that information is understood. make sure that a holistic assessment of end-of-life needs and preferences has taken place in partnership with the individualand their families and carers. assess and respond sensitively to social, psychological, and spiritual needs and wishes of the individual, as well as their physical healthcare needs. identify and record any further wishes and preferences as they become apparent about future care and treatment and verify with the local general practitioner as needed. if appropriate and requested, and for those who have capacity, you should support someone to make an advance decision to refuse treatment, sometimes referred to as a living will, and communicate this to all those involved in the provision of care. within england, an advance decision is legally binding, and the individual must name the treatments they are deciding to refuse such as ventilation or cardiopulmonary resuscitation and the circumstances in which they would be refused. an advance decision to refuse treatment is not the same as an advance statement. an advance statement can cover any aspect of future health and social care and an individual must have capacity to make decisions pertaining to the statement. it is not legally binding, but those providing health and social care must take it into account when making decisions. third, a ceiling of care/treatment escalation plan should be developed to document care planning. the purpose of this plan is to identify the wishes of the individual, their families and their carers in the case of a deterioration of physical health due to developing covid- . it is to provide guidance to the attending clinicians and should not replace clinical judgment. some individuals may already have an advance statement, advance decision to refuse treatment or power of attorney to advise and make healthcare decisions. these should be followed instead unless the clinical situation is markedly different to any envisaged by the advance statement. an example of the issues that should be covered when developing a ceiling of care/treatment escalation plan is found in table . ideally, this should be completed with the individual, families, carers, and clinical and social care staff, and it is vital that all are consulted and included and consideration should be given to future transfer to general hospital. during the pandemic, videoconferencing or teleconferencing could be used to facilitate discussion and meetings. once a care plan has been completed, it should be shared with all staff caring for the individual, and in the case of deterioration, on call medical staff, out-of-hours general practitioners, or the paramedic crew should be made aware. any decision to transfer an individual to hospital should be discussed with the family as soon as possible and a copy of the ceiling of care/treatment escalation plan should be sent, along with a covering letter if helpful. fourth, learning disability teams need to liaise with local palliative care teams for support. as end-of-life approaches, this should be recognized, and symptoms documented and discussed by the clinical team. staff should consider any recent changes in circumstances and note any new triggers in addition to sars-cov- infection (e.g., worsening pre-existing physical or mental illness). staff will need to identify whether it is appropriate to begin an open and supportive discussion with the individual, if possible, and their family and relatives about their wishes for end-of-life care, bearing in mind whether the individual wishes to have open discussions about prognosis and future care options. during the current pandemic, this may occur using videoconferencing or teleconferencing which may lead to some additional distress as relatives will not be able to be physically near their loved one. fifth, many general practitioners are likely to have implemented an end-of-life care register specifically in relation to covid- , working within the gold standards framework (see https://goldstandardsframework.org.uk/) and care must be coordinated across health and social care systems, drawing upon generic community nursing teams who deliver end-of-life care in conjunction with specialist palliative care teams. nhs england ( ) has published guidance about providing good quality healthcare to people with ids at the end of their life. this includes ensuring that each person is seen as an individual, helping them to develop an awareness of death and dying, while involving families, carers, supporters, and friends. clear communication needs to occur between all care systems ensuring that documentation is up to date, and bereavement support is available for those left behind. everyone should work to maximize comfort and wellbeing which includes helping people to understand their illness to help reduce fear and encourage coping. this includes working to help people understand why treatment is necessary and using creative methods to help encourage understanding and coping. related, it is important to complete effective person-centered pain assessment. finally, during the last days of life it is important to be aware that an individual's condition could improve. open discussions will be required with families, friends, and carers, and where possible adhere to patient wishes and preferences where needed, ensuring that anticipatory prescribing systems are in place, or there is a rapid system to access necessary medication. anticipate and help plan for any specific religious, spiritual, or cultural needs that may be necessary, helpful, and beneficial to both an individual and their family. after death, it is important to be respectful of religious, spiritual or cultural needs and beliefs and that they are met. teams need to be aware of verification and certification of death policies. ensure that appropriate information is provided to family members and carers about what to do after death, and offer support and information about bereavement, and assist as appropriate with remembrance. some of these activities will have to occur over the telephone or via videoconferencing during the pandemic. mental health and challenging behavior. the current restrictions upon all our lives have changed the way we live, work, and interact with each other. these changes are likely to cause distress for many people with ids which are likely to lead to an increase in challenging behaviors and mental health remember that this is decision specific, and capacity is assumed as the default position. . record any discussions with individuals, their family members, carers, friends, and others. . record any decisions about cardiopulmonary resuscitation. if a decision is made to not attempt cardiopulmonary resuscitation, then a do not attempt resuscitation or cardiopulmonary resuscitation form must be completed. . record information about the ceiling of care. this could be full active care which would be transfer to general hospital, or palliative/end of life care which would not be transfer to the general hospital and input from palliative care services would be needed working with generic community nursing teams who provide end-of-life care. some community-based residential services are not equipped to provide a full range of palliative care services which may necessitate transfer to hospital or a palliative care unit, especially if there is treatment available which significantly improves pain, discomfort or dignity. this could also be care within an existing inpatient psychiatric ward environment if that is where the individual is currently located. this would not involve transfer to a general hospital unless there is treatment which would significantly improve pain, discomfort or dignity which cannot be provided within the psychiatric hospital. . include information about prescribing antibiotics including whether they require oral only, and whether intravenous antibiotics may be appropriate, or no further antibiotics are to be given (unless required for symptom control). . food and fluids including whether intravenous fluids are not appropriate, or a percutaneous endoscopic gastrostomy tube is appropriate. consider wider issues about inability to swallow and whether this is part of the progression of the disease. symptoms. it is entirely likely that when an individual with ids is faced with actual or suspected sars-cov- infection, the inevitable further restrictions may lead to a worsening of mental health symptoms and/or challenging behavior. it is important not to assume that this is inherently a relapse of mental illness, as some changes occur directly as a result of environmental changes, or could be associated with sars-cov- infection and unknown effects on the nervous system , and issues related to diagnostic overshadowing should be at the forefront of clinical decision making. it is important to carefully monitor behavior and mental state, including the use of any restrictive interventions that are used within home and residential settings. community learning disabilities teams have an important role to play in maintaining community living and preventing inappropriate admission to psychiatric inpatient settings and should always be consulted and included. community learning disabilities teams have an important proactive role to play by providing advice on behavior and supporting people within the home, and the challenging behaviour foundation ( a, b) has produced some helpful guidance that may assist families and carers. wider guidance is available from other organizations (e.g., british psychological society: https:// www.bps.org.uk/responding-coronavirus). other resources from around the world have been posted online by the international association for the scientific study of intellectual and developmental disabilities ( ). if needed, training and advice to home and residential settings can be delivered using videoconferencing. we are recommending that those with ids who have severe and enduring mental health problems, inclusive of but not limited to schizophrenia, psychosis and bipolar disorder, and those with multiple mental health diagnoses, or who are taking medication that requires close monitoring (e.g., clozapine), along with those who are likely to experience an increase or reemergence of challenging behaviors that will severely impair their quality of life are rated as high risk of severe illness due to sars-cov- infection (table ) . these two additional groups have been added to table . a variety of changes are likely to lead to an increase in emotional distress during the covid- pandemic and community learning disabilities teams will need to work effectively with individuals with ids, their carers and families and providers of community-based services to help mitigate distress. changes to routine may cause increased anxiety, which may lead to an increase in challenging behavior and mental health symptoms. many of these challenges are likely to be related to difficulties with effective communication and understanding the changes, mental health problems, and other associated functions such as demand avoidance, access to tangibles inclusive of previously enjoyed activities. behavioral support plans, such as the positive behavioral support plan will need to be revised accordingly and there is an important role for the specialist advice and support of the community learning disabilities team. this would include an updated formulation as needed, along with the provision of psychological and other associated interventions to help with challenging behavior and mental health. changes to key staff including carers, community learning disabilities team members, parents and family members (who may be absent due to isolation and illness) may cause further anxiety and disruption and will need to be effectively managed, and may have a negative impact upon the continued successful implementation of positive behavioral support plans. further training may be needed, which could be delivered online by community learning disabilities teams as needed. for some, family members and carers may be admitted to hospital due to covid- which may result in the loss of life and will cause associated bereavement and grief for many people with ids, and appropriate strategies should be incorporated into a positive behavior support plan. for those family members who become unwell, it is important for services to facilitate ongoing contact using electronic methods of communication. most importantly, services must recognize the importance of normal human emotional expression during times of stress, and this should not be pathologized. people with ids may require additional help and support to understand what is happening to successfully grieve during a time when they may not be afforded the opportunities to grieve in a traditional manner (e.g., attending a funeral, seeking comfort from loved ones and family members). there is a clear role for specialist psychological interventions delivered by community learning disabilities teams. the use of ppe is likely to have a substantial impact upon some people with ids as follows: (a) it will disrupt some nonverbal communication as facial expressions will be entirely or partially covered which are vital to good communication. in such circumstances, eyes and natural gesture should be used as much as possible to facilitate positive communication, (b) equipment which covers the mouth may change speech, making intelligibility problematic, and (c) equipment may provoke anxiety among some individuals which may change the nature and quality of the interaction. it is important that staff wearing ppe introduce themselves, continue to adopt a positive tone, and use the name of the person within the interaction. it is likely to be advantageous to add a photograph of a staff member's protective clothing to help with identification. speech should be slowed down as appropriate, but not condescending, and if needed, increase the volume of speech and allow individuals time to process communication. sentences should be as clear as possible, incorporating a single piece of information; complex and long sentences with multiple conjunctions and connectives should be avoided. if helpful, use can be made of writing or drawing to aid communication, and checks made to ensure that communication has been understood. it is also important for all healthcare staff to recognize that many people with severe to profound ids may make use of signing or symbol-based communication, and those who know individuals (usually the family members and carers) well are best placed to provide guidance and support. people with ids are entitled to reasonable adjustments when accessing healthcare in england, and similar requirements exist in other jurisdictions around the world. it is vital that psychotropic medications are reviewed appropriately in line with good practice guidance (e.g., nice, ) . it is important to pay attention to side effects such as respiratory depression and cardiac effects. this would mean carefully analyzing the effects and side effects and weighing this against the importance of maintaining good mental health. be aware of issues associated with diagnostic overshadowing (e.g., a high fever may be a rare side effect called neuroleptic malignant syndrome or serotonin syndrome rather than due to . close liaison with pharmacy services will be needed to make sure that required medications are available, and medications may have to be delivered by healthcare staff or via the post. changes to medication may be required to assist in the management of mental health symptoms, and some individuals may require depot medication which is administered by general practitioners, community nurses within community learning disabilities or mental health teams. for many people with ids who are infected with sars-cov- , they will receive care at home, and many will recover while others will not develop covid- . however, some will need to be transferred to a general hospital, and when admitted, we recommend that the community learning disabilities team works closely with those in hospital to ensure a robust handover of relevant information and assist with decision making. this work may take place through liaison teams for mental health and/or ids where they are available within the general hospital, inclusive of the valued role of specialist liaison nurses for people with ids who will be able to provide specialist assistance with the provision of reasonable adjustments within a general hospital setting (macarthur et al., ) . for those who are currently detained within psychiatric settings, the treating team will have responsibility for both physical and mental healthcare. individuals should be assessed within a single occupancy room, and the clinician should wear ppe for all face-to-face interactions regardless as to whether sars-cov- infection is suspected. as a minimum, this should be a fluid resistant surgical mask, single-use disposable apron, gloves, and eye protection if blood or bodily fluid contamination to the eyes or face is anticipated. if aerosol generation procedures are likely, then an appropriate respirator mask, long-sleeved disposable fluidrepellent gown, gloves, and eye protection must be worn. note that in situations where cardiopulmonary resuscitation attempts, and the use of suction are likely, continuous positive airway pressure and the use of high flow nasal oxygen are aerosol generating procedures. it is important that staff explain their policy about isolation to all individuals within the hospital should there be suspected sars-cov- infection. this should include the specific details as to what will happen and when. appropriate communication aids may need to be used, and staff experienced in working with people with ids should be called upon as they will be acutely aware of individual communication needs. teams need to work effectively to minimize the need for restrictive interventions to implement isolation procedures through effective communication and the continued maintenance of trusted therapeutic relationships. isolation is likely to be distressing and leads to an increase in challenging behavior and the use of ppe may cause distress and appropriate action should be taken to mitigate this distress as outlined in the previous section. services should make use of provided sars-cov- testing kits and send swabs to the designated site for testing. anyone who has reported symptoms should be isolated for the number of days required by local or national policies, and physical monitoring must continue. ensure adequate nutrition and hydration, and symptomatic treatment as appropriate (e.g., paracetamol for fever, asthma medication as indicated, maintain fluid intake, complete urine output charts, etc.). watch for any signs of deterioration; fever can continue for a few days, but respiratory function may worsen between and days. action must be taken if any of the red flags are present as listed in table as adapted from greenhalgh et al. ( ) . when present, these symptoms indicate that urgent assessment is needed and further action such as escalation to an acute hospital or ongoing assertive management of health is needed. note that covid- -related pneumonia may be complicated by respiratory distress, and there are additional risks associated with dysphagia, and consistent regular physical health monitoring using standardized and validated instruments should be used (e.g., national early warning score- ; royal college of physicians, ). public health england ( c) has provided guidance on when to transfer someone to a general hospital, inclusive of those within psychiatric settings. transfer to a general hospital should occur when: ( ) they have clinical or radiological evidence of pneumonia, or ( ) acute respiratory distress syndrome, or ( ) they have influenza like illness. this is a fever ≥ . c the distress and discomfort assessment tool at tool (regnard et al., ) can be used to monitor pain and distress and use of an instrument like national early warning score (royal college of physicians, ) is recommended to monitor physical health. alexander r et al. and at least one of the following respiratory symptoms with acute onset: ( ) persistent cough (with or without sputum), ( ) hoarseness, ( ) nasal discharge, ( ) shortness of breath, ( ) sore throat, ( ) wheezing, or ( ) sneezing. clinicians should test for sars-cov- when an individual is presenting with new respiratory symptoms or fever without another cause or worsening of a pre-existing respiratory condition. early recognition of a deteriorating individual and referral to a general hospital is critical for treatment as patients may present with sepsis, pneumonia, and adult respiratory distress syndrome. those with underlying health conditions as set out in tables and are likely to progress to a complicated illness. there are important discussions that need to take place between staff within residential care settings, or psychiatric hospitals, and the general hospital and issues to be covered are presented in table . when transferring an individual to a general hospital, they should be accompanied by at least one member of staff who knows them well, taking their hospital passport and covid- care plan. staff should be supported with this task, as they may experience justifiable anxiety at the prospect of attending hospital, and can be reassured that if all the guidance is followed (e.g., regular handwashing) and wearing the correct ppe, it is safe for them to carry out escort duties. within england, if detained under the mental health act ( act ( , as revised in section leave must be authorized, and staff must always remain with the individual. if the individual is transferred under section , then the general hospital must ensure that they have adequate mental health staff to provide support, bearing in mind it would be better to have staff with a pre-existing positive relationship accompany them. for many psychiatric hospitals, they will be providing care directly to patients who develop covid- during the pandemic, and many of these patients will recover without needing to be transferred to a general hospital. however, all teams should continue to work towards the successful discharge of individuals with ids from psychiatric hospitals. where possible and appropriate, it would be useful to expedite discharge safely. there are related concerns about some of the changes that have been made to the provisions of the mental health act ( act ( , as revised in as a consequence of the coronavirus act ( ) in terms of the implications for people with ids. these changes include the removal of the requirement for two medical practitioners to agree to the detention of an individual under section , and many sections of part iii of the mental health act, if arranging for two medical practitioners is judged to be impractical or would cause delay. holding powers under section and section have been increased in duration, and a responsible clinician has been granted the authority to act as a second opinion appointed doctor, again if securing a second opinion appointed doctor is likely to be associated with unreasonable delay. there are concerns that these changes may inadvertently lead to an increase in the number of people with ids detained under the mental health act ( act ( , as revised in . it is our view that these changes should not be used disproportionately to detain people with ids within psychiatric hospitals if implemented, and community learning disabilities teams need to work effectively with all authorities during the pandemic to continue to provide excellent care and support to families to help guard against unnecessary admission to hospital continuing to work within the spirit of the transforming care (nhs england, ) agenda in england. the aim of this study was to present our initial guidelines for the care and treatment of people with ids during the covid- pandemic, developing best practice guidance. this was prompted by concerns that people with ids may be afforded poor quality care during the covid- pandemic, and especially upon contracting sars-cov- . in england, these concerns were brought to the fore when the nice ( a) recommended using the clinical frailty score to aid decisions about treating individuals who have contracted sars-cov- . the guidance was rapidly revised to exclude the use of this score with people with ids. however, there remain concerns that healthcare services will not prioritize the care of people with ids and some gp practices have actively stated that they will adopt this course of action (thomas, ) . we have developed our guidance with issues of disparity of healthcare for people with ids in mind. this is a group that has marked comorbidity (cooper et al., ; o'leary et al., ) , and some will be at very high risk of severe illness due to sars-cov- infection because of multi-morbidity. in the absence of specific criteria for rating risk due to sars-cov- infection among people with ids specifically, we have opted to adapt the risk criteria published by public health england ( d, f), incorporating mental health and challenging behavior which is prevalent among people with ids and likely to impact upon the nature of course of contracting sars-cov- as there is a risk of a relapse or increase in both mental health symptoms and/or challenging behavior. there is no direct evidence currently that sars-cov- infection will cause an increase in mental health symptoms and/or challenging behavior at the moment, but the associated changes that are occurring within our society and the required treatments are likely to lead to distress and anxiety among those with ids. it is our view, at the current time, that adapting the current guidance to include people with ids who have severe and enduring mental health problems or those who have a substantial risk of an increase in challenging behavior is a reasonable addition. community learning disabilities teams and inpatient psychiatric hospitals have an important role in addressing disparity in general healthcare, collaboratively with families and carers, for people with ids. this role is vital as it will make sure those who need help, get help, when and where it is needed, in the way that it is needed. we should all continue to work towards preventing admission to inpatient psychiatric hospitals and continue to work to facilitate timely and appropriate discharge. once the pandemic is over, we do not want to be in a position of having an increased number of people with ids within psychiatric hospitals due to difficulties with managing risk associated with sars-cov- infection or community access, or due to a deterioration in mental health or increase in challenging behavior related to the covid- pandemic. all health and social care providers need to work together to achieve this goal collaboratively, and community learning disabilities teams, together with their hospital colleagues, are vital providers of care and support. we have explicitly outlined actions that need to be taken by health and social care staff within both the community and inpatient psychiatric settings to help organize and deliver care to people with ids, inclusive of their families and carers. this includes the creation of a covid- care plan for individuals who are at very high risk, creating or updating hospital passports, improving psychological support and communication through the revision of positive behavioral support plans as needed, and the creation of a ceiling of care/treatment escalation plan. the goal of the ceiling of care/treatment escalation plan is to ensure that the wishes of individuals, families, and carers are recorded and followed appropriately, helping to ensure disparity is addressed. ids are not fatal conditions and should never be the basis for authorizing dnacpr. we recognize that many of these conversations will be distressing for individuals with ids, their families and carers, and community and inpatient staff who are experienced in providing care and treatment to people with ids are well placed to provide high quality support and care. finally, we fully recognize that our guidance has been contextualized within english policy and law. healthcare systems around the world differ, and in some countries, there are no specialist teams for people with ids offering services within the community, residential services or within inpatient psychiatric services. however, we wish to strongly encourage others to take our work and adapt it as needed to meet the needs of their own local, regional, or national populations and to ensure that individuals with ids exercise their human rights to appropriate healthcare support. medical disorders of adults with mental retardation: a population study beating the virus. london: beyond words. british broadcasting corporation a different ending: addressing inequalities in end of life care supporting 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in china: a nationwide analysis major health risks in aging persons with intellectual disabilities: an overview of recent studies the confidential inquiry into premature deaths of people with intellectual disabilities in the uk: a population-based study mortality among adults with intellectual disability in england: comparisons with the general population clinical characteristics of non-survivors with covid- in wuhan international association for the scientific study of intellectual and developmental disabilities a cascade of disparities: health and health care access for people with intellectual disabilities making reasonable and achievable adjustments: the contributions of learning disability liaison nurses in "getting it right" for people with learning disabilities receiving general hospitals care prevalence of intellectual disability: a metaanalysis of population-based studies mortality rates in the general irish population compared to those with an intellectual disability from to systematic review of the prevalence and incidence of intellectual disabilities: current trends and issues mental health problems in people with learning disabilities: prevention, assessment and management [ng ], london: national institute for health and care excellence. national institute for health and care excellence. ( a). covid- rapid guideline: critical care in adults nice updates rapid covid- guideline on critical care, london: national institute for health and care excellence clinical guide for front line staff to support the management of patients with a learning disability, autism or both during the coronavirus pandemic-relevant to all clinical specialities health inequalities experienced by people with learning disabilities: problems and possibilities in primary care early death and causes of death of people with intellectual disabilities: a systematic review coronavirus (covid- ): personal protective equipment (ppe) hub. in guidance about coronavirus (covid- ) personal protective equipment (ppe) covid- : guidance on residential care provision covid- : investigation and initial clinical management of possible cases guidance on shielding and protecting people who are clinically extremely vulnerable from covid- the health protection (coronavirus, restrictions) (england) regulations staying at home and away from others (social distancing) understanding distress in people with severe communication difficulties: developing and assessing the disability distress assessment tool (disdat) emotional disturbance and mental retardation: diagnostic overshadowing covid- and italy: what next? the lancet presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the new york city area prevalence of dysphagia in people with intellectual disability: a systematic review a global clinical measure of fitness and frailty in elderly people national early warning score (news)- , london: royal college of physicians london: hmso. the learning disability mortality review (leder) programme learning disabilities patients told they may be "too frail" for mechanical ventilation if they get covid- advance care planning in palliative care for people with intellectual disabilities: a systematic review nervous system involvement after infection with covid- and other coronaviruses characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet we wish to acknowledge the valued work of members of our consultative group in creating this guidance: saji alexander the authors have no conflict of interest to declare key: cord- -dqb em g authors: wang, wan-ying; zhou, hua; yang, ya-feng; sang, bin-sheng; liu, liang title: current policies and measures on the development of traditional chinese medicine in china date: - - journal: pharmacol res doi: . /j.phrs. . sha: doc_id: cord_uid: dqb em g traditional chinese medicine (tcm) is a medical science and cultural heritage empirically applied and reserved by chinese people for thousands of years. with comprehensive prosperity of china and rapid elaboration of technology, healthcare status of chinese people has become one of the most crucial concerns of the country. nearly policies and measures regarding tcm development have been issued since the (th) national congress of the communist party of people’s republic of china in . this review introduced a detailed evolutionary course of tcm in china with an emphasis on understanding the roadmap of tcm related policies and measures in china. traditional chinese medicine (tcm) is one of the most important achievements of chinese civilization which is also a medical science inherited over thousands of years. during the process of fighting against diseases, chinese people formed and developed tcm empirically in their daily life. recently, people in china and around world were infected by sars-cov- who might exhibit severe lung injury and lymphopenia [ ] . tcm has made great contributions to the treatment of covid- [ ] with over % involvement all over china [ ] and showed high effective rate in a multicenter, prospective, randomized controlled clinical trial [ ] . these effects are probably through the mechanism of inhibiting the sars-cov- replication and reducing pro-inflammatory cytokines [ ] [ ] [ ] . with its long history of absorption and innovation, tcm is not only a method of treatment, it also made great impacts on people's pattern of life. the remedies of tcm against diseases combines a holistic view of harmony, individuality, simplicity and preventive treatment which is on account of assimilation from natural science and humanities [ ] . the state council has issued a new guideline to implement the country's healthy china initiative focusing on disease prevention and health promotion [ ] . tcm as a crucial contributor for enhancing chinese people's health status, a large series of laws and policies have been issued for the heritage and innovation of tcm. the awarding of nobel prize in of tu youyou also highlighted the contributions of tcm to her research and raised artemisinin to a new status worldwide as "a gift from traditional chinese medicine to the world" [ ] . since the launching of the th five-year plan, great efforts have been made to improve the development of tcm: sixty-three state science and technology awards were honored to the research in the field of tcm; four tcm drugs have been allowed to conduct phase iii clinical trial in us and a number of chinese patent medicines have been recorded in european and us pharmacopoeia [ ] . it is undoubted that the central government and regulatory department are making every effort to promote the development of tcm with the aim of modernization, standardization and informatization so as to provide a precise treatment with a wider coverage. the international recognition of tcm is at the same time growing with the wide access of tcm across countries and regions worldwide. tcm acupuncture and moxibustion have been recognized as important parts of the intangible heritage of mankind by unesco [ ] and the chinese medical classics huangdi neijing (inner canon of the yellow emperor) [ ] and bencao gangmu (compendium of materia medica) [ ] have been included in the unesco memory of the world. according to statistics from the who, member states have authorized the use of acupuncture and moxibustion, of which have established laws and regulations promoting traditional medicines, and states have included acupuncture and moxibustion in their medical insurance systems [ ] . the latest global report on traditional and complementary medicine [ ] and who traditional medicine strategy: - [ ] have emphasized the contributions of traditional and complementary medicine to the goal of universal health coverage by improving equitable access to safe, quality and effective traditional and complementary medicine services. the global burden of chronic disease also urged the development and enhancement in the collaboration between conventional and traditional medicine [ ] . international organization for standardization (iso) created tcm technical committee iso/tc in focusing on quality and safety of raw materials, manufactured products and medical devices and of informatics [ ] . in [ ] . sharing one set of standards could help with the development of tcm globally. the developmental status of tcm in china could be introduced in the following five sections including tcm resources, the operation and service of tcm medical establishment, tcm education, tcm research & development (r&d) and financial appropriation income of tcm. (fig. ) for the cultivation of tcm characteristic talents, higher education in tcm subjects serves as a solid support. although the number of tcm institutions of higher education is almost the same ( ), more and more western medicine and non-medical institutions are setting up tcm subjects. moreover, the number of current and graduated students is increasing gradually including college students, bachelor students, master students and phd students. the proportion of the education level is almost the same that most tcm-subjected students (nearly %) are general undergraduates and continuing education undergraduates, but the percentage of phd students for tcm research is only around . %. tcm r&d is also carried on by ministerial, provincial and local organizations with published scientific articles and academic work, accepted and licensed patents, drug approval certificates, and other achievements at national standards. the number of professionals in tcm scientific research and technical development has increased steadily with more than half from provincial organizations working on scientific and technological activities. the key subjects involving r&d of tcm are evaluated by the number of agencies conducting them, including chinese herbal medicine, j o u r n a l p r e -p r o o f traditional chinese medicine, integrated traditional chinese & western medicine, pharmaceutical chemistry etc. the total income of tcm r&d organizations has increased in the latest years which is comprised of scientific activities, production and operation and other incomes which has nearly reached one billion. funding from the government and domestic and abroad non-government organizations also increased nearly % for supporting tcm research and development. detailly, around % of national fiscal expenditure has been spent on the section of medical and healthcare, among which, % of the money is for health administration and further divided . % goes for tcm agencies. both the amount of appropriation and its proportion increased gradually since . from the aspects of healthcare departments, the appropriation specific for tcm occupies less than % of the health administration budget and almost half of them is earmarked from tcm agencies [ ] . therefore, tcm has improved gradually in the latest ten years in the above five sections but comparing with its proportion in the whole healthcare system, there still remains large number of challenges to be solved in the future. on the other hand, there still exist obstacles that tcm has to face because of the huge healthcare demand in china [ ] . first of all, current tcm medical care system does not have a full coverage across the rural communities because of a limited number of infrastructure and practitioners [ ] . according to the statistics in , around % of tcm practitioners serve in urban areas while only % are in rural areas. secondly, insufficient number of high-level tcm experts leads to a weak point during the operation of tcm inheritance and innovation program. according to a survey of current status of tcm, there are only three tcm practitioners every ten thousand people [ ] . the tcm doctors are responsible for more than person-time patients every day, which is slightly higher than the average number of general hospitals but the annual income of tcm doctors are only % of the average income of all doctors national wide. the income of tcm hospitals is less than % of that of general hospitals which could explain the lower annual income of tcm doctors [ ] . thirdly, j o u r n a l p r e -p r o o f the sustained development of tcm is threatened by the destruction of ethnic minority medicine and the declined quality of chinese medical resources which also triggers a relatively low concentrated pharmaceutical industry. chinese crude drugs even have the highest disqualification exposure rate of all the products examined by the regulatory departments in china [ ] . there is an urgent request for the completeness of a tcm management system so as to increase its competitiveness under the global environment [ ] . fortunately, in order to overcome these difficulties, the government has not stopped guiding the direction in improving the environment for tcm development. the chinese government has set great store by tcm and rendered vigorous support to its development consistently after the founding of people's republic of china in . more importantly, since the th national congress of the communist party of china (cpc) in , the government has issued nearly major policy decisions and plans on tcm so as to improve its normative implementation and development to the rule by law [ ] . in president's report to the th cpc national congress, the necessity to pay equal attention to the development of tcm and western medicine and carrying forward the tradition and ensuring the development of tcm was emphasized [ ] . tcm is therefore ready for its renaissance with the modernized technologies, normalized system and devoted professionals. the development of tcm is ushering in a fresh age with an integrated scope of treatment, fitness, research, education, industry and culture. people all over the world would benefit enormously from the tcm services in terms of both healthcare and economy. tcm has always been a significant component of traditional chinese culture since it grows with the course of chinese history [ ] . dating back to the remote antiquity, chinese ancestors had applied certain creatures, plants and minerals to relieve their symptoms. by assimilating the essence from natural science and humanity, the theories and methods of tcm were gradually formed and recorded in written works. the four diagnostic methods: inspection, auscultation & olfaction, inquiry and j o u r n a l p r e -p r o o f palpation was summarized by bian que in the spring and autumn and warring states period ( - bc) [ ] . the theoretical frame work for tcm came in to place during the qin and han times ( bc-ad ) described in the huang di nei jing (yellow emperor's inner canon) [ ] . one of the most important theoretical foundation of tcm was the shang han za bing lun (treatise on febrile diseases and miscellaneous illnesses) created by zhang zhongjing in the eastern han dynasty ( - ), which discoursed how to propose corresponding diagnosis by differentiating the patterns of miscellaneous illnesses [ ] . during the same period, the foundation of tcm pharmaceutical theory was advanced by the masterpiece: the shen nong ben cao jing (shennong's classic of masteria medica) which guided the prescription and safety application of tcm so as to enhance their therapeutic effects [ ] . later in the ming dynasty ( - ), li shizhen complied the ben cao gang mu (compendium of materia medica), the first book in the world that categorized medical herbs scientifically, which enriched the tcm pharmaceutical theory in details [ ] . these books transformed the clinical experience into summation of theories of tcm which systematically exposed its principles and methods of treatment, the human physiology, the symptoms of illness, and the preventative treatment. the application of tcm also prospered with the development of the people's republic of china (prc) since . in the early period of prc, one of the three guidelines for health work was uniting chinese and western medicine. the first edition of chinese pharmacopoeia was published in for guiding the pharmaceutical industry in china while tcm was first recorded in the second edition of pharmacopoeia in [ , ] . later in , the cpc central committee transmitted the ministry of health's "report on implementing the party's policies regarding tcm and cultivating tcm practitioners" across the country which forcefully promoted the development of tcm. furthermore, the constitution of the prc stipulates the promotion of modern medicine and tcm to protect the health of chinese people [ ] . in , a relatively independent administration of tcm was founded by the state council, following by the establishment of respective tcm administrations in all provinces, autonomous regions and municipalities which functioned as basic organization of [ ] . in august , the drug administration law of the people's republic of china was revised in order to ensure the quality of drugs in china with several sections regarding the approval, production, circulation etc. of tcm drugs [ ] . these statements revealed the management rules for tcm which adhering to safety first, risk management, whole-process management and control, scientific supervision, and social co-governance. these historical events from ancient china to the latest days provide strong evidence on the importance of tcm which is the backbone of chinese society and chinese culture. the prosperity of tcm would play a critical role in the completeness of a medical and healthcare system providing better healthcare service with chinese characteristics. chapter of this plan emphasized that fully taking the superior advantage of tcm would play a significant role of improving the medical service in china [ ] . the aim of these policies and measures on tcm development is to resolve the major obstacles met by tcm so as to improve the health status of chinese people. the holistic characteristic of tcm could explicate its thriving impacts on a number of subsequent fields. construction of a complete scientific framework of tcm has been a long-term goal for a breaking- internationally, tcm has played an important role in the professionals, production and finance supply chain overseas especially along the "one-belt, one-road" countries [ , ] . the development of tcm has achieved enormous progress after the th cpc national conference. the primary reason is the emphasis and support from the national people's congress and the central the central committee of the party together with the state council and tcm administration departments have made great efforts on the renaissance of tcm. these policies and measures guide the principle of tcm development with detailed tasks in terms of healthcare, economy and culture. the implementation of these policies would contribute to a brighter future for tcm and benefit the well-being of mankind. in conclusion, people should have a strong faith in the reliability of tcm since the government is leading the administrators and experts to make every endeavor to support the development of tcm. j o u r n a l p r e -p r o o f ll and bss supervised all research and revised the manuscript. wyw, hz and yfw collected information. wyw and hz analyzed the data and prepared the manuscript. the authors declare no conflicts of interest. pathological findings of covid- associated with acute respiratory distress syndrome contribution of traditional chinese medicine to the treatment of covid- all the mobile cabin hospitals in wuhan are equipped with tcm experts efficacy and safety of lianhuaqingwen capsules, a repurposed 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key: cord- - vp ffg authors: morgon banks, lena; davey, calum; shakespeare, tom; kuper, hannah title: disability-inclusive responses to covid- : lessons learnt from research on social protection in low- and middle-income countries date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: vp ffg the one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the covid- pandemic unless interventions to address its economic impacts are disability-inclusive. this paper draws on the literature on disability, poverty and social protection in low- and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). it also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses for people with disabilities. amongst people with disabilities, and suggests how social protection and other economic responses should consider the needs of people with disabilities. the covid- pandemic has led to economic pressures for many households, which may disproportionately affect people with disabilities and their households. notably, the pandemic has resulted in massive disruptions to the labor market. a rapid survey of over , households in bangladesh found % of people had been rendered economically inactive and weekly income had dropped by almost % amongst poor households since the start of the pandemic (rahman & matin, ) . households with members with disabilities tend to have fewer working members to offset income losses if one or more members lose work, as people with disabilities are more likely to be un-or underemployed and other household members may forgo work to provide caregiving support (who & world bank, ) . for example, a survey of people with physical impairments in jordan found that % lived in a household with a single income earner pre-pandemic, of which % had lost their jobs due to covid- restrictions (humanity & inclusion, ) . further, people with disabilities -particularly women with disabilities -are more likely work in the informal sector (mizunoya & mitra, ) , which lacks job security and financial protections such as unemployment insurance or paid sick and carer leave. people with disabilities may also take longer to re-enter the workforce after restrictions are eased, as factors such as stigma of disability, inaccessible environments and poor access to education and training limit job opportunities (who & world bank, ) . additionally, many of the health and social services that people with disabilities require (e.g. rehabilitation, assistive devices, care for chronic conditions, psychiatry, medications, personal assistance) have been disrupted due to covid- . for example, there is concern that restrictions in china led to poor access to mental healthcare, particularly for older adults and people unable to access telehealth services (yang et al., ) . disruptions to needed services can results in deteriorating health, which may lead to higher future healthcare spending and immediate and long-term losses to functioning and productivity (shakespeare et al., ) . finally, people with disabilities and their households often have fewer coping mechanisms for managing economic stressors, as many are already living in poverty. numerous studies conducted pre-pandemic found people with disabilities have lower incomes and savings, weaker social networks, fewer assets and a heightened risk of food insecurity compared to people without disabilities (banks et al., ; who & world bank, ) . people with disabilities also incur disability-related extra costs -such as for assistive devices, health services, accessible transportation and personal assistance -that lower their disposable income (mitra et al., ) . some countries have begun implementing interventions addressing the economic impacts of covid- , such as food assistance, emergency cash transfers, unemployment assistance or expansions to existing social protection programs (imf, a). as these programs are developed, it is important to ensure their design and delivery is inclusive of people with disabilities. programs must consider whether their targeting strategies are disability-inclusive. for example, many interventions target people living in poverty using means-testing (income thresholds to determine poverty) or proxy-means-testing (household or individual characteristics to predict poverty). however, means-testing often underestimates poverty among people with disabilities by not accounting for extra costs of disability gooding & marriot, ): incorporating even conservative estimates of disabilityrelated extra costs increased the proportion of people with disabilities who were considered poor by . percentage points (pp) in vietnam (braithwaite & mont, ), . pp in bosnia and herzegovina (braithwaite & mont, ) , and . pp in cambodia . similarly, proxy means-testing often has exclusion errors that are particularly biased against people with disabilities and older adults (kidd, ) . some programs explicitly target people with disabilities. for example, georgia, mexico, mongolia, lesotho, tunisia and são tomé and principe plan to implement new or expand existing disability-targeted social assistance schemes in their covid- response (imf, a). however, determining who is disabled is methodologically and logistically challenging mont et al., ) . many disability assessments require clinical documentation of impairments, which is not in line with the conceptualization of disability espoused by the uncrpd (mont et al., ; walsham et al., ) and, particularly during covid- , may be difficult to conduct when health services are limited. further, some schemes only include people with very severe disabilities, such as people requiring full-time caregiving or deemed unable to work -excluding the much larger group of people with more moderate disabilities, who often have a high need for social protection gooding & marriot, ). functioning-based assessments of disability, involving trained community informants, may be an effective and rapid method for identifying people with disabilities for social protection and other assistance, particularly during the covid- pandemic. finally, covid- programs that are not coordinated with other social protection schemes risk the exclusion of people with disabilities. for example, some countries do not allow the receipt of multiple forms of social protection (banks, ) , which could limit access for recipients of other schemes (e.g. disability-targeted cash transfers or old age pensions) who require additional support to cope with the economic effects of covid- . previous studies have found many people with disabilities are not enrolled in schemes they are eligible for. for example, coverage of disability-targeted programs was % in cam le, vietnam (banks, walsham, minh, et al., ) , % in the maldives (hameed et al., ) , and % in tanahun, nepal (banks, walsham, neupane, et al., ) . similarly, studies of non-disability targeted program in peru and tanzania found low levels of enrolment amongst eligible people with disabilities despite high levels of poverty (bernabe-ortiz et al., ; kuper et al., ) . common barriers to enrolling in social protection schemes should be considered when developing covid- interventions. frequent challenges include: poor awareness of available program, lack of accessible information and communication (e.g. braille, screenreader compatible, sign language), misconceptions and stigma of disability amongst staff, urban-based and physically inaccessible application points, and financial and administrative difficulties gathering necessary documentation, particularly for medical assessments of disability banks, walsham, minh, et al., ; banks, walsham, neupane, et al., ; mitra, ) . adaptations to enrolment procedures may help support the inclusion of people with disabilities. for example, in some districts of nepal, disabled peoples' organizations were credited with improving enrolment in disability-targeted programs, as they provided their members with accessible information about available schemes, helped with applications, and worked with assessment panels to improve their understanding of disability (banks, walsham, neupane, et al., ) . further, decentralization and streamlining of application processes was credited with increasing enrolment in disability-targeted programs in vietnam (banks, walsham, minh, et al., ) . previous studies highlight that people with disabilities can face challenges receiving social protection benefits once enrolled, due to difficulties reaching delivery points or unpredictable delivery schedules (gooding & marriot, ) . covid- is altering delivery mechanisms in some countries, such as in the gambia, morocco and togo, where cash transfers are being distributed through mobile applications (imf, a). these strategies may improve access to benefits for some recipients, particularly those who would struggle to travel to delivery points. however, it is important that delivery methods -and information on how to use them -are accessible to people with sensory impairments and that alternatives are available for people without access to mobile technology. additionally, many people with disabilities have limited control over their entitlements, which may limit their impact. for example, approximately a third of adult recipients of disability-targeted cash transfers in vietnam, nepal, and the maldives reported that their allotment was controlled fully by others in their household (banks, ; hameed et al., ) . covid- economic responses must be relevant to people with disabilities. for example, temporary employment schemes often focus on unskilled manual labor, which is not suitable for many people with physical impairments. similarly, unemployment insurance is typically limited to the formal sector, which would exclude many people in lmics, particularly people with disabilities given their overrepresentation in this sector. encouragingly, several countries such as brazil, cabo verde, the dominican republic, georgia, honduras, indonesia, lesotho, mauritius, sudan, and togo have announced plans for expanding financial assistance to cover unemployed informal sector workers (imf, a). although evidence is limited, existing social protection programs have often shown only limited impact in protecting people with disabilities from poverty . for example, impact evaluations of regular cash transfer schemes in the maldives and lesotho found that recipients with disabilities experienced modest benefits, particularly in health; however, a large proportion of recipients were still living in poverty and were much poorer compared to people without disabilities (de groot et al., ; hameed et al., ) . impact may be even less for one-off emergency payments. to improve the adequacy of covid- economic responses, people with disabilities may require adjusted benefit packages. for example, the amount provided should consider the effect of high levels of poverty and extra costs of disability combined with low availability of alternative coping strategies on people with disabilities' ability to meet basic needs. further, interventions may be required to address the specific concerns of people with disabilities during the covid- pandemic, such as access to disability-related health and social services during restrictions. responses must also consider both the financial and non-financial barriers people with disabilities face in meeting their basic needs and improving their livelihoods. while cash transfers are important, people with disabilities often face additional non-financial barriers -what sen & nussbaum call "conversion handicaps" under the capability approach (nussbaum & sen, ) -that impede the translation of economic resources into needed goods and services. for example, people with physical impairments who receive cash transfers may not be able to purchase food if shops that are open during covid- restrictions are inaccessible or far away with no accessible transport, they rely on personal assistance or delivery services that are no longer available, they face stigma from shopworkers or other customers, or they have underlying health conditions that require stricter adherence to social distancing. complementary activities targeting these and other non-financial barriers are essential for improving the effectiveness of covid- responses. people with disabilities will be disproportionately affected by the economic implications of the ongoing covid- pandemic unless responses are disability-inclusive. key challenges and recommendations for their resolution are described in table . to support these recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability is required throughout . many recommendations will be beneficial to people without disabilities (e.g. reforming complex application procedures, benefit packages). consequently, creating disability-inclusive responses may not just reduce inequalities, but also improve programs for all recipients. all authors declare that they have no conflicts of interest  the covid- pandemic is likely to exacerbate poverty amongst the one billion people living with disabilities globally. for example, people with disabilities are more likely to live in poverty and have less job security (e.g. few work opportunities, overrepresentation in the informal sector) compared to people without disabilities, and disruption of essential disability-specific services (e.g. rehabilitation, personal assistance, social care) could lead to higher longer-term spending and decreased productivity.  planning for social protection and other interventions to address the economic impacts of covid- is underway in many countries. previous research on disability, poverty and social protection highlights that people with disabilities face challenges accessing and equally benefiting from available programs if they are not disability-inclusive.  