key: cord- - giapmcf authors: levin, jacqueline title: mental health care for survivors and healthcare workers in the aftermath of an outbreak date: - - journal: psychiatry of pandemics doi: . / - - - - _ sha: doc_id: cord_uid: giapmcf when pandemics sweep across communities, they leave behind tremendous suffering in their wake. it is not only the illness that becomes a pandemic, but the same can be inferred about fear, mourning, and despair. the reverberations of loss are felt in a multitude of ways by those left behind. often times, the mental health issues of affected persons and entire communities do not receive the attention they deserve in the light of other competing, immediate needs imparted by the devastation of the pandemic. this chapter aims to develop strategies for providing psychiatric care to survivors and their families, in the aftermath of a pandemic outbreak. lastly, special considerations in the application of psychopharmacological interventions are reviewed. antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. in cases of viral encephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disorders. major disability can result, including symptoms of depression, amnestic disorders, hypomania, irritability, and disinhibition (sexual, aggressive, and rageful) even months after recovery. psychosis may also rarely result. standard treatments with antidepressants, stimulants, mood stabilizers, neuroleptics, and electroconvulsive therapy should be applied [ ] . individuals may suffer potentially permanent cognitive deficits secondary to illness or its treatments that will require cognitive rehabilitation. in cases of delirium, if the resultant encephalopathy is severe or persistent, pharmacologic interventions with antipsychotics (such as haloperidol . - mg/ day) and mood stabilizers (such as valproic acid up to mg/kg/ day) should be considered. in addition, psychosocial interventions will need to be implemented to maintain safety and care for someone who may no longer be able to care for themselves. additional consideration on this topic is provided in the chapter entitled neuropsychiatric sequelae of infectious outbreaks. in the wake of an infectious disease outbreak, the loss of functioning imparted by illness may leave survivors feeling demoralized, helpless, and in a state of mourning over the loss of the person they used to be. if the patient experiences marked distress or significant impairment in social or occupational functioning, they may meet dsm-v criteria for adjustment disorder. therapeutic interventions in those instances should focus on helping individuals regain a sense of autonomy and mastery through rehabilitation. it is helpful to focus on gaining immediate control over some specific aspects of their lives, as well as helping the persons identify and link with agencies and supports in the community [ ] . psychotherapy, both individual and group therapy, if available, can help survivors come to terms with the loss of functioning. if the patient is left with significant depressive symptoms meeting dsm-v criteria for major depressive disorder, the psychopharmacological approach may be warranted; selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors should be considered in such cases. concurrent insomnia may be treated with melatonin, trazodone, ramelteon, or any available sedatives-hypnotics. prescribers should be aware of drug-drug interactions and cytochrome p interactions between selected psychotropics and medications prescribed by infectious disease physicians in treating survivors. patients who are at increased risk of developing delirium (i.e., elderly, dementia, and brain disease) should also be monitored for changes in mental status, attention, alertness, and orientation. psychotherapy (cognitive behavioral therapy, supportive psychotherapy, and psychodynamic psychotherapy) may also be of clinical benefit if available. enlisting local cultural and spiritual leaders may also help build hope and confidence. another important consideration is that proximity to and survival from life-threatening events (in this case illness) are known risk factors for the development of trauma-based disorders, including acute stress disorder and posttraumatic stress disorder (ptsd). ptsd is characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance leading to significant social, occupational, and interpersonal dysfunction. in the aftermath of pandemics, increased psychiatric screening and surveillance is recommended to address acute stress disorder, posttraumatic stress disorder, depressive disorders, and substance abuse. in the short-term aftermath, psychological first aid can be administered to patients by public health and public behavioral health workers. such interventions focus on establishing a respectful, supportive rapport, triaging critical needs, normalizing stress and grief reactions, supporting positive thoughts about the future, and teaching mindfulness-based techniques to decrease the levels of stress and hyperarousal (i.e., deep breathing, progressive muscle relaxation, and guided imagery). normalizing angry feelings while decreasing anger-driven behaviors can also play a therapeutic role [ ] . in the long-term aftermath of a pandemic, trauma-focused therapies and pharmacological treatments may be indicated. once a diagnosis of ptsd is made, treatment should be initiated promptly. first-line treatment consists of traumafocused cognitive behavioral therapy (cbt) to help reduce pessimistic and catastrophic thoughts about the future. exposure therapy and eye movement desensitization and reprocessing (emdr) therapies may also be utilized. if these therapeutic modalities are not readily available, selective serotonin reuptake inhibitors (ssris) and serotonin-norepinephrine reuptake inhibitors (snris) can also be considered first-line treatments, to be administered for a duration of at least - months to prevent recurrence and relapse. monotherapy or adjunctive therapy with quetiapine may also be considered. alpha-adrenergic receptor blockers such as prazosin could be used for sleep disruption and nightmares, either alone or in conjunction with an antidepressant [ ] . special consideration should also be given to individuals with preexisting mental health issues who may experience setbacks, relapses, and impairments in functioning. more vulnerable patients with serious and persistent mental disorders such as primary psychotic illnesses or developmental disorders are likely to experience destabilizing disruptions in routine and access to medications/treatments. psychotic, manic, or depressive symptoms may be intensified due to stress; increasing standing psychotropic medications may be indicated. preexisting anxiety and substance use disorders are likely to worsen in the face of constant fear and distress. it is helpful to provide patients with a supply of prn or "asneeded" extra tablets of antipsychotics or benzodiazepines as the pandemic unfolds to treat worsening symptoms. it is also prudent to enlist these patients' families and social supports to warn them of the risk for psychiatric destabilization and provide them with specific examples of worsening psychiatric symptoms to be on the lookout for. a safety plan and communication strategy should be developed with the patient and his or her family in the aftermath of a pandemic, with attention paid to potential barriers imposed by the pandemic (i.e. pharmacy closures, difficulty accessing medications). when possible, it may be prudent to prescribe a few months' additional supply of medications to be entrusted to a reliable family member. increased monitoring is prudent in the aftermath of a pandemic with bimonthly or even weekly visits, depending on the severity of illness. for patients who are unable to access their usual providers, telepsychiatry can be a helpful substitute where available. mental health professionals should be trained in the assessment of suicidality and safety concerns which may arise in the setting of acute anxiety, disability, bereavement, and multiple losses. as a special consideration, it is worth noting that survivors of pandemics may find themselves the targets of pronounced stigma and rejection by their local communities. affected individuals may blame themselves, and they may be prevented from returning to their homes or workplaces [ ] . entire cultural groups, communities, and geographic populations may become targets of stigmatization, which may serve as a barrier to seeking care [ ] . in these cases, validating the experience of the stigmatized person is of utmost importance. in some communities, survivors of pandemics have been lauded as heroes by nongovernmental agencies in an attempt to decrease stigma [ ] . fostering resilience in such persons and their communities can help them to reclaim a sense of self-efficacy and fortitude in the face of adversity [ ] . just as patients experience significant emotional impacts in the course of a pandemic, so too will the brave and selfless healthcare personnel who are charged with the responsibility of providing aid to the infected. their burden, however, is compounded by their high and persistent risk for exposure and death, separation from their loved ones which may be either enforced or due to prolonged work shifts, seeing traumatic images of their disfigured or dying patients, working during surge conditions in overburdened settings with chronically scarce supplies and medications/vaccines, experiencing hopelessness due to massive human losses in spite of their best efforts to provide care, managing human remains, experiencing workforce quarantine, witnessing the death of their colleagues, lack of reinforcements and replacements, and their own fatigue and burnout, to name a few of the many traumas they must endure in the course of their service [ ] . it, therefore, does not come as a surprise that studies of nurses who treated sars patients during the outbreak indicated high levels of stress and % rates of traumatic stress reactions, including depression, anxiety, hostility, and somatization symptoms [ ] . one study showed that even year after the sars outbreak in , healthcare worker sars survivors still had persistently higher levels of stress and psychological distress than non-healthcare worker sars survivors [ ] . similar findings have been reported in multiple studies indicating acute and persistently elevated stress levels as well as other emotional sequelae of healthcare workers during and after pandemic disease outbreaks [ ] [ ] [ ] . those findings indicate that left unaddressed, emotional needs and wounds of healthcare personnel grappling with an outbreak can reverberate long, perhaps for many years, after an outbreak has abated. healthcare personnel working at great personal peril will, therefore, require frequent and clear communication regarding the status of the pandemic and developments as they unfold. communication at every level should be monitored, with systems in place to bidirectionally transmit news among healthcare workers, their administration, healthcare facilities, and the government [ ] . leadership, structure, and clear delineation of duties and responsibilities are critical. determining staffing needs and establishing predictable schedules will lay a stable foundation for healthcare workers and ground them in the face of other destabilizing forces. healthcare workers on the frontlines should be supported to the fullest extent possible as the pandemic unfolds to prepare for what is to come. educational materials should be developed and provided that can outline what healthcare workers might expect in the course of their duties, including common reactions and stressors they may encounter from the public, patients, their friends and families, or from within themselves. this is of utmost importance, as an unprepared workforce may feel afraid to serve; in a survey of over healthcare workers across facilities in the new york metropolitan region, only . % said they would be willing to report to work during an outbreak of sars, most frequently citing fear for personal or family safety as the reason they were unwilling to work [ ] . given the real and understandable fear of contracting illness, comprehensive and repeated training on infection control and how to use personal protective equipment can help increase the confidence of the workforce that their personal safety will be maintained. healthcare personnel should also be offered periodic health assessments to reassure them of their physical well-being [ ] . preparations should also center on immunization programs, available vaccines for frontline healthcare personnel, availability of prophylactic medications, and assurances that their concerns and needs will be heard and met [ ] . a study of the psychological impact of the sars outbreak on healthcare workers in singapore found that support from supervisors and colleagues was a significant negative predictor for psychiatric symptoms and ptsd, in addition to clear communication of directives and precautionary measures which also helped reduce psychiatric symptoms [ ] . buddy systems pairing more and less experienced healthcare workers can help not only to transfer skills, but also to reduce social isolation and promote a sense of support and interconnectedness [ ] . the experience of being a healthcare worker during a pandemic is both isolating and stigmatizing; having a partner to share the experience with would be beneficial on multiple levels. administrators can improve the situation by being attentive to the psychological, physical, spiritual, and psychosocial needs of healthcare workers. systems should be implemented for rest and relief of duties to prevent burnout; it is also prudent to limit overtime [ ] . programs promoting well-being incorporating mindfulness and relaxation techniques can help healthcare workers develop self-help skills during times of increased stress; once learned, they may also be able to pass such skills on to their patients. workforce resilience programs and self-care strategies should be promoted. teamwork and morale-building activities should also be promoted, as well as wellness breaks. it may also be meaningful to plan staff-appreciation events and verbally acknowledge their ongoing efforts [ ] . spiritual leaders from the faith-based community may also be called upon to provide spiritual guidance to affected healthcare workers who would find tremendous comfort in such an outlet. it is also important to remember that healthcare workers will have their own sick family members, childcare issues, and personal affairs impressing upon them from the outside world, which can leave them feeling pulled between a sense of duty to their patients and their loved ones. psychosocial programs that are mindful of providing services for the families of healthcare workers can go a long way in supporting staff and protecting morale. lending cellular phones, laptops, or tablets to healthcare workers and their families to ensure they are able to maintain ongoing communication, as well as providing updates on websites and hotlines, can also help healthcare workers feel they are still interconnected with their families and may alleviate some of the real pressures that are felt. furthermore, healthcare workers should be regularly reminded and trained in infection control measures when they return home; for example, reminding staff of handwashing and to change clothes before entering their homes to protect family members. providing disposable scrubs or garments especially for wear in the hospital may also help decrease healthcare workers' anxiety about transmitting illness to their families back home [ ] . it may also help to designate healthcare workers a specialized status within the community, given the crucial public service role they play. for example, providing specialized identification cards that might prevent them from waiting in lines at gas stations or supermarkets, as well as fair compensation and a stipend for their families, may further promote a sense of professional pride and goodwill and may help counteract the negative impact of the stigma that they may endure. lastly, employee assistance programs should target healthcare personnel who have developed traumatic, affective, or anxiety disorders as well as those struggling with increased substance use disorders. increased mental health monitoring is advised, given healthcare workers' proximity and repeated exposure to traumatic experiences, as well as the welldocumented evidence of the persistent distress they are likely to experience. they should be considered a high-risk group for developing psychopathology in the aftermath of a pandemic and they should be given the same consideration and nurturing of any other high-risk population identified. healthcare workers should have ready access to psychiatric care, pharmacologic interventions, and both individual and group psychotherapy. they should be reassured that their families will receive the same. practitioners tasked with treating patients in the aftermath of a pandemic will face challenges in providing standard care, both due to infrastructural and crisis-related adversities, as well as secondary to unique biological changes imparted by the disease itself. it is important for practitioners to be aware of common drug interactions, dosing, and titration strategies, and special considerations for different classes of psychopharmacological agents used. this section aims to review and summarize pertinent aspects of psychopharmacological agents which may be of use to future practitioners who find themselves providing psychiatric care in the wake of a pandemic. antidepressants are first-line agents for a number of psychiatric conditions that may be encountered in the aftermath of a pandemic. such diagnoses include mood disorder secondary to a general medical condition, major depressive disorder, posttraumatic stress disorder, dissociative disorder, obsessive-compulsive disorder, and generalized anxiety disorder, to name a few. to identify and treat major depressive disorder, the psychiatric interview should focus on the psychological symptoms of depression (i.e., sad mood, anhedonia, hopelessness, worthlessness, guilt, and suicidality) rather than the vegetative symptoms (i.e., sleep disturbance, appetite change, psychomotor changes, and decreased concentration and energy), which may be of lower yield in the setting of acute medical illness. depression should also be distinguished from hypoactive delirium, which may also present with diminished appetite, sleep disturbance, and an appearance of apathy (in the case of delirium, treatment with antipsychotics will be more effective than addition of an antidepressant). an adequate trial of an antidepressant is defined as weeks of antidepressant therapy at an effective therapeutic dose. it is helpful to establish expectations with patients by reminding them that daily use is important (rather than asneeded use), that symptoms may take - weeks before they begin improving, and that common side effects such as nausea, diarrhea, headache, and sexual dysfunction may be expected. patients age and younger should be monitored for worsening suicidal ideation. for patients with significant concurrent anxiety, a slow titration may be most appropriate with temporary use of benzodiazepines until the antidepressant takes clinical effect (e.g., lorazepam . - mg orally two to three times per day). if the drug is not working within - weeks, the patient may require a dose increase or a switch should be considered. providers should treat until remission or a significant reduction in symptoms is observed, continuing treatment for year for the first episode of major depressive disorder and indefinitely if there have been two or more episodes. there are six principal selective serotonin reuptake inhibitors in common use: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. the global accessibility of these agents may vary. fluoxetine has a dose range from to mg and has the longest half-life ( - days), which makes it an ideal choice for patients in whom there are concerns for compliance or consistent access to medication. sertraline has a dose range of - mg, and its wide range of dosing making it a good choice for elderly patients or for those who may be sensitive to side effects. fluoxetine and sertraline have no renal dose adjustment, but a lower or half dose is recommended for patients with hepatic impairment. citalopram doses range from to mg, but should not exceed more than mg/day for patients over age or if the hepatic impairment is present. there is no dose adjustment for mild/ moderate renal impairment, but caution should be used in severe impairment. it is important to note that citalopram should not be combined with other qtc prolonging agents (applies to antimicrobials such as erythromycin, clarithromycin, fluoroquinolones, antifungals, and antimalarials) for increased risk of torsades de pointes [ ] . escitalopram, an enantiomer of citalopram, has dose ranges from to mg, should not exceed more than mg/day in the elderly or in cases of hepatic impairment, or if severe renal impairment is present. paroxetine doses range from to mg, with only mg/day recommended in cases of renal or hepatic impairment. it has the shortest half-life of all the ssris ( hours), resulting in an uncomfortable discontinuation syndrome and may not be ideal for patients with interrupted access to care/ medications. side effects of sedation, weight gain, constipation, and dry mouth may make it a favorable option, however, for specific patients. lastly, fluvoxamine doses range from to mg; however, many drug-drug interactions are associated with its use and should be monitored for. clinically significant interactions exist between selective serotonin reuptake inhibitors and several antiretrovirals in the setting of hiv/aids. for example, ssris shown to have decreased metabolism in the setting of ritonavir include sertraline and citalopram, but alternatively, the levels of fluoxetine and fluvoxamine are both decreased by nevirapine. fluoxetine and fluvoxamine can both increase the levels of amprenavir, delavirdine, efavirenz, indinavir, lopinavir/ritonavir, nelfinavir, ritonavir, and saquinavir [ ] . tricyclic antidepressants have common side effects such as drowsiness, confusion, dizziness, weight gain, hypotension, and tachycardia, as well as anticholinergic side effects including dry mouth, blurred vision, decreased gastrointestinal motility, and urinary retention. some of these side effects can be taken advantage of in the setting of hiv/aids, specifically weight gain, increased sleep, and decreased diarrhea [ ] . mirtazapine . - mg at bedtime similarly may be a good choice in patients with postinfectious cachexia and exhaustion as it promotes weight gain and can cause a significant sedation, making it suitable for patients suffering from insomnia. bupropion - mg/day can be helpful in postinfectious anergia, but prescribers should bear in mind that it lowers the seizure threshold. tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors are useful if there is also concurrent neuropathic pain or a lingering inflammatory process that persists following some viral infections; for example, amitriptyline - mg at bedtime, duloxetine - mg/day, or venlafaxine - mg/day. antimicrobial drugs themselves have had prominent associations with delirium and a host of other psychiatric side effects. for example, antibacterials such as quinolones have been associated with psychosis, paranoia, mania, agitation, and tourette-like syndrome, and procaine penicillin has been associated with delirium, psychosis, agitation, depersonalization, and hallucinations. mefloquine and other antiparasitic/ antimalarial drugs have been associated with confusion, psychosis, mania, depression, aggression, anxiety, and delirium. antituberculous drugs such as cycloserine have been associated with agitation, depression, psychosis, and anxiety. antivirals such as amantadine have been associated with psychosis and delirium, and interferon treatment is frequently associated with depression [ ] . in addition to being cognizant of the side effects of the treatments themselves, drug-drug interactions between antimicrobials and psychotropic drugs abound. psychiatric care providers should exercise caution when utilizing specific psychotropics (i.e., antipsychotics or tricyclic antidepressants) in the setting of other qtc interval-prolonging agents such as erythromycin or ketoconazole, due to increased risk of ventricular arrhythmias and torsades de pointes. providers should keep in mind that linezolid is an irreversible monoamine oxidase-a inhibitor and isoniazid is a weaker monoamine oxidase inhibitor-so the serotonin syndrome or hypertensive crisis can result if serotonergic antidepressants or other sympathomimetics (such as meperidine, which is an opioid analgesic) are coadministered. antimalarials have been shown to increase the levels of phenothiazine neuroleptics. clarithromycin and erythro-mycin can increase carbamazepine, buspirone, clozapine, alprazolam, and midazolam levels. quinolones may increase clozapine and benzodiazepine levels but reduce benzodiazepine effect via the gaba receptor. lastly, providers should be aware that isoniazid can increase haloperidol and carbamazepine levels [ ] . psychiatric care providers should be aware of the myriad complications of corticosteroid use, seen in up to % of patients presenting with significant neuropsychiatric manifestations. anxiety, mania, delirium, or psychosis may present with the administration of corticosteroids, and a dosedependent relationship has been observed. in most cases, a reduction of corticosteroid dose will improve symptoms; however, if this strategy is not possible or ineffective, antipsychotics or mood stabilizers should be used [ ] . in patients presenting with predominantly manic symptoms, special consideration should be given to medical comorbidities when selecting a mood stabilizer. lithium may be difficult to administer in the setting of renal dysfunction, electrolyte abnormalities, or fluid shifts. valproic acid may be relatively contraindicated in patients with significant liver disease or pancreatitis. carbamazepine has antidiuretic actions, has quinidine-like effects on cardiac conduction, and has been associated with aplastic anemia and leukopenia which prescribers should bear in mind. providing psychiatric care to survivors and healthcare workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. challenges will abound on multiple levels, but there is no substitute for preparedness. knowledge of assessment, differential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. chapter : infectious diseases. in: levenson j, editor. textbook of psychosomatic medicine colorado: the colorado department of human services division of mental health pharmacotherapy for posttraumatic stress disorder in adults ebola's mental-health wounds linger in africa an "epidemic within an outbreak:" the mental health consequences of infectious disease epidemics neill institute for national & global health law blog pandemic influenza plan: psychosocial services preparedness institute for disaster mental health at suny new paltz and new york learns public health psychological distress of nurses in taiwan who worked during the outbreak of sars stress and psychological distress among sars survivors year after the outbreak impact on health care workers employed in high-risk areas during the toronto sars outbreak psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers health care workers' ability and willingness to report to duty during catastrophic disasters can the health-care system meet the challenge of pandemic flu? planning, ethical, and workforce considerations psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore drug induced qt prolongation and torsades de pointes choosing antidepressants for hiv and aids patients: insights on safety and side effects the neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited key: cord- -stcre ol authors: wang, ning; wang, yeqiang title: promoting universal coverage of basic public services among urban residents date: - - journal: annual report on urban development of china doi: . / - - - - _ sha: doc_id: cord_uid: stcre ol in , china’s urbanization rate reached . % but, if we counted only people with urban hukous, this was only . %; there were million migrant workers in china, where they have already been playing a leading role in urbanization. nonetheless, governments are still managing applications for new permanent urban residents’ registration, demanded by rural migrant workers, by using the long-established hukou-based public service policies. this has constituted a big obstacle to the citizenization of rural migrant workers in china, caused a great deal of problems with urban management, and is contrary to social justice. in , it was made clear in the report on the work of the government that relevant authorities should accelerate reform of the household registration system and related institutions; that they should register eligible rural workers as permanent urban residents in an orderly manner, “progressively expand the coverage of basic public services in urban areas to include all their permanent residents and create an equitable institutional environment for freedom of movement and for people to live and work in contentment.” accordingly, in order to protect the rights of migrants and improve the quality of the process of social urbanization in china, the most significant tasks involve investigating the current status of basic public services in chinese towns and cities, especially the public services provided for potential new permanent migrant worker residents, and exploring methods to expand the coverage of these basic public services in urban areas to all their permanent residents. residents, and exploring methods to expand the coverage of these basic public services in urban areas to all their permanent residents. 'public services' is a concept corresponding to that of 'public good' in economics, but is not identical to the latter. public services rely on public fi nance support to satisfy public needs, and they include social services, policies benefi tting the public, and social security and public infrastructures. public services therefore relate closely to government functions and will vary with distinct levels of economic development and the needs of each society. basic, or core, public services are a function of basic registered city residents' rights to them, established by the basic needs of any society and the capabilities of governments to provide such services. regarding the public service system, the chinese government has been paying closer attention to the concept of fairness since . it has invested signifi cantly more money than before in public services for rural areas, such as compulsory education, the nrcmcs and support for the elderly; in urban areas, the provision of basic public services has expanded beyond that given to employees of state-owned organizations to cover those of non-state-owned organizations, urban residents and the low-and middleincome groups. in addition, as the number of rural migrant workers grows, migrant workers have come to represent the majority of industrial workers present in cities, and have made notable contribution to urbanization in china. consequently, these migrant workers demand access to relevant basic public services, which demand, as urbanization advances in china, is also receiving more attention. in spite of this, the provision of basic public services in urban areas to all residents remains clearly insuffi cient. an examination of basic public services follows: according to the new compulsory education law of , the state government shall be responsible for funding compulsory education. it must be made available to everyone eligible free of charge, in the name of tuition or any other fee. this was achieved fi rst in rural areas, followed by urban areas starting . regarding the provision of education services for the children of migrants, full-time public schools in host cities are playing a leading role, suggesting that local governments assume a larger share of the responsibility than before. in , the general offi ce of the state council forwarded the opinions on further improving compulsory education for children of migrant workers in cities co-issued by ministries/commissions such as the moe, emphasizing that the children of migrant workers should receive the same treatment as that of other children. the drc research team discovered in a survey that, of all children who had migrated with their parents, % were receiving compulsory education at public schools. local governments are working to address the issue of education for the children of migrant workers, depending on local conditions. for example, in the province of guangdong, which is the leading destination for non-local migrants, children of non-local migrant workers already represented % of all students who were receiving compulsory education in . since the number of non-local migrant workers is still growing, the demand for education services for all children with non-local hukou s is quickly exceeding what public elementary and middle schools can supply. by paying qualifi ed private schools for admitting children with non-local hukou s, the guangzhou municipal government, for example, is trying to increase the percentage of children with non-local hukou s who receive education in this city; some members of the cppcc guangdong provincial committee have proposed issuing "education vouchers" to let children with non-local hukou s. since children who migrate with their parents will need to take exams for admission to higher-level schools after the end of compulsory education, the outline of the national mid-and long-term education reform and development program ( - ) proposes that measures for these children to take such exams in host cities be developed. in , the moe issued the notice on organizing application for implementing pilot projects of the national education system reform , which included equal access by children who migrate with their parents to compulsory education and exams for admission to higher-level schools in host cities, as well as the inclusion of further reform of the national college entrance examination (ncee) or gaokao , system in the earliest pilot projects of education reform. by the end of , competent local authorities had all worked out schemes for students with non-local hukou s to take the gaokao in host cities (see table . ). the chinese government has been assuming more responsibility for these services and has gradually been improving the basic healthcare system for urban areas since the sars crisis of . a network in which community healthcare service organizations play a primary role, and work with public hospitals, has been built and performs such functions as ensuring urban residents have access to medical services near where they live, controlling medical costs and establishing immediate monitoring systems in xu chen and lai nanhui: "guangzhou plans to buy admission for more children of migrant workers to receive free education", yangcheng evening news , august , , http://www.chinanews.com/edu/zcdt/news/ / - / .shtml guo shaofeng and liu chang: "the moe will conduct pilot projects for children of migrants to gain equal access to compulsory education", cnr, may , , http://news. . com/ / / / s ag bd.html chongqing: on the school roll for years + steady jobs ( ); hunan: on the school roll for years + parents' residence permits ( ); heilongjiang: on the school roll for years + parents' jobs and domicile ( ); hebei: on the school roll for years + parents' jobs and residence permits ( ); henan: on the school roll + steady jobs and domicile ( ); jiangsu: on the roll of a local senior high school plus full schooling record + guardians' permanent domicile ( ); sichuan: on the school roll + residence ( ); ningxia: on the roll of a local senior high school + parents' steady jobs, domicile and social insurance premium payment for years or more ( ); inner mongolia: on the school roll for years + permanent domicile, both jobs and tax payment for years or more ( ); guizhou: on the school roll for years + parents' residence, jobs, residence permits and social insurance premium payment for years of more ( ); shanxi: on the school roll + parents' steady jobs and permanent domiciles ( ); jilin: full schooling record at senior high school + parents' jobs, domicile and social insurance premium payment for years or more ( ); tianjin: on the school roll for year or more + evidence for tax payment by parents and social insurance premium payment (from increasing in a step-by-step manner); hainan: schooling experience + permanent domicile and steady jobs ( ); shaanxi: on the school roll for years + either parent's residence permit for years or more, and pension insurance premium payments for years or more ( ); chongqing: on the school roll for years + working parents ( ) hukou yunnan: the examinee's hukou has been transferred in for years or more, and studies at a local high school for years ( ); gansu: on the roll of a local senior high school for years + the examinee and his/her parents received local hukou s at least years ago ( ); xinjiang: study at a local senior high school for three consecutive years + the examinee and his/her parents received local permanent hukou s at least years ago ( ); qinghai: the examinee must produce his/her household register and id card; examinees with non-qinghai hukou s may take exams in this province but will not compete with local ones for opportunities for going to university (n/a) transitional scheme beijing: all children, whether local or not, may register for entrance exams for local secondary or advanced vocational schools (from onward in a step-by-step manner); shanghai: in combination with the regulations on residence permits (from onward in a step-by-step manner); guangdong: in combination with the points-based hukou system (from onward in a step-by-step manner) source: http://www.eol.cn/html/g/ydgk/ . tibet has no relevant scheme at present the event of sudden disease outbreaks. this network contributes to equal access by all urban residents to public healthcare services. regarding migrant workers as a huge sub-group of migrants as a whole, the moh issued a notice in to announce that it would conduct pilot projects as part of the migrant worker healthcare program in selected counties/cities and city-administered areas in provinces other than hainan and tibet. main tasks included: health education among migrant workers; creating health records for migrant workers and making timely updates; conducting tuberculosis prevention and control among migrant workers, and making plans for their children's immunization programs; conducting programs to protect migrant workers from exposure to the aids virus and to carry out occupational disease prevention and control. each task came with quantifi ed targets. the moh hoped to summarize experience from these pilot projects before rolling migrant worker health care out across china. in , the beijing migrant worker healthcare program was launched in the haidian and daxing districts as pilot areas. china's urban social security system has gradually improved in recent years. in addition to basic pension insurance for urban workers, the basic medical and pension insurance systems for all urban residents have been established after the social insurance law was implemented. these social security systems exhibit the drive towards socialization, compliance, wide coverage and multiple dimensions of basic urban social security provision in china. in addition, a social security system for nonlocal migrant workers is being put in place. nationwide, in addition to work insurance, the percentages of employers that bought insurance for their employees, or migrant workers who bought insurance for themselves, was increasing more rapidly table . ). in , the numbers of migrant workers covered by urban basic medical and work-injury insurance increased by . and . million people respectively, compared to . regional social security systems have also been established in east, central and west china. the percentages of migrant workers covered by both work-injury and medical insurance, in particular, are higher than those of migrant workers covered by other insurances, due to the nature of their jobs. also, from a sectoral perspective, the percentages of non-local migrant workers covered by relevant insurance in such sectors as manufacturing, wholesale/retail, transport/warehousing/postal service and residential services are higher than in others such as the building industry (see table . ). in the s, the workers laid-off from state-owned enterprises (soes) due to deepening reform measures, were naturally the primary focus for service provision from urban public employment organizations. the chinese government launched two rounds of proactive employment policies, with one round being centered on the notice on further improving work relevant to the reemployment of the laid-off and unemployed people issued at the national work meeting on reemployment in september , and the other on gf [ ] no. document, promoting the continuous development of local public employment services. registered unemployed urban residents and people laid off from soes could from then on all receive free job advisory services. employment support policies for university graduates as well as disadvantaged urban families and groups (e.g. families in which nobody has a job and people who have diffi culties in getting a job) have also been improved. , as the number of rural migrant workers keeps growing, host cities, who used to focus only on employment rights' protection, have expanded the employment services to include allowing these migrants to enjoy equal access to the whole range of public employment services. in january , the state council issued the notice on providing employment management and services for migrant workers in cities , proposing to do away with unreasonable restrictions on farmers' migration into cities for work, to address late payment and underpayment of wages, and to provide appropriate training and management of these issues. later in , six ministries/ commissions such as the moa jointly issued the training program for migrant workers across china, - , which included provision for migrant worker training and tools for performance evaluation of government at all levels, with a view to improving the employment stability of migrant workers. the central government reemphasized in its no. document of that relevant authorities should remove administrative restrictions and unreasonable charges for farmers' migration into cities for work and should seek to protect their economic rights. it also required municipal governments to expand the provision of public services to migrant workers. the notice of the ministry of human resources and social security and the ministry of finance on issues regarding further improving the public employment service system issued in makes clear that the basic principle of public employment services is to provide basic public employment services in a sustainable and equitable manner across china by merging urban and rural labor markets and creating a long-term service mechanism that is geared to both urban and rural areas and that serves, in effect, all workers. wen junping: "on equal access to public employment services and the approach to realizing it", the journal of shanghai business school issue . li gongda: "on the public employment service system in china", labor security issue . on the question of legal support, the labor contract law which became effective on january , , together with the employment promotion law and the labor dispute mediation and arbitration law which were both issued in , all stipulate basic legal support for all job seekers, including migrant workers, in terms of fair employment and rights' protection. furthermore, local governments now publish policy documents on an annual basis which highlight and review the problem of underpayment to migrant workers. they also make greater efforts in providing migrant workers, especially the new generation, with employment services such as training (see table . ). improvements in public employment services are contributing to a steady increase in the quality of employment among migrant workers. housing assistance is an important part of public welfare. the housing market has been growing rapidly since the chinese government rolled out house trading amid the urban welfare reforms of the s. to provide low-income urban households with housing assistance, the then ministry of construction issued the measures for managing urban low-rent housing specifi cally focusing on measures to help lowest-income households with permanent urban hukou s in . nonetheless, the low-rent housing system has since developed slowly and has yet to be further improved. to address high housing prices and diffi culties facing urban low-income households in buying or renting housing, the state council issued the opinions of the state council on addressing diffi culties facing urban low-income households in buying or renting housing in , requiring that relevant authorities establish or improve an urban low-rent housing system, and improve and regulate affordable housing. the state council also made clear in this document that relevant authorities should work to improve housing conditions for residents, including migrant workers, living in large slums or old residential areas. it is expected that, by the end of the th five-year plan period, the provision of affordable housing will reach at least % nationwide across china, in order to solve the housing issue for urban low-and middle-income households. given the needs and spending limitations of low and middle-income groups in cities, relevant authorities have developed various forms of housing assistance, such as priority access to public rental and low-rent housing, and also to a range of other affordable housing schemes where public housing policies have brought about house/rental price limits or, for example, the accommodation of people from slum clearances, waiting to be reassigned housing. applicants for affordable housing such as low-rent and price-controlled housing must have received urban hukou s in areas administered by this city for year or more; the municipal government issued the interim measures for managing public rental housing in nanning city on october , to address the housing issue for low-and middle-income households (with hukou s, but no number of years of residence limitations) as well as for graduates and non-local migrant workers (with hukou limitations for neither group) jinan city the municipal government offi cially announced a public rental housing assistance standard on november , : barriers to application for public rental housing were lowered, and income and hukou limitations were cancelled. on the question of housing allocation, two-bedroom apartments were to become available for non-locally recruited skilled workers, certain families of three or more members, or certain single-parent families with one child of the opposite sex; one-bedroom apartments were to be made available for certain families of no more than two members or certain single people with permanent hukou s in the six districts within this city; shared rental apartments were made available for non-local single employees, with at least fi ve square meters in usable fl oor space available to each tenant anhui province the provincial government's plan was to build , social apartment units and merge public rental housing and low-rent housing into a single system; the allocation of such units would be in favor of new employees and workers with non-local hukou s shenzhen city in , the provision of affordable housing was expanded to middle-income people with no housing, and families of skilled workers with non-local hukou s that had diffi culty in buying or renting housing sichuan province in , the provincial government conducted the housing assistance for migrant workers program specifi cally aimed at migrant workers who had steady jobs and had lived in urban areas for at least a certain number of years. it was considering the allocation of % of all public rental housing to workers with non-local hukou s such as migrant workers, and the expansion of the hpf program to cover migrant workers source: ou qianheng and li gongyu: "nanjing: people from three groups may apply for public rental housing and are subject to looser hukou requirements than before", news.gxnews.com.cn, november , ; yu wen and wang jiguo: "jinan: applicants for public rental housing are no longer subject to income and hukou requirements; people with non-local hukou s become eligible for local housing assistance for the fi rst time", qilu evening news , december , ; wu liangliang: " , social apartment units will be built in anhui province this year, and will be allocated in favor of new employees and workers with non-local hukou s", anhui provincial department of housing and urban-rural development, january , ; li gang: "people with non-local hukou s in shenzhen benefi t from local housing assistance, and affordable housing will phase out", the people's daily , january , ; wan yao: "sichuan: the housing assistance for migrant workers program will be implemented this year, and % of all public rental housing will be allocated to migrant workers", the sichuan daily , february , ; the offi cial website of the mohurd, http://www.mohurd.gov.cn most migrant workers still live in dormitories provided by their employers or in rented houses in formerly rural areas reclassifi ed as cities but still basically under rural governances. in , most non-local migrant workers lived in dormitories provided by their employers or in rented or co-rented houses; those who lived in dormitories represented . % of all such workers; those who received housing allowances from their employers only represented . %, according to relevant statistics from the national bureau of statistics (nbs). we can therefore see that migrant workers who pay housing rents for themselves represent a large share of all such workers. the picture of the current coverage of basic urban public sector services shows that it has been gradually going beyond initial limitations caused by ownership systems, and it has extended provision to a larger number of low-income households, together with better quality of service. this public service system is available to nearly all permanent residents with local urban hukou s and is becoming increasingly well regulated. in addition, urban migrant workers' needs in terms of public services are increasingly being met. from a regional perspective, the provision of basic public services in eastern china is better than in central and western areas. this being said, there has been no substantial change in the overall institutional design of the basic urban public service system, which is characteristically based on hukou registration, management under the territoriality principle and the division of administrative responsibilities. new permanent residents and, in particular, rural migrant workers, have yet to be fully covered by basic urban public service provision. public elementary and middle schools in cities hosting migrant families already play a substantial role in providing compulsory education for migrant workers' children across china. nonetheless, there is wide variation in the degree of effort put into the inclusion of these children within local public urban educational systems. in the city of dongguan, for example, the children of migrant workers studying in public schools represented only . % of all such children in . migrant workers hope that their children can receive better education in cities, but their children have to return to their hometowns for the gaokao after the end of compulsory education, since the governments of most host cities have yet to make policies that integrate elementary, middle and high school education. we can easily see that local schemes for students with non-local hukou s taking the gaokao vary widely from place to place. western provinces such as yunnan still impose hukou restrictions on students who take the gaokao ; the leading destination cities of migrants in china, which are beijing, shanghai and guangdong, have similar transitional gaokao schemes for students with non-local hukou s. thus, "beijing scored zero points and shanghai also failed," as a critic put it. in , the moh conducted pilot projects for the migrant worker healthcare program. however, owing to the lack of any long-term mechanism for their inclusion in basic urban medical care service provision, migrant workers have not got equal access to other connected healthcare services: they have not been fully covered by the disease prevention and monitoring system; only a small number of the children of migrant workers are covered by the national immunization program; migrant workers have not been fully included in the urban family planning service system, and there are interregional system incompatibilities in terms of related services and allowances. the social security system in urban areas tends towards fragmentation. migrant workers, in particular, are a low percentage of those who are covered by social insurance, and there are additional institutional defi ciencies. firstly, premium rates for social insurance are on the high side, compared with the wages of migrant workers. the current rates demanded for migrant workers are "a professor at peking university: when it comes to the ncee schemes for students with non-local hukous, beijing scored zero points and shanghai also failed", the people's daily overseas edition , january , , http://gaokao.eol.cn/kuai_xun_ / /t _ .shtml han jun: "how the citizenization of migrant workers relates to the innovation of the public service system", administration reform issue . the drc research team: "the citizenization of migrant workers: the general trend and strategic orientation", china reform issue . higher than those for urban residents, since the average wage of the former is lower than that of the latter, and because the contribution base for migrants to be covered by urban social insurance equals % of the average wage of urban employees in the previous year. most migrant workers are employed in sectors such as processing/ manufacturing and services, where the labor cost represents a large share of the total cost and most employers are unwilling to pay full amounts of premiums for the employed migrant workers. secondly, pension insurance presents problems of continuation. this is because migrant workers are highly mobile, and, even if they are not rejected by the urban pension insurance system for employees, continuity of contributions cannot be guaranteed in other places. thirdly, interregional settlements for medical insurance are impossible. in , only . % of all employers of nonlocal migrant workers paid medical insurance premiums for these workers ; migrant workers who have opted to enroll in the nrcmcs (overall planning of which is made at the county level) are still unable to get medical expenses reimbursed immediately after they receive medical services where they work. fourthly and lastly, migrant workers who have not been covered by social assistance systems in their host cities, are also ineligible for medical assistance and minimum living allowances. in , migrant workers who had received non-agricultural professional skills training only represented . % of all such workers in china, according to monitoring statistics from the nbs. their survey revealed that most migrant workers had an educational level of junior high school and had received no suitable professional skills training, both of which adversely affected their profi ciency at work and, thus, their income levels. in addition, it was noted that fewer than half of non-local migrant workers, especially in the building industry, had signed labor contracts with their employers in . a research report published by the state council summarized the current problems affecting migrant workers' employment rights as: generally low wages, different pay scales for urban and rural workers in the same job, non-compliant worker management practices, poor safety at work, and low levels of organization. a survey in showed that as many as . % of the surveyed migrant workers were dissatisfi ed with their wages. not all chinese cities have included migrant workers in the local affordable housing systems. medium-and large-sized cities which are the major destinations of migrant workers are, indeed, acting more slowly than others in this regard. some municipal and provincial governments typically lift hukou -related restrictions in a selective manner -their policies tend to be in favor of those non-local workers who are more skillful or have steady jobs and have lived in host cities for a required numbers of years; such workers are already essentially the same as native city residents. most migrant workers still live in corporate dormitories. moreover, only a small number of migrant workers receive housing allowances; that is, most of them pay their housing expenses themselves. those who are covered by the urban affordable housing system merely represent a small percentage. in this time of rapid urbanization in china, the biggest problem with the current urban public service system lies in its failure to cover rural migrant workers (han jun ). the total number of migrant workers across china reached million people in , including over million non-local workers. in addition to this, there is a growing trend of whole family migration. however, although they work and live in urban areas, migrant workers cannot access the same public and welfare services as those available to native city residents. this has reduced opportunities for migrant workers and their children, and their capacity to develop in urban areas (chi fulin ) and is detrimental to the fundamental aim of improving the quality of urbanization. the provision of public services and welfare dependent on hukou registration has resulted in migrants having insuffi cient or no access to public services in urban areas. the problem of the fast-growing demand for public services for rural migrant workers and the limited availability of public funds to provide them in host cities, must be addressed; relevant authorities should also undertake to gradually improve the urban public service system and expand its coverage to all permanent residents including migrant workers, in order to embrace the principle of fair treatment and equal opportunities for improvement for all. to this end, it is fi rstly necessary to concentrate on the major objective of extending the provision of urban public services to all permanent residents, including all migrant workers. the promotion of equal access and improving the quality of public services offered should proceed at the same time. governments of host cities should assume more responsibilities to ensure the educational rights of migrant workers' children. the authorities should also assume more managerial responsibility and include educational services for the children of migrant workers when planning local educational fi nancial support. while providing such children with compulsory education mainly through local public elementary and middle schools, these governments should take additional measures to help them integrate into receptor cities. they should also subsidize private elementary and middle schools that participate in the provision of compulsory education and enhance their management. it is also necessary to improve preschool education for the children of migrant workers, in which kindergartens open to all children should play a leading role. in addition to local gaokao schemes for school students with non-local hukou s, relevant authorities should promote vocational education for the children of migrant workers and allow them to participate in entrance exams to local senior high schools and the gaokao. the authorities should seek to improve the migrant worker health information system using as a model the results from pilot projects carried out for the migrant worker healthcare program. in areas where large numbers of migrant workers live, the current community-level public medical and healthcare services should be gradually extended to cover all permanent residents, allowing migrant workers access to convenient, fairly-priced and safe community-level medical and healthcare services. it is necessary to enhance sanitation, disease prevention/control and children's immunization services in the aforementioned areas, to pay suffi cient attention to migrant workers' occupational health rights, and to ensure that migrant-worker couples have effective and convenient access to family planning services in their urban societies. firstly, since most migrant workers are in dangerous industries such as manufacturing and mining, relevant authorities should provide all migrant workers with industrial injury insurance as soon as possible. secondly, it is necessary to gradually improve the basic medical insurance system for migrant workers. thirdly, the extension of pension insurance to include all migrant workers is essential. fourthly, it is recommended that measures be undertaken that enable the interconnectivity between urban and rural social insurance systems, so as to build a large social insurance and security network in which all fi ve required insurances are managed in a unifi ed manner. this will ensure that migrant workers may select insurances and rates depending on their income and mobility levels. fifthly and lastly, it is advisable to implement fl exible transitional policies that allow for low insurance rates and to increase appropriate worker subsidies, given that migrant workers typically have low wages. firstly, it is advisable to promote employment by assisting in skills improvement. governments, companies, workers and training organizations should work together to promote vocational education and skills training for migrant workers, enabling them to get better jobs and higher incomes. secondly, relevant authorities should support employment by providing employment information. it is necessary to gradually establish a rural labor force registration system, to realize information sharing among regional public employment service organizations, and to enhance government guidance services, including the provision of public employment information, for the employment and migration of rural people. thirdly and lastly, it is necessary to ensure a steady wage increase. local governments should: continue to improve the minimum wage standard system to guide companies in properly increasing wages; allow trade unions to play a positive role in protecting workers' rights; establish a negotiation mechanism between employers and employees, and facilitate the creation of well-regulated labor relations; increase efforts in law enforcement and in monitoring employers' contractual signatures and observation of contractual obligations; increase workplace safety management, occupational health management and worker protection; and, fi nally, encourage ngos to provide migrant workers with legal assistance. firstly, given migrant workers' varying needs for housing, relevant authorities may encourage employers to build subsidized housing such as corporate dormitories for these workers. local governments should fi rstly expand access to the local public rental housing assistance system to include migrant workers who have steady jobs and who have lived in their host cities for a required number of years, before gradually serving more people, including migrants, and providing access to more types of affordable housing. it is advisable to develop a well-regulated housing rental market in urban areas to satisfy migrant workers' need for rented accommodation. secondly, relevant authorities could provide migrant workers with housing allowances and set up specifi c urban public housing funds as part of the housing assistance system; they could also think about the possibility of expanding the coverage of the urban housing provident fund (hpf) system to migrant workers who have steady jobs in cities, and could implement more fl exible policies. when it comes to tax policies, relevant authorities should grant certain tax incentives to individuals or organizations that build dormitories for migrant workers and/or provide housing rental services; they should also grant such tax incentives to migrant workers who are able to buy affordable and price-controlled housing. thirdly and lastly, relevant authorities should establish appropriate fi nancial and land supply systems which would favor the building of affordable housing for migrant workers, thereby gradually including these people in the urban affordable housing system available to all workers. on the diversifi ed supplies of public goods in china. a master's degree thesis at the graduate school of the cass the citizenization of migrant workers: government responsibility and public service innovation on equal access to basic public services vs. the issue of migrant workers key: cord- -ev qv b authors: sfeir, maroun m title: frontline workers sound the alarm: be always sure you’re right, then go ahead date: - - journal: j public health (oxf) doi: . /pubmed/fdaa sha: doc_id: cord_uid: ev qv b amid personal protective equipment shortage, clinicians, nurses, and other frontline workers across the world have faced threatening and/or firing for self-protection during this coronavirus disease (covid- ) pandemic. this perspective describes the different challenges that the stressed and overworked frontline workers encounter when they raise concerns despite being right. it also highlights the importance of communication and appropriate execution upon hearing those concerns. on december , dr wenliang li, a chinese ophthalmologist at wuhan central hospital, was the first medical professional who raised a concern in an online chatroom alarming the healthcare personnel of an outbreak related to a severe acute respiratory syndrome (sars)-like infection in seven inpatients admitted with severe respiratory tract infections after they visited the huanan seafood wholesale market in wuhan, china. thereupon, dr li was silenced by the chinese authorities in wuhan and required to sign a letter certifying he was spreading erroneous comments. subsequently, adoption of protection measures such as avoiding visits to the wuhan wildlife market, social distancing, wearing masks, hand hygiene, etc. got undeservedly delayed. unfortunately, dr li got infected by sars coronavirus (sars-cov- ) while treating patients and he died on february at wuhan central hospital in wuhan, china. later on, the chinese authorities mourned dr li's death and regretted the fact that he was reprimanded and prohibited from speaking up. dr li has been widely regarded as china's hero physician. in lieu of confrontation and pushbacks, communication and constructive execution by mitigating efforts during this coronavirus disease (covid- ) pandemic would save lives. in one way or another, frontline workers during the covid- pandemic were subject to unfair disciplinary actions across the world including the usa. social media outlets have been bursting with frustrations and fearful stories from healthcare workers and other frontline workers. for instance, early during the pandemic and before the centers for disease control and prevention (cdc) recommended wearing face coverings in public settings on april , many clinicians and nurses in the usa confessed that they faced intimidation, threatening or termination for wearing self-supplied masks in the hospitals. , some healthcare workers were told by their hospital administrative leadership that they cannot wear masks in hallways and/or that they cannot bring their own masks to the hospital. hospitals administrators justified that protective gear needs to be conserved and used as minimally as possible to the notion that it scares patients. many overwhelmed healthcare workers state that they feel they have been betrayed by their hospital administrators. in ca, nurses at an integrated delivery system were being told that they could be terminated for wearing their own n masks according to a memo by the california nurses association and the national nurses united. another nurse in oklahoma city claimed that he was fired on the spot after wearing a surgical mask while caring for patients. moreover, stressed and overworked healthcare workers shared critical concerns about lack of personal protective equipment (ppe) nationwide. alternatively, many healthcare professionals raised concerns anonymously and others reported fear of speaking up and declined to comment because they were worried about retaliation from hospital employers or citing the lawsuit. some healthcare employees were warned that they will be terminated if they speak out about inadequate ppe or if they talk on social media without authorization, in an attempt to limit reputational damage of the hospital. as the covid- crisis continues to mount, critical shortage of ppe and critical supply chain disruptions have been widely reported by healthcare workers across the nation. , hospitals were running out of supplies such as ventilators, medications, toilet paper, etc. further, healthcare workers have been frustrated of reusing masks that they have never had to reuse before across the country. healthcare workers' duty of care implies their duty to care for patients including public health emergencies and outbreak conditions. on the other hand, healthcare employers should assure safe and healthy working conditions for working employees. nevertheless, the lack of preparedness and readiness during this covid- pandemic has not secured that latter rule which lead to high potential exposure risk among healthcare workers across the nation and worldwide. in fact, safety and security of the healthcare workers are paramount. all healthcare workers must have access to appropriate ppe. if hospitals understandably cannot furnish ppe, they should allow healthcare workers to wear their own ppe. the joint commission has genuinely issued a statement on march that healthcare workers should be allowed to wear their own ppe. as of april , at least us healthcare workers had tested positive for sars-cov- and at least had died according to the cdc report. the u.s. department of health and human services published a survey of hospitals that found the shortages left the facilities unable to effectively test staff and patients who frequently waited > week for results because of delays at outside laboratories. note that many healthcare workers were denied testing. in new york city, a nurse treated patients in the intensive care unit in late march but could not get a sars-cov- real-time polymerase chain reaction (rt-pcr) test from her hospital after she started displaying nausea, abdominal pain and low-grade fever. she continued to care for patients as well as colleagues and family members despite the serious risk of exposing them without knowing she is carrying the virus. ultimately, she took it upon herself and tested positive for covid- at a private clinic. on april , the hospital employees were told that hospital would increase testing of healthcare personnel with symptoms of the sars-cov- virus. similarly, in ga, a nurse did not qualify for covid- testing after treating an infected patient with sars-cov- who died. hospitals are elseways facing a public health dilemma of testing staff with mild symptoms despite the severe shortage in testing capacity and keeping them home for days as they await results while there is a dire demand for essential healthcare workers. likewise, ignoring concerns and/or delayed appropriate and timely execution have been critical issues among other frontline workers, e.g. bus drivers. for example, a bus driver in detroit, mi, complained on social media on march of a female passenger who coughed in the bus without covering her mouth. grievously, the bus driver felt sick < weeks after expressing concern, and died of covid- just a few days after. latterly, safety measures got extended to all bus drivers by providing gloves and sanitary wipes, and obliged passengers to board and exit the bus at the bus back door away from the bus driver. such a preparedness and readiness plan implemented a little bit early would have had a better impact. in this challenging time, we should ramp up our efforts to slow the spread of covid- . we should also encourage communication with frontline workers, listen to their concerns and execute promptly and effectively. furthermore, paying tribute to the healthcare workers and other frontline workers and protecting the most vulnerable from the effects of the disease are key strategies as the covid- case numbers continue to explode. ultimately, a main lesson this covid- pandemic might teach frontline workers conforms well to david crockett's attributed quote of 'be always sure you're right, then go ahead'. author has no conflict of interest to disclose. mms designed the manuscript, contributed with acquisition of data and wrote and approved the final version of the manuscript. author has no conflict of interest to disclose. china's hero doctor was punished for telling truth about coronavirus. cnn opinion global nurses united press clips especially in areas of significant community-based transmission nurse claims he was fired for wearing face mask to treat okla. hospital patient the joint commission. joint commission issues statement on use of face masks brought from home characteristics of health care personnel with covid- -united states hospital experiences responding to the covid- pandemic: results of a national pulse survey the high price of keeping detroit moving none. key: cord- - o g q authors: polychronakis, ioannis; riza, elena; karnaki, pania; linos, athena title: workplace health promotion interventions concerningwomenworkers' occupational hazards date: journal: promoting health for working women doi: . / - - - - _ sha: doc_id: cord_uid: o g q nan in the european labor market, women today constitute an increasing part of the working population, equaling about percent of the european workforce (european agency for safety and health at work a) as a result of their dynamic entrance in the labor market during the last few decades. while women have occupied posts even in professions that so far have been considered as "traditionally male," the european labor market retains a high degree of segregation regarding women's participation rates in certain occupational sectors (european agency for safety and health at work a; ) . the european union (eu) has so far applied a gender-neutral approach (european agency for safety and health at work a; ) to policies and legislation concerning occupational safety and health (osh) to comply with world health organization (who) guidelines for equality in health standards and access to health service. however, this approach does not seem to suffice for effectively meeting gender-specific issues of occupational hygiene and safety that have emerged concerning female workers in particular. the female working population carries certain characteristics that have to be taken into consideration through the process of design and implementation of osh policies, because their interaction with the occupational environment may produce additional hazardous effects for women employees: women's workday concerns arising from their roles as mothers, spouses, or carers for the elderly, add an extra load on the mental and physical fatigue they sustain in their workplace (artazcoz et al. ; artazcoz, borrell & benach ) . everyday household tasks amount to hours of unpaid overtime on top of the -hour working day, increasing their total physical and psychological strain. as a consequence, women workers are more easily affected by burnout effect or suffer more frequently from work-related stress than their male colleagues, who continue to participate significantly less than women in house tasks. working conditions in terms of ergonomics, working pace, managing heavy workloads, and using tools or personal protective equipment (ppe) (tapp ; murphy, patton, mello, bidwell, & harp ) are often designed according to the size and the physical strength of an average male worker. this is a consequence of the fact that many occupational sectors were, until recently, almost exclusively staffed by men, and even today employ an overwhelming majority of male workers. despite the increase in the participation of female workers in many professional fields, the high cost of adequate interventions still constitutes a forceful barrier to adjusting the modern workplace to female employee's needs for health and safety. because women of child-bearing age constitute a significant part of the female workforce, the protection of women's reproductive health is an issue of great concern for eu policymakers, in terms of legislation. this applies to factors and working conditions that both directly and indirectly influence the female reproductive system, including fertility (biological, physical, or chemical hazards-e.g., endocrine disruptors that affect women's ability to conceive), pregnancy (detrimental factors for the foetus during intrauterine development), and lactation. one also has to underline the fact that pregnant women are in need of specially designed ergonomic workplaces (niedhammer, saurel-cubizolles, piciotti & bonenfant ) , that consider changing physical and biological conditions and needs throughout the gestation and post-partum period. biological predisposition determines that women employees have reduced physical strength in comparison with their male colleagues (hooftman, van der beek, bongers, & van mechelen ) . this fact creates a comparatively higher burden for female workers who perform the same tasks as men, and creates a greater risk for musculoskeletal strain. furthermore, women's reduced average muscle force places them in an unfavorable position in cases of bullying and physical violence at their workplace, both from co-workers or the public (e.g., psychiatric ward nurses). women workers are still a minority group in certain professional fields (e.g., construction, mineral extraction, heavy industry), and in most cases they remain in lower managerial positions in comparison with men. under these circumstances, women employees have limited control over administrative decisions (european agency for safety and health at work ) concerning occupational health and safety, and often lack access to the appropriate communication channels to report cases of bullying, mobbing, or even sexual harassment-especially when superiors are involved. in certain areas of industrial production (e.g., the textile industry), the female working population consists predominantly of immigrant workers with poor literacy skills, or difficulty communicating. this language barrier may, in some situations, cause work-related accidents, as well as expose workers to occupational hazards due to misconception or ignorance of safety instructions or warning labels and signs. women in europe present higher percentages of part-time employment than men, as shown in figures . and . . in many occupational sectors (e.g., cleaning industry, cashiers), the overwhelming majority of women work part time. in addition, female employees show a higher turnover rate during their career and seem to spend shorter periods, on average, in the same position (mcdiarmid & gucer ) . because of this effect, women's occupational diseases are, in many cases, significantly underreported, introducing a systematic bias in many studies on occupational hazards and creating the misperception that female workers generally occupy safer jobs. to make matters even worse, women in this kind of unstable employment pattern have, in most cases, only limited access to occupational health services and workplace health promotion activities, even though they constitute a high-priority group for similar interventions. it should be underlined, however, that under no circumstance does this genderspecific approach lead to the false conclusion that women workers constitute a (jouhette & romans ) high-risk group requiring preferential treatment over issues of occupational safety and health in comparison to male workers. such a misinterpretation could cause unacceptable discrimination against women and, in some cases, their exclusion from occupational sectors where female workers have for a long time now proven their worthiness as employees. even though available research data in the literature may suggest that certain traits or characteristics connected with gender could possibly influence the occupational risk of female employees, they fail to identify occupational hazards that are selectively or exclusively harmful to women. at this point, it is useful to categorize all gender-related parameters that have been identified as distinguishing occupational health and safety issues between male and female workers. according to previous studies, three fields of possible gender influence (kennedy & koehoorn ) on estimated occupational risk