key recommendations for disability-inclusive social protection and other economic responses to the covid- pandemic include: designing benefit packages that are relevant to and address the needs of people with disabilities; adapting eligibility criteria and assessment procedures; ensuring physical and informational accessibility in enrolment and delivery systems; training program staff on disability; and actively engaging with people with disabilities throughout program development and implementation. investigating disability-inclusion in social protection programmes in lowand middle-income countries, with case studies from vietnam and nepal london school of hygiene & tropical medicine poverty and disability in low-and middle-income countries: a systematic review disability and social protection programmes in low-and middle-income countries: a systematic review access to social protection among people with disabilities: evidence from viet nam access to social protection among people with disabilities: mixed methods research from tanahun inclusion of persons with disabilities in systems of social protection: a population-based survey and case-control study in peru disability and poverty: a survey of world bank poverty assessments and implications. alter-european journal of disability research/revue européenne de recherche sur le the impact of the lesotho child grant programme in the lives of people with disabilities: disaggregated analysis of a community randomised controlled trial including persons with disabilities in social cash transfer programmes in developing countries needs assessment: impact of covid- on people with disabilities and their families in jordan policy responses to covid- six charts show how covid- is an unprecedented threat to development in sub-saharan africa social exclusion and access to social protection schemes disability-inclusive covid- response: what it is, why it is important and what we can learn from the united kingdom's response social protection for people with disabilities in tanzania: a mixed methods study measuring disability in population based surveys: the interrelationship between clinical impairments and reported functional limitations in cameroon and india disability and social safety nets in developing countries extra costs of living with a disability: a review and agenda for future research is there a disability gap in employment rates in developing countries? disability identification cards: issues in effective design the quality of life standard of living and disability in cambodia pprc-bigd rapid survey: poverty impact of covid- access to health for persons with disabilities. geneva: united nations high commissioner for human rights social protection for people with disabilities in africa and asia: a review of programmes for low-and middleincome countries world report on disability mental health services for older adults in china during the covid- outbreak. the lancet psychiatry the one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the covid- pandemic unless interventions to address its economic impacts are disability-inclusive. this paper draws on the literature on disability, poverty and social protection in low-and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). it also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses for people with disabilities.key words: covid- ; disability; poverty; social protection; low-and middle-income countries key: cord- -i xg tpp authors: torres, camilo; verschoor, gerard title: re-imagining environmental governance: gold dredge mining vs territorial health in the colombian amazon date: - - journal: geoforum doi: . /j.geoforum. . . sha: doc_id: cord_uid: i xg tpp this article describes and analyses an encounter in the colombian amazon between indigenous practices and arrangements to manage their environment and the conservation policies of the state. indigenous peoples understand their world as populated by powerful human and nonhuman beings; for them, the moral duty of achieving happiness and abundance for all implies sustaining reciprocal and respectful relations with these beings (including the state). in contrast colombian environmental policy distinguishes between nature and culture, seeking to safeguard landscapes from human interference so that natural processes can unfold unhindered. in practice these partially connected, yet incommensurable worldviews make for a ‘perfect storm’ - opening opportunities for illegal mining. drawing on recent fieldwork among the andoke, an ethnic group well acquainted with extractivism in its different historical modalities and presently affronting the fallout of gold dredge mining we narrate how a parallel, non-state governance system makes it difficult for them to care for their land and entertain mutual and respectful relations with human and nonhuman beings (which we translate as ‘territorial health’). we conclude by arguing for the need to re-imagine environmental governance in ways that more closely engage with what we call pluriversal governance: a form of (environmental) governance that does ontological justice to those involved in the environmental conflict – including, crucially, indigenous people. to achieve just this type of 'sound' or 'good' environmental governance a variety of innovative governance arrangements have been suggested, including adaptive governance (dietz et al., ; folke et al., ) , polycentric governance (newig and fritsch, ; ostrom, a ostrom, , b or participatory and collaborative governance (ansell and gash, ) . in general, these governance varieties plea for the inclusion of a larger diversity of pieces of knowledge and perspectives (bäckstrand, ; blaikie, ; blaikie et al., ; gibson-graham, ) to secure greater feasibility and legitimacy of (government) action as well as to advance social equity and environmental justice. some of these governance innovations explicitly mention the need to include indigenous peoples (brondizio and le tourneau, ) and to integrate the different ways in which people value nature (baud et al., ) . these new (environmental) governance forms undoubtedly have their advantages. they are, for example, viable alternatives to neoliberal forms of governance supported by (supra)national environmental policy-making institutions and conservation ngos that have been much criticized for pushing market-based approaches as universal solutions to environmental problems (fletcher and büscher, ; mcafee, ; van hecken et al., ) . notwithstanding their usefulness, a shared characteristic of environmental governance processes (both neoliberal or otherwise) is that their definitions of problems and proposed solutions are deeply influenced by euro-american assumptions, paradigms and research traditions (leach et al., ) , and hardly (if at all) discuss ontology, i.e., the nature of the 'what' is governed (cf. van wezemael, ; briassoulis, ) . environmental governance, in the main, thus gravitates around the central concepts of 'nature' and 'environment' -concepts with a strong footing on euro-american ontology that are presumed to be universal. yet these concepts are far from universal and, as some commentators have shown (latour, ; stengers, ; viveiros de castro, ) , they operate on the basis of a 'multiculturalist' understanding of the world: the idea that there exists one single, power-laden reality ('nature') that can be perceived differently from a variety of culturally situated perspectivesthe euro-american generally being considered the most 'accurate' one because of the (scientific) method it applies to the study of reality. this is particularly problematic in cases such as the one described above where the main ontological premises of environmental governance (euro-american style) are not shared by the majority of on-theground actors.. indeed, in colombia as elsewhere environmental governance arrangements frequently do not resonate with the problem and solution framings of those who stand at the frontline of resource extraction (often indigenous peoples). in effect this represents an outright infringement on indigenous rights; that is, they are assaults of what descola ( ) calls a 'naturalist' ontology on 'animist' ones. indeed, for the andoke as well as for many other indigenous peoples in the americas and beyond environmental governance paradigms that operate on the basis of a multiculturalist, 'one-world-world' (law, ) are deeply troublesome: they mirror a profoundly colonial stance that, as a rule, pushes aside indigenous definitions of problems and proposed solutions -thus rendering invisible, and ultimately silencing, ontological difference (howitt and suchet-pearson, ; sousa santos, ) . by focusing on the ontologically-laden processes of environmental governance, our article contributes to what blaser and escobar ( ) see as an emerging, third-generation political ecology that focuses not only on epistemological, but above all on ontological issues. the disavowal of indigenous framings of problems and proposed (source acceded in th of april in: https://opiac.org.co/en-riesgo-la-autonomia-y-gobierno-propio-del-pueblo-indigena-andoque-con-zona-minera-indigena-en-eldepartameno-del-amazonas/). solutions in the region of the colombian amazon where we carried out our study has historically generated 'perfect storms' that offer opportunities for parallel governance institutions promoted by illegal, mostly non-indigenous actors to take hold. this has been the case over the last hundred years or so through large-scale rubber extraction (and concomitant genocide) based on indigenous slave labour (echeverri, ) , timber and fur trades bonanzas from the mid- s through the mid- s (guyot, ) , and the perhaps even more nefarious production of cocaine from the mid- s to the early s (gutierrez et al., ; thaler et al., ) overseen by paramilitary groups who at times used violence against local communities that did not want to engage in 'the business'. to redress situations of state-led environmental governance breakdown or grapple with illegal, often violencebased parallel governance forms in this article we argue that, in contexts involving indigenous peoples, managing complex environmental problems necessitates some form of what we call 'pluriversal governance' -a form of governance that does ontological justice to indigenous peoples' worldviews and different ways of thinking environmental problems. to make our argument, in the next section we first present the problem of mining in our study region, and how we went about gathering data to find the underlying sources of environmental governance breakdown. this is followed by section in which we describe state-led environmental governance arrangements and the reasons for their evident failure. section explores andoke understandings and management of their environment (which we gloss with the concept of 'territorial health') and the causes of it going awry with the relatively recent arrival of illegal gold dredge mining. in section we provide a glimpse of the workings of a parallel (though illegal) form of governance focused on dredge mining. we end with a concluding discussion in which we present the reasons for both indigenous and state-led environmental governance failure, and discuss the need for pluriversal governance -a form of governance that does ontological justice to indigenous peoples' way of understanding environmental problems. in the colombian amazon, illegal, small-scale mining has led to severe if not catastrophic social and ecological consequences. in , over . local operations affected . ha and polluted more than rivers (instituto sinchi, ) . a sizable part of these operations, , take place within the indigenous reserves or resguardos that have been created since colombia's new constitution of and which presently shelter the close to different ethnic groups living in the colombian amazon (idem). the main polluting agent is mercury, which is needed to separate gold from unwanted metals. mercury is handled with bare hands and re-used with home-made burners, exposing miners to toxic methyl-mercury gases which lead to respiratory infections and skin rashes. methylmercury finds its way into rivers after use and ends up in the food chain, accumulating in many varieties of fish and top-predators as catfish -the main source of protein of the local population. when consumed, methylmercury can lead to minamata disease (a neurological disorder). in our study region this is very worrying, with levels of methylmercury in human hair surpassing who thresholds in % of cases in (olivero-verbel et al., ) . dredging also modifies the riverbed, and transforms bluffs and riverbanks through the deposition of sediments which in turn affects terrestrial and amphibious animal species. because of these transformations (and the perceived dangers of mercury pollution) some indigenous people have stopped bathing, fishing, or washing clothes on the shores of the main rivers. miners prefer not to talk about these things, and instead boast about the earnings that allow them to access electronic gadgets, beer, and carnal pleasures. as we witnessed, in our area of study mining is coterminous with alcoholism and related diseases, spouse-battering, violent conflicts and fights, or the diving accidents that are part and parcel of this world of gold. women instead openly raise their concerns, and speculate extensively about declining fertility and the spontaneous abortions which seem to occur more frequently after the arrival of mining. they also point to the negative effects mining has on chagra (swidden) dynamics: now that their men work 'in the business' and have no time for agriculture women have difficulty providing enough food for their families -thus compromising food security. the ominous consequences of gold mining begs the question: how is this possible? what are the mechanisms at play behind the failure of environmental governance? to answer these questions we set out to collect data in the aduche resguardo (see fig. ). fieldwork there was carried out over six periods between the beginning of to the end of , with the first and second author coinciding in the field twice in . we carried out about interviews with local people, and recorded stories from gold merchants, indigenous people (both miners and non-miners), shamans, army officers and local shopkeepers. when not in the field, the first author kept regular mobile phone contact with some of the informants. apart from our semi-structured interviews we collected data on the flow of everyday life and experience by way of participant observation (fine, ) . we kept to the ethical guidelines of our home institutions, following standard procedures and practices, and always obtained consent from of our interviewees (whom we have anonymized for safety reasons). the data we use for this article were translated into english, taking care to keep as close as possible to the gossip, fears, jokes, anecdotes and other affects and emotions which we assume reproduced actors' concepts, livelihood practices, embodied moralities, as well as (in the case of andoke elders) their perceptions on the relations between human and non-human forest denizens. the colombian amazon is probably the best conserved area in the amazon basin. it counts for % of the national land area (roughly . km ). administratively, the colombian amazon is shared by six departments in turn divided in municipalities and corregimientos (nonmunicipalized areas -more on this below). the vast, continuous forests gather a large spectrum of visions and practices that shape different forms of state-led environmental governance, the largest one being the administrative figure of resguardos or indigenous reserves ( . % of the area). this is followed by forest reserves ( . %), national parks ( . %), areas substracted from former forest reserves for the purposes of colonization ( . %), and a host of other forms (gutierrez et al., ) . in practice different authorities are in charge of implementing the politico-administrative organization of the country. in national parks policies are implemented through the uaespnn (special administrative unit of the national parks system). in the resguardos aati's (associations of traditional indigenous authorities) are the formal public entities in charge of resource management. in protected areas outside of national parks two different environmental protection agencies are in charge of managing terrestrial resources: corpoamazonia in the departments of putumayo, caquetá and at its peak, in this part of the amazon rubber was extracted in more than slave camps scattered over more than , km of dense rainforest (an area roughly the size of england). uribe ( ) calculates that between , and , indigenous people were exploited, tortured and killed during the heyday of the rubber boom at the beginning of the th century. state-led environmental governance in the colombian amazon is of course not the haphazard outcome of state-indigenous peoples relations but rather the result of the ontologically inflected ways in which the state has historically framed the problems and solutions of the region. understanding governance failures thus needs to take into account that the amazon was, until very recently, seen as terra nullius awaiting colonization -"[a] land without men, for men who need land" (gonzález, : ) , as was the motto of the ministry of agriculture in the 's -a slogan translated into laws and decrees to legalize the exploitation of 'vacant land' as early as . these policies continue to this day through for example the zidres law of that propel large-scale land acquisition and legal land grabbing to promote agribusiness, mainly in the so called baldíos or public vacant lands on the andean foothills and adjacent amazonian plains (lugo, ) . as concerns indigenous population of the region, these were until very recently seen as coming with the exuberant amazonian ecosystemtheir affairs delegated to the discretionary powers of ecclesiastical missions, who in turn received huge amounts of land for their 'effort'. in fact, not until the s (and after huge pressure from national and international ethnic movements) did the colombian state stop treating amazonian ethnic groups as anachronistic, non-viable societies. by the s the colombian state underwent a complete change of heart as regards its stance towards the amazon. policies in support of the wholesale exploitation of natural resources were abruptly turned into conservation policies -even though it maintained its colonization policies in the andean foothills. the change was linked to an emerging, international 'sustainable development' discourse that gained prominence after the stockholm conference ( ), the united nation's first major conference on international environmental issues. this discourse was directly linked to narratives about a 'pristine' amazon as the 'lungs of the earth' -an image that had been carefully but actively crafted since von humboldt's expeditions in the early th century and epitomized by the works of eminent cultural ecologists (cf. meggers, ) . in these basically apolitical narratives, man was seen as the enemy of nature -an enemy that had to be kept at bay at all costs. as a result of this 'nature without people' discourse in the s huge areas of the colombian amazon were turned into national parks (some of them encompassing millions of hectares) and nature and forest reserves. to this day, and even though territorial autonomy has been granted to indigenous peoples in their resguardos, law makes it abundantly clear that this autonomy can only be exercised as long it is not contrary to the conservation vocation of the amazonian bioregion (an entity with formal rights since ). colombian state-led environmental governance is thus based on the idea that unique bioregions have ecological functions that should be conserved. this idea is strengthened by a further, euroamerican ontological assumption about the character of the bounded geographical space that should be conserved and which is best described as 'territory'. in the colombian constitution, 'territory' is defined in the politico-jurisdictional sense; that is, as a geographical space the defines and delimits the sovereignty of the nation. different types of territories exist; in the amazon these are the departments, the municipalities, and the corregimientos or non-municipalized areas. especially the latter category is important in explaining the failure of environmental governance. non-municipalized areas do not have the political-administrative status of municipalities because of their low population numbers. corregimientos lack a municipal council and are administrated by a magistrate appointed by the government of the department to which it belongs. paradoxically, according to the constitution, corregimientos do not exist: all territories must be part of a municipality. while this situation changed (on paper, at least) in this effectively means that between and nearly % of the colombian amazon found itself in a facto legal vacuum. since % of the corregimientos in the colombian amazon overlap with indigenous resguardos (duarte, ) this also means that a large proportion of lands governed by indigenous peoples were not formally recognized by the state and did thus not have the political-administrative power to exercise their territorial vision -a vision that, as we recount in the next section, differs sharply from that of state. state-led environmental governance is not the only governance form in the colombian amazon. as detailed above traditional indigenous authorities or aati's are in charge of managing natural resources within the resguardos -even if not formally recognized by the constitution until . given that dredging for gold occurs in a socioecological milieu for the most part inhabited by indigenous people, in this section we describe how andoke try to steer affairs on the basis of their understanding (however shifting and fluid) of the environment, and the reasons given by some of them to become involved in mining. to zoom in on the ontological precepts underlying indigenous environmental governance, in the next vignette we detail an episode in which the first author caught a glimpse of the concept we call 'territorial health' while falling ill. from the field notes: "tonight i am struck by a strong stomach ache. i consult the local in these co-management forms conflicts arise because e.g. national park authorities do not have a thorough understanding of the traditional territory or the shamanic concept of it (rodríguez et al., ) . in colombia no discrimination exists between small-and large-scale mining operations: all need a mining title or mining concession (law of ) as well as an environmental permit (decree of ). this effectively encourages illegality. an example of this was the titling, in the s, of the putumayo preserve (nearly million hectares) in favor of the caja de crédito agrario, industrial y minero (a state-owned bank). the bank purchased the land from the heirs of the peruvian amazon company, also known as the casa arana, which was notorious for its genocidal practices linked to rubber exploitation (echeverri, (footnote continued) martins, ; morcote-ríos et al., ; watling et al., ) demonstrating the amazon to be, to a large extent, of anthropogenic origin. these finding have had little bearing on policymakers' views. according to benavides and duarte ( ) the (short) bout of stomach ache threw some initial light on concepts of 'health' and 'environment' that were foreign to us. probing deeper in meetings with elders and shamans, walks in the forest, dances, food sharing, gold mining, and other spaces shared with the andoke during fieldwork, we slowly became aware of their more profound meaning -a meaning that was unfamiliar to us and that we argue can best be captured through the concept of 'territorial health' (henceforth th). at the basis of this notion lies the andoke's axiom that the reason for existence of all entities in the world (both human and nonhuman) is given by a 'law of origin' or yetara uai/ka'takadɨ pɨsei (estrada añokazi, ) . this law requires that all entities perform their different activities in accordance to what could be called an 'ecological calendar', and managing human-human and human-nonhuman relations well (in terms of harmony and reciprocity). good management of relations results in 'abundance' or monifue -a concept that can in turn best be translated by the notion of 'dignified life'. according to the andoke, abundance is not synonymous to material wealth, but to both material and spiritual wealth and expressed in the ability of the territory to provide food and care for all entities. 'abundance', in this sense, equals having all that is necessary to live well and in harmony with all forest and river denizens -including their spirit owners. for the andoke, abundance means the 'joy of living' (literally, the 'force of life' or toe ya' pόsοθ tu'si) -expressed as a form of collective happiness achieved through dancing, eating and generally being in the cheerful company of kin. for the andoke, abundance is closely connected to an understanding of territory as body (cf. echeverri, ) . territory, in this sense, is more than a geographical space that can be defined by its social, economic, or environmental characteristics; rather, it is a notion that hinges on the idea of territory as a rhizome dynamically mutating in time and space, where human and nonhuman entities, from the past and the present, from this and from other worlds become entangled in complex webs of (social) relations to organize and shape this 'territory'. as such, this 'body' has its own needs, appetites, desires, and so on. importantly, this body may become ill when these needs and desires are not fulfilled, or when an external entity comes to be part of this 'body' in an ill-suited way -in effect eating away at the body from the inside like a cancerous cell that expands and in time affects all organs if not removed in time. among the andoke, illness is conceived as a constant threat and manifests itself in the form of pain, indisposition, envy, hunger, madness, anger, conflicts, accidents, impulsive behaviour or weakening diseases. illness itself can be brought about by witchcraft performed by humans, (mal de gente) or by spirit owners of animals and fish (or other supranatural creatures). in the first case illness affects the individual; in the latter disease affects not only individual humans but can affect the behaviour of whole families, animal populations, or relations between humans and nonhumans. this is expressed in for example changing fish migrations or foraging patterns of game animals, altered growth cycles (and occurrence) of edible and medicinal plants, inconsistent behaviour of rivers, or shifting rainfall patterns (e.g. rain arriving late or not at all in crucial times of the ecological calendar). to remedy mal de gente, intermediation by shamans or abuelos (elderly people) able to identify the offender (and the behaviour that caused the offense) is called for. in cases where illness affects whole communities of humans or nonhumans complicated negotiations aimed to stop behaviours that are said to distort the health system ensue (e.g. the 'contaminated' fish eaten by the first author). however, the metaphor of the metastasizing, cancerous tissue alluded to above not fully captures the healing capacities of the territory/body. according to our andoke interlocutors, removal or extermination of the cause(s) of illness are not the only solution: rightful accommodation into the territory/body is also a possibility. for example, white people (once considered to be 'cancerous' cells through inquisition and the genocidal practices related to the rubber boom) may be assimilated and come to form part of the body in due time once certain practices are 'improved' (e.g. whites not anymore hunting or indiscriminately killing indigenous people -as used to be the case). in this sense, a sick body has the capacity to heal itself. importantly, the notion of th is not gendered; however, men and women are together responsible for the vitality of the territory, therefore, each gender carries out different tasks. thus, while men are most often in charge of cosmic relations, women take care of the complex dances and rituals that bring joy and strengthen harmony -two indispensable factors to secure the energy flows between humans and nonhumans which maintain fertility and thus the abundance of food and people (arango, ) . when these energy flows are interrupted, th breaks down. in our research area (the aduche reserve) gold dredge mining is widely considered to be a danger for th. according to our informants activities in the area started around / and increased shortly after the financial meltdown of when gold prices skyrocketed. dredge mining was introduced by entrepreneurs from outside the region, and increased rapidly. thus in february we counted dredges working a stretch of km between puerto santander and the mouth of the yarí river. by december of that year the number had increased to . in may we were told that dredges of different sizes were operating in this sector, and in december a total dredges combed the riverbed over a two-kilometre stretch of the aduche reserve. indigenous andoke are the largest part of the workforce on the dredges; considering andoke territorial visions, it is not surprising to find competing interpretations of the activity. the younger generation (especially the males working on dredges) would generally favour the activity -even if sometimes openly recognizing the moral dilemmas for the andoke, as well as for many ethnic groups of the amazon, the 'spirit owner' is a powerful, supra-human entity that owns and controls animals, or plants, or lakes, or rivers. between and early the numbers appear to have stabilized, but we expect numbers to again rise sharply with gold prices going through the ceiling as a result of covid- related global financial uncertainties. involved. for all people involved in 'the business' the most important driver is money. in , an average worker would make (depending on the time of year, the place, and workers' skills) between and usd in - continuous working hours. in this timespan workers would fetch between and g of clean gold. a young indigenous informant put it thus: "this job has given me a lot of money. it has given me the things that other jobs would never have given me [waving a cellular phone as a trophy]. the only downside is that my head sometimes hurts and also my eyes burn a little." in general, most adult women and men would be adamantly against mining. this sometimes leads to (open) inter-generational conflict -to the point that youths can be expelled from their parental maloka when involved in mining. elderly shamans or abuelos in turn put forth additional reasons against mining such as changing relations with water entities (as evident from the fish story in the vignette above), animals and forest spirits. some elders narrated that revengeful animal spirit owners would sent 'infected' game into the forest; consuming this meat would make one highly prone to drowning accidents. or, as an older abuelo told us, these same spirits would just decide to take it all back: likewise, we were told that the spirits owners of cassava and banana were annoyed, changing their flavours and availability. senior andoke also stated that the arrival of foreign diets (e.g. rice, candy, chips, canned food) that became accessible through mining offended spirit owners of animals and plants who felt their food offers were being turned down (despreciados) -a clear sign of miss-appreciation that was punished by the arrival of envy, pettiness, apathy, sloth or alcoholism. healing these situations, in turn, had become difficult as mining had eroded the rules of cosmic conduct, affecting the 'discipline of coca and tobacco' and weakening the very channels through which curative powers trave. as yanai -a well-known shaman of the people of the center -put it: "we shamans have been chosen and trained to run the world (manejar el mundo). we have inherited our tasks from our shamanic ancestors; it is us who must ensure that there is abundance, that there is happiness, that there is no war, that there are no illnesses. since all layers of the world are energetically interconnected we need to see to it that energy flows between the layers is not interrupted. this spiritual energy comes from our sacred places, and we need this energy to communicate between different layers! we the jaguars of the as yanai's and other elders' stories suggest, a 'perfect storm' induced by mining was in the making. the millennial task of caring for land and of ensuring territorial health was in peril. a time-honored moral economy was being disrupted by time-limited, changing state policies and a parallel form of governance focused on gold extraction. in the next section, we offer a cursory glimpse into the modus operandi of what could be called 'dredge governance'. in the second week of june we arrive (together with a university colleague and a few students) in araracuara with the biweekly, twin-engine dornier that connects bogotá and this part of the amazon. an army battalion of around soldiers is stationed next to tarmac airfield, and a few of them are in charge of inspecting the passengers (and the pilot). we know they are putting up a show: none of the soldiers would ever venture out of the heavily-protected garrison ( layers of sandbags) and airfield in fear of being hostigados (fired upon, that is) by farc-ep guerrilla. we also know that a host of different governance schemes coalesce in this beautiful place to legally protect it: a couple of indigenous resguardos, two departments, two different environmental protection agencies, the country's largest forest reserve, a phoney indigenous mining zone, a municipality, a non-municipalized area… we also know that this is a place where, for a variety of reasons (a weak presence of the state, ominous guerrilla activity, powerful local and extra-local mining interests -to name the most important) the law of the strongest rules. we are entering what the cia and international foreign affair ministries call a 'red zone'. after a -minute walk down the granite plateau that serves as both airstrip and army garrison we take a little barge to cross the mighty caquetá river. on the opposite shore puerto santander welcomes us. here we will buy errands, coordinate our fortnightly stay at the aduche resguardo, and confirm the return ticket to bogotá. walking towards the shop where all three things can be done at once we notice a number of new businesses that weren't there on our last fieldtrip. in one of thema billiards room -some men we do not recognize are playing and drinking beers. upon seeing us, one of them instinctively pulls out a mobile from his pocket and dials while keeping his eyes on us. his reaction intimidates us: it clear that he is monitoring the situation and reporting who knows what to who knows whom. we continue to the shop. the caller can still see us, but his mobile is back in his jeans and he now appears to play calmly, only sporadically watching our movements. the shop owner (whom we know) greets us, and invites us to some drinks while remarking in passing that he already knew we were on today's flight and need to buy groceries and gasoline to go to aduche -our destination. apart from the phone call, our welcoming to puerto santander has in the official minimum wage in colombia was usd. . - . troy ounces. in a troy ounce of gold averaged . usd. the maloka is a large, traditional dwelling. it is used for both domestic and ritual purposes. a salado or saltlick is an important breeding and feeding place for some animals, especially for tapirs and other ungulates. for the andoke saltlicks are sacred places that may change location when over-used. pettiness or mezquindad is a term widely used by the andoke to refer to situations in which money is treated as an individual good and not distributed generously and collectively -as local moral values centred around reciprocity dictate. many amazonian ethnic groups consider themselves to be part of the 'people of the center': andoke, uitoto, muinane, miraña, bora, yukuna, nonuya, yuri, passé, and other (smaller) groups -some of whom dwell in the interior of the amazon and live in voluntary isolation (franco garcia, ; londoño sulkin, ; pineda, ; seifart and echeverri, ; van der hammen, ) . these groups share a common linguistic origin, hierarchical structures of clearly defined lineages, as well as political views on the administration and management of their territories. according to archaeological evidence, the 'people of the center' have lived in this area of the amazon for more than . years (morcote-ríos et al., ). central intelligence agency. nothing out of the ordinary. we know the shopkeeper is involved in mining activities, has access to information about who comes and goes (he is the sole airplane ticket agent in the region) and sees to it that this information is spread 'to whom it may concern'. later in the afternoon we meet don nelson from aduche who will take us to the resguardo with his jon boat. he greets us and tells us that (indeed!) "everyone in the place already knows you're here and that you're professors and students, so no-one has made a fuzz about us going down the river". on a later occasion don sandro -shopkeeper in araracuara, links to farc-ep, undisputed local mining kingpin -told the first author that all movements by 'outsiders' were quickly reported to him and others by locals, and that within half a day most people in the region already knew who was where, doing what, and with what intentions. this 'networky' form of coordination is crucial to take timely 'precautions' and 'management measures'. in fact, actors involved in illegal activities spend a large amount of time putting in place reliable information systems and using chat services, and are willing to invest large amounts of money to make this possible (e.g. through the financing of a large telecommunications antenna in to significantly improve cellphone signal in remote areas). as we try to make clear above illegal gold mining and its consequences are not the automatic outcome of the failure of state-led and indigenous governance forms. the failures do however open a window for a diversity of individuals and organizations to exercise their agency and opportunistically make use of the circumstances -often in complicity with influential social networks that include regional and national politicians as well as representatives of (armed) illegal groups. this does not mean that illegal activities in these liminal spaces are easy or straightforward. let us again turn to don sandro, for example. don sandro arrived in the early s from florencia, the capital of the department of caquetá, but has been linked to political, economic and social activities in the region for over years. since he previously ran for mayor in the municipality of solano (department of caquetá), he can count on the support of an important national political party known to have (or have had) links with illegal activities of all sorts -some members having been convicted for this. now consolidated as an influential entrepreneur, don sandro knows the ins and outs of all illegal extraction activities past and present, and likes to boast that he has actively participated in several of them -from hunting endangered species to drug trafficking. don sandro has a wide business portfolio: he owns grocery stores and adult entertainment centers in larger cities, and imports food and other goods into the region either with the regular, weekly cargo flights from bogotá or by dinghy from florencia to puerto solano and from there with carriers and mules to araracuara. in addition, don sandro owns several mining dredges operating along the caquetá river, and has the support of the local population (his workforce). one evening, while killing time in front of his porch, he casually mentioned some of the 'problems of the trade'. he kept repeating: "it is easy to wake up dead here" or "at any moment i could be killed". for example, revealing his anxiety vis-à-vis indigenous peoples (whom he needs yet despises), he commented: the next morning the first author witnessed an incident that illustrates the dangers involved in 'the business'. showing a text message on his cellphone, don sandro exclaims: "look at this! they [farc-ep] are extorting me! they are asking me a million-and-a-half for this order [vats of mercury] from brazil!". the text message leaves no doubt: the money needs to be paid that same day -or else. after a while, he confides: "i am very tired of all this, everyone wants to take my money… my plan is to leave this godforsaken land because i am sure that this business will be short-lived and will soon stop being good for me… this bonanza is not going to bring us anything good, and this abundance of gold is going to be the downfall for all of us." after his 'errand' don sandro discloses that, paradoxically, he clandestinely provides food, drink and other necessities to another front of the same organization that extorts him… conflict and lawlessness seemed to be commonplace in 'dredge governance', and permeated all nodes of the chain we were allowed to observe. in fact, a simplistic way to explain the inability of state-led and indigenous governance forms to contain illegal mining is the capacity of this parallel governance form to instill fear (and hence compliance). living in fear of being "killed at any moment", as don sandro put it, was a tribulation many had to put up with. thus smugglers bringing in mercury from brazil awaited in anxiety whether or not those levying 'taxes' on 'their' part of the river (farc-ep, criminal organizations) would honor prior agreements; workers on dredges were scared of being accused of stealing a gram or two (which they often did) or passing information to outsiders; carroñeros never knew how to stay away of harm's way; prostitutes were terrified of males in a drinking bout soliciting their services. one could literally smell fear and death in these territories -all enshrouded in a code of silence. in aduchewhere money was to be had with such ease -the stakes were high indeed. a veritable concert of laws, decrees, and policies had miserably failed to make this a safer place. this article describes how (illegal) gold dredge mining in the colombian amazon ensues from a failure of environmental governance. how is this possible, we ask? to answer the question it is useful to think of environmental governance not as a unitary process but rather as multiplicity (briassoulis, ) ; that is, as a multitude of rivalling governance forms aiming to steer collective action. as we have seen above in our region of study three different but not unrelated modes of existence (latour, ) co-exist next to one another. all three modes are built on very particular ontological assumptions which in turn give rise to very specific, issue-oriented forms of governance. a first strand of governance arises from a naturalist, multiculturalist ontology focused on conservation; it is (mainly) performed by the institutions of the colombian state. a second form is based on an ontology of care, oriented to what we call 'territorial health', and enacted by indigenous people exclusively. a third one is centered on an ontology in which money and quick rewards are seen as the highest goods; this form is pushed by non-local entrepreneurs, and acted out by indigenous people who have turned their backs on the local moral economy. as we detailed above the first two governance forms fail dearly; the third triumphs. state-led environmental governance fails, we argue, for four reasons. the first is that colombian territorial ordering (and the governance forms it allows) is built on contradicting paradigms ('development' versus 'conservation') that draw their justification from totally different, euroamerican discourses in which man and nature are opposed entities. thus state-led environmental governance limps on the while the military can in principle access all information channeled through the antenna, illegal actors made sure their messages were sufficiently codified to hinder easy detection. carroñeros or 'vultures' are small rafts on which 'independent' workers select mercury-laden sediments often still containing unamalgamated fractions of gold discarded by larger vessels. carroñeros are a source of conflicts as they fight between them to access these sediments. thought that the amazon is terra nullius and should hence be developed by/for agribusiness and the thought that the amazon is a pristine wilderness that should be conserved. understandably, this creates disorientation among indigenous people -a confusion that often translates into distrust and a perceived lack of state legitimacy. a second reason has to do with the geographical, bounded notion of territory entertained by the colombian state, and which is at odds with indigenous, shamanic concepts of it. third, failure has to do with the politico-juridical status of non-municipalized areas (where most resguardos are found), and which creates a legal vacuum in % of the colombian amazon. finally, an important reason is that the colombian state is unable to stop the high levels of violence that are characteristic of its rural areas, and that have in fact increased in the post-conflict era. this is (partially) due to a weak presence of the state in the vast expanses of the amazon. indigenous governance on its part falters for a number of reasons very much related to the causes of state-led governance failure. the first one concerns the legal vacuum created by the constitutionally non-existent figure of corregimientos (which shelter the majority of amazonian indigenous resguardos), and this directly hinders indigenous authorities in the implementation of their territorial visions -visions of territory that contrast sharply with those of the state and prevent them from taking autonomous decisions concerning the well-being of their people. a second but significant explanation we offer for the demise of indigenous governance has to do with the ever-present threat of violence that can be exercised by groups involved in illegal mining. while we did not hear of assassinations of indigenous people opposing mining during fieldwork, it is no secret that that this is a real possibility. formal institutions, including the military, are currently incapable of guaranteeing the safety of indigenous 'activists' defending their territories against organizations that have put in place parallel governance structures that perform state functions and compete with the colombian state -to the point of sometimes displacing it. a third explanation we offer has to do with indigenous peoples' desire to obtain commodities of mass consumption. since the advent of telecommunications, dvd's and the like a few years ago, indigenous people in our study area have been exposed to a rich culture of consumerismeven when the advertised commodities are not available at all and even if few would have the means to acquire them. the ever-renewed desire created by the media is bolstered by the ostentatious usage of (expensive) gadgets such as iphones, smartwatches or expensive clothing by mining entrepreneurs, and makes indigenous people go to great lengths to achieve what they wish -even if knowingly jeopardizing territorial health. "capitalism", as french sociologist pierre bourdieu used to say, "works by seduction". it certainly does so in the colombian amazon. as is evident a certain overlap of reasons exists. so perhaps using large-scale terms such as 'state-led environmental governance' or 'indigenous governance' is profoundly inadequate because of the danger of reification i.e. that explanations for failure must inevitably be found in each dichotomous half -which we clearly cannot. yet to not use these large-scale terms would be to misrepresent important differences and underlying struggles such as, for example, the social mobilization of indigenous communities in the s and s that resulted in the consolidation of powerful and influential local, regional, and national ethnic organizations, the acceptance of indigenous thought as a source of political thought and, ultimately the recognition of indigenous rights in the constitution (gros, ) . so when we use such 'reductionist', large-scale terms we do so, following Østmo and law ( : ) , because it is analytically and politically important "to index asymmetrical patterns of significant difference between particular state and local environmentally relevant practices". thus we find it important to write that indigenous governance indexes a world populated by powerful human and nonhuman beings in which it is a moral duty to achieve happiness and abundance for all by sustaining reciprocal and respectful relations with these beings (including the state). and we find it equally expedient to state that state-led environmental governance points to arrangements that distinguish between nature and culture, seeking to safeguard landscapes from human interference so that natural processes can unfold unhindered. having said this, though, we still want to argue that state-led environmental governance is highly variable -and changing. it is, following mol ( ) , 'more than one, less than many' in that different versions of the environment also overlap in governance practices. importantly, state-indigenous relations have been imbricated in a centuries-long predicament; they are, speaking with strathern ( ) , 'partially connected': one is included in the other -but neither is reducible to the other (law, ) . a comparable argument applies to the (large-scale) term 'indigenous': indigenous practices are highly variable, and there is no such thing as an essential, unchanging 'indigenous culture'. in our specific case, and despite their relative geographical isolation, andoke ways of living are diverse and have changed historically with the arrival of money during earlier resource bonanzas, the introduction of boat engines, and the (relative) integration into market economies. likewise, the relation between andoke and (mostly) white and mestizo settlers is one of longterm reciprocal (albeit asymmetrical) entanglement, most speak spanish as a consequence of colonial history, and some youth would have difficulty in recognizing the practices or vocabularies of shamans. how to deal with failure is, from our perspective, the central element of environmental governance. since failure can, in our case, to a great extent be attributed to a clash of ontologies it follows that the challenge of designing successful environmental governance amounts to the question of how to craft ontological encounters well. we here plea for an ontological turn (holbraad and pedersen, ) in environmental governance practice; that is, the need to overcome the dualist epistemologies that separate humans (culture) from nature and then seek to achieve a kind of integration of humans in (pristine) nature. this means taking seriously indigenous ways of relating to their environment in the framing of environmental problems and solutions. there is, we believe, a dire need to put in place processes of what we would like to coin pluriversal governance: a form of governance that does ontological justice to those involved in environmental conflictincluding, crucially, indigenous peoples and their concepts. indeed, concepts originating from different (invisible, made absent, silenced) worlds could positively affect locally situated, environmental conflicts if admitted as fully-fledged members of environmental governance languages. proposing pluriversal governance begs the question whether different worlds or ontologies are commensurable or not. at first sight, state-led and indigenous governance forms seem to be incommensurable. from the outside, it looks as if they would be bumping heads, and in its latest report, global witness ( ) mentions that in colombia had the highest number of killings ( ) of environmental activists in the world. half of these activists were indigenous people. to provide an example: on the of february , dissident forces of farc-ep occupied the visitor centers of all but one of the colombian amazon's national parks. dissidents took all boats, engines and communication infrastructure from the centers, and national parks personnel was given h to leave the area -or else (personal communication, cahuinarí np warden). the'turn to ontology' in the social sciences is hotly debated. while a deeper treatment of this critique is beyond the scope of this article, controversies range from methodological concerns of how to conceive and describe radically different others (vigh and sausdal, ) , to philosophical anxieties of how to deal with the relativism entailed in shifting from 'multiculturalism' to the idea that many 'worlds' co-exist next to one another (palecek and risjord, ) , to worries about the (negative) political implications of the 'ontological turn' (graeber, ) -especially as this extends euroamerican scientific colonialism (hunt, ; todd, ; sundberg, ) . we partially agree with these critiques. any attempt at translation would seem to immediately fail as ontological assumptions and knowledge practices are just too different to be brought together. but from the inside the picture is different: as we already hinted, indigenous and non-indigenous worlds have been imbricated for centuries, yet the conditions under which each world is composed are incommensurable; they are, in effect, partially connected. commensurable, yet different. this, we argue, opens the door to dialogue. so how would pluriversal governance work in our case? first, by opening up the question over what is to count as the 'object of governance', and insisting on environmentally relevant difference in the context of asymmetrical entanglements between indigenous peoples and the (supra-) national state (Østmo and law, ) . second, by insisting that indigenous people are entitled to take their spirits and other nonhuman paraphernalia with them to governance negotiationsand not asking them politely to leave them on hooks in the cloakroom before entering the negotiation room. this amounts, at all times, to listen to different point of view and reflexively deal with the political task of anticipating, as far as common sense allows, the implications of jointly made (and negotiated) governance arrangements. on other words, one needs, following haraway ( ) , to show some conceptual politesse here. we are aware that this is a daunting task. pluriversal governance is about the active shaping of a common world; as such, it is very much a 'learning-by-doing' process. the caveat here is that the common world should not be confused for the common ground: after all, as spinoza said long ago, it is difference that makes us think. pluriversal governance means finding ways to do difference together -to think together instead of assuming we all have something in common and reach closure prematurely. doing difference together means going deeper into the encounter, into the experience of difference. convivencia y poder político entre los andoques ( ra. ilust) collaborative governance in theory and practice democratizing global environmental governance? stakeholder democracy after the world summit on 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cosmological deixis and amerindian perspectivism historical ecology, human niche construction and landscape in pre-columbian amazonia: a case study of the geoglyph builders of acre the opinions contained in this document are the sole responsibility of the authors. we want to thank all those entities (human and nonhuman) who watch over the territorial health of the amazon. these entities are immersed in socio-environmental conflicts related to gold mining that affect them and their territories. supplementary data to this article can be found online at https:// doi.org/ . /j.geoforum. . . . key: cord- - q py j authors: guan, wei-jie; liang, wen-hua; zhao, yi; liang, heng-rui; chen, zi-sheng; li, yi-min; liu, xiao-qing; chen, ru-chong; tang, chun-li; wang, tao; ou, chun-quan; li, li; chen, ping-yan; sang, ling; wang, wei; li, jian-fu; li, cai-chen; ou, li-min; cheng, bo; xiong, shan; ni, zheng-yi; xiang, jie; hu, yu; liu, lei; shan, hong; lei, chun-liang; peng, yi-xiang; wei, li; liu, yong; hu, ya-hua; peng, peng; wang, jian-ming; liu, ji-yang; chen, zhong; li, gang; zheng, zhi-jian; qiu, shao-qin; luo, jie; ye, chang-jiang; zhu, shao-yong; cheng, lin-ling; ye, feng; li, shi-yue; zheng, jin-ping; zhang, nuo-fu; zhong, nan-shan; he, jian-xing title: comorbidity and its impact on patients with covid- in china: a nationwide analysis date: - - journal: eur respir j doi: . / . - sha: doc_id: cord_uid: q py j background: the coronavirus disease (covid- ) outbreak is evolving rapidly worldwide. objective: to evaluate the risk of serious adverse outcomes in patients with coronavirus disease (covid- ) by stratifying the comorbidity status. methods: we analysed the data from laboratory-confirmed hospitalised patients hospitals in province/autonomous regions/provincial municipalities across mainland china between december (th), and january (st), . we analyse the composite endpoints, which consisted of admission to intensive care unit, or invasive ventilation, or death. the risk of reaching to the composite endpoints was compared according to the presence and number of comorbidities. results: the mean age was . years. patients ( . %) were females. severe cases accounted for . % of the study population. ( . %) patients reached to the composite endpoints. ( . %) reported having at least one comorbidity. the most prevalent comorbidity was hypertension ( . %), followed by diabetes ( . %). ( . %) patients reported having two or more comorbidities. after adjusting for age and smoking status, copd [hazards ratio (hr) . , % confidence interval ( %ci) . – . ], diabetes (hr . , %ci . – . ), hypertension (hr . , %ci . – . ) and malignancy (hr . , %ci . – . ) were risk factors of reaching to the composite endpoints. the hr was . ( %ci . – . ) among patients with at least one comorbidity and . ( %ci . – . ) among patients with two or more comorbidities. conclusion: among laboratory-confirmed cases of covid- , patients with any comorbidity yielded poorer clinical outcomes than those without. a greater number of comorbidities also correlated with poorer clinical outcomes. since november , the rapid outbreak of coronavirus disease (covid- ) , which arose from severe acute respiratory syndrome coronavirus (sars-cov- ) infection, has recently become a public health emergency of international concern [ ] . covid- has contributed to an enormous adverse impact globally. hitherto, there have been , laboratory-confirmed cases and , deaths globally as of march th , [ ] . the clinical manifestations of covid- are, according to the latest reports [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , heterogeneous. on admission, - % of patients reported as having at least one comorbidity, with diabetes ( - %), hypertension ( - %) and other cardiovascular and cerebrovascular diseases ( - %) being most common [ , , ] . previous studies have demonstrated that the presence of any comorbidity has been associated with a . -fold increased risk of developing acute respiratory distress syndrome in patients with h n infection [ ] . similar with influenza [ ] [ ] [ ] [ ] [ ] , severe acute respiratory syndrome coronavirus (sars-cov) [ ] and middle east respiratory syndrome coronavirus (mers-cov) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , covid- more readily predisposed to respiratory failure and death in susceptible patients [ , ] . nonetheless, previous studies have been certain limitations in study design including the relatively small sample sizes and single center observations. studies that address these limitations is needed to explore for the factors underlying the adverse impact of our objective was to evaluate the risk of serious adverse outcomes in patients with covid- by stratification according to the number and type of comorbidities, thus unraveling the sub-populations with poorer prognosis. this was a retrospective case study that collected data from patients with covid- throughout china, under the coordination of the national health commission which mandated the reporting of clinical information from individual designated hospitals which admitted patients with covid- . after careful medical chart review, we compiled the clinical data of laboratory-confirmed hospitalized cases from hospitals (representing . % of the certified hospitals for admitting patients with between december th , and january st , . the diagnosis of covid- was made based on the world health organization interim guidance [ ] . because of the urgency of data extraction, complete random sampling could not be applied in our settings. all clinical profiles outside hubei province were centrally provided by the national health commission. three respiratory experts from guangzhou were dispatched to wuhan for raw data extraction from wuhan jinyintan hospital where most cases in wuhan were located. our cohort included patients from wuhan jinyintan hospital, and one each from hospitals. our cohort represented the overall situation as of jan st , taking into account the proportion of hospitals (~ one fourth) and patient number ( . %, , / , cases) as well as the broad coverage (covering all major provinces/cities/autonomous regions). confirmed cases denoted the patients whose high-throughput sequencing or real-time reverse-transcription polymerase chain reaction (rt-pcr) assay findings for nasal and pharyngeal swab specimens were positive [ ] . see online supplement for further details. the interval between the potential earliest date of transmission source (wildlife, suspected or confirmed cases) contacts and the potential earliest date of symptom onset (i.e., cough, fever, fatigue, myalgia) was adopted to calculate the incubation period. in light that the latest date was recorded in some patients who had continuous exposure to contamination sources, the incubation periods of less than . day would not be included in our analysis. the incubation periods were summarized based on the patients who had delineated the specific date of exposure. the clinical data (including recent exposure history, clinical symptoms and signs, comorbidities, and laboratory findings upon admission) were reviewed and extracted by experienced respiratory clinicians, who subsequently entered the data into a computerized database for further double-check of all cases. manifestations on chest x-ray or computed tomography (ct) was summarized by integrating the documentation or description in medical charts and, if available, a further review by our medical staff. major disagreement of the radiologic manifestations between the two reviewers was resolved by consultation with another independent reviewer. because the disease severity reportedly predicted poorer clinical outcomes of avian influenza [ ] , patients were classified as having severe or non-severe covid- based on the american thoracic society / infectious disease society of america guidelines [ ], taking into account its global acceptance for severity stratification of community-acquired pneumonia although no validation was conducted in patients with viral pneumonia. the predictive ability of the need for icu admission and mortality has been validated previously [ , ] . briefly, severe cases denoted at least one major criterion (septic shock requiring vasoactive medications, or respiratory failure requiring mechanical ventilation), or at least three minor criteria (respiratory rate being times per minute or greater, oxygen index being or lower, multiple lobe infiltration, delirium or loss of consciousness, blood urea nitrogen level being mg/dl or greater, blood leukocyte count being , per deciliter or lower, blood platelet count being , per deciliter or lower, body temperature being lower than degrees, hypotension necessitating vasoactive drugs for maintaining blood pressure). comorbidities were determined based on patient's self-report on admission. comorbidities were initially treated as a categorical variable (yes vs. no), and subsequently classified based on the number (single vs. multiple). furthermore, comorbidities were sorted according to the organ systems (i.e. respiratory, cardiovascular, endocrine). comorbidities that were classified into the same organ system (i.e. coronary heart disease, hypertension) would be merged into a single category. the primary endpoint of our study was a composite measure which consisted of the admission to intensive care unit (icu), or invasive ventilation, or death. this composite measure was adopted because all individual components were serious outcomes of h n infections [ ] . the secondary endpoint was the mortality rate. statistical analyses were conducted with spss software version . (chicago, il, usa). no formal sample size estimation was made because there has not been any published nationwide data on covid- . nonetheless, our sample size was deemed sufficient to power the statistical analysis given its representativeness of the national patient population. continuous variables were presented as means and standard deviations or medians and interquartile ranges (iqr) as appropriate, and the categorical variables were presented as counts and percentages. in light that no random sampling was conducted, all statistical analyses were descriptive and no p values would be presented for the statistical comparisons except for the cox proportional hazards regression model. cox proportional hazards regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. our findings indicated that the statistical assumption of proportional hazards analysis was not violated. moreover, cox regression model was considered more appropriate than logistic regression model because it has taken into account the potential impact of the various duration of follow-up from individual patients. the age and smoking status were adjusted for in the proportional hazards regression model because they have been recognized as the risk factors of comorbidities even in the general population. the smoking status was stratified as current smokers, ex-smokers and never smokers in the regression models. the national health commission has issued , patients with laboratory-confirmed covid- in china as of january st , . at this time point for data cut-off, our database has included , cases from hospitals in province/autonomous regions/provincial municipalities (see online supplement for details). of these , cases, the mean age was . years. patients ( . %) were females. ( . %) patients were managed inside hubei province, and , ( . %) patients had a contact history of wuhan city. the most common symptom was fever on or after hospitalization ( . %), followed by dry cough ( . %). fatigue ( . %) and productive cough ( . %) were less common. at least one abnormal chest ct manifestation (including ground-glass opacities, pulmonary infiltrates and interstitial disorders) was identified in more than % of patients. severe cases accounted for . % of the study population. ( . %) patients reached to the composite endpoints during the study ( table ) . overall, the median follow-up duration was days (interquartile range: , ) . of the , cases, ( . %) reported having at least one comorbidity. the prevalence of specific we have further identified ( . %) patients who reported having two or more comorbidities. two or more comorbidities were more commonly seen in severe cases than in non-severe cases ( . % vs. . %). patients with two or more comorbidities were older (mean: . vs. . years), were more likely to have shortness of breath ( . % vs. . %), nausea or vomiting ( . % vs. . %), unconsciousness ( . % vs. . %) and less abnormal chest x-ray ( . % vs. . %) compared with patients who had single comorbidity ( table ) . non-severe cases. furthermore, comorbidities were more common patients treated in hubei province as compared with those managed outside hubei province as well as patients with an exposure history of wuhan as compared with those without ( table ) . overall, patients ( . %) reached to the composite endpoints during the study. patients ( . %) died, patients ( . %) were admitted to the icu and patients ( . %) received invasive ventilation. the composite endpoint was documented in ( . %) of patients who had at least one comorbidity as opposed to ( . %) patients without comorbidities. this figure was cases ( . %) in patients who had two or more comorbidities. significantly more patients with hypertension ( . % vs. . %), cardiovascular diseases ( . % vs. . %), cerebrovascular diseases ( . % vs. . %), diabetes ( . % vs. . %), copd ( . % vs. . %), chronic kidney diseases ( . % vs. . %) and malignancy ( . % vs. . %) reached to the composite endpoints compared with those without ( table ) . patients with two or more comorbidities had significantly escalated risks of reaching to the composite endpoint compared with those who had a single comorbidity, and even more so as compared with those without (all p< . , figure ). after adjusting for age and smoking status, patients with copd (hr . , %ci . - . ), diabetes (hr . , %ci . - . ), hypertension (hr . , %ci . - . ) and malignancy (hr . , %ci . - . ) were more likely to reach to the composite endpoints than those without (figure ) . results of unadjusted analysis was presented in table e - . overall, findings of unadjusted and adjusted analysis were not materially altered. as compared with patients without comorbidity, the hr ( %ci) was . ( %ci . - . ) among patients with at least one comorbidity and . ( %ci . - . ) among patients with two or more comorbidities (figure ). subgroup analysis by stratifying patients according to their age (< years vs. ≥ years) did not reveal substantial difference in the strength of associations between the number of comorbidities and mortality of covid- (table e ). our study is the first nationwide investigation that systematically evaluates the impact of comorbidities on the clinical characteristics and prognosis in patients with covid- in china. circulatory and endocrine comorbidities were common among patients with covid- . patients with at least one comorbidity, or more even so, were associated with poor clinical outcomes. these findings have provided further objective evidence, with a large sample size and extensive coverage of the geographic regions across china, to take into account baseline comorbid diseases in the comprehensive risk assessment of prognosis among patients with covid- on hospital admission. overall, our findings have echoed the recently published studies in terms of the commonness of comorbidities in patients with covid- [ ] [ ] [ ] [ ] [ ] . despite considerable variations in the proportion in individual studies due to the limited sample size and the region where patients were managed, circulatory diseases (including hypertension and coronary heart diseases) remained the most common category of comorbidity [ ] [ ] [ ] [ ] [ ] . apart from circulatory diseases, endocrine diseases such as diabetes were also common in patients with covid- . notwithstanding the commonness of circulatory and endocrine comorbidities, patients with covid- rarely reported as having comorbid respiratory diseases (particularly copd). the reasons underlying this observation have been scant, but could have arisen from the lack of awareness and the lack of spirometric testing in community settings that collectively contributed to the under-diagnosis of respiratory diseases [ ] . it should be stressed that the observed frequency of comorbidity may also reflect the transmission dynamics within particular age groups, case detection or testing practices or hospital admission policies during the early phases of the epidemic. consistent with recent reports [ ] [ ] [ ] [ ] [ ] , the percentage of patients with comorbid renal disease and malignancy was relatively low. our findings have therefore added to the existing literature the spectrum of comorbidities in patients with covid- based on the larger sample sizes and representativeness of the whole patient population in china. a number of existing literature reports have documented the escalated risks of poorer clinical outcomes in patients with avian influenza [ ] [ ] [ ] [ ] [ ] , sars-cov [ ] and mers-cov infections [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the most common comorbidities associated with poorer prognosis included diabetes [ , ] , hypertension [ ], respiratory diseases [ , ] , cardiac diseases [ , ] , pregnancy [ ] , renal diseases [ ] and malignancy [ ] . our findings suggested that, similar with other severe acute respiratory outbreaks, comorbidities such as copd, diabetes, hypertension and malignancy predisposed to adverse clinical outcomes in patients with covid- . the strength of association between different comorbidities and the prognosis, however, was less consistent when compared with the literature reports [ , , , ] . for instance, the risk between cardiac diseases and poor clinical outcomes of influenza, sars-cov or mers-cov infections was inconclusive [ , , , ] . except for diabetes, no other comorbidities were identified to be the predictors of poor clinical outcomes in patients with mers-cov infections [ ] . few studies, however, have explored the it has been well accepted that some comorbidities frequently co-exist. for instance, diabetes [ ] and copd [ ] frequently co-exist with hypertension or coronary heart diseases. therefore, patients with co-existing comorbidities are more likely to have poorer baseline well-being. importantly, we have verified the significantly escalated risk of poor prognosis in patients with two or more comorbidities as compared with those who had no or only a single comorbidity. our findings implied that both the category and number of comorbidities should be taken into account when predicting the prognosis in patients with covid- . our findings suggested that patients with comorbidities had greater disease severity compared with those without. furthermore, a greater number of comorbidities correlated with greater disease severity of covid- . the proper triage of patients should be implemented by carefully inquiring the medical history because this will help identify patients who would be more likely to develop serious adverse outcomes of covid- . moreover, better protection should be given to the patients with coivd- who had comorbidities upon confirmation of the diagnosis. a main limitation was the self-report of comorbidities on admission. under-reporting of comorbidities, which could have stemmed from the lack of awareness and/or the lack of diagnostic testing, might contribute to the underestimation of the true strength of association with the clinical prognosis. under-reporting of comorbidities could also lead to over-estimation of strength of association with adverse outcome. however, significant under-reporting was unlikely because the spectrum of our report was largely consistent with existing literature [ ] [ ] [ ] [ ] [ ] and all patients were subject to a thorough history taking after hospital admission. the relatively low age might help explain the low prevalence of copd in our cohort. moreover, the duration of follow-up was relatively short and some patients remained in the hospital as of the time of writing. more studies that explore the associations in a sufficiently long time frame are warranted. caution should be exercised when extrapolating our findings to other countries where there are outbreaks of covid- since the prevalence of comorbidities may differ among different countries. therefore, future studies that include an external validation of the results would be desirable. although the temperature and systolic blood pressure differed between some subgroups, they were unlikely to be clinically relevant. finally, because of the rapid evolving outbreak globally, ongoing studies with the inclusion of more patients would be needed to increase the statistical power and lend support to subgroup analyses stratified by the specific comorbidities (i.e. copd) and their association with the risk of death. data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit. data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit data are mean ± standard deviation, n/n (%), where n is the total number of patients with available data. copd=chronic obstructive pulmonary disease. icu = intensive care unit cox proportional hazard regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. shown in the figure are the hazards ratio (hr) and the % confidence interval ( %ci) for the risk factors associated with the composite endpoints (admission to intensive care unit, invasive ventilation, or death). the comorbidities were classified according to the organ systems as well as the number. the scale bar indicates the hr. cox proportional hazard regression models were applied to determine the potential risk factors associated with the composite endpoints, with the hazards ratio (hr) and % confidence interval ( %ci) being reported. the model has been adjusted with age and smoking status a b comorbidity and its impact on , patients with covid- in china: a nationwide analysis world health organization. novel coronavirus ( -ncov) situation reports clinical features of patients with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical findings in a group of patients infected with the novel coronavirus (sars-cov- ) outside of wuhan, china: retrospective case studies a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster high-resolution ct features of cases of corona virus disease in sichuan province, china the clinical dynamics of cases of covid- outside of wuhan, china epidemiological characteristics of -ncov infections in shaanxi clinical characteristics of coronavirus disease in china clinical findings in cases of influenza a (h n ) virus infection association of age and comorbidity on influenza a pandemic h n -related intensive care unit stay in massachusetts the burden of influenza complications in different high-risk groups differences in the epidemiological characteristics and clinical outcomes of pandemic (h n ) influenza, compared with seasonal influenza risk factors associated with severe outcomes in adult hospitalized patients according to influenza type and subtype effect of vaccination, comorbidities and age on mortality and severe disease associated with influenza during the season - in a spanish tertiary hospital clinical features and short-term outcomes of patients with sars in the greater toronto area prevalence of comorbidities in cases of middle east respiratory syndrome coronavirus: a retrospective study prevalence of comorbidities in the middle east respiratory syndrome coronavirus (mers-cov) risk factors for fatal middle east respiratory syndrome coronavirus infections in saudi arabia: analysis of the who line list diabetes mellitus, hypertension, and death among patients with mers-cov infection, saudi arabia impact of comorbidity on fatality rate of patients with middle east respiratory syndrome a comparative study of clinical presentation and risk factors for adverse outcome in patients hospitalised with acute respiratory disease due to mers coronavirus or other causes chongqing yunyang county people's hospital, ankang central hospital, chenzhou second people's hospital, datong fourth people's hospital, dengzhou people's hospital, fengjie people's hospital, foshan first people's hospital, fuyang second people's hospital, gongyi people's hospital, guangshan people's hospital, guoyao dongfeng general hospital, hainan people's hospital, the second affiliated hospital of hainan medical college, the first people's hospital of xiaoshan district, hangzhou, huaihua first people's hospital, jiashan first people's hospital, lu'an people's hospital, affiliated hospital of qingdao university, qingyuan people's hospital, quanzhou county people's hospital, rizhao people's hospital, shaodong people's hospital, shiyan xiyuan hospital, tongling people's hospital, wenzhou people's hospital, wenzhou central hospital, the second affiliated hospital of wenzhou medical university, wuxi fifth people's hospital zhijiang people's hospital, people's hospital of dianjiang county, chongqing, chongqing jiulongpo first people's hospital, chongqing shizhu tujia autonomous county people's hospital, the first people's hospital of wanzhou district, chongqing, yongchuan hospital affiliated to chongqing medical university, anguo hospital, the third hospital of peking university, peking university shenzhen hospital , boluo people's hospital, changde lixian people's hospital, changde second people's hospital, chenzhou central hospital, chengjiang people's hospital, dalian central hospital, danzhou people's hospital, dengzhou central hospital hangzhou first people's hospital, hangzhou lin'an district people's hospital, nanpi county hospital of traditional chinese medicine of hebei province, henan people's hospital, hefeng county central hospital, hohhot first hospital, huludao central hospital, the first affiliated hospital of hunan medical college, shenzhen union hospital of huazhong university of science and technology, huaibei people's hospital, huangshi second hospital, huangchuan people's hospital jiangyou infectious diseases hospital, jieyang people's hospital, jinhua central hospital, jinzhong pingyao people's hospital, jingjiang people's hospital, the second affiliated hospital of kunming medical university, laifeng county central hospital, yueqing people's hospital, lijiang people's hospital, lixin people's hospital, the fourth people's hospital of lianyungang, linqu county people's hospital xuanwu hospital of capital medical university, sichuan mianyang hospital, sixian hospital of traditional chinese medicine, suihua first hospital, suiping county people's hospital, tianjin fourth central hospital, tianjin haihe hospital, tiantai county people's hospital, tongchuan mining bureau central hospital, tongren people's hospital, weihai central hospital, the first affiliated hospital of wenzhou medical university, wuzhou third people's hospital, armed police hubei provincial general team hospital, xixian people's hospital, longshan county people's the first affiliated hospital of xinjiang medical university, xinmi hospital of traditional chinese medicine, xinxiang county people's hospital, xinye people's changsha eighth hospital, changsha first people's hospital, st hospital of the joint service support force of the chinese people's liberation army, central theater general hospital of the chinese people's liberation army, the first affiliated hospital of china medical university, the third affiliated hospital of zhongshan university, zhongshan second people's hospital, chongqing chengkou people's hospital, chongqing hechuan district people's hospital, chongqing red cross hospital, zhoushan women's and children's hospital, zhoukou infectious diseases hospital, zhuzhou first people's hospital, zhumadian central hospital, anlong people's hospital, anxi county hospital, anyang fifth people's hospital, anyang people's hospital, anyuan people's hospital, badong county ethnic hospital, wuyuan county people's hospital of bayannur city, baise people's hospital, the first affiliated hospital of bengbu medical college, baoding first central hospital, changping district hospital of beijing municipality, changping district hospital of traditional chinese and western medicine of beijing chizhou people's hospital, chongxin county people's hospital, chongyi people's hospital, affiliated hospital of north sichuan medical college, dazhou central hospital, dali first people's hospital, the second affiliated hospital of dalian medical university, the first affiliated hospital of dalian medical university, danyang people's hospital, daocheng people's hospital, deqing people's hospital, dezhou second people's hospital, dezhou people's hospital, dezhou qingyun people's hospital fuzhou fifth people's hospital, fuzhou dongxiang district people's hospital, fuyang district first people's hospital, ganzhou longnan county people's hospital, gaolan county people's hospital, gongcheng yao autonomous county people's hospital, gushi people's hospital, guang'an people's hospital, guangdong hospital of traditional chinese medicine, guangzhou eighth people's hospital, guangzhou th people's hospital, shenzhen hospital of guangzhou university of traditional chinese medicine, people's hospital of guiding county, hanjiang hospital of sinopharm, harbin acheng district people's hospital, nangang district people's hospital of harbin, the first affiliated hospital of harbin medical university, haikou people's hospital, hainan west central hospital, handan sixth hospital, handan central hospital, hanshan people's hospital, hangzhou dingqiao hospital, the third people's hospital of yuhang district, hangzhou, the first people's hospital of yuhang district, hangzhou, minzhou people's hospital, hefei sixth people's hospital (hefei infectious diseases hospital), he xian memorial hospital, hebei chest hospital, hechi people's hospital, hejin people's hospital, the first affiliated hospital of henan university of science and technology, zhangye people's hospital affiliated to hexi university, heyuan people's hospital, heze municipal hospital, heilongjiang provincial hospital , south yunnan central hospital of honghe prefecture, hulunbuir manzhouli hospital, hunan youxian people's hospital, the first affiliated hospital of hunan university of traditional chinese medicine, china resources wisco general hospital, huaihua chenxi county people's hospital, huai'an fourth people's hospital, huainan mashan infectious disease hospital, huangshan people's hospital, huangshi fifth hospital, huichang people's hospital, huining county people's hospital, huizhou first people's hospital, jixi people's hospital, qianan county people's hospital of jilin province, jinan fourth people's hospital, jining second people's hospital, affiliated hospital of jining medical college laixi people's hospital, the second hospital of lanzhou university, lancang second people's hospital, leping people's hospital, leshan people's hospital, lengshuijiang people's lianjiang county hospital, the first people's hospital of lianyungang, liaoning chaoyang disease control center hospital, liaocheng people's hospital, linshui people's hospital key: cord- - irru authors: pazos, f. a.; felicioni, f. title: a control approach to the covid- disease using a seihrd dynamical model date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: irru the recent worldwide epidemic of covid- disease, for which there is no vaccine or medications to prevent or cure it, led to the adoption of public health measures by governments and populations in most of the affected countries to avoid the contagion and its spread. these measures are known as nonpharmaceutical interventions (npis) and their implementation clearly produces social unrest as well as greatly affects the economy. frequently, npis are implemented with an intensity quantified in an ad hoc manner. control theory offers a worthwhile tool for determining the optimal intensity of the npis in order to avoid the collapse of the healthcare system while keeping them as low as possible, yielding in a policymakers concrete guidance. we propose here the use of a simple proportional controller that is robust to large parametric uncertainties in the model used. the novel sars-cov- coronavirus, which produces the disease known as covid- , was first reported on december in wuhan, province of hubei, china. with amazing speed it spread to the majority of the countries in the world. the outbreak has been declared as a public health emergency of international concern by the world health organization (who) on jan. , and as a pandemic on march . at the moment, there is no vaccine against this virus or effective medicines to cure the disease. health systems only try to mitigate its consequences to avoid complications and fatal outcomes. this disease showed a great capacity of contagion and high fatality rates (see updated reports in [wm ] ). patients affected by this disease experience a number of symptoms, not all clearly identified at the moment, but which are mainly cough, breathing difficulties, fever, loss of taste and smell and extreme tiredness. frequently, patients develop a form of viral pneumonia that requires hospitalization and artificial mechanical ventilation in intensive care units. the large number of patients affected by this disease threatens to collapse public health systems, increasing the fatality rates by lack of available health assistance. in this context, is very important to predict the trend of the epidemic in order to plan effective strategies to avoid its spread and to determine its impact. as the contagion is produced very easily by simple contact between people, several measures were adopted by the governments, public health systems and populations in order to reduce the transmission by reducing contact rates. examples of these measures, the so called nonpharmaceutical interventions (npis) adopted during this period include the closing of schools, churches, bars, factories, quarantine or physical-distancing policies, confinement of people in their homes, lockdown, among other social impositions that produce discomfort and clearly harm the economy. this goal sparked many articles and studies recently published on the epidemic behavior. a number of them are addressed towards determining a mathematical model that represents the dynamics of different agents involved in a population affected by the disease. the dynamic described by the model aims to make possible to answer crucial issues, such as the maximum number of individuals that will be affected by the disease and when that maximum will occur, and makes key predictions concerning the outbreak and eventual recovery from the epidemic. this information allows to devise public policies and strategies to mitigate the social impact and reduce the fatality rate. the seminal work [flng + ] exemplifies and analyses different strategies to control the transmission of the virus. most of the models adopted to represent the dynamical behavior of the covid- are based on the sir model (see [abd ] and references therein). the sir model is a basic representation widely used which describes key epidemiological phenomena. it assumes that the epidemic affects a constant population of n individuals. the model neglects demography, i.e. births and deaths by other causes unrelated to the disease . the population is broken into three non-overlapping groups corresponding to stages of the disease: • susceptible (s). the population susceptible to acquire the disease. • infected (i). the population that has acquired the virus and can infect others. • recovered (r). the population that has recovered from infection and presumed to be no longer susceptible to the disease . a brief description of these compartments is given below. susceptible people are those who have no immunity and they are not infected. an individual in group s can move to group i by infection produced through contact with an infected individual. group i are people who can spread the disease to susceptible people. finally, an infected individual recovered from the disease is moved from the group i to the group r. some references (see, for example [lzg + , ssb ]) considers the group r as removed population, or closed cases, which includes those who are no longer infectious from recovery and the ones who died from the disease. the summation of these three compartments in the sir model remains constant and equals the initial number of population n . in order to describe better the spread of epidemics, many works (see, for example [kan , gv , shd , nes ]) adopted the seir model. in the seir model a fourth group denoted as exposed (e) is added between the group s and the group i: • exposed (e). the population that has been infected with the virus, but not yet in an infective stage capable of transmitting the virus to others. this compartment is dedicated to those people who are infectious but they do not infect others for a period of time namely incubation or latent period. other works (see [abd ] for example) consider an additional compartment at the end of the sir or of the seir model to distinguish between recovered and death cases: • dead (d). the population dead due to the disease. in argentina, the daily death rate is . − . at the moment, in the covid- disease is an open question if a recovered person can get re-infected. even though some cases were recently reported, the reinfection rate value appears to be statistically negligible based on early evidence. thus, these models become the sird or the seird models, respectively. other works as [tbt + ,lzg + ,ssb ] consider the existence of other groups seeking to match the models proposed with the numbers obtained from the actual covid- disease. the work presented in [gbb + ] deserves to be mentioned. this work studies the evolution of the covid- in italy, and proposes a model denoted as sidarthe, where the letters correspond to eight groups denoted as susceptible, infected, diagnosed, ailing, recognized, threatened, healed and extinct respectively. all of them are subgroups of those presented in the seir model. this model discriminates between detected and undetected cases of infection, either asymptomatic or symptomatic, and also between different severity of illness, having a group for moderate or mild cases and another one for critical cases that require hospitalization in intensity care units. the authors affirm that the distinction between diagnosed and nondiagnosed is important because nondiagnosed individuals are more likely to spread the infection than diagnosed ones, since the later are typically isolated, and can explain misperceptions of the case fatality rate and the seriousness of the epidemic phenomena. the fact of considering more groups in the sidarthe model than in the seir model allows better discrimination between the different agents involved in the epidemic evolution, as well as a better differentiation of the role played by each one. however, the fact of considering more groups implies the knowledge of more rates, probabilities and constants that determine the dynamics between the groups. many of these values are difficult to know in practice, as well as to estimate the population of some groups, such as ailing (symptomatic infected undetected). the authors choose these constants and quantities to match the model to the actual data. of course, in order to achieve the goal of better determining public policies, we believe that the existence of some of these groups in the model used is not necessary. in order to better guide the determination of public policies to mitigate the spread of the virus we propose the use of the control theory. control theory has been successfully implemented in several areas other than physical systems control, for which it was initially designed. for example in economics, ecological and biological systems, many works demonstrate the success of its implementation. of course, regardless of the area focused, a good control strategy depends on the adequate modeling of the dynamical system to be controlled. the proposal to use control in this epidemic is not new. it has been first presented in [shd ] . in this work, the authors use the seir model to show that a simple feedback law can manage the response to the pandemic for all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . maximum survival while containing the damage to the economy. however, the authors illustrate with several examples the benefits of using feedback control, but they do not present the mathematical control laws as well as they do not prove the convergence of the trajectories in the closed loop system. examples are implemented by mean of several computational experiments which illustrate the different strategies proposed. we propose here the use of a simple proportional controller, a standard tool in control theory, to calculate the control action. this variable guides how to determine npis in order to avoid the collapse of the health system while reducing the damage to the society and the economy that npis inevitably produce. this section is addressed to model adequately the disease. a suitable model should avoid making unnecessary classifications in order to obtain key data on the behavior of the epidemic. these data include number of deaths, maximum number of infected people, time at which the maximum infection rate will occur, among other information useful to prevent and reduce the damage produced by the outbreak. the seir model assumes that exposed people have been infected but are not able to transmit the virus before a latency period. we will consider that those people continue to be in the susceptible group s, whereas we consider the group e as people who have been infected but have no symptoms yet and are capable of transmitting the virus. of course, part of this group will present symptoms after an incubation time (moving to the group i) and another part will remain asymptomatic. asymptomatic people who have been diagnosed as positive also will be considered in the group i, so this group includes all known positive cases, symptomatic or not. in addition, a critical issue is the number of infected people who need hospitalization, because the public policies must try to keep this number lower than the capacity of the health care system in order to avoid its collapse. thus we define an extra group: • hospitalized (h). the infected population who need hospitalization. in the group h we do not differentiate between people hospitalized in mild condition and those in intensive care units (icus), despite the fact that the number of people in the last subgroup is a critical problem due to an even more limited capacity in icus. figure : rate processes that describes the progress between the groups in the seihrd model. we also consider the population number n as a constant, as the seir model does. the progression of this epidemic can be modeled by the rate processes described in fig. . the proposed seihrd model for the spread of the covid- disease in an uniform population is given by the following deterministic equations, which are presented normalized with respect to the total population n . the groups s, e, i, r, h and d are the state variables of the dynamical system ( ). they are always nonnegative. the time derivativesṘ andḊ are also nonnegative, because recovered people and death cannot decrease, whereasṠ is always nonpositive, because we consider that recovered people cannot be reinfected. this fact is represented in fig. because the states r and d only have input arrows and the state s only has an output arrow. the model ( ) is a nonlinear system normalized with respect the population n , considered as a constant. hence s + e + i + h + r + d = and all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . the rate processes are modeled as follows. • αse and βsi are the transmission rates of the virus between the susceptible and the exposed population (respectively, infected population). α and β are the probability of disease transmission in a single contact with exposed (infected) people times the average daily number of contacts per person and have units of /day. typically, α is grater than β, assuming that people tend to avoid contact with subjects showing symptoms or diagnosed as positive. contacts between susceptible people and hospitalized people are neglected, excepting for healthcare workers. the probability of contagion from dead people is also neglected, despite the fact that some cases were recently reported. of course, recovered people are no longer able to transmit the virus. • u ∈ [ , ] is the effectiveness of nonpharmaceutical public health interventions (npis). u = means no intervention and the epidemic grows completely free, whereas u = implies total elimination of the disease spread. • ν is the vaccination rate, at which susceptible people became unable to be infected. unfortunately, in the covid- case ν = yet. • p is the probability that exposed people develop symptoms, γ − is the average period to develop symptoms, and ζ − is the average time to overcome the disease staying asymptomatic. • p is the probability that infected people with symptoms require hospitalization, δ − is the average time between infection and the need for hospitalization, and η − is the average time in that infected people recover without hospitalization. • p is the probability of hospitalized people die, − is the average time between the hospitalization and the death, and µ − is the average time to recover after hospitalization. the parameters used in ( ) are not very precisely determined and even differ greatly in the literature consulted (see [flng + , lgwsr , kan , lzg + , gbb + , jon , org] among many other references). most of the model adopted in the references adjust these parameters to match real data from different countries. it must be taken into account that some of these all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . parameters, mainly α and β, are not independent either from the populations and their general health status or their actions. the parameters α and β are related with the basic reproduction number r , defined as the expected number of secondary cases produced by a single (typical) infection in a completely susceptible population [jon ] . r is not a fixed number, depending as it does on such factors as the density of a community, the general health of its populace, or its medical infrastructure [shd ] . this is the most important parameter to understand the spread of an epidemic. if r > , the epidemic growths and the number of infected people increases. if r < , the epidemic decreases and after a certain time disappears, when a large enough number of people acquire antibodies and the so-called herd immunity occurs. in the actual covid- disease, r was determined to be . in wuhan, china [shd ] (between . and . according to [slx + ]), ranging from . to . in italy [shd ] and even close to . [lgwsr ] . an important remark is that many works consider r depending on the npis, admitting that these actions tend to reduce this number because the contact rates between people decrease. note that npis always occur even in countries where no government action has been taken, because people spontaneously tend to stay at home and to avoid contact with others. this fact explains the disparity of this number in different countries and reported in the references (see [lgwsr ] ). here, we consider r as a constant reproduction number in the absence of any external action, i.e., as if the disease could spread completely free, which, of course, is an unrealistic scenario. specifically, the relation between the rates α and β and r , can be calculated in model ( ) as in [jon ,gbb + ], resulting in section we propose a pair of values for parameters α and β to evaluate different epidemic scenarios. the effectiveness of the npis is considered in the variable u, which determines the rate at which susceptible people become exposed. several works [lzg + ,tbt + ,gv ,ssb ] consider these parameters as time dependent, because incorporate in these parameters the impact of governmental actions among other npis. the incubation period is estimated as γ − = . days [kan , flng + , twl + ]. the probability of developing symptoms p will be roughly estimated as all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . the period to overcome the disease without presenting symptoms is ζ − = . days (deduced from [gbb + ]). the infectious period with no need of hospitalization is widely accepted as days, so η = / . the probability to need hospitalization after the infection is p = % [low ,lzg + ,ssb ], and the time from symptom onset to hospitalization is δ − = . days [slx + ]. the probability to die after hospitalization is p = % according to [wm , flng + ] , and the average time to die is − = . days [slx + ]. the average time to recovery after hospitalization is µ − = days [flng + ]. finally, as it was noted above, there is no vaccine against this disease, so ν = . remark . of course, most of these parameters are subject to large inaccuracies, and they differ greatly in the literature consulted. however, as we will show below, the proposed control method is robust for such uncertainties as well as for measurements errors characterized as unreported or undiagnosed cases and inaccuracies in the group quantities. we propose the use of control theory to determine public nonpharmaceuticals interventions (npis) in order to control the evolution of the epidemic, avoiding the collapse of health care systems while minimizing harmful effects on the population and on the economy. as noted in [shd ] , "a properly designed feedback-based policy that takes into account both dynamics and uncertainty can deliver a stable result while keeping the hospitalization rate within a desired approximate range. furthermore, keeping the rate within such a range for a prolonged period allows a society to slowly and safely increase the percentage of people who have some sort of antibodies to the disease because they have either suffered it or they have been vaccinated, preferably the latter". the action law is given by the control variable u in ( ). no intervention from the public health agencies means u = , and the disease evolves naturally without control. at the other hand u = means the total impossibility of transmitting the virus, which, of course, is an unrealistic scenario. there are several possible choices of the reference signal or set point of the control system. one of them may be a small enough number of hospitalized people to not affect the capacity of the intensive care units (icus) available in the health care system. this reference signal maybe nonconstant, it can can go up because of an increase in available beds due to capacity additions in the health care system, by creation of provisory field hospitals, among other similar measures. by other hand, we must bear in mind that the quantities of each group described in ( ) are subject to large inaccuracies, due to unreported or undiagnosed cases, except for the number of people diagnosed as positive (i), which is quite well known, the number of hospitalized people (h) and, of course, the number of deaths (d). for that reason the output variable to be fed back only can be the infected population i or the hospitalized population h. hence, the goal of the control action is to keep the number of hospitalized people lower than the set point minimizing the external intervention which produces social discomfort and clearly harm the economy. therefore, the control action should aim to solve the following constrained optimization problem: where t is a considered period and sp is the reference signal (or set point, in the case it is considered as a constant). as a reference, the world health organization recommends a number of hospital beds per population, which means an index of . , or . %. this number will be used as the sp of the closed loop control system. however, we must bear in mind that npis impact on physical contacts between susceptible and infected or exposed people. if an individual is already infected, hospitalization will be required after at most δ − = . days or after δ − + γ − = . days on average if the infection was recent. hence, there exists a delay between the adoption of npis and their consequences on hospitalization of people. if the control action if calculated based only on the number of hospitalized people, the following . days too many people may require hospitalization, exceeding the capacity for medical care. in control jargoon, it means that there are almost two weeks with the system operating in an open loop. therefore, the control action needs to be calculated as a function of the number of infected people i (the number of exposed people e is quite unknown) in order to avoid future hospitalization requirements in the next . days at most. this strategy is known as predictive control. fig. shows the closed loop control system. the variable process is the infected population i and the control signal is the effectiveness of the npi all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. of course, in practical situations it is necessary to determine which actions and at what level correspond to a certain effectiveness of npis, but this issue is outside the scope of this paper. next, we show the results of different strategies of npis applied on the seihrd model. in this first series of experiments, we apply a constant control action u, that is, the system shown in fig. is an open loop control one. we consider as initial conditions i = e = . , h = r = d = , so s = . , that is, . % of the population is diagnosed as positive the first day and . % of the population is asymptomatic infected. during the first days of the epidemic, it was logical to consider that both exposed and infected people could spread the virus at the same ratio because the contagion between humans was not known. then, this disease could spread in a completely free scenario, in which no action is taken. this scenario has been called "naif " by several authors [ssb , lzg + ]. using the expression ( ) with r = . as in [ssb ,lzg + ], and assuming that no actions are taken during the epidemic, then α=β= . . the evolution of exposed, infected, hospitalized and dead people in this case is shown in the fig. . in this "naif " scenario, and using as initial condition infected and exposed person for different population values (n > , ) , the maximum are always . % for the exposed and . % for the infected, and the times when these maximums are reached depend on the population value n as is shown in the fig. . the delay between both maximums is a constant value all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : population of exposed, infected, hospitalized and deaths group with no npi. naif scenario of days. additionally, the number of dead people forecasted by this model is about . % of the total population. clearly, this "naif " scenario seemed to be unrealistic since people tend to avoid contact with subjects showing symptoms or diagnosed as positive due to the severity of the covid- disease. in consequence, as we stated before, in a more realistic scenario α is greater than β. in the rest of this paper we consider β = α/ to take into account this assumption. fig. shows the areas of every group along the time in the case with no npi actions for illustrative purposes (with β = α/ ). fig. shows the evolution of the hospitalized with different constant npis effectiveness u and the proposed sp. table reports some results extracted from these simulations. the results presented in table show that, if no mitigation policy is all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . (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 preprint this version posted may , . h (u= ) h (u= . *(t- )) h (u= . ) sp= . figure : population of hospitalized group with no npi (blue), with a npi of % effectiveness (yellow), with an intervention of % effectiveness applied weeks after the appearance of the first case (light blue) and sp (red). β = α/ adopted (u = ) approximately % of the population will be infected and . % will die. on the other hand, a relatively little aggressive npi, only % of effectiveness, is efficient in reducing the final number of deaths as well as the maximum number of hospitalized people, which is a crucial issue in order not to collapse the health system (the maximum value of h reaches the sp ). moreover, a late application of this strategy, after weeks since the first case arose, also significantly reduces these numbers. in this section, we simulate the behavior of the trajectories described by the normalized system ( ) subject to a proportional control action. the objective of the control action is that the number of hospitalized people does not exceed the number of available beds. of course, this number is highly variable in different countries, and can be increased during the duration of the epidemic with the construction of field hospitals, among other resources. on the other hand, as noted in sec. , to adopt as feedback variable the number of hospitalized people may lead to an overload of the health system in the following . days, for which a predictive control must be used that consider the number of infected people i. not all infected people need hospitalization. most of the symptomatic cases are mild and remain mild in severity [low , slx + ] ( − p = %). so we consider that p = % of infected people will need hospitalization in the following δ − = . days. this number plus the number of people already hospitalized h must remain below the set point. of course, we neglect the number of beds occupied by patients hospitalized for other diseases. hence, the proportional control variable is chosen as where k p is the proportional scalar gain with values between [ , ]. note that if i = , u = , and there is no need of a public intervention because no one is going to require hospitalization on the following . days, and with k p = , if a percentage of % of the infected people is equal to the number of available beds sp − h, u = which means that the public intervention must completely avoid the transmission of the virus because all these people will require hospitalization after δ − = . days on average. another point of view is to consider that this is a tracking trajectory problem, with a time dependent reference signal equal to r(t) = sp − h(t). we consider the same initial condition than in the former series of experiments, i = e = . , i.e. . % of the population infected and presenting symptoms at the first day and we suppose that . % of the population is infected and asymptomatic. fig. shows the trajectories of the variables vs. time with a gain k p = . note that the number of people hospitalized is always smaller than the set point. fig. shows the control signal vs. time. the control signal presents a maximum value of . , and the area under the curve of the control signal vs. time is . . of course, the smaller this action, the less the damage to the population and to the economy. the constant control signal equal to . presents an area under the curve equal to and equal to . when it is applied after weeks (see table ). we must bear in mind that npis are determined by governmental or popular decisions, and hardly can change every day as the control signal calculated by the proportional controller does. thus, we consider the application of npis with effectiveness shown in fig. . the amplitudes and times of this control signal were obtained from that shown in fig. . the detail of the trajectories of the states presented in fig. shows that there are no significant changes in the results presented. the maximum number of hospitalized people is . , the final number of deaths is . , and the area under the curve u vs. time is . . all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . table shows the main results of the application of npis calculated using a proportional controller with different values of the scalar gain k p . in this section we consider the more realistic situation in which the parameters are partially unknown. as mentioned in sec. there are large uncertainties in the parameters, they diverge a lot according to the researched references and they are very different according to the country studied. in this series of experiments, the parameter α is randomly chosen is also randomly chosen between . and . . the parameter β between . and . . the incubation time γ − between and days.the probability to present symptoms p between % and %. the time of recovering between and days, for both symptomatic or asymptomatic people. the probability to be hospitalized p is considered as a gaussian distribution function of mean . and standard deviation of . . the time to be hospitalized δ − is chosen between and days. the probability to die p between % and %. the time to die − between and days. finally, the time of recovering from hospitalization µ − is randomly chosen between and days. in addition, we also consider that there exists some noncompliance of the nonpharmaceutical interventions. hence, we apply to the system ( ) a control signal with gaussian distribution of mean % of that calculated in ( ) with standard deviation of %, that is, we assume that there is % on average of noncompliance with the public measures adopted. the initial conditions are also i = e = . and the gain is k p = . fig. shows the trajectories of the states of the model ( ) during days since the first symptomatic case arose. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : evolution of every group over time with a proportional control action with gain k p = (left) and considering % of noncompliance of the npis policies on average. the picture at the right is a zoom of that at the left. set point equal to . . table reports some results extracted from this series of simulations. the similarity of the results reported in tables and , as well as the trajectories shown in figs. and , show that the proportional controller is robust to parameter uncertainties and to some noncomplaince of the npis, which, of course, always occurs in practice. the proportional controller proposed to guide the adoption of npis shown its efficiency to keep the number of hospitalized people below a set point given by the health system capacity. moreover, this very simple strategy is robust to parameters uncertainties and to some level of noncompliance of the all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . figure : control signal over time using a proportional controller and considering % of noncompliance of the npis policies on average. the blue curve is that calculated in ( ), the red curve is the control signal considering the randomic noncompliance. public measures. the control signal calculated by this method aims to guide the adoption of npis in order of minimizing the social impact and the economical damages. as an example, recently the argentine government relaxed some restrictions adopted in the quarantine period, allowing more economic and recreational activities in some cities. the only criterion used to adopt this measure was the number of days in which the number of infected people doubled (the so-called doubling time). even thought this decision also can be considered as a closed loop control action, the criterion adopted is a little improvised. an open question is how to translate the rate of effectiveness of the npi calculated by the controller into concrete actions adopted by governments or public health authorities. moreover, we must bear in mind that these measures cannot be continuously varied along the time, as the control signal does, but they are decisions that will remain valid for at least few days. however, although this issue is out of the scope of this paper, some decision can be changed every day, for example, the number of individuals with permission to leave their homes or the number of people allowed to get into a store, among other little decisions that can change every day according to the control variable suggests. all rights reserved. no reuse allowed without permission. (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 preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint simcovid: an open-source simulation program for the covid- outbreak impact of nonpharmaceutical interventions (npis) to reduce covid mortality and healthcare demand modelling the covid- epidemic and implementation of population-wide interventions in italy análisis del covid- por medio de un modelo seir notes on r modeling and control of a campus covid- outbreak annelies wilder-smith, and joacim rockl ov. the reproductive number of covid- is higher compared to sars coronavirus coronavirus: what are asymptomatic and mild covid- ? a conceptual model for the coronavirus disease (covid- ) outbreak in wuhan, china with individual reaction and governmental action estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship global health -seir model world health organization. coronavirus disease (covid- ) how control theory can help us control covid- the novel coronavirus, -ncov, is highly contagious and more infectious than initially estimated a mathematical description of the dynamic of coronavirus disease (covid- ): a case study of brazil an updated estimation of the risk of transmission of the novel coronavirus ( -ncov) effect of changing case definitions for covid- on the epidemic curve and transmission parameters in mainland china: a modelling study covid coronavirus pandemic key: cord- - ng gxpv authors: zittoun, tania; baucal, aleksandar title: the relevance of a sociocultural perspective for understanding learning and development in older age date: - - journal: learn cult soc interact doi: . /j.lcsi. . sha: doc_id: cord_uid: ng gxpv this paper proposes a sociocultural psychology approach to ageing in the lifecourse. it proposes to consider sociogenetic, microgenetic and ontogenetic transformations when studying older age. on this basis, it considers that older people's lives have two specificities: a longer life experience, and a unique view of historical transformation. the paper calls for a closer understanding of the specific and evolving conditions of ageing, and for more inclusion of older citizens in public debate and policy making. finally, while this paper was being reviewed, the covid- hit the world, with important consequences for the life of older persons; we conclude the paper with a short reflexion on the implications of our proposal. we aim at defining an approach to development in older age which is grounded on four assumptions. first, we examine the developing person all life-long, and not development as an outcome; development is thus understood in an open-systemic and relational way. second, and in order to do so, life-long developing persons need to be understood in their sociocultural environments, these also being in transformation. third, the approach needs to adequately account for the specificities of developing as an older person -older than others. finally, we thus attempt to show how people can develop and maintain meaningful engagements in society (elder & giele, ; hviid & villadsen, ; teo, ; valsiner, ; valsiner et al., ; zittoun et al., ) . on this basis, we will deliberately turn our back on individualistic approaches focused on the ageing person in isolation, as well as on approaches focused on the evolution, or rather decline, of specific functions (such as cognition or memory), or on studies that consider older age independently of the life-long of the person, or even, that start with normative assumptions about what may be a successful or positive ageing, − approaches which develop widely since the mid- 's and are still exponentially growing (for recent synthesis, see anderson & craik, ; biggs, ; li, ; park & festini, ; tournier, this issue) . to develop such a theoretical frame, we draw on a sociocultural psychology of learning and development, which so far has been mainly focused on children, young adults and adults, as well as on the growing field of anthropological (droz-mendelzweig, ; lieblich, ; sarason, ) , critical gerontology, sociological and narrative approaches (freeman, ; gubrium, gubrium, , , and clinical studies of the lives of older people (aumont & coconnier, ; bergeret-amselek, ; gutton, ; quinodoz, ; villa, ) . sociocultural psychology is a theoretical approach to human experience and development that considers the mutual constitution of the person and their social and cultural world, as these dynamics are located in time and space; it also gives a central role to human experience and sense-making (cole, ; rosa & valsiner, ; valsiner, ; wertsch, ) . inspired by american pragmatism (dewey, ; james, ; peirce, ) and russian psychology (vygotsky, (vygotsky, , , it is now a flourishing field. some of its current sub-orientations such as narrative cultural psychology (bruner, ; daiute, ) , historico-cultural psychology (hedegaard et al., ) , and semiotic cultural psychology (valsiner, ; wagoner et al., ) meet in their dialogical epistemologies, and their interest for formal and informal learning as well as for human development (césar & kumpulainen, ; mäkitalo et al., ; zittoun et al., ) . in these conditions, it is surprising that sociocultural psychology has very little addressed psychology of ageing -it is hardly surprising for vygotsky, one of the main inspirations in the field who died aged (zavershneva & van der veer, ) , but more so for more recent studies. indeed, such silence reproduces a tendency visible in mainstream psychology, that is, a strong divide between psychology of the life-course-ending somewhere in mid-adulthood-and gerontology, considering older age mainly as it is accompanied by illnesses and other ailments (jeppson grassman & whitaker, ) . there are however a couple of recent sociocultural studies of the older person, such as that of manuti et al. ( ) , who propose a dialogical perspective that "implies the acknowledgement of elderly subjectivity inside social discourses and, as a consequence, the need for catching what they can say" (manuti et al., , p. ) , of authors focusing on the materiality of people's lives and can therefore adopt a mediated activity approach (e.g., engeström & sannino, ; woll & bratteteig, ) which examines care (boll et al., ) . why has sociocultural psychology not studied ageing more? it may be that it has been privileging an analysis of the cultural conditions of growth which appeared more clearly in childhood; or perhaps it is due to the fact that, as a discipline, it has to be accountable for its existence, and thus studying learning and work in youth and adults can have more direct implications for practice. more generally, sociocultural psychology may also simply reflect a global tendency, both sociocultural and theoretical-an avoidance of thinking ageing and death: beyond a classic interest for ageing in ancient greece, modern psychology has long avoided the topic. indeed, the preoccupation of the "fathers of psychology", such as piaget or watson, did not find ageing relevant for their enquiry (birren & schroots, ) ; in addition, studying ageing raises specific methodological challenges (säljö, this issue). here we aim at developing a more systematic and thorough definition of a sociocultural perspective on age. for this, we propose to approach developing ageing persons through an understanding of sociogenetic, microgenetic, and ontogenetic dynamics (duveen, ; gillespie & cornish, ; zittoun, ) . ageing cannot be approached today without an understanding of societies and their historical changes-beyond the obvious fact that older people have a very different status in communities where age is associated with wisdom than in industrialized societies. this includes three aspects that have been documented in ageing studies and critical gerontology, and that are linked to practices of social inclusion and boundary work, practical arrangements and affordances, and social representations. first, one has to examine how various groups (nation states, region, and communities), as social collectives, explicitly or implicitly include, marginalize, or exclude their oldest members (de beauvoir, ) . such dynamics of exclusion for instance take place when older people are ignored in public debates about the role of older citizens or the future of society, or by a subtle logic of suspicion (e.g., in many countries people after a certain age have to test their driving capacities every year, independently of their actual state of health). moreover, "age" as social category has to be understood in articulation with other categories: ageing poor or rich, ageing migrant, or ageing hetero-or homosexual might create specific dynamics of social inclusion and exclusion, recently addressed in terms of cross-sectionality (machat-from, ; rosenberg et al., ) . second, societies and their historical transformations have to be understood in terms of their institutions, and in industrialized societies, the policies that create the financial, symbolic and material conditions of living of the older citizens, and their related various affordances. institutions define who is "retired" and when, what guarantees and rights people have after they have finished a working life (or, for non-working people, when they reach the same age). it is thus important to note that the consensus considering the "third age" starting at around is aligned on the age of the pension (stuart-hamilton, ). institutions also define modes of housing for older citizens, urban arrangements and transports, allocations for home care, cultural offers such as universities of third age, or cheaper museum entrance, etc. developing as older person is thus radically different if one has a pension that covers % of the person's former salary and enables them to maintain their lifestyle, or if the pension falls beyond the % and demands the person to radically limit their expenses; if one lives in a town with low-buses or with no public transports, etc. (abramson, ; aneshensel et al., ; bengston, ; quesnel-vallée et al., ) . however, it is important to note that older people still may define their lives, and create margins of freedom beyond the local institutional possibilities and constraints, as we will see. third, societies produce and are shaped by social representations and discourses on ageing and what "older people" are, and what they are expected to do or not to do. important attention has been paid to "ageism" as the negative social representation of older age in societies that privilege youth and its appearance in terms of beauty, strength and performances (angus & reeve, ; casas, ; nelson, ) . in turn, older people have been said to develop resistance to their "mask of age" and become alienated (humberstone & cutler-riddick, ) . also, the emphasis on "successful", "active" or "positive" ageing, both in psychology (since the s) and in institutional and public discourses (balard, ; havighurst, ; rowe & cosco, ), mostly individualizing "success" and ignoring sociocultural and economic conditions facilitating or impeding such modes of lives (bülow & söderqvist, ) , has brought some people to experience their own less-active older age as failure, even though it may be meaningful to them (stenner et al., ) . however, with the development of critical perspectives on these categories, and also probably with the growing population of older active people, there is currently an increasing transformation of social representations of becoming older. this change can for instance be observed in a growing number of films depicting the realities of living with age (haneke, ; sorrentino, ) , an increased market of products targeting ageing persons (whether cosmetics, insurance, travel packages, clothing, etc.) or with fashion movement valorising the beauties of older people (campone, ) . hence, at a sociogenetic level, we call for a careful analysis of the historical evolution and local specificities of the dominant discourses on ageing persons, the institutional arrangements setting conditions for older people's lives, and the differentiated dynamics of social inclusion and exclusion of elderly persons. research needs to examine how older people meet these discourses, arrangements and dynamics in their everyday lives, and how they can negotiate, resist or accept them, for instance as empowering and supportive social scaffoldings for pursuing meaningful ageing. in this rapidly changing field, older people play an active role themselves, for instance through specific forms of political involvement (recently, the swiss "grand-parents for the climate", or the danish "grand-parents for asylum" [hviid, ] ). a sociocultural psychological perspective also demands an understanding of the person in her context and along her life-course. in other words, it requires understanding the person in time, in a dynamic moment of their life: how the present is related to the past and how it is oriented toward the future. to move out of a negative representation of ageing as decline, a first step would be to abandon classic models of development that consider the lifecourse as a staircase or as a curve where ageing is designated by a declining slope (e.g., sato et al., ; sato et al., ; zittoun et al., ) . drawing on recent theorisation, we propose to consider the course of life as constantly changing, and to conceptualize it as dynamic assemblage of spheres of experience (zittoun & gillespie, ) . drawing on phenomenology on the one hand, and on more psychosocial descriptions of the frames of living on the other, the notion of "sphere of experience" describes an experiential unit that a person can recognize as "the same" over time, place, and relationships, and usually includes specific activities, modes of relating to others, range of feelings, aspects of one's identity or positioning, and certain specific knowledge or know-how. spheres of experience can, for instance, include eating-with-good-friends, or gardening, or remembering one's childhood, or participate in a scientific inquiry as citizen scientist. each occurrence of "eating-with-good-friends" may be located in different places and include different foods and conversations; yet it may be the overall "same" range of experience. these spheres may be "proximal" (they take in the here-and-now of specific material and social affordances) or "distal", when they are achieved through a loop of imagining, such as "remembering one's childhood". over the day, people pass from one sphere to another through a "mild shock" (schuetz, ) . however, new experiences may demand a radical reconfiguration of some spheres of experiences (such as an illness that prevents some type of food) or their destruction, as when a good friend dies and all the possibilities of joined experience disappear. new spheres of experience can also be created, such as when one moves to a new place-liminal experiences that we have coined as transitions (zittoun & gillespie, ; zittoun et al., this issue) . in line with the main assumptions of lifecourse research, we assume of course the historical and social embeddedness of peoples' course of life, the fact that people's lives are interrelated, and that the results and timing of past event may constitute, enable or constrain current and future developments (elder, ; janet zollinger giele & elder, ) . however, we are also very sensitive to people's capacities to "rewrite" their course of life, to find or create alternative developmental trajectories, and to live not only from what has been actually achieved or failed, but also, from what has been dreamed or anticipated, or from what has not come to be actualized but is still relevant (zittoun & gillespie, ; zittoun & valsiner, ) . it is also worth noticing that we conceptualize the persons' capacities not only as individual characteristics, but as capacities emerging from the relationship between individual capacities and sociocultural conditions, policies, institutions, discourses, and tools that enhance or limit, empower or disempower, support or prevent personal navigation and capacities during a lifecourse. altogether, the approach we propose brings us to highlight the fact that development occurs if, and only if, people can maintain a sense of continuity and integrity across their spheres of experience (erikson, ) , and confer meaningfulness to their lives and future perspectives. the idea of meaningfulness may be described in several ways, but here we put emphasis on two main components. on the one hand, it implies "sense-making" of one's experience (bruner, ; freeman, ) , or "engagement" in significant activities (hviid, ; hviid & villadsen, ; lido et al., ) . it also entails a minimal orientation to the future, that has been called "creativity" of living (gutton, ; winnicott, ; zittoun & de saint-laurent, ) , or "desire for life" (quinodoz, ; villa, ) , or "imagination" as way to go beyond the here-and-now and as existential tension to what has-to-come or could possibly occur (zittoun & gillespie, ) . on the other hand, meaningfulness can be related to meaningful interpersonal relationships, social recognition, and more generally, social inclusion (sarason, b) . in this sense, meaningfulness or orientation to the future engage one's fundamental dialogicality (marková, ) with self and society, past and future, real and imaginary others, that is, an intention of living. a sociocultural psychology perspective on ageing proposes to explore the making of the person and the social as a meeting between sociogenetic and ontogenetic dynamics precisely in specific activities and interactions, that is, at the level of microgenesis. it thus proposes to identify and examine socially situated experiences and practices in the making, in all kind of real and imaginary situations that constitute everyday life. microgenetic dynamics take place in a wide range of situations and relationships, and have been studied with various focuses: in older people's daily interactions with neighbours, family members, or objects, or with objects mediating interpersonal interactions (aarsand, ; iannaccone, ) ; as part of promenades in the urban, countryside, or institutional environment (badey-rodriguez, ; guglielmetti, ; mallon, ; meijering & lager, ) ; as activities of learning, working, gardening, exercising (humberstone & cutler-riddick, ; stenner et al., ) ; or as encounters with representatives of institutions, such as doctors or care practitioners (meijering & lager, ; mortenson et al., ; sarason, ; wapner et al., ) . hence, most aspects of daily life, from walking on the beach to remembering one's childhood, have been approached microgenetically (butler, ; gubrium & holstein, ; lieblich, ) . studies have recently proposed to consider these socio-material environments as part of the conditions or the arrangements enabling life, such as for instance in studies on the "landscape of care" (milligan & wiles, ) . more generally, the invitation is to pay a close attention to the actual social, material, technical, spatial environments or "ecologies" of older people's lives, and to study the dynamic of their mutual co-constitution (säljö, this issue) . from the perspective proposed here, the socio-materiel environments are thus the settings in which people may support, or develop their spheres of experiences. these microgenetic dynamics are, we believe, key-elements to document and understand the experience of becoming and being older; but we also claim that a sociocultural psychology of growing older can only be achieved by combining these dynamics with an understanding of the sociogenetic movement involved, and by preserving the unique perspective and experience of the person unfolding in time through ontogenesis. considering ageing as part of people's lifecourses from a triple socio-, onto-and microgenetic perspectives has the advantage of being integrative, but is not specific to older people's life. our main theoretical innovation lies in the identification of the specificities of development in the life of older people, first in a rapidly changing environment, and second, as a result of life experiencing. the evolutions noted above create new life conditions for older people; as the generation of baby-boomers becomes older, we observe the making of new societal configurations. on the one hand, the societal and institutional conditions of living when growing older may differ across places. life settings may radically vary, depending on local socioeconomic living conditions (abramson, ) , or at the scale of nation-states. a recent international comparison thus shows that location (i.e., specific region/state) is the best explanation for variations in factual conditions of living and in the self-evaluated quality of life in older people, all others variables being controlled (stewart et al., ) . some national retirement systems make life difficult; others systems, which may appear better, have however for long privileged sending older people to retirement homes located at the periphery of cities or in the countryside, de facto marginalizing and excluding older citizens from the social arena. on the other hand, however, these social and geographical inequalities are themselves in transformation. institutional movements start to develop measures to fight against this tendency, for instance by rearrangements of the urban space to facilitate the mobility of frailer people, by developing intergenerational housing options (for instance in many swiss cities) or by creating new city spaces to support meaningful engagement of older citizens (e.g., "the old people's playground project" in london [perry & blason, ] ). as these conditions are rapidly growing, we have to keep a special attention on these: first, the existing or newly designed conditions may not correspond to what people getting older use to expect for their older age when they were younger. for instance, in many eastern european countries, people grew up in three-generation houses with a grand-parent, and may have expected the same for themselves when they would reach the same age. however, with the rapid urbanization and professional mobility, this expectation is often not met, adding thus to the solitude of older people the disappointment of betrayed expectations. in contrast, in urban centres, people who may have feared growing old alone may now find new shared housing for older citizens, beneficiating from new and unexpected options. second, the social categories of "older people" are also rapidly diversifying, some of them being the object of public discourses: there is currently a heightened sensitivity to gender inequalities, due to fact that former baby-boomers who may have had unconventional lifestyles now access older age; there is also an increased presence of an ageing migrant population. these "new olds", unequally social and geographically located, encounter national and institutional evolutions that were frequently designed without their active participation and that are currently evolving. not only does society try to render meaningful the increase of older citizens, but older people have also a need to make sense of becoming older in this rapidly changing society, and to take part in reshaping it, with or without the younger generation. as the younger generations shape their own present and future living conditions, society would have everything to gain if they could do so in an inclusive, participative and dialogical way. older people have the specificities of having a longer life experience and often of being released from engaging daily activities. this has some implications. first, having lived longer lives, older people are more likely to have lived through more spheres of experiences, and more reconfiguration of spheres of experiences than younger people: many family or friend-related experiences, numerous professional situations, situations related to social life, events related to leisure activities, diverse cultural events. they may have witnessed the slow transformation of some of their spheres of experience and their relatedness with social changes, for instance through technological, economic, political, and cultural changes; they may have lived many ruptures, as some spheres disappeared, and others appeared. going through these many experiences and changes, people may have learned from experience something valuable not only for them as individual persons, but for other related persons, and for the society in which they are engaged. for example, they may have developed more nuanced ways to address loss and newness, to handle the daily life and exceptional events, to deal with emotions and make sense of it. this may be called "learning from experience" (bion, ) , or also, the development of personal life philosophies (valsiner, ; van der veer & valsiner, , p. ; zittoun et al., ) (comparable intuitions have been addressed by the notion of "wisdom" in psychology [baltes, ; baltes & kunzmann, ] ). this may thus become people's life motives (thomae, ) , "practical wisdom" and engagements (hviid, ) , or "melodies of living" (zittoun et al., ) . second, as people lived their lives, they may precisely have had the opportunity to experience many and diverse social changes and transformations as well: they lived through wars, economic crises, massive population movements, radical innovations, or political transformations. experiencing first-hand sociogenetic dynamics as they were themselves developing may have brought them to identify historical or societal patterns of change, evolutions, or on the contrary, to radically change their views on the world. they may thus have developed "personal world philosophies" colouring their interpretation of social histories as well as their understanding and participation in social life (de saint-laurent, ) . depending on these two aspects (the development of personal life, and world philosophies) people becoming older may diversely engage in, or maintain activities that are meaningful to them and society. if we try to develop more general understandings of ageing, we thus need to consider the tensions between the developing persons and their evolving environment (and not only the person's functions or psyche), and to account for the diversity of dynamics taking place. at one extreme, we may hypothesize that some older people have strong engagements within their spheres of experiences, to which they confer sense, and a clear orientation to the future; they also may have learned to read patterns in the social world. as a result, they may actively engage in, and create activities in which they find sense, inclusion and purpose, and feel that they can participate to societal changes. this is for instance the case of older people engaging in political action (caissie, ) , as also exemplified in the case-study reported by pernille hviid ( ) . at another extreme, older people may have developed negative representations of institutions and the social world, which, they feel, have closed down their opportunities to participate; excluded from social life, with spheres of experience that may be less satisfying, the may have very little occasions to produce meaningful activities and therefore to develop imaginations of their future. this is for instance the case of retiree in serbia for which socioeconomic conditions are de facto marginalizing. finally, somewhere in between, people may be more or less satisfied with their social world, while having a set of good-enough engagements; thus, they may maintain a sense of orientation toward the future and create new sphere of experience even in relatively constraining situations. such position is exemplified by the cases of people living in the retirement home who may find spaces of imagining and creating in the relatively limited zone of free movement left to them (zittoun et al., this issue) . identifying how older people's development emerges out of specific sociocultural environment may thus invite us to reflect on the condition that may facilitate life engagements and meaningfulness. our societies are largely changing in terms of structure of the population and economical balances, at a period where ecological and political challenges are everyday more present. the reality of the ageing of the population is undeniable, and societies expect a rapid increase of the proportion of older people in good health, ready to engage in meaningful living, even though they are excluded (or liberated) from active professional life. older age thus constitutes the future of most of us. it is therefore not only a theoretical imperative, but an ethical one as well, to include older persons in our society. we need to empower them and secure their involvement and voice in (re)shaping institutions and policies that have significant implications for their quality of life, as well as for the future courses of lives of others. this imperative is based on two key arguments. on the one hand, older people have the right to keep developing and live meaningful lives. on the other hand, and more specifically, they are also de facto the ones with the longest life experience, and are likely to remember the past, to have learned from the changing world, and from their own course of life. they may have much to contribute to our current and future situations, and it may be essential for our societies to rely on their experiences and philosophies as well. as a consequence, as social scientists and educational researchers, as well as citizens, it is necessary to create conditions of participation, in which people can pursue meaningful lives, manifest, use and share their life experience, and become producers of the institutional conditions of their living. while we have been finalizing this paper, the covid- pandemic has transformed the everyday life of almost all people in the world, both in terms of their activities and their social relationships. it is especially true for the persons of older age since they have been recognized as sensitive group of citizens in many countries. consequently, they have been the object of various sets of policies and practices related to the covid- pandemic. in order to protect them, sanitary measures have resulted in social isolation, and interdiction to engage in the daily activities and social relationships through which their main engagements take place. most older people had to question their projects and modes of lives; 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of the covid‐ pandemic for social gerontology in australia date: - - journal: australas j ageing doi: . /ajag. sha: doc_id: cord_uid: qbk aapf nan older people, particularly those with pre-existing health conditions, are more susceptible to the sars-cov- virus that causes covid- . those who recover may face additional long-term impacts on health that make older people more likely to need additional support and affect future quality of life. public health measures to suppress the virus-social distancing, restrictions on public transport, closure of shops, clinics, public facilities and community, sporting and interest groups-increase anxiety, depression and loneliness in older people. older people may also be impacted as both providers and recipients of volunteer services, as many volunteers are older adults who have had to withdraw their services. older people tend to work in occupations with high infection risk (e.g. health and caring professions). these occupations are also low wage and/or casual, and so, people may be unable or unwilling to take time off while infected. although older people are at lower risk of job loss than the young, they are more likely to remain unemployed after losing their job. losses in financial markets have reduced the value of superannuation funds, affecting pensions for retired people. engagement with family and friends has been limited. internet-based communication and online delivery of mental health interventions offer the potential to redress social and mental well-being impacts, but difficulties with access and computer literacy may exacerbate inequalities in social participation and mental well-being for older people. grandparents have had to withdraw childminding support for families, or risk exposure to the virus. the impacts of social distancing on family dynamics are unknown, although there are positive reports of community and family initiatives to address the social impacts of the virus. closure of clinics, swimming pools and gyms may adversely impact levels of physical activity and management of long-term health conditions. health-care services have cancelled elective surgery and non-urgent clinical care, increasing risk of worsening health in older people. health services have changed practice to support older people with tele-services, though the effectiveness and uptake of these modes of delivery are not known at the population level. the pandemic may exacerbate ageism. in some countries, there was debate about whether politicians should do anything to protect people at most risk, or whether older people should be sacrificed for the sake of the economy; older people are more vulnerable to the virus and less economically productive. some people may blame older adults for the economic and social impacts of the measures taken to suppress covid- . the pandemic disproportionately impacts those from ethnic minority and low socio-economic backgrounds. indigenous australians are particular risk, with indigenous households more likely to be intergenerational as well as living in overcrowded and inadequate housing, increasing risk of virus transmission. lack of culturally appropriate information and under-engagement with mainstream health services exacerbates risk for indigenous people. dawes et al. residents and staff of aged care facilities are vulnerable to the virus due to the age and long-term health conditions of residents and communal living arrangements. family and friends and allied health services being unable to visit people living in aged care facilities may result in increased social isolation, vulnerability to abuse and neglect, and poorer health outcomes. research with aged care populations is substantially curtailed as facilities are closed to visitors. the royal commission into aged care quality and safety identified several areas of need including focusing on caring relationships, including the voices of residents and family, providing clear information to make informed choices about care, improving regulatory arrangements and supporting the aged care workforce. addressing these needs may also increase resilience to pandemics, although at least in the short term, these questions may be displaced in preference to addressing infection control and the direct impacts of the virus. there is an expectation that transmission of the virus can be suppressed until an effective vaccine is found. however, it is unclear whether an effective vaccine will ever be found. further, likelihood of future global pandemics is high. there is therefore an urgent need to develop and test solutions to facilitate health care and social participation of older adults that minimise the risk of transmitted disease in the long term. australian researchers face numerous short-and long-term challenges in addressing these urgent needs. schools and universities around the world have been closed during the pandemic. an academy of science report on the impact of the pandemic on australian universities identified dramatic reductions in international student fees and research funding. the report projected losses of up to , fulltime positions including , research-related academic staff. the federal government excluded universities from a national employment subsidy program to offset the impact of the pandemic. women and early-career researchers may be especially adversely affected. up to , international research students will not resume their research in due to research interruptions and travel restrictions. universities are dealing with financial constraints by decreasing the numbers of casual teaching staff and increasing teaching loads of permanent staff, reducing research capacity. in the short term, australian universities have suspended face-to-face testing of research participants. some universities are beginning a phased return to seeing participants, although those from particularly vulnerable populations (including older people, people with long-term health conditions and people living in aged care facilities) are set to be the last groups where data collection will restart. time-dependent studies are most affected, particularly those including longitudinal data collection and intervention studies where outcomes must be assessed at particular time points. disruption to data collection has critical impacts on postgraduate student projects where time for data collection is limited. those on short-term research contracts are disproportionately affected as the projects that they were employed to work on have had to be suspended. many research staff have found their productivity impacted by having to work from home and provide homeschooling to their children. researchers and organisation have attempted to mitigate the impact of the pandemic on research. mitigations included modifying study protocols to rely on online data collection or postal surveys. the main limitations of these approaches are the impossibility of completing certain physical testing remotely, lack of equivalence of online versions of assessments and potential bias if there are systematic differences in access and ability to use computers that are related to the outcomes of interest. institutional ethics committees have fast-tracked ethical approvals for protocol modifications. researchers have switched focus to alternative methodologies that are not reliant on collection of face-to-face data, including analysis of existing data sets, systematic reviews, surveys and internet-based interviews. journals have fast-tracked publication of research papers dealing with the impact of covid- , which are then published open access. some editors have made allowance for longer revision times and taken a pragmatic approach to shortcomings in research due to the impacts of the pandemic. funders have allowed flexibility in revising the protocols and study timelines for funded projects. the australian research council attempted to mitigate the impact of the pandemic by extending closing dates for applications to some schemes, allowing late submission of applications and extensions or changes of scope for existing projects. funding support for universities is critical to address loss of revenue. some state governments announced measures to mitigate the impact of reduced international student enrolments and supporting universities with research partnerships. the federal government should consider support for universities to carry out the research that addresses the needs of older australians. the effects of the pandemic are greatest for older people and the most vulnerable in society. given altered research priorities following the pandemic, social gerontologists must lobby for support. the current focus is justifiably on the epidemiology and the clinical impacts of the virus. in the longer term, issues of mental health for older people, prevention, and | resilience of health care and social support for older adults will grow in importance. researchers must actively engage with these questions at the earliest opportunity. to ensure that research is of greatest utility, older people should play a central role in identifying research needs and priorities, as well as in the design, implementation and dissemination of research. strategies that do not rely on faceto-face meetings are required to ensure that the voices of older people are heard by researchers and policymakers in the co-design of future solutions. the covid- pandemic exposed inequalities and vulnerabilities for older australians, particularly those with long-term conditions, people from minority communities, indigenous backgrounds and residents of aged care facilities. the pandemic also directly impacted social gerontologists. we must grapple with these challenges and take the opportunity to address these inequalities and vulnerabilities and improve health, well-being and quality of life for older australians. estimating the infection and case fatality ratio for coronavirus disease (covid- ) using age-adjusted data from the outbreak on the diamond princess cruise ship association of cardiac injury with mortality in hospitalized patients with covid- in wuhan covid- and the consequences of isolating the elderly volunteering and covid- arc centre of excellence in population ageing research, covid- and the demographic distribution of health and economic risks australian taxation office. covid- (novel coronavirus) -temporarily reducing superannuation minimum payment amounts internet-based cognitive behavior therapy for loneliness: a pilot randomized controlled trial good intentions are not enough: how informatics interventions can worsen inequality eight acts of goodness amid the covid- outbreak. greter good magazine at uc berkeley australian human rights commission texas' lieutenant governor suggests grandparents are willing to die for us economy covid- : an urgent public health research priority urban aboriginal people face unique challenges in the fight against coronavirus the coronavirus and the risks to the elderly in long-term care why we might not get a coronavirus vaccine. the guardian covid- educational disruption and response australian academy of science. impact of the pandemic on australia's research workforce australian government moves again to exclude universities from bailout, in times higher education how research funders are tackling coronavirus disruption the authors are supported by the centre for ageing, cognition and wellbeing, macquarie university. no conflicts of interest declared. key: cord- - xr mj authors: chan, fong; tansey, timothy n.; iwanaga, kanako; bezyak, jill; wehman, paul; phillips, brian n.; strauser, david r.; anderson, catherine title: company characteristics, disability inclusion practices, and employment of people with disabilities in the post covid- job economy: a cross sectional survey study date: - - journal: j occup rehabil doi: . /s - - - sha: doc_id: cord_uid: xr mj purpose in the post coronavirus disease (covid- ) recession economy, rehabilitation counselors, transition specialists, and other disability service providers must redouble their efforts to connect with employers to create employment opportunities for people with physical and mental impairments. the purpose of the present study was to investigate company characteristics and effective disability inclusion practices that are related to employment of people with disabilities. methods four hundred sixty-six employers completed a demographic questionnaire and the disability inclusion profiler. results results indicated company characteristics and disability practices were positively related to employment of people with disabilities. conclusions findings of the present study can be used by transition specialists, rehabilitation counselors, and other disability service providers to engage and connect with employers to increase employment opportunity for people with disabilities in the post covid- economy. future research and practice implications are provided. gainful employment has many known financial, psychological, social, and health benefits [ ] [ ] [ ] [ ] [ ] . suitable employment enables working-age adults to provide for themselves, access health care, connect with people, and contribute as a productive member of society [ ] . work identity (the meaning of people's jobs and its relationship to their sense of being) is a predominant part of people's self-identity and a requisite component of living a meaningful and fulfilled life [ ] . research has indicated that persons who are gainfully employed have better physical and mental health than those who are unemployed [ , ] . conversely, unemployment, income inequality, and poverty are associated with poor physical and mental health, low self-esteem, and lower levels of life satisfaction, due to the loss of income, lack of access to health care, stigma, social isolation, and psychological distress [ ] [ ] [ ] . individuals with disabilities are one of the most stigmatized and marginalized groups in the world [ ] [ ] [ ] , which results in inequities in employment, as outlined above. during the great recession (i.e., the collapse of the financial system that spans the period from december through september for a total duration of months), among prime working-age adults ( - years old), the unemployment rate of people with disabilities ranged from . to . times that of people without disabilities [ ] . in the middle of , when the united states economy was approaching full employment [ ] , many marginalized groups benefited from the robust economy and returned to the labor force in droves [ ] , with the exception of people with disabilities. despite the high demand for workers in , employers were not hiring large numbers of people with disabilities [ ] . as a result of the coronavirus disease (covid- ) pandemic, the united states economy is entering another recession [ ] . in september , the employment-topopulation ratio of . % for working-age individuals with disabilities is significantly lower than the . % rate for working-age people without disabilities [ ] . the unemployment rate for people with disabilities was . % also higher than the . % rate for people without disabilities [ ] . in the post covid- job economy, similar to the great recession, excess labor supply will significantly affect individuals with disabilities' ability to find or retain employment. as such, working-age adults with disabilities are vulnerable to the debilitating consequences of unemployment and poverty. to be effective in assisting people with disabilities find and retain employment in a grim economy, it is imperative to carefully review the employer practices literature for studies conducted before or after the great recession. lessons learned from these research studies can help transition specialists, rehabilitation counselors and other disability service providers better understand the impact of company characteristics, employment policies, and disability inclusion practices on hiring and retaining people with disabilities in strong and weak economies. gilbride et al. [ ] conducted a qualitative research study to examine characteristics of work environments and employers who are open to hiring and accommodating people with disabilities. they found that normative belief (i.e., commitments at the leadership/executive level that trickle down to all levels of the organization), diversity and disability inclusion policies and procedures, a strong focus on ability not disability, and knowledge and experience providing job accommodation and workplace supports characterized companies that are committed to hiring and supporting people with disabilities in their workforces. chan and colleagues [ ] collected more evidence on this topic by conducting a survey of employers in the midwest and found that including disability in the organization's diversity and inclusion policy and knowledge of the americans with disabilities act (ada) and job accommodations were the most significant predictors of inclusion of people with disabilities in the workplace. their findings are consistent with findings reported by habeck et al. [ ] who reported that having an in-house disability management program and inclusion of disability in companies' diversity and inclusion policies and procedures would lead to hiring and retaining people with disabilities. bezyak et al. [ ] examined seven disability inclusion strategies (i.e., internship program, trial employment, special interviewing process, for-profit job placement, disability inclusion and diversity policies and procedures, and working with state vocational rehabilitation agencies) in a sample of employers in colorado. results indicated all disability inclusion strategies in their study were positively related to hiring intention. iwanaga and colleagues [ ] reported that disability inclusion training is related to inclusion of people with disabilities in the workplace. fraser et al. [ , ] also conducted a focus group study and a quantitative study using the theory of planned behavior as their research framework. they found that company climate related to disability inclusion is influenced by normative beliefs of management or senior executives and whether they support or hinder the hiring of people with disabilities. in the post covid- job economy, it will be more difficult to help persons with disabilities find and maintain gainful employment. rehabilitation counselors, transition specialist, and disability service providers must make greater efforts to create employment opportunities for their clients. it is essential for leadership, managers, and counselors in state vocational rehabilitation agencies to focus on the local job economy, engage employers to identify their needs for specifically trained and skilled workers, and cooperate with local employers and educational institutions to provide customized training to people with disabilities to meet employer demands for skilled workers. there is an urgent need to identify characteristics of companies and disability inclusion practices that will lead to employment of people with disabilities especially during a recession. as a result, the purpose of the present study was to investigate company characteristics and effective disability inclusion practices that are related to employment of people with disabilities in the workplace. findings from this study can provide a roadmap for state vocational rehabilitation agencies and community-based rehabilitation and health organizations to engage and connect with companies that are committed to hiring people with disabilities. the following research questions were investigated: rq what is the relationship between disability inclusion practices and employment participation of people with disabilities in the workplace? rq do company characteristics and disability inclusion practices affect the employment rates of people with disabilities in the workplace? a cross-section survey design was used for the present study. institutional review board (irb) approval for this study was obtained from the university of wisconsin-madison. participants in this study included human resources managers and professionals who made hiring decisions within their companies. the organization for economic co-operation and development (oecd) classification was used to designate company size [ ] . the majority of participants were employees of large size companies (greater than or equal to employees; . %), followed by medium size companies (between and employees; . %) and small size companies (less than employees; . %). a range of industry types were represented, including professional, scientific, and technical services ( . %); health care and social assistance ( . %); accommodation, food services and retail trade ( . %); information technology ( . %); finance and insurance ( . %), and educational services ( . %). over half ( . %) of the participants' companies have federal contracts over $ , , and . % were fortune companies. only . % of the participants' companies had more than % of employees with self-identified disabilities, while . % of the participants indicated their companies had less than % of employees with disabilities in their workforces. twenty percent of the participants indicated their companies did not have any employees with selfidentified disabilities. company characteristics of interest for the current study include company size, fortune companies, and federal contractors. in the present study, the organization for economic co-operation and development's (oecd) definition for company size was used, which classifies small companies as having to employees, medium-sized companies as having to employees, and large-sized companies as those with or more employees [ ] . fortune is an annual list compiled and published by the fortune magazine that ranks of the largest united states corporations by total revenue for their respective fiscal year [ ] . lastly, federal contractor is defined by sect. of the rehabilitation act as companies with federal contracts of $ , or more [ ] . participants provided all this information as part of the demographic questionnaire. disability inclusion practices was assessed using the disability inclusion profiler (dip; [ ] ). this measure was developed based on the standard test development process recommended by crocker and algina [ ] . the test specifications, the a priori categories, and items for the a priori categories were developed based on a comprehensive review of the demand-side employment literature, a focus group and a delphi study with employers to identify effective disability inclusion practices. the final measure comprised items and six a priori categories: (a) disability inclusion commitment, (b) disability inclusion policies and procedures, (c) disability inclusion preparedness, (d) disability inclusion resources, (e) disability inclusion strategies, and (f) disability inclusion attitudes. each item was rated on a -point likert importance rating scale ( = not important, = somewhat important, = important, = very important) and a -point likert implementation scale ( = not currently in implementation, = in planning for implementation, = partial implementation, = full implementation). in the present study, the internal consistency reliability coefficients (cronbach's alpha) were . for the importance scale, . for the implementation scale, and . for the weighted implementation scale. percent of people with disabilities in the company's workforce was used as an external correlate to identify effective disability inclusion practices in the disability inclusion profiler. participants were asked to indicate the percent of individuals with self-identified disabilities in their workforce based on half percent increments, results ranged from % to greater than %. the mean utilization rate in this sample was . % (sd = . %). amazon mechanical turk (mturk) and turkprime was used to collect data for the present study. mturk has been used by thousands of researchers to obtain sample participants while turkprime provides a more user-friendly interface and additional options for data collection [ , ] . the turkprime panel was used to recruit the target population (i.e., hr managers or project managers with hiring authority). these panels, or subgroups, are created from the millions of survey responders affiliated with mturk and turkprime. the disability inclusion profiler takes about minutes to complete, and participants received a $ gift card for completing the questionnaire. the statistical package for the social sciences (spss . ) was used to analyze data for the present study. descriptive statistics were computed to provide information related to the demographic characteristics of the participants; correlational analyses were computed to evaluate the relationships between disability inclusion practices and employment rates of people with disabilities in the workplace; and three analysis of variance (anovas) were computed to compare utilization rates of people with disabilities based on company characteristics. for ease of interpretation, we have converted the weighted implementation total scores to t-scores with a mean of and a standard deviation of . in the present study, human resources managers and professionals who made hiring decisions were asked to rate the importance and stages of implementation of disability inclusion practices identified in the disability inclusion profiler. means and standard deviations of the importance, implementation, and weighted implementation scores for the disability inclusion practices, along with the correlations between these practices and employment of people with disabilities in their workplace are presented in table . as indicated in table , there are disability inclusion practices that are significantly associated with employment rates of people with disabilities in the workplace (pearson correlation coefficients between . and . , p < . ; close to a medium effect size; [ ] ), which represent the commitment of leadership/executive management in the organizations to support the inclusion of people with disabilities: • have an accommodations budget line item to cover costs of accommodations for employees. • participate in job fairs for people with disabilities. • have annual targets and assess performance to achieve application and employment goals of persons with disabilities. • have in-house (or contractual) disability management personnel that are responsible for handling issues related to the ada and job accommodations. • have a hiring manager with a disability. • senior leadership clearly communicates its commitment to employment of people with disabilities. • post statement of commitment to hiring people with disabilities on the company website. • have a senior executive with a disability. • provide disability inclusion training for company's hr recruiters. • have a mechanism to assess the number of people with disabilities in the company. there are disability inclusion practices with pearson correlation coefficients between . and . (p < . ), with an emphasis on implementing disability inclusion policies and procedures by mid-level managers, supervisors, and staff: • report progress toward hiring persons with disabilities to senior management. • have internship and summer employment programs directed toward high school and college students with disabilities. • identify and select partners that can be valuable in recruiting qualified individuals with disabilities. • include "work and disability" as a topic in the company's diversity and inclusion training. • have internal and external resources to support the goals of the company's disability employment and inclusion program. • have a mentoring program to promote advancement of diverse persons. • communicate emergency preparedness policy or procedures with specific mention of persons with disabilities. • have strategies to attract qualified applications from persons with disabilities. • include disability in the company's diversity and inclusion policies and procedures. • senior leadership communicates clearly and affirmatively the company's commitment to recruit and hire people with disabilities. • have contracts with employment agencies. • have a disability accommodation policy. • include "work and disability" as a topic in the company's new employee orientation training. • offer an employee assistance program. • have process to assess website for compliance of coding with existing law and regulations. • have policy to make all job interview candidates aware of the option to request accommodations for the interview. the total score for the disability inclusion practices was significantly associated with employment of people with disabilities in the workplace (r = . , p < . ; medium effect size; [ ] ). one-way analysis of variance (anova) was performed to compare the effect of company sizes, fortune companies, and federal contractors on implementation of disability inclusion practices. means and standard deviations of the weighted implementation scores and utilization rates are presented in tables , , and . one-way anova showed that the effect of company sizes on disability inclusion practices was significant, f ( , ) = . , p < . . post hoc analysis using the tukey hsd test indicated that the mean implementation scores for large-size companies (n = ; m = . , sd = . ) and mid-size companies (n = ; m = . , sd = . ) were significantly higher than small-size companies (n = ; m = . , sd = . ). however, there is no significant difference between large-size and mid-size companies. as a soc stages of implementation, weighted soc soc weighted by relative importance b correlation with utilization rate *p < . ; **p < . ; ***p < . expected, the standard deviation for small-size companies is greater than large-and mid-size companies, indicating a large variation among small-size companies in the implementation of disability inclusion practices. taken together, these results suggest that company size does affect disability inclusion practices, with small companies less likely to implement disability inclusion practices. one-way anova showed that the effect of company size on employment rates of people with disabilities was also significant, f ( , ) = . , p < . . post hoc analysis using the tukey hsd test indicated that the mean score for large-size companies (n = ; m = . %, sd = . %) was significantly higher than mid-size companies (n = ; m = . %, sd = . %) and small-size companies (n = ; m = . %, sd = . %). the mean employment score for mid-size companies was also significantly higher than small-size companies. collectively, these results suggest that company sizes do have an effect on employment rates of people with disabilities, with large-size companies having the highest representation of people with disabilities in their workforces and small companies having the lowest representation. one-way anova showed that the effect of being a fortune company on disability inclusion practices was significant, f ( , ) = . , p < . . the result indicated that the means score for fortune companies (n = ; m = . , sd = . ) was significantly higher than the mean score for non-fortune companies (n = ; m = . , sd = . ). fortune companies are more likely to emphasize and implement disability inclusion practices to recruit, hire, and retain people with disabilities in their workforces. one-way anova also showed that the effect of being a fortune company on employment rates of people with disabilities was significant, f ( , ) = . , p < . . the result indicated that the means score for fortune companies (n = ; m = . %, sd = . %) was significantly higher than the mean score for non-fortune companies (n = ; m = . %, sd = . %). fortune companies had significantly higher employment rates of people with disabilities in their workforces than non-fortune companies. one-way anova showed that the effect of federal contract on disability inclusion practices was significant, f ( , ) = . , p < . . the result indicated that the means score for federal contractors (sect. companies; n = ; m = . , sd = . ) was significantly higher than the mean score for non-federal contractors (n = ; m = . , sd = . ). federal contractors are more likely to emphasize and implement disability inclusion practices to include people with disabilities in their workforces. one-way anova showed that the effect of companies with federal contracts on employment rates of people with disabilities was significant, f ( , ) = . , p < . . the result indicated that the mean score for federal contractors (sect. companies) (n = ; m = . %, sd = . %) was significantly higher than the mean score for non-federal contractors (n = ; m = . %, sd = . %). federal contractors have significantly higher representation of people with disabilities in their workforce than companies without federal contracts. the present study examined the relationships between company characteristics, disability inclusion practices, and employment of people with disabilities. for company characteristics, results indicate large-and mid-size companies do have higher disability inclusion practice implementation scores and higher employment rates of people with disabilities in their workforces than small-size companies. we also found that both fortune companies and federal contractors have higher implementation scores and representation of people with disabilities in their workforces than non-fortune companies and non-federal contractors. although federal contractors are required to meet a % utilization goal of people with disabilities in their workforces, in the present study, fortune companies with . % utilization rate is appreciably higher than the . % rate of federal contractors. in addition, the sizes of companies that receive federal contracts can vary significantly. in the present study, . % of the federal contractors are large-size companies and . % are small-to mid-size companies. it should be noted that although small-size companies have lower disability for disability inclusion practices, we found that these practices can be classified into two major domains: leadership/executive management level disability inclusion practices (level ) and middle-managers, supervisors, and staff level disability inclusion practices (level ). level practices have higher implementation scores and correlations with utilization rate than level practices. it represents leadership/executive's commitments and efforts to influence down and across the organization to drive behavior change. it reflects the actions leadership/executive have taken to communicate their strong commitments and provide the infrastructure and resources needed to foster a workplace culture that supports the inclusion of employees with disabilities. specifically, in successful companies, commitment at the highest level of the organization is communicated clearly to managers, supervisors and coworkers and in the company's website. leadership sets utilization goals for employment of persons with disabilities at all levels (including senior management) of the organization and assures there is a mechanism (e.g., the voluntary self-identification of disability form cc- created by the u.s. department of labor) in the company's human resources information systems to track the number of people with disabilities working in the organization. form cc- is available from the united states department of labor's office of federal contract compliance programs website. senior management is also mandated to conduct an annual review to evaluate disability inclusion efforts and outcome. to encourage unit heads, department heads, and project managers with hiring authority to hire and retain employees with disabilities, successful companies establish an enterprise-wide accommodations budget line item to pay for applicant and employee accommodations. in addition to financial support, successful companies also ascertain the organization has in-house (or contractual) disability management specialists who are knowledgeable and have the expertise to manage issues related to the ada and job accommodations. leadership of successful companies also underscores the importance of disability inclusion training (disability inclusion preparedness) for their managers and staff. findings of level practices strongly supported the importance of the top down approach to change workplace culture and disability inclusion climate and to foster a welcoming climate for people with disabilities. level practices have a focus on execution of disability inclusion practices by mid-level managers and staff to recruit, hire, and retain people with disabilities. for example, practices consist of collecting data and reporting progress toward hiring persons with disabilities to senior management, establishing a paid internship program for high school and college students with disabilities, partnering with state vocational rehabilitation agencies and community-based rehabilitation and health organizations to recruit qualified individuals with disabilities, and developing strategies to attract qualified applications from persons with disabilities. other practices include presenting disability and employment as a topic in new employee orientation and in diversity and inclusion training and providing disability inclusion training for employees at all levels of the organization to demystify misperceptions about people with disabilities and their health conditions, job performance and social functioning. interesting, in the demand-side employment literature, inclusion of disability in companies' diversity inclusion policies and procedures is a significant predictor of employment of people with disabilities in the workplace. however, in this study, the correlation between disability inclusion policy and employment of people with disabilities is only . (p < . ; midway between small to medium effect sizes). there are many disability-inclusion practices with higher correlations with utilization rate than inclusion of disability in diversity inclusion policies and procedures. our findings clearly indicate the significant role leadership/senior management play in supporting or hindering the inclusion of people with disabilities in their workplaces, along with their influence on fostering an inviting atmosphere for people with disabilities to perform their jobs successfully in the organization. it underscores the importance of finding effective ways to connect with leadership/senior executives in order to promote employment opportunities for people with disabilities. people with disabilities have a human right to work [ ] . the positive effects of gainful employment on the health and well-being of people with disabilities are well documented [ , ] . however, the employment rate of people with disabilities is low compared to people without disabilities, making them vulnerable to the negative consequences of unemployment and poverty [ ] . it is alarming that in , when the united states' economy was approaching full employment and managers were reporting a high demand for workers, employers were still not hiring large numbers of people with disabilities [ ] . with the covid- pandemic, the u. s. economy is entering another recession [ ] . when the supply of workers is higher than the demand for workers, employers will be even more reluctant to hire people with disabilities. transition specialists, vr counselors, and other disability services providers must use innovative strategies to identify employers who have a high propensity to hire people with disabilities and redouble their efforts to connect and cooperate with employers to identify types of workers and job positions they need to fill and provide appropriate training for their clients to fill those positions. in the current study, large companies, fortune companies, and federal contractors were most receptive to hiring people with disabilities. leadership and district managers in state vocational rehabilitation agencies need to build relationships with senior executives of these types of companies to influence their attitudes toward hiring people with disabilities. a good working relationship between leaders in state vocational rehabilitation agencies and leaders in business organizations can create opportunities for rehabilitation counselors, transition specialists and other disability services providers/vendors to connect with business leaders. in turn, transition specialists, rehabilitation counselors, and other disability service providers also need to increase their employer engagement efforts by developing working relationships with companies that are active in the us business leadership network (usbln), society for human resource management (shrm), the ada regional centers, and chamber of commerce organizations in their communities. the disability inclusion profiler used in this study can be a useful tool for vocational rehabilitation professionals to initiate relationships with local companies by helping employers assess workplace culture and disability inclusion climate and provide disability inclusion training for their employees without disabilities and workplace support for employees with disabilities. previous demand-side employment research revealed that countries that use an employment quota system (e.g., germany, france, and japan) tend to have smaller disability employment gaps (i.e., the difference between employment rates of people without disabilities and people with disabilities) than countries that use anti-discrimination legislation (e.g., the united kingdom and the united states; [ ] ). federal contractors in the united states are expected to meet the utilization goal of % of people with disabilities in their workforces [ ] . for federal contractors who fail to meet the % aspiration goal, they must take steps to determine whether and where impediments to equal employment exist. this includes assessing existing personnel processes, the effectiveness of its outreach and recruitment efforts, the results of its affirmative action program audit, and any other areas that might affect the success of the affirmative action program. after conducting this assessment, the contractor must develop and execute action-oriented programs to correct any identified problem areas [ ] . rehabilitation counselors, transition specialists and other disability services providers should focus on identifying federal contractors who are not meeting the % utilization rate and offer to provide technical assistance to increase the pool of qualified workers with disabilities in these companies. the sample size (n = ) for the present study is relatively large. although there is evidence to support the use of amazon's mechanical turk for data collection [ , ] , there are studies that caution about the reliability and quality of the research data collected by this method [ ] . additional research using contact lists from the society for human resource management (shrm) and lists of federal contractors purchased from the office of federal contract compliance programs is warranted. in addition, a review of the disability inclusion practice ratings suggests that there may be two levels of practices. this is the first time the disability inclusion profiler has been used, and further psychometric testing is warranted. the current study evaluated the relationship between company characteristics, disability inclusion practices, and employment rates of people with disabilities. results indicate large and mid-sized companies, fortune companies, and federal contractors are most likely to hire people with disabilities in their workforces. disability inclusion practices can be divided into those requiring leadership/executive management commitments and efforts to drive behavioral change down and across the organization, and those that are implemented by mid-level managers, supervisors, and staff to recruit, hire, and retain people with disabilities. the top down approach is vitally important for changing workplace culture and climate to support the inclusion of people with disabilities in the workplace. these findings can be used by transition specialists, rehabilitation counselors, and other disability service providers to engage and connect with employers for the purpose of increasing employment opportunity for people with disabilities in the post covid- economy. informed consents from our participants on the condition that we use the obtained data for this study purpose but are available from the corresponding author on reasonable request. conflict of interest the authors declare that they have no conflict of interest. ethical approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. informed consent informed consent was obtained from all individual participants included in the study. work, identity and health employment as a health determinant for working-age, dually-eligible people with disabilities health, secondary conditions, and employment outcomes for adults with disabilities association of employment and health and wellbeing in people with fibromyalgia theories of personality. belmont: cengage learning a shorter working week for everyone: how much paid work is needed for mental health and well-being? health and access to care among employed and unemployed adults: united states effects of unemployment on mental and physical health psychological and physical well-being during unemployment: a meta-analytic study the stigma of disease and disability: understanding causes and overcoming injustices. washington world health organization reducing prejudice toward people with disabilities the impact of the great recession upon the unemployment of americans with disabilities is it really "full employment"? margins for expansion in the us economy in the middle of unemployment fell to . percent, lowest since new employer survey reveals corporate america still struggling to hire people with disabilities the united states is officially in recession thanks to the coronavirus crisis. the guardian identification of the characteristics of work environments and employers open to hiring and accommodating people with disabilities demand-side factors related to employment of people with disabilities: a survey of employers in the midwest region of the united states employee retention and integrated disability management practices as demand side factors disability inclusion strategies: an exploratory study. j vocat rehabil assessing disability inclusion climate in the workplace: a brief report understanding employers' hiring intention in relation to qualified workers with disabilities understanding employers' hiring intentions in relation to qualified workers with disabilities: preliminary findings development oced. oced data: enterprises by business size. oecd factsheet: the workforce innovation and opportunity act disability inclusion profiler. madison wi introduction to classic and modern test theory com: a versatile crowdsourcing data acquisition platform for the behavioral sciences crowdsourcing research: data collection with amazon's mechanical turk a power primer united nations human rights office of the high commissioner factors influencing employers' motivation to recruit and hire people with disabilities: a scoping review a reliability analysis of mechanical turk data the contents of the journal publication were publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -gb ggriv authors: qi, fei; wang, qi title: guaranteeing the health rights of people with disabilities in the covid- pandemic: perspectives from china date: - - journal: risk manag healthc policy doi: . /rmhp.s sha: doc_id: cord_uid: gb ggriv the question of how to guarantee the health rights of people with disabilities, and their health equity in particular, is frequently neglected in infectious disease pandemics. the international response to the ongoing covid- pandemic is no exception in this regard. this neglect is related to other forms of marginalization and exclusion, as people with disabilities are generally poorer and more vulnerable than their non-disabled counterparts. sustainable development goal lacks an appropriate human rights language that enshrines equality and inclusivity in pandemic prevention work and related policies and legislation; and, as a result, it does not sufficiently guarantee the health rights of people with disabilities. this paper draws on china’s pandemic prevention work to extract relevant lessons, and seeks to explain how decision-making systems and resource allocation mechanisms impact on the health rights of people with disabilities. it discusses the unique roles of justice and legislation in helping to guarantee the health rights of people with disabilities in an infectious disease pandemic, and concludes that future research should more closely consider how sustainable development goal can support sustainable development goal . sustainable development goal (sdg )-"ensure healthy lives and promote well-being for all at all ages"-is a broad health goal that calls for the achievement of universal health coverage. the coronavirus (covid- ) outbreak, which the world health organization recognized as a pandemic on march , presents a clear challenge to the realization of sdg , and specifically to guaranteeing the health rights of people with disabilities during the critical stage of an infectious disease pandemic (idp). people with disabilities are more vulnerable during pandemics, and this is mainly because they frequently require assistive devices such as wheelchairs, which greatly increases the likelihood they will be exposed to coronavirus. they will also need to periodically access nursing services, and this makes it more difficult for them to maintain the social distancing that is an essential part of pandemic prevention. many people with disabilities also have specific underlying diseases, which means that covid- is even more dangerous to them. taking people with intellectual disability as an example, the latest analysis of the mortality data of covid- cases shows that the mortality rate of patients aged and younger with intellectual and developmental disabilities (idd) is more than times that of patients of the same age who do not have idd. in a briefing delivered on may , un secretary-general guterres emphasized that: "we must guarantee the equal rights of people with disabilities to access healthcare and lifesaving procedures during the pandemic" but although article of the united nations convention on the rights of persons with disabilities (uncrpd) ('situations of risk and humanitarian emergencies') requires countries to take all necessary measures to ensure the protection and safety of those with disabilities in crisis situations, sdg still lacks the human rights language that would guarantee the health rights of people with disabilities in an idp crisis situation. this is confirmed by the fact that only four of its targets relate to healthcare and lifesaving procedures that can be applied to the covid- pandemic. these are: . . coverage of essential health services. .b. proportion of the target population covered by all vaccines included in their national programme. .b. proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis. .d. international health regulations, capacity and health emergency preparedness. none of these targets address the relative vulnerability of people with disabilities in a way that promotes the rational allocation of health resources in a pandemic, and nor do they demand equality and inclusiveness from emergency preparedness and idp response. china's previous efforts to improve the health system and legislation in accordance with sdg did not sufficiently plan for people with disabilities, and they were not included in the emergency preparedness and response. in the critical situation caused by the covid- pandemic, people with disabilities, who have a relatively weak risk resistance capacity, are facing greater challenges. between january and april , a large number of chinese cities were locked down to fight against the covid- pandemic, and public services were generally reduced or suspended. this further increased the difficulties that people with disabilities encountered when they sought to obtain nursing services and access health resources. in the initial period of the outbreak, people with disabilities usually faced a very challenging situation. institutional oversight and/or neglect could have had very serious, or even fatal, consequences for people with disabilities. this paper draws on china's actions and lessons from the pandemic to reflect on the extent to which the lack of human rights language in sdg obstructed the country's efforts to guarantee the health rights of people with disabilities. it highlights deficiencies in the legislation and emergency response plans and evaluates the extent to which these rights were actually guaranteed. after the initial outbreak, people's mobility was curtailed in a short period of time, and every confirmed indigenous case was quickly identified, quarantined, and treated freeof-charge. this meant that the spread of the virus was quickly contained. information was collected from conventional media and social media and interviews with disabled people and the organizations that represent them. analysis then revealed that the factors that affect the realization of health equity in idp are more diverse than sdg had expected. the inclusivity of the decision-making system for pandemic prevention has significantly impacted the effectiveness of efforts that seek to guarantee the health rights of people with disabilities in the pandemic. the uncertainty that accompanies covid- and similar infectious diseases means it is highly probable that epidemic prevention policies and legislation will have blind spots and irrational content to some extent. experience from china also confirmed that decision-makers had to efficiently collect information, provide feedback, correct errors and make decisions amidst ongoing chaos. if this decision-making process is not sufficiently inclusive, it will negatively impact the realization of health equity in idp. for example, the law on prevention and treatment of infectious diseases (lptid) establishes that when an infectious disease breaks out, governments across various levels (national, provincial, municipal and county) in the country should quickly establish a pandemic prevention command institution that can command all local administrative agencies and health and police departments. it also establishes they should also obey the command of higher headquarters , -this stipulation allowed china to effectively regulate the society a short period of time after submit your manuscript | www.dovepress.com risk management and healthcare policy : the start of the outbreak, and it helped to successfully reduce population movement during the lunar new year. but the lack of language that guaranteed the rights of people with disabilities in lptid resulted in the demands of some people with disabilities being ignored in the initial stages of the outbreak. this meant that people with disabilities were dangerously exposed at a time when covid- was spreading most rapidly. the government acknowledged the problem and set up a hotline that enabled people with disabilities to contact local pandemic prevention decision-making teams (all calls were recorded for later inspection by higher headquarters and supervision departments). decision-makers received severe punishments if they were found to have failed to have failed to respond to reasonable requests within a given timeframe (usually - workdays). this helped to guarantee that the needs of people with disabilities were met in many regions, including wuhan (the previous epicenter, where human resources and materials were most desperately required). a representative of mutual aid group for people with disabilities in wuhan recalled: there were people in my mutual aid group. all of us were organ transplant recipients in wuhan. after transplantation, we could not do heavy work or work for long periods of time. at the same time, we needed to take immune preparations twice a day, or we would quickly die due to organ rejection. after the lockdown of wuhan, we found that the hospitals where we normally got prescribed medicine were requisitioned as designated hospitals for novel coronavirus, and they would no longer provide other medical services. hence, we lost the access to immune preparations, and the amount of immune preparations we stored was usually available for less than days. we asked for help in many ways, but it was useless. in the end, i called the mayor's hotline with the intention of trying. i hadn't expected that the community officials and volunteers would deliver the medicine to every one of our group within hours. about ten days later, the government informed us that the immune preparations that could only be prescribed in hospitals earlier were available at the nearest pharmacies. we all survived, and i'm lucky and proud to live in this country. -mrs. ling, a liver transplant recipient personal communication, may , china also established an efficient and transparent internetbased resource allocation mechanism, which made a critical contribution to the achievement of health equity in the pandemic. it was difficult for people with disabilities to store materials during idp because any kind of shopping was an additional burden on them. they usually had to ask for help to carry what they had purchased, which increased the danger they would be exposed to the virus. the pandemic also caused a shortage of face masks and various other materials. in the initial stages of the outbreak, difficulties associated with travel and panic buying meant that people with disabilities could not obtain sufficient material, for example, some paraplegic wheelchair user are forced to use plastic bags as a substitute after running out of diapers. in response, numerous online groups were established via instant messaging apps (including wechat in china) and a large number of material suppliers, transporters and consumers were invited into the online groups for districts or communities. the government's coordinated sales, logistics and terminal delivery meant it could achieve the transparent and efficient distribution of materials during city lockdown. residents in the epidemic area could order materials in the online groups and community cadres and volunteers could send materials to each residential building in accordance with the quota. the elderly and the disabled would have materials sent directly to their homes. the transparent process of the distribution mechanism and supply chain in the online group increased the recognition of the fairness of the resource allocation mechanism by enterprises and residents, and this made the system sustainable during the pandemic. the government's command and coordination made it possible for people with disabilities to use online groups to obtain health service resources that were rarely available from general commercial channels during the idp. for example, when the hospitals were overcrowded in the initial stages of the outbreak, a large number of institutions were forced to suspend nursing services for people with disabilities. shanghai municipal government responded by organizing family physicians and people with disabilities into various communities that then established online groups. family physicians did not only provide online diagnosis, treatment and drug distribution for people with disabilities across the internet, but also extended necessary nursing services to severely disabled people. on april , , the lockdown of wuhan was lifted. on may , , there were only confirmed cases, and , patients had been cured and discharged from hospitals. in china more generally, there were , confirmed cases in a population of . billion. the data risk management and healthcare policy : submit your manuscript | www.dovepress.com dovepress suggests that the country's efforts to guarantee the health rights of people with disabilities achieved remarkable results in the period after the initial outbreak: on february , hainan province announced that none of its , people with disabilities were infected; on march , fujian province reported that none of its , blind people showed signs of infection; and on march , nanjing city announced that none of its , people with disabilities were infected. taking into account the difficulties associated with the peak of the pandemic in january and the fact that the three regions have a combined population of almost million, this was a considerable achievement. although the specific national public health data has not yet been collected, zhang haidi, chairman of the china disabled persons' federation, told the media that according to incomplete statistics, the covid- infection rate of chinese disabled persons is far below the average. we found that justice had a remarkable role in china's efforts to achieve health equity amidst the pandemic, and noted that sdg ("peace, justice and strong institutions") was more important than we had expected it to be. people with disabilities are disadvantaged in terms of their level of education and physical attributes and this makes it more difficult for them to defend their legal rights through litigation. this is one reason why they present an easy target at moments of social disorder created by critical situations. but the guidance of the supreme court has helped the chinese judiciary to generally recognize judicial activism, and this has obliged the judiciary to provide judicial relief for various social injustices and to use its authorized power to guarantee social development. this activism has been shown during the pandemic. first, efficient and targeted judicial actions (that were premised on the insight there is "no health without peace" ) provided people with disabilities with a relatively stable social order during the pandemic. a stable social order is a prerequisite for the implementation of pandemic prevention work and it is also necessary to maintain the health and safety of people with disabilities, who are more likely to be victims of violent crimes during idp. at an early stage of the outbreak, social panic and shortages resulted in theft (of medical materials), attacks on medical personnel and police (by people pretending to be pandemic prevention personnel) and burglaries. people with disabilities were not spared, and a mobility scooter was stolen in tianjin (unfortunately this was not an exceptional or isolated incident). the chinese courts adjusted their judicial policies, with the aim of assigning the best judges to criminal cases that had the potential to disrupt epidemic prevention. the initiation of public prosecution by procuratorates gave courts the power to pass sentences in days. rapid publication of these precedents helped the police to stabilize the social order. data from the supreme people's procuratorate of the people's republic of china suggests that the number of criminals arrested between january and march was . % lower than the previous year. a stable social order did not only guarantee the safety of pandemic prevention personnel, but also helped to safeguard people with disabilities and the stored medicinal materials. the activities of the chinese courts also helped to alleviate the economic impact on people with disabilities. members of this group generally tend to be poorer than non-disabled counterparts, and the economic depression caused by the pandemic is likely to exacerbate this ("many people with disabilities may not have enough money to stockpile food and medicine or afford the extra cost of home deliveries"). the chinese courts have remitted the cost of litigation for people with disabilities, which means their rights can be more easily safeguarded in the pandemic. it is especially helpful for those fighting against redundancy, as it enables them to maintain a basic income. the courts also established a national judicial aid system in , which enables the state to provide financial relief to the plaintiff who has won the lawsuit but cannot obtain compensation because the defendant has no ability to pay. local courts have used it during the pandemic to give priority relief to disabled civil litigants or criminal victims. each of the two families of disabled criminal victims in hubei province who lost their source of income to the pandemic received judicial aids of approximately $ through this system. social stagnation however made it difficult to enforce sentences in favor of people with disabilities or victims. the courts responded by asking the executive board (the agency responsible for compulsorily enforcing the sentence of the court for incoordinate litigants in china) to prioritize the applications of people with disabilities. for example, a person with disabilities in nanchang quickly received compensation (around $ submit your manuscript | www.dovepress.com risk management and healthcare policy : , ) for a traffic accident during the pandemic, which enabled him/her to survive. but it is difficult for an active judiciary to completely compensate for blind spots in the legislation, and this has restricted china's efforts to promote health equity through interventions that seek to guarantee the health rights of people with disabilities during the pandemic. the optimization of the relevant national legislation therefore needs to be taken seriously. for example, the legal system should provide a more reasonable litigation path to the realization of the interests of persons with disabilities. the provisions of the chinese procedural laws establish that generally binding rules or orders issued by the government against the public (socalled "abstract administrative actions") cannot be sued. in idp, this means that when a few pandemic prevention policies for the public damages or neglects the rights of people with disabilities, they will not be able to defend their rights through litigation. article of the law on the protection of disabled persons (lpdp) states that "people's governments at all levels and relevant departments shall take measures to facilitate the access of people with disabilities to public information". however, even at the time of writing, epidemic prevention policies in a few areas of china still lack information accessibility regulations poor information access exposes people with disabilities, including those with hearing/visual impairments and intellectual disabilities, to greater health risks. but the affected are not able to file a lawsuit based on the spirit of lpdp and are only able to "offer suggestions" to the legislature or local government. more importantly, legislators should stipulate that relevant departments should count disability data when collecting public health data. disability is a human trait similar to age, race, and gender. in article , uncrpd requires states parties undertake to collect appropriate information, including statistical and research data, to enable them to formulate and implement policies to give effect to the present convention. in idp, this means that states parties are obliged to adjust their legal systems to distinguish between disabled and non-disabled groups when they count key public health data such as mortality and infection rates in idp, so as to ensure that the statistical data can be reflected in the realization of the health rights of the disabled groups in the idp. the united states, france, russia, britain, china, and the major countries in the world are all parties to uncrpd. however, until recently, the health status of persons with disabilities has not been widely included in public health surveys, data analysis and health reports. we are still extremely lack of effective information for public health experts to reveal the impact of covid- on people with disabilities, and we still rely on indirect information to a large extent. due to the lack of disability data, it is difficult to track a considerable number of high-risk groups, and their detection rate is also unknown. china's experience demonstrates the many factors that affect the realization of the health rights of people with disabilities during idp. these include the equality and inclusiveness of the emergency plan, the pandemic prevention legislation and decision-making system, the efficiency and sustainability of the resource allocation mechanism and the degree of access to public health information. this paper concludes that more appropriate human rights language should be formulated in sdg , as this will help people with disabilities to acquire an equal life and health guarantee. this will in turn help to promote and uphold the principle of health equity. the guiding role of sdgs across the world means that the problems of people with disabilities in china are also experienced across the world. catalina devandas aguilar, the un special rapporteur on the rights of people with disabilities, observes that people with disabilities "feel they have been left behind" in the current pandemic. each country should take into account the world health organization's (who) warning that covid- may coexist with humans for a long time. they should also refer to china's experience and lessons and ask if its people with disabilities have an equal life and health guarantee in the current pandemic. the perspectives of people with disabilities should also be incorporated into the discussion of the goals and targets of sdg . the question of how sdg can support sdg should also be asked before these discussions begin. not applicable. mrs. ling has provided informed consent for the text to be published. the mutual aid group for people with disabilities in this article adheres to correct guidelines regarding organ transplants, that all organs were donated voluntarily with written informed consent, in accordance with the declaration of istanbul. all authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. qi wang reports being a member of the china law society, standing director of china civil procedure law research institute. the authors declare that they have no other potential conflicts of interest. financing transformative health systems towards achievement of the health sustainable development goals: a model for projected resource needs in low-income and middle-income countries may hospitals withhold ventilators from covid- patients with pre-existing disabilities? notes on the law and ethics of disability-based medical rationing. notes law ethics disabil based med ration united-nations. un working to ensure vulnerable groups not left behind in covid- response intellectual and developmental disability and covid- case-fatality trends: trinetx analysis guterres a we have a unique opportunity to design and implement more inclusive and accessible societies transforming our world: the agenda for sustainable development, united nations including people with disability in the covid- outbreak emergency preparedness and response in china supplementary circular on doing a good job in medical security for covid- pandemic the effect of human mobility and control measures on the covid- epidemic in china national-assembly-of-the-prc regulation on responses to public health emergencies standing-committee-of-the-national-people's-congress. law of the people's republic of china on prevention and treatment of infectious diseases communities to keep helping vulnerable circular on further improving the service of family physician contracting during the prevention and control of covid- pandemic covid- dashboard by the center for systems science and engineering (csse) real-time data report of the latest epidemic map hu f cases of current epidemic report of , disabled persons in hainan province none of the more than , blind people in fujian contracted new coronary pneumonia tang gmy none of the , disabled people in nanjing are infected with covid- life is supreme, every life is precious!; rhetoric and reality: litigation rights of chinese disabled people active justice: actively respond to social development needs. people's court daily no health without peace: why sdg is essential for health an unscrupulous thief stole a mobility scooter for lacking money courts follow the law to deal with epidemic-related crimes quickly: can be completed within three days at the fastest data from the main cases handled by the national procuratorial organs from disability and poverty in china: an analysis based on equivalence scales preventing discrimination against people with disabilities in covid- response xishui county court: facing the epidemic situation, judicial aid is not absent xinjian district court: relieving the disabled people research on the suability of abstract administrative action article -statistics and data collection the public health response to the covid- pandemic for people with disabilities disability and covid- : who counts depends on who is counted director-general's opening remarks at the media briefing on covid- - risk management and healthcare policy is an international, peerreviewed, open access journal focusing on all aspects of public health, policy, and preventative measures to promote good health and improve morbidity and mortality in the population. the journal welcomes submitted papers covering original research, basic science, clinical & epidemiological studies, reviews and evaluations, guidelines, expert opinion and commentary, case reports and extended reports. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. key: cord- - kmbaswt authors: dwolatzky, tzvi title: if not now, when? the role of geriatric leadership as covid- brings the world to its knees date: - - journal: front med (lausanne) doi: . /fmed. . sha: doc_id: cord_uid: kmbaswt nan the covid- virus is a ruthless enemy that knows no borders. the measures that governments have been forced to take are devastating economic life and exposing major inadequacies in health care systems. while the global village dissipates with the halting of international travel, people are facing lockdown in their homes in a desperate effort to curtail the spread of this virulent virus. not surprisingly, those who are older, sicker, frail, and socially isolated, are bearing the brunt of this attack. the respiratory sequelae of covid- in the older population are severe, and many require mechanical ventilatory support in intensive care units. mortality is high, and for those who survive recovery is slow. the need to treat a vast number of patients is overwhelming, resources are scarce, and difficult ethical decisions have to be made. triage criteria are being developed and are generally designed out of urgent necessity rather than being based on clear evidence-based scientific criteria ( ) . as the world struggles to cope with the worst viral pandemic of the last century, a recent report from spain shocked the reader with a new reality. elderly people have been found dead and abandoned in nursing homes in spain, the country's defence minister has said. margarita robles, speaking in a television interview, said the army had made the discoveries while disinfecting old people's homes. the military had found "the elderly absolutely abandoned, if not dead in their beds", said robles ( ). what went wrong? how did a tragedy like this happen in a country that was rated by bloomberg as the world's healthiest nation in ? ( ) . we certainly are not here to judge, and this specific incident is under investigation by the authorities. however, one may postulate regarding the reasons for such a tragic situation. one must remember that this event occurred in a very unusual situation, where the rapid spread of disease has ruthlessly destroyed infrastructure as health care needs outstrip resources. one may try to understand the personal perspective of health care workers pushed to their physical and mental limits in providing care to old and frail people at a time of crisis, while harboring their own concerns and fears. indeed, providing care for patients in an environment where the rapid spread of a highly infectious disease certainly places the health care worker at significant personal risk. moreover, in an atmosphere where the treatment of older functionally or cognitively impaired older people is considered to be futile, the door to abandonment is wide open. however, this event must serve as a wake-up call for us all-individuals, families, health care workers, policy makers, governments. as i was taught as a resident undergoing a compulsory advanced cardiac life support course, the first thing that one should do when faced with a resuscitation is to "take your own pulse." as health care workers, our first responsibility is to ensure that we are personally prepared both physically and mentally to go out to war against a deadly virus. on answering the call to go out to battle, our role is to save lives where possible, yet always to maintain human dignity and respect and alleviate suffering. this call lies at the very heart of geriatric medicine. in the mid-twentieth century, marjory warren, who is regarded as the pioneer of geriatric medicine, and was co-founder of the medical society for the care of the elderly (later becoming the british geriatrics society), fought for the medical recognition of the neglected older population. she recognized that older people had different needs, and emphasized a multidisciplinary comprehensive rehabilitative approach that forms the basis of the profession today ( ). clearly, warren was a visionary, a pioneer and a leader. generations of prominent geriatricians have followed, and geriatric medicine is a recognized medical specialty in most countries. and now, with a viral pandemic sweeping across the globe, geriatricians are actively involved in the clinical care of vast numbers of older people in the community and in hospital settings. yet, geriatricians must take on another role in the fight against coronavirus, a role of leadership. for if you remain silent at this time, relief and deliverance . . . .. will arise from another place, but you and your father's family will perish. and who knows but that you have come to your royal position for such a time as this?" ( ). it is at a time like this that geriatricians must step in to take the lead. it is imperative that we identify issues affecting the health and well-being of older people, actively promote awareness, and work to influence policy at both local and national levels. i will relate to some of the central issues that should be addressed. at the time of writing, a third of the global population is on coronavirus lockdown ( ) . social distancing and the restriction of movement, with a clear call to stay at home and thus prevent exposure to other people who may be a source of coronavirus infection, is in accordance with the world health organization's efforts to limit the spread of the virus. however, lockdown has major repercussions on the lives of older people. for older people who frequently suffer from a number of chronic conditions, health maintenance is essential. adequate control of factors such as blood glucose, blood pressure, cardiac failure, mobility in parkinson's disease, chronic pain, and many others, is essential in promoting well-being and preventing complications. with the initiation of lockdown, older people are unable to visit their family physician for checkups or to receive prescriptions, and they have limited ability to get to the pharmacy or access other medical services such as physical therapy. as the time spent in lockdown progresses, the likelihood is that many older people will develop unnecessary complications due to poor control of chronic illnesses. to prevent this a "reach-out" policy should be developed, based on the traditional and effective standardized multidimensional comprehensive geriatric assessment. such an approach will help to minimize the development of harmful geriatric syndromes, such as falls, frailty and polypharmacy. community clinics should contact older patients regularly to enquire about health status, and should obtain information regarding measurable physical signs, adequate supplies of medications, and other health needs. technology can play an important role in health monitoring by the use of smart phone applications, telemedicine, and other modalities. in addition, older people who are living alone should be encouraged to install fall detection devices, and to use wearable "call for help" pendants or wristwatches. the obvious result of lockdown is psychosocial isolation. most younger people or those with families manage to adapt to the stresses of social isolation. but for older people who are often alone and functionally limited, the lack of social contact can be devastating. contact with family members and friends is discouraged as part of the call for social distancing. the effect of loneliness on one's mental state at an older age has been clearly determined. the path to depression, anxiety and cognitive decline is often inevitable. a lack of appetite, limited food supplies, and reduced motivation to prepare adequate meals, will likely result in a deterioration of the older person's nutritional status. in an effort to alleviate these untoward results, local agencies in cooperation with volunteer organizations should identify older people who are alone at home. these people must be contacted regularly to "touch base" regarding their needs and to help them replenish dwindling supplies. they should be offered "meals on wheels" and home delivery of provisions. regular telephone contact, discussions with neighbors at a distance "over the balcony rails, " and videoconferencing with family and friends is encouraged. it is essential to maintain mental function by reading, solving crossword puzzles or sudoku, and engaging in other cognitively stimulating activities such as scrabble, chess or bridge, especially by partnering with other people on-line. older people should be encouraged to adopt a daily exercise schedule to include personal preferred forms of activity, such as stretching and isometric exercises, and walks around the house a number of times during the course of the day. current experience with the covid- outbreak clearly indicates that older people are at a markedly increased risk for complications and mortality. it has been shown that mortality begins to increase from the age of years, rapidly rising to . % in confirmed cases above the age of ( ) . the respiratory manifestations of this disease are severe and frequently require mechanical ventilation in high care and intensive care units. as such, every measure that will decrease the exposure of older people to coronavirus should be adopted, and an approach of early detection and treatment should be adopted. older people who are cognitively and/or functionally impaired and are living at home are usually cared for by nursing assistants. the continuing employment of health workers is essential at the time of crisis. in italy, healthcare workers constitute % of covid- patients. thus, protecting these workers must be a main priority. as such all health workers should be given appropriate training and protective equipment to prevent infection. in addition, this sector must be given priority for covid- testing. not only will this ensure the rights and personal safety of the workers, but it will limit the exposure of the older population to the virus. as the covid- pandemic unfolds, the tragedy of a rapid spread of the virus among frail and vulnerable older residents of nursing homes has resulted in catastrophic consequences. the centers for disease control and prevention (cdc) has issued clear guidelines for protecting residents, families and staff of long-term facilities from serious illness, complications, and death ( ) . the strategies include closing off the facility by restricting visitors, the use of personal protective equipment, the active screening of residents and staff, the implementation of social distancing and isolation of suspected cases, and the early identification, and treatment of severe illness. geriatricians and gerontologists should spearhead the implementation of these key strategies in nursing homes. as yet there is no proven vaccine or therapeutic agent for covid- . however, a number of agents are being used empirically based on clinical experience, albeit with limited supportive evidence. these include hydroxychloroquine sulfate and zinc. there is also some interest in using the interleukin- inhibitor tocilizumab, which has recently been approved by the us food and drug administration (fda) in a phase trial for severely ill covid- patients hospitalized with pneumonia ( ) . based on the knowledge that the older population is at the greatest risk, priority should be given for providing therapeutic agents particularly to older people with coronavirus infection, as much as this is possible considering local policy and availability. the unfolding coronavirus pandemic has pushed health systems way beyond their limits. demand has rapidly surpassed supplies in many countries. this has resulted in a chaotic situation where difficult decisions have to be made. probably the most painful of these decisions is who should be entitled to the use of mechanical ventilators. policy makers have rapidly designed triage systems in order to provide scarce lifesaving equipment to those most likely to benefit. considering that the prevalence of major complications is significantly higher in older people in whom the chances of survival are lower, restrictions have been developed based specifically on chronological age. geriatricians should raise their voices in opposition to such a manifestation of ageism. for years chronological age was used as an absolute criterion for withholding critical and lifesaving services from older people. treatment in intensive care units, the provision of hemodialysis, and surgical interventions, as a few examples, were not provided to those over the age of due to limited availability. decades of research, education, and lobbying by geriatricians, have convinced the medical world that one should relate to the physiological and functional state of the older person as a measure of biological age rather than to the absolute criterion of chronological age. when faced with difficult decisions due to a lack of resources we must consider age in the context of comorbidities and function. autonomy is one of the four pillars of bioethics. people have the right to determine their own destiny, and this right must be respected. in the throes of a spreading pandemic, there is a greater likelihood that an older person will have to face difficult decisions regarding life-saving measures. as such geriatricians should encourage patients to express their medical preferences in a living will. as geriatricians we are proud of our role as leaders of the medical teams caring for our older members of society. while countries fight for survival in the battle against coronavirus, we must lead the effort to ensure that older people are not forgotten, that their needs are provided, and that they are treated with the respect that they deserve. and if not now, when? hillel said: . . . if not now, when? ( ). td developed the concept of the article and wrote the manuscript. fair allocation of scarce medical resources in the time of covid- spanish nursing home world's healthiest nations the relevance of marjory warren's writings today age of coronavirus deaths cdc coronavirus long term care strategies. available online at the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © dwolatzky. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -j hnldk authors: saadat, saeida; rawtani, deepak; hussain, chaudhery mustansar title: environmental perspective of covid- date: - - journal: sci total environ doi: . /j.scitotenv. . sha: doc_id: cord_uid: j hnldk the outbreak of covid- has caused concerns globally. on january who has declared it as a global health emergency. the easy spread of this virus made people to wear a mask as precautionary route, use gloves and hand sanitizer on a daily basis that resulted in generation of a massive amount of medical wastes in the environment. millions of people have been put on lockdown in order to reduce the transmission of the virus. this epidemic has also changed the people's life style; caused extensive job losses and threatened the sustenance of millions of people, as businesses have shut down to control the spread of virus. all over the world, flights have been canceled and transport systems have been closed. overall, the economic activities have been stopped and stock markets dropped along with the falling carbon emission. however, the lock down of the covid- pandemic caused the air quality in many cities across the globe to improve and drop in water pollutions in some parts of the world. on late december in a hospital in wuhan city, in china an unusual pneumonia was noticed with a link to an animal market that sells poultry, fish and other animals to the public (xu et al., ) . this event was soon reported to the world health organization (who). in a month ( january), the causal microorganism had been identified as a novel coronavirus that was named covid- . genome sequencing and reverse transcription polymerase chain reactions tests of this virus had been done. who r&d had been started to quicken diagnostics, therapeutics and vaccine development and a candidate vaccine was prepared for initial laboratory testing . the emergency committee of who declared a global health emergency on january based of growing case notification rates at chines and international locations. the case detection rate is changing on a daily basis and could be tracked in nearly real time on the developed website by johns hopkins university and other media. in the middle of february , china suffered the huge burden of morbidity and mortality, whereas the incidence in other asian countries, in europe and north america remains low so far (velavan and meyer, ) . coronaviruses are single-stranded rna viruses that can infect not only humans, but also a huge variety of animals as well (kooraki et al., ) . these viruses were first studied by tyrell and bynoe in who cultured them from patients with common cold. due to their spherical virions morphology along with a shell and surface projections like a solar corona, these viruses were named coronaviruses. in latin corona means crown and there are four different subfamilies including alpha, beta, gamma and delta coronaviruses identified so far. alpha and beta-coronaviruses have been originated from mammalians, particularly from bats, gamma-and delta-coronaviruses originated from pigs and birds (ather et al., ) . the genome of these viruses differs between kb and kb. the beta-coronaviruses could cause severe disease and fatalities among the other seven subtypes of these viruses. alpha-coronaviruses cause mildly symptomatic or even asymptomatic infections. sarscov- is a beta-coronavirus and is related to the sars-cov virus. there are four structural genes encoding the nucleocapsid protein (n), the spike protein (s), a small membrane protein (sm) and the membrane glycoprotein (m) with an extra membrane glycoprotein (he) occurring in the hcov-oc and hku betacoronaviruses. the whole genome of sars-cov- is % identical to that of a bat coronavirus cao et al., ) . sars-cov- seemingly had made its transition from animals on an animal market in wuhan city in china. although, the efforts to identify potential intermediate hosts seem to have been neglected in wuhan and the exact transmission route have to be clarified. the primary clinical symptoms of the sars-cov- -linked disease covid- which permitted the case detection as pneumonia. recently literatures report the description of gastrointestinal symptoms and asymptomatic infections, especially among young children. the average incubation period is ranging from to days zhou et al., ) . as we are writing these lines, the pandemic affects countries and territories, with around , , infected subjects, more than , deaths and . recovered patients, according to the johns hopkins university. as who has declared the fast spreading of covid- as an epidemic, the citizens around the globe hastened to go home. for instance, in the case of wuhan city in china which has been the epicenter of the pandemic with over than million people, is shown to have produced tons of clinical trash on a single day exactly february/ which is four times the amount the city's only dedicated facility can incinerate per day. as coronavirus is spreading rapidly to other parts of the world, very soon the medical waste management could be a big issue. medical health organizations waste management companies have already taken step in coronavirus decontamination services, it is becoming very crucial for governments to find solutions soon. at the meantime, it is every individual's duty to follow the regulations while discarding of their face masks and other medical wastes (luan and ching, ) . to the end, it is possible only by mutual understanding and willingness and world will emerge stronger than this epidemic. some people are at higher risk of adverse effects from contact to medical wastes as well, including cleaners, trash collectors and some other people who have to spend a great amount of time in public places. all over the world governments stopped students to go to schools and universities, and a lot of employees are being asked to work from home, only those who are maintaining the cleanliness of cities have to go to their jobs daily, that makes them among the most vulnerable groups and one that is highly susceptible to the virus from respiratory shed droplets on the masks. they may also be infected by other pathogens existing in the discarded pieces of garbage, for instance meningitis and hepatitis b. the masks are made up of plastic based materials that are liquid-resistant and are long lasting after they are discarded, ending up in ocean or landfill. the surgical masks should not be worn longer than one day, discarding them and empty bottles of hand sanitizer along with solid tissue papers are ending up to a huge trail of medical waste in the environment. for instance, in hong kong, where covid- infection started in late january/ the medical wastes have already polluted the environment. recently, an environmental ngo ocean asia in soko islands took a survey, according to it, in hong kong a large amount of discarded single-use masks washed up to a -meter stretch of beach. gary stokes the director of the ocean asia ngo, who has been monitoring the ocean surface trash, his team has seen a few masks over the years, but now they were spotted all along the high tide line and seashore with new deposits coming with each current. while this recent covid- outbreak, the general public have started wearing surgical masks in order to take precautionary measures. when million people suddenly start wearing one or a couple of masks daily, single use gloves and hand sanitizers, the amount of trash created is going to be substantial. the contrary impacts of such medical wastes are far-reaching. when these are remained discarded in an animal's natural habitat in both land and ocean this could cause animals to mistakenly eat this as food and lead in their death (hellewell et al., ) . the diagram below illustrates the problems of polluting the environment by medical wastes while covid- pandemic (fig. ). covid- does not affect everyone in the same way. there are several reasons that's why different socioeconomic groups are affected by this pandemic in different ways. to understand the consequences, and to predict how this pandemic affects differently with various socioeconomic groups is not easy and good data is the key to it. these socioeconomic factors include population density, urban and rural settings, education level, lifestyle, the size of household and homeowners & tenants. sometimes only a single block distance neighborhood household within the socioeconomic spectrum can make a huge difference in one's life (demonstrate form the us in club vita's us longevity map). therefore, sometimes it is very unfortunate that people who are feeling the effects of covid- very severely, are probably in your neighbors (messner, ) . majority of the countries are now trying different tactics to stop the spreading of the disease and trying to limit only a subset of the people would catch the disease. it has been indicated that groups with lower socioeconomic status could be more at danger from the spread of the covid- , based on the analysis of new york showing that poor neighborhoods have been affected highly. covid- spreads by droplets shed of the respiratory system by someone with the virus, which means it would spread with higher proximity of people, larger contact networks and lower levels of hygiene. there are some factors, which increase the risk of catching the virus. -population density: close contact among people is very high in urban areas rather than rural areas. -household size: a big household will have a higher chance to bring the virus home, while in household where one person lives alone; he/she will have to catch the virus outside the household. in sweden, social-distancing regulations are not taken very strictly due to the high proportion of single person household. whereas in italy based on the multi-generational homes apparently contributed to the multiplication of the coronavirus. -social distancing level: social distancing is very effective to stop the spread of the disease, but several reasons that various groups might show dissimilar levels of social distancing: -official advice might be dependable between regions, for instance, guidance in the us has varied even between neighboring towns. access to local guidance might be different between socioeconomic groups, for instance guidance might be provided online or in particular languages. -working from home might reduce social contact, but can only be available to some people focused in jobs linked to higher socioeconomic status. -stay at home regulations would be more than a challenge for those who live in smaller and crowded houses or without outside space. -some groups would be obedient to social distancing regulations not all. -not all who are infected by the covid- will react severely to it. there are some factors that contribute to the risk of covid- but they are probably felt differently by different socioeconomic groups (lipsitch et al., ) -people who have had medical problems of diabetes, chronic respiratory disease, cardiovascular disease, or even high blood pressure and cancer are at higher risk from coronavirus (giannis et al., ; fang et al., ; zheng et al., ) . -who has warned the smokers that they might be highly at risk because to the obvious effects of smoking on the lungs and smoking is common in lower socioeconomic groups. -different socioeconomic groups do not have access to the same level of healthcare services. this would particularly common in countries like us where the huge number of uninsured population is concentrated in certain industries not to universal health care system. therefore, some socioeconomic groups are more likely at risk compared to others. so, logically higher numbers of deaths can be expected from certain parts of society. this can be highly related for pension plans using analysis of this experience of the population to predict future mortality rates. the post pandemic population may look more different compared to the start point of this outbreak. the annual percentage change in gross domestic products is shown in table. . the short-term scenarios of the covid- environmental aspects raise many questions. china is struggling to rebound from the epidemic and has to limit the re-entry of covid- to its region by put a check on travelers coming from abroad (bogoch et al., ) . in a country with such a high population, where the majority of its population has not yet experienced covid- , and has no immunological contact with this virus, the possibility of second wave is a big risk. european and north american countries has not yet reached to the peak of the epidemiological curve. one crucial aspect seems obvious: the fast control of the outbreak done by china could not be implemented to democratic countries where rights of individuals are very high. therefore, outside china no leader has the capability to enforce these measures at the level of china (bai et al., ) . the question is: what will happen in countries of indian sub-continent, the middle-east and south america, where they live in crowded forms traditionally, big gatherings are common, and the public health systems are insufficient. the possibility of secondary peak appearance could not be estimated. in the mid-term, the scenario in the southern hemisphere should be considered. not almost all south american and african countries have access to national health systems and sufficient health care services. many of these nations decided to close the borders, however very late, when they already had patients of covid- inside. all these indications show that the southern hemisphere would not escape from this pandemic. the outbreak is widening in the southern hemisphere now, and this is happening while the higher income nations are struggling over their own problems in (i) applying control actions (ii) trying to recuperate from the massive social and economic impacts, and (iii) focusing in preventing re-entry of covid- by foreign travelers (chinazzi et al., ) . the long-term scenario of probable secondary waves of outbreak is concerning as well. a second wave might be devastating more than the first one, based on other pandemics in history. economists have shown serious concerns about the economic effects of control measures taken during this crisis (hemida and abduallah, ) . however, there are many models that show the economic impacts of the disease and majority of the economists are challenged by the social and economic depth of the pandemic. they are trying to understand the control as soon as possible. although the economic losses are obvious, but still economists are not able to grasped the extending nature of the outbreak that is causing far more economic damage compared to drastic measures taken to end the pandemic globally as soon as possible (meo et al., ; anderson et al., . the covid- pandemic will have severe impact on socioeconomic growth across the globe as shown in table. . general actions to decrease person to person transmission of coronavirus are needed to control the present outbreak. special restrictions strategies and efforts should be applied to protect the highly vulnerable populations such as children, health care workers, and older aged people . a guideline has been already published for the medical employees, health care providers, and public health individuals and researchers who are interested in working in the coronavirus (mossa-basha et al., ) . the major death cases of coronavirus outbreak are happening mainly in old people probably because of a poor immune system that allows rapid growth of viral infections. the public services must provide in decontaminating reagents for sanitizing hands multiple times on a daily basis (luan and ching, ) . physical contact with contaminated and wet things must be counted in dealing with the coronavirus, particularly agents which could be a possible rout of transmission. china and some other countries such as the us applied travel screening that could control and prevent the spread of the virus. epidemiological alterations in coronavirus infections must be observed. the probable routes of transmission and subclinical infections, adaptation, progression must be taken into consideration and spreading of virus among people and potential intermediate animals and reservoirs should perceived. moreover, still there are significant numbers of questions that need to ponder. these are, but not limited to, details about how many people have been tested, how many of them turned positive and whether this range stays constant or fluctuating. additionally, only fewer pediatric cases have been reported to date; that could be due to lack of testing and not due to true infection (rothan and byrareddy, ) . only in a period of few months, the world has changed. thousands of people have been deceased, and hundreds of thousands have been infected by covid- . and the rest of people who are not infected, their entire life has been changed by this virus. in italy, the most massive travel restrictions are being placed since second world war. in london, the normal busy bars, theatres, and other public places have been closed and people are asked to stay in their homes. the flights are being canceled in all over the world. majority of people are staying at home, practicing social distancing and working remotely (harapan et al., ) . it is all happening to control the spread of coronavirus, and to decrease the death rate. however, all these changes have led some unexpected consequences. as industries, transportation systems and all other bossiness have shut down; it has caused a sudden drop in carbon emission. compared to this time last year, levels of air pollution in new york have dropped at almost % due to measures that have been to restrict the spread of virus. in china, emissions data shows a % decrease at the starting point of the year as people were told to stay at home, factories closed and coal use feel by % at china's largest power plants since the last three months of . according to the ministry of ecology and environment, the amount of good quality air was around . % compared with the same time last year in more than cities all over china. in europe, nitrogen dioxide (no ) emission dropped over northern italy, spain and uk, as shown in satellite images (ficetola and rubolini, ) . this epidemic has also caused extensive job losses and threatened the sustenance of millions of people as businesses are struggling and are shut down to control the spread of virus. economic activities have been stopped and stock markets dropped along with the falling carbon another unexpected environmental impact of coronavirus has been observed in venice, italy. as the tourist's numbers culled due to the coronavirus, the waters in venice's canals are cleaner compared to the past. while motorboats, sediment churning and other water pollutants have been dropped efficiently, residents got amazed by seeing the clear water and the fish could be seen once again in the canals. one of the other effects of coronavirus on environment is the noticeable drop in coal consumption. this contributed in a large scale drop in air pollutants in china. the number of airborne pollutants like co , co and nitrous oxides has fallen too. as millions of people are holding on lockdown across the globe, energy consumption profiles in buildings are being disturbed. as many people working from home nowadays, domestic energy consumption is predicted to rise very quickly. the predictions data showed that this has risen around to % in the us. this pandemic would ultimately save energy and also might have an effect on reducing the consumption of polluting fuels in power stations as the demand has been dropped (lau et al., ) . the covid- pandemic has changed the air quality in many cities across the world as shown in the fig. . the covid- pandemic is spreading very quickly every day, and the number of people putting on lockdown is increasing, to date more than , people have died across the globe and there is a direct loss to the world economy. however, many think that there is a good side; that the spread of virus has been decreasing air and water pollution and probably even saved lives in this process. nevertheless, this epidemic which is taking people's lives certainly should not be seen as a way of bringing about positive environmental change. first of all, it is not certain for how long this dip in emission will be. when the epidemic finally subside, then carbon and other pollutant emissions get back then it would be as if this clear sky view never happened and the changes we see today will not have lasting impact. general actions to reduce person to person transmission of covid- are required to control the current outbreak. special attention and labors should be applied to save the highly vulnerable populations including children, health care workers, and old people. there is already published guideline available for the medial employees, health care providers, and public health individuals and researchers who are interested in working in the coronavirus. most of death cases of coronavirus outbreak are happening largely in old people possibly due to a weak immune system that permits rapid growth of viral infections. the public services must provide decontaminating reagents for sanitizing hands multiple times on a routine basis. physical contact with contaminated and wet things must be taken into count while dealing with coronavirus, particularly agents that could be a possible route of transmission. epidemiological alterations in coronavirus infections must be observed taking into consideration the probable routes of transmission and subclinical infections, furthermore to the adaptation, progression, and spreading of virus among people and potential intermediate animals and reservoirs. there are still some remaining doubts that have to be considered. the most important thing is about the details of how many people have been tested, how much of them turned positive and whether this range stays constant or variable. a less number of pediatric cases have been reported to date; that could be due to lack of testing and not due to true infection. how will country-based mitigation measures influence the course of the covid- epidemic? coronavirus disease (covid- ): implications for clinical dental care presumed asymptomatic carrier transmission of covid- pneumonia of unknown aetiology in wuhan, china: potential for international spread via commercial air travel remdesivir for severe acute respiratory syndrome coronavirus causing covid- : an evaluation of the evidence the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak are patients with hypertension and diabetes mellitus at increased risk for covid- infection? comparison of air quality in some of the biggest cities around the world before the covid- pandemic and while the lockdown climate affects global patterns of covid- early outbreak dynamics coagulation disorders in coronavirus infected patients: covid- , sars-cov- , mers-cov and lessons from the past coronavirus disease (covid- ): a literature review feasibility of controlling covid- outbreaks by isolation of cases and contacts the sars-cov- outbreak from a one health perspective coronavirus (covid- ) outbreak: what the department of radiology should know early dynamics of transmission and control of covid- : a mathematical modelling study the positive impact of lockdown in wuhan on containing the covid- outbreak in china coronavirus disease (covid- ): spectrum of ct findings and temporal progression of the disease defining the epidemiology of covid- -studies needed a reusable mask for coronavirus disease sars to novel coronavirus-old lessons and new lessons biological and epidemiological trends in the prevalence and mortality due to outbreaks of novel coronavirus covid- the institutional and cultural context of cross-national variation in covid- outbreaks policies and guidelines for covid- preparedness: experiences from the university of washington the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak trop med int health, . the covid- epidemic clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china pathological findings of covid- associated with acute respiratory distress syndrome covid- and the cardiovascular system a pneumonia outbreak associated with a new coronavirus of probable bat origin key: cord- - ateeei authors: vannabouathong, christopher; devji, tahira; ekhtiari, seper; chang, yaping; phillips, steven a.; zhu, meng; chagla, zain; main, cheryl; bhandari, mohit title: novel coronavirus covid- : current evidence and evolving strategies date: - - journal: j bone joint surg am doi: . /jbjs. . sha: doc_id: cord_uid: ateeei covid- is a global pandemic that has currently infected &gt; , globally. fever and cough are the most common symptoms of the disease, and it is important to remember that the virus can even be transmitted by individuals who test positive for the disease but do not have any symptoms. currently reported mortality rates vary because of the rapid spread of the disease and different approaches to calculating this estimate, but it is clear that the risk of death is associated with age and the presence of underlying conditions. risk mitigation techniques (i.e., hand washing, social distancing, and self-isolation) have already been emphasized across major news outlets. it is essential that we continue these practices, as the outbreak is currently expected to last for many more months and we must be mindful of the lessons learned from past pandemics to prevent a second wave from occurring. the outbreak of a novel coronavirus, referred to as severe acute respiratory syndrome coronavirus- (sars-cov- ) or coronavirus disease- , with its sentinel case in wuhan, people's republic of china, in december , has spread rapidly beyond the people's republic of china. on march , , the world health organization (who) declared covid- a worldwide pandemic, at which time > , people across countries, territories, and areas had been infected by this virus . covid- has rapidly become a global public health threat, endangering the health and well-being of all people, but especially vulnerable populations , . the pandemic has also precipitated social disruption, exceptional health-care utilization, and economic instability worldwide. controlling the spread of covid- has become the singular focus of several countries, with unprecedented international collaboration and rapid dissemination of emerging scientific evidence. table i summarizes what we know about covid- . we performed a search of electronic databases (pubmed, embase, google scholar) for relevant research articles on march , . we accessed the medrxiv database for any unpublished papers, as research in this field is quickly emerging. we also searched the world health organization (who), the u.s. centers for disease control and prevention (cdc), and other government health agency websites for relevant information. what is covid- ? covid- is the disease caused by the sars-cov- virus, which belongs to the family of coronaviruses . coronaviruses are positive-sense, single-stranded ribonucleic acid (rna) viruses that infect a variety of mammalian hosts, causing a range of symptoms that primarily affect the respiratory and gastrointestinal systems . coronaviruses tend to cause mild symptoms in humans, although several strains, including the viruses responsible for the severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) outbreaks, have been linked to more severe symptoms and mortality . sars-cov- was isolated from several patients in wuhan, people's republic of china, and was identified as a novel coronavirus hitherto unknown to the medical field . the virus was named from its phylogenetic and taxonomic similarities to the sars coronavirus (sars-cov), the cause of the sars outbreak in to . sars-cov- represents the seventh known coronavirus. the transmission characteristics of sars-cov- were originally unclear, but it soon became apparent that the virus originated from an unknown animal source and was now spreading from human to human . the major route of transmission is through direct routes, such as respiratory droplets produced through coughing or sneezing, between people who are in close contact with one another, and through contact with contaminated surfaces or objects . although much of the focus has been on isolating symptomatic patients, there has been some potential evidence of transmission in asymptomatic patients (i.e., patients who are infected but not exhibiting symptoms associated with covid- ) [ ] [ ] [ ] . at the time of this writing, grow-ing evidence suggests that asymptomatic, pre-symptomatic, or mildly symptomatic individuals could be drivers of the community spread of the virus. some recent reports on asymptomatic cases have suggested that viral shedding can last close to a month , , although it is unclear how great the risk of transmission might be throughout this period. emerging mathematical models analyzing the outbreaks in singapore and tianjin, people's republic of china, also support the existence of asymptomatic and pre-symptomatic transmission of covid- . researchers analyzing the outbreak data from tianjin and singapore found that infection was transmitted, on average, . days prior to symptom onset in tianjin and . days prior to symptom onset in singapore in each cluster . several studies have sought to establish the basic reproductive number (r ) for sars-cov- . the r represents the number of new cases that can be expected to stem from each unique case. an early examination of the first patients in wuhan found that the r was . ( % confidence interval [ci], . to . ), meaning that each person infected with covid- can be expected to infect at least other people by definition , "a pandemic is the worldwide spread of a new disease." it can be transmitted between people and spread worldwide because of the absence of preexisting immunity against the new virus in humans . figure illustrates a timeline of important events associated with covid- . chinese laboratories successfully isolated a new type of coronavirus, after conducting tests on all suspected cases on january , . from the middle to late january , thailand, japan, south korea, and the united states reported their first cases of confirmed covid- , . by the end of january , , confirmed cases were identified globally across countries . on the second meeting of the international health regulations emergency committee on january , , the who declared a public health emergency of international concern (pheic) . the term pheic is defined as : "an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease; and to potentially require a coordinated international response." also, according to the who , "this definition implies a situation that is serious, unusual, or unexpected; carries implications for public health beyond the affected state's national border; and may require immediate international action." eleven days later, on february , , there were, cumulatively, , confirmed cases and deaths globally across countries, and the majority were identified in the people's republic of china . on february , , the who announced a name for the new coronavirus disease: covid- . timeline of important covid- events. since then, the numbers of confirmed cases and deaths have been escalating globally. by march , , there were > , cases and > , deaths across countries . one day later, on march , , in remarks to the media, the who director-general, dr. tedros adhanom ghebreyesus, announced covid- to be a pandemic based on > , cases in countries and , deaths due to the disease , . the countries with the highest prevalence, to date, are the people's republic of china, italy, iran, south korea, and spain . the current understanding of the incubation period, the period between exposure and the appearance of the first symptoms of infection, for covid- is limited. the current best evidence from an analysis of confirmed covid- cases detected from provinces, regions, and countries outside of hubei province between january , , and february , , estimated the median incubation period to be . days ( % ci, . to . days) . of all infected cases, researchers estimate that < . % of cases will show symptoms within . days ( % ci, . to . days) of exposure and that . % of cases will show symptoms within . days ( % ci, . to . days) . currently, real-time reverse transcription-polymerase chain reaction (rt-pcr) is considered the reference standard for detection of the sars-cov- virus in respiratory specimens. mass screening procedures (testing those with and without symptoms) and documented illness of covid- have demonstrated that the clinical spectrum of infection with sars-cov- appears to be wide, with a range including asymptomatic infection, mild upper respiratory tract illness, severe viral pneumonia with respiratory failure, and death , , . table ii presents a list of common symptoms among patients with covid- from an unpublished systematic review of retrospective studies including a total of , patients who were positive for sars-cov- . the authors found that, although fever was the most common symptom in these patients, only , patients ( . %) had fever as their onset symptom. radiographic findings revealed that , ( . %) of , patients had abnormalities on a chest computed tomographic (ct) scan, with either unilateral or bilateral ground-glass opacity and/or consolidation, with a peripheral distribution. lymphocytopenia (lymphocyte count < . · /l) was present in , ( . %) of , patients, and , ( . %) of , patients had elevated levels of c-reactive protein . because of the disease's rapid increasing case profile, the presence of asymptomatic and untested cases, and its varying effects across different patient demographic characteristics, the estimates of the mortality risk have been wide-ranging. on average, at the time of this writing, the who reported that the time between symptom onset and death ranges from to weeks , . as of march , , the who reported a mortality estimate of . % in confirmed cases globally; however, the highest incidence rate was in italy at . % . baud et al. suggested that a more representative estimate of mortality should not be relative to the number of confirmed cases (as patients are infected much earlier), but should be based on the total number of patients who were infected at the same time as those who died . to re-estimate the risk of mortality based on this approach using data as of march , , baud et al. divided the number of deaths in day by the number of confirmed cases days prior. this analysis led to mortality rates of . % ( % ci, . % to . %) for the people's republic of china and . % ( % ci, . % to . %) outside of the people's republic of china; globally, this estimate was . % ( % ci, . % to . %) . in a similar analysis on patients in wuhan, the estimate was . % . overall, when not considering the timing of infection, baud et al. argued that the risk of mortality can be underestimated . in contrast, some believe that this risk is actually overestimated because of the number of undiagnosed cases. klompas and wilson et al. suggested that currently reported estimates are inaccurate as asymptomatic positive cases have not been considered in these calculations. in addition, the risk of death increases with age and the presence of comorbidities , , . in a cross-sectional analysis that included , covid- -related deaths in the people's republic of china, the novel coronavirus pneumonia emergency response epidemiology team found that > % were patients ‡ years of age; when extending this range to those who were ‡ years of age, this number increased to > % . in terms of comorbidities, in this same study, the authors found that the mortality rate in patients with no comorbidities was about . %, whereas it was . % in patients with cardiovascular disease, . % in patients with diabetes, . % in patients with respiratory disease, and . % in patients with cancer . moreover, in a report by the who-china joint mission, they estimated that the risk of death in those without comorbidities was . %, and the incidence was higher in those with . approximately % of confirmed cases are diagnosed with mild to moderate disease (pneumonia and non-pneumonia cases), about % of cases experience severe disease (dyspnea and other respiratory problems), and the remaining % of cases are deemed critical cases (respiratory failure, septic shock, or multiple organ failure); similar to the risk of death, patients who are ‡ years of age and those with preexisting conditions are at the greatest risk of having severe disease , , . in a retrospective study on covid- patients in chongqing, people's republic of china, qi et al. evaluated patients who were categorized as severe or non-severe cases and found that patients with severe cases were significantly older (median age of . years compared with . years for patients with non-severe cases) and were more likely to have comorbid conditions ( % compared with %) . several reports have suggested that the median time from symptom onset to intensive care unit (icu) admission is approximately days , , . in a recent systematic review, fang et al. found that ( . %) of , patients were admitted to the icu . in the study by huang et al. , among confirmed cases in wuhan, % were admitted to the icu, strictly because of respiratory issues that required high-flow nasal cannula or higher-level oxygen support. in an updated study by chen et al. on patients, the icu admission rate was %, with % needing invasive mechanical ventilation and % needing noninvasive mechanical ventilation. in a larger study on , patients in china, % were admitted to the icu and . % underwent invasive mechanical intervention . in contrast, when looking at patients with severe illness only, qi et al. showed that ( %) of cases required noninvasive mechanical ventilation, % needed high-flow nasal cannula oxygen, and % required invasive mechanical ventilation . although the current evidence shows that older patients and those with underlying health conditions are at higher risks of severe disease and death, younger and, presumably, healthier individuals should still be concerned about experiencing severe outcomes if infected with covid- . the cdc recently published a report on u.s. patients with covid- , using data from february , , to march , , and, although their case-fatality rate may be low (i.e., < %), patients in the younger age groups had appreciable risks of both hospitalizations and icu admissions (fig. ) . among the cohort of patients included in the who-china joint mission report, the median time from onset to recovery (of those who survived) for mild cases was about weeks, whereas this was between and weeks for those who had severe or critical disease . the development of severe disease was about week from onset and deaths occurred at to weeks . as the number of cases continues to rise rapidly across the world, there is growing concern that health-care systems will quickly become saturated and unable to adequately respond to the outbreak. the soaring number of cases in italy (estimated at , as of march , ) requiring medical attention and hospitalization has overwhelmed the health-care system; some hospitals are filled to capacity, and there are a shortage of beds and a lack of medical equipment such as ventilators for those patients with more serious illness. in epidemiology, preventing and slowing the virus's spread so that fewer individuals require medical treatment at any given time are referred to as "flattening the curve" of the pandemic. without precautions or measures to slow the rate of infection, the projected number of people who will contract covid- over a period of time will likely increase exponentially. infection curves with a steep rise place greater demands on health-care systems, overwhelming limited health-care resources and forcing agonizing decisions about which patients will receive life-saving treatment and which patients will not. however, a flatter curve assumes the same or fewer absolute number of cases but over a longer period of time . a slower rate of infection reduces the burden on health-care systems and allows patients to receive appropriate care. a major issue faced by policymakers and health-care professionals is the apparent evidence that the virus can be spread by asymptomatic and pre-symptomatic patients [ ] [ ] [ ] . early evidence from pre-published studies of cohorts indicate that the virus is spread, on average, to days before symptoms present , . as there is no current vaccine that can protect against infection, preventing the spread of the virus, particularly in patients without symptoms, requires a comprehensive approach through collective action. international, national, and local public health authorities have made prevention and control recommendations based on current understanding of modes of transmission of the virus (table iii) . practicing proper hygiene includes frequent hand washing; avoiding touching the eyes, nose, and mouth; coughing or sneezing into a bent elbow or tissue; and wearing of masks for symptomatic individuals . social distancing involves taking deliberate steps to minimize close contact between people to limit covid- transmission in the community. examples of social-distancing measures include but are not limited to cancelling events and mass gatherings, closing schools or switching to online learning, working from home, and reducing public services such as access to community centers. additionally, many countries have begun advising their citizens to avoid all nonessential travel outside of the country, as well as banning or severely limiting incoming international flights. this seeks to limit the spread from countries with higher cases of covid- to the resident country. finally, an isolation from other individuals by a distance of m (or feet in the united states) is suggested. individuals who do not have symptoms but may have been exposed to the virus through close contact with someone diagnosed with covid- or those who have traveled outside their home country are recommended to self-isolate for days. the -day self-isolation recommendation is due to the time frame for symptoms to present, as previous studies have found that the presentation of symptoms occur by days . therefore, by isolating for days, a person would theoretically present with symptoms and would be able to be tested, while not actively spreading the virus in the community during the self-isolation period. the race for a covid- vaccine has become the focus of several research teams globally as researchers work to develop and test a vaccine that can potentially prevent future cases of the disease in vaccinated patients. groups in canada, germany, the people's republic of china, and the united states are all at varying stages of vaccine development, with human trials likely under way by the time of this article's publication [ ] [ ] [ ] [ ] . at least phase-i trials are registered on clinicaltrials.gov, including in the united states and the people's republic of china (clinicaltrials.gov identifier: nct , nct , nct , nct ) ( table iv) . one of the key lessons from previous attempts at the development of a sars coronavirus vaccine is the concern for immunopotentiation. in other words, whole-virus vaccines led to an undesired increase in infectivity or eosinophilic infiltration . johnson & johnson, the university of hong kong, and codagenix are all exploring whole-virus sars-cov- vaccine options. however, given the aforementioned concerns with regard to increased infectivity following immunization and the general dangers associated with live virus vaccines, extensive testing will be needed before these vaccines are available for clinical use . another potential vaccine strategy is subunit vaccines, which rely on eliciting an immune response against the spike (s) protein to prevent its docking with the host angiotensinconverting enzyme (ace ) receptor . a number of entities, including the university of queensland, novavax, clover biopharmaceuticals, and baylor college of medicine, have all made progress toward either a sars-cov or sars-cov- subunit vaccine. given the limited potential for host immunopotentiation and the similarities between sars-cov and sars-cov- amino acid expression, the potential for a subunit vaccine may be the most promising in the short term. the final option is a nucleic acid vaccine, for which several major biotechnology companies already have platforms. to date, there has not been a successfully licensed human nucleic acid vaccine, although promising results in animal studies have continued . overall, although there has been impressive and rapid progress toward a vaccine already, a vaccine that is ready for widespread use is still likely months, possibly years, away, given the testing, regulatory, and manufacturing hurdles that will need to be cleared. the race for a vaccine provides hope, but should not be relied on to compensate for a lack of containment strategies in the meantime. aggressive measures aimed at slowing viral spread will necessarily be the primary public health strategy for the near future. no specific treatment is currently recommended for covid- . similar to many other viral illnesses, the current mainstays of treatment include early recognition and isolation, along with symptomatic and oxygen therapy . considerations for the advanced levels of care including critical care depend on the development of further symptoms, including pneumonia or acute respiratory distress syndrome (ards). the use of systemic corticosteroids and antibiotics is not recommended except when targeting specific comorbid conditions . no antiviral treatments are currently approved, but alphainterferon ( million units inhaled twice daily), lopinavir-ritonavir (kaletra), remdesivir, and chloroquine have all been proposed as potentially beneficial and may be trialed if available in severe cases [ ] [ ] [ ] . a randomized controlled trial (rct) of lopinavirritonavir compared with standard care included patents with covid- . eligible patients were adult patients with covid- , pneumonia, and compromised oxygen saturation. there was no significant difference between the groups in terms of time to clinical improvement or mortality, with more adverse events in the intervention group . no high-quality evidence exists on remdesivir in this context, but it has been shown to effectively inhibit sars-cov- in vitro, particularly in combination with chloroquine . at least ongoing rcts are evaluating the efficacy of remdesivir in covid- (nct and nct ). chloroquine has been found to inhibit sars-cov- in vitro , and a number of trials are ongoing to test its clinical efficacy. although no formal results are yet available, early results have reportedly been promising, so much so that the expert consensus from the department of science and technology of guangdong province in the people's republic of china has recommended chloroquine mg twice daily for patients with mild to severe covid- who do not have any contraindications . convalescent plasma from recovered patients is also being actively investigated, based on positive experience with previous coronavirus outbreaks. however, there is a lack of evidence for convalescent plasma in covid- , and there is a risk of thrombotic events as well as attenuation of the immune response, which can leave patients at a potentially higher risk for reinfection or other infections. lessons from history: the first and second waves as discussed above, we are now experiencing our third human coronavirus epidemic of the century, with occurring in each decade so far. in addition, the pandemics of h n and the influenza (also known as the spanish flu) may provide clues into what may be expected moving forward. one of the common threads seen in both outbreaks was the phenomenon of multiple waves (fig. ) . both epidemics began in the late winter and early spring, at which point the relevant governments and public health systems began to take steps to limit the viral spread. in the case of the influenza pandemic, the death rates of the first wave were limited, and, between august and october , there were very few deaths occurring from the disease. however, the second wave, which was by far the deadliest of the waves, occurred between september and november . many theories have been proposed for the nature and timing of this second wave, including less favorable transmission conditions (rising temperatures, improved airflow, and less indoor crowding) in the summer months, although the exact reasons remain unclear . a smaller, third wave followed in early . the influenza pandemic also provides an example of the importance and effectiveness of the aforementioned practice of social distancing (fig. ) . a study compared the public health policies of philadelphia and st. louis during the pandemic, in which st. louis enacted public health measures such as social distancing in a rapid and strict fashion, and philadelphia enacted some less stringent measures weeks after the appearance of the first case . in fact, despite the first case being reported on september , , a citywide parade was held in philadelphia days later. the difference in outcomes between the cities was striking, with philadelphia showing weekly death rates of per , and cumulative peak death rates of per , and st. louis showing weekly death rates of per , and cumulative peak death rates of per , . similarly, the sars epidemic, which was first recognized in late february , also had a spring peak. on may , , the who removed toronto from the sars concern list, as there had been no new cases of community spread or death for days . shortly after, as hospitals began to dismantle their precautions, a second peak of cases developed in middle to late may ; most of these cases were clustered around a single hospital, with probable and suspect cases during this second wave . we do not have any clear understanding whether the coronavirus will recur in waves; the future behavior is unknown. the mers epidemic did not present with a second wave, and the timings of the second waves for the influenza epidemic and sars were very different. perhaps the most important lessons that can be taken from these previous outbreaks are simply a continued vigilance and preparedness for a possible second wave and a high index of suspicion for any new cases of undifferentiated respiratory illness in the weeks to months following a slowdown in new cases. finally, the past can also provide context with regard to the size and impact of past pandemics. table v contains a list of selected past pandemics with their absolute and relative (as a proportion of the global population) death tolls. we are in the midst of an unprecedented pandemic, the likes of which we have not seen in over a century. although the global response has been vigilant and focused, research continues to evolve and our understanding of the ultimate impact of covid- remains largely unknown. it is impossible to accurately predict the trajectory of covid- because of its rapidly evolving nature , , but some groups have recently attempted to forecast this using advanced modeling techniques , . these models are likely gross overestimates, given that they assume no containment measures are in place. even with aggressive containment procedures, the outbreak is unlikely to see meaningful resolution for weeks to months. peng et al. used public data from the national health commission of china from january , , to february , , and estimated that, for the majority of the people's republic of china, anti-epidemic success will be seen around mid-march ; however, in wuhan, this is expected to occur closer to the beginning of april . in another model by wu et al., the authors performed a generalized logistic growth model (data from infected cases between january , , and march , ) and estimated that, in japan, there will be a total of , cases by the end of march and , cases by the end of june and that around . % of italy (> , people) will be infected by the end of the outbreak. understanding big data sets will be key to future innovations and prevention. this outbreak has created millions of data points and provides an opportunity to test the promise of machine learning and artificial intelligence. the allen institute for ai (artificial intelligence) in seattle, washington, has recently partnered with other researchers to create the covid- open research dataset (cord- ) . this free resource contains relevant articles about covid- and related viruses, allowing researchers to apply advanced methods, such as natural language processing, to try to generate new information about the disease. the covid- pandemic has led to a heavy burden on the health-care system, leaving many surgeons with questions as to how to handle this situation, in terms of their practice and caring for their patients. a number of major institutions, surgical associations, and physicians with direct experience treating patients with suspected or confirmed covid- have recently released statements or published recommendations to offer guidance to surgeons, in particular, and all frontline health-care workers [ ] [ ] [ ] [ ] [ ] [ ] [ ] . we summarize their guidance here: . assess all planned elective or nonemergency surgical procedures and clinic visits to determine whether or not they can be postponed or cancelled, keeping in mind that it may be another to weeks (or more) until we see some resolution. . shift urgent inpatient diagnostics and surgical procedures to outpatient settings, when possible. . minimize the use of essential items (e.g., beds, personal protective equipment, cleaning supplies, ventilators). . plan for the potential surge of critical care patients and have additional space and supplies readily available. . create multiple teams that are completely insulated from each another. . limit or cancel nonessential travel, not only to prevent the spread of the disease, but also to ensure that you are available to help your local health-care system to manage a possible increase in patient admissions or to reorganize the workforce if a colleague becomes infected. . if they cannot be cancelled altogether, complete conferences, educational courses, panels, meetings, and even follow-up patient examinations virtually or remotely. . if a surgical procedure is necessary for a patient with suspected or confirmed covid- , use an operating room with a negative-pressure environment, frequent air exchange, and a separate access. airborne spread is a concern during aerosol-generating procedures, so it is also important to understand the airflow within an operating room and have the proper equipment and protocols in place to limit the spread of infection in this setting. anterooms in which to put on and remove protective equipment should be available, or even constructed, adjacent to the operating room. use disposable surgical items and protective equipment. use double caps, n masks, medical goggles, and boots. minimize entry into and exit from the operating room during surgical procedures. allocate time between procedures to allow staff and the operating room to go through proper decontamination procedures. . keep posted on updates provided by the cdc and the who on a regular basis. summary covid- is a global pandemic that has currently infected > , globally. fever and cough are the most common symptoms of the disease, and it is important to remember that the virus can even be transmitted by individuals who test positive for the disease but do not have any symptoms. currently reported mortality rates vary because of the rapid spread of the disease and different approaches to calculating this estimate, but it is clear that the risk of death is associated with age and the presence of underlying conditions. risk mitigation techniques (i.e., hand washing, social distancing, and self-isolation) have already been emphasized across major news outlets. it is essential that we continue these practices, as the outbreak is currently expected to last for many more months and we must be mindful of the lessons learned from past pandemics to prevent a second wave from occurring. n coronavirus disease (covid- ) situation report - chinese ibd quality care evaluation center committee. 