can be identified. because of job and task segregation observed among the european workforce, osh studies based on occupational categorization alone have been insufficient in assessing potential health risks for women, because their tasks may vary significantly from men's even if they carry the same professional title (Östlin ) . women follow different time patterns of exposure through part-time or shift work, and usually carry out tasks requiring more precise, repetitive movements than male workers (hooftman et al. ; stellman ) . • female workers have smaller (on average) body dimensions (hooftman et al. ) , which differentiates their occupational exposure: a. in professions involving manual handling, greater physical workload may be required by women to perform the same tasks as men. b. in cases of chemical exposure through the skin, the female body provides smaller available surface for absorption. c. protective equipment is often ineffective for women employees (protective clothing, gloves, masks, and respirators) (han dh ) . protective equipment originally designed for male workers does not fit appropriately to the shape and size of the female body and does not fully prevent exposure to hazardous agents. • under normal conditions, women present lower alveolar ventilation rate and cardiac output (brown, shelley & fisher ) , which reduces the input rate of volatile chemicals into their body • in the case of benzene (a proven carcinogen) and other volatile organic compounds (vocs), it has been experimentally demonstrated that women present higher blood/air partition coefficients (brown et al. ) (greater blood / air concentration fraction), increasing the amount of chemicals diffused from alveoli to the blood compartment • concerning the metabolism of chemical compounds, potential gender-related disparities in enzymic activity (gandhi, aweeka, greenblatt & blaschke ) (e.g., cytochromes p , transporting enzymes) have been reported, although research results are contradictory • in the case of exposure to metals, women appear to absorb greater amounts of cadmium through digestion, possibly due to a common absorption pathway for iron and cadmium (vahter, berglund, Åkesson & lidén ) (especially for menstruating women with low body-iron storage) • chemicals absorbed into the bodies of women workers are distributed in a relatively smaller body mass than men, because their body mass index (bmi) is lower (gandhi et al. ) . as a further consequence: a. women present a relatively higher organ blood flow, which increases the rate at which chemical substances circulating in blood compartment are delivered to the tissues. b. women's renal clearance (gandhi et al. ) (a parameter that is directly related to body weight) is slower in comparison with men's, and therefore their capacity to excrete toxic compounds, as well as their metabolites, through daily production of urine is low. • bodily distribution of chemicals in women also differs in regard to their concentration in plasma. experiments on gender influence on the distribution of certain drugs, indicate that (gandhi et al. ): a. plasma volume is generally lower in females (the same total-body chemical burden may produce more toxic plasma concentrations in women). a. the concentration of certain binding proteins for drug metabolites or other chemicals in plasma depends heavily on hormonal status-especially estrogens (e.g., pregnancy, menstrual phase, and menopause). • the female body carries a greater proportion of adipose tissue than that of males (brown et al. ; gandhi et al. ) , and as a result it demonstrates a different pharmacokinetic response to lipophilic metabolites (e.g., prolonged retain and increased metabolism of benzene). • in professions involving exposure to inorganic lead, blood concentrations do not provide a reliable criterion of chronic exposure in the case of female employees. as the metal gradually accumulates in the bone tissue, demineralization of women's skeleton during periods of increased bone turnover (as in pregnancy or menopause) releases significant quantities of lead into their bloodstream (vahter m et al. ) . • women present different social and dietary habits, such as smoking (e.g., cadmium absorption) (vahter m et al. ) and alcohol or coffee consumption (mcgovern ) , which may act as modifiers to environmental exposures • the use of chemical substances for household tasks (e.g., cleaning products), hobbies (e.g., fertilizers in gardening), or other activities involving application of potentially harmful agents (including cosmetics and artificial hair dyes) may subject women to further exposure outside their daily work hours • wearing jewelery is an additional nonoccupational source of skin exposure to metals for women (e.g., nickel) (vahter m et al. ) , increasing the burden of metal-induced occupational dermatitis for women employees • female employees in occupations involving manual tasks may also have to sustain additional workloads arising from family demands, especially in large families with children under years old, or elderly persons over years old (artazcoz et al. ) , which may contribute to producing symptoms of physical fatigue or musculoskeletal strain. • increased family demands of female workers, combined with strenuous job tasks may also have a serious impact on women's mental health (disturbed work-life balance, inadequate leisure time, lack of personal life) (artazcoz et al. ) • besides the immediate toxic effects of certain metals such as cadmium on humans (affecting both men and women), there is ongoing research on possible estrogenlike activity as well as its potential association with breast cancer through the activation of estrogenic receptors (brama m et al. ) • the manifestation of certain gender-specific cancers (e.g., breast cancer, which occurs almost exclusively in women) seems to involve among others, interaction between genetic expression (e.g. atm tumor suppressors) (mcgovern ) and environmental exposures • the manifestation of autoimmune diseases (highly frequent among the female population) might be triggered or accelerated by substances or agents commonly used in certain professions (as in the case of lupus erythematosus and mercury exposure) (mcgovern ) • the varying composition of the labor force in different occupational sectors may have introduced a significant bias in epidemiological studies concerning occupational hazards for women: a. especially in the heavy industry and construction sectors, which employ almost exclusively male employees, the small minority of women who work alongside their male co-workers in various positions may have been overlooked (niedhammer et al. ) in osh studies, introducing exclusion bias (concerning women workers) because of the difficulties researchers had in finding women employees to participate in their studies. b. on the other hand, women-focused osh research has concentrated on the relatively small number of professions that master the majority of the female work-force. this fact probably explains the relatively large volume of studies on health-care professions (which are easily accessible to research), while women workers remain heavily underrepresented in osh studies in other sectors (messing & stellman mager ) c. the majority of studies that focus exclusively on women workers deal with mental health issues and psychological parameters (messing & stellman mager ; niedhammer et al. ) , while other work-related hazards such as exposure to chemicals, radioactive material, biological factors, electromagnetic fields, noise, or ergonomic factors are either indirectly examined by surveys on mixed working populations (where results are adjusted for gender), or even worse, by generalizing epidemiological evidence of osh conducted among male employees. • the segregation of tasks performed within the same job department or even under the same occupational title, may introduce misclassification bias when the influence of gender on occupational risk is under study. any observed excess risk among women workers (e.g. musculoskeletal injuries) in comparison with men, should not necessarily be attributed to the role of gender, especially when such results are based only on job title (hooftman et al. ). in such cases, further quantification of exposure (job exposure matrices, stratification according to tasks) is essential in determining whether the declination in study results arises from differences in performed tasks, or is truly related to gender-e.g., the excess risk for developing carpal tunnel syndrome in female workers seems to be eliminated in professions with strictly defined tasks (mcdiarmid, oliver, ruser & gucer ) . • other forms of bias related to gender have been identified in the design of clinical, as well as osh, studies: a. an observer error due to adopting "male perspective and way of thinking" (pinn ) in interpreting epidemiological data. b. the "male norm" bias, arising from the use of male workers as standard (pinn ) , even for occupational health and safety issues where both sexes are affected (e.g., occupational cancer). • there are indications that many of the existing studies on women workersespecially those concerning occupational musculoskeletal injury-may suffer from perceptual bias (the increased likelihood of employees to report injuries), or overrating the severity of related symptoms in questionnaire surveys according to the way they perceive their working environment or their degree of job satisfaction (strazdins & bammer ) . taking into account that female workers are generally occupied in less satisfactory, underpaid jobs with repetitivemonotonous tasks (hooftman et al. ) , over-reporting may contribute significantly to the excess risk found by many relevant studies for female employees. • for the majority of female workers employed outside the dangerous industrial or construction sectors, there is little public awareness of the occupational exposures they sustain from their working environment because they usually do not face immediate danger of acute toxic effects or death. this fact may introduce a significant recall bias in relative studies because women workers are either unable to identify potentially harmful agents they have been exposed to, or tend to underestimate the extent of such exposures (e.g., unawareness of types of agents involved in their tasks that may constitute reproductive hazards) (bauer, romitti & reynolds ) . • in mixed working populations, the healthy worker effect appears stronger for male than female employees , which is possibly attributable to the fact that men are hired to perform more physically demanding tasks than women and are therefore subjected to more rigorous selection during the hiring process. the existing research evidence indicates a widely accepted false sense of safety in many of the professional sectors employing predominantly women, which has been recognized in earlier occupational health and safety studies in the united states as the so-called generally recognized as safe (gras) status (mcdiarmid & gucer ) for most of the female professions. this is partially due to the fact that male workers, especially in heavy industry (construction workers, miners, welders, heavy machinery operators), are expected to face a higher number of severe or even fatal incidents or occupational diseases (niedhammer et al. ) , than those in the safe tertiary sector. gras reflects the commonly held belief that certain drugs and chemicals are safe if empirical knowledge obtained by their wide use over a period of years does not indicate they are detrimental to the population. as a consequence, this approach is also adopted in occupational sectors, where such materials have been widely used-the majority of which involve femaledominated professions where, until recently, osh research has been considered nonessential. contemporary evidence-based medicine, however, requires more solid epidemiological data to conclude whether this group of occupations is as safe as is currently presumed. in addition, there is an increasing need to study the possible sideeffects on health from exposure to thousands of chemical compounds present in jobs generally considered as nonhazardous (cleaning agents, drugs, cosmetics, food preservatives). the latter translates as a need to expand the field of occupational health and safety research and place the so-called female professions under a more thorough and systematic investigation. according to official statistics of the european agency for safety and health at work, certain occupational sectors (health professionals, education workers) employ mostly females while the percentage of women in other professions (construction workers, heavy industry) (european agency for safety and health at work ) remains relatively low. figure . presents the distribution of the female working population in different occupational activities, in the european union. for many of the professions where women are highly represented, research has explored specific occupational hazards. in tables . in the health services sector, women are employed in various positions (e.g., nurses, laboratory technicians, emergency room technicians) and face a multitude of occupational risks, some of which are cited in table . . women are also often employed in the education sector, especially in nursery and primary education, and therefore face diverse occupational risks, some of which are specific to the profession (e.g., voice disorders). table . presents some of the related occupational hazards for this category of workers. while affected by many occupational hazards, some of which are cited in table . , women working in the cleaning industry are also disadvantaged due to the fact that (gavana, tsoukana, giannakopoulos, smyrnakis, & benos, ; gyorkos et al., ; nakazono, nii-no, & ishi, ; skillen, olson, & gilbert, ; valeur-jensen et al., ) • vascular problems (kovess-masfety, sevilla-dedieu, rios-seidel, nerriere, & chee, ) of the lower extremities due to extended standing (sandmark, wiktorin, hogstedt, klenell-hatschek, & vingard, ) in upright position • voice disorders due to overuse of vocal chords duff, proctor, & yairi, ; kooijman et al., ; kosztyla-hojna, rogowski, ruczaj, pepinski, & lobaczuk-sitnik, ; roy, ; sliwinska-kowalska et al., ; sulkowski & kowalska, ; thibeault, merrill, roy, gray, & smith, ; williams, ) • exposure to increased levels of noise (behar et al., ) • musculoskeletal problems (fjellman-wiklund, brulin, & sundelin, ; sandmark, ; yamamoto, saeki, & kurumatani, ) (handling and lifting small children in day care centres, physical education teachers, inadequate body posture) • work-related stress (fjellman-wiklund et al., ; zidkova & martinkova, ) • children's or adolescent's violent behavior (lawrence & green, ) • exposure to infectious agents • dermatitis due to direct skin contact with irritating substances (weisshaar et al., ) • dermal infections (staphylococcus, fungi) (mcbryde, bradley, whitby, & mcelwain, ) • inhalation of irritating vapours and airborne micro-particles containing dust or other allergens (j. j. jaakkola & jaakkola, ) • musculoskeletal disorders due to handling or lifting heavy objects, inadequate body posture (balogh et al., ; mondelli et al., ) • fall injuries (stairs, slippery floors) (kines, hannerz, mikkelsen, & tuchsen, ) • workplace violence (chen & skillen, ) • sexual harassment table . food production industry workers workplace hazards • inhalation of airborne allergens emitted from food processing (e.g., artificial dyes, flour, animal proteins) • dermal infections (staphylococcus, b-haemolytic streptococcus, bacillus anthracis, fungi) • dermatitis (allergic or irritating) from skin contact to foods themselves or substances used for their processing (jappe, bonnekoh, hausen, & gollnick, ; kanerva, estlander, & jolanki, ) • exposure to zoonoses (processing animal products) • musculoskeletal disorders (handling and lifting excessive loads, inappropriate body postures, poor ergonomic design of workstations, repetitive strain) (chyuan, du, yeh, & li, ) • injuries (falls due to slippery floors, burns, lacerations from knives or used tools) (courtney et al., ) • exposure to extreme temperatures (cold in refrigerators, excessive heat in kitchens) their occupation is often unregulated, and thus no occupational safety and health services are available to them. the food production sector involves various types of work, from food preparation to packaging, storing, and more, involving mainly biological and chemical hazards due to immediate contact with food. table . presents a non-exhaustive lists of related occupational hazards. a large number of women are employed in the sector of hospitality services (e.g., waitresses, cooks, bar attendants) and are subject to a number of risks, some of which are listed in table . . the textile sector is heavily industrialized, and women working in this sector face many and serious risks, some of which are cited in table . . laundry workers are also faced with heavy tasks such as long hours on their feet, exposure to extreme temperatures, and lifting heavy loads, as can be seen in table . . table . hospitality services industry-restaurant workers' workplace hazards • exposure to extreme temperature conditions (excessive heat in cookers) • musculoskeletal injury due to handling or lifting heavy objects-repetitive movementsstrenuous workload (chyuan et al., ; dempsey & filiaggi, ) • dermatitis induced by skin contact with foods or cleaning agents (jappe et al., ; kanerva et al., ) • dermal infections (skin contact to infected food surfaces, development of fungal infections due to extended exposure to humidity) • injuries (falls due to slippery floors, falling objects, skin lacerations from sharp objects, burns from heat-emitting objects or appliances) (courtney et al., ; horwitz & mccall, ) • inhalation of micro-particles (food-cooking, passive smoking, poor ventilation) (svendsen, jensen, sivertsen, & sjaastad, ) • workplace violence (graham, bernards, osgood, & wells, ) • sexual harassment • work-related stress (low levels of job satisfaction, stressful working conditions) table . textile industry-clothing manufacture workplace hazards • exposure to increased levels of noise (weaving machines) (bedi, ; cardoso, oliveira, silva, aguas, & pereira, ) • increased concentration of fibres, micro-particles and organic solvents (artificial dyes, chemicals used in textile processing) in workplace environment (bakirci et al., ; ghio et al., ) • musculoskeletal injury (poor ergonomic design (choobineh, lahmi, hosseini, shahnavaz, & jazani, ) of the production line, repetitive movements (bjorksten, boquist, talback, & edling, ) , lifting and handling heavy objects) • visual fatigue • injuries (entanglement in moving parts of equipment, skin lacerations by sharp objects) • intense work-related stress (strenuous workload, intense work pace in production lines, low level of job satisfaction) ceramic and pottery workers face a series of specific occupational risks connected with the nature of their profession, as presented in table . . light manufacturing includes many types of industries, employing mainly nonspecialized workers and therefore involving diverse types of exposure. table . presents some of the hazards involved in these occupational activities. (dorevitch & babin, ) • musculoskeletal injury due to poor ergonomic design, handling heavy loads, repetitive muscle strain, vibrations (martinelli & carri, ) • stressful working conditions -strenuous work pace in production lines table . light manufacture workers' workplace hazards • musculoskeletal injury due to poor ergonomic design (equipment, tools and workstations that don't fit the physical dimensions of female workers), handling and lifting heavy loads, repetitive movements (bjorksten et al., ; roquelaure et al., ) • visual fatigue (untimanon et al., ) • exposure to chemical agents (e.g., metals & solvents in electronic circuits manufacture, drug by-products in the pharmaceutical industry) (clapp, ; ladou, ) • stressful working conditions in production lines call center work is a newly developed sector that employs mostly women who are faced with risks such as visual fatigue, musculoskeletal disorders, and other hazards as presented in table . . hairdressing is a female-dominated sector that, until recently, has been regarded as a safe occupation. however, current literature associates this profession with various hazards, some of which are included in table . . the tertiary sector-especially office workers-are faced with hazards arising mainly from poor ergonomic design and poor indoor air quality, as shown in table . . hazards in agriculture are linked mainly to a high risk of injuries and to the use of chemical substances such as pesticides, herbicides, and others, as shown in table . . (best et al., ) (inadequate body postures (osteras, ljunggren, gould, waersted, & bo veiersted, ) , poor ergonomic design (boyles, yearout, & rys, ) ) • vascular problems of the lower extremities due to prolonged standing in upright position • dermal infections (ballas, psarras, rafailidis, konstantinidis, & sakadamis, ; schroder, merk, & frank, ) (skin lacerations from scissors or other sharp tools (moghadam, mazloomy, & ehrampoush, ) , dermal fungi from continuous exposure to humidity) • dermatitis (khrenova, john, pfahlberg, gefeller, & uter, ; perkins & farrow, ) (irritating or allergic) (cavallo et al., ; doutre, ) induced by contact to cosmetics (amado & taylor, ; iorizzo, parente, vincenzi, pazzaglia, & tosti, ; katugampola et al., ; sosted, hesse, menne, andersen, & johansen, ) , artificial hair dyes (belinda thielen, ; rastogi, sosted, johansen, menne, & bossi, ) or even protective gloves (foti et al., ) • allergic asthma (akpinar-elci, cimrin, & elci, ; allmers, nickau, skudlik, & john, ; macchioni et al., ; moscato et al., ) induced by exposure to volatile substances (baur, ; berges & kleine, ; gala ortiz et al., ; hoerauf, funk, harth, & hobbhahn, ; hollund & moen, ; labreche, forest, trottier, lalonde, & simard, ; piipari & keskinen, ) and particles (cosmetics, hair sprays (albin et al., ; montomoli, cioni, sisinni, romeo, & sartorelli, ) , dryers • job-related stress (strenuous working conditions, low job satisfaction) (mcbride, firth, & herbison, ; perry & may, ) • exposure to zoonoses due to close contact with animals or animal products (bacillus anthracis, mycobacterium, brucellosis, viral infections e.g. avian influenza) • exposure to chemical compounds during transportation, storage, mixing or application of fertilizers, pesticides or herbicides (buranatrevedh & roy, ; garcia, ) • exposure to allergens through inhalation or direct skin contact (pollen, animal proteins, fungi) (linaker & smedley, ) • exposure to natural phenomena (extreme heat, frost, thunderstorms, floods) • job related stress (stressful working conditions, job insecurity, low income, low job satisfaction) • violence at the workplace (verbal or physical abuse) • sexual harassment this section will focus on how theories and models of health promotion can be put into practice for the design and implementation of workplace interventions concerning osh issues targeted at female workers. the example that will be used is work-related reproductive disorders. the specific health topic has been selected as an example for three primary reasons: • reproductive disorders have been associated with a wide range of occupational hazards (e.g. physical, chemical, biological agents) • a large number of professions employing women involve exposure to hazards such as those mentioned in the above point • further research is needed on this topic because many of the traditionally female professions considered generally safe may involve unidentified risks for women's reproductive health reproductive hazards constitute a field of increasing interest for occupational hygienists and health professionals across the world. there is little or no information at all about the possible effects on female reproductive health of the vast majority of chemical substances introduced by the thousands every year in industrial production (lawson et al. ) . even in cases of widely used chemicals, the existing literature of their possible detrimental effects on women's reproductive physiology is relatively poor. for most of the agents considered as hazardous for the reproductive system, their causal relationship to problems in human reproduction has not been adequately documented and gender differences in exposure or toxicity have not been thoroughly examined. because female workers constitute a nonhomogenous population of diverse occupational categories, various physical, chemical, and biological exposures are under examination concerning their potential risks on the reproductive health of women. a non exhaustive list of factors under investigation concerning their potential harmful effects on female reproductive health is presented in table . . the precede-proceed model of planning will be used as a framework to guide the diagnostic phase of the suggested intervention (gielen & mcdonald ; green & kreuter ; green, kreuter, deeds & partridge ; national cancer institute b; ransdell. ) . the outline of this theoretical model is presented in figure . . • precede provides the methodological framework for the design of tailored educational interventions targeting specific populations. it is based on the medical model, involving an initial diagnostic approach to the needs of a patient, before prescribing a specific treatment. as an analogy, precede constitutes a tool to design a specific educational plan, according to the identified needs of the target group. • proceed has been an addition to the original model, to further include environmental determinants (e.g., policies, managerial and economic issues) that influence human attitudes towards specific health behaviors. this model follows a reverse course, towards the origin of certain health behaviors to target interventions for the causal factors themselves, rather than just the symptoms. the outline of the process that takes place in nine stages is presented in figure . . for our example, only the diagnostic part of the model will be analyzed. despite the fact that we have already chosen occupational reproductive hazards as our intervention subject in this case, the stage of social diagnosis is supposed to have taken place before making our choice. for any workplace health promotion effort to be effective, the key issue must be tailored according to the needs of the predefined target population. even though women's reproductive health may seem like a scientifically important field of intervention, our target group of women employees may not consider it to be a highpriority issue-either because they consider having more important health problems or because they are not adequately informed on the possible impact of similar disorders on their personal health status. the main focus of health professionals at this stage is to investigate: • the target group's perception of their quality of life • the most important determinants of their quality of life (e.g., career, family, health) • their expectations and concerns about their health status • whether reproductive health issues are considered an important enough factor for women that an intervention through a whp program is valuable the focus of health professionals during this phase is to identify-through analyzing epidemiological evidence-the impact of the specific problem on the predefined target group (e.g., female workers in a factory, women employed in a specific profession). furthermore, this procedure aims at prioritizing the specific subgroups that face the highest risk of exposure to reproductive hazards and need more immediate preventive measures. this stage includes: • identification of work-related parameters, as well as individual behaviors that may influence the reproductive health status of women employees • evaluation of specific indicators of reproductive health disorders in our target population. some of these indicators are listed in table . one of the specific interests of health professionals at this stage is to locate groupings of reproductive disorder indicators in certain subgroups (specific job tasks, worksite-specific reproductive hazards) of the population, to prioritize them as intervention groups (e.g., focusing a whp program for the prevention of reproductive disorders on oncology unit nurses in case they present higher incidence of congenital defects compared to the rest of health care personnel) table . potential indicators of reproductive disorders (lawson et al. ) . increased infertility rates among women of a specific industry . a prolonged conception period among female workers . frequent reports of menstrual disorders and early menopause by female employees in the company's medical files . male/female ratio of births . reported pregnancy complications among employed pregnant workers (e.g., diabetes, hypertension, pre-eclampsia, etc.) . reduced (or increased) average birth-weight of infants . increased rates of pre-term deliveries (and miscarriages) . number of sick-leave days among pregnant employees (for problems related to pregnancy) . increased rates of congenital defects among infants of female workers . increased incidence of neoplasms of reproductive organs among employed women it is imperative during the initial design of a tailored whp intervention program for the prevention of occupation-induced female reproductive disorders, to incorporate a set of behavioral and environmental change indicators that serve as general objectives for the program. whp professionals, prior to the development of an intervention plan, should conduct behavioral and environmental diagnosis to identify existing key issues concerning osh attitudes and beliefs and practices in the organization (employees, executives, and company administration) and the safety status of facilities, procedures, and equipment. these key issues may include (state of alaska ): • personal accountability: this parameter is crucial for the success or failure of any prevention program, both on worksites and in the general population. it is important to adjust the program's aims and methods according to women's perceptions of its personal influence on their health status. female employees should be able to recognize their personal responsibility and contribution to the effective implementation of the preventive measures and practices by the completion of the whp intervention. • attitude towards change: a key component for the design of an effective intervention prevention program is taking into account the degree to which women agree with the proposed changes (safety behavior, practices, osh regulatory environment), so that invention methods can be modified accordingly. at this stage, therefore, health professionals should evaluate the awareness status and the ability of female employees to adopt the desired safety practices introduced by the whp program on both personal and collective levels to determine the kind of messages and strategies appropriate for the specific population. • participation: one of the primary targets of the whp intervention is to achieve a high degree of participation in the program's activities, as it is one of the key elements that significantly influences results. it is important at this stage to recognize and alleviate barriers that are driving women to abstain from similar programs. furthermore, there is a need to identify the subgroups of female workers where the focus of the intervention needs to be to promote their involvement. • occupational hazard identification: apart from recognizing that female workers are at a high risk for reproductive disorders, the whp program should also concentrate on specific protective measures and proposals for these groups of employees. it is essential, therefore, to identify and record existing working conditions of women in the specific organization in detail, to determine their possible detrimental effect on the reproductive physiology of those same women, and assess the existent osh status of their job tasks. this process includes recording: . procedures (production line, manual tasks, strenuous work pace, extreme climate conditions, emission of fumes/particles, and stressful conditions) . hazardous agents (physical, chemical, and biological) involved in female workers' tasks or working environment . equipment used in specific tasks (radiation sources, vibrating parts, electromagnetic fields) . existing protective measures (ventilation systems, separate mixing chambers for chemicals, lifting devices for manual handling, radiation shields, ppe, rotation of night shift workers, etc.) for women employees . potential for osh improvement (substitution of procedures or agents, automatization of tasks, amelioration of working conditions, change of job post, or rotation of workers) this part of the diagnostic process involves the identification of the educational needs of female employees, as well as the structural changes that are needed in the specific organization to effectively introduce the whp interventions for the protection of women worker's reproductive health. this process will be used to shape our strategic approach towards the target population, through the analysis of determinants of compliance with safety practices at individual, collective, and organizational levels. three categories of such factors may be identified-namely, predisposing, enabling, and reinforcing factors, that will be further analyzed: predisposing factors: health professionals may recognize multiple potential fields of intervention on which to focus the whp program: the whp program may introduce certain interventions to promote the desirable change to compliance in osh practices. • personalized information on female reproductive system and occupational risks involved • health awareness building on reproductive health issues and their importance • wide dissemination of existing scientific evidence on reproductive hazards for women employees (population awareness) • creation of peer support systems among groups of women workers to promote compliance with safety procedures • detailed recording of job tasks for female employees and identification of sources of exposures to known or potential reproductive hazards • introduction of specific safety guidelines and policies for the prevention of reproductive disorders • establishment of clear communication channels between employees and administration to report their concerns or personal experience on relative issues • improvement of the existing surveillance system for reporting suspicious cases among women workers reinforcing factors whp program officials may utilize numerous tactics to support the desired prevention strategy at this field. • provision of access to supplementary information resources on reproductive health issues and available prevention methods to the population of women employees • application of periodic follow-up sessions and use of frequent reminders (letters, telephone calls, e-mail messages) to retain an increased awareness level among female workers • dispensation of easily accessible screening services for exposure of employees to reproductive hazards • building a support network for the compliance of individuals with occupational safety practices by appointing safety committees that include female workers at risk for reproductive hazards • organization of group discussions among workers of specific occupational categories to share common experiences and concerns on related issues • projection of specific employees as models of good conduct in osh issues involving reproductive hazards prevention • presentation of statistics on results of exposure level reduction, or outcomes, if available (e.g., reduction on rate of miscarriages) organizational level- • active participation of women employees in the decision-making process concerning applied safety policies in the company • representation of female workers from different occupational sectors within the organization in administrative issues regarding the design of workstations and job tasks, and the introduction of new technologies, materials, and procedures • introduction of incentives for the compliance of employees with safety policies whp professionals should conduct this final diagnostic procedure before the implementation of the prevention program, to determine whether the program's scope and activities are compatible with the administrative and policy framework of the organization. the main issues to be identified at this stage are: • whether the policies and safety regulations related to potential reproductive hazards are in accordance with the program's requirements and the existence of requisite modifications or complementary arrangements • whether the program introduces any interventions that are in conflict with the organization's operational framework • whether the selected form of intervention (information campaign, skill building sessions, group activities) is appropriate for the existing company culture in osh issues • which of the existing structures and activities in the organization are useful to the program's strategic planning. some examples of similar structures and activities are presented in table . . • whether the company's administration is sufficiently flexible to adopt the participatory decision model proposed by the program for the resolution of osh issues • whether the organization's field of activities and operational status allows for alternative practices, procedures, and materials. table . sites an indicative list of similar practices and procedures. . systematic record of occupational medical history of workers . safety committees appointed by company's employees . trade-union department specialized in osh issues for female employees . registry of recognized occupational reproductive disorders . official forms for reporting employees remarks on working conditions and related hazards . detailed registry of materials, substances and processes utilized in each department of the organization (toxicity, carcinogenicity, potential for endocrine disrupting activity) . regular group meetings among workers and administration representatives . periodic screening of working population for hazardous occupational exposures the primary concern of whp professionals in the design of an educative intervention for women workers is to provide a tailored program according to the specific target population and its educational needs. the selection of a specific approach for this educational needs assessment depends heavily on the available resources (staff, time, expenditure limitation) of the program. listed below are some of the available techniques, and the form in which they may be employed, to obtain related information from the female workers' population (national cancer institute a; pfizer ; younger, wittet, hooks & lasher ) : women employees can be accessed individually, either at their worksite or through telephone or internet surveys, to fill in specifically designed questionnaires. some of the questions that may be included in such a questionnaire are listed in table . . this approach involves two-hour sessions of small work groups of six to ten women employees who testify their individual concerns, experiences, and percep- tions on work-related reproductive health issues. the activity takes place under the continuous supervision of an expert facilitator (health professional). the workgroup is selected on the basis of common socioeconomic and ethnic characteristics (e.g., representation of low literate immigrant female workers) as well as their specific job tasks. the application of this technique offers the whp program a more comprehensive insight into the target population profile (younger et al. ) , as well as the specific needs of certain special subgroups of womens workers (e.g., effective approach and training techniques, use of appropriate educative material). women employees are interviewed in the form of open-ended questions, where they are encouraged to identify themselves and their educational needs by trained professionals (instead of being guided by specific queries). even though this technique is the most time-consuming, it offers the most in-depth needs identification (younger et al. ) . these committees are formed by women employee representatives of specific at-risk populations, and consult whp professionals on specific issues related to reproductive health disorders among certain categories of workers, contributing their own experiences and concerns. the ecological model (mcleroy, bideau, steckler & glanz ) that was presented in the first chapter of this book offers the opportunity to identify the determinants of individual behavior within the wider context of social groups or organizations to which a person belongs. this perspective can therefore be useful for implementing comprehensive whp programs addressing specific health issues. analyzing the profile of a specific organization according to the five individual levels of the ecological perspective model-intrapersonal, interpersonal, institutional, community, and policy-one can identify multiple and multi-component potential interventions for the protection of female workers from the main categories of reproductive hazards recognized in the existing literature. at the intrapersonal level, workplace health promotion activities focus on individual skill building for female workers in the form of personal counseling on issues of reproductive health. the general scope of these interventions, some of which are presented in table . , is the introduction of a number of issues including: • identification of occupational reproductive hazards, personal risk factors, and related symptoms • requested behavioral changes towards prevention • skill-building in the correct use of equipment, materials, and safety practices • access to scientific resources and specialized health services workplace health promotion interventions at this level appeal to groups of working women instead of individuals. this stage of whp involves skill-building sessions, team collaboration and support activities, and health education, which may vary in group size or duration according to the educational needs of a specific working population. these groups can be selected according to common epidemiological or social characteristics of the workers (e.g., age, education, ethnicity) to adequately tailor any intervention. table . presents some of the group activities that may take place within the context of whp: cited in table . is a list of available interventions at the institutional (or company) level concerning organizational measures, practices, and policies that may be implemented for the protection of women worker's reproductive health. to implement effective workplace health promotion programs for the protection of female reproductive health, health professionals should not neglect the fact that the female working population in a specific worksite acquires certain characteristics that • group training sessions on radioactive material safe handling, and protective measures against ionizing radiation • group skill-building on stress management techniques, workplace design for the protection of pregnant women employees, safe manual handling methods • group education on infectious agents hazardous for female reproductive health, their transmission pathways, methods for prevention generic: • creation of employee's groups to constitute models of "best practice" and provide a supportive environment for the adoption of safety techniques (or "healthy behaviour") among women workers • creation of idea-exchanging groups, for identification of specific workplace reproductive hazards and special issues of concern for women workers define a community. the main focus of a successful whp project at this level is to incorporate the issue of reproductive health in the safety culture of female workers. this involves organizing targeted group activities for female workers that addresses the problem of reproductive hazard prevention through the community's system of "group norms, inner rules and beliefs" (edlich, winters, hudson, britt & long ) , and create a climate of awareness on issues related to female employees. at this level, workplace health promotion programs involve contacts with stakeholders (trade union members, employee representatives, company executives) and policymakers to propose measures, policies, and legal provisions for the protection of female workers' reproductive health, some of which are listed in table . . whp programs may utilize multiple channels of communication to deliver messages related to women's reproductive health protection. the approach may take various forms (prevention ): • proposals (by health professionals) for specific changes in the production line -substitution of chemical factors which are detrimental for female reproductive health with "safer" compounds • proposals for specific design changes in facilities, to isolate chemical procedures • frequent measurements by health technicians in the workplace to record concentration of chemicals, and identification of high risk population • training of occupational physicians and nurses in: a) identification of chemical reproductive hazards b) available preventive measures c) early diagnosis of reproductive disorders • re-positioning of pregnant employees to reduce potential exposure to chemicals • provision to all staff members of specific company's guidelines on occupational safety and reproductive hazards prevention (official forms, leaflets, electronic mail), as well as standard operating procedures for using chemicals • rotation of workers to reduce potential exposure • definition of a strict company's policy on health protection for non-smokers • placement of warning signs to prohibit smoking in the company • provision of adequate outdoor spaces, and timebreaks for smokers • funding of campaigns and incentives on smoking cessation for employees • proposals for specific design changes (e.g. armoring improvement, isolation of radioactive material) to avoid exposure of personnel to radiation • frequent radiation measurements in the workplace environment to identify potential sources of exposure and high risk employees • provision (to all staff) of specific directives on safe use of radiation emitting equipment (instruction sheets, official forms, leaflets, electronic mail) • re-positioning of pregnant employees to reduce potential exposure. rotation of workers to reduce potential exposure • proposals to administration to conduct adequate modifications in ergonomic design and provision of special equipment table . (continued) potential hazard intervention opportunities • proposals to administration for the introduction of specific safety regulations concerning female employees (especially during pregnancy): a) time-schedule modification, b) maximum working hours, c) mandatory time-breaks, d) provision of sick-leave days, e) maximum allowed weight for manual handling, f) re-positioning of pregnant employees, g) zero-tolerance policy on aggressive behavior against employees • providing staff with the organization's safety guidelines for preventing physical strain (instruction sheets, official forms, leaflets, electronic mail). rotation of workers to reduce physical strain • provision to all staff of educative material on potential effects of infectious agents to female reproductive health • introduction of collective safety guidelines for all health-care personnel • provision of adequate safety equipment to prevent accidental transmission of infectious agents (safety syringe mechanisms, syringe disposal vessels, goggles, masques, gloves) • extensive vaccination program for child-bearing age personnel (health care workers, teachers, nursery workers) lectures constitute single courses or one-shot education interventions (prevention ) providing general information on the topic of occupational reproductive hazards for women (risk factors, generic preventive measures). presentations and lectures may be used as well to carry health messages among the staff in an effort to establish general acceptance and support for the company's pertinent safety regulations and policies. (lawson et al., ) • systematic occupational exposure assessment to identify high risk female employees • proposal for legislative regulation to substitute hazardous agents with "safer" chemical compounds • promotion of scientific research on gender specific reproductive issues for female workers • obligatory reproductive health surveillance of women workers in high risk for reproductive disorders • systematic registry of birth defects according to maternal occupational exposures • production of specifically designed protective equipment for female workers this form of communication is able to provide wide-scale access to the population of working women (e.g., access to agricultural workers in distant areas, low-literacy skill employees) through billboards, magazines, and newspapers published by the company, or items of special interest to certain professional sectors, such as leaflets referring to reproductive safety issues. health professionals may utilize this channel to address generic guidelines for prevention on issues of reproductive health either to female workers themselves or to their coworkers, which may effect women employees through their tasks or behavior (e.g., men employees smoking indoors, safe storage or handling of hazardous chemicals in the workplace). this form of health promotion is based on establishing an interactive information service for the prevention of occupational reproductive disorders (prevention ) . this service should incorporate a telephone center with the ability to provide personal telephone counseling to women employees, as well as a hotline for answering women's questions concerning reproductive health issues. furthermore, this service should develop an electronic library, accessible through the internet, for all female workers and the general public, providing official safety guidelines for reproductive hazards and answers to related questions. finally, it enables continuous sensitization of high-risk female employees through frequent electronic reminders and their activation in safeguarding their reproductive health. media has proven to be one of the most effective communication channels for many health issues and health promotion activities. it can be utilized to address messages on a larger scale, mostly by health professionals who work in workplace health promotion programs on community, national, or european level. it uses public announcements, short messages, and commercials to address reproductive health hazard prevention issues through radio, television, and newspapers. in some cases, this form of health promotion may be useful for approaching female workers who are not easily accessible by other workplace health promotion programs, such as occupations in small enterprises, part-time employment, and female agricultural workers in remote areas. • violent behavior intense psychological stress (artazcoz lazcano, cruz i cubells, moncada i lluis, & sanchez miguel exposure to ionizing radiation (x-ray & computed tomography departments, nuclear laboratories, patients treated with radioactive drugs) anaesthetic gases, cytotoxic drugs • infectious diseases airborne, blood borne • dermatitis (allergic, irritative) • disturbance of the regular circadian -metabolic rhythm gimeno, felknor, burau, & delclos, ) and micro particles indoor air quality and health in offices and other non-industrial working environments prevalence and risk factors of occupational asthma among hairdressers in turkey incidence of asthma in female swedish hairdressers current findings about the development of obstructive airway diseases in hairdressers (bk numbers: / ) women's occupational dermatologic issues associations of self estimated workloads with musculoskeletal symptoms among hospital nurses combining job and family demands and being healthy: what are the differences between men and women? gender inequalities in health among workers: the relation with family demands stress and work-related tension in the nurses and clinical aides of a hospital predictors of early leaving from the cotton spinning mill environment in newly hired workers interdigital pilonidal sinus in a hairdresser self-assessed and directly measured occupational physical activities-influence of musculoskeletal complaints, age and gender evaluation of reports of periconceptual occupational exposure: maternal-assessed versus industrial hygienist-assessed exposure work-related obstructed airway diseases by irritative noxae in the low concentration range evaluation of occupational environment in two textile plants in northern india with specific reference to noise noise exposure of music teachers laundry workers: cleaning up an industry. we can do it: protecting women workers hazardous substances in the air at hairdressers' workplaces work-related musculoskeletal disorders in hairdressers the hazards of surgical smoke. not to be sniffed at! british journal of perioperative nursing : the journal of the neck and shoulder ailments in a group of female industrial workers with monotonous work ergonomic scissors for hairdressing heat exposure standards and women's work: equitable or debatable? women health cadmium induces mitogenic signaling in breast cancer cell by an eralpha-dependent mechanism a pharmacokinetic study of occupational and environmental benzene exposure with regard to gender occupational exposure to endocrine-disrupting pesticides and the potential for developing hormonal cancers occupational hazards of inhalational anaesthetics effects of long term exposure to occupational noise on textile industry workers' lung function dna damage and tnf(alpha) cytokine production in hairdressers with contact dermatitis risk evaluation and health surveillance in hospitals: a critical review and contributions regarding experience obtained at the s. gerardo dei tintori hospital in monza health care providers and professional hazards promoting personal safety of building service workers: issues and challenges. aaohn journal : official journal of the american association of occupational health nurses workstation design in carpet hand-weaving operation: guidelines for prevention of musculoskeletal disorders nurses confronting sexual harassment in the medical environment musculoskeletal disorders in hotel restaurant workers mortality among us employees of a large computer manufacturing company factors influencing restaurant worker perception of floor slipperiness handle with care: the american nurses association's campaign to address work-related musculoskeletal disorders prioritizing safe patient handling: the american nurses association's handle with care campaign epidemiology of voice problems in dutch teachers cross-sectional investigation of task demands and musculoskeletal discomfort among restaurant wait staff work-related violence and the ohs of home health care workers working in clients' homes: the impact on the mental health and well-being of visiting home care workers. home health care services quarterly health hazards of ceramic artists occupational contact urticaria and protein contact dermatitis are health care providers who work with cancer drugs at an increased risk for toxic events? a systematic review and meta-analysis of the literature prevalence of voice disorders in african american and european american preschoolers prevention of disabling back injuries in nurses by the use of mechanical patient lift systems gender issues in safety and health at work -a review. luxembourg: office for official publications of the european communities european agency for safety and health at work ( b) including gender issues in risk assessment [electronic version mainstreaming gender into occupational safety and health. luxembourg: office for official publications of the european communities eurostat ( ) european social statistics: labour force survey results : office for official publications of the european communities fjellman-wiklund a, brulin c, and sundelin g ( ) physical and psychosocial work-related risk factors associated with neck-shoulder discomfort in male and female music teachers prevalence of sensitivity to rubber additives and latex in hairdressers with hand and/or forearm contact dermatitis diagnostic approach and management of occupational asthma by persulfate salts in a hairdresser. allergy and asthma proceedings : the official journal of regional and state allergy societies sex differences in pharmacokinetics and pharmacodynamics pesticide exposure and women's health adequacy of vaccination coverage at school-entry: cross-sectional study in schoolchildren of an urban population pulmonary fibrosis and ferruginous bodies associated with exposure to synthetic fibers the precede-proceed planning model organisational and occupational risk factors associated with work related injuries among public hospital employees in costa rica bad nights or bad bars? multi-level analysis of environmental predictors of aggression in late-night large-capacity bars and clubs health promotion planning: an educational and environmental approach knowledge, attitude and practices among health care workers on needle-stick injuries high rubella seronegativity in daycare educators fit factors for quarter masks and facial size categories the risk of adverse reproductive and developmental disorders due to occupational pesticide exposure: an overview of current epidemiological evidence traumatic injuries in agriculture haz-map ( b) cadmium and compounds. occupational exposures to hazardous agents retrieved glycol-ethers. occupational exposure to hazardous agents occupational exposure to sevoflurane, halothane and nitrous oxide during paediatric anaesthesia. waste gas exposure during paediatric anaesthesia chemical exposure in hairdresser salons: effect of local exhaust ventilation gender differences in self-reported physical and psychosocial exposures in jobs with both female and male workers quantification and risk analysis of occupational burns: oregon workers' compensation claims, to environmental factors in infertility risk factors for neck pain in office workers: a prospective study allergic contact dermatitis in hairdressers: frequency and source of sensitisation professional cleaning and asthma office work, sbs and respiratory and sick building syndrome symptoms garlic-related dermatoses: case report and review of the literature principal results occupational allergic contact dermatitis from spices a multicentre review of the hairdressing allergens tested in the uk occupational risk for hepatitis a: a literature-based analysis exposure assessment in epidemiology: does gender matter? development of hand eczema in hairdressers, to years after the start of training -a follow-up study of "posh-studie" participants perilous work: nurses' experiences in psychiatric units with high risks of assault industrial sectors with high risk of women's hospital-treated injuries risk factors for voice problems in teachers an analysis of occupational dysphonia diagnosed in the north-east of poland do teachers have more health problems? results from a french cross-sectional survey work practice and some adverse health effects in nurses handling antineoplastic drugs case report: occupationally related recurrent varicella (chickenpox) in a hospital nurse characterization of chemical exposures in hairdressing salons printed circuit board industry perceiving classroom aggression: the influence of setting, intervention style and group perceptions workgroup report: implementing a national occupational reproductive research agenda-decade one and beyond gender differences in the healthy worker effect among synthetic vitreous fiber workers voice symptoms of call-centre customer service advisers experienced during a work-day and effects of a short vocal training course respiratory illness in agricultural workers making manufacturing a safe work environment for women workers. we can do it: protecting women workers evaluation of the exposure to biomechanical overload of the upper limbs and clinical investigation in a female population employed in the manual loading of production lines in ceramics factories noise exposure and hearing loss in agriculture: a survey of farmers and farm workers in the southland region of new zealand an investigation of contact transmission of methicillin-resistant staphylococcus aureus women in agriculture: risks for occupational injury within the context of gendered role male and female rate differences in carpal tunnel syndrome injuries: personal attributes or job tasks? the "gras" status of women's work sex matters: exploring differences in responses to exposures an ecological perspective of health promotion programs workplace violence in health care: recognized but not regulated sex, gender and women's occupational health:the importance of considering mechanism ovarian intrafollicular processes as a target for cigarette smoke components and selected environmental reproductive disruptors the effect of health education in promoting health of hairdressers about hepatitis b based on health belief model: a field trial in yazd carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners occupational asthma among hairdressers occupational asthma and occupational rhinitis in hairdressers energy cost of physical task performance in men and women wearing personal protective clothing rubella infections of the school teachers in sapporo municipal schools after their employment adapting osha ergonomic guidelines to the rehabilitation setting theory at a glance: a guide for health promotion practice theory at a glance" a guide for health promotion practice how is sex considered in recent epidemiological publications on occupational risks? muscle pain, physical activity, self-efficacy and relaxation ability in adolescents gender inequalities in occupational health: harvard school of public health accidental exposure to biological risk among health care workers of a sanitary area prevalence of occupational hand dermatitis in u.k. hairdressers noise and chemical induced hearing loss: special considerations for farm youth pfizer principles for clear health communication nd edition agents causing occupational asthma in finland in - : cow epithelium bypassed by moulds from moisture-damaged buildings sex and gender factors in medical studies: implications for health and clinical practice lik sprava safe handling of hazardous drugs needlestick injuries among health care workers. a literature review designing and evaluating intervention plans evaluating cdc-funded health department hiv prevention programs occupational risky business: injury prevention behaviors of farm women and children using the precede-proceed model to increase productivity in health education faculty [electronic version unconsumed precursors and couplers after formation of oxidative hair dyes labour market latest trends - rd quarter data active epidemiological surveillance of musculoskeletal disorders in a shoe factory histology and pathology laboratories. chemical hazard prevention and medical/health surveillance musculoskeletal dysfunction in physical education teachers physical work load in physical education teachers barber's hair sinus in a female hairdresser: uncommon manifestation of an occupational dermatosis framing personal risk in public health nursing the prevalence and risk factors for occupational voice disorders in teachers glutaraldehyde exposure and its occupational impact in the health care environment contact dermatitis to hair dyes in a danish adult population: an interview-based study division of labor standards and safety, occupational safety and health ( ) the manager's handbook: a reference for developing a basic occupational safety and health program for small businesses women, work and musculoskeletal health occupational voice disorders: an analysis of diagnoses made and certificates issued in - exposure to cooking fumes in restaurant kitchens in norway effects of glutaraldehyde exposure on human health occupational risk factors associated with voice disorders among teachers health risks of occupational exposure to anticancer (antineoplastic) drugs in health care workers assessment of dna damage in nurses handling antineoplastic drugs by the alkaline comet assay assessment of dna damage in nurses handling antineoplastic drugs by the alkaline comet assay visual problems among electronic and jewelry workers in thailand association between occupational asthenopia and psycho-physiological indicators of visual strain in workers using video display terminals please put this in the proper format and move this reference to its alphabetical place in the "p's" weaver vm secondary individual prevention of occupational skin diseases in health care workers, cleaners and kitchen employees: aims, experiences and descriptive results. int arch occup environ health williams nr ( ) occupational groups at risk of voice disorders: a review of the literature chemical occupational risks identified by nurses in a hospital environment work-related musculoskeletal disorders and associated factors in teachers of physically and intellectually disabled pupils: a self-administered questionnaire study seroprevalence of varicella, measles and hepatitis b among female health care workers of childbearing age immunization and child health materials development guide zidkova z and martinkova j ( ) psychic load in teachers of elementary schools key: cord- -c xypzdx authors: alahmad, barrak; kurdi, hussam; colonna, kyle; gasana, janvier; agnew, jacqueline; fox, mary a title: covid- stressors on migrant workers in kuwait: cumulative risk considerations date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: c xypzdx as a marginalised subpopulation, migrant workers often fall short from protection by public policies, they take precarious jobs with unsafe working and living conditions and they grapple with cultural and linguistic barriers. in light of the current covid- pandemic, migrant workers are now exposed to additional stressors of the virus and related responses. we applied a comprehensive qualitative cumulative risk assessment framework for migrant workers living in kuwait. this pandemic could be one of the few examples where the stressors overlap all domains of migrant workers’ lives. no single intervention can solve all the problems; there must be a set of interventions to address all domains. local authorities and employers must act quickly to stop the spread, ensure easy access to testing and treatment, provide adequate housing and clear communication, encourage wide social support, safeguard financial protection and mental well-being and continuously re-evaluate the situation as more data are collected. background nearly . % of the world's population lives outside their home country, and half of them are estimated to be migrant workers. in many countries, migrant workers are recognised as one of the most vulnerable subpopulations, as they: ( ) often are excluded from protections provided by public policies; ( ) frequently take precarious jobs with less pay and longer hours; ( ) often work in unsafe working conditions with little occupational safety and health (osh) training; and ( ) grapple with major cultural and language barriers. on march , the who declared that the infectious covid- outbreak caused by the severe acute respiratory syndrome coronavirus , is a pandemic. since its initial cluster of pneumonia cases in wuhan, china, the virus has infected millions and caused hundreds of thousands of deaths globally. migrant workers are particularly susceptible to this infection-an additional stressor combined with those identified above. understanding the detrimental effects of covid- alone on workers' health may not be sufficient. recent osh risk assessment frameworks and methods have advanced towards cumulative risk assessment (cra). these cumulative frameworks recognise that an occupational exposure to a contagion like covid- does not occur in isolation from other stressors. in light of the current pandemic, we anticipate that employers and authorities must now address the variable job health and safety needs of migrant workers. in kuwait, there is a considerable heterogeneity with regards to vulnerable employment and extreme working poverty. non-kuwaiti migrant workers make up more than % of the total population and are mostly employed in low-skilled sectors and domestic work. about % of non-kuwaitis are males, and only % of non-kuwaitis have educational attainment of high-school or higher. the majority of the migrant non-kuwaiti subpopulation come to the country unaccompanied by their families. striking differences in health outcomes attributable to bmj global health environmental exposures such as heat and air pollution between the kuwaiti and the non-kuwaiti subpopulations have been recently documented. this work investigates the multiple stressors associated with the covid- pandemic on migrant workers by applying a holistic cra framework, using kuwait as an example. furthermore, we use the framework to suggest potential interventions for individuals, employers and authorities to improve the health of migrant workers in the country. the conventional risk assessment process is typically applied to address one hazard at a time. in reality, workers are often exposed to multiple hazards at any given time. the us environmental protection agency defines cumulative risk as 'the combined risks from aggregate exposures to multiple agents or stressors'. in this paper, we will apply a workplace cra framework that was presented by fox et al. in brief, the framework acknowledges that multiple stressors in different domains can interact with each other resulting in cumulative risk that can then be used to inform new risk management approaches, exposure reduction and prevention strategies. the model assumes that stressors arise from four dynamic interactive domains: the workplace (occupational); ambient environment; individual (behaviour and genetic); and community (family and other social interactions) ( figure ). this cra framework will provide a qualitative evaluation of multiple stressors affecting migrant workers in kuwait (table ) . we apply the framework in a stepwise process starting with identifying the importance and scope of the problem, that is, why it should matter and who should care (step ). steps - assess the target population, the stressors/hazards, the overall pattern of health among the target population and consider the interactions between stressors and the domains. finally, we propose potential interventions in light of the findings from the previous steps (step ) . the first confirmed cases in kuwait occurred on february , among four kuwaiti passengers who arrived on an evacuation flight from iran. since then, more than % of the total cases have been non-kuwaiti nationals (https:// corona. e. gov. kw/). the situation is not much different in other gulf states. uncontrolled outbreaks within clusters of migrant workers can result in catastrophic outcomes including the loss of many lives, an overwhelmed healthcare system and other deleterious economic losses. however, even if the spread of the infection is controlled, enforced lockdowns and business closures can have dire consequences for migrant workers. most migrant workers in kuwait are men from south and southeast asia. examples of essential non-healthcare migrant work in kuwait include staffing in the retail and food, transportation, security and construction industries. these workers are continuously interacting with the rest of their community and may potentially contract the disease from infectious individuals. migrant workers who are in non-essential businesses that remain closed could figure a cumulative risk assessment framework for occupational health and safety with four overlapping domains described by fox et al. the occupational domain (highlighted) cannot be viewed in isolation from other domains. bmj global health be living in labour camps outside the city or in other cramped dormitories. the workplace several dangerous trades occupied by migrant workers present health threats from chemical and physical exposures, often existing as mixtures or in combinations. issues associated with these hazards can be significantly amplified among migrant workers due to language and cultural barriers. as a consequence, the effectiveness of any occupational prevention measure (eg, work practices and wearing personal protective equipment) can be compromised. language barriers also make it difficult for migrant workers to report symptoms or raise concerns with their managers. training on measures such as social distancing and/or hygiene instructions may not be supported for the typical wide range of languages among worker populations. a large proportion of migrant workers in kuwait live in cramped dormitories with poor housing conditions: small rooms with tens of men living together; unmaintained and shared toilets; poor or no ventilation; and high risk of bed bugs and other pests. such environments with consistent close proximity among occupants have the potential to increase covid- outbreaks among migrant workers. in addition, there are environmental exposures like heatwaves and air pollution that can independently increase vulnerability and promote comorbidities; migrant workers in kuwait have been shown to be especially vulnerable to air pollution. the community nearly % of the non-kuwaiti subpopulation are males. the majority are not accompanied by their families. their distant families rely on them for financial support (eg, transferring money and shipping goods) to meet basic needs such as paying school fees and getting food. for many households in the receiving countries, money from migrant workers is likely the sole source of cash. however, migrants are often employed in less secure or precarious jobs with no permanent employment contract. this imposes significant job uncertainty. the current pandemic undoubtedly has compounded severe financial hardship and interpersonal difficulties within families who may not be able to survive job loss or delayed payments. returning home is rarely an option. during the covid- induced lockdowns, migrant workers will likely face mounting debts, unemployment and difficulties in daily living. the lockdowns in workers' home countries have had enormous negative impacts on daily wages of labourers who were unable to earn their daily living and were not able to move. these stressors are difficult to address since the political climate in the host country may also bring about xenophobia, suspicion and unequal rights. the current immigration system in kuwait and other gulf states (the kafala system) requires all migrant workers to have an in-country sponsor for their visa and legal status. this system restricts changing employers and has been associated with trafficking and forced labour. it is unlikely that workers would have an option to transfer to jobs with less risk of exposure to covid- . although a large proportion of migrant workers in kuwait are young and healthy, those living with comorbidities, some of which might be due to work-related illnesses or injuries, may be more vulnerable to the effects of covid- . we do not have data on the prevalence of unhealthy behaviours that can increase the risk of severe covid- illness, such as smoking or diet. furthermore, there might be difficulty accessing healthcare due to documentation status, limited knowledge of health coverage, costs and poverty. without serviceable command of the local language, migrant workers were found to be likely to take more dangerous jobs and incur occupational injuries. additionally, the constantly changing covid- lockdown and curfew messages may not reach migrant workers, putting them in legal jeopardy. violating curfew is a serious offence in kuwait that could lead to deportation for non-nationals. in addition, migrant workers experience difficulty communicating with medical professionals, have little knowledge of the health insurance systems and report lack of access to interpreters. all these factors contribute to low turnout at testing stations and treatment centres for covid- . in addition, such barriers to healthcare utilisation may result in delayed presentation for a number of days before seeking help, likely affecting the severity of outcomes from the infection. there have been numerous reports of person-to-person transmission of covid- within the same household. high air exchange rates, proper use and disinfection of toilets, and open spaces were associated with lower aerosol transmission of covid- . self-isolation is nearly impossible. people living in areas with high outdoor air pollution levels were shown to be at higher risk of dying from covid- . although social lockdowns have substantial positive impact on the overall environment and air pollutants, especially no and particulate matter, it is unclear how this reduction in short-term exposure can translate into public health gains for migrant workers. individuals with low educational attainment and low income are more likely to be exposed to factors contributing to poor health compared with those with more socioeconomic resources. additionally, stress from the uncertainty of precarious jobs and fear of job loss or deportation can have negative mental health outcomes. other mental disorders can also be exacerbated by financial hardship for migrant workers who are no longer able to send money to their families because of the lockdown orders. beyond mental health, stress is also associated with premature death and coronary heart disease. with regard to behavioural factors, there is some evidence that smoking is associated with poor progression and health outcomes from covid- exposures. cra considerations even when we only focus on the health impacts of covid- on workers in the occupational domain, we saw a strong influence from other related stressors originating from sources across all domains. considering figure , covid- adds to the existing serious health risks experienced by migrant workers in kuwait. put another way, this pandemic could be one of the few examples where the risk overlaps all aspects of migrant workers' lives (as seen in shaded area - figure ). no single intervention can solve all the problems outlined; rather, a set of interventions that address all domains is in order. we propose a holistic approach to this multidimensional problem for the migrant workers in kuwait, consistent with the global call to action to protect migrant health from covid- . stop the spread (community/individual) the prevalence and incidence of infection among migrant workers are not known. kuwait has taken many public health control measures to stop and slow down the spread of covid- , including closures of schools and universities, closures of all non-essential businesses, a full border lockdown and a partial curfew. when the disease started spreading in areas populated by migrant workers, the government enforced zonal isolation. outreach to migrant worker communities to educate about the symptoms of illness and its prevention and active public health surveillance efforts are needed to identify cases at an early stage and prevent the progression to severe illness as well as reduce the number of people who could potentially get infected. ideally, health authorities would employ testing to further understand the distribution and the spread of the disease although capacity to test remains limited in many places. absent testing, monitoring hospitalisations and deaths linked with contact investigations help identify and move cases into treatment. healthcare access (community/individual) migrant workers should have free access to testing and treatment for covid- . easy-access facilities should include drive-through and walk-in testing. these are alternative solutions for temporary testing operations that can reduce patient-provider exposure and accelerate test administration. for example, large segments of the migrant workers subpopulation may not have access to cars; therefore, a walk-in testing booth is an appropriate option. similarly, mobile clinics and field hospitals in underserved areas can be very important to protect vulnerable marginalised groups from covid- . free health services including health education, screening and advice can be provided by mobile clinics. workers who do not live near hospitals and do not have access to adequate transportation can benefit the most. in addition, unlawful migrant workers may be reluctant to report symptoms or access testing facilities because they fear detention and deportation. this reluctance can carry a significant risk to the health of these workers and that of the community. in the short term, let public health take precedence over enforcement; immigration authorities should send clear messages to encourage unlawful migrant workers to get covid- tests and report symptoms. temporary housing (workplace/environment/community) many workers may not be able to effectively self-isolate should they test positive for covid- . in cases where housing conditions cannot be adjusted to new social distancing protocols, the government has to work with employers to consider some form of separate temporary housing for migrant workers who test positive. these include hotels and other temporary housing on work sites. moving forward, the authorities need to create a long-term plan to improve the living facilities for all workers. information access (workplace/community) migrant workers may be at risk of being penalised for unknowingly breaking curfew laws. the government must work with the relevant embassies to provide workers with information on covid- in a language they understand. similarly, employers must have training programmes that incorporate methods that transcend linguistic and cultural barriers such as pictograms, illustrations and hands-on exercises. worker protection (workplace/community) many workers are now facing layoffs, furloughs, nonpayment and late payment of wages putting them in significant financial hardship. the government and employers should reach some mutual agreement to continue paying workers living in isolated zonal areas or under health quarantine. any gaps in financial support to workers should be adequately covered. community support (environment/community/individual) many individuals and organisations are putting in enormous time and effort to provide relief for migrant workers in kuwait. community volunteers, charity organisations, donors and non-profit organisations should come together to raise funds to cover basic necessities for migrant workers such as meals, masks and sanitary supplies. community support can go beyond daily essentials towards mental well-being of workers through implementing mental health programmes, provision of internet connectivity and prepaid phones for worker to contact their families. continuous evaluation (all domains) implemented policies must be continuously reassessed in light of the fast-changing situation and new data. it is key that policy evaluation is carried out at a high temporal (daily monitoring) and spatial (household level) resolution. that is, there should be careful monitoring of the number of new confirmed cases, deaths, hospitalisations and admissions to intensive care among migrant workers. furthermore, geospatial mapping of cases through geographic information systems are critical for identifying emerging clusters. migrant workers are a marginalised subpopulation in kuwait. they often fall short of protection by public policies, face language and cultural barriers and take precarious jobs with more hazards, less pay and longer hours. the covid- pandemic has placed multiple extraordinary stressors on migrant workers in kuwait both on and off the job. we applied a cumulative risk assessment framework that enabled us to assess stressors on migrant workers in the workplace, environment, community and individual domains. we used the framework to inform new risk management approaches and exposure reduction strategies that address these multiple stressors. although our assessment lacked quantitative data, we highlighted the type of data that would be needed to ensure continuous re-evaluation. this may be resource intensive (money, people and time), but a coordinated effort aimed at key social supports will have substantial health benefits for the entire community. this cumulative risk assessment framework for migrant workers in kuwait can be applied in other countries and different settings. twitter barrak alahmad @barrak ilo global estimates on migrant workers: results and methodology. geneva: international labour office migrant workers and their occupational health and safety implications of applying cumulative risk assessment to the workplace the public authority for civil information. government of kuwait extreme temperatures and mortality in kuwait: who is vulnerable? acute effects of air pollution on mortality: a -year analysis in kuwait framework for cumulative risk assessment inter nation social lockdown versus medical care against covid- , a mild environmental insight with special reference to india trafficking and contract migrant workers in the middle east do immigrants work in riskier jobs? a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster aerodynamic analysis of sars-cov- in two wuhan hospitals exposure to air pollution and covid- mortality in the united states nurture to nature via covid- , a self-regenerating environmental strategy of environment in global context socioeconomic status and health. the challenge of the gradient effects of social determinants on chinese immigrant food service workers' work performance and injuries: mental health as a mediator the neglected health of international migrant workers in the covid- epidemic stress and cardiovascular disease covid- and smoking: a systematic review of the evidence sex difference and smoking predisposition in patients with covid- global call to action for inclusion of migrants and refugees in the covid- response the impact of language and culture diversity in occupational safety competing interests none declared.patient consent for publication not required.provenance and peer review not commissioned; externally peer reviewed.data availability statement no additional data are available.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /.orcid id barrak alahmad http:// orcid. org/ - - - key: cord- -znbqpwgu authors: aye, baba title: health workers on the frontline struggle for health as a social common date: - - journal: development (rome) doi: . /s - - -z sha: doc_id: cord_uid: znbqpwgu through the lens of health workers’ concerns, the article interrogates the impact of the neoliberal turn of the s on the loss of the ideal and pursuit of health as a social common. it highlights the great recession as a confirmation of the failure of the neoliberal project but notes that this the project continues with even greater frenzy. capturing the dynamics which inhibit the world health organization, it calls for mass mobilization to reclaim health as a social common. health workers have been the first line of humankind's defence against the rampaging incursion of the microbial world, in the shape of sars-cov- . they have received accolades from peoples and governments alike. in many european cities, people would come out on their balconies at a designated time every evening to shout in honour of health and social care workers. governments as well, joined this chorus, without government officials batting an eye. many questions were not considered or were left unanswered as the waves of applaud came. why were health and social care workers saddled with so much work such that many were running insane shift periods? why was there a global shortage of personal protective equipment (ppe) for so long? how seriously were decision-makers taking the important need to safeguard the health of those taking care of our health in this pandemic? some of these questions have been raised in several ways in the literature in this turbulent year. this tends to be as part of attempts to understand why the pandemic happened and how can a similar situation be avoided in the future. finding answers for these questions requires our grasping the root of the problem. it is the primacy of for-profit interests in health which undermine the provision of health as the fundamental human right and social common which it is meant to be. health, including that of the health and social worker has become a commodity. tons of applauses without systemic change, ushering in a post-neoliberal world would be empty. crises like the present pandemic present opportunities for structural change. health workers are on the frontline delivering much needed care across the world. they are also on the frontline of struggle to bring about such systemic change. this article contextualizes the problem by putting neoliberal health reforms in perspective. it then looks at efforts of health workers roles in the current period, despite daunting challenges and tries to understand why the best intentions of the world health organization might not be enough to ensure the realization of its mandate. it then concludes with a return to a fundamental point made in the alma ata declaration -a pressing need for a new global social compact, for health as a common to become reality. 'since the s, neoliberal health and social welfare policies around the world shifted resources from the public to the private sector'. this has had adverse effect 'on the wellbeing of health and human service care workers' as well as patients (abramovitz and zelnick : ) . health workers have faced increasing work intensity and less control on the job, leaving them 'emotionally and physically depleted'. high levels of on-the-job stress and burnout became a regular feature of their lives. this ideologically-driven decline of public expenditure in healthcare; privatization of healthcare services, and; dismantling of public health infrastructures (navarro : ) , went on overdrive from the end of the s as the fall of the soviet empire paved way for capitalist triumphalism of the neoliberal order, best captured with fukuyama's vision of the 'end of history' at the time (fukuyama ) . radical changes were made in the public sector as new public management (npm) became the norm in western countries, rolling back the welfare state of the post-world war ii order. the rights-based essence of public service delivery was eroded, in fact, if not always in words. along with privatization, cost cutting measures became engrained in the public sector in imitation of the supposedly inherent efficiency of the private sector. healthcare delivery was not spared. on the contrary health, as one of the fastest growing sectors of the economy (in an age where the value of everything was considered only as its worth in dollars or euros), was a major target of the neoliberal anti-public sector reforms. this was pushed through with a flurry of 'health reforms' which entailed marketization of healthcare delivery. the presence and influence of for-profit interests in health and social care grew exponentially. global healthcare companies, big pharmaceuticals and insurance firms grew in numbers, wealth, and influence. with the use of outsourcing, contracting out and diverse forms of public-private partnerships, they latched onto public health systems, milking it of resources. an increasing number of workers delivering health and social care in public health systems became fixedterm contract staff. as the welfare state was being rolled back in the west, the developmental-interventionist state which had been able to prioritize healthcare delivery was also being smashed in the developing world. international financial institutions played a key role in this. many countries were embroiled in debts after a series of economic setbacks in the s from the oil crisis to the volcker shock. as they turned to the international monetary fund and world bank in the s, they were slammed with structural adjustment programmes. and while imf loans are officially meant to help member countries tackle balance of payment problems, the conditionalities that went with these included setting caps on public sector employment. these ceilings have been identified as key impediments to hiring or retaining health sector workers, and are linked to medical "brain drain" as health workers migrate in search of better employment opportunities (kentikelenis : ) the great recession at the end of the s demonstrated the failure of neoliberalism in practice. but to reassert the resultant dent of neoliberal hegemony, governments stuck even more religiously with the ideology of this failed god. instead of less, we had more neoliberalization of health and care as well as social life as a whole. fiscal discipline was pushed through with austerity measures, as governments and international finance institutions did all they could to make working-class people bear the cost of economic recovery, while bailing out corporations whose profit maximization led to the crisis. the public wage bill was either cut or had caps put on it in out of by (ortiz et al. ) . health and social workers were particularly hard hit. for example, a guardian survey showed that nhs staff were the 'most stressed public sector workers' in britain. this is not surprising, as they are 'under-resourced and definitely understaffed' as one of the respondents of the survey said. and on top of that, they are underpaid. their wages were frozen for years and after that, wage increases were capped at % for another year until . the case in greece was no better. the salaries of healthcare workers were cut twice in . first by % in january and then by another % in june (economou et al. ) . in a world where profit had become god, with productivity and 'efficiency' its trusted servants, increases in health sector wages were considered at best as a cost disease (baumol and bowen ). but, as the pandemic shows quite clearly, reducing the value of human labour to the economic logic of productivity does great injustice to workers concerned and our collective humanity. to roll back the commodification of health and devaluing of the labour of healthcare requires holistic root and branch radical reforms aimed at enthroning universal public healthcare. the pandemic met a global health workforce that was understaffed, underpaid, under-resourced and overstressed. but health workers rose to perform what was close to miracles, putting their lives at risk to save lives. with their lived experiences at a critical hour for humankind, they demonstrated and emphasized the social commons that health in its essence is. from the doctors and scientists in china who dared local party officials to get information out on the new coronavirus, to the indian nurses and doctors who wore diapers to save personal protective equipment which was in short supply health workers demonstrated courage and self-sacrifice. marketization of healthcare prepared the ground for hospitals that felt like war zones as surges spiked in different countries. like the polish cavalry charge at krojanty in , ill-equipped though they have been, healthcare workers bought humankind time as much as they could, in the face of the rampaging sars-cov- . the task was made the more difficult by a number of interrelated causes within the neoliberal paradigm which had informed health reforms over the decades. the privatization of healthcare was one of such key determinants. analysis covering countries for example, that preponderance of private provision of healthcare as well as cross-cutting policies such as 'reduction in the number of hospital beds per people' result in significantly higher 'rates of covid- prevalence and mortality across countries' by up to . % and . % respectively (assa and calderon : ) . this analysis was concerned more with the direct impact of privatization and cuts in public hospitals beds on the higher risks of covid- prevalence and mortality. we need to also consider the indirect impact. the plummeting of public health investment in europe since contributed to increasing pre-existing health states which predisposed persons to being infected. for example, public health spending in england fell by £ m since . this might have 'caused , deaths and a rise in chronic conditions like diabetes, that incidentally also make you more likely to die from covid- ' (mackenzie : ) . as several former and serving united nations special rapporteurs point out, the pandemic exposes the catastrophic impact of privatizing vital services such as water and sanitation, and health. the social and economic determinants of health are as much part of the fabric of our collective humanity which should not be left to the determination of market forces. the consequences of the reign of such corporations over our social commons, as the pandemic shows, could be disastrous. the global shortage of ppe was a stark case of an emergency within the global health emergency. but it did not just happen. it speaks to how global supply chains have evolved to best serve profit maximization as the first law of social production, which explains why governments across the world were not prepared in several other ways, when the pandemic broke out. one of the lessons from the - sars outbreak was that ensuring the health of health workers and preparing for surge capacity must be accorded priority, to avert the worst impact of epidemic outbreaks. and several simulation exercises which should have informed governments and the international community to look beyond the logic of on-time production to ensure consummation of these priorities. these include nhs england's exercise cygnus which showed lack of crisis preparedness of the british government for a flu pandemic. the who's r&d blueprint for action to prevent epidemics' disease x in should likewise have also served as caution for stockpiling ppe. but, with for-profit interests upping policy formulation that puts people first, why keep capital expended on such essential equipment tied down before a pandemic's pandora escaped from its box? this demonstration of 'savage capitalism', as noam chomsky puts it, was not just passive in terms of not having needed medical devices ready, it was also active. as chomsky informs, drawing lessons from the ebola outbreak in , the obama administration entered a contract to make 'high-quality, low-cost ventilators' available for such eventualities as now befall the world was sabotaged by a corporation which bought the original smaller company contracted, because 'it was competing with their own expensive ventilators'. but while neoliberal hegemony continues to hold sway, pushing the maxim of there being no such thing as social commons, the pandemic forced the hands of several governments to take radical and far-reaching actions to safeguard the social commons, in the early months of the pandemic. these included the requisitioning of private hospitals, conversion of factories to produce needed medical devices, supplies and ppe. this was however not with the spirit of ubuntu which health workers demonstrated. these temporary measures did not necessarily amount to taking the private health facilities into public hands or their 'nationalization' as sensationalized in the press. there is a pressing need to go beyond the limited and feeble demonstrations of government's turn to seeming consideration of health as a social common, and only so during emergencies like the covid- pandemic. founded in as part of the multilateral united nations system, the world health organization has a mandate 'to act as the directing and co-ordinating authority on international health work' towards achieving the objective of 'the attainment by all peoples of the highest possible level of health' (who ) . from the s when the world bank delved into lending to the health sector on a large scale, this leading role of the organization has been challenged (clift ) . the rise of diverse global health initiatives over the last few decades have accelerated this whittling of who's real powers. and relatedly, its increasing reliance on voluntary contributions, including-indeed increasingly more-from philantrocapitalist foundations. this has severe long-term implications. these 'nonstate actors' influence has helped to consolidate the hold of private interests on the health system internationally and in countries across the world leading to; undermining of accountability mechanisms, institutional hybridization, weakening of 'public sector and government responsibility' for health and social care, fostering opacity and the illusion of a redistribution of wealth by the elite. the multi-stakeholderism promoted by philantrocapitalism, and perennial failure of governments to live up to their financial and other commitments whittle the capacity of who to serve in reclaiming health as a social common. it is against this background that such laudable resolutions that would have helped safeguard the health and well-being of health workers such as the working for health: five-year plan for health employment and inclusive economic growth have failed to translate into concrete steps on the ground. the politics of the covid- global response echoes the need for reinstatement of the who's leading role in international health. global health initiatives such as gavi and cepi occupy more or less equal place in the access to covid- tools accelerator (act-accelerator), while who cannot arrest the unfurling of vaccine nationalism. the neoliberal turn of the s represents a loss of the trajectory of social progress towards health as a social common. commodification and marketization of health which started with the incursion of international financial institutions at that period reflected a change in the global social and economic order to one of the most naked forms of capitalism. this laid the basis for nightmare which health workers have faced in the pandemic-overworked, underpaid and ill-protected. health works realize the need to change this situation. public services international, the global trade union federation which brings together thirty million workers across the world, about half of which are in the health and social sector has called for 'rapid changes in policies….that put people and planet over profit'. this requires advocacy and lobbying of the who and countries. but even much more it requires monumental social mobilization to restructure the world as we know it, with public health for all at the heart of such this. we must remember that it took 'the combination of militant social movements and structural changes in the economy' to give birth to 'the rise of the welfare state' (abramovitz and zelnick : ) . it is also important to note that the alma ata declaration recognized the fundamental importance of economic and social development (at the time envisioned as the 'new international economic order') for the fullest attainment of health for all and reduction of health inequities to become reality. 'the post-covid- age will usher in a new era of social and political relations' (horton : ) . but the nature of this is not pre-defined. it could be more of the same as the post-great recession age has been. we must contest it and fight for it to be an age of health as a social common-a post-neoliberal age. double jeopardy: the impact of neoliberalism on care workers in the united states and south africa privatization and pandemic: a cross-country analysis of covid- rates and health-care financing structures es?id= &lang=en. accessed ry_analy sis_of_covid - _rates _and_healt h-care_finan cing_struc tures performing arts, the economic dilemma: a study of problems common to theater, opera, music, and dance the role of the world health organization in the international system the impact of the financial crisis on the health system and health in greece the end of history? the covid- catastrophe, what's gone wrong and how to stop it happening again structural adjustment and health: a conceptual framework and evidence on pathways covid- the pandemic that should have never happened and how to stop the next one neoliberalism and its consequences: the world health situation since alma ata the decade of adjustment: a review of austerity trends - in countries world health organization (who). . constitution of the world health organization key: cord- -wr j j authors: vasudevan, gayathri; singh, shanu; gupta, gaurav; jalajakshi, c. k. title: mgnrega in the times of covid- and beyond: can india do more with less? date: - - journal: indian j labour econ doi: . /s - - - sha: doc_id: cord_uid: wr j j covid- has ushered in a renewed focus on health, sanitisation and, in unexpected ways, on the need for productive employment opportunities in rural india. mgnrega, the rural employment guarantee programme, has had a mixed track record in terms of providing adequate employment to those who need it the most, the quality of asset creation and adequacy of wages offered. this paper makes a case for reorienting a small portion of mgnrega spending to create micro-entrepreneurs out of the ‘reverse migrating’ masons, electricians, plumbers and others in rural areas who can directly contribute to augmenting health and sanitization infrastructure in the likely new normal. this will provide relief to those whose livelihoods have been severely impacted and eventually lower dependence on public finances. we propose approval of a new work type for sanitization works without any hard asset creation under mgnrega and roping in the private sector for its project management skills to quickly skill up the returning migrants as well as to match work with workers on an ongoing basis. in rural areas, major livelihood activities are irregular mainly due to seasonal fluctuations in agriculture and allied activities. this leads to periodic withdrawal from labour force, especially by the marginal labourers, who shift back and forth between what is reported as domestic and gainful work. many workers migrate to other parts of the country in search of work. lack of alternate livelihoods and skill development are the primary causes of migration from rural areas. due to covid- pandemic, india is facing a severe challenge of unemployment and reverse migration (fig. ) . migrant workers are heading back to their native places in the hope of sustaining themselves better than they would be able to manage in hostile living conditions in host locations with limited work opportunities. most migrant workers are daily-wage earners, and absence of work for extended periods makes it difficult to afford high cost of living in urban areas. added to this is the uncertainty around the timelines for normalization of the current situation. mahatma gandhi national rural employment guarantee act (referred to as mgnrega hereafter) was introduced by government of india in to target causes of chronic poverty through the 'works' (projects) that are undertaken, and thus ensuring sustainable development for all. mgnrega is the largest work guarantee programme in the world with the primary objective of guaranteeing days of wage employment per year to rural households. the programme emphasizes on strengthening the process of decentralization by giving a significant role to panchayati raj institutions (pris) in planning and implementing these works. this paper critically evaluates the suitability of mgnrega in its current form as a panacea for alleviating stress in rural india. the key question we discuss here is whether mgnrega can provide meaningful work in the post-covid- world, how more employment could be generated with the same effective spending and reliance on projects under mgnrega be reduced going forward. the focus of the scheme is on rural employment and asset creation. a total of days of work is guaranteed per household with the budget shared in : ratio by centre and states. the daily wage has recently been increased to rs. by the centre although there is significant interstate variation in the wages paid (increased wage rates effective from april, and notified on march, ). in many cases, the scheme wage rates are lower than the minimum wages in respective states. spending under mgnrega projects is mandated to be at least % on wages to unskilled labour with the remaining % for semi-skilled/skilled labour and material. however, there are exceptions to this. one of the prominent examples is construction of toilets. the scheme is implemented via gram panchayats. the centre's focus is on 'convergence' with spending on other major schemes. convergence in this context implies that where possible, the objective of jobs and asset creation under mgnrega is be achieved in alignment with the schemes rolled out by other departments. mgnrega funds cannot be used for other schemes, but the reverse is what convergence aims to promote. more than projects are permissible under mgnrega and classified into four main categories, namely: public works relating to natural resources management, individual assets for vulnerable sections, common infrastructure for deendayal antyodaya yojana-national rural livelihoods mission (day-nrlm) compliant self-help groups, and rural infrastructure. total fy - spending by the centre was rs. , crores, while the original budget for fy was rs. , crores. in the wake of covid- -related reverse migration, the centre has recently enhanced this amount by rs. , crores. in the financial year - , approximately crore workers availed of work under the scheme. mgnrega is also one of the focus areas in the centre's recently announced rs. lakh crore stimulus package. however, as we discuss in the following sections, this would not be enough to provide meaningful employment to the large number of returnee migrants, and a meaningful reorientation of spending can help create a pool of micro-entrepreneurs in short time. with a possibility of reasonable income-generating opportunities outside mgnrega-related works, this pool is expected to have lower dependence on government spending in future. a study by institute of social and economic change (isec ) of projects between fy and fy under mgnrega reveals the following top categories: rural connectivity ( %), water conservation ( %), land development ( %), renovation of water bodies ( %), flood control ( %), micro-irrigation works ( %), provision of irrigation facility ( %), drought proofing ( %) and other activities, as approved by ministry of rural development, ( %). however, as with schemes of this scale and nature, work completion rates under mgnrega have been low at least for the period under consideration (table ) . besides other factors such as time taken for completing documentation and abandonment of non-feasible projects, this also demonstrates the need for better project management and execution skills. the following is an extract (section . ) from the nd report of the standing committee on rural development ( development ( - presented to the th lok sabha. "the working group on mgnrega have also mentioned that findings related to quality, durability and rate of work completion suggest that the problem is not in the design of the act but the usefulness of the scheme is dependent on the strength of its implementation at the field level. for instance, lack of planning in areas like potential demand and need for mgnrega works, participation of villagers and prioritization of works in the gram sabha (gs), and focus on creation of productive assets based on principles of watershed, etc., can greatly reduce the development potential of mgnrega. taking up of planned works, relevant to the need of the region and demand of the beneficiaries is also vital for ensuring ownership of assets and their development utility in the long run." the most distressed section of migrants is what has been termed in the literature as vulnerable circular migrants (srivastava ) . these include both short-term seasonal and long-term (semi-permanent) occupationally vulnerable workers. srivastava ( ) has estimated that there were approximately . crore short-duration circular migrant workers in - . of these . crore, about . crore were engaged in non-agriculture work, . crore were in urban areas, and . crore were working in other states ( . crore of out of . crore in urban locations). in the same study, the number of vulnerable long-term circular migrant workers has been estimated at . crores in . putting together the numbers of short-term seasonal/ circular and long-term occupationally vulnerable workers gives us about . crore workers whose livelihoods may have been adversely impacted with the onset of covid . about . crore ( . crores short-term above and . crores longterm) of these . crore migrants were estimated to be a part of the workforce in urban india-the epicentre of covid in india. a little less than half of these . crore workers- . crores-were interstate migrant workers in . based on - nss data used in srivastava ( ) , states that primarily contribute to short-duration out-migration for employment are bihar ( . %), uttar pradesh ( %) and west bengal ( %), madhya pradesh ( . %), jharkhand ( . %) and rajasthan ( . %). these states also had the highest shares in interstate outmigrants reflecting their low levels of income. uttar pradesh and bihar also have more than % share in long-term out-migration. the task force on eliminating poverty constituted by niti aayog in (occasional paper ) has noted that, on average, most beneficiaries under mgnregs have been able to avail of only days of work and recommends better targeting of the scheme to ensure the poorest of the poor get the promised days of work opportunity. if - % of . crores migrant workers in urban india (including the . crores interstate workers in above) return to their home destinations, the scheme has to accommodate between . and . crores new workers. this will add roughly - % to the pool of existing workers, and the current employment situation in the country will also force inactive users to demand employment under mgnrega. the incremental allocation (over last year's actuals) is about rs. , crores. considering these numbers, the average availability of work per person will reduce further below days and is inadequate in addressing the challenges facing rural india. this reverse migration has altered the labour market's demand and supply dynamics significantly. areas that previously had negative net migration rates are now expected to be labour surplus. locations that were attractive for labour to migrate to, will find it difficult to attract and retain labour. what this essentially means is that locations that were hitherto the biggest sources of migrant workers will have an excess supply of unskilled/semi-skilled labour available to work at low reservation wages. given the continued requirements around social distancing, we expect movement of people to be somewhat restricted and a more-or-less closed labour market in the foreseeable future. this will mean that some portion (~ - % ) of migrants will stay back in their villages and not return to the places of work soon. on the other hand, covid- has demonstrated the gaps in india's health and sanitisation infrastructure. in addition, sanitisation has assumed unprecedented importance in our lives, in both rural and urban india. rural india can benefit from effectively utilising this surplus labour in augmenting its health and sanitization infrastructure. table shows that top districts account for % of all male migrants. the next % is spread over the districts shown against numbers to . these are the areas that need intervention on an urgent basis. early/incomplete data collected by the office of relief commissioner, government of uttar pradesh, in table suggest % of returning migrants are unskilled. governments, both at the centre and in states, are facing several challenges today. at the top of the list is rehabilitation of returning migrants including provision of quarantine facilities, covid screening, essential supplies, etc. equally critical is to immediately provide these workers income-earning opportunities, especially to seasonal migrants who are unlikely to migrate for work soon. at the very least, they are not expected to return with families leaving behind - adults in the village. on health and sanitisation fronts, adequate health facilities including those for mental health are required given the large number of people back in villages now and most having returned after long period of hardships and joblessness. sanitisation needs to be ensured as per new requirements, and necessary steps need to be taken at local levels to ensure there is no spread of infection in rural areas. in addition, restoration of public and private property post-cyclone amphanrelated destruction is also an important focus area for governments in west bengal and odisha. a. sanitisation of public and private assets. it must be noted that sanitisation is to be seen as something distinct from regular cleaning work. overall, public places such as schools, anganwadis, health centres, common areas, shops, community assets such as panchayat office, post office, police chowki, cooperative society offices and bank branches where a lot of people come in contact with each other need effective sanitisation. the new physical distancing norms also necessitate construction of individual toilets versus community toilets in order to abate spread of communicable diseases. while unavoidable where common services are provided (e.g. bus stands, train station), common toilets in residential areas are not very effective in disease prevention. the jal jeevan mission which aims to provide piped water to every household needs to be fast tracked by reaching more and more households at the earliest. with respect to health-related aspects, additional construction is required particularly to attend to critical services like maternal labour rooms which are being currently doubled up as isolation wards. similarly, non-covid-related medical services which have been side-lined for lack of space and resources need augmenting including construction of adequate physical space and healthcare workers. it is well documented that the returning indian soldiers from world war i carried h n influenza to the rest of the country ultimately resulting in the death of . crore indians. the current reverse migration from cities (the epicentres of covid- ) to rural areas has potential for the wider spread of disease in rural areas which have far inferior medical facilities and preparedness than urban india. temporary structures to host screening, testing and quarantine facilities for these migrant workers need immediate work. c. frequency of cleaning (and sanitisation) work needs to be far more than that in the pre-covid world. d. storage for agriculture produce: creation of small warehouses at the village level for storage of produce. there is a well-documented shortage of storage space in india (oecd ). it is estimated that lack of storage facilities depresses the realised price as well as results in direct wastage of - % of physical output ( - % in overall supply chain). e. restoration of public and private property post-cyclone amphan-related destruction. the we propose the following changes to the existing mgnrega guidelines. . a new category of works without any physical asset creation as such needs to be approved. . funding from mgnrega for paying wages to sanitization and hygiene workers. works. these will be labour and material contractors. there are not any as of now for sanitisation and hygiene-related works. these fpc will be different from the existing mates or mistris as they would need to quickly acquire skills in short time that were, in the pre-covid times, acquired over a period of time with experience. mates or mistris are experts for overseeing work assigned to their group of workers ~ in each group. . sanitisation as a concept is new, so trained manpower is necessary. sanitisation and hygiene workers (different from those currently involved in cleaning jobs) will drive sanitization efforts across the gp. both the fpc and sanitisation workers will be collectively called sanitisation and hygiene entrepreneurs (she). ing in the project management expertise with respect to quickly mobilising, skilling and maintaining a pool of sanitisation and hygiene workers for gp level works as well as in matching workers to work outside mgnrega projects. we represent these project management consultants as pmcs hereafter in the note. under mgnrega, % of total expenditure can be on administrative expenses. of this, % needs to be utilised at the gp level. these funds can be utilised on the skilling of she. as we show later in this note, just this portion of funds will not be enough and governments need to make more funding available through other components of mgnrega and other schemes. states need to propose changes to be made in the scheme to centre given there will be no asset creation and the work is of regular nature. the proposal needs to include the following: justification for the work, areas where the work will be undertaken, number of wage seekers to be employed (employment potential), nature of durable asset to be created, expectations from the work to strengthen the livelihood base of the rural poor, other benefits that may accrue such as continued employment opportunities, strengthening of the local economy and improving the quality of lives of people. the model project should contain the following: unit cost of the work, the split between labour and material component and between skilled and semi-skilled component, transparency and accountability mechanisms, expected final outcome (asset that will be created), benefit to the livelihood base of the rural poor and any other benefit likely to accrue. what we propose is to build a pool of micro-entrepreneurs involved in: . sanitisation and hygiene activities . infrastructure development/rehabilitation projects gram panchayats (gp) could use these mainly sanitisation and health entrepreneurs (she) to take care of sanitisation and hygiene needs with respect to public and private assets under the new normal. work guarantee under mgnrega could act as a floor for basic sustenance, and a one-time government subsidy for training and buying equipment could get a large number of these workers take the first steps towards sustainable self-employment. these she need not restrict themselves to work allocated by gp and could also take on private work related to health and sanitisation. however, on their own, workers lack information on how to go about providing these services. on the other side, gp will find it difficult to get hold of such service providers who are trained. gp will want this at the lowest possible costs which can be provided by someone who is locally based and whose services can also be used on an ad hoc basis. it is in this context that private sector organizations with experience in project management of large-scale interventions can be roped in. experience of private sector organisations that have engaged considerably with the panchayati raj department and understand the skills and rural space quite well will be useful. given their project management experience, these institutions can monitor quality of the work, train workers to improve their skills and ensure quality assurance to the villages. support needs to be provided on an urgent basis to masons, plumbers, electricians and painters-a large category of returnees to rural india in the current situation. this support comes not only in the form of capacity building via professionalisation of skills but also as forward and backward market linkages, business skills, compliance and support in obtaining loans from the formal financial system to ensure an increased income to these micro-contractors. details of specific mgnrega works/ tasks that these workers can be involved in are provided in "appendix". these project management consultants can act as a platform assisting and working with the gram panchayats on the one hand and service providers/contractors/workers on the other. they must have the necessary skills to train and create a talent pool of fair practice contractors (fpc) who can work on creating new as well as disinfecting existing common infrastructure at the village level and also private assets. they should also maintain a database through their skilling initiatives of a pool of trained workers to draw on. these she (workers as well as the fpcs) come with a stamp of quality from the pmc on the basis of its training, mentoring and monitoring interventions. this is not the case currently even though gram panchayats have been allocating work to contractors. pmc will assist the gps to assess their works requirement (for infrastructure build-up as well as for embedding sanitisationrelated measures) and create the project requirement documents. from the talent pool of contractors and workers, pmc will screen and choose micro-entrepreneurs, facilitate the contract process and monitor the work done by them to ensure quality output. pmc will monitor the quality of work, using photographic evidence. given the new requirements around sanitization needs, gps may not be equipped to handle this on their own. at the moment, contractors and workers mainly learn on the job. in our experience, they are not aware of the most efficient ways of working and organizing their services business. pmc can use technology to bring the service providers and the customers (gps) together in an efficient manner. pmc must be equipped to conduct online training for contractors/workers and also create a portal for gps which will have a template for them to assess the requirement and create a 'project document' and process contract. for the she, only a part of their overall business needs to come from gps as discussed above. through extensive training on different aspects related to running a small business, pmc's intervention can empower them with the necessary skills and infrastructure to expand private income-enhancing opportunities. once self-sufficient and connected with a pool of available workers facilitated by the pmc's technology platform, she can look at opportunities outside their own villages for expansion and over a short period of time lessen their dependence on work opportunities funded under mgnrega. from the point of view of supporting economic activity, another concept that merits attention is that of common service centres (csc). these csc aimed at shortening the end-to-end value chains are already being piloted by organisations such as selco foundation in bengaluru. csc involve establishment of infrastructure (physical and digital, in sizes and prices that are affordable) and systems (standard operating procedures, efficient use of technology) in a manner that can respond to local needs and be a catalyst for economic activities in a local area. some of the common services these csc can provide include: tailoring centres, mechanic shops, local provision stores with refrigeration for perishable consumables, agriculture-related storage infrastructure and equipment. these csc can also be used as telemedicine centres for first level testing and care in the fight against covid- at the village level. depending on the predominant livelihood in the region, agriculture processing or value-add facilities can be developed. the facilities could be government or cooperative owned, but run on revenue-based model-providing cold storage facilities for horticulture produce, milk chilling, agriculture processing, or food processing units. in summary, what the above examples demonstrate is that it is possible to reduce reliance on public funding beyond the initial grant and create an avenue for further job creation in rural areas without putting undue strain on public finances. given the huge requirement for sanitisation, we expect sanitisation workers to earn at least rs. , - , a month on a sustainable basis without necessarily relying on public funds after the first days of work under mgnrega. as shown in the table below, based on our assumptions, spending of rs. , crores (including rs. crores one-time) will be required to train, endow with initial start-up material and employ a new breed of sanitization and hygiene entrepreneurs as well as plumbers, electricians, masons and telemedicine workers in , villages across the country for a period of days. after this time, these workers should be in a strong position to take on private work in rural as well as in urban areas and earn far more than the subsistence wages under mgnrega. the training would be done by appointed pmcs who would develop an ecosystem for sanitization services and connect these workers with work in rural and urban areas on an ongoing basis. this paper has attempted to quantify the scale of reverse migration india is witnessing in the current times and the action needed to make mgnrega spending more effective. we also analysed the profile of these migrants and which areas people are migrating back to. the scale of reverse migration and the lack of opportunities in rural india despite enhancements in fund allocation to mgnrega point to a grim situation. projects under mgnrega have had limited completion rate in the past, and the scheme overall has been inadequate in providing the assured minimum days of work to those who need it the most. in the new normal, healthcare, sanitisation and hygiene will have a priority focus. a project management discipline, connecting labour to work opportunities and vice versa and the need for micro-self-employment is the need of the hour. more can be achieved with the same level of public finances if people are connected to and shown the way to private income enhancement opportunities. impact of mgnrega on wage rate, food security and rural urban migration: a consolidated report. project leader-prof ministry of rural development, government of india eliminating poverty: creating jobs and strengthening social programs. niti aayog, government of india committee for agriculture implementation of mahatma gandhi national rural employment guarantee act understanding circular migration in india: its nature and dimensions, the crisis under lockdown and the response of the state. institute for human development job role-wise categorization of permitted works for mason, plumber, electrician and painter. key: cord- -khhzlt y authors: jain, aditya; leka, stavroula; zwetsloot, gerard i. j. m. title: work, health, safety and well-being: current state of the art date: - - journal: managing health, safety and well-being doi: . / - - - - _ sha: doc_id: cord_uid: khhzlt y this introductory chapter will present a review of the current state of the art in relation to employee health, safety and well-being (hsw). the work environment and the nature of work itself are both important influences on hsw. a substantial part of the general morbidity of the population is related to work. it is estimated that workers suffer million occupational accidents and million occupational diseases each year. the chapter will first define hsw. it will then review the current state of the art by outlining key hsw issues in the contemporary world of work, identifying key needs. it will then discuss the evolution of key theoretical perspectives in this area by linking theory to practice and highlighting the need for aligning perspectives and integrating approaches to managing hsw in the workplace. this chapter focuses on the relationship between work, health, safety and wellbeing. the work environment and the nature of work itself are both important influences on health, safety and well-being (hsw). as a result, workplace health and safety or occupational health and safety have been key areas of concern for many years. traditionally, more focus has been placed on safety concerns in the workplace while health concerns became more prominent with the changing nature of work. well-being on the other hand, is increasingly being considered in relation to work and the workplace in recent years. a good starting point in understanding this evolution in focus and thinking is definitions. according to the oxford dictionary, safety is defined as the condition of being safe; freedom from danger, risk, or injury. safety can also refer to the control of recognized hazards in order to achieve an acceptable level of risk. in terms of work, this mainly concerns physical aspects of the work environment. however, the changing nature of work was associated with the emergence of new types of risk relating to psychological and social aspects of the work environment. this brought about greater focus on health at work. a very influential definition that shaped thinking and action in subsequent years was the world health organization definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (world health organization [who], ) . this definition promoted a more holistic view of health away from a mere focus on physical aspects towards considering social and mental health aspects. although the who definition already referred to a state of well-being, definitions of well-being include additional dimensions to health, such as social, economic, psychological, and spiritual. well-being refers to a good or satisfactory condition of existence; a state characterized by health, happiness, and prosperity. obviously achieving this state is not relevant to the workplace or work alone but rather an overall evaluation of one's life across many areas. as such, actions to improve hsw can be taken within the work context and outside of it. actions taken in the workplace represent workplace interventions that are implemented in the work setting and consider the characteristics of work environments and workers. on the other hand, actions taken outside the workplace represent public health interventions that are implemented in various settings (for example, in schools, communities or countries) and take into consideration the characteristics of particular populations. a key question in terms of hsw interventions when it comes to the workplace concerns responsibility. while every individual is responsible for their own actions in various contexts of life, in a specific setting like the work environment, additional responsibility lies with the employer since the work environment will expose workers to particular work characteristics that might in turn pose a certain level of risk to their hsw. while employer responsibility might be formalized under law, this is not the case across countries or in relation to all possible types of risks to workers' hsw, and in particular new and emerging risks, or risks that are either new or gain in prevalence with the changing nature of work. accordingly, it is important to consider not only legal duties that employers have towards their workforce but also ethical duties that will extend beyond legal compliance. in addition, while employers bear a legal responsibility towards their workforce, they also bear responsibility towards society. this has meant that enterprises have increasingly been held accountable towards society and that interventions in the workplace, whether legally required or not, are now being increasingly considered in terms of their impact beyond the workforce alone but rather society as a whole (see chapters , , and ). this represents a blurring of boundaries between traditional occupational safety and health and public health initiatives that have also resulted in greater emphasis on the concept of well-being in addition to health and safety. at its first session in , the joint international labour organization (ilo)/ world health organization (who) committee on occupational health defined the purpose of occupational health. it revised the definition at its th session in to read as follows: occupational safety and health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize, the adaptation of work to man and of each man to his job. almost years later, the target set through this declaration seems ambitious in many parts of the world, both in developed and developing countries. to understand why, it is worth understanding the context underpinning developments in this area as well as current priorities and needs. in recent years, globalization of the world's economies and its repercussions have been perceived as the greatest force for change in the world of work, and consequently in the scope of occupational safety and health, in both positive and negative ways. liberalization of world trade, rapid technological progress, significant developments in transport and communication, shifting patterns of employment, changes in work organization practices, the different employment patterns of men and women, and the size, structure and life cycles of enterprises and of new technologies can all generate new types and patterns of hazards, exposures and risks. demographic changes and population movements, and the consequent pressures on the global environment, can also affect safety and health in the world of work. let us first consider key impacts on the changing nature of the work environment. different types of products and services, organizational structures and work processes, and tools and resources are used in the modern workplace. three main drivers have been proposed in relation to these changes. the first is globalization, a term which refers to the integration of national and regional economies, which became more prevalent since the nineteenth century. according to the organization for economic co-operation and development (oecd, ) , the rapid integration into world markets by six economies (brazil, russia, india, indonesia, china and south africa) was an important component of globalization during the past decades. globalization has led to increased competition across organizations, to a shift in the type of business operations in which companies are engaged, and to extensive outsourcing of activities, primarily to low-wage countries. flanagan ( ) examined the effects of globalization on working conditions (hours, remuneration and safety) and concluded that globalization has led to greater flexibility of the work process, with more part-time employment, temporary employment and independent contracting of staff (european agency for safety & health at work [eu-osha], ; kawachi, ) . houtman and van den bossche ( ) confirmed these conclusions on the basis of eurostat data, reporting that more employees in europe hold a temporary employment contract and yet more people will work 'on call'. oecd reports also confirm these trends. they also highlight that average wage growth has not been equivalent to growth in labour productivity, which is also an outcome of the erosions of the bargaining power of workers in the process of globalization (oecd, ). organizational restructuring which has been on the increase due to economic crises in different parts of the world may have been partly a cause of this. organizational restructuring is accompanied by job insecurity and can result in unemployment with subsequent negative impacts on hsw. however, restructuring should not only be considered a serious threat to individual hsw for those who lose their job (the 'direct victims') but also to their immediate environment (e.g. kieselbach et al., ). in addition, evidence during the past two decades showcases the impact of restructuring on the so-called 'survivors' as concerns health, well-being, productivity, and organizational commitment (kieselbach et al., ) . the second key development is the tertiarization of the labour market, manifested in increased demand for staff in the services sector and reduced employment opportunities in industry and agriculture. this became apparent in the early years of the twentieth century but in recent decades may have been reinforced by globalization, since the outsourcing of manual labour to low-wage countries left predominantly the service economy elsewhere (eu-osha, ; peña-casas & pochet, ) . the third key development relates to technological advancement and the emergence of the internet, which has led to many changes and innovations in work processes. many forms of manual work have become obsolete and staff must offer different skills and qualifications (joling & kraan, ) . moreover, 'new work', a term which amongst others refers to telework, i.e. working from home or a location other than the traditional office, is now more widespread. this can result in blurring the borders between working and private life. work can take place outside the traditional working hours as well as at home or when travelling. hence, it may impinge on the need for rest and recuperation, or interfere with personal commitments. also new forms of working methods such as lean production (a production practice according to which the expenditure of resources other than for the creation of value for the end customer is wasteful and should be eliminated, womack & jones, ) , and just-in-time production (a production strategy that strives to improve a business' return on investment by reducing in-process inventory and associated costs, womack & jones, ) have been introduced (eu- osha, ; kompier, ) . overall there has been concern of the effects new forms of work may have on the hsw of workers, organizations and communities (e.g. benach, amable, muntaner, & benavides, ; benavides, benach, diez-roux, & roman, ; quinlan, ; quinlan, mayhew, & bohle, ; sauter et al., ; virtanen et al., ) . it is also important to mention the prevalence of small and medium-sized enterprises (smes) that are believed to be responsible for over % of new jobs created globally. moreover, in most developing and emerging countries, they also employ more people than large enterprises do. however, occupational safety and health (osh) is often less well managed in smes, creating working conditions that are less safe and posing greater risks to the health of workers than larger enterprises (croucher, stumbitz, quinlan, & vickers, ) . in particular, smes have less time to devote to providing osh training and information due to economies of scale, and have less expertise in hsw. research also confirms a common lack of awareness of the cost implications of occupational accidents and diseases amongst sme owners and managers, as well as a tendency for smes to be reactive, rather than adopting proactive and preventive strategies towards osh (croucher et al., ) . however, there are also changes in the workforce that are associated with hsw in the workplace. the next section considers the most important of these. alongside the factors changing the nature of work itself, changes can also be seen in the working population, with noteworthy trends being: (a) the ageing workforce; (b) the feminization of the workforce; and (c) increased immigration (leka, cox, & zwetsloot, ) . let us now consider these issues in more detail. in industrialized countries, the share of people aged -plus has risen from % in to % and is expected to reach % ( million) by . in developing countries, the share of people aged -plus has risen from % in to % and is expected to reach % ( . billion) by (world economic forum [wef], ). the global population is projected to increase . times from to , but the number of -plus will increase by nearly %, and the -plus by about %. women have a life expectancy of . years more than men and account for about % of the -plus group, rising to % of the -plus group, and % of the -plus group (wef, ) . in response to these global trends, four strategies have been proposed: raising the normal legal retirement age; using international migration to ameliorate the economic effects of population ageing; reforming health systems to have more emphasiz on disease prevention and health promotion; and rethinking business practices, encouraging businesses to employ more older workers, even on a part-time basis (wef, ) . according to the oecd ( ) most countries will have a retirement age for both men and women of at least years by , and this has already been implemented in many countries. this represents an increase from current levels of around . years on average for men and . years on average for women. the same report stresses that high levels of youth unemployment will lead to widespread poverty in old age as young people struggle to save for retirement. since population ageing in industrialized nations has been a prevalent trend in the past decades (ilmarinen, ) , lessons can be learned from it in relation to the workforce. most reviews and meta-analyses in the scientific literature make clear that there is no consistent effect of age on work performance (e.g., benjamin & wilson, ; griffiths, ; salthouse & maurer, ) . overall, older workers perform as well as younger workers. furthermore, there are many positive findings with regard to older workers. for example, older workers demonstrate less turnover and more positive work values than younger workers (warr, ) . they also exhibit more positive attitudes to safety and fewer occupational injuries (siu, phillips, & leung, ) although there is some evidence that it is tenure (time on the job) that should be examined rather than age per se (breslin & smith, ) . however, the evidence from epidemiological and laboratory-based studies paints a less favourable picture of older people's performance. such studies reveal age-related declines in cognitive abilities such as working memory capacity, attention capacity, novel problem-solving, and information processing speed. agerelated deterioration is also documented in motor-response generation, selecting target information from complex displays, visual and auditory abilities, balance, joint mobility, aerobic capacity and endurance (kowalski-trakofler, steiner, & schwerha, ) . as workers get older, they suffer from more musculoskeletal disorders (eurostat, ) , and they are more likely to report work-related stress (griffiths, ) . recent models of ageing and work propose that certain mediating factors underpin the relationship between chronological age, work performance and behaviour and might function at three levels: individual, organizational and societal. at the individual level, for example, experience, job knowledge, abilities, skills, disposition, and motivation may operate (kanfer & ackerman, ) . other mediating variables may reflect organizational policies and practices: for example, age awareness programmes, supervisor and peer attitudes, management style, the physical work environment and equipment, health promotion, workplace adjustments, and learning and development opportunities (griffiths, ) . however, policies and systems implemented so far have, in most countries, not been adequately successful in keeping people healthier and in employment for longer (oecd, ) . a further level of exploration for the relationship between age and work performance might be provided by examining global markets, the wider employment context and worker protection (johnstone, quinlan, & walters, ; quinlan, ) . as discussed, in developed countries there has been a decline in manufacturing and a recent export of some service sector work to developing countries. the way work is designed and organized has changed substantially with a growth in contingent or 'precarious' work and an increase in part-time work, home-based work, telework, multiple job-holding and unpaid overtime. these changes might make it increasingly difficult for older workers to gain or maintain employment, and such employment may entail inferior and unhealthy working conditions. these changes in work design and management have also been accompanied by changes in worker protection; for example, a decline in union density and collective bargaining, some erosion in workers' compensation and public health infrastructure and cutbacks in both disability and unemployment benefits -again contexts which are unlikely to favour vulnerable workers, such as older workers. as such older workers may be affected by increased exposure to certain occupational hazards; decreased opportunities to gain new knowledge and develop new skills; less support from supervisors, and discrimination in terms of selection, career development, learning opportunities and redundancy (chiu, chan, snape, & redman, ; maurer, ; molinie, ) . pronounced gender differences in employment patterns can be observed as a result of a highly segregated labour market based on gender (burchell, fagan, o'brien, & smith, ; fagan & burchell, ; vogel, ) . gender segregation refers to the pattern in which one gender is under-represented in some jobs and overrepresented in others, relative to their percentage share of total employment (fagan & burchell, ) . a growing body of evidence indicates that a high level of gender segregation is a persistent feature of the employment structure globally (e.g. anker, ; burchell et al., ; rubery, smith, & fagan, ) . some scholars have argued that estimates suggest that gender segregation in the labour market is so pervasive, that in order to rectify this imbalance approximately % of women would have to change jobs or professions (messing, ) . considering differences in employment patterns according to gender (and without taking into account sectors where both genders are represented, e.g. agriculture), women's jobs typically involve caring, nurturing and service activities for people, whilst men tend to be concentrated in managerial positions and in manual and technical jobs associated with machinery or physical products. since men and women are differently concentrated in certain occupations and sectors, with different aspects of job content and associated tasks, they are exposed to a different taxonomy of work-related risks (burchell et al., ; eu-osha, ) . for example, women are more frequently exposed to emotionally demanding work, and work in low-status occupations with often restricted autonomy, as compared to men. this differential exposure can result in differential impacts on occupational ill health for men and women (eu-osha, ; oecd, ) . furthermore, due to the gender division of labour, women and men play different roles in relation to children, families and communities with implications for their health (premji, ) . even though women are increasingly joining the paid workforce, in most societies they continue to be mainly responsible for domestic, unpaid work such as cooking, cleaning and caring for children, and so they carry a triple burden (e.g. loewenson, ) . women are also largely represented among unpaid contributing family workers, those who work in a business establishment for a relative who lives in the same household as they do (ilo, ) . balancing responsibilities for paid and unpaid work often leads to stress, depression and fatigue (duxbury & higgins, ; manuh, ) , and can be particularly problematic when income is low and social services and support are lacking. the lack of availability of child care may also mean that women must take their children to work where they may be exposed to hazardous environments. increased migration of workers from developing countries to developed countries or from poorer to more affluent developed countries is still the norm and increasing. migrant workers can be divided into highly-educated and skilled workers, both from developing and industrialized countries, and unskilled workers from developing countries (takala & hämäläinen, ) . they can also be classified as legal and illegal (or regular and irregular) migrant workers who have a different status and, therefore, varying levels of access to basic social services (who, ) . often lowskilled and seasonal workers are concentrated in sectors and occupations with a high level of occupational health and safety risks (who, ) . ethnic minority migrants have been found to have different conditions in comparison to other migrants, and to report lower levels of psychological well-being (shields & price, ) . women migrants represent nearly half of the total migrants in the world and their proportion is growing, especially in asia. they often work as domestic workers or caregivers while men often work as agricultural or construction workers (ilo, ) . in general, migrant workers tend to be employed in high risk sectors, receive little work-related training and information, face language and cultural barriers, lack protection under the destination country's labour laws and experience difficulties in adequately accessing and using health services. common stressors include being away from friends and family, rigid work demands, unpredictable work and having to put up with existing conditions (magana & hovey, ) . in addition, migrant workers' cultural background, anthropometrics and training may differ from those of nationals of host countries, which may have implications in relation to their understanding and use of equipment (kogi, ; o'neill, ) . as can be understood so far, both the nature of work and of workplaces as well as workforce characteristics depend on wider socioeconomic and political influences. a large body of literature has summarized and examined these influences under the area of the social determinants of health. the following section briefly considers these determinants. new forms of work organization and employment have to be considered within the wider picture of employment and working conditions across the world. labour markets and social policies determine employment conditions such as precarious or informal jobs, child labour or slavery, or problems such as having high insecurity, low paid jobs, or working in hazardous conditions, all of which heavily influence health inequalities. figure . shows various interrelationships between employment, working conditions and health inequalities. let us consider unemployment and associated job insecurity as social determinants of health. in the ilo estimated that there were almost million unemployed people in the eu, million of whom were from eu- countries. overall, million people were unemployed in with a quarter of the increase of four million in global unemployment being in the advanced economies, and three quarters being in other regions, with marked effects in east asia, south asia and sub-saharan africa (ilo, a). the same report also highlighted that in those regions where unemployment did not increase further, job quality worsened as vulnerable employment and the number of workers living below or very near the poverty line increased. in the eu, the financial crisis resulted in unprecedented levels of youth unemployment, averaging % for the eu as a whole. the rates for young people (aged - ) not in employment, education or training are . % in the south and peripheral eu countries, and . % in the north and core of the eu (european commission [ec], ). in a pattern intensified by the financial crisis, structural unemployment has been growing and unemployment varies from . % in the south of the eu and peripheries in , to . % in the north and central countries (ec, ) . a large proportion of jobs destroyed were in mid-paid manufacturing and construction occupations (european foundation for the improvement of living & working conditions [eurofound] , ). as a consequence of reduced employment opportunities, poverty has increased in the eu since . household incomes are declining and . % of the eu population is now at risk of poverty or exclusion. children are particularly affected as unemployment and jobless households have increased, together with in-work poverty (ec, ) . this has implications for quality of life and general population health beyond workplace health and safety due to the impact on personal finances. an ilo report summarized the potential impact of financial crises on organizations and health and safety as shown in table . . the surge of unemployment creates tension and negatively impacts public perceptions for social welfare, job security, and financial stability. increased job insecurity reflects the fear of job loss or the loss of the benefits associated with the job (e.g. health insurance benefits, salary reductions, not being promoted, changes in workload or work schedule). it is one of the major consequences of today's turbulent economies and is common across occupations, and both private and publicsector employees (ashford, lee, & bobko, ; ferrie et al., ; sverke, hellgren, & naswall, ) . several studies have shown that job insecurity has detrimental effects on the physical and mental health of employees, and on many organizational outcomes, including performance, job satisfaction, counterproductive behaviours, and commitment (e.g. ferrie et al., ; sverke et al., ) . increased unemployment has given rise to different forms of flexible and temporary employment, also through the introduction of relevant policies such as flexicurity. flexicurity is an integrated strategy for enhancing flexibility and security in the labour market. it attempts to reconcile employers' need for a flexible workforce with workers' need for security (ec, ) . however, several studies have warned of the possible negative outcomes of new types of work arrangements, highlighting that they could be as dangerous as unemployment for workers' health (benach & muntaner, ) . for example, workers on fixed-term contracts are commonly found to have inadequate working conditions by comparison with permanent employees. new forms of work organization and patterns of employment can be summarized in terms of flexible working practices including temporary and part-time employment, tele-working, precarious employment, and home working. although these new practices can result in positive outcomes such as more flexibility, a better worklife balance, and increased productivity, research has also identified several potential negative outcomes. for example, teleworkers may feel isolated, lacking support and career progression (e.g. ertel, pech, & ullsperger, ; schultz & edington, ) . in addition, temporary, part-time and precarious employment can result in higher job demands, job insecurity, lower control and an increased likelihood of labour force exit (benach et al., ; quinlan, ; quinlan et al., ) . workers engaged in insecure and flexible contracts with unpredictable hours and volumes of work are more likely to suffer occupational injuries (ilo, a (ilo, , b . although awareness and evidence in developing countries lags far behind those in the industrialized world, evidence has started to accumulate showing similar findings in developing countries (kortum, leka, & cox, ) . these various complex relationships between the wider socio-economic context, employment and working conditions have resulted in a more complex profile of risk factors that may affect hsw in the workplace. new forms of work organization and the move towards a service based economy have also resulted in new and emerging risks affecting the workforce, organizations and society. these will be considered next. an 'emerging osh risk' is often defined as any occupational risk that is both new and increasing (eu-osha, ). new means that the risk was previously unknown and is caused by new processes, new technologies, new types of workplaces, or social or organizational change; or, a long-standing issue is newly considered to be a risk due to changes in social or public perceptions; or, new scientific knowledge allows a long standing issue to be identified as a risk. a risk is increasing if the number of hazards leading to the risk is growing; or, the likelihood of exposure to the hazard leading to the risk is increasing (exposure level and/or the number of people exposed); or the effect of the hazard on workers' health is getting worse (seriousness of health effects and/or the number of people affected) (houtman, douwes, zondervan, & jongen, ). an article published on eu-osha's osh wiki on new and emerging risks summarizes them as follows (houtman et al., ) : • emerging physical risks: ( ) physical inactivity and ( ) the combined exposure to a mixture of environmental stressors that increase the risks of musculoskeletal disorders (msds), the leading cause of sickness absence and work disability. • emerging psychosocial risks: ( ) job insecurity, ( ) work intensification, high demands at work, and ( ) emotional demands, including violence, harassment and bullying. • emerging dangerous substances due to technological innovation: ( ) chemicals, with specific attention to nanomaterials, and ( ) biological agents. the growing use of computers and automated systems, aimed at optimizing productivity, has caused an increase in sedentary work or prolonged standing at work, resulting in an increase in physical inactivity. work demands are also commonly cited as reasons for physical inactivity (e.g. trost, owen, bauman, sallis, & brown, ) as well as an increase in travelling time to work (houtman et al., ) . physical inactivity is associated with increased health risks such as coronary heart disease, type ii diabetes, and certain types of cancers and psychological disorders (depression and anxiety) (department of health, ; who, ; zhang, xie, lee, & binns, ) . another important result of inactivity is obesity which can lead to several adverse health effects, such as back pain, high blood pressure, cardiovascular disorders, and diabetes (houtman et al., ) . in addition, sedentary jobs are associated with an increased prevalence of musculoskeletal complaints or disorders, e.g. neck and shoulder disorders (e.g. korhonen et al., ) , and upper and lower back disorders (e.g. chen, mcdonald, & cherry, ) . such disorders may lead to sick leave and work disability (e.g. steensma, verbeek, heymans, & bongers, ) . the established health risks associated with sedentary work are premature death in general, type ii diabetes and obesity (van uffelen et al., ) . as concerns msds, there is a considerable body of research indicating that biomechanical or ergonomic risks in combination with psychosocial risks can generate work-related msds (e.g. bongers, ijmker, & van den heuvel, ; briggs, bragge, smith, govil, & straker, ; eu-osha, ) . psychosocial risk factors at work have a greater effect on the prevalence of musculoskeletal complaints when exposure to physical risk factors at work is high rather than when it is low. in addition, factors such as low job control, high job demands, poor management support or little support from colleagues, as well as restructuring, job redesign, outsourcing and downsizing have been shown to be causally related to increased risks in msds (houtman et al., ) . job insecurity has been discussed earlier and is an important stressor resulting in reduced well-being (psychological distress, anxiety, depression, and burnout), reduced job satisfaction (e.g. withdrawal from the job and the organization) and increased psychosomatic complaints as well as physical strains (e.g. wagenaar et al., ) . all these effects are negatively related to personal growth as well as to recognition and participation in social life (de cuyper et al., ) . additionally, decreased well-being and reduced job satisfaction of employees negatively affects the effectiveness of the organization (houtman et al., ) . there are several increasing demands workers are exposed to in the modern workplace including: quantitative (high speed, no time to finish work in regular working hours), qualitative (increased complexity), emotional (emotional load due to direct contact with customers i.e. service relationship situations), and often physical loads as well (houtman et al., ) . the widespread use of information and communication technology (ict) has led to work intensification. developments in technology use in terms of mechanization, automation, and computerization, has led to the substitution of human activities by machines. on the other hand, the use of computers and smart phones with internet access provides easy access to all kinds of information but may also lead to the expectation from colleagues, supervisors and clients that one is always available and can be contacted (e.g. by email). ict work may then lead to stress symptoms due to excessive working hours, workload and increasing complexity of tasks or isolation in home workers; information overload; pressure of having to constantly upgrade skills; human relationships replaced by virtual contacts; and physical impairments such as repetitive strain injuries and other msds due to using inadequate or ergonomically unadapted equipment (houtman et al., ) . psychosocial hazards such as high job demands and low control have been systematically found to be causally linked to cardiovascular heart disease (e.g. backé, seidler, latza, rossnagel, & schumann, ; eller et al., ) , msds (e.g. da costa & vieira, ) as well as mental health problems such as depression and anxiety (e.g. bonde, ; netterstrom et al., ) . in addition, long term absence and disability are causally related to these types of risks (e.g. duijts, kant, swaen, brandt, & van den zeegers, ) . furthermore, as the labour market shifts towards the service industry, emotional demands at work increase with harassment or bullying and violence contributing to this increase (houtman et al., ) . those affected by violence and harassment in the workplace tend to report higher levels of work-related ill health. the proportion of workers reporting symptoms such as sleeping problems, anxiety and irritability is nearly four times greater among those who have experienced violence, bullying and harassment than amongst those who have not (houtman et al., ) . nanotechnology has been defined as the design, characterization, production and application of structures, devices and systems by controlling shape and size at nanometre scale (eu-osha, ). due to their small size, engineered nanomaterials (enms) have unique properties that improve the performance of many products. nanomaterials have applications in many industrial sectors (currently the main areas are materials and manufacturing industry including automotive, construction and chemical industry, electronics and it, health and life sciences, and energy and environment). a key issue of enms is the unknown human risks of the applied nanomaterials during their life cycle, especially for workers exposed to enms at the workplace. workers in nanotechnology may be exposed to novel properties of materials and products causing health effects that have not yet been fully explored. the manufacture, use, maintenance and disposal of nanomaterials may have potential adverse effects on internal organs (eu-osha, ). although there is a considerable lack of knowledge, there are indications that because of their size, enms can enter the body via the digestive system, respiratory system or the skin. once in the body, enms can translocate to organs or tissue distant from the portal of entry. such translocation is facilitated by the propensity of the nanoparticles to enter cells, to cross membranes and to move along the nerves (iavicoli & boccuni, ) . the enms may accumulate in the body, particularly in the lungs, the brain and the liver. the basis for the toxicity appears to be primarily expressed through an ability to cause inflammation and to raise potential for autoimmune deficits, and may induce diseases such as cancer (houtman et al., ) . other dangerous substances concerns include diesel exposure and its link to lung cancer and non-cancer damage to the lung; and man-made mineral fiber exposure (classified as being siliceous or non-siliceous) and the link of their structure to inflammatory, cytotoxic and carcinogenic potential (houtman et al., ) . another three chemical risks have been identified as emerging with a view to allergies and sensitizing effects. they are epoxy resins, isocyanates and dermal exposure (eu-osha, ). epoxy resins have become one of the main causes of occupational allergic contact dermatitis. skin sensitization of the hands, arms, face, and throat as well as photosensitization have also been reported. isocyanates are powerful irritants to the mucous membranes of the eyes and of the gastrointestinal and respiratory tracts. direct skin contact can cause serious inflammation and dermatitis. isocyanates are also powerful asthmatic sensitizing agents (houtman et al., ) . finally, risks related to global epidemics are the most important biological risk issue. pathogens such as the severe acute respiratory syndrome (sars), ebola, and marburg viruses are new or newly recognized. in addition, new outbreaks of wellcharacterized outbreak-prone diseases such as cholera, dengue, measles, meningitis, and yellow fever still emerge (houtman et al., ) . it should be stressed that the profile of risks in the workplace constantly changes and there are additive effects that exacerbate negative impacts. the following section provides an overview of key challenges in relation to hsw in the modern workplace while also acknowledging the lack of research in relation to some of the new and emerging risks identified earlier. the ilo has published global estimates of fatal and non-fatal occupational (ilo, ) and fatal work-related diseases (ilo, b). . million deaths occur annually across countries for reasons attributed to work. over , are caused by occupational accidents while the biggest mortality burden comes from work-related diseases, accounting for about million deaths. globally, cardiovascular and circulatory diseases at % and cancers at % were the top illnesses responsible for / of deaths from work-related diseases, followed by occupational injuries at % and infectious diseases at %. as a result, approximately people die every day due to these causes: occupational accidents kill nearly people every day and work-related diseases provoke the death of approximately more individuals. there were also over million non-fatal occupational accidents (requiring at least four days of absence from work) in , meaning that occupational accidents provoke injury or ill health for approximately , people every day (ilo, b). major industrial accidents are stark reminders of the unsafe conditions still faced by many. for example, the april collapse of the rana plaza building in bangladesh resulted in the death of individuals and injured more, mostly factory workers making garments for overseas retail chains. the international community has since expressed concerns about market pressures which strive to keep basic production costs low, the role of national authorities, and the responsibilities of multinational enterprises and other stakeholders in supply chains towards the health and safety of workers. hazardous sectors such as mining, construction, shipping, and in particular fishing continue to take a heavy toll on human lives and health. meanwhile, the nuclear industry continues to pose serious problems regarding the radiological protection of site workers and the environment. in particular, the protection of emergency workers at the fukushima daiichi power plant in japan has become a focus of international attention since the east japan earthquake. occupational health has recently become a much higher priority, in light of the growing evidence of the enormous loss and suffering caused by occupational diseases and ill health across many different employment sectors. even though it is estimated that fatal diseases account for about % of all work-related fatalities, more than half of all countries do not provide official statistics for occupational diseases (ilo, b). these therefore remain largely invisible, compared to fatal accidents. moreover and as discussed previously, the nature of occupational diseases is changing rapidly, as new technologies and global social changes aggravate existing health risks and create new ones. for example, long-latency diseases include illnesses such as silicosis and other pneumoconioses, asbestos-related diseases and occupational cancers that may take decades to manifest. such diseases remain widespread, as they are often undiagnosed until they result in permanent disability or premature death. pneumoconioses account for a high percentage of all occupational diseases. for example, in latin america, there is a % prevalence rate of silicosis amongst miners, and this figure reaches % among miners over the age of . in vietnam, pneumoconioses account for . % of all compensated occupational diseases (ilo, b) . the use of asbestos has been banned in more than counties, including all eu member states, but the number of deaths from asbestos-related diseases is increasing in many industrialized countries because of exposure that occurred during the s and later. in germany and the uk, for example, the number of deaths from asbestos-induced mesothelioma has been increasing for some years and was expected to peak in - (health & the number of cases of work-related stress, violence and psychosocial disorders has also been increasing. these have often been attributed at least in part to recession-driven enterprise restructuring and redundancies which can be very damaging psychologically. european studies have shown that a large and rapid rise in unemployment has been associated with a significant increase in suicide rates (e.g. lundin & hemmingsson, ). meanwhile, a review of mortality studies in countries across the world has also shown an increase in cardiovascular mortality rates by an average of . % in periods of crisis (falagas, vouloumanou, mavros, & karageorgopoulos, ) . the impact of the issues discussed in this section is presented in chapter . on the basis of the available evidence, it is now recognized that a new paradigm of prevention is required, one that focuses on work-related diseases and not only on occupational injuries. recognition, prevention and treatment of both occupational diseases and accidents, as well as the improvement of recording and notification systems are high priorities for improving the health of individuals and the societies they live in. several perspectives and associated approaches have been taken to promote hsw in the workplace over the years as priorities change and new issues and knowledge emerge. the following section will provide an overview of some key perspectives that have led to the development of modern holistic models to promote hsw in the workplace. the field of occupational health and safety has been defined as the science of the anticipation, recognition, evaluation and control of hazards arising in or from the workplace that could impair the hsw of workers, taking into account the possible impact on the surrounding communities and the general environment (alli, ) . given the broad scope of this definition, several disciplines are relevant to osh that relate to control of the multitude of hazards in the workplace. furthermore, since social, political, technological and economic changes are constantly impacting upon the workplace, the field of osh has been evolving to address new and emerging issues in line with different perspectives. some disciplines of relevance to osh include engineering, ergonomics, toxicology, hygiene, medicine, epidemiology, psychology, sociology, education, and policy. these disciplines often diverge in terms of theoretical foundation and as a result emphasize different aspects in terms of understanding and dealing with osh issues. however, in recent years there has been convergence in thinking about the work environment and a trend towards more holistic perspectives and approaches when considering hsw. indeed, while hsw issues were in the past approached from a mono-disciplinary perspective, multi-disciplinarity is now advocated as the necessary way forward. however, in practice osh professionals often still employ mono-disciplinary perspectives in dealing with accidents and diseases in the workplace, seeking to protect individual workers rather than preventing negative impacts of the work environment and promoting positive outcomes. solely focusing on ameliorating harm rather than promoting hsw has also been criticized in recent years by scholars emphasizing a salutogenic (health promoting) instead of a pathogenic (disease preventing) perspective. let us now consider some of these approaches further in relation to safety, health and well-being. it has been argued that occupational safety has developed and evolved through three ages: . a technical age, . a human factors age, and . a management and culture age (hale & hovden, ) (or as hudson, described them through a technical wave, a systems wave and a culture wave). several authors have since then suggested new ages in safety science. the first age of safety concerned itself with the technical measures to guard machinery, stop explosions and prevent structures collapsing. it lasted from the nineteenth century through until after the second world war and was interested in accidents having technical causes (hale & hovden, ) . the period between the world wars saw the development of research into personnel selection, training and motivation as prevention measures, often based on theories of accident proneness (see hale & glendon, for a review; burnham, for the accident-prone theory). this brought about the second age of safety, which developed separately to technical measures until the period of the s and s, when developments in probabilistic risk analysis and the rise and influence of ergonomics led to a merger of the two approaches in health and safety. there was a move away from an exclusive dominance of the technical view of safety in risk analysis and prevention, and the study of human error and human recovery or prevention came into its own (hale & hovden, ) . just as the second age of human factors was ushered in by increasing realizations that technical risk assessment and prevention measures could not solve all problems, so were the s characterized by an increasing dissatisfaction with the idea that health and safety could be captured simply by matching the individual to technology. in the s management and culture were the focus of development and research, based on many influential thinkers such as heinrich who published his ground-breaking safety management textbook in heinrich, , the sociotechnical management literature (e.g. elden, ; thorsrud, ; trist & bamforth, ) , the social organizational theory of lewin ( ) , the loss prevention approach (bird, ) , and the introduction of participative management in safety (e.g. simard & marchand, ) . however, reason ( ) contended that an over-reliance on osh management systems and insufficient understanding of, and insufficient emphasis on, workplace culture, can lead to failure because "it is the latter that ultimately determines the success or failure of such systems" (p. ). criticism of overreliance on systems was also influenced by the resilience engineering school that posited that instead of focusing on failures, error counting and decomposition, we should address the capabilities to cope with the unforeseen. the ambition is to 'engineer' tools or processes that help organizations to increase their ability to operate in a robust and flexible way. hopkins ( ) views safety culture as one aspect of organizational culture, or more particularly an organizational culture that is focused on safety. further, culture is viewed as a group, not an individual, phenomenon; efforts to change culture, should, in the first instance, focus on changing collective practices (the practices of both managers and workers) and the dominant source of culture is what leaders pay attention to. much of hopkins' work draws on reason's ( ) notion that a safe culture is an informed culture and sutcliffe's ( , ) principles of collective mindfulness and high reliability organizations (i.e. organizations that are able to manage and sustain almost error-free performance despite operating in hazardous conditions where the consequences of errors could be catastrophic). collective mindfulness is based on the premise that variability in human performance enhances safety whilst unvarying performance can undermine safety, particularly in complex socio-technical systems. glendon, clarke, and mckenna ( ) argued that each of the first three periods of development build on one another and refer to this process of development as the fourth age of safety or the integration age where previous ways of thinking are not lost, but remain available to be reflected upon as multiple, more complex perspectives develop and evolve. however, as the limitations of osh management systems and safety rules that attempt to control behaviour have become evident, it has also been proposed that a fifth age of safety has emerged, the adaptive age; an age which transcends the other ages of safety. the adaptive age challenges the view of an organizational safety culture and instead recognizes the existence of socially constructed sub-cultures. the adaptive age embraces adaptive cultures and resilience engineering and requires a change in perspective from human variability as a liability and in need of control, to human variability as an asset and important for safety (borys, else, & leggett, ) . resilience engineering is similar to collective mindfulness since it also focuses on the importance of performance variability for safety. however, what sets resilience engineering apart from collective mindfulness is the focus on learning from successful performance (hollnagel, ) , i.e. why things go right as well as why things go wrong (also called the safety approach (hollnagel, ) . one particular major development in the safety evolution was the move towards managing risks in the work environment. this implied that it is impossible to completely control all aspects of work to avoid negative outcomes, risks always remain. in an ever-changing work environment, a continuous assessment of risks is needed that will point to key risks that may pose a threat to workers' hsw. these then need to be managed following appropriate actions at various levels with the focus being on prevention. the risk management paradigm has been hugely influential not only in terms of managing safety but also managing health as will be discussed in the following sections. let us then consider it further next. in the wake of the chernobyl disaster in , sociologist ulrich beck published 'risikogesellschaft', later published in english as 'risk society: towards a new modernity' in . beck argued that environmental risks had become the predominant product of industrial society. he defined a risk society as "a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself" (beck, , p. ) . while according to british sociologist anthony giddens ( ) , a risk society is a society that is increasingly preoccupied with the future (and also with safety), which generates the notion of risk. giddens ( ) defined two types of risks as external risks (for example natural disasters) and manufactured risks (for example, those derived from industrial processes. as manufactured risks are the product of human activity, authors like giddens and beck argue that it is possible for societies to assess the level of risk that is being produced, or that is about to be produced, in order to mitigate negative outcomes (i.e. responsibility with managing these risks lies with society and more precisely with experts able to do so). one such area is osh risk management. hazard, something that can cause harm if not controlled, is a key term in osh risk management. the outcome is the harm that results from an uncontrolled hazard. in the context of osh, harm describes the direct or indirect degradation, temporary or permanent, of the physical, mental, or social well-being of workers. a risk is a combination of the probability that a particular outcome will occur and the severity of the harm involved (nunes, ) . hazard identification or assessment is an important step in the overall risk assessment and risk management process. through this, hazards are identified, assessed and controlled/eliminated as close to source as reasonably as possible. as technology, resources, social expectations or regulatory requirements change, hazard analysis focuses control measures more closely towards the source of the hazard aiming at prevention. hazard-based programmes may not be able to eliminate all risks to hsw but they avoid implying that there are 'acceptable risks' in the workplace (nunes, ) . a risk assessment needs to be carried out prior to making an intervention. this assessment should identify hazards, identify all affected by the hazard and how, evaluate the risk, and identify and prioritize appropriate control measures. the calculation of risk is based on the likelihood or probability of the harm being realized and the severity of the consequences. the assessment should be recorded and reviewed periodically and whenever there is a significant change to work practices. the assessment should include practical recommendations to control the risk. once recommended controls are implemented, the risk should be re-calculated to determine if it has been lowered to an acceptable level (nunes, ) . risk assessment and calculation is usually easier as regards physical risks but more complex as regards biological, and even more so psychosocial, risks. despite this, the risk management paradigm has been applied to all these types of risks to hsw, and is used extensively both as concerns occupational injury and occupational health. it also represents the cornerstone of osh legislation across countries. osh management systems are based on this paradigm (see chapter for more details). following the pdca (plan-do-check-act) cycle methodology (deming, ) , risk management is a systematic process that includes the examination of all characteristics of the work system where the worker operates, namely, the workplace, the equipment/machinery, materials, work methods/practices and work environment. the main goal of risk management is to eliminate or at least to reduce the risks that cannot be avoided or eliminated to an acceptable level. risk management measures should follow the hierarchy of control principles of prevention, protection and mitigation. worker participation is key in the process of risk management. the risk management process should be reviewed and updated regularly, for instance every year, to ensure that the measures implemented are adequate and effective. additional measures might be necessary if the improvements do not show the expected results (nunes, ) . periodic risk management is also important since workplaces are dynamic due to changes in equipment, substances or work procedures, and new hazards might emerge. another reason is that new knowledge regarding risks can become available, either leading to the need of an intervention or offering new ways of controlling the risk. the review of the risk management process should consider a variety of types of information and draw them from a number of relevant perspectives (e.g. staff, management, stakeholders). however, risk management has been criticized for focusing too heavily on avoiding (controlling) possible negative outcomes and not promoting positive and healthy work environments. this development in thinking has stemmed from a parallel move from pathogenic to salutogenic approaches in health and its management. this evolution in thinking about health and well-being will be considered next. approaches in occupational health and occupational hygiene have evolved in line with developments in several disciplines, including safety engineering, medicine and psychology. the risk management perspective is the cornerstone of occupational hygiene as is evident by its definition. the international occupational hygiene association (ioha, n.d.) refers to occupational hygiene as the discipline of anticipating, recognizing, evaluating and controlling health hazards in the working environment with the objective of protecting worker health and well-being and safeguarding the community at large. although occupational health definitions similarly place great focus on managing risk factors, they overall refer to the promotion and maintenance of health and well-being of employees. similarly to the evolution of perspectives in safety, these definitions have been influenced by the evolution of thinking on health and well-being over the years (schulte & vainio, ) . perspectives on health and illness started with a focus on pathogenesis, as pioneered and developed by williamson and pearse ( ) which is the study of disease origins and causes. pathogenesis starts by considering disease and infirmity and then works retrospectively to determine how individuals can avoid, manage, and/or eliminate that disease or infirmity. the dose-response relationship of the change in effect on an organizm caused by differing levels of exposure (or doses) to a stressor after a certain exposure time was influential in treating disease and illness (as was in chemical safety). this leads professionals using pathogenesis to be reactive because they respond to situations that are currently causing or threatening to cause disease or infirmity (becker, glascoff, & felts, ) . a major shift came in with antonovsky's concept of salutogenesis, the study of health origins and causes, which starts by considering health and looks prospectively at how to create, enhance, and improve physical, mental and social well-being (antonovsky, ) . the assumption of salutogenesis that action needs to occur to move the individual towards optimum health, prompts professionals to be proactive because their focus is on creating a new higher state of health than is currently being experienced (antonovsky, ) . the difference between the biomedical model (based on pathogenesis) and health promotion which is now the cornerstone of public health (based on salutogenesis) is a move away from risk and disease towards resources for health and life (eriksson & lindström, ) , initiating processes not only for health but wellbeing and quality of life. perceived good health is a determinant of quality of life. according to breslow ( ) , the first era of public health involved combating communicable diseases while the second dealt with chronic diseases. their focus was on developing and maintaining health since health provides a person the potential to have the opportunity and ability to move towards the life they want. to facilitate management of health in the first two eras, measurement of the signs, symptoms and associated risks of disease and infirmity were of paramount importance. in the third era of public health most people expect a state of health that enables them to do what they want in life. to facilitate management of an evolved health status, it is necessary to develop new health measures that must go beyond detecting pathogenesis and its precursors to measuring those qualities associated with better health (breslow, ) . however, salutogenesis also presumes that disease and infirmity are not only possible but likely because humans are flawed and subject to entropy (antonovsky, ) . according to a salutogenic perspective, each person should engage in health promoting actions to cause health while they secondarily benefit from the prevention of disease and infirmity. pathogenesis, on the other hand in a complementary fashion primarily focuses on prevention of disease and infirmity, with a secondary benefit of health promotion. both approaches are needed to facilitate the goal of better health and a safer and more health enhancing environment. pathogenesis improves health by decreasing disease and infirmity and salutogenesis enhances health by improving physical, mental, and social well-being. together, these strategies will work to create an environment that nurtures, supports, and facilitates optimal well-being (becker et al., ) . around the same time when salutogenesis was introduced, in a article in science, psychiatrist george l. engel introduced a new medical model, the biopsychosocial model. the biopsychosocial model is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc.), psychological factors (mood, personality, behaviour, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.) . it holds to the idea that biological, psychological, and social processes are integrally and interactively involved in physical health and illness. it was pioneering in advocating the premise that people's psychological experiences and social behaviours are reciprocally related to biological processes. as a result, interventions should address all these dimensions and not narrowly focus on limited perspectives (such as only the biological perspective for example). more focus was now placed on psychological and social factors in the understanding of health and illness. indeed, the traditional medical model of ill health was increasingly recognized as having achieved limited success in tackling occupational health conditions such as stress, anxiety, depression and msds (white, ) . these challenges which have been shown to now have an increasing prevalence in the workplace (as discussed earlier), do not have a clear underlying physical basis nor do they demonstrate a linear relationship between injury, pain and disability. instead, they appear to be strongly mediated by psychological and social factors. accordingly, waddell ( ) categorized such conditions as 'common health problems'. the challenges presented by common health problems contrasts with the past success of occupational medicine in dealing with conditions that have an identifiable cause and a clear relationship between dose and response (waddell & burton, ) . the psychological models that were developed within the fields of occupational, and occupational health psychology, mainly to make sense of the concept of stress, were similarly influenced by conceptualizations of health, illness and safety. early models viewed stress either as a noxious stimulus in the environment (engineering models, derived from engineering) or a response to exposure to aversive of noxious characteristics of the environment (physiological models, derived from medicine). contemporary models focus on the interaction between the environment and the individual and emphasize either explicitly or implicitly the role of psychological processes, such as perception, cognition, and emotion (psychological models). these appear to determine how the individual recognizes, experiences, and responds to stressful situations, how they attempt to cope with that experience and how it might affect their physical, psychological, and social health (cox & griffiths, ) . the risk management paradigm remains an influential perspective in dealing with new and emerging risks in the psychosocial work environment. however, while we are a long way from the challenge of work-related stress being tackled effectively, there has started to be a shift towards promoting well-being at work and not only preventing stress and its associated negative outcomes in terms of both health and safety. this shift has followed trends in public health (discussed earlier) and also psychology towards more positive concepts. the positive psychology movement, championed by seligman and csikszentmihalyi ( ) , is an attempt to shift the emphasis in psychology away from a preoccupation with the pathological, adverse and abnormal aspects of human behaviour and experience. the positive psychology literature offers a number of perspectives that help with understanding how well-being can arise in work situations (lunt et al., ) . for example, the concept of flow was introduced by csikszentmihalyi ( ) which can be defined as a subjective condition where an individual is fully absorbed in, and engaged with, the task he or she is carrying out, promoting an experience of competence and fulfillment. as is evident from our discussion on perspectives on hsw so far, several useful models have been proposed from various disciplines with parallel developments can be observed across these disciplines. however, it should also be noted that often scholars and practitioners operate in silos, ignoring the interplay among the various approaches, and lessons that can be learned from one another. the recent focus on well-being has brought about the question of whether approaches in the workplace should focus only on factors influencing the individual's experience in the work environment or wider influences, considering more the social determinants of health discussed at the beginning of this chapter. in line with this thinking, some holistic models have emerged that recognize the interplay between workplace and non-workplace factors in determining hsw that will be discussed next. the starting point in the development of holistic models of hsw is the recognition that safety and health are different to well-being. as discussed at the beginning of this chapter, well-being refers to a good or satisfactory condition of existence; a state characterized by health, happiness, and prosperity. in particular, three key concepts have been discussed as relevant to well-being: happiness, quality of life and resilience (lunt et al., ) . layard ( ) defined happiness as feeling good; its inverse is feeling bad and wishing for a different experience. factors that affect our levels of happiness include among others family relationships, our financial situation, work, community and friends, our health, personal freedom and personal values. quality of life overlaps with contemporary interpretations of happiness. quality of life is a subjective state that encompasses physical, psychological, and social functioning. a defining feature of quality of life is its basis on the perceived gap between actual and desired living standards. resilience of individuals has been described as partly a context dependent characteristic, in that what enables resilience in one environment may be less adaptive in another (lunt et al., ) . increasingly it is recognized that resilience is important at different organizational levels (teams, organizations) and that these different levels are to some degree interacting (e.g. schelvis, zwetsloot, bos, & wiezer, ) . it is also important to recognize that even though well-being at work may be primarily an employer's responsibility (as well as the worker's), well-being of the worker or workforce is also the responsibility of others in society (e.g. governments, insurance companies, unions, faith-based and non-profit organizations) or may be affected by non-work domains (schulte et al., -see also chapter ). indeed, the well-being of the workforce extends beyond the workplace, and public policy should consider social, economic, and political contexts. schulte et al. ( ) also provide examples of holistic policy models aiming at the promotion of well-being in the workplace that include the who healthy workplace model and the niosh total worker health model (discussed in the next chapter). to promote hsw holistically, there needs to be synergy and integration among the various perspectives. to achieve this, these perspectives need to be aligned considering current knowledge and existing needs, developing capabilities, and mainstreaming a strategic approach in policy and practice. the following chapter considers key policy approaches to managing hsw at the macro level (international, regional, national), meso level (sectoral), and micro level (organizational). subsequent chapters further consider how alignment across perspectives can be achieved in policy and practice. this chapter has provided an overview of the current state of the art in relation to hsw in the workplace as regards key determinants, outcomes and perspectives. with the changing nature of work and new characteristics of the workforce, new challenges are emerging in the workplace. perspectives on how to address these challenges have changed in line with these developments as well as the evolution of knowledge and the impact of wider socio-economic and political factors. emerging issues such as psychosocial factors, the increasing prevalence of non-communicable diseases, and the shift towards well-being (and not merely safety and health) demand new ways of thinking in addressing hsw in the workplace. continuing to work in silos and adopting mono-disciplinary perspectives will not allow us to move forward in this complex landscape. a strategic alignment of perspectives and integrated approaches are needed. this book aims to promote a way forward by outlining and critically evaluating developments in hsw in the workplace, and providing a framework for action in policy and practice. fundamental principles of occupational health and safety gender and jobs: sex segregation of occupations in the world health, stress and coping the salutogenic model as a theory to guide health promotion content, cause, and consequences of job insecurity: a theory-based measure and substantive test the role of psychosocial stress at work for the development of cardiovascular diseases: a systematic review risk society: towards a new modernity salutogenesis years later: where do we go from here? the consequences of flexible work for health: are we looking at the right place precarious employment and health: developing a research agenda employment, work and health inequalities: a global perspective how do types of employment relate to health indicators? findings from the second european survey on working conditions facts and misconceptions about age, health status and employability management guide to loss control psychosocial factors at work and risk of depression: a systematic review of the epidemiological evidence epidemiology of work related neck and upper limb problems: psychosocial and personal risk factors (part i) and effective interventions from a bio behavioural perspective (part ii) the fifth age of safety: the adaptive age trial by fire: a multivariate examination of the relation between job tenure and work injuries health measurement in the third era of health prevalence and associated factors for thoracic spine pain in the adult working population: a literature review working conditions in the european union: the gender perspective accident prone: a history of technology, psychology, and misfits of the machine age incidence and suspected cause of workrelated musculoskeletal disorders age stereotypes and discriminatory attitudes towards older workers: an east-west comparison work-related stress: a theoretical perspective can better working conditions improve the performance of smes? an international literature review flow: the psychology of optimal experience risk factors for work-related musculoskeletal disorders: a systematic review of recent longitudinal studies literature review of theory and research on the psychological impact of temporary employment: towards a conceptual model at least five a week: evidence on the impact of physical activity and its relationship to health (a report from the chief medical officer) a meta-analysis of observational studies identifies predictors of sickness absence work-life balance in the new millennium: where are we? where do we need to go? democratization and participative research in the developing of local theory work-related psychosocial factors and the development of ischemic heart disease: a systematic review the need for a new medical model: a challenge for biomedicine a salutogenic interpretation of the ottawa charter working hours and health in flexible work arrangements women, men and working conditions in europe how to tackle psychosocial issues and reduce work-related stress priorities for occupational safety and health research in the eu- expert forecast on emerging psychosocial risks related to occupational safety and health european agency for safety and health at work (eu-osha) priorities for occupational safety and health research in europe communication from the commission to the european parliament, the council, the european economic and social committee and the committee of the regions -towards common principles of flexicurity: more and better jobs through flexibility and security report on the current situation in relation to occupational diseases' systems in eu member states and efta/eea countries, in particular relative to commission recommendation / /ec concerning the european schedule of occupational diseases and gathering of data on relevant related aspects health and safety at work in europe gender, jobs and working conditions in europe economic crises and mortality: a review of the literature employment status and health after privatisation in white collar civil servants: prospective cohort study globalization and labor conditions: working conditions and worker rights in a global economy consequences of modernity risk and responsibility human safety and risk management ageing, health and productivity: a challenge for the new millennium healthy work for older workers: work design and management factors individual behaviour and the control of danger management and culture: the third age of safety. a review of approaches to organizational aspects of safety, health and environment rr -projection of mesothelioma mortality in great britain industrial accident prevention: a scientific approach resilience: the challenge of the unstable safety i and safety ii: the past and future of safety management lessons from gretley: mindful leadership and the law monitoring new and emerging risks trends in quality of work in the netherlands implementing safety culture in a major multi-national challenges and perspectives of occupational health and safety research in nanotechnologies in nanotechnologies in europe the ageing workforce-challenges for occupational health protecting workplace safety and health in difficult economic times -the effect of the financial crisis and economic recession on occupational safety and health statutory occupational health and safety workplace arrangements for the modern labour market use of technology and working conditions in the european union aging, adult development, and work motivation globalization and workers' health health in restructuring: innovative approaches and policy recommendations ergonomics and technology transfer into small and medium sized enterprises new systems of work organization and workers' health work related and individual predictors for incident neck pain among office employees working with video display units perceptions of psychosocial hazards, work-related stress and workplace priority risks in developing countries safety considerations for the aging workforce happiness: lessons from a new science the european framework for psychosocial risk management (prima-ef) field theory in social science: selected theoretical papers women's occupational health in globalization and development unemployment and suicide. the lancet applying the biopsychosocial approach to managing risks of contemporary occupational health conditions: scoping review psychosocial stressors associated with mexican migrant farmworkers in the midwest united states women in africa's development: overcoming obstacles, pushing for progress career-relevant learning and development, worker age, and beliefs about selfefficacy for development one eyed science: occupational health and women workers age and working conditions in the european union the relation between work-related psychosocial factors and the development of depression occupational safety and health risk assessment methodologies ergonomics in industrially developing countries: does its application differ from that in industrially advanced countries? globalization and emerging economies. paris: organization for economic co-operation and development. organization for economic co-operation and development a good life in old age? monitoring and improving quality in long-term care. paris: organization for economic co-operation and development convergence and divergence of working conditions in europe building healthy and equitable workplaces for women and men: a resource for employers and workers representatives workers' compensation and the challenges posed by changing patterns of work: evidence from australia. policy and practice in health and safety the global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research managing the risks of organizational accidents women's employment in europe: trends and prospects aging, job performance, and career development the changing organization of work and the safety and health of working people: knowledge gaps and research directions exploring teacher and school resilience as a new perspective to solve persistent problems in the educational sector -a case of the netherlands. teachers and teaching: theory and practice considerations for incorporating "well-being" in public policy for workers and workplaces well-being at work -overview and perspective employee health and presenteeism: a systematic review positive psychology: an introduction the labour market outcomes and psychological well-being of ethnic minority migrants in britain. london: home office a multilevel analysis of organizational factors related to the taking of safety initiatives by work groups age differences in safety attitudes and safety performance in hong kong construction workers prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature no security: a meta-analysis and review of job insecurity and its consequences globalization of risks organization development from a scandinavian point of view. doct. / some social and psychological consequences of the longwall method of coal-getting correlates of adult participation in physical activity: review and update occupational sitting and health risks: a systematic review temporary employment and health: a review the gender workplace health gap in europe predicting long-term incapacity for work: the case of low back pain is work good for your health and well-being? london: the stationery office differences among demographic groups and implications for the quality of working life and work satisfaction age and job performance managing the unexpected managing the unexpected biopsychosocial medicine: an integrated approach to understanding illness science, synthesis, and sanity: an inquiry into the nature of living lean thinking: banish waste and create wealth in your corporation global population ageing: peril or promise? preamble to the constitution of the world health organization. official records of the world health organization, , . world health organization (who) raising awareness of stress at work in developing countries: a modern hazard in a traditional working environment: advice to employers and worker representatives world health organization (who) sedentary behaviours and epithelial ovarian cancer risk key: cord- - orflz authors: vuolo, mike; kelly, brian c.; roscigno, vincent title: covid- mask requirements as a workers’ rights issue: parallels to smoking bans date: - - journal: am j prev med doi: . /j.amepre. . . sha: doc_id: cord_uid: orflz nan considerable public debate has emerged regarding the importance of wearing masks to prevent the spread of coronavirus disease (covid- ) , and thus whether they should be required in workplaces. recognizing precedents for constraining individual behavior within workplaces, this article draws parallels to smoking bans and argues that mask requirements should be considered fundamental occupational health protections. as with smoking in confined spaces dispersing environmental tobacco smoke, mask-less patrons exacerbate risks for workers via the diffusion of respiratory droplets. the context of indoor environments matters for the prevention of these potential health hazards. smoke particulates diffuse in confined spaces to those nearby, accumulating to levels that can result in or aggravate health conditions. , for covid- , confined indoor spaces facilitate the diffusion of respiratory droplets containing the virus-diffusion that can be reduced by masks. although valid reasons exist to require masks outdoors where individuals congregate, this article focuses on indoor requirements because delays in addressing this issue, especially as states reopen with varying degrees of rapidity, will very likely be detrimental to public health and particularly the well-being of frontline workers. the sources of implementation of workplace mask requirements vary. like smoke-free environments, private businesses are free to implement mask requirements for customers and employees even absent public policy. some, however, choose not to implement requirements owing to fears of alienating customers, some of whom, as protests have revealed, view the imposition of health guidelines as an infringement on individual liberties. for the sake of occupational health, state and local governments should take an active stance to promote mask wearing in workplaces for the enhancement of population health in general, but the health of frontline workers in public-facing industries in particular. responding to images of mask-less crowds patronizing recent business re-openings, u.s. health secretary azar said, "that's part of the freedom we have here in america." this encapsulates the main argument against mask requirements, as something akin to infringement on individual liberties. notably, similar arguments have been expressed regarding smoking in workplaces. individual liberties should not be taken lightly, of course, but such liberties do not extend to the imposition of risk to others. even political philosophies emphasizing personal liberties over state intervention, such as libertarianism and liberalism, recognize the limits of rights to the point of harm to others. [ ] [ ] [ ] yet, as demonstrated by viral videos showing confrontations between employees and customers, many individual liberty proponents are defensive even with precedents for restricting certain liberties for the sake of reducing hazards to others. indeed, this point was summarized well by craig jelinek, president and ceo of costco, who stated, "this is not simply a matter of personal choice; a face covering protects not just the wearer, but others too… and our employees are on the front lines." similar to smoking inside retail shops, restaurants, or public transportation, today's mask-less patron impedes workers' rights to safe and healthy occupational environments in addition to posing risks to other patrons. although a mask refuser or smoker might argue that other patrons could simply frequent mask-wearing/smoke-free establishments, or even not go out at all, such logic neglects workplace rights and risks to workers' health. this point is all the more pressing considering that: ( ) the primary rationale against stay-at-home orders was to return workers to their jobs and ( ) many states have indicated that workers who refuse would forego unemployment benefits. this creates a difficult choice, as workers cannot simply change jobs in the face of emergent health risks, especially given difficulties finding employment in another field for which one is qualified. moreover, because health policies and job options are geographically determined, workers will likely face the same environment if reemployed elsewhere. there is little reason why debates about indoor mask wearing should not consider the same standards that undergirded original arguments for indoor smoking bans-those grounded in concerns for workplace safety and health, and executed and monitored by local and state agencies. , indeed, decades of research have shown that smoking bans led to measurable improvements in working conditions and worker health. , [ ] [ ] [ ] although the literature on covid- and occupational health is only just developing, studies on mask wearing released thus far imply that frontline workers will spend long hours with potential exposure to covid- and its harms without similar protections or oversight. although some (e.g., individual rights proponents) will cry foul about uniform protections being an attack on individual liberty or business functioning and profit, it is important to recognize that smoking bans were originally contested for the same reasons but now are less often viewed as such. extending mask requirements to the types of workplaces that have long been smoke-free, including those in which workers interface with the public-such as retail and transportation/travel-is essential for the health and safety of workers. although smoke-free policies are not universal in restaurants and bars (contested locations for mask wearing as well), existing smoking bans offer a clear precedent-a precedent wherein worker's rights to a healthy work environment ultimately take precedence over patrons' preferences. private business owners may resist, viewing any government intervention as an affront to a free market and business rights. such tensions, however, are hardly new. there is a long history of pitting business interests against labor generally and the rights of workers to security, fair compensation, and safety and health in the u.s. although workers have tended to be on the losing end of these battles for the last several decades, federal and state governments are more inclined to intervene during times of economic instability in a manner that is simultaneously good for workers and business. here too, there are parallels to smoking bans. many service-industry owners initially argued that they would lose revenue if they obeyed smoking bans, yet such revenue disruptions did not materialize. this was due, in part, to the fact that the geographic nature of bans restricts customer alternatives. indoor mask requirements for the sake of employees, and other patrons as well, would work similarly if federal, state, and local governments take a stronger stance for their citizenry and those workers most at risk. intimately tied to the question of workers' rights to a healthy workplace and potential oversight/protections are concerns about inequality. the particular flashpoints for both smoking bans and mask requirements are public-facing workplaces, particularly in service and retail industries. these sectors are disproportionately composed of lower wage and racial/ethnic minority workers. in this manner, mask requirements within public-facing workplaces may be a key means to reduce covid- inequalities. lower wage and minority workers already experience health disparities, including sicknesses linked to both smoking and covid- . they are also simultaneously disadvantaged when it comes to healthcare access. by urging a return to work without mask requirements, states are essentially requiring vulnerable populations to risk their health for the benefit of patrons. from health and inequality research, including on smoking bans, it is relatively easy to anticipate that not requiring masks in workplaces open to the public will exacerbate inequalities in covid- for already vulnerable segments of the lower-wage and racial/ethnic minority workforce, which will have broader inequitable impact on their families and communities. second, consistent and monitored legal requirements for mask wearing, particularly indoors, will be especially essential for workers' rights to safety and well-being until the pandemic is resolved. as states reopen, some more rapidly than others, the immediate health benefits of mask-centered policy cannot be overstated given current evidence on the role of respiratory particulates in viral transmission and the ability of masks to reduce these particulates. further, for smoking bans and other tobacco control policies, a key behavioral mechanism for change was denormalization ; that is, the process of identifying and defining a behavior as non-normative with the aim of benefitting public health. by emphasizing workers' rights to a healthy working environment, the same mechanisms may be applied to masks. denormalizing mask refusal may lead to wider substantive changes that promote public health, and potentially extend mask wearing more broadly, including to outdoor spaces where people congregate and even beyond the covid- pandemic. mask wearing is ubiquitous in countries in east asia, which some have credited to the normalization of mask-wearing behavior resulting from past epidemics in the region. , thus, if mask wearing can be normalized now through policies targeting covid- , workers may experience reduced risk not only from covid- , but also future airborne epidemics and common illnesses such as influenza. thus, even though mask-wearing requirements can eventually be lifted when the pandemic subsides, there may be long-term benefits to normalizing mask wearing, such that voluntary adoption during influenza season occurs. third, many business owners enforce a smoking ban even when not required by law. in the interests of their workers, businesses should implement mask-wearing policies in locales lacking such laws. as an additional incentive to business owners, the perception of a healthy and safe working climate is associated with increased worker productivity, along with the health benefits to employees. finally, smoking ban enforcement often occurs informally, via business owners, employees, and other patrons, with state authorities stepping in only when violations are consistent. although smoking and mask-wearing violations are both easy to identify, the risk from the smoker is clear from the behavior. it is much more difficult, on the other hand, short of a test, to detect whether an individual is infected with covid- and putting workers at risk. if anything, however, this discrepancy makes indoor mask requirement policies all the more important, as it remains unknown who may pose a risk to workers, especially given the possibility of asymptomatic transmission. given the mortal threat of covid- to some and the possibility of a second wave of the pandemic, clear and consistent policies for mask wearing and enforcement by state and local governments is warranted. having such policies will enable employers to do what is right for patrons while simultaneously conferring on employees the dignity and protections they deserve. much as indoor smoke-free policies do not eliminate all threats to impaired pulmonary and cardiovascular health, indoor mask requirements are unlikely to eliminate all covid- risks to workers. other actions are necessary as well, such as the centers for disease control and prevention's recommendations for businesses: distancing where possible, reducing the need to touch surfaces and disinfecting frequently touched surfaces, and handwashing breaks and proper sanitary practices. nonetheless, as smoking bans greatly reduced exposure to environmental tobacco smoke for workers, mask requirements would greatly reduce exposure to respiratory droplets that enable viral transmission. ultimately, much like stepping outside to smoke, wearing a mask until the pandemic is resolved may feel like a nuisance; however, both pose a relatively small inconvenience when compared with workers' rights to a healthy, safe work environment. science, politics, and ideology in the campaign against environmental tobacco smoke change in indoor particle levels after a smoking ban in minnesota bars and restaurants physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and metaanalysis so far, no spike in coronavirus in places reopening, u.s. health secretary says. reuters second treatise of government: an essay concerning the true original, extent and end of civil government on liberty and other essays a full vindication of the measures of congress video shows costco worker calmly handle customer berating him over mask policy. nbc news do smoking ordinances protect non-smokers from environmental tobacco smoke at work? effects of a smoke-free law on hair nicotine and respiratory symptoms of restaurant and bar workers effects of smoking restrictions in the workplace workplace smoke-free policies and cessation programs among us working adults the achievement of american liberalism: the new deal and its legacies the effect of ordinances requiring smoke-free restaurants and bars on revenues: a follow-up race, gender, and new essential workers during understanding sociodemographic differences in health--the role of fundamental social causes disparities in the population at risk of severe illness from covid- by race/ethnicity and income moving upstream: the effect of tobacco clean air restrictions on educational inequalities in smoking among young adults covid- : should the public wear face masks? perceived workplace health and safety climates: associations with worker outcomes and productivity covid- ): general business frequently asked questions the authors have no conflicts of interest, grant support, or financial disclosures to report. key: cord- -xu zf l authors: ros, maxime; neuwirth, lorenz s. title: increasing global awareness of timely covid- healthcare guidelines through fpv training tutorials: portable public health crises teaching method date: - - journal: nurse educ today doi: . /j.nedt. . sha: doc_id: cord_uid: xu zf l introduction: the current covid- pandemic has prompted a timely response from the healthcare system train a large and diverse group of healthcare workers/responders swiftly. methods: in order to address this need, we created a downloadable pedagogical video content through first-person point-of-view to rapidly train users on covid- procedures in the revinax® handbook mobile app. eight new tutorials were designed through this technology platform to assist healthcare workers/responders caring for covid- patients. a survey was then sent to assess their interest. results: in one-month since the app was created, it was downloaded by , users and a feedback survey determined that the users valued the tutorials in helping them learn covid- procedures efficiently in real-time. the fast-growing number of downloads and positive user feedback evidences that we created a valuable educational tool with an emergent- and growing-demand. discussion: the . % app user response rate, showed largely positive feedback of the covid- tutorial. the fact that these healthcare workers/responders took the time to complete the survey during a pandemic was indicative of its immediate value. further, the app users indicated that they fpv tutorial was rather helpful in addressing their training needs regarding their roles in covid- patient care during the pandemic. conclusion: the tutorials were deployed to offer efficient and rapid global public health educational outreach as a tool to address covid- healthcare training in a timely manner. time to act has never been more crucial than the current coronavirus (hereon referred to as pandemic that has forced the immediate utilization of technology due to social distancing requirements and has also increased a complex set of challenges for the applied medical and public health systems to address in coordination with other countries globally. this situation is truly unprecedented, yet a major concern has been to institute a concerted effort in limiting sources of contamination from the greater population by limiting the number of patients seen that are only symptomatic to hospitals. the rationale for this strategy was to not overwhelm the hospitals capacity to operate and delivery adequate patient care during these trying times and is consistent from what we have learned from flattening the curve as the initial response (branas et al., ) . in the current covid- surge that the world is facing, there is an eminent need to rapidly train many healthcare workers/responders to adapt their job duties to meet the new covid- guidelines (world health organization [who] , ). to implement appropriate patient care in response to covid- , healthcare workers/responders must first protect themselves to ensure patient care can be delivered and second, in order to limit the spread of covid- via patient, person, and other surface contaminations (huh, ) . notably, this patient care control response requires an ever-changing adaptation of workplace, hygiene, and patient care practices for healthcare workers/responders to be able to safely work in a hospital j o u r n a l p r e -p r o o f and if unaffected by covid- are over worked to help curb its spread), which are a significant factor contributing to overwhelming the hospital capacity (adams & walls, ) . thus, in an effort to reduce these challenges, some healthcare professionals are being transferred, re-deployed (i.e., both elective and non-elective) to work in different hospital environments (i.e., between city, county, state, or even country), and perhaps not within their original specialty to help address the covid- pandemic. in some cases of predicted healthcare worker/responder shortages and increases trends for overwhelming hospital capacity, current university/college medical doctors, nurses, etc. are graduating earlier than their degree timeline in an effort to deploy more healthcare workers/responders to support the individuals already in the frontlines (harvey, ) . a fundamental problem that is directly attached to this issue of healthcare worker/responder supply and demand during the covid- pandemic, is how can the healthcare system adequately train such a large number of and diverse group of health-care workers/responders in such a short time-period? the frontline health-care workers/responders must be as best prepared as possible in order to take care of patients. depending upon the healthcare and/or hospital centers in which these health-care workers/responders were stationed, some had time to be trained in a simulated environment, whereas others were trained through online courses for their students (rose, ) . this is also consistent with the social distance requirements to reduce unnecessary close proximity of a formal in-person educational classroom in order to educate and train students as well as j o u r n a l p r e -p r o o f communication sought to provide covid- healthcare workers/responders a means to rapidly create educational content that can be deployed (i.e., at any time including just before any medical/surgical procedure) adequately, efficiently, and meaningfully to best alleviate the issues faced by hospitals, health-care workers/responders, and patients. in particular, the healthcare and/or hospital centers have used videos to share the challenges they faced along with their expertise to better inform their constituents amongst and within their healthcare worker/responder and hospital communities. notably, scientific societies have worked towards producing online courses with video content to help translate and explain the behavioral skills that they would like healthcare workers/responders to acquire and reliably replicate within the real world/applied healthcare environment (e.g., how to properly don and remove personal protective equipment [ppe] to reduce the likelihood of contamination; rush university medical center, ). it is important to note that training videos are easier to create, facilitate, and deploy in such hospital care settings, but offer a passive learning approach that may lack necessary levels of engagement (i.e., lack of sustained and focused attention by the learner). this is critical as such a passive learning format may also create inadvertent lapses or gaps in learning that is expected to be acquired by the health-care worker/responder. ros et al. ( ) has previously described more actively engaging and meaningful way to create and develop pedagogical video content to acquire new skills through the following: ) first person point-of-view (fpv); ) shorter refined chapter modules; ) with additional pedagogical data to reinforce learning new behavioral skills. the fpv has demonstrated a greater value that has shown to translate into increase learner comprehension and a reduction in learner mistakes within the real environment (fiorella et al., ) . this fpv method in creating content that can be more easily acquired and retained by the learner, was initially described using an immersive j o u r n a l p r e -p r o o f virtual reality application (ivra; i.e., which requires a head-mounted display [hmd] ), but also can be deployed more economically and efficiently through a smartphone. given the unprecedented covid- situation, we anticipated the release of a new healthcare worker/responder application with guidelines to scale up and provide rapid training content that could be used on the healthcare workers/responders personal smartphones to increase the efficiency, transferability, and reliability across local and more distant environments through technology as a responsible global public health educational outreach. the content that was developed complied with general data protection regulations (gdpr) for users that chose to download it on their smartphones. the current content was developed to address the covid- healthcare worker/responder needs was modeled from the fpv content that was used to create neurosurgical physician and medical care content (ros et al., ) , but with the aim to apply it to a wider healthcare worker/responder audience. the creation of the learning content (i.e., tutorial) involved the following three steps: first, the procedure was recorded in d from the expert medical professional's fpv (i.e., using the equipment worn by the expert performing the procedure). the fig. presents the hardware set-up on an expert. second, the movie was organized into refined chapter modules corresponding to the different steps of the surgery (i.e., the editing process comprised calibration, synchronization, and stabilization of the two videos). finally, the voice over comments were recorded and the imaging was then drawn along with data that were incorporated into the tutorial. the learning content was extended to create content specifically dedicated to nurses as what was done previously (ros et al., ) . in response to the covid- pandemic and the need for ongoing j o u r n a l p r e -p r o o f surgical interventions, the current tutorial was created and deployed within one week and the first eight novel tutorials were specifically designed for healthcare workers/responder taking care of covid- patients. the rapid production of these tutorials comprised a step-by-step assessment to reliably ensure the learners interest. this included adding three more tutorials on how to safely approach a covid- positive patient. the first tutorials were produced and captures outside of the hospital setting: j o u r n a l p r e -p r o o f -"prone decubitus" (we already recorded this, but for operating room, not for an intensive care unit). the tutorials have been deployed since that can be easily accessed as a the revinax® handbook -nurses app on any healthcare workers'/responders' smart phone that is released as a download on the appstore and the playstore, for both i-phone and android users, respectively. the fig. shows the user interface of the app. following the download and tutorial usage, the healthcare workers/responders were asked to complete a short survey in order to obtain user feedback on this responsible global public health educational outreach technology. the survey questions were as follows: -is the revinax® app a good tool to support you to gain competencies? (answers from "not at all" to "absolutely") -did you get a better understanding of certain procedures expected of you through the tutorials? (yes or no) -more specifically, did the tutorials from the covid- category make you feel ready to take care of these patients? (answers from "not at all" to "absolutely") -more generally, did the tutorials address your training/learning need right now? (not at j o u r n a l p r e -p r o o f pictures. dr john macintyre took a series of photographs of a knee in various degrees of flexion and extension, then suturing them and projected the procedures. it helped medical students to study different aspects of the animated movement. the first time a video was used in lectures was the same year that paul schister filmed patients with parkinson's disease to explain and illustrate their different motor symptoms. notably, the first surgical video was recorded during the first half of the th century. at that time, there were skeptics regarding the pedagogic value of movies, when compared to traditional lectures and more hands-on applied practicum training. for example, medical videos portraying clinical examinations relevant to the discussion of new types of syndromes were shown to students. as the demographic of new generations of students have changed over time (e.g., first-generation immigrant and first-generation college students, etc.; mukherji et al., ) , students may prefer different applied learning formats over a traditional lecture (neuwirth et al., (neuwirth et al., , and the traditional practicum applied learning can be leveraged through an active fpv tutorial (ros et al., ) perhaps better than the passive medical videos. regardless, medical movies have been used progressively and in a variety of ways for public health purposes. they have been most recently used to provide medical explanations and promote disease prevention programs, thereby underlining the pedagogical of transferring education through the power of movies. during the latter half of the th century, british universities developed a large database that includes a variety of medical movies explicitly for study purposes (essex-lopresti, b) . at the beginning of the st century, it became clear that watching medical movies represented an effective way, at least for learning about surgical techniques (hayden et al., ) . thus, surgeons should be encouraged to develop movie j o u r n a l p r e -p r o o f databases for use in their schools or for publication in modern peer-reviewed journals (brunaud, ) . one of the main advantages of the immersive tutorial, in contrast to medical videos, is that it enables the user to live the experience from a fpv: to learn through "the expert's own eyes." an interesting study published by fiorella et al. ( ) compared learning a procedure from a fpv to learning from the opposite side (i.e., non-fpv or opposing observer perspective to mirror the person doing the task). compared to the group that learned from the fpv, the learning from the opposite side group made up to % more mistakes, while reproducing the assembly of an electronic system. these results suggest that fpv learning increases the learners' skill acquisition, comprehension, and behaviors as evidenced by less errors. further, these results may be uniquely explained by the way that mirror neurons (i.e., neural circuits that are explicitly involved in our visual monitoring of others, encode empathy, and facilitate the learning of watching others doing a task, assigning it value, and then implementing the tasks ourselves; rizzollati & craighero, ) work more optimally by reducing its "cognitive load" (van gog et al., ) . such a reduction of cognitively load, may in turn, free up more cognitive reserves to further aid in the skill acquisition, comprehension, and behavioral exhibition of transformative learning via fpv. this situation presents yet another fundamental question, as to what would be the value of a fpv tutorial world-wide system in contrast to a university's medical video library? j o u r n a l p r e -p r o o f formats. thus, an analogous argument can be made here with respect to medical movies compared to fpv tutorials within a pandemic directly effecting people globally. an advantage to the learning in fpv compared to medical videos is that the possibility for an immediate local download on a healthcare workers'/responders' smart phone can be accessed at any time in realtime prior to, during, or after patient care interactions. also, if it is downloaded on the users smartphone it can then be accessed and viewed at any time irrespective of network signal or service issues. since the fpv tutorial is edited, it permits the healthcare worker/responder with the possibility to self-navigate through or to skip to chapters/modules of most relevance to them. this feature has been shown to have a distinct pedagogical value (zhang et al., ) as healthcare workers/responders can easily browse the necessary information, thereby increasing efficiency of patient care services. the survey results showed that the tutorials offered a better understanding of the procedures the healthcare workers/responders were to complete, thereby making them more confident and feeling ready to face the situations to care for covid- patients. the results of the survey suggested that the learning content delivered to them through the app seemed to address their needs. it is important to note that the majority of the audience here were nurses, but these tutorials has also piqued the interest of some physicians. more importantly, these tutorials have also piqued the interest of next generation medical/healthcare professional students, which is consistent with a generational shift in learning format displays. the present rapid communication sought to evaluate the interest, usage, and potential of the fpv covid- tutorial for healthcare workers/responders during a pandemic as a responsible global public health educational outreach technological tool. the findings of this adjunctive pedagogy have shown to be well received by frontline nurses and future nursing j o u r n a l p r e -p r o o f students. further, the information allows the healthcare worker/responder a wide range of flexibility to initial learn, relearn, and review the material as needed to help as a powerful and rapid transferable medical intervention. there may be limitations to this technology as not all countries and hospitals may employ the same procedures, which have to be taken into consideration. however, for the most part, these tutorials were developed keeping in mind the most universal applications possible to help alleviate this important concern. moreover, these tutorials have been translated from french and the voice-over recording has begun in english, as a universal language, to be deployed in many other countries. in closing, it is better to be ready to face an emergency and to have this material already available, but in case of a change of the evolving recommendations, concerns for re-infection of or resurgence of covid- , the current tutorials were designed and deployed to offer efficient, effective, and rapid responsible global public health educational outreach technology tool direct towards alleviate the overwhelming experiences that hospitals, healthcare workers/responders, and patients face due to the covid- pandemic. supporting the health care workforce during the covid- global epidemic flattening the curve before it flattens us: hospital critical care capacity limits and mortality from novel coronavirus (sars-cov ) cases in us counties will watching videos make us better surgeons? journal of visceral surgery it's all a matter of perspective: viewing first-person video modeling examples promotes learning of an assembly task covid- : medical schools given powers to graduate final year students early to help nhs developing an educational video on lung lobectomy for the general surgery resident how to train health personnel to protect themselves from sars-cov- (novel coronavirus) infection when caring for a patient or suspected case making the case for real diversity: redefining underrepresented minority students in public universities addressing diverse college students and interdisciplinary learning experiences through online virtual laboratory instruction: a theoretical approach to error-based learning in biopsychology addressing diverse college key: cord- - khfkyh authors: stephany, fabian title: does it pay off to learn a new skill? revealing the economic benefits of cross-skilling date: - - journal: nan doi: nan sha: doc_id: cord_uid: khfkyh this work examines the economic benefits of learning a new skill from a different domain: cross-skilling. to assess this, a network of skills from the job profiles of , online freelancers is constructed. based on this skill network, relationships between , different skills are revealed and marginal effects of learning a new skill can be calculated via workers' wages. the results indicate that the added economic value of learning a new skill strongly depends on the already existing skill bundle but that acquiring a skill from a different domain is often beneficial. likewise, the data illustrate how to reveal valuable skills required for new and opaque technology domains, such as artificial intelligence. as technological and social transformation is reshuffling jobs' task profiles at a fast pace, the findings