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marion; johns, fleur title: loops, ladders and links: the recursivity of social and machine learning date: - - journal: theory soc doi: . /s - - -x sha: doc_id: cord_uid: e jb sex machine learning algorithms reshape how people communicate, exchange, and associate; how institutions sort them and slot them into social positions; and how they experience life, down to the most ordinary and intimate aspects. in this article, we draw on examples from the field of social media to review the commonalities, interactions, and contradictions between the dispositions of people and those of machines as they learn from and make sense of each other. a fundamental intuition of actor-network theory holds that what we call "the social" is assembled from heterogeneous collections of human and non-human "actants." this may include human-made physical objects (e.g., a seat belt), mathematical formulas (e.g., financial derivatives), or elements from the natural world-such as plants, microbes, or scallops (callon ; latour latour , . in the words of bruno latour ( , p . ) sociology is nothing but the "tracing of associations." "tracing," however, is a rather capacious concept: socio-technical associations, including those involving non-human "actants," always crystallize in concrete places, structural positions, or social collectives. for instance, men are more likely to "associate" with video games than women (bulut ) . furthermore, since the connection between men and video games is known, men, women and institutions might develop strategies around, against, and through it. in other words, techno-social mediations are always both objective and subjective. they "exist … in things and in minds … outside and inside of agents" (wacquant , p. ) . this is why people think, relate, and fight over them, with them, and through them. all of this makes digital technologies a particularly rich terrain for sociologists to study. what, we may wonder, is the glue that holds things together at the automated interface of online and offline lives? what kind of subjectivities and relations manifest on and around social network sites, for instance? and how do the specific mediations these sites rely upon-be it hardware, software, human labor-concretely matter for the nature and shape of associations, including the most mundane? in this article, we are especially concerned with one particular kind of associative practice: a branch of artificial intelligence called machine learning. machine learning is ubiquitous on social media platforms and applications, where it is routinely deployed to automate, predict, and intervene in human and non-human behavior. generally speaking, machine learning refers to the practice of automating the discovery of rules and patterns from data, however dispersed and heterogeneous it may be, and drawing inferences from those patterns, without explicit programming. using examples drawn from social media, we seek to understand the kinds of social dispositions that machine learning techniques tend to elicit or reinforce; how these social dispositions, in turn, help to support according to pedro domingos's account, approaches to machine learning may be broken down into five "tribes." symbolists proceed through inverse deduction, starting with received premises or known facts and working backwards from those to identify rules that would allow those premises or facts to be inferred. the algorithm of choice for the symbolist is the decision tree. connectionists model machine learning on the brain, devising multilayered neural networks. their preferred algorithm is backpropagation, or the iterative adjustment of network parameters (initially set randomly) to try to bring that network's output closer and closer to a desired result (that is, towards satisfactory performance of an assigned task). evolutionaries canvas entire "populations" of hypotheses and devise computer programs to combine and swap these randomly, repeatedly assessing these combinations' "fitness" by comparing output to training data. their preferred kind of algorithm is the so-called genetic algorithm designed to simulate the biological process of evolution. bayesians are concerned with navigating uncertainty, which they do through probabilistic inference. bayesian models start with an estimate of the probability of certain outcomes (or a series of such estimates comprising one or more hypothetical bayesian network(s)) and then update these estimates as they encounter and process more data. analogizers focus on recognizing similarities within data and inferring other similarities on that basis. two of their go-to algorithms are the nearest-neighbor classifier and the support vector machine. the first makes predictions about how to classify unseen data by finding labeled data most similar to that unseen data (pattern matching). the second classifies unseen data into sets by plotting the coordinates of available or observed data according to their similarity to one another and inferring a decision boundary that would enable their distinction. machine learning implementations; and what kinds of social formations these interactions give rise to-all of these, indicatively rather than exhaustively. our arguments are fourfold. in the first two sections below, we argue that the accretive effects of social and machine learning are fostering an ever-more-prevalent hunger for data, and searching dispositions responsive to this hunger -"loops" in this paper's title. we then show how interactions between those so disposed and machine learning systems are producing new orders of stratification and association, or "ladders" and "links", and new stakes in the struggle in and around these orders. the penultimate section contends that such interactions, through social and mechanical infrastructures of machine learning, tend to engineer competition and psycho-social and economic dependencies conducive to evermore intensive data production, and hence to the redoubling of machine-learned stratification. finally, before concluding, we argue that machine learning implementations are inclined, in many respects, towards the degradation of sociality. consequently, new implementations are been called upon to judge and test the kind of solidaristic associations that machine learned systems have themselves produced, as a sort of second order learning process. our conclusion is a call to action: to renew, at the social and machine learning interface, fundamental questions of how to live and act together. the things that feel natural to us are not natural at all. they are the result of long processes of inculcation, exposure, and training that fall under the broad concept of "socialization" or "social learning." because the term "social learning" helps us better draw the parallel with "machine learning," we use it here to refer to the range of processes by which societies and their constituent elements (individuals, institutions, and so on) iteratively and interactively take on certain characteristics, and exhibit change-or not-over time. historically, the concept is perhaps most strongly associated with theories of how individuals, and specifically children, learn to feel, act, think, and relate to the world and to each other. theories of social learning and socialization have explained how people come to assume behaviors and attitudes in ways not well captured by a focus on internal motivation or conscious deliberation (miller and dollard ; bandura ; mauss ; elias ) . empirical studies have explored, for instance, how children learn speech and social grammar through a combination of direct experience (trying things out and experiencing rewarding or punishing consequences) and modeling (observing and imitating others, especially primary associates) (gopnik ). berger and luckmann ( ) , relying on the work of george herbert mead, discuss the learning process of socialization as one involving two stages: in the primary stage, children form a self by internalizing the attitudes of those others with whom they entertain an emotional relationship (typically their parents); in the secondary stage, persons-in-becoming learn to play appropriate roles in institutionalized subworlds, such as work or school. pierre bourdieu offers a similar approach to the formation of habitus. as a system of dispositions that "generates meaningful practices and meaning-giving perceptions," habitus takes shape through at least two types of social learning: "early, imperceptible learning" (as in the family) and "scholastic...methodical learning" (within educational and other institutions) (bourdieu , pp. , ) . organizations and collective entities also learn. for instance, scholars have used the concept of social learning to understand how states, institutions, and communities (at various scales) acquire distinguishing characteristics and assemble what appear to be convictions-in-common. ludwik fleck ( fleck ( [ ) and later thomas kuhn ( ) famously argued that science normally works through adherence to common ways of thinking about and puzzling over problems. relying explicitly on kuhn, hall ( ) makes a similar argument about elites and experts being socialized into long lasting political and policy positions. collective socialization into policy paradigms is one of the main drivers of institutional path dependency, as it makes it difficult for people to imagine alternatives. for our purposes, social learning encapsulates all those social processes-material, institutional, embodied, and symbolic-through which particular ways of knowing, acting, and relating to one another as aggregate and individuated actants are encoded and reproduced, or by which "[e]ach society [gains and sustains] its own special habits" (mauss , p. ) . "learning" in this context implies much more than the acquisition of skills and knowledge. it extends to adoption through imitation, stylistic borrowing, riffing, meme-making, sampling, acculturation, identification, modeling, prioritization, valuation, and the propagation and practice of informal pedagogies of many kinds. understood in this way, "learning" does not hinge decisively upon the embodied capacities and needs of human individuals because those capacities and needs are only ever realized relationally or through "ecological interaction," including through interaction with machines (foster ) . it is not hard to see why digital domains, online interactions, and social media networks have become a privileged site of observation for such processes (e.g., greenhow and robelia ), all the more so since socialization there often starts in childhood. this suggests that (contra dreyfus ) social and machine learning must be analyzed as co-productive of, rather than antithetical to, one another. machine learning is, similarly, a catch-all term-one encompassing a range of ways of programming computers or computing systems to undertake certain tasks (and satisfy certain performance thresholds) without explicitly directing the machines in question how to do so. instead, machine learning is aimed at having computers learn (more or less autonomously) from preexisting data, including the data output from prior attempts to undertake the tasks in question, and devise their own ways of both tackling those tasks and iteratively improving at them (alpaydin ) . implementations of machine learning now span all areas of social and economic life. machine learning "has been turning up everywhere, driven by exponentially growing mountains of [digital] data" (domingos ) . in this article, we take social media as one domain in which machine learning has been widely implemented. we do so recognizing that not all data analysis in which social media platforms engage is automated, and that those aspects that are automated do not necessarily involve machine learning. two points are important for our purposes: most "machines" must be trained, cleaned, and tested by humans in order to "learn." in implementations of machine learning on social media platforms, for instance, humans are everywhere "in the loop"-an immense, poorly paid, and crowdsourced workforce that relentlessly labels, rates, and expunges the "content" to be consumed (gillespie ; gray and suri ) . and yet, both supervised and unsupervised machines generate new patterns of interpretation, new ways of reading the social world and of intervening in it. any reference to machine learning throughout this article should be taken to encapsulate these "more-thanhuman" and "more-than-machine" qualities of machine learning. cybernetic feedback, data hunger, and meaning accretion analogies between human (or social) learning and machine-based learning are at least as old as artificial intelligence itself. the transdisciplinary search for common properties among physical systems, biological systems, and social systems, for instance, was an impetus for the macy foundation conferences on "circular causal and feedback mechanisms in biology and social systems" in the early days of cybernetics ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . in the analytical model developed by norbert wiener, "the concept of feedback provides the basis for the theoretical elimination of the frontier between the living and the non-living" (lafontaine , p. ) . just as the knowing and feeling person is dynamically produced through communication and interactions with others, the ideal cybernetic system continuously enriches itself from the reactions it causes. in both cases, life is irrelevant: what matters, for both living and inanimate objects, is that information circulates in an everrenewed loop. put another way, information/computation are "substrate independent" (tegmark , p. ). wiener's ambitions (and even more, the exaggerated claims of his posthumanist descendants, see, e.g., kurzweil ) were immediately met with criticism. starting in the s, philosopher hubert dreyfus arose as one of the main critics of the claim that artificial intelligence would ever approach its human equivalent. likening the field to "alchemy" ( ), he argued that machines would never be able to replicate the unconscious processes necessary for the understanding of context and the acquisition of tacit skills ( , )-the fact that, to quote michael polanyi ( ) , "we know more than we can tell." in other words, machines cannot develop anything like the embodied intuition that characterizes humans. furthermore, machines are poorly equipped to deal with the fact that all human learning is cultural, that is, anchored not in individual psyches but in collective systems of meaning and in sedimented, relational histories (vygotsky ; bourdieu ; durkheim ; hasse ) . is this starting to change today when machines successfully recognize images, translate texts, answer the phone, and write news briefs? some social and computational scientists believe that we are on the verge of a real revolution, where machine learning tools will help decode tacit knowledge, make sense of cultural repertoires, and understand micro-dynamics at the individual level (foster ). our concern is not, however, with confirming or refuting predictive claims about what computation can and cannot do to advance scholars' understanding of social life. rather, we are interested in how social and computational learning already interact. not only may social and machine learning usefully be compared, but they are reinforcing and shaping one another in practice. in those jurisdictions in which a large proportion of the population is interacting, communicating, and transacting ubiquitously online, social learning and machine learning share certain tendencies and dependencies. both practices rely upon and reinforce a pervasive appetite for digital input or feedback that we characterize as "data hunger." they also share a propensity to assemble insight and make meaning accretively-a propensity that we denote here as "world or meaning accretion." throughout this article, we probe the dynamic interaction of social and machine learning by drawing examples from one genre of online social contention and connection in which the pervasive influence of machine learning is evident: namely, that which occurs across social media channels and platforms. below we explain first how data hunger is fostered by both social and computing systems and techniques, and then how world or meaning accretion manifests in social and machine learning practices. these explanations set the stage for our subsequent discussion of how these interlocking dynamics operate to constitute and distribute power. data hunger: searching as a natural attitude as suggested earlier, the human person is the product of a long, dynamic, and never settled process of socialization. it is through this process of sustained exposure that the self (or the habitus, in pierre bourdieu's vocabulary) becomes adjusted to its specific social world. as bourdieu puts it, "when habitus encounters a social world of which it is the product, it is like a 'fish in water': it does not feel the weight of the water, and it takes the world about itself for granted" (bourdieu in wacquant , p. ) . the socialized self is a constantly learning self. the richer the process-the more varied and intense the interactions-the more "information" about different parts of the social world will be internalized and the more socially versatile-and socially effective, possibly-the outcome. (this is why, for instance, parents with means often seek to offer "all-round" training to their offspring [lareau ]) . machine learning, like social learning, is data hungry. "learning" in this context entails a computing system acquiring capacity to generalize beyond the range of data with which it has been presented in the training phase. "learning" is therefore contingent upon continuous access to data-which, in the kinds of cases that preoccupy us, means continuous access to output from individuals, groups, and "bots" designed to mimic individuals and groups. at the outset, access to data in enough volume and variety must be ensured to enable a particular learnermodel combination to attain desired accuracy and confidence levels. thereafter, data of even greater volume and variety is typically (though not universally) required if machine learning is to deliver continuous improvement, or at least maintain performance, on assigned tasks. the data hunger of machine learning interacts with that of social learning in important ways. engineers, particularly in the social media sector, have structured machine learning technologies not only to take advantage of vast quantities of behavioral traces that people leave behind when they interact with digital artefacts, but also to solicit more through playful or addictive designs and cybernetic feedback loops. the machine-learning self is not only encouraged to respond more, interact more, and volunteer more, but also primed to develop a new attitude toward the acquisition of information (andrejevic , p. ). with the world's knowledge at her fingertips, she understands that she must "do her own research" about everything-be it religion, politics, vaccines, or cooking. her responsibility as a citizen is not only to learn the collective norms, but also to know how to search and learn so as to make her own opinion "for herself," or figure out where she belongs, or gain new skills. the development of searching as a "natural attitude" (schutz ) is an eminently social process of course: it often means finding the right people to follow or emulate (pariser ) , using the right keywords so that the search process yields results consistent with expectations (tripodi ) , or implicitly soliciting feedback from others in the form of likes and comments. the social media user also must extend this searching disposition to her own person: through cybernetic feedback, algorithms habituate her to search for herself in the data. this involves looking reflexively at her own past behavior so as to inform her future behavior. surrounded by digital devices, some of which she owns, she internalizes the all-seeing eye and learns to watch herself and respond to algorithmic demands (brubaker ). data hunger transmutes into self-hunger: an imperative to be digitally discernible in order to be present as a subject. this, of course, exacts a kind of self-producing discipline that may be eerily familiar to those populations that have always been under heavy institutional surveillance, such as the poor, felons, migrants, racial minorities (browne ; benjamin ) , or the citizens of authoritarian countries. it may also be increasingly familiar to users of health or car insurance, people living in a smart home, or anyone being "tracked" by their employer or school by virtue of simply using institutionally licensed it infrastructure. but the productive nature of the process is not a simple extension of what michel foucault called "disciplinary power" nor of the self-governance characteristic of "governmentality." rather than simply adjusting herself to algorithmic demands, the user internalizes the injunction to produce herself through the machine-learning-driven process itself. in that sense the machine-learnable self is altogether different from the socially learning, self-surveilling, or self-improving self. the point for her is not simply to track herself so she can conform or become a better version of herself; it is, instead, about the productive reorganization of her own experience and self-understanding. as such, it is generative of a new sense of selfhood-a sense of discovering and crafting oneself through digital means that is quite different from the "analog" means of self-cultivation through training and introspection. when one is learning from a machine, and in the process making oneself learnable by it, mundane activities undergo a subtle redefinition. hydrating regularly or taking a stroll are not only imperatives to be followed or coerced into. their actual phenomenology morphs into the practice of feeding or assembling longitudinal databases and keeping track of one's performance: "step counting" and its counterparts (schüll ; adams ) . likewise, what makes friendships real and defines their true nature is what the machine sees: usually, frequency of online interaction. for instance, snapchat has perfected the art of classifying-and ranking-relationships that way, so people are constantly presented with an ever-changing picture of their own dyadic connections, ranked from most to least important. no longer, contra foucault ( ) , is "permanent self-examination" crucial to self-crafting so much as attention to data-productive practices capable of making the self learnable and sustaining its searching process. to ensure one's learnability-and thereby one's selfhood-one must both feed and reproduce a hunger for data on and around the self. human learning is not only about constant, dynamic social exposure and world hunger, it is also about what we might call world or meaning accretion. the self is constantly both unsettled (by new experiences) and settling (as a result of past experiences). people take on well institutionalized social roles (berger and luckmann ) . they develop habits, styles, personalities-a "system of dispositions" in bourdieu's vocabulary-by which they become adjusted to their social world. this system is made accretively, through the conscious and unconscious sedimentation of social experiences and interactions that are specific to the individual, and variable in quality and form. accretion here refers to a process, like the incremental build-up of sediment on a riverbank, involving the gradual accumulation of additional layers or matter. even when change occurs rapidly and unexpectedly, the ongoing process of learning how to constitute and comport oneself and perform as a social agent requires one to grapple with and mobilize social legacies, social memory, and pre-established social norms (goffman ) . the habitus, bourdieu would say, is both structured and structuring, historical and generative. social processes of impression formation offer a good illustration of how social learning depends upon accreting data at volume, irrespective of the value of any particular datum. the popular insight that first impressions matter and tend to endure is broadly supported by research in social psychology and social cognition (uleman and kressel ) . it is clear that impressions are formed cumulatively and that early-acquired information tends to structure and inform the interpretation of information later acquired about persons and groups encountered in social life (hamilton and sherman ) . this has also been shown to be the case in online environments (marlow et al. ) . in other words, social impressions are constituted by the incremental build-up of a variegated mass of data. machine learning produces insight in a somewhat comparable way-that is, accretively. insofar as machine learning yields outputs that may be regarded as meaningful (which is often taken to mean "useful" for the task assigned), then that "meaning" is assembled through the accumulation of "experience" or from iterative exposure to available data in sufficient volume, whether in the form of a stream or in a succession of batches. machine learning, like social learning, never produces insight entirely ab initio or independently of preexisting data. to say that meaning is made accretively in machine learning is not to say that machine learning programs are inflexible or inattentive to the unpredictable; far from it. all machine learning provides for the handling of the unforeseen; indeed, capacity to extend from the known to the unknown is what qualifies machine learning as "learning." moreover, a number of techniques are available to make machine learning systems robust in the face of "unknown unknowns" (that is, rare events not manifest in training data). nonetheless, machine learning does entail giving far greater weight to experience than to the event. the more data that has been ingested by a machine learning system, the less revolutionary, reconfigurative force might be borne by any adventitious datum that it encounters. if, paraphrasing marx, one considers that people make their own history, but not in circumstances they choose for themselves, but rather in present circumstances given and inherited, then the social-machine learning interface emphasizes the preponderance of the "given and inherited" in present circumstances, far more than the potentiality for "mak[ing]" that may lie within them (marx (marx [ ). one example of the compound effect of social and automated meaning accretion in the exemplary setting to which we return throughout this articlesocial media-is the durability of negative reputation across interlocking platforms. for instance, people experience considerable difficulty in countering the effects of "revenge porn" online, reversing the harms of identity theft, or managing spoiled identities once they are digitally archived (lageson and maruna ) . as langlois and slane have observed, "[w]hen somebody is publicly shamed online, that shaming becomes a live archive, stored on servers and circulating through information networks via search, instant messaging, sharing, liking, copying, and pasting" (langlois and slane ) . in such settings, the data accretion upon which machine learning depends for the development of granular insights-and, on social media platforms, associated auctioning and targeting of advertising-compounds the cumulative, sedimentary effect of social data, making negative impressions generated by "revenge porn," or by one's online identity having been fraudulently coopted, hard to displace or renew. the truth value of later, positive data may be irrelevant if enough negative data has accumulated in the meantime. data hunger and the accretive making of meaning are two aspects of the embedded sociality of machine learning and of the "mechanical" dimensions of social learning. together, they suggest modes of social relation, conflict, and action that machine learning systems may nourish among people on whom those systems bear, knowingly or unknowingly. this has significant implications for social and economic inequality, as we explore below. what are the social consequences of machine learning's signature hunger for diverse, continuous, ever more detailed and "meaningful" data and the tendency of many automated systems to hoard historic data from which to learn? in this section, we discuss three observable consequences of data hunger and meaning accretion. we show how these establish certain non-negotiable preconditions for social inclusion; we highlight how they fuel the production of digitally-based forms of social stratification and association; and we specify some recurrent modes of relation fostered thereby. all three ordering effects entail the uneven distribution of power and resources and all three play a role in sustaining intersecting hierarchies of race, class, gender, and other modes of domination and axes of inequality. machine learning's data appetite and the "digestive" or computational abilities that attend it are often sold as tools for the increased organizational efficiency, responsiveness, and inclusiveness of societies and social institutions. with the help of machine learning, the argument goes, governments and non-governmental organizations develop an ability to render visible and classify populations that are traditionally unseen by standard data infrastructures. moreover, those who have historically been seen may be seen at a greater resolution, or in a more finelygrained, timely, and difference-attentive way. among international organizations, too, there is much hope that enhanced learning along these lines might result from the further utilization of machine learning capacities (johns ) . for instance, machine learning, deployed in fingerprint, iris, or facial recognition, or to nourish sophisticated forms of online identification, is increasingly replacing older, document-based ones (torpey )-and transforming the very concept of citizenship in the process (cheney-lippold ). whatever the pluses and minuses of "inclusiveness" in this mode, it entails a major infrastructural shift in the way that social learning takes place at the state and inter-state level, or how governments come to "know" their polities. governments around the world are exploring possibilities for gathering and analysing digital data algorithmically, to supplement-and eventually, perhaps, supersede-household surveys, telephone surveys, field site visits, and other traditional data collection methods. this devolves the process of assembling and representing a polity, and understanding its social and economic condition, down to agents outside the scope of public administration: commercial satellite operators (capturing satellite image data being used to assess a range of conditions, including agricultural yield and poverty), supermarkets (gathering scanner data, now widely used in cpi generation), and social media platforms. if official statistics (and associated data gathering infrastructures and labor forces) have been key to producing the modern polity, governmental embrace of machine learning capacities signals a change in ownership of that means of production. social media has become a key site for public and private parties-police departments, immigration agencies, schools, employers and insurers among others-to gather intelligence about the social networks of individuals, their health habits, their propensity to take risks or the danger they might represent to the public, to an organization's bottom line or to its reputation (trottier ; omand ; bousquet ; amoore ; stark ) . informational and power asymmetries characteristic of these institutions are often intensified in the process. this is notwithstanding the fact that automated systems' effects may be tempered by manual work-arounds and other modes of resistance within bureaucracies, such as the practices of frontline welfare workers intervening in automated systems in the interests of their clients, and strategies of foot-dragging and data obfuscation by legal professionals confronting predictive technologies in criminal justice (raso ; brayne and christin ) . the deployment of machine learning to the ends outlined in the foregoing paragraph furthers the centrality of data hungry social media platforms to the distribution of all sorts of economic and social opportunities and scarce public resources. at every scale, machine-learning-powered corporations are becoming indispensable mediators of relations between the governing and the governed (a transition process sharply accelerated by the covid- pandemic). this invests them with power of a specific sort: the power of "translating the images and concerns of one world into that of another, and then disciplining or maintaining that translation in order to stabilize a powerful network" and their own influential position within it (star , p. ) . the "powerful network" in question is society, but it is heterogeneous, comprising living and non-living, automated and organic elements: a composite to which we can give the name "society" only with impropriety (that is, without adherence to conventional, anthropocentric understandings of the term). for all practical purposes, much of social life already is digital. this insertion of new translators, or repositioning of old translators, within the circuits of society is an important socio-economic transformation in its own right. and the social consequences of this new "inclusion" are uneven in ways commonly conceived in terms of bias, but not well captured by that term. socially disadvantaged populations are most at risk of being surveilled in this way and profiled into new kinds of "measurable types" (cheney-lippold ). in addition, social media user samples are known to be non-representative, which might further unbalance the burden of surveillant attention. (twitter users, for instance, are skewed towards young, urban, minority individuals (murthy et al. ).) consequently, satisfaction of data hunger and practices of automated meaning accretion may come at the cost of increased social distrust, fostering strategies of posturing, evasion, and resistance among those targeted by such practices. these reactions, in turn, may undermine the capacity of state agents to tap into social data-gathering practices, further compounding existing power and information asymmetries (harkin ) . for instance, sarah brayne ( ) finds that government surveillance via social media and other means encourages marginalized communities to engage in "system avoidance," jeopardizing their access to valuable social services in the process. finally, people accustomed to being surveilled will not hesitate to instrumentalize social media to reverse monitor their relationships with surveilling institutions, for instance by taping public interactions with police officers or with social workers and sharing them online (byrne et al. ) . while this kind of resistance might further draw a wedge between vulnerable populations and those formally in charge of assisting and protecting them, it has also become a powerful aspect of grassroots mobilization in and around machine learning and techno-social approaches to institutional reform (benjamin ) . in all the foregoing settings, aspirations for greater inclusiveness, timeliness, and accuracy of data representation-upon which machine learning is predicated and which underlie its data hunger-produce newly actionable social divisions. the remainder of this article analyzes some recurrent types of social division that machine learning generates, and types of social action and experience elicited thereby. there is, of course, no society without ordering-and no computing either. social order, like computing order, comes in many shapes and varieties but generally "the gap between computation and human problem solving may be much smaller than we think" (foster , p. ) . in what follows, we cut through the complexity of this socialcomputational interface by distinguishing between two main ideal types of classification: ordinal (organized by judgments of positionality, priority, probability or value along one particular dimension) and nominal (organized by judgments of difference and similarity) (fourcade ) . social processes of ordinalization in the analog world might include exams, tests, or sports competitions: every level allows one to compete for the next level and be ranked accordingly. in the digital world, ordinal scoring might take the form of predictive analytics-which, in the case of social media, typically means the algorithmic optimization of online verification and visibility. by contrast, processes of nominalization include, in the analog world, various forms of homophily (the tendency of people to associate with others who are similar to them in various ways) and institutional sorting by category. translated for the digital world, these find an echo in clustering technologies-for instance a recommendation algorithm that works by finding the "nearest neighbors" whose taste is similar to one's own, or one that matches people based on some physical characteristic or career trajectory. the difference between ordinal systems and nominal systems maps well onto the difference between bayesian and analogical approaches to machine learning, to reference pedro domingos's ( ) useful typology. it is, however, only at the output or interface stage that these socially ubiquitous machine learning orderings become accessible to experience. what does it mean, and what does it feel like, to live in a society that is regulated through machine learning systems-or rather, where machine learning systems are interacting productively with social ordering systems of an ordinal and nominal kind? in this section, we identify some new, or newly manifest, drivers of social structure that emerge in machine learning-dominated environments. let us begin with the ordinal effects of these technologies (remembering that machine learning systems comprise human as well as non-human elements). as machine learning systems become more universal, the benefits of inclusion now depend less on access itself, and more on one's performance within each system and according to its rules. for instance, visibility on social media depends on "engagement," or how important each individual is to the activity of the platform. if one does not post frequently and consistently, comment or message others on facebook or instagram, or if others do not interact with one's posts, one's visibility to them diminishes quickly. if one is not active on the dating app tinder, one cannot expect one's profile to be shown to prospective suitors. similarly, uber drivers and riders rank one another on punctuality, friendliness, and the like, but uber (the company) ranks both drivers and riders on their behavior within the system, from canceling too many rides to failing to provide feedback. uber egypt states on its website: "the rating system is designed to give mutual feedback. if you never rate your drivers, you may see your own rating fall." even for those willing to incur the social costs of disengagement, opting out of machine learning may not be an option. failure to respond to someone's tag, or to like their photo, or otherwise maintain data productivity, and one might be dropped from their network, consciously or unconsciously, a dangerous proposition in a world where self-worth has become closely associated with measures of network centrality or social influence. as bucher has observed, "abstaining from using a digital device for one week does not result in disconnection, or less data production, but more digital data points … to an algorithm, … absence provides important pieces of information" (bucher , p. ) . engagement can also be forced on non-participants by the actions of other users-through tagging, rating, commenting, and endorsing, for instance (casemajor et al. ) . note that none of this is a scandal or a gross misuse of the technology. on the contrary, this is what any system looking for efficiency and relevance is bound to look like. but any ordering system that acts on people will generate social learning, including action directed at itself in return. engagement, to feed data hunger and enable the accretion of "meaningful" data from noise, is not neutral, socially or psychologically. the constant monitoring and management of one's social connections, interactions, and interpellations places a nontrivial burden on one's life. the first strategy of engagement is simply massive time investment, to manage the seemingly ever-growing myriad of online relationships (boyd ). to help with the process, social media platforms now bombard their users constantly with notifications, making it difficult to stay away and orienting users' behavior toward mindless and unproductive "grinding" (for instance, repetitively "liking" every post in their feed). but even this intensive "nudging" is often not enough. otherwise, how can we explain the fact that a whole industry of social media derivatives has popped up, to help people optimize their behavior vis-a-vis the algorithm, manage their following, and gain an edge so that they can climb the priority order over other, less savvy users? now users need to manage two systems (if not more): the primary one and the (often multiple) analytics apps that help improve and adjust their conduct in it. in these ways, interaction with machine learning systems tends to encourage continuous effort towards ordinal self-optimization. however, efforts of ordinal optimization, too, may soon become useless: as marilyn strathern (citing british economist charles goodhardt) put it, "when a measure becomes a target, it ceases to be a good measure" (strathern , p. ) . machine learning systems do not reward time spent on engagement without regard to the impact of that engagement across the network as a whole. now, in desperation, those with the disposable income to do so may turn to money as the next saving grace to satisfy the imperative to produce "good" data at volume and without interruption, and reap social rewards for doing so. the demand for maximizing one's data productivity and machine learning measurability is there, so the market is happy to oblige. with a monthly subscription to a social media platform, or even a social media marketing service, users can render themselves more visible. this possibility, and the payoffs of visibility, are learned socially, both through the observation and mimicry of models (influencers, for instance) or through explicit instruction (from the numerous online and offline guides to maximizing "personal brand"). one can buy oneself instagram or twitter followers. social media scheduling tools, such as tweetdeck and post planner, help one to plan ahead to try to maximize engagement with one's postings, including by strategically managing their release across time zones. a paying account on linkedin dramatically improves a user's chance of being seen by other users. the same is true of tinder. if a user cannot afford the premium subscription, the site still offers them one-off "boosts" for $ . that will send their profile near the top of their potential matches' swiping queue for min. finally, wealthier users can completely outsource the process of online profile management to someone else (perhaps recruiting a freelance social media manager through an online platform like upwork, the interface of which exhibits ordinal features like client ratings and job success scores). in all the foregoing ways, the inclusionary promise of machine learning has shifted toward more familiar sociological terrain, where money and other vectors of domination determine outcomes. in addition to economic capital, distributions of social and cultural capital, as well as traditional ascriptive characteristics, such as race or gender, play an outsized role in determining likeability and other outcomes of socially learned modes of engagement with machine learning systems. for instance, experiments with mechanical turkers have shown that being attractive increases the likelihood of appearing trustworthy on twitter, but being black creates a contrarian negative effect (groggel et al. ) . in another example, empirical studies of social media use among those bilingual in hindi and english have observed that positive modes of social media engagement tend to be expressed in english, with negative emotions and profanity more commonly voiced in hindi. one speculative explanation for this is that english is the language of "aspiration" in india or offers greater prospects for accumulating social and cultural capital on social media than hindi (rudra et al. ) . in short, wellestablished off-platform distinctions and social hierarchies shape the extent to which on-platform identities and forms of materialized labor will be defined as valuable and value-generating in the field of social media. in summary, ordinality is a necessary feature of all online socio-technical systems and it demands a relentless catering to one's digital doppelgängers' interactions with others and with algorithms. to be sure, design features tend to make systems addictive and feed this sentiment of oppression (boyd ). what really fuels both, however, is the work of social ordering and the generation of ordinal salience by the algorithm. in the social world, any type of scoring, whether implicit or explicit, produces tremendous amounts of status anxiety and often leads to productive resources (time and money) being diverted in an effort to better one's odds (espeland and sauder ; mau ) . those who are short on both presumably fare worse, not only because that makes them less desirable in the real world, but also because they cannot afford the effort and expense needed to overcome their disadvantage in the online world. the very act of ranking thus both recycles old forms of social inequality and also creates new categories of undesirables. as every teenager knows, those who have a high ratio of following to followers exhibit low social status or look "desperate." in this light, jeff bezos may be the perfect illustration of intertwining between asymmetries of real world and virtual world power: the founder and ceo of amazon and currently the richest man in the world has . million followers on twitter, but follows only one person: his ex-wife. ordinalization has implications not just for hierarchical positioning, but also for belonging-an important dimension of all social systems (simmel ) . ordinal stigma (the shame of being perceived as inferior) often translates into nominal stigma, or the shame of non-belonging. not obtaining recognition (in the form of "likes" or "followers"), in return for one's appreciation of other people, can be a painful experience, all the more since it is public. concern to lessen the sting of this kind of algorithmic cruelty is indeed why, presumably, tinder has moved from a simple elo or desirability score (which depends on who has swiped to indicate liking for the person in question, and their own scores, an ordinal measure) to a system that relies more heavily on type matching (a nominal logic), where people are connected based on taste similarity as expressed through swiping, sound, and image features (carman ) . in addition to employing machine learning to rank users, most social media platforms also use forms of clustering and type matching, which allow them to group users according to some underlying similarity (analogical machine learning in domingos's terms). this kind of computing is just as hungry for data as those we discuss above, but its social consequences are different. now the aim is trying to figure a person out or at least to amplify and reinforce a version of that person that appears in some confluence of data exhaust within the system in question. that is, in part, the aim of the algorithm (or rather, of the socio-technical system from which the algorithm emanates) behind facebook's news feed (cooper ) . typically, the more data one feeds the algorithm, the better its prediction, the more focused the offering, and the more homogeneous the network of associations forged through receipt and onward sharing of similar offerings. homogenous networks may, in turn, nourish better-and more saleablemachine learning programs. the more predictable one is, the better the chances that one will be seen-and engaged-by relevant audiences. being inconsistent or too frequently turning against type in data-generative behaviors can make it harder for a machine learning system to place and connect a person associatively. in both offline and online social worlds (not that the two can easily be disentangled), deviations from those expectations that data correlations tend to yield are often harshly punished by verbal abuse, dis-association, or both. experiences of being so punished, alongside experiences of being rewarded by a machine learning interface for having found a comfortable group (or a group within which one has strong correlations), can lead to some form of social closure, a desire to "play to type." as one heavy social media user told us, "you want to mimic the behavior [and the style] of the people who are worthy of your likes" in the hope that they will like you in return. that's why social media have been variously accused of generating "online echo chambers" and "filter bubbles," and of fueling polarization (e.g., pariser ). on the other hand, being visible to the wrong group is often a recipe for being ostracized, "woke-shamed," "called-out," or even "canceled" (yar and bromwich ) . in these and other ways, implementations of machine learning in social media complement and reinforce certain predilections widely learned socially. in many physical, familial, political, legal, cultural, and institutional environments, people learn socially to feel suspicious of those they experience as unfamiliar or fundamentally different from themselves. there is an extensive body of scholarly work investigating social rules and procedures through which people learn to recognize, deal with, and distance themselves from bodies that they read as strange and ultimately align themselves with and against pre-existing nominal social groupings and identities (ahmed ; goffman ) . this is vital to the operation of the genre of algorithm known as a recommendation algorithm, a feature of all social media platforms. on facebook, such an algorithm generates a list of "people you may know" and on twitter, a "who to follow" list. recommendation algorithms derive value from this social learning of homophily (mcpherson et al. ) . for one, it makes reactions to automated recommendations more predictable. recommendation algorithms also reinforce this social learning by minimizing social media encounters with identities likely to be read as strange or nonassimilable, which in turn improves the likelihood of their recommendations being actioned. accordingly, it has been observed that the profile pictures of accounts recommended on tiktok tend to exhibit similarities-physical and racial-to the profile image of the initial account holder to whom those recommendations are presented (heilweil ) . in that sense, part of what digital technologies do is organize the online migration of existing offline associations. but it would be an error to think that machine learning only reinforces patterns that exist otherwise in the social world. first, growing awareness that extreme type consistency may lead to online boredom, claustrophobia, and insularity (crawford ) has led platforms to experiment with and implement various kinds of exploratory features. second, people willfully sort themselves online in all sorts of non-overlapping ways: through twitter hashtags, group signups, click and purchasing behavior, social networks, and much more. the abundance of data, which is a product of the sheer compulsion that people feel to self-index and classify others (harcourt ; brubaker ) , might be repurposed to revisit common off-line classifications. categories like marriage or citizenship can now be algorithmically parsed and tested in ways that wield power over people. for instance, advertisers' appetite for information about major life events has spurred the application of predictive analytics to personal relationships. speech recognition, browsing patterns, and email and text messages can be mined for information about, for instance, the likelihood of relationships enduring or breaking up (dickson ) . similarly, the us national security agency measures people's national allegiance from how they search on the internet, redefining rights in the process (cheney-lippold ). even age-virtual rather than chronological-can be calculated according to standards of mental and physical fitness and vary widely depending on daily performance (cheney-lippold , p. ). quantitatively measured identities-algorithmic gender, ethnicity, or sexuality-do not have to correspond to discrete nominal types anymore. they can be fully ordinalized along a continuum of intensity (fourcade ) . the question now is: how much of a us citizen are you, really? how latinx? how gay? in a machine learning world, where each individual can be represented as a bundle of vectors, everyone is ultimately a unique combination, a category of one, however "precisely inaccurate" that category's digital content may be (mcfarland and mcfarland ) . changes in market research from the s to the s, aimed at tracking consumer mobility and aspiration through attention to "psychographic variables," constitute a pre-history, of sorts, for contemporary machine learning practices in commercial settings (arvidsson ; gandy ; fourcade and healy ; lauer ) . however, the volume and variety of variables now digitally discernible mean that the latter have outstripped the former exponentially. machine learning techniques have the potential to reveal unlikely associations, no matter how small, that may have been invisible, or muted, in the physically constraining geography of the offline world. repurposed for intervention, disparate data can be assembled to form new, meaningful types and social entities. paraphrasing donald mackenzie ( ), machine learning is an "engine, not a camera." christopher wylie, a former lead scientist at the defunct firm cambridge analytica-which famously matched fraudulently obtained facebook data with consumer data bought from us data brokers and weaponized them in the context of the us presidential election-recalls the experience of searching for-and discovering-incongruous social universes: "[we] spent hours exploring random and weird combinations of attributes.