of this study help to clarify skill sets required for mastering new technologies and designing individual training pathways. this can help to increase employability and reduce labour market shortages. this paper asks: does it pay-off to learn something new? it examines the economic benefits of cross-skilling; the process of learning a new skill from a different skill domain. in doing so, this work leverages data of , online freelancers and their skill portfolios to create a network in which , skills are connected if they are jointly held by the same worker. the findings of this study show that learning a new skill can add between to percent on the average worker wage. the results suggest that acquiring a skill from a new profession could be of even higher economic value. however, the benefits of cross-skilling largely depend on the composition of the existing skill bundle. similarly, this work exhibits how to contextualise skill requirements for newly emerging and still opaque technology domains, such as artificial intelligence (ai). the work is motivated by the rapidly changing composition of occupations due to task automation (frey & osborne, ; acemoglu & autor, ) , resulting in the paradoxical situation of simultaneous unemployment and labour shortage (autor, ) . a conventional policy response has been to align national education systems with changing labour market demand. this response is increasingly ineffectual as technological and social transformation outpaces national education systems (collins & halverson, ) . workers have to some extent begun to assume greater personal responsibility for reskilling, via skill-based online training (allen & seaman, ; lehdonvirta, margaryan, & davies, ) . however, often the economic benefits of reskilling strategies are unclear and precise skill requirements for mastering emerging technologies, such as ai or big data, remain opaque (de mauro et al., ) . this work aims to overcome re-skilling limitations by assessing the economic benefit of cross-skilling strategies and sketching valuable training pathways, in reference to existing individual skill sets. furthermore, the empirical relationship of digital skill sets will help to establish a common taxonomy to be used by policy makers, education providers, and recruiters, so that job market mismatches can be reduced. the know-how of this real-time and market data-driven evaluation can be developed into a tool for job market entrants and targeted re-education campaigns. globally, the value of such a "cross-skilling compass", as presented with a first interactive online prototype for this project , could be highest in regions where traditional education infrastructure is lagging behind. the remainder of this study is organised as follows: in the next section, a literature review embeds the work into discussions on automation of tasks and personalisation of training. section two illustrates the approach of the work and highlights the importance of skill diversity. section four presents the data collected and the methods. section five summarises the results and section six concludes with policy implications and possible extensions of the work. the periodic warning that automation and new technologies are going to terminate large numbers of jobs is a recurring theme in economic literature (frey & osborne, ; brynjolfsson & mcafee, ; acemoglu & autor, ) . a popular early historical example is the luddite movement of the early th century: a group of textile artisans in england protested the automation of their industry by seeking to destroy some of the machines. in contrast to recurring fears of mass unemployment, current literature shows that the (digital) technology revolution, rather automates tasks than vanishing entire occupations (autor, ) . in this process, technological and social transformation change the skill composition of professions (acemoglu & autor, ) . the work that is thereby eliminated has different skill requirements than the newly created jobs, resulting in the paradoxical situation of simultaneous unemployment and labour shortage (autor, ) . as the pace of technological and social change accelerates, the skills gap grows rapidly (milano, ) . history suggests that the skills gap, even more so than the elimination of jobs per se, causes heightened economic inequality (card & dinardo, ) and retards firm growth (krueger & kumar, ) during times of technological and social transformation. more fundamentally, the very notion of occupations is increasingly problematic in large sectors of the economy. the contemporary notion of occupations arose from the industrial revolution, as mass production required large numbers of workers with uniform bundles of skills (featherman & hauser, ) . but today's knowledge workers strive to build unique specialisms and combinations of skills that differentiate them from other workers (hendarman & tjakraatmadja, ) . even low-end service workers can end up developing extremely heterogeneous skill sets, because they cobble together incomes from idiosyncratic combinations of gigs ranging from coffee serving to uber driving (fuller, kerr, & kreitzberg, ) . tracking labour demand in terms of occupations assumed to consist of uniform bundles of skills therefore fails to produce the kind of information that individual, corporate, and national decision makers need to successfully overcome the skills gap. a conventional policy response to closing the skill gap has been to align national education systems with changing labour market demand. this response is increasingly ineffectual as technological and social transformation outpaces national education systems (collins & halverson, ) . large employers are likewise struggling to keep their workforces' skills up to date (illanes et al., ) . workers have to some extent begun to assume greater personal responsibility for reskilling, via online courses, distance education tools, and entrepreneurial approaches to work (allen & seaman, ) . this trend is amplified as the covid- pandemic tightens economic budgets and forces workers into individual and remote reskilling. similar to the reshuffling of task compositions, digital technologies have enabled a process that has become a defining paradigm of the digital economy: rebundling (mcmanus et al., ) . first, in the early days of the internet, download platforms, at times operating illegally, allowed music lovers to access songs individually without having to acquire the artist's entire album. the single item (song) was unbundled from the original bundle (album). later, at a second stage, streaming platforms, like spotify, reversed the trick by allowing the (re)bundling of previously unrelated items. users could listen to songs from different artists for one single price. the mastery of this strategy has made digital entertainment companies superstars firms (eriksson et al., ) . in music (dabager et al., ) , broadcasting (hoehn & lancefield, ) or gaming (mcmanus et al., ) , things that have been unbundled rarely remain that way. the economic benefit of individualised rebundling is too strong. similarly, this paradigm has affected the way we learn new skills. at first, in the debundling phase, digital technologies allowed education providers to provide topical online courses (wulf et al., ) . at a later stage, platforms like coursera or datacamp performed the rebundling and offered a whole set of topical courses for a single price (bates, ) . the acquisition of individual skills (programming in python) has been detached from its original domain of training (studying informatics). however, despite advances in personalised reskilling, a sizable skill gap persists on the labour market. current approaches to addressing the skills gap are based on predicting demand for entire occupations or at best for abstract skills such as social skills or creativity. but in many occupations, technological and social transformation is leading the concrete skills that make up the occupation to change regularly and decisively. nursing has been transformed by successive generations of electronic health record systems, clinical decision support systems, and diagnostic technologies (adams et al., ) . web application development has rapidly rotated from perl to php to ruby to python to other development platforms (purer, ). firms and workers who fail to reskill while there is still demand for their skills risk dropping out of the market entirely once demand tips. most recent research shows that just-in-time skills development, motivated by the demands of the work at hand, or by perceived market shifts, has emerged, as formal training courses are unaffordable for workers who can't take time off paid work (kester et al., ) . in addition, cultural aspects in traditional stem education, for example, still hinders female participation, despite efforts to alter it (kahn & ginther, ) . instead research shows that independent professionals, including women, prefer informal, digital, social learning resources like stack overflow and tutorial videos to develop new skills (yin et al., ) . newest findings show that independent it professionals today develop new skills incrementally, adding closely related skills to their existing portfolio (lehdonvirta, margaryan, & davies, ) . their work examines the skill development of freelancers on online labour platforms. indeed, online freelance platforms might have become early "laboratories" for the de-and rebundling of incremental skills. it could be argued that, for work, freelance platforms, such as upwork , have become what spotify is for music: they allow freelancers to jointly sell previously detached skill components for one hourly price. the role of the data scientist is a prime example of how the rebundling of skills from different domains, i.e., visualisation, programming, and statistics, is an economically profitable offer. the work by anderson ( ) confirms that diverse rebundles of skills from different domains are profitable in general. in this situation of rapidly changing market dynamics, systematic oversight is key. however, individuals often lack foresight into which skills are rising, which skills are most valuable and which skills their existing portfolio is complementary to. they get locked into path dependencies that may result in dead ends that prevent them from re-skilling into new areas (escobari, seyal, & meaney, ) . in light of the rapid reshuffling of occupational profiles and the failed attempts to develop farsighted re-skilling strategies, this work proposes an economic evaluation of cross-skilling pathways with, at least, the following four goals: ) develop an endogenous categorisation of skills. ) evaluate the economic benefit of learning a new skill. ) reveal the skill context of the domain of artificial intelligence. ) sketch valuable cross-skilling trajectories based on individual skill bundles. in pursuing these goals, the study can rely on previous data-driven approaches to assess skill and human capital evaluation. traditionally, measures of human capital rely on the count years of experience, training, or education or divide workers categories, e.g., of laborers and management (willis, ) . however, a growing body of literature suggests that years of training and broad worker categories fail to address the importance of skill specialisation, diversity, and recombination in knowledge generation (hong & page, ; lazear, ; woolley et al., ; ren & argote, ; aggarwal & woolley, ) . in addition, the rise of the knowledge economy (powell & snellman, ) has sparked new interest in a more nuanced measure of skill composition. in this context, several papers have taken skill diversity and individual cognitive abilities into account for estimating their effect on wages (bowles et al., ; heckman et al., ; borghans et al., ; altonji, ; autor & handel, ) . a central conclusion of past contributions on skill diversity is that the relationship between wages and skills does not only depend on a worker's individual skills but also, how they are combined. the question of skill synergies arises (allinson & hayes, ) . for some skills (e.g., programming in javascript and visualisation techniques) it can be argued that skill synergies emerge. the bundle of skills is more valuable than the sum of its parts. it could be argued that skill synergies are constrained to an occupational domain, e.g., programming in python and translating russian should have little skill synergies. certainly, the value of additional skills depends on the skill portfolio that the worker already possesses (altonji, ) . however, this work precisely investigates how limited synergy effects of skill bundling are and if cross-skilling, the acquisition of a new skill outside of the existing skill portfolio, might indeed be profitable. the data for this analysis stems from the freelancing platform upwork , which falls under the category of online labour markets (olm). these platforms are websites that mediate between buyers and sellers of remotely deliverable cognitive work (horton, ) . the sellers of work on olms are either people in regular employment earning additional income by "moonlighting" via the internet as freelancers or they are self-employed independent contractors. the buyers of work range from individuals and early-stage startups to fortune companies (corporaal & lehdonvirta, ) . olms can be further subdivided into microtask platforms, e.g., amazon mechanical turk, where payment is on a piece rate basis or freelancing platforms, such as upwork, where payment is on an hourly or milestone basis (lehdonvirta, ) . between and , the global market for online labour has grown approximately % (kässi & lehdonvirta, ) . in light of the covid- pandemic and it's significant economic repercussions across industries (stephany et al., a) , olms continue to increase in popularity due to a general trend of work at distance (stephany et al.. b) . upwork is usually perceived as the globally most popular freelance platform (kässi & lehdonvirta, ) . this study utilises olm data, as platforms like upwork have become early "laboratories" of the rebundling of skill sets. their data allow us to monitor skill rebundling in a global workforce by near real-time reporting location, asking wages, previous income, gender attributes (forenames), and up-to-date skill bundles on a granular level. for the methodological approach of this paper, the work by anderson ( ) is referential. anderson constructs a human capital network of skills from online freelancers and shows that workers with diverse skills earn higher wages. the limitation of anderson's work is that a skill specific evaluation in the context of cross-skilling is not addressed. this work aims at adding this cross-skilling perspective and exemplary sketches economically valuable cross-skilling pathways in times of shifting occupational profiles. similar to anderson ( ) , this work uses the rich toolbox of network analysis for the characterisation of skill relationships. given a sample of , freelancers with multidimensional skill portfolios, a network is constructed in which . skills are nodes and two skills are connected by a link if a worker has both. links are weighted according to how often the two skills co-occur. first, this skill network provides us with an endogenous categorisation of skills based on their relationship in application and the context dependency of human capital. in a second step, the wage proposals of workers allow a statistical assessment of skills. via calculating regression coefficients, the economic value of the most popular individual skills can be derived: age β ountry β og(earned) β kill w i = + β * c i + * l + * s i,j + e i ( ) ε , .., and j ε , .., i . n . the linear regression model ( ) uses all workers ( ) as ε , .., i . n observations and considers their country of origin and amount of money earned as characteristics when estimating the worker's asking wage. in addition, each of the most popular skills are considered as an explanatory feature in the linear regression. lastly, the method addresses the issue of cross-skilling. based on the existing skill portfolio of a worker, skill coefficients are again calculated. this time only a subset of workers is considered: ( ) age β ountry β og(earned) β kill , w k = + β * c k + * l k + * s k,j + e i ε a, .., and j ε , .., k . m < n . here the accounts between a and m fall into a specific occupational domain, e.g., translation and writing, as the majority of their skills are located in this skill cluster. hence the coefficient of the skill characteristic ( ) only refers β to the additional wage this skill contributes within a smaller subset of workers with the skill bundle . this cross-referencing allows ε a, .., k . m < n us to indicate the potential additional marginal value of acquiring a new skill if added to a specific skill portfolio. as the first part of the analysis a skill network is constructed, shown in figure . the network uses the information of , workers and , unique skills. in this network, unique skills are represented as nodes. they are connected if simultaneously advertised by the same worker. the edges between two nodes grow in strength the more workers combine a pair of skills. the (unweighted) degree centrality of each node is represented by its size. based on the relationship between skills via workers, a louvain clustering method is applied that minimises the number of edges crossing each other. seven distinct clusters emerge, as highlighted in different colours. by highlighting the ten most prominent skills -in terms of degree centrality -of each cluster, we can see conceptual consistency within once a larger set of skills is considered at the same time, the model validity is scrutinised by potential multicollinearity. the skill clusters differ in size (of skills and workers employing them) but their conceptual consistency underlines the effectiveness of this endogenous clustering approach. in comparison to human classification of skills in the context of online freelance markets, similarities and differences occur. kässi and lehdonvirta ( ) , for example, classify skills in six different domains that do not include d, graphic, and audio design individually. the endogenous clustering approach, however, clearly indicates that these skill groups form individual clusters of their own but they are similar to each other and though group together at the left hand side of the skill network. skill clusters also differ significantly with regard to the asking wages of workers, as shown in figure , ranging from a median of usd per hour, asked by workers in admin and support to usd/hour in software and tech. to usd/hour in legal. however, the wage spread within and across skill domains is sizable. in software and technology, asking wages range from . to usd per hour. the rich variety of skill combinations allows us to assess the value of adding a new skill to a worker's skill portfolio. via linear regression models, we can calculate beta coefficients for the most popular skills for six domains , as shown in figure . the added value of learning one of the most popular skills varies significantly. on average, for ten of the skills the beta coefficient is positive, for four skills (voice talent, python, audio editing, and copywriting), results are statistically significant (p> . ). but even within the group of significantly profitable skills, the spread is large. being knowledgeable in voice talent adds % to the average worker's asking wage, while copywriting skills contribute % . negative coefficients indicate that workers with these skills ask for significantly lower wages than the average online freelancer. with the endogenous classification of skill groups at hand, we can perform an evaluation of learning a new skill based on the already existing skill bundle of a worker. for this purpose, two analyses are performed. first, the value of skill diversity is assessed. skill domains are attributed to each worker based on her skill bundle. while each worker has a dominant skill category (the relative majority of all of her skills are in this domain), some workers also add skills from other domains to their portfolio. in figure , wage distributions of different skill diversities are shown across the major six skill groups. in general, it can be noticed that across skill domains, workers with more diverse skill bundles have higher wages. in particular, for workers with very diverse bundles, i.e., adding skills from three domains other than the major skill category, wages on the th quartile (lines) of the distribution are shifted upwards. figure : across skill domains, asking wages increase when skills from other domains are added to the workers' portfolio. workers in the top earning quartiles (lines) ask for significantly higher wages when demanding skills from three domains other than their defining skill bundle (observation sizes in legal are too small). in a second step, the linear regression explaining workers' asking wages is performed for the complete set of workers and the six major skill domain subsets. figure summarises the coefficients of the most popular skills in the eight scenarios. figure : learning a new skill, like copywriting or python, pays off in general, but even more when added to skill bundles like translation and writing or admin and support. in contrast to the added economic value for the complete set of workers, we see that some skills, like programming in python, increase the worker asking wage over proportionally in the skill context of admin & support. similarly, knowing how to do copywriting contributes significantly more when added to graphic design. other skills, like audio editing, however, do contribute to an average worker's wage, but fail to make a difference conditional to special skill bundles. figure illustrates three of these cross-skilling trajectories. figure : the cross-skilling trajectories for skills like python, javascript, or copywriting, can be examined individually and compared with each other. as an example, it is of little surprise that, on average, knowing how to program with python, allegedly the data science super skill (grus ) , adds more to a worker wage than knowing how to work with javascript. however, once we add these skills to a bundle in the domain of d design, the picture turns upside down. designers that know python can't add wage but workers that are skilled in javascript can increase their wage by more than % on average. similarly, as shown in the lower panel of figure , the skill of copywriting adds about % to the average worker wage. in the domain of graphic design, on the other hand, knowing how to do copywriting has an impressive additional value of more than % of the average wage in this domain. these skill trajectories are an illustration of what online labour market data allow us to say about cross-skilling trajectories in general. the data enable us to evaluate the economic benefit of individual skills based on the existing skill bundle of a person and to sketch sustainable cross-skilling pathways. a further obstacle in developing effective and timely reskilling pathways is the lack of skill contextualisation of newly emerging technologies. the rapid expansion of such emerging digital technologies, like ai, is creating a huge demand for labour skilled in the development and application of these domains. however, the fast change of skill profiles in new technology environments makes it difficult for companies to find adequately trained experts. at the same time, it is unclear which types of skills constitute newly emerging areas of digital technologies (de mauro et al. ) . companies are not able to satisfy their rapidly growing demand for talents in information and communication technologies (ict). projections show that positions for digital technology talents are the fastest growing job segment in the united states with estimated , , openings by the end of (miller and hughes ) , leading to a significant excess demand for ict professionals. the results of qualification mismatches are lower labour and economic productivity (mcgowan & andrews ) . this can be particularly harmful for economies in regions with low levels of growth, where expert labour in ict is already scarce. often, the description of skills and responsibilities of experts in domains such as big data or ai is fuzzy and firms tend to apply subjective interpretations. as de mauro et al. ( ) illustrate in detail, the emergence of the expert role of the data scientist is a typical example for a simplistic job description that downsizes the complexity and variety of skills required to retrieve information and transform it into economically valuable insights. research indicates that there is a clear gap regarding the formal taxonomy of skills and educational needs in new technology domains like ai (miller & hughes ; song & zhu ) . the presented approach of creating skill networks can help to reveal precise skill sets that are related to ai. figure shows a subset of nodes from the skill network in figure . here, only skills from profiles are considered that have appeared under the search term "artificial intelligence". similar to figure , skills are connected if jointly advertised by the same worker. skills are strongly clustered around the domains of software and technology and admin and support. in absolute terms, ai appears most frequently in the skill context of software and technology; skills related to ai belong to this domain. however, taken the size of the different skill clusters into account, legal is the skill domain most strongly populated by ai skills; seven out of legal skills ( . %) are connected to ai. similarly to the analysis in the previous subsection, for all of the skills that are related to the search term "artificial intelligence" wage coefficients are calculated. figure shows all positive (both significant and insignificant) coefficients. in the domain context of ai, skills in the field sales, web and software services, as well as, learning python add to the average worker's asking wage. the most profitable skills to learn in the context of ai are situated in the field of ales (sales letter and sales writing). workers with one of these skills earned on average up to eleven times more than the average worker. likewise, skills in software as a service -saas (six times) or python (four times) are profitable skills in the ai domain. as technological change accelerates, task automation shifts occupational skills requirements, challenging the global workforce to constantly reskill. to avoid skill gaps and systematic labour market mismatches, approaches to reskilling need to step-up, as traditional education policies are too slow for the fast-changing pace of technological and social change. in addition, situations like the covid- lockdown further accelerate digitalisation trends while limiting economic resources of companies to up-skill their employees and constraining workers to learn remotely from home. in light of this grand challenge, this work explores the foundations of new modes of re-skilling via sketching cross-skilling pathways based on online labour market data. online labour markets have become early laboratories for the de-and rebundling of skills from previously unrelated domains. the statistical analysis of diverse skill portfolios and wages of online workers allows an evaluation of the economic benefit of learning a new skill. furthermore, the endogenous categorisation of skills via skill networks gives us insights into the value of learning a new skill depending on the already existing skill portfolio of each worker. we see that some skills are, in terms of additional wage, more valuable than others. on average, performing voice overs tribles worker's wages, while knowing how to program in python enhances wages by %. these figures are independent of a worker's previous earnings and location, which likewise influence asking wages. in addition to the economic evaluation of individual skills, this work assesses the added economic value of learning a new skill in addition to a defined skill portfolio, i.e., cross-skilling. the conditioning on skill domains is a relevant perspective, as individual examples show. compared to the average worker, copywriting skills are, in terms of added wage, about ten times as valuable when added to a skill bundle in d design. sketching personalised cross-skilling trajectories is mandatory for future educational formats, as skill portfolios become more fragmented and re-skilling opportunities more granular. this work is a first exploration of a quantitative and market data based assessment of cross-skilling. it comes with limitations and opens space for future investigations. the strong point of this work is the potential for individual recommendation based on existing skill bundles. ideally, researchers and policy makers could use this blueprint to develop new tools for a granular and near real-time assessment of individual development potentials, recommending which skill to learn next . as an improvement of this method, the presented findings should be enriched with on-site labour market wages from a broader set of occupations. likewise, a monitoring of cross-skilling trajectories over time could enable more nuanced and far-sighted statements about the emergence of new skills and the future of learning something new. skills, tasks and technologies: implications for employment and earnings skill-mix changes and work intensification in nursing do you see what i see? the effect of members' cognitive styles on team processes and errors in task execution grade level: tracking online education in the united states the cognitive style index: a measure of intuition-analysis for organizational research multiple skills, multiple types of education, and the labor market: a research agenda skill networks and measures of complex human capital why are there still so many jobs? the history and future of workplace automation putting tasks to the test: human capital, job tasks, and wages what's right and what's wrong about coursera-style moocs the economics and psychology of personality traits the determinants of earnings: a behavioral approach the second machine age: work, progress, and prosperity in a time of brilliant technologies skill-biased technological change and rising wage inequality: some problems and puzzles rethinking education in the age of technology: the digital revolution and schooling in america platform sourcing: how fortune firms are adopting online freelancing platforms an empirical analysis of digital music bundling strategies human resources for big data professions: a systematic classification of job roles and required skill sets spotify teardown: inside the black box of streaming music realism about reskilling: upgrading the career prospects of america's low-wage workers. workforce of the future initiative on the measurement of occupation in social surveys the future of employment: how susceptible are jobs to computerisation? the gig economy: leasing skills to pay the bills data science from scratch: first principles with python the effects of cognitive and noncognitive abilities on labor market outcomes and social behavior relationship among soft skills, hard skills, and innovativeness of knowledge workers in the knowledge economy era broadcasting and sport groups of diverse problem solvers can outperform groups of high-ability problem solvers online labor markets retraining and reskilling workers in the age of automation forceatlas , a continuous graph layout algorithm for handy network visualization designed for the gephi software women and stem (no. w ) online labour index: measuring the online gig economy for policy and research just-in-time, schematic supportive information presentation during cognitive skill acquisition skill-specific rather than general education: a reason for us-europe growth differences? balanced skills and entrepreneurship skills formation and skills matching in online platform work: policies and practices for promoting crowdworkers' continuous learning (crowdlearn) flexibility in the gig economy: managing time on three online piecework platforms labour market mismatch and labour productivity steering incentives and bundling practices in the telecommunications industry the digital skills gap is widening fast. here's how to bridge it the quant crunch: how the demand for data science skills is disrupting the job market digital innovation management: reinventing innovation management research in a digital world the knowledge economy php vs. python vs. ruby-the web scripting language shootout transactive memory systems - : an integrative framework of key dimensions, antecedents, and consequences big data and data science: what should we teach distancing bonus or downscaling loss? the changing livelihood of us online workers in times of covid- the corisk-index: a data-mining approach to identify industry-specific risk assessments related to covid- in real-time back to the future-changing job profiles in the digital age everything you always wanted to know about ai -nowcasting digital skills with wikipedia wage determinants: a survey and reinterpretation of human capital earnings functions. handbook of labor economics evidence for a collective intelligence factor in the performance of human groups massive open online courses learning to mine aligned code and natural language pairs from stack overflow research commentary-the new organizing logic of digital innovation: an agenda for information systems research table : network metrics of the skills with the highest degree centrality in each of the seven skill cluster key: cord- - n jp l authors: baatiema, leonard; sumah, anthony mwinkaara; tang, prosper naazumah; ganle, john kuumuori title: community health workers in ghana: the need for greater policy attention date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: n jp l from the s to the s, the who, united nations and other agencies mooted the idea of formally training and recognising community health workers (chws) to complement efforts to improve primary healthcare delivery in low and middle income countries. recently, chws have been recognised as important players in the achievement of the health-related millennium development goals (mdgs). despite this recognition, little understanding exists in ghana about the activities of chws: who they are; how they are recruited; what they do; level of health policy support; contribution to healthcare delivery and the challenges they face. based on a rapid scoping review of the existing literature, and our experience working in ghana, this paper reflects on the role of chws in healthcare delivery in ghana. we argue that chws have played critical roles in improving health service delivery and outcomes, including guinea worm eradication, expanded immunisation coverage, maternal and child health, and hiv/aids treatment and management. however, these achievements notwithstanding, chws face challenges which prevent them from being optimally productive, including capacity problems, neglect by the healthcare system, high attrition rates and inadequate supervision. policymakers in ghana therefore need to give increased attention to chws, provide remuneration for their activities, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities. the concept and role of community health workers (chws) have enjoyed renewed interest in global health since the alma-ata declaration in . [ ] [ ] [ ] [ ] [ ] [ ] chws have evolved over the past decades with its antecedence in the 'feldshers' in th-century russia, the barefoot doctors programme in china during the early s, and the who seminal work 'health by the people' in . recent recognition that chws are important players in global efforts to achieve the health-related millennium development goals (mdgs) highlights this attention. in , the one million chws campaign project worth us$ . billion was announced to boost the capacity of chws to deliver healthcare in sub-saharan africa. this current drive to recruit more chws is a recognition of their role in sustaining the mdg gains, as well as in ultimately achieving the more recent sustainable development goals (sdgs). a surge in the evidence of their contribution has recently been acknowledged in a cochrane review on maternal and child health. evidence in several low and middle income countries (lmics) suggests that marked reductions in child and maternal mortality through health promotion interventions, immunisation campaigns and other community driven initiatives could be attributed in part to the role played by chws. [ ] [ ] [ ] [ ] [ ] key questions what is already known about this topic? ▸ the contributions of community health workers (chws) to healthcare delivery have been recognised globally. ▸ there is a lack of global consensus on chws' scope of practice. ▸ there is inadequate health policy support for chws in low and middle income countries. what are the new findings? ▸ this analysis presents systematic and comprehensive evidence of chws' contributions and health policy gaps in ghana. ▸ it has contributed in clarifying the various classification of chws and their scope of practice. ▸ it has also highlighted evidence of inadequate health policy support for chws. ▸ the formulation of a national policy on chws. ▸ the establishment of a professional and regulatory body to regulate the standards and practice of chws. ▸ the development of a long-term strategy that will see the gradual replacement or absorption of chws into the formal health service in ghana. with the current ageing population and wave of epidemiological transition globally (the impact of which is projected to be felt more by populations in lmics), studies suggest that chws are rising to the task of ensuring that the impact is less felt by communities and health systems. [ ] [ ] [ ] the potential contributions of chws to tackling the current global health security threat posed by the zika virus, yellow fever, middle east respiratory syndrome (mers) and influenza, especially in the area of surveillance, cannot be overemphasised. despite the general consensus about the importance of chws among the global health community, health policy interventions to recognise and support optimal delivery of healthcare by chws are lacking, especially in lmics. in ghana, although a number of studies and reports have highlighted chws' activities, there is inadequate health policy support for them. to the best of our knowledge, no studies currently exist in ghana to have systematically profiled chws and their contribution to healthcare delivery. there is yet no consensus or comprehensive assessment of their roles, scope of activities and constraining factors to their productivity in ghana. this analysis paper therefore addresses this knowledge and policy gap. to analyse the activities of chws and the extent of health policy support in ghana, we conducted a literature review of published and unpublished works, including reports on the activities of chws in ghana (see box for search strategy deployed to search and retrieve relevant literature for this study). this paper also incorporates insights from our experiences of working in ghana as community health services researchers, affiliates of the ghana health service and development workers who have contributed to the design and implementation of numerous community-driven health interventions in collaboration with chws. despite an international consensus about the importance of chws to healthcare delivery, a universal definition of chws remains evasive. ambiguity further abounds in the mainstream literature on the characterisation of chws. however, during the recent united states agency for international development (usaid) chw evidence summit, there was some consensus that a chw is "a health worker who receives standardized training outside the formal nursing or medical curricula to deliver a range of basic health, promotional, educational, and mobilization services and has a defined role within the community system and larger health system". we find this definition to be insightful and thus will significantly support our analysis of chws in this paper. in ghana, two complementary types of chws are notable. the first category are an informal, poorly trained health service-supporting chws. in this category, chws are informally a part of the health system, and the health authorities or collaborating development partner (non-governmental organisation, ngo) takes responsibility for their recruitment, training, incentives and/or remuneration. the second strand of chws exists where chws are representatives of the community and act in the interest of the community. chws under this category have no or limited affiliation with the formal healthcare system, and mainly spearhead community-driven preventive health activities. despite this distinction, we admit that many chws might be combining both roles in practice. from our experiences and in our view, a 'hybrid' form of chws (a mix of the two categories) can be found in ghana. similar to the international trend, chws are diversely named in ghana, including but not limited to names such as community health volunteers (chvs), traditional birth attendants (tbas), village health volunteers, community health champions, peer health educators, community child growth promoters, community nurses, community health committee members, community-based surveillance volunteers (cbsvs), community-based agents and lay health workers. - these different characterisations generally reflect the diverse and ambiguous identities of chws in the international health literature and in health policy programmatic interventions. - for the purpose of clarity, we refer to chws in this paper as any of the above category of health workforce who, though not formal employees of the health system in ghana, are either a health service-supporting chw or community representatives, who have been identified, a rapid literature review of both published and unpublished works was conducted in academic science complete, cinahl, embase, global health medline, google scholar, isi web of knowledge, popline pubmed, psycinfo and web of science. no year limit was included in the search. we also undertook a review of reports on the activities of community health workers (chws) in ghana. the search sought to retrieve relevant documents ( programmatic and scholarly reports) on the activities of chws, especially in ghana, using key words such as community health workers, chw, village health worker, community health volunteer, lay health worker, traditional birth attendants, tbas, health promoters, ghana, remuneration, financing, health policy, impact, activities, training, practice and training. relevant papers and information were retrieved and reference lists screened for more relevant studies. studies which discussed the activities of chws with particular reference to ghana were critically assessed for relevant information. in order to establish the activities of chws in the context of the globe, works related to chws in general were included based on relevance to the study aim. in addition, the scope of the literature included in this paper was confined to works which reported, described, analysed and synthesised the activities of chw in the context of ghana. importantly, the paper incorporates insights on the activities of chws through anecdotes, authors' personal experiences and field reports. trained or untrained, and assigned roles in the community for which they receive no or some form of formal remuneration. historically, chws such as tbas have operated in most ghanaian communities. however, attempts to formally organise and recognise them came after the alma-ata declaration on primary health care (phc). village health workers (vhws) provided the first semblance of chws in ghana. these were local community representatives whose actions and activities were mostly based on altruism. although their roles such as community mobilisation, health awareness creation and immunisation campaigns were critical to the modest gains ghana achieved from implementing the phc strategy, their activities were short-lived such that by the s, vhws were no longer used. lack of coordination and inadequate supervision of their activities were among the reasons why the vhws programme was discontinued. as a result, community health nurses (chns) were introduced to deliver healthcare in mostly deprived parts of ghana. unlike the vhws, chns were recruited, provided professional training in nursing training colleges, deployed into mostly rural parts of ghana and formally remunerated to provide healthcare. however, the relatively long period needed to train them and funding challenges limited adequate training and deployment of chns. consequently, the activities of vhws were reinvigorated in the early s. central to their re-emergence was the navrongo experiment, a pilot project which culminated in the current community-based health planning and services (chps) concept. since then, chws have continued to evolve both in name and role. currently, cbsvs form the majority of chws in ghana. however, there is still lack of clarity on their contribution, recruitment, scope of practice and remuneration. chws: contributions to healthcare in ghana evidence of the success of a plethora of community health interventions supported and delivered by chws exists in the international health policy and systems research literature. although chws are involved in many domains of healthcare delivery in ghana, our review identified four important areas where chws' contributions have been immense. these four areas are examined in this paper. the navrongo experiment is one of the areas where chws' contributions to healthcare delivery have been acknowledged globally. the navrongo community health and family planning project, popularly referred to as the navrongo experiment, which culminated in the birth of the current chps programme in ghana, sought to improve access to healthcare in deprived communities using mostly community-driven resources and structures. the intervention was conceptualised under the assumption that by recruiting, training and deploying community health officers to rural communities, inequities in access to healthcare services between urban and rural settings could be bridged. under the navrongo experiment, chws played several critical roles, including outreach services, community mobilisation for health educational talks and referral to health facilities. the navrongo experiment resulted in increased access to healthcare services, immunisation coverage, reduced child and maternal mortality while improving the rural population's overall health. for example, within a period of years of its implementation, the results pointed to a % reduction in childhood mortality rate and % reduction in fertility rate. given this landmark success, results from this experimental intervention led to the conceptualisation and implementation of the chps programme as the country's main policy enactment aimed at improving access to health services in rural ghana. owing to its overall success, ghana's chps programme has been acclaimed as among the most successful community-based health programmes globally. [ ] [ ] [ ] [ ] guinea worm eradication without the diverse contributions of cbsvs, ghana's current success in eradicating the guinea worm (dracunculiasis) would have been unlikely. ghana was ranked second globally in among the guinea worm endemic countries. currently, however, ghana is guinea worm free. studies and reports from the ghana health service and non-state actors (ngos) have underscored the critical roles played by chws in eradicating the guinea worm in ghana. [ ] [ ] [ ] [ ] their roles included community mobilisation for awareness raising campaigns on the spread of the guinea worm, administration of palliative care, door-to-door distribution of drugs, referral to health centres for treatment, and distribution of water filters in communities. indeed, their role was so critical that both the national guinea worm eradication programme and some development partners (eg, carter center) have acknowledged it as being the most important factor in ghana's guinea worm eradication campaign. promotion of maternal and child health globally, chws have been acclaimed as having played a tremendous role in decreasing childhood illnesses and mortalities. notably, case management of childhood illness is one area where their contribution has been highly commended by the who and unicef. a study in ghana reported that chws were instrumental in establishing community health post, making home visits to provide healthcare services such as administration of antibiotics, oral rehydration solution and zinc to treat childhood illnesses such as pneumonia, diarrhoea and malaria. similar results have been reported by other studies globally. again in ghana, the role of tbas has been reported to double the number of women referred to clinics and hospitals for potentially life-saving care and support. indeed, in several communities in bolgatanga, kassena nankana and bawku west districts of ghana, oxfam has trained and evaluated the work of some tbas. the evidence from oxfam's work has shown positive results. in each of the communities where oxfam trained and worked with tbas, the number of women being referred by tbas to clinics and hospitals for potentially life-saving care doubled. maternal mortality has similarly reduced by %. further, between and , one of the authors ( jkg) was involved in a community-based pilot health project in communities in nadowli district, upper west region, ghana. this project was implemented by world vision ghana in partnership with ghana health services. the project trained cbsvs and tbas to perform a number of tasks, including recording births and deaths, and reporting disease outbreaks. several tbas also got trained to detect danger signs during pregnancy and labour and to make quick referral of pregnant women to health facilities to receive skilled care. the tbas were all provided basic consumables such as hand gloves, hand sanitisers, new packs of cutting blades and kerosene lanterns (to be used in the night when there is no electricity). the main aim of the project was to improve tbas' skills and resource them adequately to conduct normal deliveries, particularly in hard-to-reach rural communities. in mid- , an initial evaluation was done. the evaluation results showed that antenatal care attendance in some communities had increased twofold (ie, % in to % in ). qualitative interviews with women and tbas suggested that many tbas who received the training and essential consumables actively encouraged and referred pregnant women to healthcare facilities. also, among women who delivered at home with tbas, infections resulting from the use of bare hands and other unhygienic practices by tbas (such as the same blade being used to sever the umbilical cords of two babies) during labour were reported to have reduced. the women and tbas who participated in the interviews largely attributed the increase in the number of referrals to health facilities for skilled delivery and a reduction in infections during labour to the training tbas received and the supply of hand gloves, hand sanitisers and new blades. in fact, these positive results from ghana are supported by evidence from other low income contexts. [ ] [ ] [ ] [ ] [ ] notwithstanding these evidences, tbas' activities in maternal healthcare until now are still surrounded with controversies because the who official position only permits tbas to make referrals and not conduct home deliveries. however, based on this evidence from the upper east region and the fact that in ghana only % of births are attended to by a skilled attendant (defined here as a doctor, nurse or midwife), and % by tbas, we consider the who position on tbas as untenable in lmics such as ghana where the capacity to provide skilled and supervised delivery is limited. in other parts of the world especially in sub-saharan africa, the role of chws has been important in the fight against the spread of hiv/aids. - in ghana, the literature suggests that chws were recognised as a conduit to providing voluntary counselling and testing services. a cross-sectional survey conducted in northern ghana reported an overwhelming acceptance ( . %) of the use of lay health counsellors to provide community-based voluntary counselling and testing services. we noted, however, that only a few studies have covered the activities of chws in hiv/aids prevention and treatment in communities. our experience in working at the community level in ghana shows that chws are a key cadre of health staff working closely with chos and ngos in raising hiv/aids awareness, mobilising communities against stigma and discrimination and providing a culturally acceptable or a community-competent context for people living with hiv/aids. despite this, the district health information management system (dhims), a comprehensive database which reports on all aspects of services delivered by the ghana health service, does not report on chws' contribution to hiv/aids prevention and management. this suggests that even in contexts where their contribution is not in doubt, the healthcare system has not adequately documented or recognised their role. prior to the inception of the one million chw campaign (to which we return later), there was no national framework to guide the recruitment of chws in ghana. as a result, their recruitment was dependent on the community, the health programme, and the donor agency or development partner (ngo) involved. from the international literature and our experiences in ghana as well, chws are generally recruited from their own communities based on their level of acceptability in their respective communities, previous involvement in community-driven initiatives, high sense of dedication to duty and literacy (education) level. although these considerations are important, they are no doubt subjective and may affect the objective assessment and recruitment of chws. our experience in some communities shows that the lack of clearly defined recruitment criteria and strategy has often generated tensions among community members. indeed, some earlier studies have indicated how recruiting chws from local communities often served to generate tension and/or perpetuate gender inequalities. an important dimension regarding the recruitment of chws in ghana is the active role of ngos and other non-state actors. many ngos and other non-state actors who operate and/or implement parallel or vertical healthcare programmes in ghana often recruit parallel chws. in most cases, this parallel recruitment is often without regard for existing structures. from our experience, the ngos' style of engagement with chws can be problematic because recruiting chws without recourse to already existing structures can breed conflicts, duplication of efforts, lack of community participation and ownership of a particular health intervention and redundancies following the completion of the programmes of such organisations. comparable to the global situation, the scope of practice for chws lacks clarity and remains undefined in ghana. there has been a long-standing debate as to what exactly their roles should be and to what extent they are supposed to act in providing healthcare. according to a report by unicef, in south asia, one chw can provide healthcare services to about to households. generally, chws tend to provide more preventive and promotive healthcare, rather than curative. in other settings, the roles of chws have been observed to vary from community mobilisation for immunisation campaigns, health talks, first aid, creating awareness on disease control and health promotion to activities such as registration of births and deaths. in ghana, owing to the acute shortage of health personnel, chws' scope of practice has broadened beyond prevention and health promotional activities to encompass some curative care such as treatment for malaria and diarrhoea. generally, the scope of practice of chws in ghana varies widely, including serving as aids to community health officers, home visits, disease surveillance, maintaining environmental sanitation, nutrition education, home management of minor ailments like uncomplicated malaria, social mobilisation, and providing a limited range of reproductive and child health services. while this varied and flexible scope of practice may be a unique strength, it is therefore to be inferred that the lack of clarity on the operational mandates of chws in ghana has often undermined the effectiveness and efficiency of their roles in healthcare delivery at the community level. as observed by some researchers, a reasonable involvement of chws in limited activities has the tendency to enhance outcomes in community-based health interventions compared with an unlimited scope of practice. remuneration of chws is a controversial subject that has eluded consensus among stakeholders. internationally, the discourse is suggestive of the need to compensate their services in the form of a fee or in kind by the beneficiary communities. some other nonmonetary incentives such as providing bicycles, certificates or free healthcare to chws are also common. as a result, the who has underscored the need to pay chws reasonable wages in order to enhance their productivity, sustain community-driven interventions and reduce their attrition rates. [ ] [ ] [ ] the available literature has copiously cited the positive correlation between incentivising chws and lower rates of attrition. in ghana, chws are not remunerated by governments, and a spirit of volunteerism and altruism is rather emphasised. chws are required to draw satisfaction from community recognition, ability to gain skills and experience and the opportunity it presents to them to build social capital and access other job opportunities. this contradicts the who position and existing literature, which recommend the remuneration of chws. for instance, in the work of lehmann and sanders, the non-payment of chws under the premise that they were volunteers and offered services based on altruistic motives failed to motivate the chws to support the sustainability of community-based health interventions. our experience suggests that contrary to the government's view that chws activities should be inspired by altruism, chws usually have high expectations of rewards in the form of regular wages, stipends and some form of career opportunities to eventuate them into the health system. while chws are gaining increasing attention as important players in healthcare delivery in ghana and elsewhere, they are beset with multiple challenges. chws face capacity problems as they receive little or no formal training. one author noted this as a fundamental concern among chws as most of the experience they require for their job are gathered on the job. quite notably, the ghana health service recently attempted to address this challenge by developing training guides for some categories of chws. however, from our experience, there has been limited uptake of these training guides. we have also observed the inadequate supply of basic equipment such as wellington booths, bicycles, hand gloves and the first aid kit that some chws use to facilitate their work. neglect or inadequate recognition of chws is another fundamental challenge. as noted earlier, the absence of a policy directive on chws lends credence to our position. the current policy position of the government, which does not remunerate chws for contributing to deliver community health service, only exacerbates the dwindling enthusiasm of chws and the time they commit to their duties. this, to a large extent, affects negatively their productivity and retention. further, this has the potential to increase their attrition rates as has been reported in other settings to vary between . % and %. also, the attendant long-run effect of this situation is the high costs involved in selecting and training new chws as replacements. the inadequate recognition of chws has further led to the lack of a framework to regulate their practices as evidenced in the varying roles chws assume as espoused in earlier sections of this paper. the situation creates an inherent ambiguity and varying expectations of their roles which affects the optimum engagement of chws. in ghana, there are neither mechanisms nor a framework to regulate their practice or certify chws as having the requisite competencies to practice as in the case of other health professionals such as medical doctors, nurses or chns. to be able to attain standardisation and integration of the services of chws into the health system, a form of oversight is required. this may take the form of a regulatory or professional body which will provide some form of certification or licensing to duly recognise their competencies and standardise their practices. lack of effective supervision of chws is one of the notable problems chws face in ghana. our experiences in northern ghana suggest that laxity in the supervision of chws is mainly due to the already overstretched nature of the health system, which is attributable in part to the human resources for health crises. given that chws are now taking up more curative care activities in addition to the preventive-based care interventions, their activities should be supervised and coordinated closely to potentially optimise their productivity and improve health outcomes as evident in studies from other settings. also, a further step by the ministry of health (moh) to scale up the number of frontline staff to provide healthcare to the rural communities is the current partnership with the one million chw campaign project to introduce a new cadre of chws in ghana. this represents an important health policy direction in improving access and health outcomes of the rural populace in ghana. the one million chw campaign proposed to introduce a world-class cadre of chws to extend essential health services to household levels functioning as an integral component of the community health system. conceptually and based on the literature on chws, this category of chws will be an informal extension of the formal healthcare system with explicitly defined roles, training and remuneration to augment the delivery of healthcare. notably, this new cadre of chws differs substantially from the chws who are the subject of this paper except in their duties. while the policy issues of existing chws still remain to be addressed, the new programme only proposes to recognise the existing chws provided they will be useful in providing voluntary assistance to the formally remunerated new cadre of chws, and their continuous existence will be dependent on the particular health district. a justifiable policy question may therefore be why introduce a new cadre of chws to take up duties which were essentially carried out by a particular workforce but whose contribution has hitherto not been recognised and whose integration into the new programme has not been explicitly addressed. if such concerns are not addressed, there will most likely be challenges such as conflicting roles, tension between chws of the one million chw campaign and existing chws, lack of community participation and a threat to the sustainability of community-based health interventions. the preceding analysis points to a general policy deficit regarding chws in ghana, given the lack of a national framework to guide activities of chws such as recruitment, credentialling, scope of practice, remuneration, career development, performance management, supervisory mechanisms, integration into the formal health system, capacity development and logistical requirement and deployment. despite the active involvement of chws in the health system, they are invisible nationally and subnationally in terms of policies, strategies and budgeting. we therefore recommend the following immediate and long-term measures to forestall anticipated and existing challenges faced by chws: . the establishment or enactment of a national policy on chws which should define and outline the relevant aspects of their recruitment, credentialling, scope of practice, remuneration, career development, performance management, supervisory mechanisms, integration into the formal health system, capacity development and logistical requirement and deployment. . the establishment of a professional and/or regulatory body that will exercise oversight over chws by defining, monitoring or enforcing the standards and practice of chws in ghana including licensing or a form of certification. . the development of a long-term strategy that will see the gradual replacement or absorption of chws into the mainstream or formal health service in ghana. . that the proposed one million chw campaign project should incorporate an integration plan aimed at enlisting existing deserving chws who have a wealth of experience and skill to their credit and to further develop the capacities of those with inadequate skills to enable them to enlist and participate in the programme. . finally, policy steps should be taken to critically review the who position on tbas' roles in promoting maternal health. given the shortage of skilled birth attendants (sbas) in ghana and across sub-saharan africa as indicated by the latest who report on the 'state of the world's midwifery', it is clear that the ideal of ensuring skilled attendance at all births is not feasible or achievable in the short term. therefore, reasonably acceptable equity and efficiency arguments can be made for the building of working partnerships with and incorporation of tbas into the maternal healthcare system in contexts such as ghana where skilled maternal healthcare provision is acutely limited. indeed, widespread collaboration through policy support for the healthcare system to identify, train and enhance the skill sets of tbas is recommended. partnerships between tbas and sbas would also be critical for helping healthcare workers to learn from tbas how best to address the cultural needs and concerns of childbearing women. thus, even if the ghanaian health system were to train and deploy sufficient numbers of sbas to all parts of the country in the future, tbas could still play important roles in helping healthcare workers to provide culturally competent care. conclusion this relatively modest contribution by chws to healthcare delivery in ghana suggests the need for state and non-state actors alike to build better working partnerships with chws, provide financial remuneration, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities. in addition, there is the need for policy definition to harmonise the issues relating to chws in general. this is because chws play an indispensable role in delivering health to their communities and assume and actively play the role of health activists and advocates. the reported challenges faced by chws can be addressed through appropriate national policy articulation, and therefore development partners should work in partnership with the government of ghana to put in place these policies. handling editor douglas noble. contributors lb and ams conceived the study. lb, ams, pnt and jkg searched the literature. lb drafted the manuscript. all authors contributed substantially to the review of the manuscript for critical and intellectual content. all authors have read and approved the final version of the manuscript for publication. competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. data sharing statement no additional data are available. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. see: http:// creativecommons.org/licenses/by-nc/ . / producing effective knowledge agents in a pluralistic environment: what future for community health workers? thirty years after alma-ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-saharan africa questioning the solution: the politics of primary health care and child survival can the deployment of community health workers for the delivery of hiv services represent an effective and sustainable response to health workforce shortages? results of a multicountry study community health workers and the response to hiv/aids in south africa: tensions and prospects community health workers for universal health-care coverage: from fragmentation to synergy feldshers and health promotion in the ussr the barefoot doctors of the people's republic of china health by the people global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems million community health workers in sub-saharan africa by lay health workers in primary and community health care for maternal and child health and the management of infectious diseases achieving child survival goals: potential contribution of community health workers lay health workers in primary and community health care: a systematic review of trials. geneva: world health organization an intervention involving traditional birth attendants and perinatal and maternal mortality in pakistan cardiovascular disease prevention in ghana: feasibility of a faith-based organizational approach effectiveness of community health workers in the care of persons with diabetes effectiveness of community health workers in the care of people with hypertension using lay counsellors to promote community-based voluntary counselling and hiv testing in rural northern ghana: a baseline survey on community acceptance and stigma the amount and value of work time of community medicine distributors in community case management of malaria among children under five years in the ejisu-juaben district of ghana community health workers: what do we know about them? the state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. world health organization community and formal health system support for enhanded community health worker performance. a us government evidence summit. final report assessment of the adherence of community health workers to dosing and referral guidelines for the management of fever in children under years: a study in dangme west district accelerating reproductive and child health programme impact with community-based services: the navrongo experiment in ghana factors influencing sustainability of community-based health volunteers activities in the kassena-nankana east and west districts of northern ghana the ghana community-based health planning and services initiative for scaling up service delivery innovation community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness community-based health workers: head start or false start towards health for all? community health workers: a review of concepts, practice and policy concerns. a review as part of ongoing research of international consortium for research on equitable health systems (crehs) chasing out traditional birth attendants in ghanaimplications for maternal and newborn health interventions to improve motivation and retention of community health workers delivering integrated community case management (iccm): stakeholder perceptions and priorities bridging the gap between evidence-based innovation and national health-sector reform in ghana accelerating reproductive and child health program development: the navrongo initiative in ghana assessing participation in a community-based health planning and services programme in ghana scaling up health system innovations at the community level: a case-study of the ghana experience guinea worm disease outcomes in ghana: determinants of broken worms dracunculiasis eradication: ministerial meeting motivations and challenges of community-based surveillance volunteers in the northern region of ghana pilot study of the use of community volunteers to distribute azithromycin for trachoma control in ghana innovative approaches to infectious disease prevention in women the role of case containment centers in the eradication of dracunculiasis in togo and ghana community participation in the eradication of guinea worm disease the impact of health education to promote cloth filters on dracunculiasis prevalence in the northern region ghana: guinea worm eradication program gets results in country atlanta early treatment of childhood fevers with pre packaged antimalarial drugs in the home reduces severe malaria morbidity in burkina faso community case management of fever due to malaria and pneumonia in children under five in zambia: a cluster randomized controlled trial world health organization/ united nations children's fund joint statement on integrated community case management: an equity-focused strategy to improve access to essential treatment services for children valuing and sustaining (or not) the ability of volunteer community health workers to deliver integrated community case management in northern ghana: a qualitative study two-year evaluation of intermittent preventive treatment for children (iptc) combined with timely home treatment for malaria control in ghana factors related to retention of community health workers in a trial on community-based management of fever in children under years in the dangme west district of ghana improving maternal healthcare in ghana and beyond does tba training increase use of professional antenatal care services: a review of the evidence assessment of the role of traditional birth attendants in maternal health care in oredo local government area traditional birth attendant training for improving health behaviours and pregnancy outcomes why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in west java province are traditional birth attendants good for improving maternal and perinatal health? yes community health workers for art in sub-saharan africa: learning from experiencecapitalizing on new opportunities scaling up access to antiretroviral treatment in southern africa: who will do the job? a systematic review of task-shifting for hiv treatment and care in africa role and outcomes of community health workers in hiv care in sub-saharan africa: a systematic review populism and health policy: the case of community health volunteers in india management of sick children by community health workers. intervention models and programme examples what works for children in south asia: community health workers community health workers: a front line for primary care? population council. community health volunteers training manual lay workers in directly observed treatment (dot) programmes for tuberculosis in high burden settings: should they be paid? a review of behavioural perspectives health worker motivation in africa: the role of non-financial incentives and human resource management tools the female community health volunteer programme in nepal: decision makers' perceptions of volunteerism, payment and other incentives training the health workforce: scaling up, saving lives world health organization, pepfar and unaids. task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines national experience in the use of community health workers. who health workforce attrition in the public sector in kenya: a look at the reasons world health organization. task force for scaling up education and training for health workers. global health workforce alliance scaling up working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in ghana are large-scale volunteer community health worker programmes feasible? the case of sri lanka a community health worker intervention to address the social determinants of health through policy change community health workers " " for primary care providers and other stakeholders in health care systems frontline health workers coalition. a commitment to community health workers: improving data for decision making the state of the world's midwifery : delivering health, saving lives key: cord- -vca wo authors: tufts, steven; savage, lydia title: labouring geography: negotiating scales, strategies and future directions date: - - journal: geoforum doi: . /j.geoforum. . . sha: doc_id: cord_uid: vca wo abstract in our editorial introduction to this themed issue on labour geography, we outline some important on-going debates in the relatively young field of labour geography and suggest future directions for research. first, there is the key question of labour as an active agent in the production of economic landscapes. the agency of labour will likely remain a defining feature of labour geography, but perhaps it is not as important to construct theoretical analytical boundaries as it is to define labour geography as a political project. second, debates continue surrounding the production of scale and the multiscalarity of organized labour. third, labour geographers have yet to engage in any sustained fashion with unpacking the complex identities of workers and the way in which those identities simultaneously are shaped by and shape the economic and cultural landscape. fourth, there is some debate on the costs and benefits of a ‘normative’ labour geography which emphasizes what workers and their organizations ‘could’ or even ‘should’ do. lastly, we challenge the assumption that labour geographers have not yet asserted themselves as activists in their own right. we conclude the editorial by introducing the articles included in the issue. while these articles may not address every gap in the literature, they do contribute in significant ways to move the labour geography project forward. in our editorial introduction to this themed issue on labour geography, we outline some important ongoing debates in the relatively young field of labour geography and suggest future directions for research. first, there is the key question of labour as an active agent in the production of economic landscapes. the agency of labour will likely remain a defining feature of labour geography, but perhaps it is not as important to construct theoretical analytical boundaries as it is to define labour geography as a political project. second, debates continue surrounding the production of scale and the multiscalarity of organized labour. third, labour geographers have yet to engage in any sustained fashion with unpacking the complex identities of workers and the way in which those identities simultaneously are shaped by and shape the economic and cultural landscape. fourth, there is some debate on the costs and benefits of a 'normative' labour geography which emphasizes what workers and their organizations 'could' or even 'should' do. lastly, we challenge the assumption that labour geographers have not yet asserted themselves as activists in their own right. we conclude the editorial by introducing the articles included in the issue. while these articles may not address every gap in the literature, they do contribute in significant ways to move the labour geography project forward. Ó elsevier ltd. all rights reserved. it has been well over a decade since herod's ( ) explicit call for instilling labour theoretically as a more active agent in the production of economic landscapes. several geographers seriously took up the challenge and labour geography has emerged as a viable sub-discipline (castree et al., ; herod, ; savage and wills, ) . it is only expected, that labour geographers (self-identified, labeled as such by others, or simply guilty by association) have recently engaged in a period of reflection and assessment of existing research gaps and possible future directions for the project. castree ( ) , lier ( ) , and ward ( ) have all provided some useful reflection on what future labour geographies might entail in order to remain theoretically relevant to contemporary questions of work, employment, and labour organization. herod (with colleagues) has himself attempted to expand geographical thinking into discussions of work and employment practices beyond the confines of the discipline (herod et al., ) . the fact that labour geography is now in a position where there is enough literature to review and (re)assess should be viewed as an accomplishment in itself. it is also a positive sign that relatively junior researchers continue to engage with questions of work in a similar theoretical manner and that non-geographers have been inspired by such approaches. this themed issue is evidence of the project's determination to move forward and the contributions address some of the issues raised by those who have recently taken stock of labour geography's early years. prior to introducing the articles and how they fit into current discussions we briefly outline some important debates identified by ourselves and others. first, there is the key question of labour as an active agent in the production of economic landscapes. lier ( ) succinctly summarizes how the dissatisfaction with structuralist marxist economic geography led researchers to pay more attention to the agency of multiple actors. castree ( ) speaks of labour agency as perhaps the necessary 'analytical boundary' for defining the discipline. indeed, wills ( ) in a recent keynote address differentiated labour geography approaches which illuminate the agency of workers from those that still emphasize the power of neoliberal capital to shape global economic production (defined as the political economy of work). the agency of labour will likely remain a defining feature of labour geography, but perhaps it is not as important to construct theoretical analytical boundaries as it is to define labour geography as a political project. for example, much of the work of peck ( peck ( , is very much concerned with mapping the complex terrain of neoliberalism and the manner in which capital and the state relentlessly attack labour and reorganize spatial patterns of production in order to maintain accumulation. if a full exploration of the agency of labour is to be a qualifying factor, peck (and many others for that matter) would be left outside of the labour geography project. yet, labour geographers require rich understandings of the way capital and states seek to control labour at a number of interlocking scales in order to better understand how labour is implicated in and resistant to such processes. instead, what labour geographers (narrowly defined) and those who study the political economy of work have in common is a strong sense of the lack of sustainability and social justice in the contemporary division of labour. perhaps, labour geography can be defined as approaches which seek to understand the diverse processes which both limit and build labour's capacities to create more equitable economic systems. here, we are suggesting nothing more than revisiting herod's ( herod's ( , initial intervention which was never aimed at completely subverting the theoretical role of capital or the geographically uneven capacities of workers to shape the economic landscape. but more significantly, we are opening up labour geography to engage with discussions of noncapitalist and post-capitalist economic formations which still require a great deal of labour (see gibson-graham, ) . perhaps of even more immediate importance is the need to apply a labour geography perspective to cases in the global south, where the exercise of 'agency' takes on significantly different form and meaning. second, there are debates surrounding the production of scale and the multiscalarity of organized labour. herod ( herod ( , was initially influenced by the work of harvey ( ) , smith ( ) , and swyngedouw ( ) in his theorizations of how workers 'jump scales' at particular moments. savage ( ) has argued that scale is contested in organizations and tensions (as currently experienced by the seiu in their efforts to 'scale-up' the justice for janitors campaign) inevitably challenge organizational structures. tufts ( ) conceptualizes union renewal as a spatial circuit dependent on multiscalar action which occurs at a variety of reinforcing scales. like savage, he notes that these reinforcing strategies are not easily maintained and a number of 'breaks' between local and international priorities can disrupt the renewal process. clearly, labour geographers will be tasked with uncovering how labour struggles to overcome the 'geographical dilemmas' which continue to confront workers who reproduce themselves in uneven economic contexts (see castree et al., ) . while there may be some consensus on the multiscalar nature of successful labour action, there remains little agreement on the processes which foster such power. third, labour geographers have yet to engage in any sustained fashion with unpacking the complex identities of workers and the way in which those identities simultaneously are shaped by and shape the economic and cultural landscape. for example, while many researchers have focused on globalization, only a few have attended to the need to look at the lives of women despite the number of women in the global workforce and their significant role in the economy. yet in varied and often locally specific ways, capital relies on racialized and gendered ideologies and social relations to recruit and discipline workers and to create a global low-paid labour force. sassen ( ) has called the reliance of globalization on women's work ''the feminization of survival" because it is women's work that generates revenues for governments, wages and remittances for families and profits for corporations. more women are engaged in paid work today than ever before (more than men in some countries), yet women still face higher unemployment rates, receive lower wages than men and represent % of the world's million working poor (ilo, ) . further, most statistics do not even begin to account for workers employed in commercial sex work, the informal economy, and unpaid labour required for social reproduction. it is here where perhaps there is a need for an unpaid labour geography which links the role of household economies to the ability of workers to shape economic landscapes (kelly, ). nagar et al. ( ) detail the specific contributions that could be made to this area of research by geographers and argue that this work would greatly enrich our understanding of the global economic landscape. despite what we see as a need for more research in this area, there are a number of new and important directions in uncovering the role workers and their organizations play in the continued segregation of labour markets and the reproduction of exclusion around such identities as race, gender, ethnicity, and sexuality. mcdowell et al. ( ) document how changes in the workplace actively reinforce stereotypes through the division of labour in the hotel sector, while tufts ( ) explores how unions may be active participants in the same processes even as they challenge racism in the workplace. there are exciting avenues for labour geography to pursue the role workers play in shaping cultural landscapes which are implicated in but beyond material questions. fourth, there is some debate on the costs and benefits of a 'normative' labour geography which focuses on what 'could' or even 'should' be. castree ( ) sees such a normative bias as indicative in much labour geography as researchers are biased toward proworking-class outcomes. as hinted at above, we do not see this as a problem as it would be hard to see any cohesive labour geography project which accommodated research approaches seeking to discipline the agency or workers against capital. furthermore, the notion of objective research has been called into question by feminists, who have long argued that even the most seemingly objective, scientific research has an implicit 'normative bias' (e.g., harding, ) . we do see however, a much larger problem with the inherent bias towards institutions in many studies (of which we are both complicit). in part, this is a theoretical and empirical trap as organized labour does indeed have the power to exercise significant agency and the institutional presence to serve as a convenient research subject/partner. there is a need, however, for researchers to engage more fully with rank-and-file members who may or may not participate in union life. as for the study of non-union workers and sectors, much is being done to explore how workers exercise power without union capacities and how they are building institutional alternatives. this is of crucial importance when studying migrant workers, a vulnerable group whose agency is not as easily made evident and is arguably understudied by (narrowly defined) labour geographers (see castree, ; lier, ) . fortunately, recent work on migrant workers in global cities is addressing these shortcomings (may et al., ) . there is a wealth of research on immigrant labour markets in canada and a number of researchers are engaged in documenting the exploitive temporary foreign worker programs which have evolved over the post-war period and the emerging resistance to these relations through workers action centres and fights for legislative change. admittedly, migrant workers are rarely discussed from a specific labour geography perspective (mcdowell, ) . lastly, there is an issue over the active role researchers themselves can play in advocating and fighting for change. castree ( ) argues that the activist component of labour geography can be made stronger. we feel, however, that here he has set up an unnecessary strawperson. first, labour geographers are engaged in a range of activist projects that are simply not documented in journals and book chapters and as a consequence are not easily 'reviewable'. one notable exception is the continuing work of wills and her colleagues on living wage campaigns in the uk. in some contexts, publicizing certain types of activism may still be detrimental to one's career. geographers have found their way into the labour movement as consultants, paid staff, rank-and-file activists and community organizers and some disseminate findings in partnership with union staff. while a broader survey would uncover the extent of labour activism among geographers, we do not see any reason to think it still is (or ever was) strictly the domain of marxist political scientists and sociologists. labour geography will undoubtedly continue to evolve and we feel a number of researchers within and outside the formal discipline are positioned to move forward and address some of the gaps which have been recently identified. in this themed issue of geoforum, we feature five articles which do not address every shortcoming in the still relatively young labour geography project, but do contribute in significant ways. the ease with which capital moves across space has long been understood to be one of the biggest challenges to labour activism and organizations. even as many researchers have cautioned that unions need to move with care in scaling up their actions lest they lose local power, most unions have made at least sporadic attempts to engage in some form of labour internationalism. few unions have moved as aggressively as the us-based service employees international union's (seiu). seiu leadership has declared that the labour movement must ''jump scale" to match the global strategies of capitalism. the stated goal of the seiu is to organize workers across borders under the same union banner and negotiate multi-national labour agreements with global corporations. aguiar and ryan ( ) examine the prospects for the seiu's efforts to 'export" their successful justice for janitors (jfj) campaign. aguiar and ryan discuss how the jfj model is being exported to canada and australia to organize cleaners and assess the prospects for ''going global." the authors conclude that jfj is, in fact, a complex and multiscalar campaign which involves local negotiation and is flexible enough to adapt to diverse contexts. anderson ( ) proposes that unions can exploit the uneven global economic landscape in much the same way as capital does. in his research on the driving up standards campaign (a public transport sector initiative involving the american seiu and ibt, and the british t&g), he argues that when unions expand the scale of their activities, they can create multiple networks and nodes for activism which in turn, results in multiplying the number of corporate vulnerabilities that can be targeted. drawing upon the deleuzian notion of lines of flight to explore the multiple sites for activism, anderson contends that just as labour faces uneven support and expectations from states, consumers, workers, and shareholders, so do tncs. he finds, however, that the ability of unions to create and maintain transnational networks and sustained activism is a difficult prospect as unions have difficulty ''unlocking powers" that are more often rooted in national and local contexts. though he concludes that unions can be successful in challenging capital by ''bending scales", he maintains that they must use supple strategies that recognize the temporal and spatial aspects of their challenges and any challenge to global capital will ''require the capacity to exert pressure from a variety of angles over a sustained period of time." while the tendency for unions to rely upon locally spatially rooted practices can pose challenges for sustaining transnational activism, the local state and city are crucial points of engagement in the work of rhee and zabin ( ) on home-and communitybased caregivers in the us. the authors analyze union efforts to organize workers who provide homecare, childcare, and services to people with developmental disabilities. demand for services in the care industry in the us is growing rapidly and is characterized primarily by a privatized ''flexible" workforce of women, workers of color, and immigrants working in private homes or small facilities for low wages. rhee and zabin document how unions have simultaneously pursued two strategies that jump scale to organize and represent caregivers. the first strategy is to raise labour and service standards on a state-by state basis and to aggregate workers in various organizations to better represent them. the second strategy is to build coalitions between caregivers, consumers and advocates at multiple scales. these two approaches have led to the formation of crucial linkages between workplace organizing, community alliance building, and policy development. more important they have brought workplace politics into the broader field of urban politics, forging place-based solidarities in order to build legitimacy and popular support for local social welfare expenditures and workers' rights. while the debate over business unionism versus social movement unionism and organizing models of unionism continue, tufts ( ) proposes a model of ''schumpterian unionism." he positions his model on a continuum between idealized business unionism and social movement unionism. while such union practices are not capable of transforming neoliberalism, they do allow for the continued agency of unions in harsh economic and political environments where ceaseless 'creative destruction' of local economies continue to disrupt workers' lives. here, multiscalar union practices are theorized as they exist under contemporary capitalist formations and links are made to union participation in local politics and neoliberal state policy. the theoretical discussion is grounded in the case of unite-here local in toronto and the union's response to the outbreak of severe acute respiratory syndrome (sars) in which resulted in a world health organization travel advisory for the city and the layoff of thousands of hospitality workers. the article concludes with a call for labour geographers to become more engaged in broader debates of neoliberal restructuring and capital-state theory. finally, mills and clarke ( ) make a compelling case for unions to rethink and revamp their external and internal practices in order to better organize and represent aboriginal workers in canada. they argue that the complex history of the indigenous communities in canada presents unions with a challenge distinctly different from organizing other historically underrepresented groups since aboriginal peoples have an inherent right to self-governance. they outline the efforts of two national public sector unions as they approach organizing and representing aboriginal workers in two broad categories of workplaces: workplaces that are not located on recognized aboriginal territory or in the north and/or are owned and managed by settlers, and workplaces that are either aboriginal owned and managed and/or are located on recognized aboriginal territories or in the north. union activities in the former have primarily involved drawing connections between a colonial past and present day inequalities to address racism in the workplace and labour market while in the latter, largely non-unionized, organizing has been the priority. mills and clarke hold that as unions are guided by principles of social movement unionism and indigenity, alternative models of organizing evolve that ultimately extend the boundaries of union activism. moreover, as unions seek to be more inclusive of aboriginal workers, they must recognize and grapple with their own internal racism and colonial practices and adopt new approaches informed by the voices and activism of aboriginal workers. together, these articles cover significant challenges and opportunities facing anglo-american labour movements. we do not, however, expect this to be anywhere near an exhaustive treatment and hope that labour geographers will continue to develop new ways of understanding contemporary labour movements which are crucial to the regulation, sustainability, and reproduction of economic landscapes. geographies of the justice for janitors labour's lines of flight: rethinking the vulnerabilities of transnational capital labour geography: a work in progress spaces of work: global capitalism and the geographies of labour a postcapitalist politics . feminism and methodology the condition of postmodernity. basil blackwell from a geography of labor to a labor geography: labor's spatial fix and the geography of capitalism organizing the landscape: geographical perspectives on labor unionism labor geographies: workers and the landscapes of capitalism working space: why incorporating the geographical is central to theorizing work and employment practices global employment trends for women. international labour organization from global production networks to global reproduction networks: households, migration, and regional development in cavite, the philippines places of work, scales of organizing: a review of labour geography keeping london working: global cities, the british state and london's new migrant division of labour thinking through work: complex inequalities, constructions of difference and trans-national migrants division, segmentation and interpellation: the embodied labours of migrant workers in a greater london hotel we will go side-by-side with you". labour union engagement with aboriginal peoples in canada locating globalization: feminist (re)readings of the subjects and spaces of globalization work-place: the social regulation of labor markets aggregating dispersed workers: union organizing in the ''care" industries women's burden: counter-geographies of globalization and the feminization of survival justice for janitors: scales of organizing and representing workers new geographies of trade unionism mapping the futures: local culture neither global nor local: 'globalisation' and the politics of scale we make it work": the cultural transformation of hotel workers in the city emerging labour strategies in toronto's hotel sector: toward a spatial circuit of union renewal hospitality unionism and labour market adjustment: toward schumpeterian unionism? thinking geographically about work employment and society keynote speech. developing theoretical approaches in labour geography key: cord- -cpd yl c authors: ng, qin xiang; de deyn, michelle lee zhi qing; lim, donovan yutong; chan, hwei wuen; yeo, wee song title: the wounded healer: a narrative review of the mental health effects of the covid- pandemic on healthcare workers date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: cpd yl c nan health systems and healthcare workers worldwide are experiencing tremendous stress because of the growing coronavirus disease pandemic. in many ways, the causative virus, the severe acute respiratory syndrome coronavirus (sars-cov- ), is unlike the common flu or the sars virus. it is highly contagious and infected persons may remain relatively asymptomatic (tandon, ) . much j o u r n a l p r e -p r o o f about the virus also remains unknown, including its incubation period and transmission dynamics . cases increase at an exponential rate, may have complicated needs and are typically not discharged until at least days later . expectedly, there have been increasing reports of high rates of anxiety and depressive symptoms amongst frontline medical staff (lai et al., ; tan et al., ) , and calls for healthcare workers involved in the fight against covid- to receive screening and counselling by professional mental health providers. a rapid review of the pubmed and google scholar databases using the text words, "covid- " or "ncov" or "sars" or "sars-cov- " and "mental health" or "psychiatry" or "psychology", "anxiety" or "depression" or "stress", up to may, , we found ten observational studies on the mental health effects of the covid- pandemic on healthcare workers. these studies and their key findings are summarised in table . -levels of social support for medical staff were significantly associated with self-efficacy and sleep quality and negatively associated with the level of anxiety and stress. -levels of anxiety were significantly associated with the levels of stress. this negatively impacted self-efficacy and sleep quality. -anxiety, stress, and self-efficacy were mediating variables associated with social support and sleep quality. notably, the studies were all from asia (singapore, india and china). the chinese studies generally found that female gender and direct contact with covid- patients were significant risk factors associated with higher levels of psychological distress (lai et al., ; lu et al., ; kang et al., ; . poor sleep quality and insomnia may also be more prevalent amongst healthcare workers (huang & zhao, ; xiao et al., ; . besides the demanding nature of the work and other occupational hazards, being in direct contact with a covid- patient puts healthcare workers at higher risk of disease exposure. there may also be anticipatory anxiety and fear of spreading the virus to family members living in the same household. the studies conducted in singapore found overall lower prevalence of psychological symptoms compared to the chinese studies chew et al., ) , but reported higher prevalence of physical symptoms e.g. headache, which could reflect somatization. the studies also highlighted the importance of pandemic readiness and preparedness, especially for non-medical staff, who may be less familiar with communicable diseases. wearing full ppe is exhausting and proper work-rest cycles should be ensured. skin damage due to frequent handwashing and enhanced infection-prevention measures could also compound one's psychological distress (lan et al., ) . in the current climate, even the best among us can feel overwhelmed, emotionally distressed and be left with the scars of vicarious traumatization. an effective pandemic response must also include a mental health response, both for the public and also the healthcare force. it is important to continually support healthcare workers and their psychological needs. as resources could be scarce at the moment, timely psychological support could take many forms (ng et al., ) . these include availing counselling services, informal or formal supervision and establishing peer support systems j o u r n a l p r e -p r o o f among colleagues. future studies on this subject should also employ a mixed-methods design to explore specific themes and intervention strategies. swiss psychiatrist carl jung famously said that, "it is his own hurt that gives the measure of his power to heal [..] this, and nothing else, is the meaning of the greek myth of the wounded physician." in the same vein, i hope all healthcare workers can draw strength from their struggles and transform despair into hope. keywords: covid- ; pandemic; mental health; healthcare workers; doctors; nurses no conflict of interest to declare. none. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. not applicable. none a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak. brain, behavior, and immunity psychological symptoms among frontline healthcare workers during covid- outbreak in wuhan. general hospital psychiatry generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey the mental health of medical workers in wuhan factors associated with mental health outcomes among health care workers exposed to coronavirus disease skin damage among health care workers managing coronavirus disease- vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control. brain, behavior, and immunity psychological status of medical workforce during the covid- pandemic: a cross-sectional study psychological impact of the covid- pandemic on health care workers in singapore the covid- pandemic personal reflections on editorial responsibility. asian journal of psychiatry unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- mental health and psychosocial problems of medical health workers during the covid- epidemic in china. psychotherapy and psychosomatics none.j o u r n a l p r e -p r o o f key: cord- -x ccpvkn authors: lachish, tamar; tenenboim, shiri; schwartz, eli title: humanitarian aid workers date: - - journal: travel medicine doi: . /b - - - - . - sha: doc_id: cord_uid: x ccpvkn traveling to extreme environments for humanitarian aid mission is now common. humanitarian aid workers (haws) typically travel for extended periods, work in close proximity to local populations, and work in high-risk environments in low-resource regions. owing to the nature of their work, haws are often unable to avoid high-risk behaviors and frequently encounter stressful conditions, leading to psychologic repercussions. although morbidity might be high, death during volunteer missions is not common and it is usually not attributable to infectious diseases. medical evacuations are also not common. one unique aspect of ill-returning haws might be their threat to public health in their home countries, as was demonstrated in the – ebola outbreak in west africa. thus pretravel and posttravel physical and psychologic screening evaluations, in addition to routine health care, are essential for this population. traveling to extreme environments for the purpose of providing humanitarian aid is becoming more common with greater interconnectedness. the number of humanitarian agencies, including both united nations (un) bodies and nongovernmental organizations (ngos), involved in complex emergencies and other humanitarian aid missions has increased significantly in the last two decades and has been accompanied by an increase in the number of recruited personnel designated to work in complex environments. , the humanitarian aid worker (haw) community is an extremely diverse group of organizations and individuals. most haws originate from north america or west and central europe and their popular destinations include africa (especially the sub-saharan region) and southeast asia, but the caribbean, central and south america, and eastern europe are also temporary homes for many. they may travel for a period ranging from a few days to a few years and practice many different kinds of aid (medical, educational, agricultural, etc.). most of them are in their s or s, but some are even elderly. they may be professional or nonprofessional; they may travel in big groups, in families with children, or as individuals. [ ] [ ] [ ] [ ] [ ] [ ] [ ] data about the extent of this phenomenon is still scarce. however, two surveys done in the united states in an interval of two decades demonstrated an increase in the percentage of travelers reporting volunteer work as their main travel purpose. out of surveyed americans who traveled to developing countries between and , % did so for the purpose of voluntary/missionary activities. in , the number more than tripled with % reported traveling as volunteers or medical aid providers. the geosentinel network, the largest global database of travel-related morbidity, documented % of long-term travelers (> months abroad) traveled for volunteer or missionary purposes. as well, % of the shortterm travelers (< month) traveled for similar reasons. if this reflects the nature of traveling, aid workers may become, if they are not already, a group of travelers that pose a specific challenge for travel medicine practitioners as well as for mental health specialists. this group is different from typical travelers because they tend to travel for longer periods, , work in close proximity to local populations, and practice high-risk professions (medical work, peacekeeping missions, security, drivers, etc.) in low-resource environments that have poor infrastructures. in addition they tend to practice high-risk behaviors. , despite this fact, there are limited data focusing on this group; peace corps volunteers (pcvs), the international committee of the red cross (icrc), and various un agency employees represent one source of information, but these groups tend to be better organized, with structured recruiting, screening, and surveillance programs. this contrasts significantly with the many other volunteers sent on behalf of small, sometimes very inexperienced ngos. additional data may be extrapolated from few publications that focus on expatriates, long-term travelers, or others focusing on aid workers from different organizations. therefore generalizations are difficult to make and personally tailored recommendations should be favored. those who practice in field hospitals in disaster-stricken areas are another subset of travelers whose medical recommendations are complex as the teams are exposed to unpredictable environments of physical, medical, and emotional nature. these groups also tend to move on very short notice. , the risk of death among aid workers is influenced dramatically by the nature of their work and the country and situation in which they find themselves. traveling to areas following natural disasters or to areas with ongoing violent conflict is common, as is engaging in high-risk work such as peacekeeping missions, security, or medical care where there is little infrastructure. nevertheless, published data clearly traveling to extreme environments for humanitarian aid mission is now common. humanitarian aid workers (haws) typically travel for extended periods, work in close proximity to local populations, and work in high-risk environments in low-resource regions. owing to the nature of their work, haws are often unable to avoid high-risk behaviors and frequently encounter stressful conditions, leading to psychologic repercussions. although morbidity might be high, death during volunteer missions is not common and it is usually not attributable to infectious diseases. medical evacuations are also not common. one unique aspect of ill-returning haws might be their threat to public health in their home countries, as was demonstrated in the - ebola outbreak in west africa. thus pretravel and posttravel physical and psychologic screening evaluations, in addition to routine health care, are essential for this population. the current literature addressing disasters in poor-resource countries places most of the focus on the victims of the disasters and the diseases emerging among them. illness among rescue teams or volunteers to natural disaster areas is reported only anecdotally. the only study known that has focused solely on the morbidity of the staff deployed in a field hospital was done during the deployment of the israeli defense force field hospital to nepal following the earthquake. gastrointestinal (gi) complaints were by far the most common, with % of the entire staff affected. the group concluded that despite practicing in a standalone and well-equipped facility, prevention of gi problems was very difficult. thus, critical to all aid missions is careful briefing with regard to the challenges of food and water hygiene. a structured guideline may simplify the short preparation phase, as summarized in the experience of the israeli defense force field hospital to the philippines following the tsunami. we highlight some of the conditions we believe require special attention or those that may influence the health recommendations that should be provided to haws. malaria-endemic countries are common destinations for aid workers. the length of stay in the host country poses a challenge for the consulting physician recommending the proper chemoprophylaxis to minimize adverse effects and ensure adherence to treatment. despite prior knowledge about transmission of the parasite, relief workers fail to continuously incorporate protection measures into their daily life. a comparison of knowledge regarding health risk during travel between haws and other travelers was done at the institute pasteur in france. although ngo travelers had better knowledge about the transmission route of malaria, no difference was observed in their knowledge regarding means of prevention or symptoms requiring prompt medical consultation. furthermore, even medical doctors and nurses working for prolonged periods in malaria-risk areas are reluctant to take long-term malaria prophylaxis. in a study in a health care setting in equatorial guinea, including western medical staff and their families, almost half (n = ) chose not to take any malaria chemoprophylaxis. this report of poor adherence to malaria prophylaxis should prompt demonstrates that death during volunteer missions is not common and neither is medical evacuation. contrary to the common perception, "obscure" tropical diseases are rarely the cause of death. of , pcvs, died during missions between and . almost % of these deaths were caused by unintentional injuries (especially motor vehicle accidents). in the following years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) of > , volunteers, deaths occurred during service. among the deaths, involved unintentional injuries; were due to homicide; from chronic illnesses ( from heart conditions, from cancer), and only from infectious diseases ( from malaria, from sepsis). almost all the fatal injuries were of volunteers age - . death from chronic illnesses were more common in the older age group. comparing the first two decades and the following two decades of pcvs showed a decline in the overall death rate by more than half. this decrease was mainly attributed to the decline in motor vehicle accidents and the decreasing number of deaths from chronic illness. these changes resulted from restriction of motorcycle use by volunteers and better pretravel screening of applicants with chronic illnesses. , according to the aid worker security report, during a new record for violence against civilian aid operations was set, with attacks affecting aid workers; among them aid workers were killed, were seriously wounded, and were kidnapped. over half of all violent incidents occurred in the context of an ambush or roadside attack in escalating conflict-stricken areas. death from disease or "natural causes" is rare. in a report that examined cases of death among aid workers ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , only % of deaths were disease related. interestingly one-third of worker fatalities from ngos were from diseases in comparison to only % of worker fatalities from the un. this may be explained by better pretravel medical screening and preparation by the un, compared to small ngos, which may focus on recruitment. though catastrophic events leading to death during aid missions are uncommon, morbidity is significantly higher. this was reflected in a survey conducted among icrc personnel serving an average of months. among them, one-third ( . %) reported a decline in health, and . % reported having at least one medical problem during their mission. the rate of medical problems identified among them varied between regions, while traveling to africa seemed to pose a greater risk in almost all reported categories of medical issues. a wide range of illnesses are suffered during missions (table . ). these include conditions with similar incidence to those reported by geosentinel among ill-returned travelers: gastrointestinal ( %), febrile ( . %), and dermatologic ( . %). however there are specific conditions that seem to be overexpressed among volunteers such as psychologic problems, gynecologic complaints, and dental emergencies (see table . ). it is very important to note, however, that geosentinel clinics (which, as mentioned, deal only with ill-returned travelers) are typically those whose specialty is travel and tropical medicine, and these providers do not typically see general medicine, surgery, trauma, or dental problems. natural disasters in poor-resource countries such as the nepal earthquake, haiti earthquake, the indian ocean tsunami, among others, resulted in the dispatch of foreign aid, including field hospitals. these hospitals are mobile, self-contained, self-sufficient health care facilities capable of rapid deployment of immediate emergency requirements for a specified period of time. occupational exposure is another possible source of infection. it has long been established that health care workers are at increased risk of acquiring bloodborne infections through percutaneous or mucosal exposure. health care workers traveling to hiv-prevalent countries are estimated to be at an even higher risk. a british study found that the risk of health care workers in developing areas of acquiring hiv infection through work was . % over years, which represents in every workers per year. another study showed that almost one-third of british medical students doing an elective period in a hospital in a developing country had experienced at least one exposure to potentially infectious body fluids during their clinical training. of these exposures, % were unreported ; % of american medical volunteers reported exposure to blood splash, and . % experienced a needlestick. although the number of exposures do not necessarily differ from those in their home country hospitals, the risk may be much higher due to reusable and perhaps not disinfected medical devices; absence of a stable supply of protective measures such as gloves, gowns, and masks; a higher prevalence of patients with high hiv viral loads; and lack of knowledge or access to appropriate postexposure prophylaxis. needlestick exposure poses a risk to a wide range of diseases other than hiv/aids. among other potential infections are dengue virus and other hemorrhagic fever viruses, syphilis, and trypanosomiasis. hepatitis b and c viruses are of special importance in low-income and middle-income countries. the risk of rabies is considered to increase with longer duration of travel. since volunteers tend to travel for longer periods, and since they tend to stay in more remote areas, postdisaster areas, or even work in farms or directly with animals, one may assume they may even be at greater risk than the typical traveler. of norwegian missionaries and aid workers serving in different regions, % were exposed to proven or suspected rabies during their mission. pcvs are times more likely to be exposed to rabies risk abroad than in the united states, and numbers are as high as bites per , volunteers per year. the wisdom of preexposure prophylaxis is thus critical to discuss with all such workers. oral health is an essential component of well-being and dental emergencies may pose a challenge to volunteers in developing countries. dental research efforts toward more realistic and safe chemoprophylactic regimens. preliminary reports examining the efficacy of twice-per-week prophylaxis with atovaquone-proguanil in long-term travelers to west africa offer a potentially easy solution using a medication that is currently available. studies substantiating such user-friendly regimens are needed. tuberculosis (tb) is one of the most prevalent infections in the world. limited data are available regarding infection risk among travelers and aid workers. unlike long-term travelers for tourist purposes, aid workers have a higher tendency to work and live in close proximity to local communities. pcvs typically live with local families and many volunteers work in health-related fields, in educational systems, prisons, orphanages, among other areas where they are at higher risk of acquiring a tb infection. in a dutch study, . % of dutch travelers to high tb-endemic regions were identified as newly tb-infected patients. the overall incidence rate was . per person-months of travel after the exclusion of health care workers. the infection rate is of a similar magnitude to the average risk for the local populations in the endemic areas. not surprisingly, working in patient care abroad-a common volunteerism choice-was an independent risk factor with an odds ratio of . . in a study examining the tuberculin conversion rate in a group of long-term aid workers from new zealand, the tb conversion rate was . per person-months. despite this rate of newly infected persons, active tb cases are very rare. the average conversion rate varies among different regions and countries (tables . data regarding hiv infection in travelers or humanitarian workers are scarce. the data that do exist suggest a very low rate of transmission, , though some data are old and may not be representative. numerous reports suggest that casual and unprotected sex are common practice among aid workers. , those returning from longer missions were more likely to have engaged in risky behavior, as were males and younger volunteers. in a review from new zealand, tracking volunteers for years, there were no hiv or hepatitis c virus (hcv) infections detected. on postassignment questioning, . % of volunteers reported unprotected sex with someone other than their regular partner and . % reported a potential exposure to blood and/or blood products. haws who serve in remote, undeveloped destinations and more commonly those working or volunteering in medical situations may serve as vectors for transmission of diseases across borders. the most alarming example for this potential threat was the - ebola outbreak in west africa. in addition to the delay in recognizing the existence of the outbreak, the western world and international aid organizations were not fully prepared to contain the spread of the disease, neither within the disease-stricken areas nor across borders. the most common "vectors" for the ebola cases that were imported to western countries were evacuated haws or those traveling commercially during the disease incubation period. the rapid development of interagency preparedness managed to contain the threat with only a few secondary ebola cases (three nurses who treated ebola patients). the lessons learned during and after this outbreak should serve as a model for preparedness and guidance against other potential threats. one might imagine as well the potential for transmission across borders of novel and severe respiratory illnesses such as influenza, middle east respiratory syndrome (mers), and the like. remaining vigilant and prepared are keys to prevention and management of such threats. as mentioned, relief workers are comprised of a diverse group of organizations and individuals, thus general health recommendations should be tailored according to the age of the volunteer, the duration of travel, destination, nature of work, and other variables. the different aspects of pretravel recommendations for haws are summarized in tables . , . , . , and . . in a systemic review examining the available pretravel health advice guidelines given to humanitarian aid workers, high-risk hazards for aid workers were identified (often location specific), including travelers' diarrhea, vectorborne infections, accidents, violence, tb, hiv, hepatitis a, leptospirosis, typhoid fever, and seasonal influenza. the above mentioned are all (for the most part) preventable, provided that pretravel medical and psychologic assessments and/or education sessions become mandatory and that the travelers remain vigilant and compliant. unfortunately, despite efforts at strict adherence to food and water services are often lacking or primitive, with most developing countries having an extremely low density of dentists per population. on the other hand, it appears that dental problems are a common complaint of long-term travelers, expatriates, and volunteers. eight percent of business trip interruptions were reported to be caused by dental emergencies. among us pcvs serving years in madagascar, dental problems were reported as the fourth most common health problem, with . % of volunteers reporting an event during service. similar numbers were reported by pcvs in africa, with even higher numbers noted among icrc personnel. mental health problems are consistently among the most reported health problems among relief workers overseas (see table . ). however, the extent of the phenomenon is often overlooked, and the emotional needs of volunteers are often left unmet. anthropologist kalervo oberg was the first to apply the term "cultural shock" to people who travel outside of their familiar culture. the term suggests that travel and the experience of a new culture, considered as a positive and exciting experience by most people, may be an unpleasant surprise or even shocking for others. contact with an unfamiliar culture can lead to anxiety, stress, mental illness, and in extreme cases physical illness and suicide. , exposure to extreme events with multiple casualties poses an even greater risk of long-term mental health consequences. [ ] [ ] [ ] relief workers are usually younger and motivated individuals, who travel to places that are both geographically and culturally remote from their usual environs. they often travel without their family or familiar companion. they may travel to war zones and postdisaster areas where they may be exposed to large-scale death and suffering. as well, they often have great aspirations, sometimes unrealistic, about their future volunteer work and its effect on the community. these may all serve as precipitating factors for the development of emotional distress expressed by a wide range of symptoms, and may even develop into more serious mental health conditions. two percent of pcvs in madagascar seek mental health counseling outside of the routine support provided by the organization. the rate of reported mental health problems was more than double that among other volunteers in the entire african region. over % of icrc volunteers reported upon return that their missions were more stressful than they had expected; % reported exhaustion for at least week during their mission, while similar numbers reported sleeping problems; % used sleeping pills. others reported behavior changes as contributors to stress: % reported an increase in alcohol consumption; % admitted to smoking more than usual, and an additional % started to smoke for the first time. these behavior changes were more common among those reporting exhaustion. three percent reported having used illegal drugs, mainly cannabis, during their stays. suicide as a leading cause of death among international volunteers was first noticed in the peace corps: % of all reported deaths from to were due to suicide. these numbers declined drastically after applying a better screening procedure, with only one reported suicide in the following years. , unfortunately many organizations do not have a parallel screening process and follow-up capabilities. finally it should be emphasized that culture shock and emotional distress may also occur upon return home. this readjustment back to their own culture after a period of time abroad has been termed "reverse culture shock." in this part of their adjustment, volunteers may feel especially lonely without the support of the organization or the expatriate group with which they felt most comfortable. proper resettlement into his or her culture and community (tables . and . ). these recommendations should be executed both by the providers and by the recruiting humanitarian organization, and a comprehensive program, if feasible, is favored. precautions or insect precautions, illnesses such as travelers' diarrhea, typhoid, and vectorborne diseases still occur. during missions, especially those that are long term or to crisis areas, volunteers should undergo a refreshment of health guidelines regarding wide-range risk behavior activities, either individually or in groups. in addition, debriefing mechanisms should be implemented with emphasis on peer support (table . ) . posttravel follow-up is unfortunately a neglected topic. emotional and physical aspects of the volunteer should be addressed to ensure consider chronic medication supply for a minimum of months and sustained mechanisms for future shipments of drugs. use of local brands is not recommended . provide self-treatment medications: diarrheal diseases (antibiotic appropriate to region and traveler), malaria standby therapy, first-aid kit . provide malaria prophylaxis as needed . provide a mechanism for obtaining hiv postexposure prophylaxis . provide for availability of malaria rapid test kit (for groups, as recommended) provide psychologic assessment to evaluate the ability of the volunteer to adjust to the specific mission . assist organizations in developing and implementing pretravel preparedness programs, including background of host country, work environment, and cross-cultural issues . promote knowledge regarding risk behaviors with possible health implications. this may include a wide range of topics such as traffic accident awareness, safe sex, tuberculosis, or schistosomiasis prevention provide continuous professional accompaniment of the volunteer to minimize insecurity and stress . give periodic oral and/or written refreshment of personal safety and risk behavior recommendations . consider group administration of malaria prophylaxis or a reminder mechanism to maximize adherence . engage in regular debriefing sessions, either in a group or one on one, allowing volunteers to express stress and difficulties during mission . encourage prompt professional intervention if posttraumatic stress disorder (ptsd) signs or symptoms are suspected . provide periodic personal medical consultations for prolonged missions the state of the world's refugees health risks and risk-taking behaviors among international committee of the red cross (icrc) expatriates returning from humanitarian missions health-related challenges in united states peace corps volunteers serving for two years in madagascar tuberculosis risk in us peace corps volunteers fatalities in the peace corps: a retrospective study fatalities in the peace corps. a retrospective study: through pre-travel health, immunization status, and demographics of travel to the developing world for individuals visiting a travel medicine service pre-travel health advice-seeking behavior among us international travelers departing from boston logan international airport geosentinel surveillance network. illness in long-term travelers visiting geosentinel clinics comparison of knowledge on travel related health risks and their prevention among humanitarian aid workers and other travellers consulting at the institut pasteur travel clinic in hiv risk behavior among peace corps volunteers preparation of medical personnel for an early response humanitarian mission-lessons learned from the israeli defense forces field hospital in the philippines obtain serologic testing for hiv, hepatitis b virus, hepatitis c virus, and other agents where suspected exposures may have occurred evaluate for posttraumatic stress disorder signs and symptoms, especially following crisis intervention missions postexposure chemoprophylaxis for occupational exposure to human immunodeficiency virus in traveling healthcare workers infection risks following accidental exposure to blood or body fluids in healthcare workers: a review of pathogens transmitted in published cases rabies exposure among norwegian missionaries working abroad health problems encountered by the peace corps overseas on the medical edge: preparation of expatriates, refugee and disaster relief workers, and peace corps volunteers culture shock: adjustment to new cultural environments culture shock and travelers world health organization/un joint medical services. occupational health of field personnel in complex emergencies: report a pilot study acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers frequency of ptsd in a group of search and rescue workers two months after bingol (turkey) earthquake posttraumatic stress disorder among professional and non-professional rescuers involved in an earthquake in taiwan morbidity among the israeli defense force response team during nepal, post-earthquake mission aid-worker security report deaths among humanitarian workers geosentinel surveillance of illness in returned travelers guidelines for the use of foreign field hospitals in the aftermath of sudden-impact disasters effectiveness of twice a week prophylaxis with atovaquone-proguanil (malarone®) in long-term travelers to west-africa risk of infection with mycobacterium tuberculosis in travellers to areas of high tuberculosis endemicity dengue fever, tuberculosis, human immunodeficiency virus, and hepatitis c virus conversion in a group of long-term development aid workers hiv- and hiv- infections among u.s. peace corps volunteers returning from west africa reducing the risk of nosocomial hiv infection in british health workers working overseas: role of post-exposure prophylaxis medical students' risk of infection with bloodborne viruses at home and abroad: questionnaire survey key: cord- -a j vz authors: chan, lai gwen; kuan, benjamin title: mental health and holistic care of migrant workers in singapore during the covid- pandemic date: - - journal: journal of global health doi: . /jogh. . sha: doc_id: cord_uid: a j vz nan m igrant worker populations in singapore as well as other countries, despite advances in legislation and protections [ ], continue to face longstanding issues of barriers to equal access to health care [ ] , information and resources targeted at the host country's local population, and even exclusion from national crisis response plans particularly pandemic preparedness plans [ ] . non-governmental organizations (ngos) have a vital role in filling this gap by providing accessible services (eg, welfare, health care, crisis), liaison between employers and financing agents, and advocacy by representation of their needs and concerns in multi-agency collaborations. specifically, mental health care for this population has been lacking because language and cultural barriers make it challenging for general health care services to incorporate this aspect. high levels of stigma towards mental illness in the home countries of migrant workers also add to the burden of unmet needs for focused mental health support. the scarcity of such services even among the ngo sector became amplified during the covid- pandemic in singapore when mass quarantine and isolation of migrant worker accommodations severely reduced ngos' access to them. healthserve [ ] was one such ngo which, in the years since it was founded, has established strong networks of friendship and goodwill between ministerial agencies, employers, migrant worker dormitory operators and migrant workers. healthserve operates low-cost primary care clinics including case work support to workers who had sustained workplace injuries, and commenced a mental health and counselling department, the first among the other migrant worker ngos, in . when news broke in early april about the gazetting of large migrant worker dormitories as isolation areas because of clusters of confirmed covid- cases there [ ] , healthserve anticipated the unprecedented magnitude of mental health and psychosocial care needs and stepped forwards with a manual of recommendations on how to engage the migrant worker population as well as how to address the mental health and psychosocial care needs (an adaptation and application of the interim briefing note mental health and holistic care of migrant workers in singapore during the covid- pandemic this paper describes a collaborative model between a non-governmental organization and other governmental and healthcare stakeholders in addressing mental health and holistic care of migrant workers, as well as how the model evolved as more real-time experience about this population's needs and responses were gained. addressing mental health and psychosocial aspects of cov-id- outbreak developed by the iasc's reference group on mental health and psychosocial support in emergency settings [ ]). (table ) . this was circulated to governmental and community teams who were involved in migrant worker outreach. it describes a tiered model of care where the recommended interventions get increasingly specific and specialized as one moves up the tiers. for example, tier recommends basic communication and connection strategies to meet basic needs for safety, and the highest tier describes specialized mental health services delivered by mental health professionals. this manual continues to be an evolving document as more is learnt and as policies change in real-time. the experience gained as described in this paper will be a critical reference for other healthcare systems where barriers remain in migrant workers' access to healthcare, especially in planning for future disease outbreaks. tier • enable autonomy over simple daily routines that are culturally and religiously appropriate: -provide resources/equipment needed to maintain dignity in lifestyle eg, housekeeping necessities, toiletries, food for cooking comfort foods (within appropriate social distancing measures & contexts) social considerations in basic services and security • provide freedom, space, resources for religious rituals • ensure basic, positive daily communications through any broadcasting system in appropriate languages basic themes in establishing sense of safety: • give adequate advanced notice and information about any upcoming transitions, eg: -transfers from dormitory to hospital or isolation facility or discharge back -explain their medical condition, reason for transition, what to expect after transition etc • repeat and reinforce information post-transition similarly • sensual comforts (eg, preferred foods) • have staff trained in psychological first aid to look, listen and link • provide a means for feedback and concerns to be raised and addressed eg, -message boards, -whatsapp chat groups, -daily face-to-face check-ins, and -ensure timely updates on the concerns raised • habitual comforts (eg, familiar routines) • provide information and access to covid specific information, eg, https://covid .healthserve.org.sg/ • provide information and access to self-help resources, eg, healthserve hotline • hearing and feeling heard • written information in the form of care cards or health booklets can be helpful but audio-visual forms are preferred because verbal comprehension abilities are generally stronger than reading comprehension • ensure access to chronic disease management tier • healthserve website to be regularly refreshed with mental wellness content • encourage self-enablement and empowerment • provide resources for suggested appropriate pleasurable activities, eg, -games (playing cards, carrom, chess, etc) -craft work, art/drawing -outdoor movie screening -etc strengthening personal resilience and community and family supportsactivating social networks, supportive spaces • plan special activities, foods, occasions to be looked forward to • enable celebration of significant cultural/religious festivals in appropriate ways • encourage helping and looking out for each other who are in the same cohorted space, and have autonomy over their space (eg, 'cleanest room / corridor / block' competitions) basic themes: • encourage ground-up initiatives and ideas on activity scheduling and system improvements • connection • communication • announce and celebrate achievements • contribution • harness technology to enable new ways of expression, communications and communal activities • meaning tier hospitalized or quarantined workers • prepare a pool of available translators and have a low threshold for calling on them for help • develop communications scripts for use between patient/healthcare worker and healthcare worker/ patient's next of kin • include aspects from tier and tier in admissions orientation (such as sources of information and self-help) non-specialised supports -basic emotional and practical support by community workers • posters and informational materials on healthserve's hotline to be displayed prominently for awareness and self-help • referral pathways for onsite teams to refer cases to healthserve tele-befriender service or onsite teams to allow access to healthserve to provide outreach -all attending teams (medical and non-medical) are advised to proactively detect signs of emotional distress dormitory workers healthserve "tele-befriender" service in the form of : or group sessions, fronted by volunteers and supervised by mental health experts • posters and informational materials on healthserve's hotline to be displayed prominently at medical post • referral pathways for onsite teams to refer cases to healthserve tele-befriender service or onsite teams to allow access to healthserve to provide outreach -all attending teams (medical and non-medical) are advised to proactively detect signs of emotional distress • employers and dormitory managers can also refer to healthserve tele-befriender service by sending a text message to the healthserve hotline tier • cross-referral across health care institutions to accord appropriate care for individuals requiring more intense intervention specialised services -mental health care by mental health specialists • early involvement of skilled resource from tertiary hospitals and national institutes for just-in-time care • proposed workflows for referral and escalation (to be developed according to jurisdiction) additional strategies were adopted by healthserve and these are the ones with the greatest impact: . proactively approaching the inter-agency task force [ ] that had been set up to provide support to dormitory operators and the migrant workers living there in order to be a representative voice for migrant workers as well as offer recommendations on how best to engage this population. this was made possible through pre-existing networks with ministerial agencies and a high level of trust between parties. this collaboration continues to be active and deepen and ensured that mental health care continues to be a priority. . partnered medical teams providing on-site medical care to dormitories to conduct small group engagement with migrant workers for needs assessment. concerns and feedback were systematically gathered and resulted in rapid improvements to care and services provided on the ground as well as future planning. these concerns included issues related to food provision, fears of covid- transmission, lack of timely information, fears of deportation etc. . healthserve's communications team also set up a specific covid- information webpage [ ] accessible in different languages of the migrant workers, with information regarding the pandemic, social support that is available, as well as mental wellness information. a separate team of volunteers also prepared a pipeline of content to regularly refresh the webpage. from experience, migrant workers tended to use social media platforms more frequently, hence healthserve also ensured its social media pages [ ] were regularly refreshed with content and the relevant links to further online information. healthserve also engaged the partnership of the country's major telecommunications providers to send out sms (short messaging system) blasts pointing the migrant worker population to these online resources and worked with social media companies to target relevant information specific to migrant workers. one key learning was that this population tended to consume information via video and audio rather than text and health-serve hence worked closely with media houses to produce content in these formats. videos featuring celebrities from the workers' home countries were particularly well-received. . outreach to and partnerships were made with the national centre for infectious diseases (ncid, where the bulk of covid- cases were given acute care) and the community isolation facilities (where covid- patients were decanted from acute hospitals) so as to provide support on how to apply the manual's recommendations in the specific settings. for example, creating videos to be broadcast in hospital rooms on what to expect in their journey as a patient traversing through the health care system, creating simple and pictorial health booklets in native languages to empower migrant workers to take charge of their own health and mental well-being, setting up of remittance booths/kiosks for online remittance, supporting muslim migrant workers who wanted to observe ramadhan (setting up prayer corners, providing prayer mats, specific foods and timings to break fast), and even encouraging ground-up initiatives such as providing haircuts. there was much positive qualitative feedback about these. . psychiatric departments of different hospitals and the country's tertiary psychiatric hospital also reached out to establish partnerships, referral pathways and escalation protocols for migrant workers identified to require more specialised mental health assessment and interventions. these have proven to be useful especially as cases of major mental illness and serious self-harm began to emerge and the numbers requiring psychiatric intervention are rising. . healthserve also actively "walked the ground" for outreach to migrant workers who were not living in established purpose-built dormitories. such workers were usually living in factory-converted dormitories or private rental apartments, and a smaller group were those given a special permit to remain in singapore while awaiting workmen's injury compensation or salary disputes to be resolved. this had the impact of reaching even the most marginalized migrant workers who would otherwise have fallen through the cracks in the system. "walking the ground" also provided opportunities to engage with the dormitory teams and managing agents of care facilities, who did not have prior experience with engaging migrant workers, to build trust and establish the informal networks that were essential for access and timely responses. . chronic disease management began to emerge as an important health care need for discharged migrant workers who had been diagnosed whilst being treated for covid- . healthserve agreed to receive these referrals to its primary care clinics and worked with the different health care providers on referrals and continuity of care. this aspect was also identified as a health care need that will continue to exist beyond the covid- pandemic and will require further conversation with stakeholders and policy changes regarding their health care financing. . finally, continued mental health commitment by the healthserve board beyond co-vid- was important for both partners and management. the board determined that mental health services would be needed for the longer term to not only address the longer term sequelae of covid- but also to respond to the heightened awareness of mental health and psychological well-being of the migrant workers and committed further resources to sustain the services established during this time and to expand them. mrcpsych(uk) department of psychiatry tan tock seng hospital the views expressed in the submitted article are authors' own and not an official position of the affiliated institution.funding: none. lgc contributed to the intellectual content and the writing of the manuscript. bk contributed to the intellectual content. the authors completed the icmje unified competing interest form (available upon request from the corresponding author), and declare no conflicts of interest.it is now almost three months since the spike in covid- cases among migrant workers, and mental health and suicide prevention have now become one of the key priorities on the task force's agenda. this experience has demonstrated how a medical ngo can engage in a functional, effective, and evolving collaboration with both governmental and non-governmental stakeholders as recommended by the world health organization in its interim guidance [ ], so as to ensure that the voice of the migrant worker population is represented and balanced policies regarding their management are made. it is neither too early nor too late to address mental health and psychosocial concerns of the migrant worker population. nevertheless, it is hoped that this capacity would be built in sooner rather than later in future pandemics and that this paper would serve as a crucial guidance for other jurisdictions. key: cord- -dnuakd h authors: chan, hui yun title: hospitals’ liabilities in times of pandemic: recalibrating the legal obligation to provide personal protective equipment to healthcare workers date: - - journal: liverp law rev doi: . /s - - -z sha: doc_id: cord_uid: dnuakd h the covid- pandemic has precipitated the global race for essential personal protective equipment in delivering critical patient care. this has created a dearth of personal protective equipment availability in some countries, which posed particular harm to frontline healthcare workers’ health and safety, with undesirable consequences to public health. substantial discussions have been devoted to the imperative of providing adequate personal protective equipment to frontline healthcare workers. the specific legal obligations of hospitals towards healthcare workers in the pandemic context have so far escaped important scrutiny. this paper endeavours to examine this overlooked aspect in the light of legal actions brought by frontline healthcare workers against their employers arising from a shortage of personal protective equipment. by analysing the potential legal liabilities of hospitals, the paper sheds light on the interlinked attributes and factors in understanding hospitals’ obligations towards healthcare workers and how such duty can be justifiably recalibrated in times of pandemic. the onslaught of covid- has led to a worldwide race for personal protective equipment ("ppe") ranging from protective goggles, gloves, full face shields, fluid repellent gowns, aprons, surgical masks, and medical equipment such as ventilators and respiratory machines. the british medical association has repeatedly issued urgent pleas to the uk government for the timely supply of ppe for frontline healthcare staff in delivering patient care. frontline healthcare workers without ppe continue to face severe infection risks posed by ppe shortage constitutes a pressure point for healthcare systems, with strong correlations between its scarcity and high covid- infections and death among healthcare workers. covid- has claimed more than healthcare workers' lives, and infected more than , in the usa, while ppe shortage and substandard ppe in spain have resulted in more than , healthcare workers becoming infected. reports of heightened stress experienced by frontline staff are not new; either from the fear of being infected or in transmitting the infections to their families. the shortage has prompted drastic reactions from some governments in downgrading ppe protection standard inconsistent with who advice, inevitably raising questions about harm to healthcare workers. this measure in turn produced several adverse effects on care provision. it has created an exodus of critical healthcare staff due to their inability to continue working. clinical decisions were made to either delay care or minimise the risks of harm (while still working in high risk environments), underscoring rationing in action, and making difficult situations more taxing. although they are not compelled to continue treating patients, the inability to do so generated moral guilt as they see their colleagues on the frontline operating in hazardous conditions. recent developments have witnessed strong responses from the public and healthcare workers, ranging from pursuing legal actions against the government or their employers (hospitals) for breaching their obligations of care towards employees to calling for a full public inquiry into pandemic management, including the status of the ppe stockpile. specific claims by healthcare workers include the legality of guidance on reusing ppe and permitting patients to be treated without ppe in contravention of their right to protection of health and safety at work. this development is not only confined to the uk, as doctors in spain have launched legal actions against the health authorities for breach of duty in ppe procurement failure. considerable coverage continued to be given to issues concerning allocation of scarce resources, the clinical and moral dilemma to treat, and the urgent need to have protective gears for frontline staff. the pressing legal considerations regarding employer's failures in procuring sufficient resources for pandemic purposes remain under-explored. this paper examines how the pandemic affects the obligations of hospitals as employers towards their frontline healthcare staff in fulfilling their responsibilities during pandemic, and the impetus on re-evaluating existing and future legal obligations. it considers the extent to which hospitals have breached their obligations in failing to take appropriate measures to safeguard the health and safety of their employees and to prevent them from being exposed to avoidable risks. while convincing justifications are available regarding the difficult roles of hospitals during pandemic, significantly persuasive arguments can be made for hospitals' liability in breaching their duty to ensure the safety of healthcare workers. these claims will be considered in determining the extent to which such liability can be recalibrated in times of pandemic. while the analyses are drawn from the uk context, the substantive importance is equally relevant as the battle for critical medical supplies is felt across the world. an employer's duty is personal and non-delegable. the employer's duty is one of reasonable care and skill, to provide a safe place and system of work, with adequate plant and equipment, including competent employees and resources, according to the industry and environment in which they operate. such obligations extend to maintaining the equipment and ensuring that they are of sufficient quantity, necessitating regular inspections and monitoring. providing a safe system of work signals a gamut of considerations; ranging from ensuring proper working systems, arrangements and instructions, identifying the purpose of the work, specific tasks and scope to assess risks and install precautionary measures for the employees' health and safety. a system of work thus encompasses an assessment of the adequacy for the "whole course of the job or it may have to be modified or improved to meet circumstances which arise." the consequence of this duty is that the system ought to be reasonably safe, and not perfectly safe, through assessing the inevitable dangers associated with the work, guided by industry norms. these norms often evolve through time and employers must be aware of such developments in updating their emanuel et al. ( ) , ranney et al. ( ) . wilsons & clyde coal company v english [ ] ac , lunney et al. ( , p safety standards to reflect current knowledge based on best scientific evidence. consequently, though it can be suggested that the science of covid- is still developing, the lack of knowledge regarding its effect may not automatically preclude employers from being liable. doctors, surgeons and nurses employed in the service of hospitals are treated as employees under the law and hence they are owed a duty of care. the common law duty of care identified above thus obliges hospitals to provide competent staff, adequate material and a safe, proper system and effective supervision. the extent to which employers ought to provide for ppe invites considerations such as the risk, likelihood, magnitude and consequences of the injury, and the availability and costs of providing such protective equipment. in hospitals, the provision of adequate plant and equipment signifies ppe such as gloves, masks, full length gowns, shields and goggles. hospital working zones have become "contagion hubs" with streams of patients (symptomatic and asymptomatic) receiving care and treatment from healthcare workers. it is reasonably anticipated that healthcare workers are continuously exposed to significant infection risks from treating these patients. the provision of ppe is directly relevant to the work for which healthcare workers are employed to do, and which are normally and reasonably expected to be provided with, consistent with who guidelines for treatment of infectious diseases. the omission to provide ppe to frontline staff unavoidably attracts questions of hospitals' negligence. in determining whether the employers are negligent in failing to remedy the lack of ppe, reference is made to a number of important factors under the common law and statutory instruments. factors that illuminate the liability of the parties, such as the nature of the work, its inherent risks, the (im)possibility of establishing precautionary measures in preventing or reducing the likelihood of risks materialising, the extent to which such measures commensurate with the means and ends, are examined. risk assessments, particularly whether the risks are amplified by the failure to provide in an otherwise acceptable risk in employment, common practices, and resources similarly influence the determination of duty. statutory duties under the health and safety act, regulations on ppe , the relevant guidance issued by the department of health and social care and public health england to healthcare workers are relevant considerations. risk assessment is an important feature in determining the likelihood of injury and whether a breach has occurred in a system of work. it sets the level of reasonableness of precautionary measures against the health and safety risks employees may encounter in the course of their employment. the firemen assuming risks associated with not having a jack fitted in the truck, thus precluding their employers from liability. it has been questioned whether this approach has unjustly discriminated claimants from emergency services that continue to assume risks for the greater good but is otherwise uncompensated for the injuries sustained. there is considerable force in this reasoning that applies to frontline healthcare workers. they face prolonged risks on a daily basis, which includes periods of emergency and hours with clinical rotations between high and low infection risks zones in hospitals. their purpose is to save lives, but without ppe they are putting the lives of patients at risk. the likelihood of injury is real and the gravity of the consequences is magnified. while there are risks inherent in patient treatment, infectious diseases attract extra hazardous elements into the work. the seriousness of harm caused to healthcare workers is not considered small. infected healthcare workers would be off sick, unable to treat, and face the possibility of death. the risks of infection are higher without ppe compared to those with basic ppe. standard public health practices require healthcare workers to don appropriate ppe. this in turn invites questions on cost and practicability in addressing the risks that persist in daily clinical encounters. although frontline healthcare work is not intrinsically dangerous compared to crane workers in the building industry, the cumulative risks arising from covid- , and other preventable factors could potentially render such employment dangerous. healthcare workers combating infectious diseases accept the associated risks that are intrinsic to the work; that does not mean that they have voluntarily assumed all those risks which could be prevented or reduced with the exercise of reasonable care by the hospitals. the example of healthcare staff at weston hospital in england who tested positive after contact with infected patients only goes to demonstrate the severity of the situation. if we accept that covid- is hazardous, then it justifies the protection from the risks of infection through ppe provision. ppe constitutes the first line of protection against infections, as they need to be in close proximity to patients. ppe thus can reduce the chances of infection and in some cases prevent further infections among healthcare workers. such risks clearly outweighed the cost of providing ppe, and the omission to provide is obvious. while the likelihood of the majority of the healthcare workers to succumb to the virus is small owing to the age and health demography, the consequences of such infection materialising are grave if they were infected. courts usually take into account established practices in assessing whether the defendants have breached their standard of care given the circumstances prevailing at the time. it can be reasonably said that ppe is a common practice; logical and of common sense in treatment of infectious diseases. hospitals should act in accordance with such approved, common practice of ensuring adequate ppe supply. the most practical preventive measure, which is providing ppe is not onerous, compared to the risks of injury to healthcare workers. while cases have shown that employers have not breached their duty in failing to provide protective screens or suitable emergency vehicles for the employees at wartime, ultimately, balancing these risks against the measures to remove the risk requires a consideration of the end to be achieved. the end to be achieved in the pandemic context is the dual outcomes of protecting public health and maintaining the health and safety of healthcare workers in the course of their employment. statutory instruments have given the duty of care a stronger emphasis. the personal protective equipment at work regulations ("ppe regulations") under the health and safety at work act clearly set out the types of legal responsibilities that employers should follow. ppe under the regulations means "all equip-ment…intended to be worn or held by a person at work and which protects the person against one or more risks to that person's health or safety, and any addition or accessory designed to meet that objective." consequently, ppe in the hospital context