… one day we found ourselves wondering whether there were donors to anti-gay churches who also shopped at organic food stores. we did a search of the consumer data sets we had acquired for the pilot and i found a handful of people whose data showed that they did both. i instantly wanted to meet one of these mythical creatures." after identifying a potential target in fairfax county, he discovered a real person who wore yoga pants, drank kombucha, and held fire-andbrimstone views on religion and sexuality. "how the hell would a pollster classify this woman?" only with the benefit of machine learning-and associated predictive analytics-could wylie and his colleagues claim capacity to microtarget such anomalous, alloyed types, and monetize that capacity (wylie , pp. - ) . to summarize, optimization makes social hierarchies, including new ones, and pattern recognition makes measurable types and social groupings, including new ones. in practice, ordinality and nominality often work in concert, both in the offline and in the online worlds (fourcade ). as we have seen, old categories (e.g., race and gender) may reassert themselves through new, machine-learned hierarchies, and new, machine-learned categories may gain purchase in all sorts of offline hierarchies (micheli et al. ; madden et al. ) . this is why people strive to raise their digital profiles and to belong to those categories that are most valued there (for instance "verified" badges or recognition as a social media "influencer"). conversely, patternmatching can be a strategy of optimization, too: people will carefully manage their affiliations, for instance, so as to raise their score-aligning themselves with the visible and disassociating themselves from the underperforming. we examine these complex interconnections below and discuss the dispositions and sentiments that they foster and nourish. it should be clear by now that, paraphrasing latour ( , p. ), we can expect little from the "social explanation" of machine learning; machine learning is "its own explanation." the social does not lie "behind" it, any more than machine learning algorithms lie "behind" contemporary social life. social relations fostered by the automated instantiation of stratification and association-including in social mediaare diverse, algorithmic predictability notwithstanding. also, they are continually shifting and unfolding. just as latour ( , p. ) reminds us not to confuse technology with the objects it leaves in its wake, it is important not to presume the "social" of social media to be fixed by its automated operations. we can, nevertheless, observe certain modes of social relation and patterns of experience that tend to be engineered into the ordinal and nominal orders that machine learning (re)produces. in this section, we specify some of these modes of relation, before showing how machine learning can both reify and ramify them. our argument here is with accounts of machine learning that envisage social and political stakes and conflicts as exogenous to the practice-considerations to be addressed through ex ante ethics-by-design initiatives or ex post audits or certifications-rather than fundamental to machine learning structures and operations. machine learning is social learning, as we highlighted above. in this section, we examine further the kinds of sociality that machine learning makes-specifically those of competitive struggle and dependency-before turning to prospects for their change. social scientists' accounts of modes of sociality online are often rendered in terms of the antagonism between competition and cooperation immanent in capitalism (e.g., fuchs ). this is not without justification. after all, social media platforms are sites of social struggle, where people seek recognition: to be seen, first and foremost, but also to see-to be a voyeur of themselves and of others (harcourt ; brubaker ) . in that sense, platforms may be likened to fields in the bourdieusian sense, where people who invest in platform-specific stakes and rules of the game are best positioned to accumulate platform-specific forms of capital (e.g., likes, followers, views, retweets, etc.) (levina and arriaga ) . some of this capital may transfer to other platforms through built-in technological bridges (e.g., between facebook and instagram), or undergo a process of "conversion" when made efficacious and profitable in other fields (bourdieu ; fourcade and healy ) . for instance, as social status built online becomes a path to economic accumulation in its own right (by allowing payment in the form of advertising, sponsorships, or fans' gifts), new career aspirations are attached to social media platforms. according to a recent and well-publicized survey, "vlogger/youtuber" has replaced "astronaut" as the most enviable job for american and british children (berger ) . in a more mundane manner, college admissions offices or prospective employers increasingly expect one's presentation of self to include the careful management of one's online personality-often referred to as one's "brand" (e.g., sweetwood ) . similarly, private services will aggregate and score any potentially relevant information (and highlight "red flags") about individuals across platforms and throughout the web, for a fee. in this real-life competition, digitally produced ordinal positions (e.g., popularity, visibility, influence, social network location) and nominal associations (e.g., matches to advertised products, educational institutions, jobs) may be relevant. machine learning algorithms within social media both depend on and reinforce competitive striving within ordinal registers of the kind highlighted above-or in bourdieu's terms, competitive struggles over field-specific forms of capital. as georg simmel observed, the practice of competing socializes people to compete; it "compels the competitor" (simmel (simmel [ ). socially learned habits of competition are essential to maintain data-productive engagement with social media platforms. for instance, empirical studies suggest that motives for "friending" and following others on social media include upward and downward social comparison (ouwerkerk and johnson ; vogel et al. ) . social media platforms' interfaces then reinforce these social habits of comparison by making visible and comparable public tallies of the affirmative attention that particular profiles and posts have garnered: "[b]eing social in social media means accumulating accolades: likes, comments, and above all, friends or followers" (gehl , p. ) . in this competitive "[l]ike economy," "user interactions are instantly transformed into comparable forms of data and presented to other users in a way that generates more traffic and engagement" (gerlitz and helmond , p. )-engagement from which algorithms can continuously learn in order to enhance their own predictive capacity and its monetization through sales of advertising. at the same time, the distributed structure of social media (that is, its multinodal and cumulative composition) also fosters forms of cooperation, gift exchange, redistribution, and reciprocity. redistributive behavior on social media platforms manifests primarily in a philanthropic mode rather than in the equitypromoting mode characteristic of, for instance, progressive taxation. examples include practices like the #followfriday or #ff hashtag on twitter, a spontaneous form of redistributive behavior that emerged in whereby "micro-influencers" started actively encouraging their own followers to follow others. insofar as those so recommended are themselves able to monetize their growing follower base through product endorsement and content creation for advertisers, this redistribution of social capital serves, at least potentially, as a redistribution of economic capital. even so, to the extent that purportedly "free" gifts, in the digital economy and elsewhere, tend to be reciprocated (fourcade and kluttz ) , such generosity might amount to little more than an effective strategy of burnishing one's social media "brand," enlarging one's follower base, and thereby increasing one's store of accumulated social (and potentially economic) capital. far from being antithetical to competitive relations on social media, redistributive practices in a gift-giving mode often complement them (mauss ) . social media cooperation can also be explicitly anti-social, even violent (e.g., patton et al. ) . in these and other ways, digitized sociality is often at once competitive and cooperative, connective and divisive (zukin and papadantonakis ) . whether it is enacted in competitive, redistributive or other modes, sociality on social media is nonetheless emergent and dynamic. no wonder that bruno latour was the social theorist of choice when we started this investigation. but-as latour ( ) himself pointed out-gabriel tarde might have been a better choice. what makes social forms cohere are behaviors of imitation, counter- an exception to this observation would be social media campaigns directed at equitable goals, such as campaigns to increase the prominence and influence of previously under-represented groups-womenalsoknowstuff and pocalsoknowstuff twitter handles, hashtags, and feeds, for example. recommendation in this mode has been shown to increase recommended users' chance of being followed by a factor of roughly two or three compared to a recommendation-free scenario (garcia gavilanes et al. ). for instance, lewis ( , p. ) reports that "how-to manuals for building influence on youtube often list collaborations as one of the most effective strategies." imitation, and influence (tarde ) . social media, powered by trends and virality, mimicry and applause, parody and mockery, mindless "grinding" and tagging, looks quintessentially tardian. even so, social media does not amount simply to transfering online practices of imitation naturally occuring offline. the properties of machine learning highlighted above-cybernetic feedback; data hunger; accretive meaning-making; ordinal and nominal ordering-lend social media platforms and interfaces a distinctive, compulsive, and calculating quality-engineering a relentlessly "participatory subjectivity" (bucher , p. ; boyd ) . how one feels and how one acts when on social media is not just an effect of subjective perceptions and predispositions. it is also an effect of the software and hardware that mediate the imitative (or counter-imitative) process itself-and of the economic rationale behind their implementation. we cannot understand the structural features and phenomenological nature of digital technologies in general, and of social media in particular, if we do not understand the purposes for which they were designed. the simple answer, of course, is that data hunger and meaning accretion are essential to the generation of profit (zuboff ), whether profit accrues from a saleable power to target advertising, commercializable developments in artificial intelligence, or by other comparable means. strategies for producing continuous and usable data flows to profit-making ends vary, but tend to leverage precisely the social-machine learning interface that we highlighted above. social media interfaces tend to exhibit design features at both the back-and front-end that support user dependency and enable its monetization. for example, the "infinite scroll," which allows users to swipe down a page endlessly (without clicking or refreshing) rapidly became a staple of social media apps after its invention in , giving them an almost hypnotic feel and maximizing the "time on device" and hence users' availability to advertisers (andersson ) . similarly, youtube's recommendation algorithm was famously optimized to maximize users' time on site, so as to serve them more advertisements (levin ; roose ) . social media platforms also employ psycho-social strategies to this end, including campaigns to draw people in by drumming up reciprocity and participation-the notifications, the singling out of trends, the introduction of "challenges"-and more generally the formation of habits through gamification. prominent critics of social media, such as tristan harris (originally from google) and sandy parakilas (originally from facebook), have denounced apps that look like "slot machines" and use a wide range of intermittent rewards to keep users hooked and in the (instagram, tiktok, facebook, …) zone, addicted "by design" (schüll ; fourcade ) . importantly, this dependency has broader social ramifications than may be captured by a focus on individual unfreedom. worries about the "psychic numbing" of the liberal subject (zuboff ) , or the demise of the sovereign consumer, do not preoccupy us so much as the ongoing immiseration of the many who "toil on the invisible margins of the social factory" (morozov ) or whose data traces make them the targets of particularly punitive extractive processes. dependencies engineered into social media interfaces help, in combination with a range of other structural factors, to sustain broader economic dependencies, the burdens and benefits of which land very differently across the globe (see, e.g., taylor and broeders ) . in this light, the question of how amenable these dynamics may be to social change becomes salient for many. recent advances in digital technology are often characterized as revolutionary. however, as well as being addictive, the combined effect of machine learning and social learning may be as conducive to social inertia as it is to social change. data hunger on the part of mechanisms of both social learning and machine learning, together with their dependence on data accretion to make meaning, encourage replication of interface features and usage practices known to foster continuous, data-productive engagement. significant shifts in interface design-and in the social learning that has accreted around use of a particular interface-risk negatively impacting data-productive engagement. one study of users' reactions to changes in the facebook timeline suggested that "major interface changes induce psychological stress as well as technology-related stress" (wisniewski et al. ) . in recognition of these sensitivities, those responsible for social media platforms' interfaces tend to approach their redesign incrementally, so as to promote continuity rather than discontinuity in user behaviour. the emphasis placed on continuity in social media platform design may foster tentativeness in other respects as well, as we discuss in the next section. at the same time, social learning and machine learning, in combination, are not necessarily inimical to social change. machine learning's associative design and propensity to virality have the potential to loosen or unsettle social orders rapidly. and much as the built environment of the new urban economy can be structured to foster otherwise unlikely encounters (hanson and hillier ; zukin ) , so digital space can be structured to similar effect. for example, the popular chinese social media platform wechat has three features, enabled by machine learning, that encourage openended, opportunistic interactions between random users-shake, drift bottle, and people nearby-albeit, in the case of people nearby, random users within one's immediate geographic vicinity. (these are distinct from the more narrow, instrumental range of encounters among strangers occasioned by platforms like tinder, the sexual tenor of which are clearly established in advance, with machine learning parameters set accordingly.) qualitative investigation of wechat use and its impact on chinese social practices has suggested that wechat challenges some existing social practices, while reinforcing others. it may also foster the establishment of new social practices, some defiant of prevailing social order. for instance, people report interacting with strangers via wechat in ways they normally would not, including shifting to horizontallystructured interactions atypical of chinese social structures offline (wang et al. ). this is not necessarily unique to wechat. the kinds of ruptures and reorderings engineered through machine learning do not, however, create equal opportunities for value creation and accumulation, any more than they are inherently liberating or democratizing. social media channels have been shown to serve autocratic goals of "regime entrenchment" quite effectively (gunitsky ) . likewise, they serve economic goals of data accumulation and concentration (zuboff ) . machine-learned sociality lives on corporate servers and must be with regard to wechat in china and vkontakte in russia, as well as to government initiatives in egypt, the ukraine, and elsewhere, seva gunitsky ( ) highlights a number of reasons why, and means by which, nondemocratic regimes have proactively sought (with mixed success) to co-opt social media, rather than simply trying to suppress it, in order to try to ensure central government regimes' durability. meticulously "programmed" (bucher ) to meet specific economic objectives. as such, it is both an extremely lucrative proposition for some and (we have seen) a socially dangerous one for many. it favors certain companies, their shareholders and executives, while compounding conditions of social dependency and economic precarity for most other people. finally, with its content sanitized by underground armies of ghost workers (gray and suri ), it is artificial in both a technical and literal sense-"artificially artificial," in the words of jeff bezos (casilli and posada ). we have already suggested that machine-learned sociality, as it manifests on social media, tends to be competitive and individualizing (in its ordinal dimension) and algorithmic and emergent (in its nominal dimension). although resistance to algorithms is growing, those who are classified in ways they find detrimental (on either dimension) may be more likely to try to work on themselves or navigate algorithmic workarounds than to contest the classificatory instrument itself (ziewitz ) . furthermore, we know that people who work under distributed, algorithmically managed conditions (e.g., mechanical turk workers, uber drivers) find it difficult to communicate amongst themselves and organize (irani and silberman ; lehdonvirta ; dubal ) . these features of the growing entanglement of social and machine learning may imply dire prospects for collective action-and beyond it, for the achievement of any sort of broad-based, solidaristic project. in this section, we tentatively review possibilities for solidarity and mobilization as they present themselves in the field of social media. machine learning systems' capacity to ingest and represent immense quantities of data does increase the chances that those with common experiences will find one another, at least insofar as those experiences are shared online. machine-learned types thereby become potentially important determinants of solidarity, displacing or supplementing the traditional forces of geography, ascribed identities, and voluntary association. those dimensions of social life that social media algorithms have determined people really care about often help give rise to, or supercharge, amorphous but effective forms of offline action, if only because the broadcasting costs are close to zero. examples may include the viral amplification of videos and messages, the spontaneity of flash mobs (molnár ) , the leaderless, networked protests of the arab spring (tufekci ) , or of the french gilets jaunes (haynes ), and the #metoo movement's reliance on public disclosures on social media platforms. nonetheless, the thinness, fleeting character, and relative randomness of the affiliations summoned in those ways (based on segmented versions of the self, which may or may not overlap) might make social recognition and commonality of purpose difficult to sustain in the long run. more significant, perhaps, is the emergence of modes of collective action that are specifically designed not only to fit the online medium, but also to capitalize on its technical features. many of these strategies were first implemented to stigmatize or sow division, although there is no fatality that this is their only possible use. examples include the anti-semitic (((echo))) tagging on twitter-originally devised to facilitate trolling by online mobs (weisman ) but later repurposed by non-jews as an expression of solidarity; the in-the-wild training of a microsoft chatter bot, literally "taught" by well-organized users to tweet inflammatory comments; the artificial manipulation of conversations and trends through robotic accounts; or the effective delegation, by the trump campaign, of the management of its ad-buying activities to facebook's algorithms, optimized on the likelihood that users will take certain campaign-relevant actions-"signing up for a rally, buying a hat, giving up a phone number" (bogost and madrigal ) . the exploitation of algorithms for divisive purposes often spurs its own reactions, from organized counter-mobilizations to institutional interventions by platforms themselves. during the black lives matter protests, for instance, kpop fans flooded rightwing hashtags on instagram and twitter with fancams and memes in order to overwhelm racist messaging. even so, often the work of "civilizing" the social media public sphere is left to algorithms, supported by human decision-makers working through rules and protocols (and replacing them in especially sensitive cases). social media companies ban millions of accounts every month for inappropriate language or astroturfing (coordinated operations on social media that masquerade as a grassroot movement): algorithms have been trained to detect and exclude certain types of coalitions on the basis of a combination of social structure and content. in , the british far right movement "britain first" moved to tiktok after being expelled from facebook, twitter, instagram, and youtube-and then over to vkontakte or vk, a russian platform, after being banned from tiktok (usa news ). chastised in the offline world for stirring discord and hate, the economic engines that gave the movement a megaphone have relegated it to their margins with embarrassment. the episode goes to show that there is nothing inherently inclusive in the kind of group solidarity that machine learning enables, and thus it has to be constantly put to the (machine learning) test. in the end, platforms' ideal of collective action may resemble the tardean, imitative but atomized crowd, nimble but lacking in endurance and capacity (tufekci ) . mimetic expressions of solidarity, such as photo filters (e.g., rainbow), the "blacking out" of one's newsfeed, or the much-bemoaned superficiality of "clicktivism" may be effective at raising consciousness or the profile of an issue, but they may be insufficient to support broader-based social and political transformations. in fact, social media might actually crowd out other solidaristic institutions by also serving as a (feeble, often) palliative for their failures. for example, crowdsourced campaigns, now commonly used to finance healthcare costs, loss of employment, or educational expenses, perform a privatized solidarity that is a far cry from the universal logic of public welfare institutions. up to this point, our emphasis has been on the kinds of sociality that machine learning implementations tend to engender on the social media field, in both vertical (ordinal) and horizontal (nominal) configurations. we have, in a sense, been "reassembling the social" afresh, with an eye, especially, to its computational components and chains of reference (latour ) . throughout, we have stressed, nonetheless, that machine learning and other applications of artificial intelligence must be understood as forces internal to social life-both subject to and integral to its contingent properties-not forces external to it or determinative of it. accordingly, it is just as important to engage in efforts to reassemble "the machine"-that is, to revisit and put once more into contention the associative preconditions for machine learning taking the form that it currently does, in social media platforms for instance. and if we seek to reassemble the machine, paraphrasing latour ( , p. ) , "it's necessary, aside from the circulation and formatting of traditionally conceived [socio-technical] ties, to detect other circulating entities." so what could be some "other circulating entities" within the socio-technical complex of machine learning, or how could we envisage its elements circulating, and associating, otherwise? on some level, our analysis suggests that the world has changed very little. like every society, machine-learned society is powered by two fundamental, sometimes contradictory forces: stratification and association, vertical and horizontal difference. to be sure, preexisting social divisions and inequalities are still very much part of its operations. but the forces of ordinality and nominality have also been materialized and formatted in new ways, of which for-profit social media offer a particularly stark illustration. the machinelearnable manifestations of these forces in social media: these are among the "other circulating entities" now traceable. recursive dynamics between social and machine learning arise where social structures, economic relations and computational systems intersect. central to these dynamics in the social media field are the development of a searching disposition to match the searchability of the environment, the learnability of the self through quantified measurement, the role of scores in the processing of social positions and hierarchies, the decategorization and recategorization of associational identities, automated feedback that fosters compulsive habits and competitive social dispositions, and strategic interactions between users and platforms around the manipulation of algorithms. what, then, of prospects for reassembly of existing configurations? notwithstanding the lofty claims of the it industry, there is nothing inherently democratizing or solidaristic about the kinds of social inclusiveness that machine learning brings about. the effects of individuals and groups' social lives being rendered algorithmically learnable are ambivalent and uneven. in fact, they may be as divisive and hierarchizing as they may be connective and flattening. moreover, the conditions for entry into struggle in the social media field are set by a remarkably small number of corporate entities and "great men of tech" with global reach and influence (grewal ) . a level playing field this most definitely is not. rather, it has been carved up and crenellated by those who happen to have accumulated greatest access to the data processing and storage capacity that machine learning systems require, together with the real property, intellectual property, and personal property rights, and the network of political and regulatory lobbyists that ensure that exclusivity of access is maintained (cohen ) . power in this field is, accordingly, unlikely to be reconfigured or redistributed organically, or through generalized exhortation to commit to equity or ethics (many versions of which are self-serving on the part of major players). instead, political action aimed at building or rebuilding social solidarities across such hierarchies and among such clusters must work with and through them, in ways attentive to the specifics of their instantiation in particular techno-social settings. to open to meaningful political negotiation those allocations and configurations of power that machine learning systems help to inscribe in public and private life-this demands more than encompassing a greater proportion of people within existing practices of ruling and being ruled, and more than tinkering around the edges of existing rules. the greater the change in sociality and social relations-and machine learning is transforming both, as we have recounted-the more arrant and urgent the need for social, political and regulatory action specifically attuned to that change and to the possibility of further changes. social and political action must be organized 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the publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations as well as numerous articles that explore and theorize national variations in political mores, valuation cultures, economic policy, and economic knowledge. more recently, she has written extensively on the political economy of digitality, looking specifically at the changing nature of inequality and stratification in the digital era since , she has been conducting fieldwork on the role of digital technology and digital data in development, humanitarian aid, and disaster relief-work funded, since , by the australian research council. relevant publications include "global governance through the pairing of list and algorithm" (environment and planning d: society and space ); "data, detection, and the redistribution of the sensible acknowledgments we are grateful to kieran healy, etienne ollion, john torpey, wayne wobcke, and sharon zukin for helpful comments and suggestions. we also thank the institute for advanced study for institutional support. an earlier version of this article was presented at the "social and ethical challenges of machine learning" workshop at the institute for advanced study, princeton, november . key: cord- -qwgmn t authors: livingston, gill; huntley, jonathan; sommerlad, andrew; ames, david; ballard, clive; banerjee, sube; brayne, carol; burns, alistair; cohen-mansfield, jiska; cooper, claudia; costafreda, sergi g; dias, amit; fox, nick; gitlin, laura n; howard, robert; kales, helen c; kivimäki, mika; larson, eric b; ogunniyi, adesola; orgeta, vasiliki; ritchie, karen; rockwood, kenneth; sampson, elizabeth l; samus, quincy; schneider, lon s; selbæk, geir; teri, linda; mukadam, naaheed title: dementia prevention, intervention, and care: report of the lancet commission date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: qwgmn t nan the number of older people, including those living with dementia, is rising, as younger age mortality declines. however, the age-specific incidence of dementia has fallen in many countries, probably because of improvements in education, nutrition, health care, and lifestyle changes. overall, a growing body of evidence supports the nine potentially modifiable risk factors for dementia modelled by the lancet commission on dementia prevention, intervention, and care: less education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, and low social contact. we now add three more risk factors for dementia with newer, convincing evidence. these factors are excessive alcohol consumption, traumatic brain injury, and air pollution. we have completed new reviews and meta-analyses and incorporated these into an updated risk factor life-course model of dementia prevention. together the modifiable risk factors account for around % of worldwide dementias, which consequently could theo retically be prevented or delayed. the potential for prevention is high and might be higher in low-income and middle-income countries (lmic) where more dementias occur. our new life-course model and evidence synthesis has paramount worldwide policy implications. it is never too early and never too late in the life course for dementia prevention. early-life (younger than years) risks, such as less education, affect cognitive reserve; midlife ( - years) , and later-life (older than years) risk factors influence reserve and triggering of neuropathological developments. culture, poverty, and inequality are key drivers of the need for change. individuals who are most deprived need these changes the most and will derive the highest benefit. policy should prioritise childhood education for all. public health initiatives minimising head injury and decreasing harmful alcohol drinking could potentially reduce young-onset and later-life dementia. midlife systolic blood pressure control should aim for mm hg or lower to delay or prevent dementia. stopping smoking, even in later life, ameliorates this risk. passive smoking is a less considered modifiable risk factor for dementia. many countries have restricted this exposure. policy makers should expedite improvements in air quality, particularly in areas with high air pollution. we recommend keeping cognitively, physically, and socially active in midlife and later life although little evidence exists for any single specific activity protecting against dementia. using hearing aids appears to reduce the excess risk from hearing loss. sustained exercise in midlife, and possibly later life, protects from dementia, perhaps through decreasing obesity, diabetes, and cardio vascular risk. depression might be a risk for dementia, but in later life dementia might cause depression. although behaviour change is difficult and some associations might not be purely causal, individuals have a huge potential to reduce their dementia risk. in lmic, not everyone has access to secondary education; high rates of hypertension, obesity, and hearing loss exist, and the prevalence of diabetes and smoking are growing, thus an even greater proportion of dementia is potentially preventable. amyloid-β and tau biomarkers indicate risk of progression to alzheimer's dementia but most people with normal cognition with only these biomarkers never develop the disease. although accurate diagnosis is important for patients who have impairments and functional concerns and their families, no evidence exists to support pre-symptomatic diagnosis in everyday practice. our understanding of dementia aetiology is shifting, with latest description of new pathological causes. in the oldest adults (older than years), in particular, mixed dementia is more common. blood biomarkers might hold promise for future diagnostic approaches and are more scalable than csf and brain imaging markers. wellbeing is the goal of much of dementia care. people with dementia have complex problems and symptoms in many domains. interventions should be individualised and consider the person as a whole, as well as their family carers. evidence is accumulating for the effectiveness, at least in the short term, of psychosocial interventions tailored to the patient's needs, to manage neuropsychiatric symptoms. evidence-based interventions for carers can reduce depressive and anxiety symptoms over years and be cost-effective. keeping people with dementia physically healthy is important for their cognition. people with dementia have more physical health problems than others of the same age but often receive less community health care and find it particularly difficult to access and organise care. people with dementia have more hospital admissions than other older people, including for illnesses that are potentially manageable at home. they have died disproportionately in the covid- epidemic. hospitalisations are distressing and are associated with poor outcomes and high costs. health-care professionals worldwide around million people live with dementia, and this number is projected to increase to million by , rising particularly in low-income and middleincome countries (lmic) where around two-thirds of people with dementia live. dementia affects individuals, their families, and the economy, with global costs estimated at about us$ trillion annually. we reconvened the lancet commission on dementia prevention, intervention, and care to identify the evidence for advances likely to have the greatest impact since our paper and build on its work. our inter disciplinary, international group of experts presented, debated, and agreed on the best available evidence. we adopted a triangulation framework evaluating the consistency of evidence from different lines of research and used that as the basis to evaluate evidence. we have • three new modifiable risk factors for dementia • new evidence supports adding three modifiable risk factors-excessive alcohol consumption, head injury, and air pollution-to our lancet commission on dementia prevention, intervention, and care life-course model of nine factors (less education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, and infrequent social contact). • modifying risk factors might prevent or delay up to % of dementias. • be ambitious about prevention • prevention is about policy and individuals. contributions to the risk and mitigation of dementia begin early and continue throughout life, so it is never too early or too late. these actions require both public health programmes and individually tailored interventions. in addition to population strategies, policy should address high-risk groups to increase social, cognitive, and physical activity; and vascular health. • specific actions for risk factors across the life course • aim to maintain systolic bp of mm hg or less in midlife from around age years (antihypertensive treatment for hypertension is the only known effective preventive medication for dementia). • encourage use of hearing aids for hearing loss and reduce hearing loss by protection of ears from excessive noise exposure. • reduce exposure to air pollution and second-hand tobacco smoke. • prevent head injury. • limit alcohol use, as alcohol misuse and drinking more than units weekly increase the risk of dementia. • avoid smoking uptake and support smoking cessation to stop smoking, as this reduces the risk of dementia even in later life. • provide all children with primary and secondary education. • reduce obesity and the linked condition of diabetes. sustain midlife, and possibly later life physical activity. • addressing other putative risk factors for dementia, like sleep, through lifestyle interventions, will improve general health. • tackle inequality and protect people with dementia • many risk factors cluster around inequalities, which occur particularly in black, asian, and minority ethnic groups and in vulnerable populations. tackling these factors will involve not only health promotion but also societal action to improve the circumstances in which people live their lives. examples include creating environments that have physical activity as a norm, reducing the population profile of blood pressure rising with age through better patterns of nutrition, and reducing potential excessive noise exposure. • dementia is rising more in low-income and middleincome countries (lmic) than in high-income countries, because of population ageing and higher frequency of potentially modifiable risk factors. preventative interventions might yield the largest dementia reductions in lmic. summarised best evidence using, where possible, goodquality systematic reviews, meta-analyses, or individual studies, where these add important knowledge to the field. we performed systematic literature reviews and meta-analyses where needed to generate new evidence for our analysis of potentially modifiable risk factors for dementia. within this framework, we present a narrative synthesis of evidence including systematic reviews and meta-analyses and explain its balance, strengths, and limitations. we evaluated new evidence on dementia risk in lmic; risks and protective factors for dementia; detection of alzheimer's disease; multimorbidity in dementia; and interventions for people affected by dementia. nearly all the evidence is from studies in highincome countries (hic), so risks might differ in other countries and interventions might require modification for different cultures and environments. this notion also underpins the critical need to understand the dementias related to life-course disadvantage-whether in hics or lmics. our understanding of dementia aetiology is shifting. a consensus group, for example, has described hippocampal sclerosis associated with tdp- proteinopathy, as limbic-predominant age-related tdp- encephalopathy (late) dementia, usually found in people older than years, progressing more slowly than alzheimer's disease, detectable at post-mortem, often mimicking or comorbid with alzheimer's disease. this situation reflects increasing attention as to how clinical syndromes are and are not related to particular underlying pathologies and how this might change across age. more work is needed, however, before late can be used as a valid clinical diagnosis. the fastest growing demographic group in hic is the oldest adults, those aged over years. thus a unique opportunity exists to focus on both human biology, in this previously rare population, as well as on meeting their needs and promoting their wellbeing. the number of people with dementia is rising. predictions about future trends in dementia prevalence vary depending on the underlying assumptions and geographical region, but generally suggest substantial increases in overall prevalence related to an ageing population. for example, according to the global burden of diseases, injuries, and risk factors study, the global age-standardised prevalence of dementia between and was relatively stable, but with an ageing and bigger population the number of people with dementia has more than doubled since . however, in many hic such as the usa, the uk, and france, age-specific incidence rates are lower in more recent cohorts compared with cohorts from previous decades collected using similar methods and target populations (figure ) and the age-specific incidence of dementia appears to decrease. all-cause dementia incidence is lower in people born more recently, proba bly due to educational, socio-economic, health care, and lifestyle changes. , however, in these countries increasing obesity and diabetes and declining physical activity might reverse this trajectory. , in contrast, age-specific dementia prevalence in japan, south korea, hong kong, and taiwan looks as if it is increasing, as is alzheimer's in lmic, although whether diagnostic methods are always the same in comparison studies is unclear. [ ] [ ] [ ] modelling of the uk change suggests a % increase in the number of people with dementia from to , % of that expected if age-specific incidence rates remained steady, such that by there will be · million uk people with dementia. models also suggest that there will be future increases both in the number of individuals who are independent and those with complex care needs. figure : incidence rate ratio comparing new cohorts to old cohorts from five studies of dementia incidence iidp project in usa and nigeria, bordeaux study in france, and rotterdam study in the netherlands adjusted for age. framingham heart study, usa, adjusted for age and sex. cfas in the uk adjusted for age, sex, area, and deprivation. however, age-specific dementia prevalence is increasing in some other countries. iid=indianapolis-ibadan dementia. cfas=cognitive function and ageing study. adapted from wu et al, by permission of springer nature. hazard ratio incidence ratio ( %ci) in our first report, the commission described a life-course model for potentially modifiable risks for dementia. life course is important when considering risk, for example, obesity and hypertension in midlife predict future dementia, but both weight and blood pressure usually fall in later life in those with or developing dementia, so lower weight and blood pressure in later life might signify illness, not an absence of risk. [ ] [ ] [ ] [ ] we consider evidence on other potential risk factors and incor porate those with good quality evidence in our model. figure summarises possible mechanisms of protection from dementia, some of which involve increasing or maintaining cognitive reserve despite pathology and neuropathological damage. there are different terms describing the observed differential susceptibility to agerelated and disease-related changes and these are not used consistently. , a consensus paper defines reserve as a concept accounting for the difference between an individual's clinical picture and their neuropathology. it, divides the concept further into neurobiological brain reserve (eg, numbers of neurones and synapses at a given timepoint), brain maintenance (as neurobiological capital at any timepoint, based on genetics or lifestyle reducing brain changes and pathology development over time) and cognitive reserve as adaptability enabling preser vation of cognition or everyday functioning in spite of brain pathology. cognitive reserve is changeable and quantifying it uses proxy measures such as education, occupational complexity, leisure activity, residual approaches (the variance of cognition not explained by demographic variables and brain measures), or identification of functional networks that might underlie such reserve. [ ] [ ] [ ] [ ] [ ] [ ] early-life factors, such as less education, affect the resulting cognitive reserve. midlife and old-age risk factors influence age-related cognitive decline and triggering of neuropathological developments. consistent with the hypothesis of cognitive reserve is that older women are more likely to develop dementia than men of the same age, probably partly because on average older women have had less education than older men. cognitive reserve mechanisms might include preserved metabolism or increased connectivity in temporal and frontal brain areas. [ ] [ ] [ ] [ ] [ ] people in otherwise good physical health can sustain a higher burden of neuropathology without cognitive impairment. culture, poverty, and inequality are important obstacles to, and drivers of, the need for change to cognitive reserve. those who are most deprived need these changes the most and will derive the highest benefit from them. smoking increases air particulate matter, and has vascular and toxic effects. similarly air pollution might act via vascular mechanisms. exercise might reduce weight and diabetes risk, improve cardiovascular function, decrease glutamine, or enhance hippocampal neurogenesis. higher hdl cholesterol might protect against vascular risk and inflammation accompanying amyloid-β (aβ) pathology in mild cognitive impairment. numbers of people with dementia in lmic are rising faster than in hic because of increases in life expectancy and greater risk factor burden. we previously calculated that nine potentially modifiable risk factors together are associated with % of the population attributable fraction (pafs) of dementia worldwide: less education, high blood pressure, obesity, hearing loss, depression, diabetes, physical inactivity, smoking, and social isolation, assuming causation. most research data for this calcu lation came from hic and there is a relative absence of specific evidence of the impact of risk factors on dementia risk in lmic, particularly from africa and latin america. calculations considering country-specific prevalence of the nine potentially modifiable risk factors indicate paf of % in china, % in india and % in latin america with the potential for these numbers to be even higher depending on which estimates of risk factor frequency are used. , therefore a higher potential for dementia prevention exists in these countries than in global estimates that use data predominantly from hic. if not currently in place, national policies addressing access to education, causes and management of high blood pressure, causes and treatment of hearing loss, socioeconomic and commercial drivers of obesity, could be implemented to reduce risk in many countries. the higher social contact observed in the three lmic regions provides potential insights for hic on how to influence this risk factor for dementia. we could not consider other risk factors such as poor health in pregnancy of malnourished mothers, difficult births, early life malnutrition, survival with heavy infection burdens alongside malaria and hiv, all of which might add to the risks in lmic. diabetes is very common and cigarette smoking is rising in china while falling in most hic. preventing dementia meta-analysis found variation of the rates of dementia within china, with a higher prevalence in the north and lower prevalence in central china, estimating · million people are living with dementia, whereas a slightly later synthesis estimated a higher prevalence of around million. , these data highlight the need for more focused work in lmic for more accurate estimates of risk and interventions tailored to each setting. risk factors in early life (education), midlife (hypertension, obesity, hearing loss, traumatic brain injury, and alcohol misuse) and later life (smoking, depression, physical inactivity, social isolation, diabetes, and air pollution) can contribute to increased dementia risk (table ) . good evidence exists for all these risk factors although some late-life factors, such as depression, possibly have a bidirectional impact and are also part of the dementia prodrome. , in the next section, we briefly describe relevant newly published and illustrative research studies that add to the commission's evidence base, including risks and, for some, mitigation. we have chosen studies that are large and representative of the populations, or smaller studies in areas where very little evidence exists. we discuss them in life-course order and within the life course in the order of magnitude of population attributable factor. higher childhood education levels and lifelong higher educational attainment reduce dementia risk. , - new work suggests overall cognitive ability increases, with education, before reaching a plateau in late adolescence, when brain reaches greatest plasticity; with relatively few further gains with education after age years. this suggests cognitive stimulation is more important in early life; much of the apparent later effect might be due to people of higher cognitive function seeking out cognitively stimulating activities and education. it is difficult to separate out the specific impact of education from the effect of overall cognitive ability, , and the specific impact of later-life cognitive activity from lifelong cognitive function and activity. , cognitive maintenance one large study in china tried to separate cognitive activity in adulthood from activities for those with more education, by considering activities judged to appeal to people of different levels of education. it found people older than years who read, played games, or bet more frequently had reduced risk of dementia (n= , odds ratio [or]= · , % ci · - · ). the study excluded people developing dementia less than years after baseline to reduce reverse causation. this finding is consistent with small studies of midlife activities which find them associated with better late-life cognition; so for example, in people aged - years, followed up until - years, travel, social outings, playing music, art, physical activity, reading, and speaking a second language, were associated with maintaining cognition, independent of education, occupation, late-life activities, and current structural brain health. similarly, engaging in intellectual activity as adults, particularly problem solving, for people born in , was associated with cognitive ability acquisition, although not the speed of decline. the use it or lose it hypothesis suggests that mental activity, in general, might improve cognitive function. people in more cognitively demanding jobs tend to show less cognitive deterioration before, and sometimes after retirement than those in less demanding jobs. , one systematic review of retirement and cognitive decline found conflicting evidence. subsequently, a -year study of people found older retirement age but not number of years working, was associated with lower dementia risk. those retiring because of ill health had lower verbal memory and fluency scores than those retiring for other reasons. another study found a two-fold increase in episodic memory loss attributable to retirement (n= , mean age years), compared to non-retirees, adjusting for health, age, sex, and wealth. similarly, in a cohort of people retiring at a mean age of years, verbal memory declined % ( % ci - ) faster than before retirement. a cognitive intervention or cognition-orientated treatment comprises strategies or skills to improve general or spe cific areas of cognition. computerised cognitive training programmes have increasingly replaced tasks that were originally paper-and-pencil format with computerbased tasks for practice and training. three systematic reviews in the general population found no evidence of generalised cognition improvement from specific cognitive interventions, including computerised cognitive training, although the domain trained might improve. [ ] [ ] [ ] a meta-analysis of controlled trials of at least hours of computerised cognitive training, (n= , control n= ) for mild cognitive impairment, found a moderate effect on general cognition post-training (hedges' g= · , · - · ); however few high quality studies and no long-term high quality evidence about prevention of dementia currently exists. a meta-analysis of trials of computerised, therapy-based and multimodal interventions for mild cognitive impairment found an effect on activities of daily living (d= · ) and metacognitive outcomes (d= · ) compared to control. a third systematic review identified five high quality studies, four group-delivered and one by computer, and concluded the evidence for the effects of cognitive training in mild cognitive impairment was insufficient to draw conclusions. a comprehensive, high quality, systematic overview of meta-analyses of cognitive training in healthy older people, those with mild cognitive impairment and those with dementia, found that most were of low standard, were positive and most reached statistical significance but it was unclear whether results were of clinical value because of the poor standard of the studies and heterogeneity of results (figure ). in the only randomised controlled trial (rct) of behavioural activation ( people) for cognition in amnestic mild cognitive impairment, behavioural activation versus supportive therapy was associated with a decreased -year incidence of memory decline (relative risk [rr] · , · - · ). hearing loss had the highest paf for dementia in our first report, using a meta-analysis of studies of people with normal baseline cognition and hearing loss present at a threshold of db, which is the who threshold for hearing loss. in the commission, we found an rr of · for dementia in populations followed up over - years, with the long follow-up times making reverse causation bias unlikely. a subsequent meta-analysis using the same three prospective studies measuring hearing using audiometry at baseline, found an increased risk of dementia (or · , % ci · - · ) per db of worsening of hearing loss. a cross-sectional study of individuals designed to be representative of the us population, with a mean age of · years, found a decrease in cognition with every db reduction in hearing, which continued to below the clinical threshold so that subclinical levels of hearing impairment (below db) were significantly related to lower cognition. although the aetiology still needs further clarification, a small us prospective cohort study of adults without baseline cognitive impairment, (baseline mean age · years), and at least two brain mris, with a mean of years follow-up, found that midlife hearing impair ment measured by audiometry, is associated with steeper temporal lobe volume loss, including in the hippocampus and entorhinal cortex. a -year prospective study of people aged years or older found increased dementia incidence in those with self-reported hearing problems except in those using hearing aids. similarly, a cross-sectional study found hearing loss was only associated with worse cognition in those not using hearing aids. a us nationally representative survey of people older than years, tested every two years for years, found immediate and delayed recall deteriorated less after initiation of hearing aid use, adjusting for other risk factors. hearing aid use was the largest factor protecting from decline (regression coefficient β for higher episodic memory · ; p< · ) adjusting for protective and harmful factors. the long follow-up times in these prospective studies suggest hearing aid use is protec tive, rather than the possibility that those developing dementia are less likely to use hearing aids. hearing loss might result in cognitive decline through reduced cognitive stimulation. the international classification of disease (icd) defines mild tbi as concussion and severe tbi as skull fracture, oedema, brain injury or bleed. single, severe tbi is associated in humans, and mouse models, with widespread hyperphosphorylated tau pathology, and mice with apoe ε compared to apoe ε allele have more hippocampal hyper-phosphorylated tau after tbi. , tbi is usually caused by car, motorcycle, and bicycle injuries; military exposures; boxing, horse riding, and other recreational sports; firearms; and falls. a nationwide danish cohort study of nearly million people aged years or older, followed for a mean of years, found an increased dementia (hr · , % ci · - · ) and alzheimer's disease risk ( · , · - · ). dementia risk was highest in the months after tbi ( · , · - · ) and increased with number of injuries in people with tbi (one tbi · , · - · ; ≥ tbis · , · - · ). risk was higher for tbi than fractures in other body areas ( · , · - · ) and remained elevated after excluding cognitive training cognitive stimulation mixed cognition-oriented treatments favours control favours intervention those who developed dementia within years after tbi, to reduce reverse causation bias. similarly, a swedish cohort of over million people aged years or older, found tbi increased -year dementia risk (or · , % ci · - · ); and risk remained elevated, albeit attenuated over years ( · , · - · ). icd defined single mild tbi increased the risk of dementia less than severe tbi and multiple tbis increased the risk further (or · , % ci · - · for single tbi; · , · - · for more severe tbi; and · , · - · for multiple tbi). a nested case control study of early onset clinically diagnosed alzheimer's disease within an established cohort also found tbi was a risk factor, increasing with number and severity. a stronger risk of dementia was found nearer the time of the tbi, leading to some people with earlyonset alzheimer's disease. military veterans have a high risk of occupational tbi, and formal record keeping allows long-term follow-up. a study of veterans with tbi with propensitymatched veterans without tbi found dementia risk was associated with tbi severity (hr · , % ci · - · for mild tbi without loss of consciousness; · , · - · for mild tbi with loss of consciousness; and · , · - · for moderate to severe tbi). similarly women veterans with tbi had increased risk of dementia compared to those without tbi ( · , · - · ). a cohort study of older adults with concussion, found the risk of dementia doubled, with in developing dementia over a mean follow-up of · years, although those taking statins had a % reduced risk of dementia compared to those who were statin-free. they suggest future rcts as statins might mitigate injury-related brain oedema, oxidative stress, amyloid protein aggregation, and neuroinflammation. the term chronic traumatic encephalopathy describes sports head injury, which is not yet fully characterised and covers a broad range of neuropathologies and outcomes, with current views largely conjecture. the evidence has subsequently been strengthened by a study on scottish former soccer players reporting that they are more likely than controls to have alzheimer's disease specified on their death certificates (hr · , % ci · - · ) and to have been prescribed any dementiarelated medications (or · , % ci · - · ) but not on medical records. the study controlled for socioeconomic class based on residential address, which in footballers might be less linked to level of education. persistent midlife hypertension is associated with increased risk of a late life dementia. in the framingham offspring cohort comprising people, elevated systolic blood pressure (≥ mm hg in midlife; mean age years) was associated with an increased risk of developing dementia (hr · , % ci · - · ) over an year follow-up period. in this study risk increased further if hypertension persisted into later life (mean age years; hr · , % ci · - · ). in the same cohort, people in late midlife (mean age years) with ideal cardiovascular parameters (current non-smoker, body mass index [bmi] · - kg/m², regular physical activity, healthy diet, optimum blood pressure < /< mm hg, cholesterol, and normal fasting blood glucose) were compared to people with at least one of these risks. those with ideal cardiovascular parameters had a lower -year risk of all-cause dementia (hr · , % ci · - · ), vascular dementia ( · , · - · ) and clinically diagnosed alzheimer's disease ( · , · - · ). in a uk cohort study of civil servants, a single measure of systolic blood pressure of mm hg or higher at age years but not at age or years was associated with increased risk of dementia ( · , · - · ). in those with persistent systolic blood pressure of mm hg or higher, from mean age to years, dementia risk is increased even if free of cardiovascular disease relative to those without hypertension ( · , · - · ). a further cohort study has provided potential insights into mechanisms, reporting that midlife hypertension, defined as from age years, was associated with reduced brain volumes and increased white matter hyperintensity volume but not amyloid deposition. of note, blood pressure declines in later life and this decline is associated with and, potentially caused by, dementia development (hr · , % ci · - · ). , , antihypertensive drugs, aspirin, and statins the us and puerto rico systolic blood pressure intervention trial (sprint) in hypertensive adults aged years and older, was stopped early because of significantly fewer cardiovascular events and deaths occurring in the intensive treatment arm (aiming for systolic < mm hg, n= ) in comparison with standard treatment (systolic < mm hg, n= ). cognitive assessment continued after stopping the trial intervention in sprint mind. in the intensive compared with the standard treatment group, there were · dementia cases as opposed to · cases/ personyears (hr · ; % ci · - · ) within on average years from the end of the intervention period and years after baseline. pre-specified secondary outcomes were also reduced in the intensive arm for mild cog nitive impairment ( · vs · cases/ person-years; hr · , % ci · - · ), combined mild cognitive impairment or dementia ( · vs · cases/ person-years; hr · , % ci · - · ) making this the first trial to suggest reduction of risk for mild cognitive impairment. those who were lost to follow-up were at greater risk of dementia than those who continued but follow-up rates did not differ according to intervention group. four meta-analyses of blood pressure medications to lower high blood pressure with six studies overlap have provided combined estimates of effects. all metaanalyses suggest reduced dementia in those in the interventions arms for outcomes of any dementia as well as clinically diagnosed alzheimer's disease. the first included randomised controlled trials (rcts) of any drug to lower blood pressure and reported a reduction in risk of around % at marginal significance (rr · , % ci · - · ). meta-regression showed risk lowered more if the achieved systolic pressure differential was larger between the intervention and control group. the second included trials and observational studies of diuretics involving people (median age years) with · years median follow-up (dementia hr · , % ci · - · and alzheimer's disease · , · - · ). the third included used individual participant data from six observational studies; (dementia · , · - · and alzheimer's disease · , · - · ; figure ). the fourth focused on people prescribed calcium channel blocker only, included rcts and observational studies comprising hypertensive older adults (median age years, median follow-up · years) found lowered dementia risk (rr · , % ci · - · ). a metaanalysis addressing which class of anti-hypertensive drug to use to lower risk of either incident dementia or cognitive decline, found over participants in studies and reported no consistent difference in effect according to which class of drug was used. a cochrane review reported good evidence that statins given to older people at risk of vascular disease do not prevent cognitive decline or dementia. one rct found mg aspirin versus placebo in healthy adults older than years did not reduce dementia (hr · , % ci · - · ), death, physical disability, or cardiovascular disease over a period of · years. studies of physical activity are complex. patterns of physical activity change with age, generation, and morbidity and are different across sex, social class, and cultures. the studies suggest a complicated relationship with the potential for both risk reduction and reverse causation. meta-analyses of longitudinal observational studies of - years duration showed exercise to be associated with reduced risk of dementia. a further overview of sys tematic reviews concluded that there is convincing decreased incident dementia evidence for physical activity protecting against clinically diagnosed alzheimer's disease. since the commission, the hunt study of participants aged - years has been published, reinforcing the previous literature in this area. at least weekly midlife moderate-to-vigorous physical activity (breaking into a sweat) was associated with reduced dementia risk over a -year period of follow-up (hr · , % ci · - · ) but the confidence intervals were wide. in contrast the whitehall study reporting on the -year follow-up of people, found that more than · hours of self-reported moderate-to-vigorous physical activity per week, lowered dementia risk over , but not years. very long-term studies are unusual; however, one -year study recruited women (mean age ) purposively to be representative of the swedish population and reported that % of the participants with low baseline peak fitness, % with medium, and % with high fitness developed dementia (high vs medium hr · , % ci · - · , low vs medium · , · - · ). an individual-level meta-analysis of observational studies of relatively younger adults included participants' data (mean baseline age · years; mean follow-up duration · years), reporting an increased incidence of all-cause dementia (hr · , % ci · - · ) and clinically diagnosed alzheimer's disease ( · , · - · ) in those who were physically inactive in the -year period before diagnosis. notably, however, no difference in dementia risk measured - years before time of dementia incidence was found except in those with comorbid cardio-metabolic disease (rr · , % ci · - · ). people might stop exercising due to prodromal dementia so inactivity might be either a consequence or a cause or both in dementia and might be more of a risk in those with cardiovascular morbidity. as with other outcomes, exercise might be required to be sustained and continue nearer the time of risk. since the commission several meta-analyses and systematic reviews have been published with three high quality meta-analyses which we include. the first included rcts with an unclear total number of participants examining moderate or vigorous exercise of any frequency lasting - min per session in cognitively normal adults aged older than years. this analysis reported global cognitive improvements (standard mean difference [smd]= · , % ci · - · ) for moderate or vigorous resistance ( studies) or aerobic exercise ( studies) lasting - min per session with no difference between them but no effect found for yoga. a second meta-analysis of rcts in people with mild cognitive impairment found global cognition improved in the intervention group ( · , · - · ) with aerobic exercise having a higher effect ( · , · - · ). this study did not have dementia as an outcome measure. a third meta-analysis of rcts of longer term exercise found five studies (four lasting months and one months) with participants with normal baseline cognition. the incidence of dementia was · % (n= ) for exercisers and · % (n= ) for controls (random effect rr · , % ci · - · ; fixed effect as no evidence of heterogeneity · , · - · ). the authors concluded that the study showed no significant effect of exercise for reducing dementia, mild cognitive impairment, or clini cally significant cognitive decline but was underpowered. who guidelines have been published since the commission, suggesting specific activity levels drawing on these, and one further systematic review which considered sex differences on the effect of exercise. , it concluded the evidence points towards physical activity having a small, beneficial effect on normal cognition, with a possible effect in mild cognitive impairment, mostly due to aerobic exercise. evidence about the effect of specific types of exercise, such as progressive muscle resistance training, on dementia risk is scarce. in the commission we reported on diabetes as a risk factor for dementia. distinguishing between treated and untreated diabetes as a risk factor for dementia is challenging in observational studies. in a pooled metaanalysis from over · million individuals with type diabetes across cohort studies, including with dementia, diabetes was associated with an increased risk of any dementia (rr · , % ci · - · for women and · , · - · for men). the risk of dementia increased with the duration and severity of diabetes. the effect of different diabetic medications on cognition or dementia outcomes remains unclear as few studies have investigated this area. however, one meta-analysis of cohort studies of diabetes reported that, cross sectionally, people with diabetes taking metformin had lower prevalence of cognitive impairment (three studies or · , % ci · - · ) and, longitudinally, reduced dementia incidence (six studies hr · , % ci · - · ) compared with those taking other medications or no medication. however another analysis did not find a protective effect of metformin for incident dementia (three studies, rr · , % ci · - · ) with possible harm with insulin therapy ( · , · - · ); but this did not account for severity of diabetes of those with type diabetes on insulin. a cochrane review reported intensive compared to standard diabetes control trials with year follow up (n= ), showing no impact on cognitive decline ( · , % ci · - · ) or dementia ( · , · - · ). overall type diabetes is a clear risk factor for development of future dementia; however, whether any particular medication ameliorates this risk is unclear. intensive diabetic control does not decrease the risk of dementia. studies of individual cardiovascular risk factors usually control for other cardiovascular risks, which cluster in individual people. this does not take into account the combinations and contexts in which risk occurs. a uk study of people aged years followed up for years, calculated a cardiovascular health score based on four behaviour-related (smoking, diet, physical activity, bmi) and three biological (fasting glucose, blood cholesterol, blood pressure) metrics each coded on a three-point scale ( , , ). a better score was associated with a lower risk of dementia (hr · , % ci · - · per point scale increment), for both behaviour-related (hr/ point increment in subscales · , % ci · - · ) and biological subscales ( · , · - · ), main tained in people free of cardiovascular disease over the follow-up ( · , % ci · - · ). these authors also reported an association of the score on the scale with hippocampal atrophy and total brain volume but not white matter hyperintensities. this finding underlines the importance of clustering of cardio vascular risk factors in midlife, as studies of individual risk factors in this sample had not shown a significant association, when controlling for other individual risks. heavy drinking is associated with brain changes, cognitive impairment, and dementia, a risk known for centuries. an increasing body of evidence is emerging on alcohol's complex relationship with cognition and dementia outcomes from a variety of sources including detailed cohorts and large-scale record based studies. alcohol is strongly associated with cultural patterns and other sociocultural and health-related factors, making it particularly challenging to understand the evidence base. a french -year longitudinal study of over million people admitted to hospital, found alcohol use disorders (harmful use or dependence as defined in icd) were associated with increased dementia risk, calculated separately for men and women (women hr · , % ci · - · , men · , · - · ). the relationship of dementia with alcohol use disorders was particularly clear in the earlier onset dementias (age less than years) in which · % had an alcohol use disorder noted in their records (n= ; · % all dementias). a systematic review incorporating studies of light to moderate drinking using a variety of definitions reported a reduced risk of dementia compared with not drinking (rr · ; % ci · - · ). risk was not reported separately for men and women. drinking less than units of alcohol per week ( unit of alcohol= ml or g pure alcohol) might be associated with a lower risk of dementia. , a -year follow-up study of men and women volunteers from uk biobank aged - years who drank, included few heavy drinkers and did not analyse abstainers. the study reported that those who drank more than units per week declined slightly more in reaction time in a perceptual matching task than those who drank less (β =− · , % ci − · to − · ). the uk whitehall study with years follow-up, included participants aged - years at baseline. drinking more than units per week and long-term abstinence were both associated with a % ( % ci - and - respectively) increase in dementia compared to drinking less than units. drinking more than units was also associated with right sided hippocampal atrophy on mri. overweight is an emerging concern, given the changing bmi across the world's ageing population. new evidence supports the relationship between increased bmi and dementia from a review of longitudinal studies including people aged to years, followed up for up to years. it reported obesity (bmi ≥ ; rr · , % ci · - · ) but not being overweight (bmi - ; · , · - · ) was associated with late-life dementia. in a further meta-analysis of individual level data from · million adults (aged ≥ years), which included two studies from the meta-analysis cited above, higher body mass measured before probable preclinical and prodromal dementia was associated with increased dementia risk (rr · , · - · / -unit increase in bmi). a meta-analysis of seven rcts ( participants) and longitudinal studies ( participants) of overweight and obese adults without dementia, mean age years, found weight loss of kg or more in people with bmi greater than was associated with a