is broad enough to include all equipment that protect healthcare workers from infectious particles arising from aerosol generating procedures, ventilators, respirators or testing facilities with high concentrations of droplets or airborne diseases. regulation ( ) provides the litmus test for the suitability of such ppe. ppe are considered "suitable" relative to the risks involved for the purpose of carrying out the work, the conditions and duration of exposure, the state of health of the wearer, the workstation's characteristics, and practicable in controlling the risks. ppe has to be hygienic and for the sole use of the wearer, thus the guidance to reuse them may raise questions, unless they are addressed by having adequate measures that ensure the hygiene is not compromised where reuse is needed. such ppe should also be maintained and replaced. the exposure to covid- infections is directly workrelated, and employers have the means to protect and implement control measures to reduce the chances of risks materialising. these circumstances directly oblige hospitals to ensure that ppe stockpiles are sufficient so that they are readily at hand when they are needed by the healthcare workers. the difficulty arises when there is a disparity between the actual supply and provision of ppe, and meeting compliance with the legal requirements. recent public health england (phe) guidance has emerged in response to the pandemic in advising hospitals on establishing a safe system of work through yorkshire traction company limited v walter searby [ ] ewca civ ; in daborn v bath tramways ltd [ ] all e.r. , at , the driver of ambulance with left-hand drive was found not negligent when, in wartime, she turned to the right without giving a signal. watt v hertfordshire [ ] all e.r. . regulation ( )(a). for example the phe guidance noted that some ppe may be reused, subject to effective cleaning system. regulations and . phe is tasked with national oversight and leadership on public health issues, and in this capacity support nhs, manage national public health service and support the public health workforce development, see also herring ( , p ). organisational means, ranging from suitable work processes, engineering controls, environment, and provision and use of both work equipment and ppe (single sessional use of particular ppe, reusable ppe) and decontamination procedures. the guidance recognised the employers' legal obligation to protect workers from health and safety risks in controlling and limiting infection transmissions, including assessing risks associated with patient influx, and reduced staff numbers due to illness. this aspect corresponds with regulation in assessing the risks of injury and the purpose and adequacy of such gears where available. however, developing phe guidance, in addressing ppe shortage highlighted "the compromise needed to optimise the supply of ppe in times of extreme shortage… protect stock levels from unnecessary use and support staff to use the right equipment." such modifications mean that ppe are used throughout the session unchanged between patients, "as long as it is safe to do so", which differ from the who guidance. other modifications, such as lower grade face masks reflect a standard which is lower than the who recommendation. while reusing gloves should be avoided, some ppe such as face masks, gowns and eye protection are only liable to be changed when they are visibly contaminated or damaged. the implication is that such ppe would have lost the protective function, putting the healthcare workers at risk under the guise of protection. the direct correlation between staff engagement and patient experience demonstrates the close association between the quality of care patients received and the provision of treatment by healthcare workers. the nhs, a government-funded healthcare service under which hospitals in the uk operate sets the standards for service provision and professionalism. in essence, it commits to provide high quality, safe and effective care, and recognises that a valued and supported workforce will translate to quality patient care. the nhs constitution, which outlines the basic principles and values of the nhs governing the relationships between healthcare workers, patients and the public generally, illuminates particular rights under employment laws, and nhs pledges to their staff, with the overarching priority of delivering patient centred care. patients have the right to be treated professionally by qualified healthcare workers as part of a safe system of work in a clean and secure public health england, department of health and social care and nhs england ( ). guidance: handbook to the nhs constitution for england ( ). nhs, the nhs constitution for england ( ). several guidance were published advising hospitals of rapid changes to ppe use and disposal: guidance: introduction and organisational preparedness may https ://www.gov.uk/gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/intro ducti on-and-organ isati onal-prepa redne ss; guidance: covid- personal protective equipment (ppe) may https ://www.gov.uk/ gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/covid - -perso nalprote ctive -equip ment-ppe produced jointly by department of health and social care (dhsc), public health wales (phw), public health agency (pha) northern ireland, health protection scotland (hps), public health england and nhs england. environment, signalling the necessity of an appropriately equipped and maintained environment. the cyclical nature of patient care and duty to staff is clearly reflected, with explicit recognition that staff should be provided with the resources and support to deliver quality patient care and for healthcare workers to identify and eliminate risks to patients. the failure to provide ppe for healthcare workers has significant relevance and broader implications to patient care. healthcare workers with substandard or without ppe are exposed to infection risks, rendering them susceptible to absence from work for at least days, resulting in workforce depletion. this is especially critical for healthcare workers functioning in high risk zones. healthcare workers operating in other units would be asked to support the continuity of care for covid- patients, thus creating a void in patient care in less critical areas. frontline healthcare workers face immense pressure treating patients under crisis. while there is an expected level of stress that corresponds with the nature of the work in providing care, transferring workers from other specialty units to assist their frontline colleagues may prove exacting, given that their training and competency for the job can vary. the rerouted human resources meant that patients in other units are inadvertently neglected due to reduced staff. another serious, adverse outcome is the risks of transmitting the infection to patients where healthcare workers are unaware that they have been infected; particularly in asymptomatic situations. ppe greatly reduce the risks of infection in the first place, for both the health and safety of the healthcare workers and patients. the strong correlation between the augmented risks of infection and ppe shortage creates a system where patients are harmed. the commitment to deliver quality patient care and a good working environment has, unfortunately, become questionable in this environment. while the nhs constitution provides for avenues of complaints to line managers, the bureaucracy meant that staff will continue to face infection risks unless they refuse to treat patients. prior insights from previous pandemic and the lack of remedial measures to address the weaknesses identified in the healthcare system during national pandemic simulation exercises may raise valid concerns regarding errors of judgement that resulted in the inability to provide ppe in a timely manner. public authorities hold and exercise discretionary powers within the constraints of complex decisions, social utility and organisational objectives. however, are we setting a standard too high for the nhs managers in procuring ppe, given the prevailing circumstances? are there any exceptions to this duty in times of pandemic, where it can be reasonably anticipated that healthcare systems may become inundated, resulting in the necessity of working within a less than optimal environment? the following sections consider arguments see walker v northumberland cc [ ] all er . bowcott ( ) . and counterarguments limiting hospitals' legal obligations towards healthcare workers. the characteristics of covid- are essential in understanding the severity of the pandemic, its impact on the healthcare systems, and why particular focus on the legal obligations of hospitals towards healthcare staff becomes significant now and in the future. the morphology of covid- has garnered international attention, with scientists investigating its biochemical components for preventive, containment and vaccine trials purposes. it was first reported in wuhan, hubei province of china on december , with origins traced to the s as common viruses that infect humans, particularly in respiratory functions. the transmission methods and survival on various surfaces have been the subject of intense scrutiny with findings that the virus can be detected on surgical masks for up to seven days. hospital working areas such as intensive care units, self-isolation wards, doorknobs and keyboards are found to carry high concentration of viruses. viruses were present in the body for more than a week prior to visible symptoms with the highest virus load found in the early stages of infection, suggesting that asymptomatic individuals could be more infectious than symptomatic ones as sources of population transmissions. these findings are crucially linked to the recommendations for use, reuse and disposal of ppe and its effect on healthcare workers who were infected. around % of infections in england recorded between april and june were found in health and social care workers resulting from their direct interactions with patients in hospitals. spain, italy, china and the usa have reported between % and % of infection cases from healthcare workers while treating infectious patients. this underscored the detrimental effects of ppe shortage on healthcare workers. the lack of ppe has cast the spotlight on augmented risks to healthcare workers. such risks of harm are widely acknowledged. healthcare workers experienced psychological and moral distress, frustrations and anxiety in carrying out treatment decisions, fear of risking their health, and infecting their families and patients. they are similarly exposed to emotional harms from being prevented to voice their concerns on health and safety, or compelled to provide care under unsafe circumstances. the british medical association has repeatedly supported the position that healthcare workers should not continue working with substandard ppe or without basic ppe that could prevent them from avoidable harm. however, this has not allayed the harmful consequences to healthcare workers. ibid. wilson et al. ( ) . who ( ). british medical association ( ), carrington ( ), smyth ( ) . british medical association (n , p ). european centre for disease prevention and control ( ). the force of the covid- exigency poses an arguably persuasive factor in limiting employers' liability. while covid- is frequently hailed as unprecedented, the nature of influenza pandemic is not completely unknown. history has revealed examples of pandemic that occurred across centuries with various degrees of severity. once the who declared covid- as a pandemic, ppe became global focal points. countries rushed to secure additional ppe, with demands far exceeding supply within an asymmetrical circulation of medical resources. although the challenge of scarce resources is a common predicament affecting hospitals, simulation exercises (e.g.: public health england ) undertaken in some developed countries provide ample opportunities for advance preparatory measures. the experiences of frontline healthcare workers from other countries several months before the pandemic reached the uk would have constituted sufficient notice of the gravity of the situation. hospitals have grown in complexity through centuries. the extent to which institutional structures, devolved administrations and resourcing constraints provide justifications for their omission needs to be determined within their role as public authorities. the nhs structure is represented by a complex matrix of quasi-government, private entity with specific powers and responsibilities, thus affecting their liability to healthcare workers as employees, moving beyond the simplicity of hospitaldoctor employment relationship. it has been said that "to describe the structure of the nhs is not an easy task…partly because it is a labyrinthine and partly because the nhs has been and still is undergoing enormous structural changes with bodies being created, merged and destroyed at an astonishing rate." the nhs is funded from taxes, with allocations approved by parliament, and expenditures controlled by clinical commissioning groups. nhs managers work in a complex environment, from purely administrative to larger roles of system management and leadership with accountability to frontline healthcare workers, the department of health, private providers, and subject to public scrutiny. nhs managers are expected to balance several competing rights, among others the public health, healthcare workers' rights and organisational constraints. the creation of internal market supported by the health and social care act has been critiqued as one of the structural problems permeating nhs which produced a considerably weakened responsive capability during pandemics. continuous public sector changes, marketisation strategies walsh ( ) . and funding cuts have led to the government's reliance on private firms to provide services during public health emergencies. suggestions that phe decisions were politically influenced have led to allegations that ppe guidelines were not necessarily led by public health science, as seen in the case of lowering ppe standards due to shortage, contrary to who recommendations. hospitals performed their functions within the wider framework of organisational complexities, decision-making hierarchies and limitations, and political willpower. they often have statutory responsibilities involving difficult and sensitive judgements to make. they also inadvertently suffer from particular authority or financial barriers, which puts them in unenviable positions when faced with claims of negligence in equipping employees with ppe. the discretionary powers available for public authorities, other remedial options and consequences for public service delivery influence how standards are determined. a finding of liability may result in obstructions with the exercise of discretionary powers guided by particular reasoning within the system for purposes of efficient and necessary governmental machinery. the structural determinants illuminate the systemic failures that plagued these entities. as christian witting accurately observed : "in some cases, decisions made at a high political level inevitably entail difficulty in meeting service targets or in under-servicing, and must be expected to result in failures in care. the failures in care that result are systemic in nature. their acceptability is politically pre-determined and courts might have little authority to redress them." resource availability within public authorities remains a pressure point among competing sets of considerations. it indicates the dilemma of meeting social needs for the effective functioning of society within a finite environment of resources. public authorities traverse the boundaries of public and private law in judicial applications of the law of negligence, human rights and statutory powers. this is reflected in the nhs context, which represents one of the most politically charged and publicly contentious issues of all times. daborn demonstrated that in cases of national emergency, the lack of available transportation resources, the inherent limitations of the ambulance and the need for continuity in emergency services precluded the defendant from further duties. while not a complete defence, public service liability is closely connected to resource constraints, weighing against the finding of liability. cases have shown that although public body should not be treated any differently from commercial employers, financial constraints and rigidity in decision-making are relevant factors. this signifies the balance between resource availability and cost and practicability of preventing workplace injury. the issue of how far the duty should go when it comes to omissions to provide ppe in a pandemic context is unresolved. given the public health crisis precipitated by the pandemic, it is likely that hospitals would be 'forgiven' for their failure in fulfilling their legal obligations on the basis of emergency and their constraints as public authorities. however, hospitals are the linchpin in delivering frontline healthcare services and maintaining public health in an infectious disease setting. it is argued that hospitals should depart from an approach that expose healthcare workers to infection risks, harm public health and is inconsistent with the core nhs patient centred care principle. the provision of ppe is fundamental to healthcare workers in carrying out their work. ppe protect healthcare workers, and in turn enable them to deliver crucial care especially in times of pandemic. it is not an infallible method, but without these ppe they are most likely to suffer from injury and harm from the risks of infection. the failure to provide ppe to healthcare workers is a failure to deliver care to patients at critical points. the size, capacity and resources available to hospitals are influential considerations; nevertheless, they are not determinative to the extent of justifying the omission to provide ppe. a comparison can be drawn to ppe provision during normal times and in times of emergency. in normal times, the impact, while it may be felt, may not be acute for patient delivery care because the limit has not been breached. however, in emergency times, the impact of the failure to provide ppe to healthcare workers is severe. the daborn and watt v hertfordshire cases had established the importance of the end to be achieved in saving lives, consequently such emphasis can be inferred as recalibrating the obligations of essential services and balancing the rigidity and prescribed exclusion of liability. when the objectives are to save lives and ensure the continuity of vital healthcare delivery, it would appear contradictory to omit the provision of ppe that directly enable the treatment and care of patients. the lives of frontline healthcare workers and patients justified the provision of ppe. these arguments deviate from the standard argument of resource constraints, but they offer a strong reasoning why they should not be precluded. imposing the duty to provide ppe is therefore central in ensuring healthcare workers are protected from the risks of infection and to realise the aim of delivering patient-centred care to the public. thus, this duty should be adjusted to the extent of meeting the requirement of basic provision of ppe and ensure the continuity of such ppe supply in spite of the pandemic. this argument may seem contentious because there are persuasive cases that will preclude the finding of liability in a situation where resources are scarce and that individuals are expected to endure the crisis. however, hospitals need to demonstrate that they have proper mechanisms in place to address shortages in prolonged crisis instead of relying on arguments of budgetary limitations and hierarchy in decision-making. these points need to be identified at each step along the way to determine if the standard of care has been reasonably met. while cases involving public authorities often lend weight to the exclusion of liabilities; they can be distinguished from the current situation in several ways. first, the shortage in question is remedied by the availability of vehicles for the continuity of services, despite not the usual vehicle (e.g.: left-hand drive in daborn). the covid- situation represents a context where healthcare workers have exhausted these basic supplies and faced the consequences of no ppe for the remaining clinical encounters. second, covid- is not a singular incident but an event that is urgent in nature and continues on a daily basis. the severity of the harm meant that without any protection they face a high likelihood of being infected. the lowered standards of ppe use and recommendation for reusing ppe are attempts at remedying the complete shortage. the argument is that some protection is better than no protection. although hospitals are attempting to meet their obligations; ppe which are visibly damaged would cause harm under the guise of protection. the persistent lack of funding to hospitals has contributed to an environment where ppe shortage is tolerated and accepted as standard (though not reasonable) practice. ppe guidelines that decrease the health and safety standard exemplifies resource consideration. it is difficult to comprehend, even at the basic level, for employers not to provide essential ppe for protection against known risks within standard public health measures. covid- is an infectious disease, and the reasonable response is to provide ppe that eliminate or reduce the risks from exposure to such infections. while the purpose of the work is such that infections are incidental to the nature of the employment, ppe is an indispensable and cost-effective measure in minimising such risks. in spite of the difficulty in functioning within a resourcelimited environment, ppe is not purely best practice, but fundamental medical practice. an implication flowing from these considerations is recalibrating the mutual obligations between hospitals and their employees, underpinned by effective healthcare delivery consistent with the nhs constitution. a blanket approach to the finding of liability may be unsuitable, as not all hospitals are similarly equipped, though it remains incumbent on hospitals to fulfil their basic obligations without jeopardising the safety of healthcare workers. parallels can be drawn to the established standards and practices relating to ppe for employees working with hazardous materials. ppe can be modified but only to the extent where they are capable of providing full protection to healthcare workers, and not lower than the recommended standards. ppe availability inculcates a sense of assurance that frontline healthcare workers are valued and appreciated, both by the public and their employers, and for the workers, the confidence in carrying out their roles in treating and caring for infectious patients. system deficiency may be influential in determinations of liability, but it does not always prevail over what is reasonably expected from hospitals. hospitals have the moral duty to take care where their actions will affect those who might be affected by the failure to provide adequate and safe ppe: staff and patients. such duty falls within the remit of nhs managers. as covid- progresses, hospitals ought to have foreseen the impact of ppe on healthcare workers and patients; given the length of the pandemic, rather than a singular emergency. not all finding of liability will automatically result in floodgates, trivial claims or become burdensome for public authorities. rather, it reflects the social and public expectations of what is fair and reasonable. the legal claims filed by healthcare workers for ppe shortage reflect societal expectations of what ought to be done in ensuring healthcare workers are provided with sufficient ppe. departing from this standard would have stretched the limits of acceptable assumption of risks. the public, while accepting that covid- is an unprecedented health threat to the population, will not be kind in their assessment of the measures to contain the pandemic, particularly in response to the dearth of vital medical resources in times of crisis. it becomes imperative to recognise their vulnerabilities and to keep healthcare workers safe. systemic failures may well be compelling, but it is unsatisfactory to then say, there is nothing hospitals could do. reports have continuously demonstrated the correlation between the lack of ppe and higher risks of infection for healthcare workers compared to the public. this naturally translates to poor patient care as they become sick. there is clear neglect in ensuring stockpiles of ppe in meeting the basic requirement of ensuring workers' health and safety. the lack of clear direction and protocols in management and leadership has contributed to the failure of establishing a safe system of work. what would a reasonable healthcare provider do? it is to provide adequate ppe when it is needed and to have processes in place to supplement the stockpile. the saving of lives is a continuous emergency, reflected by the number and severity of patients healthcare workers treat daily. the discretionary power should be exercised towards ensuring resources are allocated towards meeting the obligations of hospitals during pandemic, in preparing sufficient ppe for healthcare workers. for example, the procurement team of the nhs trust is responsible for purchasing supplies and equipment for the hospital, where specific purchasing rules and budgetary limits apply. this translates to broader governmental responsibilities within the decision-making authority which subsequently influenced the overall level of pandemic preparedness. the long-term deficiency in preparedness for a potential infectious diseases outbreak, and the failure to remedy ppe availability through systematic and appropriate procurement arrangements for continuous supply have contributed towards hospitals' inability to replenish severely dwindled ppe stocks in a timely manner. these cumulative factors have resulted in the breaching of ppe limits to the detriment of healthcare workers. the hesitance towards advance preparedness is remarkable, given the window period available to the uk with precedents from china and neighbouring european countries. hospitals, especially the well-resourced ones, with the hindsight of previous experiences in treating patients under the deluge of pandemic could have phelps v london borough of hillingdon [ ] a.c. . parshley ( ) . hunter ( ), mahase ( a, b, c, d). foreseen the need to install precautionary measures to safeguard the continuity of essential supplies and safe functioning of workplace for healthcare workers. adopting such preparatory measures would have enabled a safer response strategy for critical patient care in anticipation of increased burden on the frontline staff, adjusted according to the size and scope of the hospitals' operations and resources. the next section offers practical recommendations in pre-empting ppe shortage. the failure of hospitals in providing healthcare workers with ppe has resulted in concerted and self-help measures in procuring ppe. the most common preparation is stockpiling essential ppe. this comes as a benefit of hindsight; nonetheless valuable in preparation for second or third waves of infections, and as crucial planning for future pandemics. for example, prior to the onset of infected cases in new york, some hospitals have acquired millions worth of ppe as early as february on the basis that "you can never have enough." this foresight paid off, enabling healthcare workers to continue working while protected. an appreciation for improved procurement procedures in place, such as the role of supply chains in ppe procurement is integral in successful pandemic preparation. the public-private procurement chain has ensured that new zealand has sufficient ppe for the healthcare workers and the population, with additional weekly supplies from local manufacturers. the shortage in the uk remains acute. reports have emerged that care home workers were requested to continue caring for infectious patients without ppe in the event of extreme shortage. local councils are responsible for delivering healthcare services (e.g.: care homes and community mental health services) which falls outside the nhs supply chain scope. this means that they are most likely to lack ppe in times of national emergency. jurisdictional divisions have, unfortunately hampered the effective cooperation for public health to the detriment of frontline healthcare workers and the public. the systemic impediments in the nhs organisational structures might be difficult to overcome immediately, but the awareness of how ppe delivery is hampered by these institutional barriers can pave the way for alternative routes to remedy the situation. supply chain management and logistical issues are beyond the remit of employees personally, and those in charge of organisational operations should be responsible in fulfilling the obligations in ensuring that ppe are in stock and at hand when they are needed. this means having additional supplies for emergency purposes ornstein ( ) . covid coronavirus: tonnes of ppe now in auckland warehouse apr, https ://www.nzher ald. co.nz/nz/news/artic le.cfm?c_id= &objec tid= . taylor ( ) . see further laurie and hunter ( ). while procurement for additional ppe is in progress to ensure continuity in supply for healthcare workers. consequently, measures include revisiting internal procedures in assessing the individual levels of preparedness in hospitals, and preparing alternative plans in redirecting patients to hospitals with more capability to deal with infectious patients if the scale and capacity of the local hospitals do not permit the proper treatment and availability of care to the patients without risking staff safety. it is equally valuable to treat the pandemic as akin to disaster response with mass casualties as it enables the operation of protocols and processes for such emergencies occurring for a substantial period of time. nhs managers must be aware of such developments, encompassing clinical and administrative appreciations of the effect global supply chain has on essential ppe procurement in planning and reducing the gap between stock depletion and arrivals. this entails building good, working relationships with relevant suppliers and producers. as resources are finite, having operational plans in advance at the institutional level would alleviate the burden of dealing with these issues during emergency when there are absolutely no ppe available. infrastructural planning, reorganisation and improvisation are essential to remedy the weaknesses that prevented hospitals from fulfilling their obligation in providing a safe system of work and adequate plant and equipment for the purpose of caring for patients. it is not advocated that there should be a perfect system but a functioning system at a fundamental level that ensures that employees' health and safety are not compromised in times of pandemic, and that risks are controlled within reasonable limits. longer term measures include instituting improved communication among hospitals within proximate areas in breaking the disease transmission chains locally and regionally. this approach will facilitate local capabilities in minimising the disease spread, especially in under-resourced and rural areas healthcare services. such regional networking approach has resulted in successful pandemic response among hospitals in lombardy, italy in coping with patient surge. the current decentralised decision-making approach in the nhs and the lack of effective communication policies in disaster management have led to critical resourcing issues. processes and procedures that allow a centralised, consistent response mechanism in national emergency are essential in ameliorating some of the difficulties in pandemic response and management. for example, an emergency "clearinghouse" that acts as a centre is helpful to identify areas with high needs for ppe so that immediate actions can be taken to distribute ppe to these critical areas. increasing local production capacity and supply in times of crisis are central in ensuring uninterrupted supply from local sources and less reliance on external producers during ppe scarcity. spain, for example has aimed to produce millions of masks and other essential ppe on a monthly basis to meet the needs of healthcare workers. when the shortage was first reported, the local and national level cavallo et al. ( ) . hunter (n ). livingston et al. ( ) . sappal ( ). communities in the uk were very supportive towards the healthcare workers in creating homemade ppe and supplying them to healthcare workers. although this is admirable, these supplies may not meet the adequate level of protection to ensure that infection risks are minimised. one way of overcoming the obstacle is to create a streamlined effort between local governments, charitable organisations and local volunteer groups to ensure they meet the safety requirements. this approach would help local and independent manufacturers to achieve local production capacity for the benefit of the communities within a shorter amount of time, and less dependent on outsourced procurement agencies or importation. it is also a stop-gap measure while awaiting incoming ppe supplies from centralised distribution centres. this move is advantageous to the local communities, as local hospitals can continue to treat patients without being forced to turn them away due to ppe shortage. reusing ppe is an option to ease the pressures of ppe shortage. however, the direction to reuse ppe can only be safely implemented where there are protocols for cleaning, disinfecting and storing reusable ppe and limited to ppe that are capable of being reused safely. such essential protocols must include appropriate laundry capacity, whether in hospitals or outsourced to commercial entities. other options include repurposing suitable equipment into ppe that are safe to use for eye and face shields, such as gas masks or sports eye protectors. employees should not be put in an already vulnerable position without the minimum support and infrastructure to carry out their work. the pressing problem of insufficient ppe represents the tip of the iceberg. it reveals a fragile structure in the healthcare system, with the implications of covid- felt long after it has come and gone. the level of provision of care for the population in times of pandemic is closely connected to the health workers' risks and safety. the analyses bring to light the importance of implementing sustainable measures for population health. more innovative ideas are needed for producing and replenishing important resources to pre-empt the domino effect arising from a lack of resources in times of pandemic. hospitals are obliged to be more forthcoming in providing clarity with regards to the supply of resources, and to accommodate the possible reluctance of healthcare workers in working in unsafe circumstances. frontline workers who are being prevented from airing their concerns on the severe lack of adequate ppe is detrimental to their functions in providing care. it could not be said to have met the aims of patient safety when staff are not equipped, valued, empowered or supported in carrying out their work. this paper has highlighted how the pandemic has affected the legal obligations of hospitals to healthcare workers in the provision of ppe. hospitals as employers have obligations towards healthcare workers, which include providing a safe livingston, desai, and berkwits (n ). ibid; cavallo, donoho and forman (n ). working environment and adequate equipment. the nature and extent of their duty are affected by their role as public authorities and in times of emergency. hospitals usually do not incur liability on the basis that they have service provisions that are influenced by resource constraints, limits in decision-making authority and bureaucracy. daborn and watt v hertfordshire exemplify the types of constraints public authorities face in providing social services, which weighed against the finding of liability. there are persuasive arguments from both perspectives in determining the extent of liability hospitals may incur in their failure to provide ppe in a timely manner. yet legal actions against governments and hospitals have opened up the possibility to reconsider the scope of liability, and the fulfilment of the expected standard under pandemic circumstances. the analyses show nhs managers would be in breach of duty for provision of ppe on the basis that the purpose of their activity is relevant in determining if an employer has breached a duty of care to an employee. while the negligence may be arguably excused during crises, the failure to meet the basic resourcing needs of frontline healthcare workers has breached the minimum standard and ethical imperatives in protecting them from life-threatening harm while they continue to treat an increased influx of patients. additionally, it has highlighted broader issues that plagued ppe procurement readiness preceding the pandemic. the analyses have indicated the extent to which the meeting of legal obligations in a pandemic can be undermined by external, underlying pressures arising from austerity policies introduced throughout the years, and an increasingly privatisation-oriented procurement practice, consequently weakening the public sector capacity in competently meeting public health threats. it is hard to dismiss the consistent pleas from frontline healthcare workers. such pleas strengthened the recognition of obligations to provide ppe. maintaining public health and safety in times of pandemic is of utmost importance; however the public can only be properly cared for where healthcare workers are able to continue working in a relatively safe environment in the midst of a pandemic. the fundamental need for ppe and the health and safety of healthcare workers must be prioritised. while this paper has gestured towards the obligations in providing ppe, the analyses have shed light on the inextricable implications of sound governance in meeting health priorities during a pandemic. it has canvassed a broader profile of underlying issues and proposed recommendations, emphasising the need for cohesive measures to address ppe shortage and alleviate the risks to frontline healthcare workers. the state may not be able to salvage the deaths and distress caused to frontline healthcare workers, but it can act more substantively to protect them and to restore public trust that the healthcare system would not collapse in times of pandemic. it has been argued here that hospitals ought to maintain their obligations to provide ppe to healthcare workers, because a failure to adequately protect them is also a failure to protect public health. supporting the health care workforce during the covid- global epidemic lacking beds, masks and doctors, europe's health services struggle to cope with the coronavirus apr bma. . covid- : ppe for doctors doctor couple challenge uk government on ppe risks to bame staff covid- -ethical issues. a guidance note uk strategy to address pandemic threat 'not properly implemented. the guardian hospital capacity and operations in the coronavirus disease (covid- ) pandemic-planning for the nth patient bereaved relatives call for immediate inquiry into covid- crisis doctors step up plea for adequate protection against coronavirus covid coronavirus. . tonnes of ppe now in auckland warehouse cecilia faulty batch of face masks prompts the isolation of more than a thousand spanish healthcare staff doctors to file legal challenge to ppe guidance fair allocation of scarce medical resources in the time of covid- european centre for disease prevention and control: an agency of the european union guidance: considerations for acute personal protective equipment (ppe) shortages s-infec tion-preve ntion -and-contr ol/covid - -perso nalprote ctive -equip ment-ppe. department of health and social care (dhsc) guidance: handbook to the nhs constitution for england bma demands urgent ppe solution after italian doctors die from covid- oxford: oup. high proportion of healthcare workers with covid- in italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority covid- and the stiff upper lip-the pandemic response in the united kingdom covid- : doctors still at "considerable risk" from lack of ppe, bma warns mapping, assessing and improving legal preparedness for pandemic flu in the united kingdom how a decade of privatisation and cuts exposed england to coronavirus sourcing personal protective equipment during the covid- pandemic text and materials, th ed global stocks of protective gear are depleted, with demand at " times" normal level, who warns covid- : % of cases will hit nhs over nine week period, chief medical officer warns covid- : hoarding and misuse of protective gear is jeopardising the response, who warns novel coronavirus: australian gps raise concerns about shortage of face masks protecting health care workers against covid- -and being prepared for future pandemics covid- : doctors' leaders warn that staff could quit and may die over lack of protective equipment nhs. . the nhs constitution for england how america's hospitals survived the first wave of the coronavirus remember the n mask shortage? it's still a problem exercise cygnus report tier one command post exercise pandemic influenza press release: new personal protective equipment (ppe) guidance for nhs teams up to % of staff tested at hospital after covid- patient contact had virus critical supply shortages the need for ventilators and personal protective equipment during the covid- pandemic spanish government faces legal action over lack of ppe for medics spain gears up to manufacture million masks a month as well as other vital covid- equipment stone, will, carrie feibel. . covid- has killed close to u.s. health care workers, new data from cdc shows care home staff could be asked to work without ppe under council plan the changing role of managers in the nhs king's fund department of health with powers derived from national health service act national health service and community care act implementing the code of conduct for nhs managers here's how some of the countries worst hit by coronavirus are dealing with shortages of protective equipment for healthcare workers covid- : the history of pandemics shortage of personal protective equipment endangering health workers worldwide who and countries are engaged in massive preparedness activities covid- news: uk could eliminate coronavirus entirely, say scientists national health service rationing: implications for the standard of care in negligence street on torts key: cord- -appzi a authors: hu, zeming; chen, bin title: the status of psychological issues among frontline health workers confronting the coronavirus disease pandemic date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: appzi a nan in late december , an outbreak of a pneumonia caused by novel coronavirus disease (covid- ) infection was reported in wuhan, hubei province, china, which has since spread domestically and internationally ( ) . according to a report by the world health organization (who), as of may , , , , cases of covid- infection have been confirmed globally using specific laboratory rt-pcr ( ) . among these cases, , were from china, , from italy, , from iran, and , , from the usa. most of the infected patients are admitted to designated hospitals for systemic treatment and isolation. this has resulted in unprecedented psychological distress and other mental health symptoms among frontline health workers worldwide engaged in the fight against the covid- pandemic ( ). in the lancet, unfortunately, it was reported that healthcare workers were infected at a stage when the transmissibility of covid- was not well-defined ( , ) . as an increasing number of studies about the transmission routes of severe respiratory syndrome coronavirus (sars-cov- ) have been conducted, healthcare workers who come into direct contact with confirmed or suspected patients are at high risk of infection despite the use of personal protective equipment (ppe). according to the national health commission of china, more than , medical professionals have been infected with covid- . in italy, as of april , , , healthcare providers who handled confirmed patients had been infected, and physicians died ( ) . this implies that medical staff, especially those at the frontline in the fight against the pandemic without sufficient ppe or other essential equipment, are likely to fear for their own safety and that of their close friends, colleagues, and even families. infected health workers confirmed covid- patients potentially causing a negative feeling of frustration and helplessness. healthcare workers are therefore under tremendous mental health stress during the ongoing covid- crisis ( ) . prevailing evidence indicates that elderly patients complicated with chronic diseases or common comorbidities are susceptible to acute respiratory distress syndrome (ards), acute respiratory failure, and multiple organ failure among other conditions ( ) . with no specific and effective antiviral drugs or vaccines, patients infected with covid- are seemingly staring death in the eye. such patients are primarily given symptomatic treatment to relieve severe clinical manifestations with the help of breathing machines. effective communication with patients and relatives is compromised by the use of ppe, which covers most of the face. this challenging situation makes health professionals feel guilty, helpless, and depressed, which eventually results in common mental disorders such as anxiety, depressive disorders, and post-traumatic stress disorder (ptsd) ( ) . as the covid- outbreak continues to spread, many suspected infections or close-contact visits to designated hospitals increase the workload and number of working hours for healthcare providers. this leads to emotional strain and physical exhaustion. the critical situation mentioned above is a reminder of previous infectious disease outbreaks. healthcare providers who participated in the fight against the previous sars outbreak have experienced a broad range of psychological problems, including stress, depression, and anxiety, some of which have persisted for several months after the outbreak ( ) . research from the h n influenza epidemic shows that many healthcare workers developed symptoms of ptsd, depression, anxiety, and burnout within a few weeks of the outbreak ( ). this is consistent with a recent psychological survey that demonstrated that the odds of developing depression, anxiety, stress, and insomnia symptoms among health professionals working in the designated hospitals are . , . , . , and . %, respectively ( ) . another recent survey from china indicated that a considerable proportion of medical staff who participated in the epidemic prevention and control reported symptoms of depression ( . %), anxiety ( . %), distress ( . %), and insomnia ( %) ( ) . therefore, effective strategies to subvert mental breakdown among medical providers are needed as part of the public health response to the ongoing covid- pandemic. in this opinion piece, we highlight the utility of psychological services and support systems for healthcare workers participating in the control of covid- pandemic. strategies and initiatives employed by the chinese health authorities to handle the psychological issues among frontline health workers during the early stage of the covid- epidemic as well as the lessons learnt are discussed. the chinese government has set up multidisciplinary mental health teams, including the psychosocial response team, psychological intervention technical support team, psychological intervention medical team, and psychological assistance hotline team, all of which are mandated to implement preparedness strategies to reduce the negative psychological impact of covid- on medical providers ( ) . the strategies utilized include telephone-, internet-, and application-based counseling and intervention by online platforms. the who and many other institutions have designed guidelines to provide psychological support for medical staff during the current pandemic outbreak. for instance, the who has released a -point guideline for mitigating the developing psychological issues among healthcare workers ( ) . the guideline highlights the need for medical professionals to protect themselves, their family members, friends, and colleagues accordingly. in addition to the social support systems provided by organizations, building proper self-awareness, peer support, and team support will equip medical workers with the capacity to cope with mental health stress during the current pandemic. a smooth relationship between healthcare workers and covid- patients should be established ( ) . healthcare workers should work as team to avoid burnout ( ) . mechanisms for effective communication should be put in place to allow health care workers update their leaders about their working conditions and schedule for break from work ( ) . during treatment, medical professionals should ensure that each treatment procedure is effective, understand the availability of medical resources, and learn to establish self-confidence ( ) . medical workers should have enough sleep since inadequate sleep and high workloads may weaken the immune system ( ) . thus, hospitals should provide essential services such as a place to rest, food, daily living supplies, avenues for communication with families to alleviate anxiety, and sufficient ppe ( ) . this will improve the psychological well-being of medical staff. the importance of peer and team support from colleagues or teams should not be underestimated. peer groups share common experiences through shorthand ways known to all members. members of the peer group communicate freely without the fear of breaking taboos as their social rules have been established. talking to co-workers who may be conversant with the experiences in the working environment is an approach with which we can control emotional stress during this pandemic ( ) . furthermore, teams need to encourage each other and find approaches to assist new members feel safe, valued, and welcome as quickly as possible. constant encouragement, cheering, and affirmation of each other will improve the treatment outcomes. team members should not blame each other, and, in case of mistakes, solutions should be developed in a timely manner. observance of these factors will undoubtedly improve the capacity of healthcare workers to cope with the immense psychological pressure during the on-going covid- pandemic ( ) . the safety and mental health of first-line medical workers must be closely monitored during the fight against a pandemic. frontline health workers need effective support to help them cope with arising mental health problems. first, health authorities worldwide must implement strategies to address problems such as high workloads, hospital supplies, hospital beds, among others. second, social support, including online services and guidelines provided by organizations, should be utilized to timely, effectively, and efficiently mitigate the psychological impacts among health workers. third, proper self-awareness, peer support, and team support are encouraged as part of healthcare system response in the context of public health emergency. healthcare workers should prioritize their own well-being as much as possible, addressing their essential needs for food, rest, and sleep and understanding the treatments they can afford. in addition, the feasibility and effectiveness of communication and encouragement within groups or teams should be suggested to minimize the detrimental consequences during the covid- pandemic. the timely address of psychological crisis among medical workers preferably based on the above strategies is important. zh drafted and revised the manuscript. bc reviewed the manuscript for approval. all authors agreed the final version. a novel coronavirus outbreak of global health concern novel coronavirus (sars-cov- ) situation reports managing mental health challenges faced by healthcare workers during covid- pandemic clinical features of patients infected with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study mental health in the coronavirus disease emergency-the italian response timely mental health care for the novel coronavirus outbreak is urgently needed the mental health of medical workers in wuhan, china dealing with the novel coronavirus long-term psychological and occupational effects of providing hospital healthcare during sars outbreak immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers online mental health services in china during the covid- outbreak factors associated with mental health outcomes among health care workers exposed to coronavirus disease mental health and psychosocial considerations during the covid- outbreak research on the strategy of solving the psychological crisis intervention dilemma of medical staff in epidemic prevention and control covid- : supporting nurses' psychological and mental health mental health care for medical staff and affiliated healthcare workers during the covid- pandemic psychological stress of medical staffs during outbreak of covid- and adjustment strategy mental health care for medical staff in china during the covid- outbreak looking after doctors' mental wellbeing during the covid- pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence the authors declare 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 © hu and chen. 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- -esa w authors: pinzón, carlos; rocha, camilo; finke, jorge title: algorithmic analysis of blockchain efficiency with communication delay date: - - journal: fundamental approaches to software engineering doi: . / - - - - _ sha: doc_id: cord_uid: esa w a blockchain is a distributed hierarchical data structure. widely-used applications of blockchain include digital currencies such as bitcoin and ethereum. this paper proposes an algorithmic approach to analyze the efficiency of a blockchain as a function of the number of blocks and the average synchronization delay. the proposed algorithms consider a random network model that characterizes the growth of a tree of blocks by adhering to a standard protocol. the model is parametric on two probability distribution functions governing block production and communication delay. both distributions determine the synchronization efficiency of the distributed copies of the blockchain among the so- called workers and, therefore, are key for capturing the overall stochastic growth. moreover, the algorithms consider scenarios with a fixed or an unbounded number of workers in the network. the main result illustrates how the algorithms can be used to evaluate different types of blockchain designs, e.g., systems in which the average time of block production can match the average time of message broadcasting required for synchronization. in particular, this algorithmic approach provides insight into efficiency criteria for identifying conditions under which increasing block production has a negative impact on the stability of a blockchain. the model and algorithms are agnostic of the blockchain’s final use, and they serve as a formal framework for specifying and analyzing a variety of non-functional properties of current and future blockchains. a blockchain is a distributed hierarchical data structure that cannot be modified (retroactively) without alteration of all subsequent blocks and the consensus of a majority. it was invented to serve as the public transaction ledger of bitcoin [ ] . instead relying on a trusted third party, this digital currency is based on the concept of 'proof-of-work', which allows users to execute payments by signing transactions using hashes through a distributed time-stamping service. resistance to modifications, decentralized consensus, and robustness for supporting cryptocurrency transactions, unleashes the potential of blockchain technology for uses in various industries, including financial services [ , , ] , distributed data models [ ] , markets [ ] , government systems [ , ] , healthcare [ , , ] , iot [ ] , and video games [ ] . technically, a blockchain is a distributed append-only data structure comprising a linear collection of blocks, shared among so-called workers, also referred often as miners. these miners generally represent computational nodes responsible for working on extending the blockchain with new blocks. since the blockchain is decentralized, each worker possesses a local copy of the blockchain, meaning that two workers can build blocks at the same time on unsynchronized local copies of the blockchain. in the typical peer-to-peer network implementation of blockchain systems, workers adhere to a consensus protocol for inter-node communication and validation of new blocks. specifically, workers build on top of the largest blockchain. if they encounter two blockchains of equal length, then workers select the chain whose last produced block was first observed. this protocol generally guarantees an effective synchronization mechanism, provided that the task of producing new blocks is hard to achieve in comparison to the time it takes for inter-node communication. the effort of producing a block relative to that of communicating among nodes is known in the literature as 'proof of work'. if several workers extend different versions of the blockchain, the consensus mechanism enables the network to eventually select only one of them, while the others are discarded (including the data they carry) when local copies are synchronized. the synchronization process persistently carries on upon the creation of new blocks. the scenario of discarding blocks massively, which can be seen as an efficiency issue in a blockchain implementation, is rarely present in "slow" block-producing blockchains. the reason is that the time it takes to produce a new block is long enough for workers to synchronize their local copies of the blockchain. slow blockchain systems avert workers from wasting resources and time in producing blocks that are likely to be discarded in an upcoming synchronization. in bitcoin, for example, it takes on average minutes for a block to be produced and only . seconds to communicate an update [ ] . the theoretical fork-rate of bitcoin in was approximately . % [ ] . however, as the blockchain technology finds new uses, it is being argued that block production needs to be faster [ , ] . broadly speaking, understanding how speed-ups in block production can negatively impact blockchains, in terms of the number of blocks discarded due to race conditions among the workers, is important for designing new fast and yet efficient blockchains. this paper introduces a framework to formally study blockchains as a particular class of random networks with emphasis in two key aspects: the speed of block production and the network synchronization delays. as such, it is parametric on the number of workers under consideration (possibly infinite), the probability distribution function that specifies the time for producing new blocks, and the probability distribution function that specifies the communication delay between any pair of randomly selected workers. the model is equipped with probabilistic algorithms to simulate and formally analyze blockchains concurrently producing blocks over a network with varying communication delays. these algorithms focus on the analysis of the continuous process of block production in fast and highly distributed systems, in which inter-node communication delays are cru-cial. the framework enables the study of scenarios with fast block production, in which blocks tend to be discarded at a high rate. in particular, it captures the trade-off between speed and efficiency. experiments are presented to understand how this trade-off can be analyzed for different scenarios. as fast blockchain systems tend to spread to novel applications, the algorithmic approach provides mathematical tools for specifying, simulating, and analyzing blockchain systems. it is important to highlight that the proposed model and algorithms are agnostic of the concrete implementation and final use of the blockchain system. for instance, the 'rewards' for mining blocks such as the ones present in the bitcoin network are not part of the model and are not considered in the analysis algorithms. on the one hand, this sort of features can be seen as particular mechanisms of a blockchain implementation that are not explicitly required for the system to evolve as a blockchain. thus, including them as part of the framework can narrow its intended aim as a general specification, design, and analysis tool. on the other hand, such features may be abstracted away into the proposed model by tuning the probability distribution functions that are parameters of the model, or by considering a more refined base of choices among the many probability distribution functions at hand for a specific analysis. therefore, the proposed model and algorithms are general enough to encompass a wide variety of blockchain systems and their analysis. the contribution of this work is threefold. first, a random network model is introduced (in the spirit of, e.g., and erdös-renyi [ ] ) for specifying blockchains in terms of the speed of block production and communication delays for synchronization among workers. second, exact and approximation algorithms for the analysis of blockchain efficiency are made available. third, based on the proposed model and algorithms, empirical observations about the tensions between production speed and synchronization delay are provided. the remaining sections of the paper are organized as follows. section summarizes basic notions of proof-of-work blockchains. sections and introduce the proposed network model and algorithms. section presents experimental results on the analysis of fast blockchains. section relates these results to existing research, and draws some concluding remarks and future research directions. this section overviews the concept of proof-of-work distributed blockchain systems and introduces basic definitions, which are illustrated with the help of an example. a blockchain is a distributed hierarchical data structure of blocks that cannot be modified (retroactively) without alteration of all subsequent blocks and the consensus of the network majority. the nodes in the network, called workers, use their computational power to generate blocks with the goal of extending the blockchain. the adjective 'proof-of-work' comes from the fact that producing a single block for the blockchain tends to be a computationally hard task for the workers, e.g., a partial hash inversion. definition . a block is a digital document containing: (i) a digital signature of the worker who produced it; (ii) an easy to verify proof-of-work witness in the form of a nonce; and (iii) a hash pointer to the previous block in the sequence (except for the first block, called the origin, that has no previous block and is unique). technical definitions of blockchain as a data structure have been proposed by different authors (see, e.g., [ ] ). most of them coincide on it being an immutable, transparent, and decentralized data structure shared by all workers in the network. for the purpose of this paper, it is important to distinguish between the local copy, independently owned by each worker, and the abstract global blockchain, shared by all workers. the latter holds the complete history of the blockchain. definition . the local blockchain of a worker w is a non-empty sequence of blocks stored in the local memory of w. the global blockchain (or, blockchain) is the minimal rooted tree containing all workers' local blockchains as branches. under the assumption that the origin is unique (definition ), the (global) blockchain is well-defined for any number of workers present in the network. if there is at least one worker, then the blockchain is non-empty. definition allows for local blockchains to be either synchronized or unsynchronized. the latter is common in systems with long communication delays or in the presence of anomalous situations (e.g., if a malicious group of workers is holding a fork intentionally). as a consequence, the global blockchain cannot simply be defined as a unique sequence of blocks, but rather as a distributed data structure against which workers are assumed to be partly synchronized to. figure presents an example of a blockchain with five workers, where blocks are represented by natural numbers. on the left, the local blockchains are depicted as linked lists; on the right, the corresponding global blockchain is depicted as a rooted tree. some of the blocks in the rooted tree representation in figure are labeled with the identifier of a worker, which indicates the position of each worker in the global blockchain. for modeling, the rooted tree representation of a blockchain is preferred. on the one hand, it can reduce the amount of memory needed for storage and, on the other hand, it visually simplifies the inspection of the data structure. furthermore, storing a global blockchain with m workers containing n unique blocks as a collection of lists requires in the worst-case scenario o(mn) memory (i.e., with perfect synchronization). in contrast, the rooted tree representation of the same blockchain with m workers and n unique blocks requires o(n) memory for the rooted tree (e.g., using parent pointers) and an o(m) map for assigning each worker its position in the tree, totaling o(n + m) memory. a blockchain tends to achieve synchronization among the workers due to the following reasons. first, workers follow a standard protocol in which they are constantly trying to produce new blocks and broadcasting their achievements to the entire network. in the case of cryptocurrencies, for instance, this behavior is motivated by paying a reward. second, workers can easily verify (i.e., with a fast algorithm) the authenticity of any block. if a malicious worker (i.e., an attacker ) changes the information of one block, that worker is forced to repeat the extensive proof-of-work process for that block and all its subsequent blocks in the blockchain. otherwise, its malicious modification cannot become part of the global blockchain. since repeating the proof-of-work process requires that the attacker spends a prohibitively high amount of resources (e.g., electricity, time, and/or machine rental), such a situation is unlikely to occur. third, the standard protocol forces any malicious worker to confront the computational power of the whole network, assumed to have mostly honest nodes. algorithm presents a definition of the above-mentioned standard protocol, which is followed by each worker in the network. when a worker produces a new block, it is appended to the block it is standing on, moves to it, and notifies the network about its current position and new distance to the root. upon reception of a notification, a worker compares its current distance to the root with the incoming position. such a worker switches to the incoming position whenever it represents a greater distance. to illustrate the use of the standard protocol with a simple example, consider the blockchains depicted in figures and . in the former, either w or w produced block , but the other workers are not yet aware of its existence. in the latter, most of the workers are synchronized with the longest branch, which is typical of a slow blockchain system, and results in a tree with few and short branches. some final remarks on inter-node communication and implementations for enforcing the standard protocol are due. note that message communication in the standard protocol is required to include enough information about the position of a worker to be located in the tree. the detail degree of this information depends, generally, on the design of the particular blockchain system. on the one hand, sending the complete sequence from root to end as part of such a message is an accurate, but also expensive approach, in terms of bandwidth, computation, and time. on the other hand, sending only the last block as part of the message is modest on resources, but can represent a communication conundrum whenever the worker being notified about a new block x is not yet aware of the parent block of x. in contrast to slow systems, this situation may frequently occur in fast systems. the workaround is to use subsequent messages to query the previous blocks of x, as needed, thus extending the average duration of inter-working communication. the network model generates a rooted tree representing a global blockchain from a collection of linked lists representing local blockchains (see definition ) . it consists of three mechanisms, namely, growth, attachment, and broadcast. by growth it is meant that the number of blocks in the network increases by one at each time step. attachment refers to the fact that new blocks connect to an existing block, while broadcast refers to the fact that the newly connected block is announced to the entire network. the model is parametric in a natural number m specifying the number of workers, and two probability distributions α and β governing the growth, attachment, and broadcast mechanisms. internally, the growth mechanism creates a new block to be assigned at random among the m workers by taking a sample from α (the time it takes to produce such a block) and broadcasts a synchronization message, whose reception time is sampled from β (the time it takes the other workers to update their local blockchains with the new block). a network at a given discrete step n is represented as a rooted tree t n = (v n , e n ), with nodes v n ⊆ n and edges e n ⊆ v n × v n , and a map w n : { , , . . . , m − } → v n . a node u ∈ v n represents a block u in the network and an edge (u, v) ∈ e n represents a directed edge from block u to its parent block v. the assignment w n (w) denotes the position (i.e., the last block in the local blockchain) of worker w in t n . definition . (growth model) let α and β be positive and non-negative probability distributions. the algorithm used in the network model starts with v = {b }, e = {} and w (w) = b for all workers w, being b = the root block (origin). at each step n > , t n evolves as follows: uniformly at random, a worker w ∈ { , , . . . , m − } is chosen for the new block to extend its local blockchain. a new edge appears so that e n = e n− ∪ {(w n− (w), n)}, and w n− is updated to form w n with the new assignment w → n, that is, w n (w) = n and w n (z) = w n− (z) for any z = w. broadcast. worker w broadcasts the extension of its local blockchain with the new block n to any other worker z with time β n,z sampled from β. the rooted tree generated by the model in definition begins with block (the root) and adds new blocks n = , , . . . to some of the workers. at each step n > , a worker w is selected at random and its local blockchain, ← · · · ← w n− (w), is extended to ← · · · ← w n− (w) ← n = w n (w). this results in a concurrent random global behavior, inherent to distributed blockchain systems, not only because the workers are chosen randomly due to the proofof-work scheme, but also because the communication delays bring some workers out of sync. it is important to note that the steps n = , , , . . . are logical time steps, not to be confused with the sort of time units sampled from the variables α and β. more precisely, although the model does not mention explicitly the time advancement, it assumes implicitly that workers are synchronized at the corresponding point in the logical future. for instance, if w sends a synchronization message of a newly created block n to another worker z, at the end of logical step n and taking β n,z time, the message will be received by z during the logical step n ≥ n that satisfies another two reasonable assumptions are implicitly made in the model, namely: (i) the computational power of all workers is similar; and (ii) any broadcasting message includes enough information about the new and previous blocks, so that no re-transmission is required to fill block gaps (or, equivalently, that these re-transmission times are included in the delay sampled from β). assumption (i) justifies why the worker producing the new block is chosen uniformly at random. thus, instead of simulating the proof-of-work of the workers to know who will produce the next block and at what time, it is enough to select a worker uniformly and take a sample time from α. assumption (ii) helps in keeping the model description simple. without assumption (ii), it would be mandatory to explicitly define how to proceed when a worker is severely out of date and requires several messages to get synchronized. in practice, the distribution α that governs the time it takes for the network, as a single entity, to produce a block is exponential with meanᾱ. since proofof-work is based on finding a nonce that makes a hashing function fall into a specific set of targets, the process of producing a block is statistically equivalent to waiting for a success in a sequence of bernoulli trials. such waiting times would correspond -at first-to a discrete geometric distribution. however, because the time between trials is very small compared to the average time between successes (usually fractions of microseconds against several seconds or minutes), the discrete geometric distribution can be approximated by a continuous exponential distribution function. finally, note that the choice of the distribution function β that governs the communication delay, and whose mean is denoted byβ, heavily depends on the system under consideration and its communication details (e.g., its hardware and protocol). this section presents an algorithmic approach to the analysis of blockchain efficiency. the algorithms are used to estimate the proportion of valid blocks that are produced during a fixed number of growth steps, based on the network model introduced in section , for blockchains with fixed and unbounded number of workers. in general, although presented in this section for the specific purpose of measuring blockchain efficiency, these algorithms can be easily adapted to compute other metrics of interest, such as the speed of growth of the longest branch, the relation between confirmations of a block and the probability of being valid in the long term, or the average length of forks. definition . let t n = (v n , e n ) be a blockchain that satisfies definition . the proportion of valid blocks p n in t n is defined as the random variable: the proportion of valid blocks p produced for a blockchain (in the limit) is defined as the random variable: their expected values are denoted withp n andp, respectively. note thatp n andp are random variables particularly useful to determine some important properties of blockchains. for instance, the probability that a newly produced block becomes valid in the long run isp. the average rate at which the longest branch grows is approximated byp/ᾱ. moreover, the rate at which invalid blocks are produced is approximately ( −p)/ᾱ and the expected time for a block to receive a confirmation isᾱ/p. although p n and p are random for any single simulation, their expected valuesp n andp can be approximated by averaging several monte carlo simulations. the three algorithms presented in the following subsections are sequential and single threaded , designed to compute the value of p n under the standard protocol (algorithm ). they can be used for computingp n and, thus, for approximatingp for large values of n. the first and second algorithms compute the exact value of p n for a bounded number of workers. while the first algorithm simulates the three mechanisms present in the network model (i.e., growth, attachment, and broadcast -see definition ), the second one takes a more timeefficient approach for computing p n . the third algorithm is a fast approximation algorithm for p n , useful in the context of an unbounded number of workers. it is of special interest for studying the efficiency of large and fast blockchain systems because its time complexity does not depend on the number of workers in the network. algorithm simulates the model with m workers running concurrently under the standard protocol for up to n logical steps. it uses a list b of m block sequences that reflect the local copy of each worker. the sequences are initially limited to the origin block and can be randomly extended during the simulation. each iteration of the main loop consists of four stages: (i) the wait for a new block to be produced, (ii) the reception of messages within a given waiting period, (iii) the addition of a block to the blockchain of a randomly selected worker, and (iv) the broadcasting of the new position of the selected worker in the shared blockchain to the other workers. the priority queue pq is used to queue messages for future delivery, thus simulating the communication delays. messages have the form (t , i, b ), where t represents the arrival time of the message, i is the recipient worker, and b the content that informs that a (non-specified) worker has the sequence of blocks b . the statements α() and β() draw samples from α and β, respectively. the overall complexity of algorithm depends, as usual, on specific assumptions on its concrete implementation. first, let the time complexity to query α() and β() be o( ), which is a reasonable assumption in most computer programming languages. second, note that the following time complexity estimates may be higher depending on their specific implementations (e.g., if a histogram is used instead of a continuous function for sampling these variables). in particular, consider two implementation variants. for both variants, the average length of the priority queue with arbitrarily large n is expected to be o(m), more precisely, mβ/ᾱ. consider a scenario in which the statement b i ← b is implemented by creating a copy in o(n) time and the append statement is o( ) time. the overall time complexity of the algorithm is o(mn ). now consider a scenario in which b i ← b merely copies the list reference in o( ) time and the append statement creates a copy in o(n) time. for the case where n m, under the assumption that the priority queue has log-time insertion and removal, the time complexity is brought down to o(n ). in either case, the spatial complexity is o(mn). a key advantage of algorithm is that with a slight modification it can return the blockchain s instead of the proportion p n , which enables a richer analysis in the form of additional metrics different than p. for example, assume algorithm : simulation of m workers using a priority queue. algorithm : simulation of m workers using a matrix d .., β(), , β(), ..., β() j'th position end return zn− algorithm is a faster alternative to algorithm . it uses a different encoding for the collection of local blockchains. in particular, algorithm stores the length of the blockchains instead of the sequences themselves. thereby, it suppresses the need for a priority queue. algorithm offers an optimized routine that can be called from algorithm . let t k represent the (absolute) time at which block k is created, h k the length of the local blockchain after being extended with block k, and z k the cumulative maximum given by the spatial complexity of algorithm is o(mn) due to the computation of matrix d and its time complexity is o(nm + n ) when algorithm is not used. note that there are n iterations, each requiring o(n) and o(m) time for computing h k and d k , respectively. however, if algorithm is used for computing h k , the average overall complexity is reduced. in the worst-case scenario, the complexity of algorithm is o(k). however, the experimental evaluations suggest an average below o(β/ᾱ) (constant with respect to k). thus, the average runtime complexity of algorithm is bounded by o nm + min{n , n + nβ/ᾱ} , and this corresponds to o(nm), unless the blockchain system is extremely fast (β ᾱ). algorithms and compute the value of p n for a fixed number m of workers. both algorithms can be used to compute p n for different values of m. however, the time complexity of these two algorithms heavily depends on the value of m, which presents a practical limitation when faced with the task of analyzing large blockchain systems. this section introduces an algorithm for approximating p n for an unbounded number of workers. it also presents formal observations that support the proposed approximation. recall that p n can be used as a measure of efficiency in terms of the proportion of valid blocks that have been produced up to step n in the blockchain t n = (v n , e n ). formally: this definition assumes a fixed number of workers. that is, p n can be written as p m,n to represent the proportion of valid blocks in t n with m workers. for the analysis of large blockchains, the challenge is to find an efficient way to estimate p m,n for large values of m and n. in other words, to find an efficient algorithm for approximating the random variables p * n and p * defined as: the proposed approach modifies algorithm by suppressing the matrix d. the idea is to replace the need for computing d i,j by an approximation based on the random variable β and the length of the blockchain h k in each iteration of the main loop. note that the first row can be assumed to be wherever it appears because d ,j = for all j. for the remaining rows, an approximation is introduced by observing that if an element x m is chosen at random from the matrix d of size (n − ) × m (i.e., matrix d without the first row), then the cumulative distribution function of x m is given by this is because the elements x m of d are either samples from β, whose domain is r ≥ , or with a probability of /m since there is one zero per row. therefore, given that the following functional limit converges uniformly (see theorem below), each d i,j can be approximated by directly sampling the distribution β. as a result, algorithm can be used for computing h k by replacing d i,j with β(). theorem . let f k (r) := p (x k ≤ r) and g(r) := p (β() ≤ r). the functional sequence {f k } ∞ k= converges uniformly to g. proof. let > . define n := and let k be any integer k > n. then using theorem , the need for the bookkeeping matrix d and the selection of a random worker j are discarded from algorithm , resulting in algorithm . the proposed algorithm computes p * n , an approximation of lim m→∞ p m,n in which the matrix entries d i,j are replaced by samples from β, each time they are needed, thus ignoring the arguably negligible hysteresis effects. algorithm : approximation for lim m→∞ p m,n simulation t , h , z ← , , for k ← , ..., n − do algorithm * stands for algorithm with β() instead of di,j (approximation) the time complexity of algorithm implemented by using algorithm with β() instead of d i,j is o(n ) and its space complexity is o(n). if the pruning algorithm is used, the time complexity drops below o(n + nβ/ᾱ)) according to experimentation. this complexity can be considered o(n) as long asβ ᾱ. this section presents an experimental evaluation of blockchain efficiency in terms of the proportion of valid blocks produced by the workers for the global blockchain. the model in section is used as the mathematical framework, while the algorithms in section are used for experimental evaluation on that framework. the main claim is that, under certain conditions, the efficiency of a blockchain can be expressed as a ratio betweenᾱ andβ. experimental evaluations provide evidence on why algorithm -the approximation algorithm for computing the proportion of valid blocks in a blockchain system with an unbounded number of workers-is an accurate tool for computing the measure of efficiency p * . note that the speed of a blockchain can be characterized by the relationship between the expected values of α and β. definition . let α and β be the distributions according to definition . a blockchain is classified as: chaotic ifᾱ β , and fast ifᾱ ≈β. definition captures the intuition about the behavior of a global blockchain in terms of how alike are the times required for producing a block and for local block synchronization. note that the bitcoin implementation is classified as a slow blockchain system because the time between the creation of two consecutive blocks is much larger than the time it takes for local blockchains to synchronize. in chaotic blockchains, a dwarfing synchronization time means that basically no (or relatively little) synchronization is possible, resulting in a blockchain in which rarely any block would be part of "the" valid chain of blocks. a fast blockchain, however, is one in which both the times for producing a block and broadcasting a message are similar. the two-fold goal of this section is first, to analyze the behavior ofp * for the three classes of blockchains, and second, to understand how the trade-off between production speed and communication time affects the efficiency of the data structure by means of a formula. in favor of readability, the experiments presented next identify algorithms and as a m and a ∞ , respectively. furthermore, the claims and experiments assume that the distribution α is exponential, which holds true for proof-of-work systems. claim unless the system is chaotic, the hysteresis effect of the matrix entries note that theorem implies that if the hysteresis effect of the random variables d i,j is negligible, then algorithm is a good enough approximation of algorithm . however, it does not prove that this assertion holds in general. experimental evaluation suggests that this is indeed the case, as stated in claim . figure summarizes the average output of a m and the region that contains half of these outputs, for several values of m. all outputs seem to approach that of a ∞ , not only for the expected value ( figure .