significant improvement in attention and memory. all but one of the studies included participants aged younger than years. the rcts reported memory improvement over - weeks (smd= · , % ci · - · ) and short-term longitudinal studies found improvement over a median of weeks (smd= · , % ci · - · ); however, data about the long-term effects or the effect of weight loss in preventing dementia are absent. smokers are at higher risk of dementia than nonsmokers, and at a higher risk of premature death before the age at which they might have developed dementia, introducing some bias and uncertainty in the association between smoking and risk of dementia. , stopping smoking, even when older, reduces this risk. among men aged older than years, stopping smoking for more than years, compared to continuing, substantially reduced dementia risk over the subsequent years (hr · ; % ci · - · ). worldwide, % of nonsmoking adults and % of children are estimated to be exposed to second-hand smoke; although literature on the impact of this exposure and dementia risk is scarce. one study indicated that in women aged - years, second-hand smoke exposure was associated with more memory deterioration and the risk increased with exposure duration even after controlling for other confounding factors. depression is associated with dementia incidence, with a variety of possible psychological or physiological mechanisms. it is also part of the prodrome and early stages of dementia. reverse causation is possible whereby depressive symptoms result from dementia neuropathology that occurs years before clinical dementia onset. these explanations are not mutually exclusive. as in diabetes, few studies considering depression as a risk factor for dementia have distinguished between treated and untreated depression. in a meta-analysis of studies, with participants, with follow-up from to years, a depressive episode was a risk factor for dementia (pooled effect size · , % ci · - · ). meta-regression analysis revealed a non-significant trend for the association between depression and incident dementia to be weaker when the length of follow-up was longer. the norwegian hunt study, suggested that symptoms of psychological distress predicted dementia years later however with wide bounds of uncertainty (hr · , % ci · - · ). two further studies differentiate between late-life and earlier life depressive symptoms. the uk whitehall study, in a follow-up of people, reports that in late life these symptoms increase dementia risk but not at younger ages (follow-up years hr · ; % ci · - · ; follow-up years · , · - · ). , a -year longitudinal study of initially cognitively healthy men, aged - years, found depression was associated with · ( % ci · - · ) times the incidence of dementia but this association was accounted for by people developing dementia within years of depression. the use of antidepressants did not decrease this risk. a study of people with mild cognitive impairment and with a history of depression from the australian longitudinal alzheimer's disease neuroimaging initiative, considered the effect of selective serotonin-reuptake inhibitor (ssri) treatment, such as citalopram, known to reduce amyloid plaque generation and plaque formation in animal models. the study found that more than years of such treatment was associated with delayed progres sion to clinically diagnosed alzheimer's disease. people treated with antidepressants seem likely to differ from those who are not treated. thus, the question of whether antidepressant treatment mitigates dementia risk remains open. social contact, now an accepted protective factor, enhances cognitive reserve or encourages beneficial behaviours, although isolation might also occur as part of the dementia prodrome. several studies suggest that less social contact increases the risk of dementia. although most people in mid and later life are married, by the time they reach older age, disproportionate numbers of women are widowed as they outlive their husbands, thus reducing their social contact. in these generations, marital status is therefore an important contributor to social engagement. additionally, most marriages are in the relatively young, and married people usually have more interpersonal contact than do single people-this gives a long-term estimate of the effect of social contact. a systematic review and meta-analysis including people worldwide found dementia risk to be elevated in lifelong single (rr · , % ci · - · ) and widowed people ( · , · - · ), compared with married people and the association was consistent in different sociocultural settings. studies adjusted for sex and we do not know if a differential risk between men and women exists. differences persisted in studies that adjusted for education and physical health so might be attributable to married people having more social contact, rather than solely because they tend to have better physical health and more education, although residual confounding is possible. a systematic review and meta-analysis of longitudinal cohort studies of social isolation and cognition included participants aged or more years at baseline, with follow-up of - years. high social contact (measured through either or both of social activity and social network) was associated with better late-life cognitive function (r= · , % ci: · - · ) and no differences according to sex or length of time followed up. a new meta-analysis found that in long-term studies (≥ years), good social engagement was modestly protective (n= , rr= · , % ci · - · ); but loneliness was not associated with dementia risk. no long term (> years) studies of loneliness and dementia outcomes have been done. a uk -year follow-up study of people found that more frequent social contact at age years was associated with lower dementia risk over years of follow-up (hr for one standard deviation social contact frequency · , % ci · - · ). this finding suggests more frequent social contact during late middle age is associated with a modest reduction in dementia risk, independent of socio-economic and other life style factors. a japanese longitudinal cohort study of adults aged older than years with a mean of years follow-up calculated a five-point social contact scale based on: marital status; exchanging support with family members; having contact with friends; participating in community groups; and engaging in paid work. it found the score to be linearly associated with reduced dementia risk; those who scored highest on the five-point scale were % less likely to develop incident dementia compared with those in the lowest category. despite clear cultural variation in the meaning and perception of social isolation, findings of protective effect of more social contact are largely consistent in different settings and for either sex across the studies and metaanalyses. , , little evidence of the effects of social interventions on dementia exists but a systematic review of low quality rcts of adults aged or more years with normal cognition found facilitated meeting and discussion groups were associated with improved global cognition and increased brain volume at follow-up. air pollution and particulate pollutants are associated with poor health outcomes, including those related to non-communicable diseases. attention has turned to their potential effect on the brain. animal models suggest airborne particulate pollutants accelerate neurodegenerative processes through cerebrovascular and cardiovascular disease, aβ deposition, and amyloid precursor protein processing. , although the higher levels of dementia from air pollutants are still subject to the potential for residual confounding, the effects on animal models are evidence of physiological effects over and above those driven by life-course deprivation. high nitrogen dioxide (no ) concentration (> · µg/m³; adjusted hr · , % ci · - · ), fine ambient particulate matter (pm) · from traffic exhaust ( · , · - · ) [ ] [ ] [ ] and pm · from residential wood burning (hr= · , % ci · - · for a μg/m³ increase) are associated with increased dementia incidence. traffic often produces no and pm · and it is hard to separate their effects, although evidence for additive effects of different pollutants exists. [ ] [ ] [ ] a systematic review of studies until including longitudinal studies with - years follow-up of air pollutants exposure and incident dementia, found exposure to pm · , no , and carbon monoxide were all associated with increased dementia risk. the attributable burden of dementia and excess death from pm · in one large -year us study was particularly high in black or african american individuals and socio-economically disadvan taged communities and related to particulate pm · concentrations above the us guidelines. mechanisms by which sleep might affect dementia remain unclear, but sleep disturbance has been linked with β-amyloid (aβ) deposition, , reduced glymphatic clearance pathways activation, low grade inflammation, increased tau, hypoxia , and cardiovascular disease. sleep disturbance is hypothesised to increase inflammation which raises aβ burden, leading to alzheimer's disease and further sleep disturbance. two meta-analyses showed similar findings. the first was a synthesis of longitudinal studies with an average of · years follow-up and the second reported crosssectional and prospective cohort studies of mixed quality with different methods of measuring sleep. sleep disturbances were defined broadly, often self-reported and including short and long sleep duration, poor sleep quality, circadian rhythm abnormality, insomnia, and obstructive sleep apnoea. all these disturbances were associated with a higher risk of all-cause dementia (rr · ; % ci · - · ) and clinically diagnosed alzheimer's disease ( · , · - · ) compared with no sleep disturbance, although not all cohort studies excluded those with cognitive impairment or dementia at baseline from their analyses. a u-shaped association has been reported between sleep duration and risk of mild cognitive impairment or dementia with higher risks of dementia with less than hours (hr= · ; % ci · - · ) compared with more than and less than and more than hours sleep ( · , · - · ) and risks for allcause dementia and clinically diagnosed alzheimer's disease being similar. , [ ] [ ] [ ] the postulated mechanisms of reduced sleep leading to accumulation of alzheimer's type pathology is inconsistent with the evidence that both more sleep and less sleep are associated with increased risk of dementia. new onset late-life sleep disturbance, a few years before clinical dementia, might be part of the natural history of the dementia syndrome, appearing to be a risk factor, or reflect other disorders, for example, mood disturbances or cardiovascular disease. , hypnotic use might increase risks although this is unclear and a study suggests that findings of a connection were related to reverse causality and confounders. when benzodiazepine use was considered, in one study, sleep length was no longer significant but not in all studies. those taking hypnotics were at greater risk of dementia than those who did not regardless of sleep duration. medication for sleep disturbance might be harmful and benzodiazepines are associated with falls, hospital admissions, and possibly dementia. , diet nutrition and dietary components are challenging to research with controversies still raging around the role of many micronutrients and health outcomes in dementia. observational studies have focused on individual components ranging from folate and b vitamins, vitamin c, d, e, and selenium amongst others as potential protective factors. there has been a move towards considering the evidence base for whole diets in the last years, particularly high plant intake such as in the mediterranean diet (high intake of vegetables, legumes, fruits, nuts, cereals, and olive oil; low intake of saturated lipids and meat) or the similar nordic diet, rather than individual nutrients, which might reduce cognitive decline and dementia. one example is a longitudinal cohort study of partici pants, ages - years, in which those reporting the highest intake of green leafy vegetables, equivalent to · servings per day, had less cognitive decline over · years than those reporting the lowest intake (β= · standardised units % ci · - · ). the authors report this difference as being equivalent to being years younger. a further prospective cohort study with three midlife dietary assessments in people, followed up for a mean of nearly years, found neither healthy dietary pattern nor mediterranean diet protected from dementia, except in those with cardiovascular disease, suggesting that diet might influence dementia risk by protecting from the excess risk of cardiovascular risk factors. as well as whole diets, there has been some interest in multi-nutrient interventions. a systematic review and a cochrane review including rcts of supplements (a, b, c, d, and e; calcium, zinc, copper, and multivitamins trials, n- fatty acids, antioxidant vitamins, and herbs) found a lack of evidence for supplement use to preserve cognitive function or prevent dementia in middleaged ( - years) or older people (aged years and older). , cochrane reviews found no evidence for beneficial effects on cognition of those with mild cognitive impairment of supplementation with b vitamins for to months or with vitamin e in preventing progression from mild cognitive impairment to dementia. a -month rct of people of a multi-nutrient drink containing docosahexaenoic acid, vitamins b , b , folic acid, and other nutrients; found no significant effect on preventing cognitive deteriora tion in prodromal alzheimer's dis ease. the authors comment that the control group's cognitive decline was much lower than expected, leading to an inadequately powered trial. meta-analysis of two rcts with participants with normal cognition found the mediterranean diet improved global cognition compared to controls (smd · , % ci · - · ). a further meta-analysis identified five rcts (n= ) with a weak effect on global cognition (smd · , % cl · - · ) but no benefit of mediterranean diet for incident cognitive impairment or dementia. the who guidelines recommend a mediterranean diet to reduce the risk of cognitive decline or dementia, as it might help and does not harm, but conclude vitamins b and e, polyunsaturated fatty acid, and multicomplex supplementation should not be recommended. the finger rct was a -year multidomain intervention to prevent cognitive decline and dementia in people with cardiovascular risk factors aged - years, recruited from a finnish national survey. similar multidomain studies were discussed in the commission. finger found a small group reduction in cognitive decline in the intervention group compared with control (comprehensive neuropsychological test battery z score · , % cl · - · ) regardless of baseline sociodemographic, socio-economic, cognitive, or cardiovascular status. however, in a subgroup analysis, greater beneficial effects were observed on processing speed in individuals with higher baseline cortical thickness in alzheimer's disease areas. the healthy ageing through internet counselling in the elderly (hatice) study recruited older people (≥ years) in the netherlands, finland, and france with two or more cardiovascular risk factors. , it compared an interactive internet platform plus remote support by a coach, aiming to improve self-management of vascular risk factors, with a non-interactive control platform with basic health information. a small improvement in the cardiovascular risk composite primary outcome was observed in the intervention group compared with the control group at months, mainly through weight loss, and the dementia risk score was slightly lower in those who received the intervention (mean difference − · , % ci − · to − · ). a larger effect was observed in the younger age group ( - years) and those with the lowest level of education, who had a higher baseline risk, suggesting that targeting high-risk popula tions might be more effective. several multi domain preventive trials are ongoing-for example, world wide fingers. we incorporated excessive alcohol consumption, tbi, and air pollution into our life-course model of dementia, as well as the original nine risk factors, because of the updated evidence. to calculate new rrs for excessive alcohol consumption, tbi and air pollution, we systematically reviewed the literature and did new metaanalyses for excessive alcohol consumption and tbi. for the other nine factors, we used values for rr and risk factors prevalence from our previous analysis and calculated communality using the same method as in the commission. we used a representative sample of over uk community-dwelling adults, to calculate communality (clustering of risk factors) of risk factors for which data existed, to allow calculation of each factor's unique risk. as we could find no datasets measuring tbi, with the other risk factors of interest, we could not calculate its communality. we therefore used the mean of the other communalities to calculate a weighted paf, so we could include tbi. we used cohabitation as a proxy measure for social contact, and urbanicity for air pollution exposure. our analysis found four principal components, explaining % of the total variance between the eleven risk factors, suggesting substantial overlap. the appendix (p ) shows the paf formula and the steps in calculating communality and we detail our new meta-analyses we searched, from inception to oct , , embase, allied, and complementary medicine, medline, and psycinfo terms "dementia" or "dement*" or "ad" or "vad", "alzheimer*" and "alcohol" or "ethanol" or "alcohol*" or "drink*" or "drunk*" to update an earlier review. we used inclusion criteria: original populationbased cohort studies measuring drinking during midlife, as alcohol intake tends to fall with age; alcohol consumption quantified at baseline by units or number of drinks (one drink, · units) per week; and all-cause dementia ascertained at follow-up using validated clinical measures. we contacted authors for additional data. three studies met our inclusion criteria. , , we converted hrs to rrs and used raw data to calculate rr, for our random effects meta-analysis using generic inverse variance methods. the rr associated with drinking-more than units ( g) of alcohol weeklycompared with lighter drinking was · ( % cl · - · ; figure ). we used health survey england figures for heavier drinking prevalence to calculate paf as we could not find a worldwide estimate. the weighted paf was · . to estimate the rr of tbi of all severities for all cause dementia, we searched embase, medline, and psycinfo from jan , , to oct , , updating an earlier search, using terms ("traumatic brain injury" or "head injury" or "brain injury" or tbi) and (neurodegeneration or "cognitive dysfunction" or dementia or "alzheimer's disease" or "parkinson's disease" or "frontotemporal dementia"). we converted hr figures to rr. , we used inclusion criteria: original population-based cohort studies, baseline tbi of all severities reported, and allcause dementia ascertained at follow-up using validated clinical measures. we combined four new studies meeting inclusion criteria , , , with the four studies meeting criteria from the original review in a random effects metaanalysis. the pooled rr was · ( % ci · - · ) for all cause dementia from all severities of tbi (figure ) although there was heterogeneity in study-specific estimates, possibly because of different popula tions. we used the tbi adult population prevalence of · % from a metaanalysis to calculate paf. the weighted paf was · . chu et al ( ) fann et al ( ) gardner et al ( ) nordström et al ( ) nordström et al ( ) wang et al ( ) total ( % ci) heterogeneity τ = · , χ = · , df= (p< · ); i = % test for overall effects: z= · (p< · ) · · a systematic review synthesised observational studies, finding consistently increased risk of dementia from air pollution, but heterogeneous comparator groups precluded meta-analysis. we updated the search, using the same search terms and searching medline, embase, and psycinfo from sept , , (the end date of the last search) to oct , . we included longitudinal studies with assessment of all cause air pollution exposure; use of formal assessment of cognitive function at baseline; report of incident all-cause dementia, data from adults (age ≥ years); and a minimum follow-up of months. as meta-analysis was not possible, we used data from the only study of allcause air pollution with the outcome of all-cause dementia, with low-moderate risk of bias. this population-based, observational cohort was from canada, where pollutant concentrations are among the lowest in the world and examined people, with a mean baseline age of years. we calculated the rr of dementia for those in the three highest quartiles compared to the lowest was · ( · - · ) . the attributable fraction for exposure to the highest three quartiles versus the lowest quartile of pm · and no was · % ( · - · ). the weighted paf was · . table displays the prevalence, commu nality, relative risk, unweighted and weighted pafs adjusted for communality. figure shows the updated life-course model of potentially modifiable risk factors for dementia, including the three new risk factors. this commission is the most comprehensive ana lysis to date and updates the commission with emerging risk factor evidence convincing enough to calculate paf for potentially reversible risk factors. we reviewed the literature systematically for the chosen risk factors and provided illustrative new literature to update our synthesis and identify data to calculate communality. we find a hopeful picture with an estimate of around % of all cases of dementia being associated with potentially modifiable risk factors. we have made assumptions to calculate this new model. we used global figures for dementia risk although we know the risk factors prevalence varies between countries and most global research is from hic, so lmic are under-represented because of lack of data. we have assumed a causal relationship between risk factors and dementia, although we have been cautious and not included risk factors with less good evidence. no single database exists with all risk factors together, but we found of the factors in a uk database and used the mean figure for communality calculations for tbi. we calculated communality for the other . we do not know how far findings of communality in other geographical populations might differ, or in those with a differing distribution of age groups or sex. we found that social isolation was not explicitly measured and had to use proxies, such as cohabitation when considering prevalence, which are approximate. specifically, evidence for the association of alcohol misuse with dementia comes from hic and future studies from lmic are needed to complete the picture. exposure to air pollution changes over a lifetime and is inextricably linked to poverty and deprivation. however, the effects on animal models suggests specific physiological effects over and above those driven by life-course deprivation. we also considered the overlap with education for this and other risk factors and the correction for education, strongly inversely linked to deprivation, will address at least some of the confounding. however, the results in one study which reported the effect of air pollution on incident dementia showed very little early life difference in estimates before and after adjustment for education and other risk factors, suggesting little residual confounding exists. we were also unable to metaanalyse data on pollution and thus unlike the other relative risks, the figure comes from only one study, from an area of low pollution so is likely to be an underestimate. the longitudinal evidence linking potentially modifiable risk factors to dementia generally fulfils causality criteria in observational data (strength, consistency, biological plausibility, temporality, dose-response, coherence, and quasi-experimental studies, for example, more education or using hearing aids). when measuring a risk nearer to the age of dementia onset, then it is more likely that prodromal change affects, or even causes it. alternatively, a risk factor might act on preclinical pathology or even cause dementia near the time of exposure. thus, excessive alcohol, and tbi are particularly important in young-onset dementia, although many early onset dementias relate to genetic risks. risk factors might also matter more at a time of higher biological vulnerability, which the studies we have drawn on cannot establish. the length of exposure required for risk or protection effect, and their interrelationships as they change across life is unclear-it seems probable that longer or more intense exposure has stronger effects. additionally, as our communality figures show, risk factors overlap. we cannot establish from these data if having multiple risk factors has an additive or synergistic effect. association does not prove causation, however, as already noted, the reductions in prevalence and incidence in several hic suggests that at least some of the risk factors estimated here do have a causal relationship with the clinical expression of dementia. we judge that sufficient new evidence supports adding three additional modifiable risk factors for dementia to our commission model (excessive alcohol, traumatic brain injury, and air pollution). we have been able to add updated evidence on the nine risk factors implicated in the commission (education, hypertension, hearing impairment, smoking, obesity, depression, inactivity, diabetes, and social contact). reduction of these risk factors might be protective for people with or without a genetic risk, although study findings have not been entirely consistent. [ ] [ ] [ ] [ ] as we noted in the commission, others have previously calculated an estimate of the risk associated with apoε at % taking into account some other risk factors and this estimate highlights how relatively important potentially modifiable risk factors are in dementia. , for some risk factors, the pattern of risk and the individual's other health, both physical and mental, might be especially important. currently, the evidence suggests a mediterranean or scandinavian diet might have value in preventing cognitive decline in people with intact cognition, particularly as one component of a healthy lifestyle, although how long the exposure has to be or during which ages is unclear. we do not recommend taking additional vitamins, oils, or mixed dietary supplements as a means of preventing dementia as extensive testing in trials has not led to signals of beneficial effects. data from rcts on interventions to prevent cognitive decline, all-cause dementia, or alzheimer's disease are few. for some key life influences, only observational data, particularly related to natural experiments such as changing the statutory education age, are possible. these influences should be investigated systematically wherever possible. others can theoretically be investigated but the long follow-up required for midlife risk and protective factors and non-random attrition in longer studies are challenging. using intermediate endpoints, such as cognition, and dementia onset in research remains uncertain because no intermediate markers with such a close relationship to dementia outcomes exist that it would be possible to predict with certainty for any given individual, age, and sex. overall, the evidence for treating hypertension is strongest and high blood pressure throughout midlife increases the risk of dementia even without stroke. although a need for more evidence is apparent, recommendations should not wait, as clear indications of ways to reduce the chances of developing dementia without causing harm will also lead to other health and wellbeing benefits. our recommended strategies for dementia risk reduction include both population-wide and targeted interventions (panel). it is important to remember that more socially disadvantaged groups, including black, asian, and minority ethnic groups, are particularly at risk. although we have more to learn about effectiveness, avoiding or delaying even a proportion of potentially modifiable dementias should be a national priority for all. not all dementia will be preventable and we present the latest evidence on intervention and care for dementia. to date the emphasis has been on specific subtypes of dementia, most notably on alzheimer's disease, which has been conceptualised over the years in a variety of changing diagnostic criteria-eg, dsm iv and dsm v. , intense efforts have been put into biomarkers for early preclinical detection of the disease process before it becomes dementia. biomarkers need to show reliability and validity, and for dementias they also need to be very closely and clearly related to clinical syndrome outcomes in the way that, for example, human papillomavirus is for cervical cancer, and hypertension has been for stroke. markers of neurodegeneration linked to clinical dementia include brain volume loss-ie, hippocampal volume loss and entorhinal cortex and medial temporal cortical thinning-seen in structural imaging. the most studied molecular markers are in alzheimer's disease and are amyloid and tau, which pet and csf detect clinically. the prevalence of particular pathologies at different ages is important in interpretation of such studies. so, for example, population derived studies show increases in plaques in the population from less than % at age - years to around % at age - years. amyloid imaging detects amyloid in the brain with high sensitivity and specificity in both cognitively normal and people with alzheimer's disease when the gold-standard comparison is either neuropathology or clinical diag nosis, distinguishing alzheimer's disease from other neurodegenerative conditions. amyloid imaging is not a diagnostic test for dementia. a us study of randomly selected older people from the community recruited people (mean age of years). the prevalence of pet detected amyloid positivity increased from · % ( % ci · - · ) of people without cognitive impairment aged - years to · % ( % ci · - · %) aged - years. in -year follow-up pet positivity was associated with a higher probability of developing alzheimer's disease compared with those who were amyloid negative (hr · , % ci · - · ). in participants with mild cognitive impairment who were amyloid positive the probability (hr · , % ci · - · ) was not very different to those who were amyloid negative ( · , · - · ). similarly, an -year follow-up study of volunteers (average age years) in australia found that cognitively normal pet amyloid-positive people had an elevated risk of developing alzheimer's disease compared with amyloid negative ( · % vs · %; or · , % ci · - · ). over % of the people who were pet amyloid-positive did not go onto develop a cognitive impairment within years, showing positive status does not predict impairment for most people in a timeframe that might be a useful prognostic window. follow-up at years of amyloid-positive participants with normal cognition or mild cognitive impairment versus amyloid negative people found the same pattern of increased risk ( · , · - · ). risk also increases per year of age (hr · , % ci · - · /year), and apoeε status ( · , · - · ). most people who are amyloid positive with no other markers have not developed alzheimer's disease dementia during their lifetime. a model of lifetime risks of people who are amyloid positive without any other biomarkers finds it to be · % for a -year-old woman who is cognitively normal at baseline, · % for a -year-old woman and · % for a -year-old woman. the -year risk is considerably less, so a -year-old woman with only amyloid biomarkers but who is cognitively normal and has no neurodegeneration has a -year alzheimer's disease risk of · % and a man · %, but the risk is higher with accompanying neurodegeneration (table ) . overall, the knowledge of pet-measured amyloid and tau status and mri-derived cortical thickness in a general population derived sample, only adds a small improvement, which might not be clinically important for predicting memory decline over a model with clinical and genetic variables. using amyloid pet in patients with cognitive impairment of uncertain causes, results in changes to the clinical diagnosis of alzheimer's disease and sometimes to medication prescription. we do not know whether pet use improves patient care or decreases care costs. many people have a mixed cause of dementia and a positive result does not indicate only alzheimer's disease. pet imaging is very costly (us$ in the usa) and although used in some clinical settings remains the topic of research to understand its usefulness in broader populations. fluid biomarkers-ie, blood and cerebrospinal fluid tests-have become a more practical focus of interest since it has become possible to measure specific proteins linked to the proteins associated with the neuropathologies of alzheimer's disease. a composite blood biomarker for amyloid tested in a discovery dataset and then a validation cohort of participants aged - years who were already taking part in studies in japan or australia had areas under the receiver operating risks are particularly high in more socially disadvantaged populations including in black, asian, and minority ethnic groups. • prioritise childhood education for all, worldwide • implement social public health policies that reduce hypertension risk in the entire population • develop policies that encourage social, cognitive, and physical activity across the life course for all (with no evidence for any specific activities being more protective) • scrutinise the risks for hearing loss throughout the life course, to reduce the risk of exposure to this risk factor • reduce the risk of serious brain trauma in relevant settings, including occupational and transport • national and international policies to reduce population exposure to air pollution • continue to strengthen national and international efforts to reduce exposure to smoking, both for children and adults, and to reduce uptake and encourage cessation • use hearing aids for hearing loss; we need to help people wear hearing aids as many find them unacceptable, too difficult to use, or ineffective • avoid or discourage drinking or more units of alcohol per week • prevent head trauma where an individual is at high risk • stopping smoking is beneficial regardless of age • reduce obesity and the linked condition of diabetes by healthy food availability and an environment to increase movement • sustain midlife, and possibly late-life physical activity characteristic curves of · % for discovery and · % for validation. the blood biomarker had sensitivity and specificity above % against amyloid pet measurement and correlated with csf concentrations of aβ - . these results are similar to other amyloid blood biomarkers , and harmonisation to a common reference standard is now vital. although csf aβ - / - ratio and amyloid pet are now considered interchangeable, csf tau biomarkers have only correlated weakly with brain tau as currently measured by radioligands. neurofilament light protein is measured in many cohorts; however, it is non-specific. people with huntington's disease, multiple sclerosis, mild cognitive impairment, and alzheimer's disease might have raised blood neurofilament light concentrations, which are a marker of neurodegeneration. [ ] [ ] [ ] to be useful in clinical practice biomarkers must be well understood in the populations to which they are going to be applied, including the effects of age and sex on results. there is now reasonable evidence that amyloid and tau measured by pet or in fluid indicate increased risk for development of cognitive impairment in older adults but at the individual level prognostication is not possible as most cognitively normal people with these markers do not develop dementia within a clinically relevant timeframe. negative amyloid results can be useful for ruling out current alzheimer's pathology in people with cognitive impairment when the cause is uncertain and show an individual is unlikely to develop alzheimer's disease during the next few years. high neurofilament light concentrations indicate a neuro degenerative process but not its cause. the value of biomarkers, in terms of diagnostic value, has not been addressed in different representative populations and particularly not in those from lmic. the potential advantages of blood biomarkers are their low cost and their wider acceptability and applicability in many settings. in many areas of medicine more reliable diagnostic tests have improved research, including epidemiological and public health research and trials, to help distinguish cause from symptom (tuberculosis from a fever) or assess risk factor and disease (hyper cholesterolaemia and ischaemic heart disease). those biomarkers developed for the underlying biology of the dementia syndrome are subject to the same assessment of value. in the commission, we discussed that when concerns are raised by patients or family, an accurate diagnosis is helpful. such a diagnosis provides a gateway to intervention and services where available, for planning for possible futures, and support for family, as well as to research. unfortunately, these services are not always available. national plans for dementia support timely diagnosis and offer help to individuals and their families. we did not address screening of those not presenting with concerns but rigorous systematic reviews by the us task force on prevention have found an absence of evidence of benefit and harm. the first trial of population screening took place in the usa, screening primary care patients aged years or older. no clear benefit or harm in terms of quality of life, mood, or increasing diagnostic rates was found. other strategies might become more valuable in time such as sensitive awareness of risk factors, when routine records suggest an individual might be deteriorating cognitively. people with dementia have complex problems with symptoms in many domains. those providing support and any interventions must consider the person as a whole, as well as their context and their close carers, whether family or friends. individuals' medical, cognitive, psychological, environmental, cultural, and social needs must be given consideration. in the context of under provision of services, this notion is and will continue to be a challenge. dementia, as an illness which affects cognition by definition, affects the ability to organise activities and people with dementia often need help to do what they enjoy-for example, listen to music, or go to gardens and parks. wellbeing is one of the goals of dementia care. data are relative risk ( % ci) or %. reproduced from brookmeyer and abdalla by permission of elsevier. cholinesterase inhibitors have a useful, modest role in improving cognition and activities of daily living in patients with mild-to-moderate alzheimer's disease and memantine can be prescribed in combination or each drug used separately for moderate and severe alzheimer's disease. , , however, although available in most countries these drugs are no longer remunerated in france because it is felt that they offer only a small benefit while shifting clinician's attention from other interventions. whether non-prescribing of this drug will help patients by removing an intervention with known benefit or be detrimental to them is unknown. no advances have been reported in aβ therapeutics, with negative results from phase trials of monoclonal antibodies (eg, solanezumab, crenezumab) and inhibitors of β-secretase, a protease involved in the production of aβ peptides. aducanumab previously abandoned as futile now has further unpublished results. three ht antagonists and the calcium channel blocker nilvadipine , have also been ineffective. these drugs also show substantial impact during treatments at socalled therapeutic concentrations on the leakiness of blood vessels. the long-term impact of such side-effects is unknown. anti-tau, anti-amyloid, and anti-inflammatory drugs continue to be in focus and some argue that pre-symptomatic interventions are necessary, especially if targeting aβ production, but no evidence of efficacy and some evidence of worsening target symp toms currently exists. a meta-analysis of controlled trials of people with mild dementia, completing or more hours of group-based computerised cognitive training (mean age - years, · % female participants), found a small, statistically significant beneficial effect on overall cogni tion, driven by two trials of virtual reality or video games (smd= · , % ci · - · ), one with a low and one with a high risk of bias. a cochrane review found trials of cognitive training, only one of which over lapped with the study above, with around participants with mild-tomoderate dementia, most with a high or uncertain risk of bias. people completing cognitive training, compared with usual treatment or non-specific activities, had small-to-moderate effects on overall cogni tion (smd · , % ci · - · ) and specific cognitive abilities such as verbal fluency and improvements lasted for a few months to year. no direct evidence was observed to suggest that cognitive training was better than cognitive stimulation therapy. the dementia and physical activity rct found moderate-to-high intensity aerobic and strength exercise training did not slow cognitive impairment in people with mild-to-moderate dementia but improved physical fitness. the us reducing disability in dementia study implemented an at-home multicomponent intervention including exercise education, training to increase pleasant events, and activator-behaviour-consequence problemsolving approach over weeks by case managers in community dwelling people with dementia older than years and their family carer and were able to follow up ( · %). the study found increased physical activity; days of taking or more minutes of exercise (effect size · , % ci · - · after the treatment and · , · - · at months) in a before and after intervention comparison. neuropsychiatric symptoms are common and often clus tered in people with dementia. these symptoms might precede dementia and are associated with tau and amyloid neuropathology. this suggests that underlying neurobiological mechanisms might underpin neuropsychiatric symptoms. however, other drivers relating to the personal history and the environment of the person with dementia are also likely to exist. neurodegeneration could lead to increased vulnerability to stressors or triggers. genetics, cognitive reserve, resilience, medical comorbidities, and environment including responses of carers might modify these relationships. needs and responses will also be individual and relate to a person's own social, cultural, and historical context. first-line assessment and management of neuropsychiatric symptoms should focus on basic health: describe and diagnose symptoms; look for causes such as pain (using validated pain assessments might help), illness, discomfort, hunger, loneliness, boredom, lack of intimacy and worry that could cause the behaviours and alleviate these while considering risks of harm. no new evidence of medication effectiveness for these symptoms exists; risperidone in low doses ( · mg daily) and some other antipsychotics are sometimes effective but often ineffective and have adverse effects. specific initiatives have led to a decrease in antipsychotic prescriptions for people with dementia, although often replaced with other psycho tropics (figure ), such as benzodiazepines, antidepres sants, and mood stabilisers. these psychotropics lack evidence of efficacy for neuropsychiatric symptoms but show clear evidence of possible harm; for example, trazodone and benzodiazepines increase fall-related injuries. major policy changes should be assessed carefully, within and across countries for unintended consequences (and perhaps unexpected benefits) and their costs. evidence is slowly accumulating for the effectiveness, at least in the short term, of person-centred evidence-based psychosocial interventions. in germany, a -month cluster rct of nurse-delivered, supervised dementia care management used a computer-assisted nurse assessment to determine personalised intervention modules, then a multi-disci plinary team discussion and agreement with the physician for people (mean age years) with dementia living at home with a primary carer or alone. the mean mini mental state examination (mmse) was , only % had a formal diagnosis of dementia; the majority of participants ( %) had mild dementia but some had moderate and some severe dementia. the intervention consisted of psychosocial management of treatment and care, medi cation management and carer support, and education and discussion with a psychiatrist or neurologist. the intervention, compared with care as usual, was associated with better outcomes for neuropsychiatric symptoms (neuropsychiatric inventory [npi] score − · , % ci − · to − · ), however this effect could be because of deterioration in care as usual (in the care as usual group npi increased from · to · ; in the intervention group npi increased from · to · ). this between-group reduction in neuropsychiatric symptoms was greater than that expected, extrapolating from other study results, with antipsychotic medication. effects on quality of life were only apparent for those people living with a carer. an eight-session home-based tailored activity programme rct, tailored both to the person with dementia living at home and to a family member compared with eight telephone-based education sessions, recruited participants with % follow-up, imputing values for the rest. the study reported a large reduction in overall neuropsychiatric symptoms immediately after the intervention, which were better in the group receiving home-based tailored activity programme on the neuropsychiatric inventory (mean difference in score · , % ci · - · ), and on functional dependence and pain but this was not sustained months later. noncompleters had more severe neuropsychiatric symptoms. since the commission two new systematic reviews of antidepressants to treat depression in dementia reported moderate quality evidence that antidepressant treatment for people with dementia does not lead to better control of symptomatology compared with placebo. , agitation agitation is distressing for people with dementia and those around them, and contributes substantially to the overall costs as the level of agitation increases. the body of evidence on this key behaviour is growing, mostly focused on care-home settings. these findings are valuable as these populations are most affected; however, because many people with dementia reside at home a major gap in knowledge remains. care home residents with agitation often find sitting still difficult and therefore might not be included in activities. , two new cluster rcts of professionals delivering multicomponent, interdisciplinary, interventions in care homes successfully reduced agitation. the wheld study included participants with or without neuropsychiatric symptoms and provided person-centred care, aiming to improve communication with people with dementia. it implemented social, sensory experiences or other activities; educated about antipsychotic review; and addressed physical problems, finding lower cohen mansfield agitation inventory (cmai) at months (md − · points, % ci − · to − · ). the time study for people with moderate-to-high levels of agitation consisted of a manual-based comprehensive assessment of the resident and structured case conference for the staff and doctor, to create a tailored plan, and then implement it. this intervention led to reduced agitation at weeks (npi − · points, % ci − · to − · ; cmai − · points, − · to − · ) and weeks (npi − · , − · to − · ; cmai − · , − · to − · ). these effect sizes are similar to those seen for medications, but without harmful side-effects. , a further rct studied a six-session intervention with staff in groups, teaching staff to understand agitation as related to medical, psychological, or social unmet needs and to implement strategies to meet these needs, using the describe, investigate, create, and evaluate approach. the intervention did not reduce agitation symptoms, although it was cost-effective, improving quality of life. overall, the current evidence for agitation in care homes favours multi-component interventions by clinical staff, including considering if drugs might harm, and not drug interventions. thus a major gap remains in knowledge about people living at home who comprise the majority of those with dementia. people with dementia might be wrongly thought to have delusions when they misremember, and new psychotic symptoms are often due to delirium, thus thorough assessment of symptoms is essential. management of psychosis in dementia should start with non-pharmacological interventions; however, evidence for effectiveness of these interventions for psychosis in dementia is weaker than for agitation. antipsychotics for psychosis in dementia should be prescribed in as low a dose and for the shortest duration possible. however, a cochrane review of antipsychotics withdrawal found two trials with participants with dementia who had responded to antipsychotic treat ment. these reported that stopping antipsychotics was associated with symptomatic relapse suggesting the need for caution in any medication withdrawal in this group. there was lowquality evidence that, in general, discon tinuation might make little or no difference to overall neuropsychiatric symptoms, adverse events, quality of life or cognitive function. apathy apathy might be conceptualised as the opposite of engagement, comprising reduced interest, initiative, and activity. like people without dementia, those with dementia engage more in preferred activities, but require additional support to do so. a study in care homes observed engagement increased during activities in those who attended the groups. a cochrane review of the few people who had been in drug rcts of methylphenidate versus placebo for apathy in dementia found small improvements on the apathy evaluation scale (md − · , % ci − · to− · , n= , three studies, low-quality evidence) but not on the npi apathy subscale (md − · , % ci − · to · , n= , two studies). there is no evidence that medication for sleep in dementia is effective and considerable evidence for harm-ie, earlier death, increased hospitalisation, and falls-exists. , test ing of non-pharmacological interventions is ongoing. carer distress related to neuropsychiatric symptoms rather than the dementia symptoms was associated in one study with increased use and costs of health services, high lighting the need for effectively identifying, educating, and supporting distressed carers. an rct reporting -year follow-up after the eight session strategies for relatives intervention-manual-based coping intervention delivered by supervised psychology graduates-found continuing effectiveness for depressive symptoms in carers (adjusted md − · ; % ci − · to − · ) and risk of case-level depression, with patient-related cost being approximately times lower than those who did not receive the intervention (median £ vs £ in the final year; p= · ). another us study followed up people, mean age years, % women. caregiver depression rather than symptoms of people with dementia predicted emergency department use for people with dementia, with a % (rr · , % ci · - · ) increase. functioning a uk rct of sessions of cognitive rehabilitation focused on individual goal attainment with therapy delivered at home by an occupational therapist or nurse to participants with mild-to-moderate dementia (mmse ≥ for inclusion; mean ) and a family carer. individuals had two or three goals; the most common was engaging in activities ( % of goals). the intervention group reported increased goal attainment over and months compared with usual treatment (effect size · , % ci · - · at both and months). the treatment did not improve participants' quality of life, mood, selfefficacy, cognition, carer stress, or health status and was not cost-effective. a systematic review of rcts without meta-analysis for overall effect size, concluded that all interventions which had improved functioning in people living with dementia in the community have been individual rather than group interventions. these were: in-home physiotherapist delivered aerobic exercise (two studies, larger one positive, people with alzheimer's disease; smaller study negative, people with alzheimer's disease), individualised cogni tive rehabilitation (mild or moderate dementia; two studies; cognitive reserve intervention groups and controls), and in-home activities-focused occupa tional therapy (people with mild to moderate dementia, three studies, intervention, controls) reduced functional decline compared to controls but group-exercise and reminiscence therapies were ineffective. multimorbidity is a huge challenge in dementia, not only because people with dementia have increased rates of other illnesses, but also because they often find it parti cularly difficult to organise care. people with dementia might forget to tell their family or health professionals of symptoms, struggle to understand or follow agreed plans, and are more likely to forget to drink and eat, increasing falling and infection rates. people with dementia consult primary care less often and have fewer dental visits than those without dementia and their family members, if involved, often feel they lack knowledge to assist. health-care professionals need education to be more comfortable, understanding, and positive in communicating with people with dementia. around - % of people diagnosed with dementia in primary care have at least two other chronic illnesses. , people who are physically more frail are more likely to have dementia, but the relationship between pathology and symptoms in these people is comparatively weak suggesting that dementia might be from other causes. compared to the general older population, people with dementia have increased rates of cerebro vascular disease, [ ] [ ] [ ] [ ] stroke, parkinson's disease, , dia betes, , skin ulcers, anxiety and depression, , pneu monia, incontinence, and electrolyte disturbance. multimorbidity in people with dementia is associated with faster functional decline and worse quality of life for people with dementia and their family carers. severe acute respiratory syndrome coronavirus , was first identified in patients with viral pneumonia in hubei province, china. severity and mortality of the associated disease (covid- ) worsen with increasing age and with pre-existing illnesses such as hypertension and diabetes, and thus many people with dementia are at particular risk. death certificates from the uk indicate that dementia and alzheimer's disease were the most common underlying conditions, specified in deaths ( · % of all deaths involving covid- ) in march to may, . many charities, practitioners, and academics supporting people with dementia have issued guidance based on current evidence and best practice, including advance consideration of whether people would wish to be hospitalised if they develop severe covid- . concern has been expressed that the illness and consequent distancing might increase family carer stress, loneliness, neuropsychiatric symptoms and use of psychotropic medication, and lead to complications, including future dementia. interventions delivered remo tely through technology have also been implemented in some places. [ ] [ ] [ ] [ ] people with dementia might struggle to adhere to measures to reduce virus transmission, as they might not understand or remember about required changes to behaviour, such as physical distancing and hygiene, leading to increased risk to themselves and their carers. they might additionally be vulnerable if they depend on others for daily activities or personal care, as this necessitates close personal contact. this situation is particularly concerning in those care homes, where many residents have dementia and where many covid- deaths have occurred in many countries [ ] [ ] [ ] with reports of more than half of residents being admitted to hospital. in us nursing homes, among people with confirmed covid- , residents living with dementia made up % of covid- cases; yet, accounted for % of all deaths (an increased risk of · ). the number of people living together in care homes means that the infection of an individual, either staff or resident, could endanger more people than in traditional or family households. although evidence exists that if staff are sufficiently and rigorously protected they are unlikely to develop covid- , many staff have become unwell and some have died. , illness means that there are fewer people to care for residents at a time when they need particularly high levels of care. this situation is par ticularly relevant in the care of residents with dementia, if they are expected to remain in their own rooms, rather than eating and participating in activities with others. staff or residents might also be moved between care homes and increase risk in other homes. restrictions on visitors to private homes, care homes, and hospitals might cause greater distress for people with dementia and they might not understand why people are wearing masks, recognise who is behind it, or understand speech when lips are covered. lack of restrictions means that the visitors might also be at elevated risk. the impacts of covid- on people with dementia might be particularly severe in lmics, due to smaller health budgets for testing and protective equipment, capacity of health-care systems, quality of care home provision and patterns of workforce mobility. thus, people with dementia are particularly vulnerable to covid- because of their age, multimorbidity, and difficulties in maintaining physical distancing. [ ] [ ] [ ] we recommend rigorous public health measures of protective equipment and hygiene, including not moving staff or residents between care homes or admitting new residents when their covid- status is unknown, should mitigate impacts on people with dementia. it is also imperative that there is frequent and regular testing of staff in care homes for infection, ensuring staff have sick pay so that they do not come in when symptomatic and interim care is being set up for people discharged from hospital so that only those who are covid- free come to live in care homes. resident testing should encompass asymptomatic as well as symptomatic people, when there is exposure within the home to covid- . in the future, many homes might be able to start to provide oxygen therapy so that those who do not want to be admitted to hospital are still able to access oxygen therapy. in addition, it is also important to reduce isolation by providing the necessary equipment and a brief training to relatives on how to protect themselves and others from covid- ; so that they can visit their relatives with dementia in nursing homes safely when it is allowed. further evidence is needed to inform responses to this and future public health emergencies. hospitalisation in people with dementia is associated with adverse, unintended consequences, including distress, func tional and cognitive decline, and high economic costs. [ ] [ ] [ ] people with dementia have · to times more hospital admissions than others with similar illnesses. , [ ] [ ] [ ] a systematic review and meta-analysis including studies of people with dementia found that in the six studies which compared the two groups, people with dementia had increased hospital admissions compared with those without dementia, after adjusting for age, sex, and physical comorbidity (rr · , % ci · - · ; figure ). hospitalisation rates in people with dementia ranged from · to · per person-year in high-quality studies. admissions are often for conditions that might be manageable in the community (potentially preventable hospitalisations). people with dementia experience longer and more frequent admissions and readmissions; health-care expenditure for people with moderate-severe dementia is around double that of people without dementia. , , early detection and management of physical ill-health in people with dementia, particularly of pain, falls, diabetes, incontinence, and sensory impair ment, is important. , , however, no intervention has successfully reduced number of hos pital admissions of community-dwelling people with demen tia, although education, exercise, rehabilitation, and telemedicine have reduced admissions for older people without dementia. high-quality care for people with dementia takes longer than caring for others with the same condition. recognition of dementia in hospital inpatients is necessary for optimum care, but dementia is often undetected or unrecorded. in the uk however, detection rates have increased over the past years. dementia and delirium frequently occur together. in one hospital inpatients' survey nearly % of those older than years experienced delirium; those with prior cognitive impairment had times the risk of devel oping delirium than those without (or · , % ci · - · ). people with delirium without known dementia are more likely to be diagnosed with dementia in the future than others, either because of pre-existing undiagnosed dementia or cognitive impairment, present in · % ( % ci · - · ) and · % ( · - · ) respectively of one cohort, or because delirium has neurotoxic effects and so precipitates dementia. people with similar people diagnosed with alzheimer's disease had mixed causes of dementia. although alzheimer's disease neuropathology was the commonest cause of dementia, alzheimer's disease changes rarely occurred on their own, so only % of people with dementia had pure alzheimer's disease pathology. people who have alzheimer's disease patho logy without developing dementia tend to have fewer age-related health deficits than those who develop it with even low concentrations of plaques and tangles. a moderation analysis showed that the relationship between alzheimer's disease pathology and dementia status differed according to level of frailty (adjusted for age, sex, and education) with increasing frailty weakening the relationship between alzheimer's disease pathology and dementia (figure ). as with delirium, some of this additional health risk might be modifiable. this approach suggests a new type of therapy focus on specific agerelated processes that underpin many diseases of late life might reduce the incidence or severity of dementia. the numbers of people dying with dementia are increasing but the evidence for the best end-of-life care is scarce. trends in age-standardised death rates ( · %) for dementia increased slightly between - , with pronounced increases in the usa and japan and decreases in western europe and central latin america. dementia is more readily being included on death certificates, which accounts for some of the rise. the increase might be related to dementia manifesting at later ages, with higher physical frailty leading to a faster decline. most people with dementia might die while still in the mild-to-moderate stages whereas only about a quarter of those dying with dementia have severe dementia. , the trajectory of dementia is often unpredictable and palliative care initiation should reflect need not prognosis. neuropatho logy show faster cognitive decline if they develop delirium than if they do not. additionally, older people without dementia declined cognitively more than twice as fast after an emergency hospital admission for any cause, compared with those not admitted, suggesting any severe illness is associated with cognitive decline. risk factors for delirium in dementia include sensory impairment, pain, poly pharmacy, dehydration, intercurrent illnesses, such as urinary tract infections or faecal impaction, and an unfamiliar or changing environment. delirium in older people should prompt consideration of underlying dementia. most research on delirium prevention has been in people without dementia. it suggests targeting hydration, stopping medication predisposing to delirium, monitoring the depth of anaesthesia, and sleep promotion. however, no evidence for medication efficacy, including cholinesterase inhibitors, antipsychotic medication, or melatonin exists. [ ] [ ] [ ] the hospital elder life program an intervention to prevent delirium in those admitted to hospital-reduces delirium incidence and includes people who are cognitively impaired. this multidisciplinary treatment consists of daily visits, orientation, therapeutic activities, sleep enhancement, early mobilisation, vision and hearing adaptation, fluid repletion, infection prevention and management of constipation, pain, and hypoxia, and feeding assistance. a network meta-analysis of drugs for prevention and treatment of delirium did not include studies of people with dementia, thus we cannot use this to recommend drugs for people with dementia and delirium as this research might be inapplicable to them. little high-quality research exists on managing delirium in dementia. one rct compared care at a specialist medical and mental health unit to usual care for confused people older than years, acutely admitted to hospital and found no difference in the primary outcome of days spent at home or in hos pital, but increased family satisfaction. a further rct of cognitively stimulating activities for people with delirium in dementia did not improve the delirium. no definitive evidence that any medication improves delirium in people with dementia exists: cholinesterase inhibitors, antipsychotics, and sedating benzodiazepines are ineffective and antipsychotics and benzodiazepines are associated with mortality and morbidity. , , [ ] [ ] [ ] [ ] given the risk of dementia in people who develop delirium, its prevention, and possibly advances in its management, might offer a means for dementia prevention. the fastest growing demographic group in most advanced countries are people aged years and older. one well characterised post-mortem cohort of the oldest old (n= ; mean age years) dying with dementia, found that neuropathological features of alzheimer's disease account for about half of the cognitive decline seen as decision making about end of life is complex and simple rules of thumb, co-designed with staff and carers, provided clarity in some small studies. one rct testing decision-aids about families' and doctors' goals of care for people with advanced dementia led to increased palliative care content in care plans. , in a -month uk prospective study, care home residents with advanced dementia from homes were likely to be living with distressing symptoms, specifically agitation ( %) or pain ( % on movement). capacity to make abstract decisions, including about the future, might be lost early in dementia. therefore, advance care planning, designed to empower people with dementia and improve quality of dying, might theoretically be something everyone should do before developing dementia. however, people might not be able to predict their future wishes. this might explain why family carer proxies show only low-to-moderate agreement with stated end-of-life treatment preferences of people with dementia. advance care planning might, however, reduce carers' uncertainty in decision making and improve perceptions of quality of care. partners of people dying with dementia experience poorer mental health than those facing bereavement from other causes possibly because of long and difficult caring responsibilities. this might be ameliorated through sensitive and timely information, particularly regarding the progression of dementia, individually or through family and staff case-conferencing. , conclusions knowledge about risk factors and potential prevention, detection, and diagnosis of dementia is improving although significant gaps remain. in this commission report, we have specified policy and individual changes to delay the onset of cognitive impairment and dementia and better ways to support and treat people with dementia and their families and to improve their quality of life. interventions, including organisation of the complex physical illness and social needs, to support people affected by dementia can have a huge effect when 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prevention, diagnosis, intervention, and care by we are partnered by university college london (ucl), the alzheimer's society, uk, the economic and social research council, and alzheimer's research uk, and would like to thank them for financial help. these organisations funded the fares, accommodation, and food for the commission meeting but had no role in the writing of the manuscript or the decision to submit it for publication. we would like to thank bernadette courtney, jacques gianino, and nuj monowari, from ucl, london, uk, for their administrative help, including managing finances, booking rooms and food, and setting up a website supported by the university college london hospitals national institute for health research biomedical research centre. we would like thank henrik zetterberg for advice on biomarkers and dementia.