(a) ), but also in terms of the generated p.d.f. (figure .(b) ). similar results were obtained with several distribution functions for β. in particular, the exponential, chi-squared, and gamma probability distribution functions were used (with k ∈ { , . , , , , }), all with different mean values. the resulting plots are similar to the ones depicted in figure . as the quotientβ/ᾱ grows beyond , the convergence of a m becomes much slower and the approximation error is noticeable. an example is depicted in figure , where a blockchain system produces on average blocks during the transmission of a synchronization message (i.e., the system is classified as chaotic). even after considering workers, the shape of the p.d.f. is shifted considerably. the error can be due to: (i) the hysteresis effect that is ignored by a ∞ ; or (ii) the slow rate of convergence. in any case, the output of this class of systems is very low, making them unstable and useless in practice. an intuitive conclusion about blockchain efficiency and speed of block production is that slower systems tend to be more efficient than faster ones. that is, faster blockchain systems have a tendency to overproduce blocks that will not be valid. claim if the system is either slow or fast, then p * =ᾱ α +β . figure presents an experimental evaluation of the proportion of valid blocks in a blockchain in terms of the ratioβ/ᾱ. for the left and right plots, the horizontal axis represents how fast blocks are produced in comparison with how slow synchronization is achieved. if the system is slow, then efficiency is high because most newly produced blocks tend to be valid. if the system is fast, however, then efficiency is balanced because the newly produced blocks are likely to either become valid or invalid with equal likelihood. finally, note that for fast and chaotic blockchains, say for − ≤β/ᾱ, there is still a region in which efficiency is arguably high. as a matter of fact, even if synchronization of local blockchains takes on average a tenth of the time it takes to produce a block, in general, the proportion of blocks that become valid is almost %. in practice, this observation can bridge the gap between the current use of blockchains as slow systems and the need for faster blockchains. a comprehensive account of the vast literature on complex networks is beyond the scope of this work. the aim here is more modest, namely, the focus is on related work proposing and using formal and semi-formal algorithmic approaches to evaluate properties of blockchain systems. there are a number of recent studies that focus on the analysis of blockchain properties with respect to metaparameters. some of them are based on network and node simulators. other studies conceptualize different metrics and models that aim to reduce the analysis to the essential parts of the system. in [ ] , a. gervais et al. introduce a quantitative framework to analyze the security and performance implications of various consensus and network parameters of proof-of-work blockchains. they devise optimal adversarial strategies for several attack scenarios while taking into account network propagation. ultimately, their approach can be used to compare the tradeoffs between blockchain performance and its security provisions. y. aoki et al. [ ] propose simblock, a blockchain network simulator in which blocks, nodes, and the network itself can be instantiated by using a comprehensive collection of parameters, including the propagation delay between nodes. towards a similar goal, j. kreku et al. [ ] show how to use the absolut simulation tool [ ] for prototyping blockchains in different environments and finding optimal performance, given some parameters, in constrained platforms such as raspberry pi and nvidia jetson tk . r. zhang and b. preneel [ ] introduce a multi-metric evaluation framework to quantitatively analyze proof-of-work protocols. their systemic security analysis in seven of the most representative and influential alternative blockchain designs concludes that none of them outperforms the so-called nakamoto consensus in terms of either the chain quality or attack resistance. all these efforts have in common that simulation-based analysis is used to understand non-functional requirements of blockchain designs such as performance and security, up to a high degree of confidence. however, in most of the cases the concluding results are tied to a specific implementation of the blockchain architecture. the model and algorithms presented in this work can be used to analyze each of these scenarios in a more abstract fashion by using appropriate parameters for simulating the blockchain growth and synchronization. an alternative approach for studying blockchains is through formal semantics. g. rosu [ ] takes a novel approach to the analysis of blockchain systems by focusing on the formal design, implementation, and verification of blockchain languages and virtual machines. his approach uses continuation-based formal semantics to later analyze reachability properties of the blockchain evolution with different degrees of abstraction. in this direction of research, e. hildenbrandt et al. [ ] present kevm, an executable formal specification of ethereum's virtual machine that can be used for rapid prototyping, as well as a formal interpreter of ethereum's programming languages. c. kaligotla and c. macal [ ] present an agent-based model of a blockchain systems in which the behavior and decisions made by agents are detailed. they are able to implement a generalized simulation and a measure of blockchain efficiency from an agent choice and energy cost perspective. finally, j. göbel et al. [ ] use markov models to establish that some attack strategies, such as selfish-mine, causes the rate of production of orphan blocks to increase. the research presented in this manuscript uses random networks to model the behavior of blockchain systems. as future work, the proposed model and algorithms can be specified in a rewrite-based framework such as rewriting logic [ ] , so that the rule-based approach in [ , ] and the agent-based approach in [ ] can both be extended to the automatic analysis of (probabilistic) temporal properties of blockchains. moreover, as it is usual in a random network approach, topological properties of blockchain systems can be studied with the help of the model proposed in this manuscript. in general, this paper differs from the above studies in the following aspects. the proposed analysis is not based on an explicit low-level simulation of a network or protocol; it does not explore the behavior of blockchain systems under the presence attackers. instead, this work simulates the behavior of blockchain efficiency from a meta-level perspective and investigates the strength of the system with respect to shortcomings inherent in its design. therefore, the proposed analysis differs from [ , , , ] and is rather closely related to studies which consider the core properties of blockchain systems prior to attacks [ , ] . the bounds for the meta-parameters are more conservative and less secure, compared to scenarios in which the presence of attackers is taken into account. finally, with respect to studying blockchains through formal semantics, the proposed analysis is able to consider an artificial but convenient scenario of having an infinite number of concurrent workers. formal semantics, as well as other related simulation tools, cannot currently handle such scenarios. this paper presented a network model for blockchains and showed how the proposed simulation algorithms can be used to analyze the efficiency (in terms of production of valid blocks) of blockchain systems. the model is parametric on: (i) the number of workers (or nodes); and (ii) two probability distributions governing the time it takes to produce a new block and the time it takes the workers to synchronize their local copies of the blockchain. the simulation algorithms are probabilistic in nature and can be used to compute the expected value of several metrics of interest, both for a fixed and unbounded number of workers, via monte carlo simulations. it is proven, under reasonable assumptions, that the fast approximation algorithm for an unbounded number of workers yields accurate estimates in relation to the other two exact (but much slower) algorithms. claims -supported by extensive experimentation-have been proposed, including a formula to measure the proportion of valid blocks produced in a blockchain in terms of the two probability distributions of the model. the model, algorithms, and experiments provide insights and useful mathematical tools for specifying, simulating, and analyzing the design of fast blockchain systems in the years to come. future work on the analytic analysis of the experimental observations contributed in this work should be pursued. this includes proving the two claims in section . first, that hysteresis effects are negligible unless the system is extremely fast. second, that the expected proportion of valid blocks in a blockchain system is given byᾱ/(ᾱ +β), beingᾱ andβ the mean of the probability distributions governing block production and communication times, respectively. furthermore, the generalization of the claims to non-proof-of-work schemes, i.e. to different probability distribution functions for specifying the time it takes to produce a new block may also be considered. finally, the study of different forms of attack on blockchain systems can be pursued with the help of the proposed model. introducing blockchains for healthcare simblock: a blockchain network simulator blockchain technologies: the foreseeable impact on society and industry emergence of scaling in random networks application of public ledgers to revocation in distributed access control the limits to blockchain? scaling vs. decentralization on scaling decentralized blockchains information propagation in the bitcoin network on random graphs on the security and performance of proof of work blockchains bitcoin blockchain dynamics: the selfish-mine strategy in the presence of propagation delay. performance evaluation blockchain application and outlook in the banking industry bc-med: plataforma de registros médicos electrónicos sobre tecnología blockchain kevm: a complete formal semantics of the ethereum virtual machine the application of blockchain technology in e-government in china managing iot devices using blockchain platform a generalized agent based framework for modeling a blockchain system blockchain solutions for big data challenges: a literature review evaluating the efficiency of blockchains in iot with simulations conditional rewriting logic as a unified model of concurrency challenges and security aspects of blockchain based on online multiplayer games bitcoin: a peer-to-peer electronic cash system blockchain in government: benefits and implications of distributed ledger technology for information sharing formal design, implementation and verification of blockchain languages blockchain technology in the chemical industry: machine-to-machine electricity market how blockchain is changing finance toward more rigorous blockchain research: recommendations for writing blockchain case studies early-phase performance exploration of embedded systems with absolut framework lay down the common metrics: evaluating proof-of-work consensus protocols' security ), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made. the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use key: cord- -svkssyk authors: mirvis, philip h. title: from inequity to inclusive prosperity: the corporate role date: - - journal: organ dyn doi: . /j.orgdyn. . sha: doc_id: cord_uid: svkssyk nan from inequity to inclusive prosperity: the corporate role philip h. mirvis is business basically greedy, selfish, and evil? you might think so if you read social media maven arianna huffington's pigs at the trough or david korten's when corporations rule the world or just about anything by business critic naomi klein. the comic strip dilbert presents a weaselly picture of scheming, self-interested bosses and documentaries like supersize me, the corporation, and capitalism: a love story by michael moore dramatize the seamy profit-driven side of big business. you find this fare too biased or leftish? edelman's global trust barometer finds that only one-in-five of the world's public believe "the system is working for me ( ) and % agree that capitalism as it exists today does more harm than good in the world" ( ). stated simply, the private sector, historic engine of economic growth, jobs, and trade, source of most goods and services, and driver of progress and rise of the middle class, is now suspect. these attitudes are not universal. trust is business is high in china, where million have risen out of poverty in the past two decades; in india whose middle class has increased to over % of the populace today and is projected to rise to nearly % by ; and also in singapore, now ranked as the world's most competitive economy. where is trust in business in a trough? russia, germany, japan, the uk, and to a lesser extent the us. "we are living in a trust paradox," says richard edelman, edelman ceo, "since we began measuring trust years ago, economic growth has fostered rising trust. this continues in asia and the middle east but not in developed markets, where national income inequality is now the more important factor. fears are stifling hope, and long-held assumptions about hard work leading to upward mobility are now invalid." the covid- pandemic in the us has brought inequities into sharp relief. while most high-wage workers could shelter in place and work remotely from their homes, lowerwage workers faced a double-jeopardy: disproportionate numbers of them were laid-off and those who kept working, in health care, social services and other "essential" businesses were more apt to be exposed to the virus. african american and hispanic workers (and their communities) suffered higher rates of infection and death as a function of exposure and underlying health disparities. as health official dr. fauci put it, the virus shines "a very bright light on some of the real weaknesses and foibles in our society." business leaders are waking up to fairness. some ceos of major american companies recently declared, "americans deserve an economy that allows each person to succeed through hard work and creativity and to lead a life of meaning and dignity." in their "statement of purpose of a corporation", these ceos said they would be no longer bound by the single-minded pursuit of profits, but instead pledged to lead their companies "for the benefit of all stakeholders--customers, employees, suppliers, communities and shareholders." a recent survey by accenture and the un global compact reports that % of ceos believe our global economic systems need to refocus on equitable growth. among big companies, nestlé has been a pioneer in shared value. its chairman emeritus and former ceo, peter brabeck-letmathe states, "we believe that the true test of a business is whether it creates value for society over the long term." over the past fifteen years the company has helped cocoa and dairy farmers in africa and latin america to adopt more productive and sustainable agricultural practices and promoted local cluster development among smallholders in organizational dynamics ( ) xxx, xxx-xxx sciencedirect j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / o r g d y n villages in india and elsewhere that increases their access to capital and earning power. in the us, compare the practices of employee-oriented discounter costco versus wal-mart's sam's club. costco pays its u.s. hourly workers on average over $ per hour, not including overtime, while sam's club's average wage is about $ an hour. along the same lines, electronics retailer best buy offers a viable career path and development opportunities to its employees while its one-time competitor circuit city (now out of business) routinely dismissed longer tenure employees in lieu of giving them salary increases. looking for a company that has the right priorities for prosperity? when the author began working with ben & jerry's in the mid- s, the company's guiding purposes were to "have fun" (jerry) and "give back to the community" (ben) and, oh yes, make the world's best ice cream. b&j gained legions of fans through its ice cream add-ins (huge chocolate chunks, cherries, pretzels, and cookie dough), offthe-wall brands (cherry garcia, chunky monkey), and creative campaigns to support social change. on the financial side, b&j's paid local farmer's a guaranteed premium for supplying cream (to support them during market downturns), devoted . % of its pretax profits to charity, and established a -to- salary ratio between the ceo and lowest-earning-worker (later raised to to when the company hired a ceo from outside its ranks). it also gave same-sex partners equal access to the benefits of married couples, such as health insurance and parental leave. all of this was guided by the company's commitment to "linked prosperity--for everyone that's connected to our business: suppliers, employees, farmers, franchisees, customers, and neighbors alike." while appealing, this framework provided scant guidance of how to respond to operational priorities and financial pressures. nor did it forestall conflicts over the company's image and positioning in select product and social investments (like introducing "peace pops" at the start of the gulf war). through a series of retreats, first with board members, then with management, all b&j leaders spoke to their personal views of what the company was all about. employees chimed in at all-staff meetings. there was within b&j's a sharp divide over the ice cream maker's communal versus commercial emphasis. one influential board member drafted a "three-part" statement that detailed the firm's economic, social, and quality missions--all to be considered equally under the rubric of "linked prosperity." this was debated by board members and managers and then adopted as the company's mission. in , john elkington conducted b&j's first social audit. seeing the firm's three-part mission statement, a lightbulb went on and elkington generalized the idea to the "triple bottom line" (variously termed tbl or bl) whereby companies would be accountable for their economic, social, and environmental performance. within a decade, companies were devising "balanced scorecards", issuing annual reports based on standards of the global reporting initiative (gri), covering a full roster of sustainability measures, and being ranked on the dow jones sustainability index (djsi) and the london stock exchange ftse good index. note that this combination of new accounting measures and methods, peer pressure as more companies adopted them, and heightened public exposure in rankings spurred many businesses to improve and accelerate their response to important social and environmental issues. ben &jerry's was acquired by unilever in . initially, unilever had trouble digesting b&j and its progressive practices. but as things settled out ben and jerry are once again speaking out for causes (including the occupy wall street and black lives matter movements) and unilever ceo paul polman has bought-in to their linked prosperity business model stating: "this key metric is how ben & jerry's measures success". the last four decades have seen rising income inequality in the u.s. according to irs data, as analyzed by piketty, saez, and others, the top % of earners saw their share of total us income increase from % in to upwards of % today. americans in the top % today average over times more income than the bottom %. the richest-of-the-rich, the nation's top . %, are taking in over times the income of the bottom %. meanwhile, an estimated % of the total u. s. population ( million people) are either poor or lowincome. one real-world implication: a recent survey found that some % of americans would struggle to come up with $ for an unexpected expense. currently, the wealth gap is higher in the us than in any other oecd country. this has not led to greater prosperity in the nation. on the contrary, households in switzerland and australia have over x the median wealth of the us which also lags behind new zealand, japan, canada, ireland, france and the uk on this count. the wealth gap fueled the occupy protest movement that began in (we are the %) and while this movement has faded, mass public protests over economic issues, including "yellow vests" in france and a million women march in chile, have been reported in over twenty nations the past few years. the rich are getting richer worldwide. with serious consequences. analyses show that income inequality = gender inequality with women lagging in employment opportunities in many developing economies and facing a wage gap versus men in developed ones. on a broader scale, low income and poor people in inequitable nations have a much harder time than otherwise in accessing education, health care, housing, and the basic necessities of life. what is causing increased inequality? some blame globalization for intensifying it and for the loss of high paying jobs. but there are different stories about the fruits of globalization and who benefits from it. new manufacturing and technology workers in china or india mostly say globalization is good. it has brought them capital, access to lucrative international markets, and a wireless connection to the world. their nations are more prosperous as a result. multinational corporations, their shareholders, and many who work for them have made dramatic gains. access to new markets and cheaper inputs create bigger profit margins and greater returns on capital and knowledge. globalization has driven real price decreases for many consumer products and made branded goods more available around the world. and talent markets in bangalore, beijing, and sao paulo are just as heated up as in new york, london, and tokyo. yet the same benefits have not accrued to everyone and there is increasing concern over globalization's social and ecological consequences. many developing countries lack sufficient governance, infrastructure, and human capital to find a niche in the competitive global system. in the last decades, the gap between the average per-capita gdp in the twenty richest and poorest countries has doubled. poor farmers have been pitted against one another in export markets and must compete with cheaper (often subsidized) imports from richer nations. small-scale manufacturers have been driven out of business. meanwhile, the prospects for youth the world over have fallen behind the rapid pace of change, creating an atmosphere of instability and discontent that affects everyone. according to the bureau of economic analysis, million u.s. jobs have been sent overseas since . certainly globalization, with attendant outsourcing and offshoring by corporations, trade policy and pacts, and china's accession to the wto, has been a key contributing factor but many point to automation as another culprit for the decline in manufacturing jobs. us factories are twice as productive compared to two decades ago, but operate with many fewer employees. executives offer many reasons why they simply cannot pay their people better, invest in long term growth, and keep factories open, retrain employees, and create more equitable pay systems. they point variously to wall street, competitive pressures, talent markets, regulation, and other "realities" of running a profitable business. how can they possibly do more "good" alongside their fiduciary duties? in a now infamous article in the new york times magazine, the late nobel laureate economist milton friedman spelled out the fundamental precept of the free enterprise system: "there is one and only one social responsibility of business--to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud." this is the orthodox view of responsible business. it is the received wisdom passed on to m.b.a.s and the logic behind jensen and meckling's agency theory, which contends, among other things, that managers' interests and incentives must be aligned wholly with those of shareholders (the owners) and that executives (their agents) must be monitored and controlled to prevent any "opportunism" that takes monies away from shareholders. this theory was the intellectual fuel behind the shareholder rights movement that began in the s and that has led generally to higher shareholder returns, but also to widespread corporate restructuring, downsizing, hostile takeovers, cheap labor outsourcing, and the like. management fixations on quarterly returns and short-term profit taking seem to be its enduring legacy. but maybe not. scholars joseph bowers and lynne paine argue that agency theory is "at odds with corporate law" and that while shareholders are beneficiaries of a company's activity, they do not have "dominion" over its assets. and speaking to business school professors, the late sumantra ghoshal has highlighted how agency is a "bad" management theory that destroys "good" management practices. an alternative perspective is that companies are responsible to all of their stakeholders, not only financial shareholders, but also employees, customers, suppliers, business partners, communities, and others. this is the perspective embraced by signatories to the business roundtable's corporate purpose pledge. and for good reason: studies show that stakeholder-oriented companies outperform shareholder-driven firms and have better morale. on the practical side, warren e. buffett, head of berkshire hathaway, jamie dimon, ceo of jpmorgan chase, and laurence d. fink, ceo of blackrock, have each criticized quarterly guidance because it impedes investing to achieve long term goals. several companies have stopped reporting quarterly earnings. we cited how the use of balanced scorecards and bl accounting schemes work against maximizing short term results and for investing for the longer term. but beyond adjustments in scorekeeping, the biggest change has been in how business leaders think about their responsibilities. will their pledge to manage their business in the interests of all stakeholders shift corporate priorities? historically stewardship meant taking care of someone else's money, property, and other assets--as, for example, a bailiff serving the lord of the manor in medieval times. nowadays, i have argued that the concept of stewardship is central to an enhanced vision of corporate responsibility whereby a society entrusts a company to care for its resources. reaching beyond sustainability, stewards not only protect and preserve, but also enhance society's resources--natural and human. this expands the idea of inclusive prosperity from consideration of an individual employees (me), to a company's workforce overall (we), to working people and their interests more broadly (a collective "all of us"). this expanded perspective on inclusion intersects with theories and social movements concerning diversity, equity, and justice. most large companies today have made commitments to support diversity in their hiring and employment, dealings with suppliers and customers, and in their community relations. this applies to diversity in race, gender, ethnicity, age, sexual orientation, and so on. and, again, it makes good sense: studies find that firms with a more diverse workforce generally do better than their counterparts. committing to equity and justice is a more complex consideration. most agree that everyone should have equality opportunity to get a job, advance in a company, or do business with one, but not that there should be equality in outcomes--e.g., getting the same pay and rate of promotion, or operating on the same business terms. the idea that business should be "woke" and attend to and remedy histor-ical injustices to blacks (#blacklivesmatter) and women (#metoo) adds to the complexity. nonetheless, inequity and injustice are there. a recent pew survey found that % of women believe that they are paid less than a man doing the same job, % say they are treated as incompetent at work, and % say they receive less support than men. a study by aarp found that nearly two-of-three workers age or over have experienced agerelated discrimination on their jobs. more broadly, blacks ( %), hispanics ( %), and asians ( %) in the us are far more likely than whites to say that being white helps people to get ahead. what should a company do on these accounts? beyond pledges to not discriminate or exploit (e.g., obey the law), there are defensive reasons that a company might focus on these matters (risks of lawsuits, reputation damage, etc.). but corporate values and culture also play a role and select companies are taking affirmative and data-based steps recruit and hire for diversity, equalize pay and promotion rates across different "classes" of employees, and redress economic inequities in society. listen to tony prophet, chief equality officer, salesforce on this count: "inequality, in all its forms -gender, lgbtq, racial, or otherwise -is an issue that every company must address for its own benefit and to create a better world. we believe businesses need to focus on closing the equality gap with the same energy put into creating new products and markets." top corporate executives have seen their pay grow by more than % over the past years, nearly times the rate of average workers. to put a spotlight on this pay gap, the securities and exchange commission passed a rule that required public companies to report the ratio of compensation for their ceo in comparison to that of a median employee. the result? the average chief executive of an s&p company earned times more than their median employee in (the first year the ruling took effect). what has happened since? no changes in corporate ceo pay practices were reported in , although in a number of ceos chose to cut their pay and forego bonuses in light of the pandemic. still, many big company ceos make in a single day what their everyday workers earns in an entire year. defenders make the case that ceos, like high earners in sports and entertainment, are "superstars" who lead winning (and profitable) teams. the evidence finds otherwise, however, as ceo pay (including stock options) is only marginally related to a company's annual bottom-line and not at all to its longer-term stock performance. an analysis of the top- "overpaid" ceos (making times more than their median employee) shows how things are out-of-kilter, as "the most overpaid ceos, in aggregate, underperformed the s&p index by an incredible . % and actually destroyed shareholder value, with a negative . % financial return." how about pay equity inside firms? the research group glassdoor reports that men earn . % higher base pay than women on average (women earn cents per dollar men earn). when comparing workers of similar age, education and experience, the gap shrinks to . %. and when comparing workers with the same job title, employer and location, the gender pay gap in the u.s. is still . % ( . cents per dollar). companies can tackle equal pay for equal work via audits of their pay practices. an audit at salesforce revealed a statistically significant difference in pay between men and women. "it was everywhere," ceo benioff admitted in a minutes interview. "it was through the whole company, every department, every division, every geography." the company responded by spending $ million in to start to correct things and then another $ million in to eliminate differences by gender, race, and ethnicity across the company. and while audits can help firms gauge their problems and progress in these regards, leading firms are also offering training in handling unconscious bias that contributes to hiring and job discrimination. recent legislation in the us lowered the corporate federal income tax to % (versus the previous % rate). a study found that profitable companies paid an effective federal income tax rate of . % on their income (the first year the lower rate took effect) and that many big companies, including amazon, chevron, halliburton, and ibm, did not pay federal income taxes at all. this doesn't sit well with the public--over two-thirds of whom say companies pay "too little" in taxes. there is also concern that states and communities give up "too much" when it comes to wooing business investments in plants and offices. in , wisconsin agreed to provide foxconn with $ billion in cash incentives for a new flatscreen manufacturing plant, projected to employ about , workers at average annual salaries around $ , . as of this writing, foxconn is woefully behind schedule on hiring, seems to have changed what kind of plant it is building, and has refused to renegotiate its deal with wisconsin lawmakers. in , general electric announced it would relocate from connecticut to boston induced by over $ million in state incentives. in , however, ge scrapped plans for building a -story office tower on the waterfront and has staffed its boston hq with rather than the planned-for people. at least ge refunded $ million to the state. bottom line: tax incentives for building plants or relocating facilities don't typically pay off. an association called chief executives for corporate purpose (cecp) reports that large companies it sampled gave $ billion to charity in , an uptick from prior years. there was also higher giving as a percentage of pre-tax profits from . % to . %. certainly reduced tax rates are a factor in increased giving. what do companies invest in? priorities are k- and stem education, health and social services, and community economic development. inarguably, philanthropy is good for business and for communities. termed "strategic philanthropy" where companies spend on business-related issues. back in the day, corporate charity was done quietly and often anonymously. today, its trumpeted and an integral part of the corporate reputation building platform. in turn, employees volunteer via company sponsored (and branded) service days. companies are taking seriously the roi on their good works. nearly all corporate foundations and csr functions measure their impact through surveys of employees, of customers, and via corporate brand trackers. is corporate philanthropy only about roi nowadays? one exception is johnson & johnson. j&j's credo states: "we believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services." when the company asked doctors and nurses about their most vexing problems, they repeatedly heard "the shortage of nurses." in response, j&j launched its campaign for nursing's future which included imaginative advertising and engaged its staff and partners in nursing school recruiting efforts, nursing ambassador programs, leadership and communication training for newly promoted nurse managers, and mentoring programs for new nurses as well as fundraising galas, and media events. the results? the campaign led to a significant increase in the public's ranking of nursing as a career choice and, importantly, in the number of À year olds who think of it as a good career choice. recruitment and retention rates in the nursing profession are substantially improved, too. the upshot: j&j chooses programs and countries to support based on need and not whether they present a business opportunity. the evidence is clear that companies that are growing, employ high skill workers, and operate in red hot talent markets pay their employees better. median salaries in tech firms like google, facebook, and the like, and in consulting and finance, top the lists on employee compensation in recent years--at over $ , in . what is happening otherwise? researchers report that over two-thirds of the jobs created in the us the past few decades feature lowwages and low-hours. roughly million americans between the ages of to (or % of all workers) qualify as "lowwage." their median hourly wages are $ . , and median annual earnings were about $ , in . while the media points a finger at big companies like walmart, target, amazon, and cvs for exploiting their workers, these employers have, as a result of state and local legislation plus some public shaming, increased entry-level and median pay significantly the past few years. note, too, that many retailers and pharmacies operating during the pandemic increased hourly pay some $ or more and enhanced paid leave for sickness. but the vast majority of low wage workers are employed in small and mid-size businesses. here you find less job security, health care coverage and much less paid sick, vacation, and holiday leave. there are many companies, large and small, that provide good paying jobs. most "great places to work" pay competitive salaries to full-time employees, and offer a benefit package that includes health coverage, paid vacation, sick, and parental leaves, a company contribution to a pension or k account, training monies or tuition reimbursement, and typically an incentive scheme, bonus plan, and/or stock options. we noted how costco and best buy opt to create good jobs for their lower level workers. how about walmart--the lb gorilla of low-cost retail? when greg foran, then heading walmart in the us, found zeynep ton's the good jobs strategy, he said "bingo"! walmart upped its wages but in doing so the company also made changes in its operations and employment practices. walmart rolled out a new induction process that includes training for new hires on customer service, merchandising, teamwork, and communication, and provided mentoring by experienced employees, plus it provided them a clear picture of career paths and what skills and experience are needed to advance. to increase efficiency, employees also got handheld computers to scan prices and check inventory. the kicker: walmart employees are eligible for quarterly bonuses based on store performance. top employers are compensating part-time workers better, too. home depot, for example, offers its part-time employees tuition reimbursement, (k) matching, an employee stock purchase program, paid maternity and paternity leave, and dental and vision insurance. starbucks has strong full-and part-time employee benefits. its founder howard schultz launched a campaign to "create jobs for usa" and found a financial partner, community development financial institutions, to enable citizens to lend money to small businesses. this jobs campaign created or retained more than jobs and raised over $ million to support small business job creation. how do employers in declining industries maintain good paying jobs? pridgeon and clay (p&c), a grand rapids, mich. auto supplier, was hit hard in the auto industry meltdown. but their focus on research and development, product innovation, and training positioned them for recovery. rather than replace workers, they prepared and trained their existing workforce. they even instituted an in-house training program, which provided wage increases of more than % for entering the training and additional wage incentives for those that graduated. as a result, p&c rebounded far better than many, adding millions in revenues and growing their employee base from to . you've seen the "pay gap" between men and women in the us. it is even more pronounced for latina and black women. and, sadly, the overall pay gap between white versus black men in the us seems to be widening. all of these pay gaps shrink when making apples-to-apples comparisons between peoples having the same credentials and jobs. but understand the bigger picture: women and minorities in the us are over-represented in low income jobs. another company that cleaned up its pay structure is paypal. an audit of its hourly and call center employees found that % struggled to make ends meet and were living paycheck to paycheck, despite earning at or above marketlevel wages. then paypal took actionraising wages, reducing healthcare costs, making all employees shareholders, and launching financial literacy and planning courses for staff. it is also notable that over % of its employees who are vps or higher are women or people of color as is half its board of directors. what else can be done? estimates are that just % of large employers offer on-or near-site child care and only % offer child care stipends. roughly one-in-three provide paid maternity and paternity leave. and some % provide flextime work schedules for employees that enable them to better balance their work and personal time. us-based companies lag behind their european counterparts in family friendliness. the consequences are notable. nearly three-infour working parents report that their jobs have been impacted by childcare problems. many are also pressed by the financial and practical costs of caring for elderly parents. breakdowns in child-and elder-care lead to increased absences and lost productivity costing us businesses $ billion annually. finally, consider the gig economy. actually there are two different gig economies. one is composed of folks who drive for uber or lyft, make deliveries for amazon flex or door dash, provide goods and services on etsy or fiverr, and all manner of freelancers. the other includes on-call, independent, and temporary workers, the so-called contingent workforce. as there is no "official" designation of gig workers, estimates are they comprise anywhere from - % (contingent workers) to - % (including multiple job holders and those with a "side hustle") of the us workforce. but however you count and categorize those with "alternative work arrangements", this workforce . segment is expected to grow in the years ahead. touted benefits for gig workers include greater freedom and flexibility and for freelancers the chance to be "your own boss". downsides include social isolation and, for many, substandard pay and benefits, no pension, and scant job security. how do corporations factor into the gig economy? first, many more companies are employing contingent workers, not only for added flexibility but especially because it saves them money--lots of it. second, firms outsource and offshore jobs to gig economy workers--to handle customer calls and provide administrative support and web services--in lieu of creating more full-time jobs. finally, campaigners and regulators alike are pushing uber and other app-based firms to classify and treat independent contractors as employees. california recently passed legislation to this effect that affects over million workers. listen to state senator maria elena durazo, "today the so-called gig companies present themselves as the innovative future of tomorrow, a future where companies don't pay social security or medicare. let's be clear: there is nothing innovative about underpaying someone for their labor." companies that orient themselves to stakeholders and assume the role of stewards reach beyond their fence line to promote equity and inclusion in communities and society. this means going beyond a bare-bones "jobs, profits, taxes" agenda to investing in communities and societal infrastructure. ben & jerry's was a pioneer in using its business to drive inclusive prosperity. in the late s, the company hooked up with greyston bakery, in yonkers, ny to supply brownie wafers for its ice cream sandwiches. the bakery provides "great deserts by great people doing great deeds." combining an economic and social mission, it sells brownies to food purveyors and the public made by the "chronically unemployed" --ex-convicts, former drug abusers, and disadvantaged youth--whom it hires and trains in business and social skills. the partnership got off to a rocky start. the first shipments of brownie wafers to b&j melted in transport and arrived as a two-ton block. rather than send them back to greyston (who could not afford a loss of that size), the b&j team chipped the block into chunks and mixed them with ice cream. ben & jerry's chocolate fudge brownie ice cream was born! the flavor sold well, which meant b&j soon needed more brownies. more brownies meant more bakers, allowing greyston to hire and train more people from the yonkers community who couldn't otherwise find jobs. between and , greyston created over three thousand brownie-baking jobs, generating about $ million in payroll and providing benefits to about , families through the greyston foundation. rush university medical center, on chicago's westside, has partnered with residents, community leaders, nonprofit organizations and other health care institutions, to redress inequities in access to healthcare. the center conducts an annual community health needs assessment and sets goals for reducing inequities and enhancing community access to health services. some of its programs include free mammograms for women lacking health insurance, communitybased education on healthy eating and exercise, plus participation in community food banks and shelters for the homeless. interestingly, rush's community needs assessment identified many vulnerabilities in its patient population that it incorporated into its emergency preparation plans. when the covid- pandemic hit chicago, rush rapidly converted its ambulance bay into a triage center, treated patients in bed units secured by thick glass doors with a negativepressure system to prevent infections from escaping, and tested new treatment protocols, such as putting patients on their stomachs to improve oxygenation. while many of nation's hospitals had their hallways overloaded with patients in the heat of the pandemic and oxygen had to be wheeled in via portable tanks, rush was credited with having the "foresight" to build state-of-the-art practices into its protocols. on a larger scale, ford, gm, chrysler, toyota and other auto suppliers contribute to focus-hope, a nonprofit based in detroit, mi., with money and employee volunteers who help to train, mentor, and provide internships for those looking to reskill or prepare themselves for jobs in industry. focus-hope has trained (or retrained) over , men and women (primarily african-americans) to become machinists, cad-cam operators, it specialists, and systems engineers and partners with area universities which provide college degrees for trainees. it also runs a day-care center, a food american businesses have for decades assisted k- schools with donations of money, books, technology, and such, sponsorship of science fairs, employees' volunteering as student mentors, and even adopt-a-school programs. yet % of employers say that today's high school (and college grads!) are not prepared for their higher skilled jobs. (and some % of youth report that their formal schooling did not prepare them for the job they want.) select high tech firms have stepped into the breach with specialized training programs in communities that make use of corporate tools, know-how, and human resources. some of the most noteworthy include cisco's networking academy, microsoft's "unlimited potential" and "youthspark" campaigns, dell's "teckknow" program, and intel's "education corps" volunteers that prepare students to operate in a digital economy. tech company motivations here include not only enlarging the pool of skilled job entrants but also creating a high paid workforce that can pay for and use their goods and services! you may recall that ibm convened an education summit in with a group of ceos, state governors, and president bill clinton to focus on systemic changes in k- education. ibm then launched twenty-five demonstration projects in u. s. school districts during this period through its signature social campaign "reinventing education," which applied the company's technology and know-how to education. today ibm operates four p-tech (pathways to technology) schools that offer disadvantaged students the chance to receive a high school diploma and associate's degree within six years, as well as a shot at an ibm job. students take traditional high school classes and get workplace training, intensive stem education classes, college courses, and often real-world job experience as well -all at no charge. according to ibm's projections, there will be million jobs by that require post-secondary degrees, though not necessarily a four-year college degree. to scale this venture, ibm has partnered with more than businesses (like american airlines and volkswagen) to start over p-tech schools across the us and around the world. goldman sachs , small businesses is a $ million investment to help entrepreneurs create jobs and economic opportunity by providing them with greater access to education, financial capital and business support services. the program currently operates in markets in the u.s. through a network of more than academic and community partners. small business owners participate in a hundred hours of education over the span of three months, either in a classroom or virtually, in a kind of crash course mba. the subject matter: how to scale their own business. the emphasis is on peer-to-peer learning among the thirty or so entrepreneurs in a cohort who also get -to- coaching and mentoring from goldman employees. to date nationally, over small business owners have graduated and some % of graduates see revenue growth and % report creating new jobs six months after completing the program. another way to support small business is to take care of your suppliers. caterpillar's supplier diversity program focuses on increasing opportunities for small businesses owned by minorities, women, veterans, or the disabled. the program requires that all suppliers meet caterpillar's requirements concerning quality, capacity, and cost. caterpillar runs a -day transformation program to help suppliers adopt lean manufacturing processes and eliminate waste in their operations and caterpillar employees serve as mentors to participants. a supplier development college offers both free and fee-based courses and train the trainer programs so participants can cascade knowledge to coworkers. on a global scale, coca-cola's by initiative provides economic empowerment for nearly million women entrepreneurs across the company's value chain--include retailers, suppliers, producers, and more. women participating in by get business skills training, access to financial services and assets, and connections with peers and mentors. an early study of the program found that women increased sales an average of % after receiving business skills training and that their average personal income increased % over one year. participants reported that, on average, they could better afford basic expenses for themselves and their family, such as expenses for children's education, medical visits, and clothing. and two-thirds reported they were able to put money into savings each month. jp morgan chase is making big investments in detroit, michigan. over the past five decades, detroit's population declined significantly from a peak of . million in the s to less than , today, causing a large drop in the city's tax base and decimating city services. in june , detroit filed for chapter bankruptcy, with estimated debts of more than $ billion. a year later the city emerged from bankruptcy but nearly , buildings, or % of the city's total stock, was empty. in early , jp morgan chase made a $ million commitment to the city of detroit. they coupled this financial investment by sending in employee volunteers -in the form of their detroit service corps. in november , their first team partnered with four local not-for-profit organizations to support neighbourhood and workforce development. to date, nearly employees have helped detroit organizations to improve their capabilities and strengthen community outreach. the combination of financial support and employee assistance from morgan chase enabled these local organizations to provide training and career education to nearly , detroiters and technical assistance to , entrepreneurs and small businesses, yielding more than jobs. recently, jp morgan chase offices expanded its local service corps and grants to chicago, new york, london, paris, and hong kong. cities also need investments in technology and infrastructure. ibm runs a "smarter cities challenge" where a team of ibm executives joins with city officials and community groups to study and develop innovative solutions to urban problems. the execs are volunteers and their on-site assignment is limited to three weeks. but their impact can be substantial. for instance, ibmers helped the city of rochester, ny to develop an integrated digital platform that enables city service providers to share data about the people with whom they work. this enhanced coordination among the providers and integrated services for locals-in-need. in san jose, ca., a smarter cities team helped to develop a "rental unit registry" that includes a database and analytics dashboard to help the city track rentals governed under its rent control ordinance. a second project is a website that guides prospective renters to available affordable housing. to date, over cities worldwide have received challenge grants and assistance. now these are not just good works. ibm is focused on creating a "smarter planet" and city governments are big customers for its sensors and services. corporate conduct and philanthropy have a global dimension. recall how a few years ago some textile workers--sewing clothes for sears, j.c. penney, walmart and the gap--died in the collapse of a shoddy garment factory in bangladesh. these companies joined in a coalition of businesses from countries, international labor representatives, and ngos to work with the government of bangladesh to reach an accord on building safety in factories. as a result of the accord, % of the hazards reported at factories in bangladesh have been eliminated and the minimum wage for workers increased from $ to $ a month. banks, beginning with one launched by nobel peace prize winner mohammed yunus, have introduced micro-credit lending whereby the poor can pool their modest savings and get small loans. repayment rates have been upwards of %. this model has spread into other businesses where, for example, mexican cement-maker cemex introduced its patrimonio hoy program that gives customers technical assistance and loans to design, build and fund improvements in their housing. note, too, to how telecommunication companies are lifting up the world's poor. the story behind africa's "rise" features political and economic reforms, to be sure, but it is also hinges on the telecommunications revolution. africa today has more than million mobile phone subscribers--more than the u.s. and europe combined. a decade ago, kenya-based safaricom, partly owned by vodacom, introduced m-pesa (m for mobile and pesa is swahili for money) in kenya and tanzania to enable people to use their mobile phones to transfer monies, pay bills, and secure microfinancing. the share of the "unbanked" in the region that uses mpesa rose from % to % in twelve years and today an estimated % of kenya's gross national product flows through the channel. vodaphone is now effecting a "reverse innovation" by introducing the service into europe. finally, select companies today are building out base-ofthe-pyramid (bop) business models to provide more affordable goods and services, as well as employment opportunities, to the world's poor. sc johnson, the world's leading maker of insect control products, worked hand-in-hand with rwandan farmers to sustainably farm and harvest the plant for products like raid. in turn, the partners set up a motorcycle-based distribution system to bring insecticides (aerosols and coils) to areas with endemic malaria. to sell them in an affordable and culturally compatible way, they set up wow club memberships, involving seven or more homemakers, that can share in the purchase of four different pest control and home cleaning products in refillable formats. wow membership also includes group coaching sessions around home and family-care best practices and loyalty rewards. but bop investment is not only needed in developing nations. many inner-city neighborhoods in the us are "food deserts" where locals cannot get access to fresh produce and affordable staples. grocers shaws and pathmark have built stores in inner-cities that feature a dizzying variety of racially and ethnically targeted brands, at multiple price points, and locally originated store layouts and displays. like other companies operating in bop markets, shaw's had to do its own sociological study of customer's needs. the shaw's market team identified forty-two different ethnic and religious affiliations within inner-city new haven, connecticut. to develop the right product mix, shaw's management collaborated with community groups and organized meetings with the ethnic leadership to discuss product offerings. you can, for example, find fresh goat meat in some storesmeeting the needs of consumers from caribbean countries. whole foods followed this practice in setting up a market in inner city detroit. globally, about . billion adults remain unbanked--without an account at a financial institution or via a mobile money provider. in response, a variety of microfinance institutions (mfis) have been started offering individual loans, savings products and micro-insurance, not just for small businesses, but for farms, schools and individuals paying for education, health care and such. nonetheless, demand outpaces supply and mfis face constant threats of market failure. part of the challenge is how to connect mfis to larger capital pools and social impact investors. credit suisse saw growing interest among its clients in social impact investing. the global bank developed microfinance debt funds and private equity funds that would invest in small, undercapitalized mfis--and offered those funds to its wealthy clients. while this helped provide capital relief, it did not address problems mfis encountered in vetting loan applications, managing data, deploying the latest technology, and combatting fraud. credit suisse then launched its microfinance capacity building initiative which helped to create a microfinance ecosystem of several intermediary lending institutions (finca, accion, women's world banking, planet finance, and others). this enables mfis to bundle funds into investible instruments and speed currency conversions. credit suisse employees, through the bank's pro bono program, work with its partners to conduct market and risk management studies and offer them training, it and hr support, and relevant mobile solutions. recent achievements include: backing some , students worldwide by increasing households' ability to afford the education of their children. raising the income of more than , people living in rural areas by increasing their access to working assets, such as short-term loans, and by improving their cash and inventory management. equipping managers at mfis with training and tools during a three-year period to better serve the needs of women (through new credit, savings and insurance products). all of this, according to laura hemrika, spearheading the capacity building initiative, has enabled micro-finance to reach . billion of the world's poorest people. the united nation's sustainable development goals variously call on countries and companies to eradicate poverty, achieve equality, and promote inclusive prosperity. while progress on the fronts is evident, we have a ways to go to realize these goals--and further still given the economic impact of the covid- pandemic. according to the world bank, the virus is projected to push one-half billion people worldwide and tens-of-millions in the us back into poverty and shred national safety nets. where are some of the bright spots? globally, more than $ . trillion are invested sustainably, representing more than $ in every $ under professional management. a recent survey from morgan stanley shows % of asset owners are pursuing environmental, social, and governance (esg) factors when making investment decisions. interestingly, the study found that while three-fourths are motivated to do so to reduce risks, as many are seeking financial returns! what this means is that the business case for corporate responsibility has gained traction with investors. employee stock ownership can also be expanded. the national center for employee ownership estimates that million us employees participate in an employee ownership plan. research also shows that % employee-owned companies show consistent revenue and profit growth, report less turnover, and that both household net wealth ( % higher) and average income ( % higher) are greater for workers of employee-owned companies. now some are optimistic that, after the virus abates, companies will "reset" their agendas and seriously tackle two slower-moving crises: economic inequality and climate change. many of the conditions and frameworks are in place to speed progress including heightened public expectations of business in these regards, new accounting and public reporting schemes, activists and investors pressing for and rewarding positive action, and a clear and compelling business case. there are, in addition, public policy and regulatory measures that advocates of more inclusive prosperity have proposed. still, i suspect that, short of regulation, the key ingredient will be more "enlightened" management cum stewardship. yet many are dubious that the private sector can reduce the wealth gap and improve the upward mobility of lowincome and disadvantaged workers. corporate moves toward philanthrocapitalism, shared value, and doing well by doing good (such as described here) are seen by critics as window-dressing. it seems to them that capitalism is the culprit--that inequality is in its dna. hopefully, this article presents a more uplifting picture of what some companies are doing and makes a case that businesses overall can and would benefit from doing more. to size the challenge ahead, consider these two findings from a recent survey of the american public: % want large corporations to promote an economy that serves all americans; yet only % believe large corporations 'walk to talk" in promoting this kind of economy. for up-to-date information on wages and wealth, see internal revenue service (irs), organization for economic co-operation and development (oecd), and economic policy institute and, for data junkies, the world inequality database. compensation info is available at the bureau of labor statistics (bls) and at glassdoor.com, payscale.com, and other wage tracking sites (as self-reported). for business compensation practices, see periodic reports by the society of human resource management and by commercial firms like willis towers watson and mercer. polls on public attitudes toward business, income and wealth, and such include edelman's global trust barometer (annually) and select ones by cone theory of the firm: managerial behavior, agency costs and ownership structure the error at the heart of corporate leadership how and where diversity drives financial performance. harvard business review, . to learn how businesses responds positively to inequities, see a better world for latest trends, visit websites like businessfightspoverty.org and sharedvalue.org. my own writings on business stepping up include googins stewardship and human resource management: from me to we to all of us the link between competitive advantage and corporate social responsibility research fellow, gncc and babson lewis institute, c/o rabbitbrush + models orgdyn- ; no. of pages from inequity to inclusive prosperity: the corporate role key: cord- -sjjedgws authors: bhaskar, sonu; sharma, divyansh; walker, antony h.; mcdonald, mark; huasen, bella; haridas, abilash; mahata, manoj kumar; jabbour, pascal title: acute neurological care in the covid- era: the pandemic health system resilience program (reprogram) consortium pathway date: - - journal: front neurol doi: . /fneur. . sha: doc_id: cord_uid: sjjedgws the management of acute neurological conditions, particularly acute ischemic stroke, in the context of coronavirus disease (covid- ), is of importance, considering the risk of infection to the healthcare workers and patients and emerging evidence of the neuroinvasive potential of the virus. there are variations in expert guidelines further complicating the picture for clinicians in acute settings. in this light, there is a compelling need for further formulation of recommendations that compile these variations seen in the numerous guidelines present. health system protocols for managing ongoing acute neurological care and intervention need consideration of safety and well-being of the frontline healthcare workers and the patients. we examine existing pathways and their efficacy to mitigate viral exposure to the healthcare workers and patients and synthesize a systemic approach to manage patients with acute neurological conditions in the covid- scenario. early experiences with a covid- positive stroke patient treated with endovascular thrombectomy is presented to highlight the urgent need for adequate personal protective equipment (ppe) during acute neuro-interventional procedures. neurotropism is a well-known feature of beta-coronaviruses, of which severe acute respiratory syndrome coronavirus (sars-cov- ), the virus which causes coronavirus disease (covid- ) ( ), is one, with effects on the brain stem, and in particular, the cardiorespiratory center thought to result in breathing dysfunction ( ) . the italian experience has displayed the presence of neurological symptoms in covid- positive patients ( ) . the chinese study from wuhan published in jama neurology reported neurological manifestations in a significant proportion ( . %) of patients with covid- ( ) . recent findings surrounding anosmia as an early symptom of covid- have invoked further interest in this hypothesis ( ) . the role of the central component in hyposmia could also be suspected. those presenting with symptoms of skeletal muscle damage are at higher risk of liver and kidney damage. it is evident that the virus is able to cross the blood-brain barrier (bbb), which is postulated to occur post-infection due to interactions with the angiotensin-converting enzyme (ace ) receptor present at various sites within the cerebral circulation ( ) . another case report on a female airline worker with covid- positive status developing acute necrotizing hemorrhagic encephalopathy ( ), a condition that is typically seen following cytokine storm in influenza, suggests possible bbb compromise. independent of possible neurotropism, covid- infection is associated with coagulopathy (elevated d-dimer and severe platelet reduction) and may disrupt blood pressure regulation through interaction with the ace receptor. covid- could possibly contribute to ischemic and hemorrhagic stroke aside from neurotropism ( ) . taken together these anecdotal reports suggest a possible neuroinvasive potential of the virus. management of patients with acute ischemic stroke during covid- pandemic could be challenging and certain precautions must be taken in order to protect healthcare workers, particularly in the delivery of endovascular treatment, where aerosol could be produced during the procedures, to prevent further vector transmission ( ) . as a result of this, various modifications of the traditional code stroke are being discussed amongst hospitals, and in particular, khosravani et al. ( ) propose the concept of the "protected code stroke" whereby management of patients with a suspected stroke is modified in the context of the covid- pandemic to protect healthcare workers. a conservative approach involving fever screening, history taking to rule out covid- risks and the presence of infectious symptoms could replace routine "code stroke." minimizing healthcare workers in the same room as the patient, specifications surrounding personal protective equipment use, and the delegation of specific roles to limit the risk of infection have been suggested. however, this protocol is not ratified by other major associations and does not consider the surgical aspects associated with endovascular treatment, a major gap that must be addressed. various bodies have put forth guidelines into how surgery should be conducted in these times to minimize harm to patients and healthcare workers alike. however, they are non-specific to endovascular treatment. nonetheless, general intercollegiate surgical guidelines ( ) are available, and emphasize the importance of not undertaking procedures that may result in poorly controlled aerosol production, minimization of theater staff, team changes required during a prolonged surgery, and intubation and extubation within the operation theater itself, with only necessary staff members present. this differs from the "society of american gastrointestinal and endoscopic surgeons and the european association of endoscopic surgery recommendations regarding surgical response to covid- crisis ( ), " which recommend that "unless there is an emergency, there should be no exchange of room staff." notably, neither of these guidelines are specific to endovascular treatment. the society of neurointerventional surgery recently released "recommendations for the care of emergent neuro-interventional patients in the setting of covid- ( ) , " which consider the management of patients before, during and after thrombectomy. they agree with the model proposed by khosravani et al. ( ) with regards to presuming covid positive status unless proven otherwise. notably, these guidelines concur with the "consensus statement from society for neuroscience in anesthesiology & critical care" about "anesthetic management of endovascular treatment of acute ischemic stroke during covid- pandemic ( ), " in that general anesthesia should be used if there are concerns surrounding the need for mid-procedural conversion and intubation which could be very detrimental and could expose the whole team, a scenario that should be avoided at all cost. however, these latter guidelines do not address the issue of separating covid- patients from others in terms of scanning equipment, radiology suites, and decontamination protocols. given the possible neuroinvasive potential of covid- , there is a need to consider both the short and long-term implications of covid- , and implement systems-level methods of assessing, addressing, and longer-term monitoring (figure ). we expect that there is a significant amount of variability based on institution and country with respect to covid- testing. for example, the earliest possible result time for covid testing at one of our hospitals is h but the serology test that would take minutes to give a result was just food and drug administration (fda) approved and hopefully will be introduced soon but until this is available widely it will be practically difficult to rule out covid- during code stroke (at least at many hospitals in the us and elsewhere), and as such, we propose that all patients undergoing code stroke be presumed covid- positive. this is concurrent with the american heart association (aha) emergency guidelines for stroke centers in the context of covid- ( ) . all covid- positive patients should be triaged into covid- neuro or covid- non-neuro wards depending upon the presence of neurological symptoms ( ) . common neurological complaints include dizziness, headache, anosmia, and dysgeusia ( ) . in patients with a suspected acute stroke: • all acute stroke patients should be treated as covid positive until proven otherwise, and full personal protective equipment (ppe) should be used when responding to a code stroke ( , ) . • telemedicine should be used to determine eligibility and perform intravenous thrombolysis [trans plasminogen activator (tpa)] to minimize potential exposure to infectious patients ( , ) . patients who receive tpa do not need to be admitted to the icu, if stable. prior to the pandemic, it was standard practice in the us to admit all post-tpa patients to the icu for h. however, the aha recommends that there is little evidence to support post-tpa icu stay ( ) . • separate scanning equipment and radiology suites for negative, suspected, and confirmed covid- patients, with clear decontamination protocols after each patient ( ) . • separate suites for endovascular treatment of negative and suspected/confirmed covid- patients, with extra equipment stocked in the latter to prevent staff having to retrieve equipment. clear decontamination protocols after each patient ( ) . • in all theaters, minimize exposure to staff and the number of perioperative workers ( , ) . • in the case of long procedures, team changes should be encouraged to minimize prolonged exposure to healthcare workers ( ) . • a lowered threshold for general anesthesia administration in terms of concerns surrounding the need for mid-procedural conversion ( , ). • where possible, post thrombectomy recovery should occur outside of icu in the stroke unit if those beds are required for covid- patients ( ). • it is recommended that suspected covid- patients should be treated as covid- positive until the polymerase chain reaction (pcr) diagnosis confirms otherwise, and such patients should be admitted to covid- positive wards. separate stroke units for covid- positive and negative patients are recommended. • to ensure the quality of stroke care for covid- stroke patients, such patients could be admitted to other wards for covid- positive patients. dysphagia management, physical or logo therapy, and standard in-hospital rehabilitation of stroke patients should be provided; however, concerned staff should wear adequate ppe to prevent exposure and transmission. • healthcare workers in secondary hospitals and radiology facilities are recommended to wear adequate ppes when caring for someone with a confirmed or suspected case of covid- . it is advised that patients in which neurological symptoms are present: • patients should be monitored for short-term and/or possibly long term cognitive or neurological impairments. cognitive impairment could be assessed using routine tests such as mini-mental state examination (mmse) by treating clinicians. large scale community screening with good sensitivity/specificity could also be administered using telephone, by informant proxy or directly by post [such as cognitive assessment screening test (cast)] provided the test has a good sensitivity/specificity balance (> %) ( ) . • for patients presenting with neurological symptoms in future, past covid- infection should be ascertained, along with the clinical severity, and corroborating imaging findings. • in addition, imaging could be used to assess the damage to the blood brain barrier (bbb) to examine whether covid- induces a transient or long-term change. bbb assessment and permeability quantification could be done either: (a) semi-quantitatively by comparing the scans before and after contrast injection, or (b) quantitatively using perfusionweighted or permeability magnetic resonance imaging (mri) technique, vis a vis dynamic contrast-enhanced mri (dce-mri) ( ) . for all acute neurological conditions, a major concern revolves around the decrease in the proportion of acute presentations due to fear of contracting covid- while accessing health services and the presumption that all healthcare resources are now mobilized to prioritize covid- patients ( ). this could have negative consequences vis a vis long-term disability subsequent to permanent brain damage due to acute neurological emergencies such as traumatic brain injury ( ) . similarly, earlier symptoms of emergent brain tumors, such as headache and ataxia ( ) may be neglected or cranial neuropathies from mass effect of a brain aneurysm, due to the perceived cons of seeking help. as of yet, significant gaps exist in the literature pertaining to how to address delayed or absence of presentation. use of telemedicine where possible, social distancing within clinics for patients coming to the hospitals and systems-level separation of patients with fever and respiratory symptoms from those without having been proposed as possible solutions to minimize the impact ( ) . public health campaigns surrounding measures that are in place to minimize infection transmission and ill consequences of failing to present with a condition that does indeed warrant medical attention need to be pursued. also, the longterm negative impact of the delayed presentation should be emphasized. a recent case report identified a link between frequent convulsive seizures and covid- infection in the context of emergent epilepsy ( ) . in light of these anecdotal findings, it is relevant that guidelines pertaining to seizure management in covid- cases are not available, to the best of our knowledge. with regards to chronic epilepsy patients, longer-term medicine prescription, use of telemedicine, and optimal seizure management plans have been recommended ( ) . similar issues exist with respect to the management of aneurysmal presentations as no specific guidelines exist in the covid- scenario. the number of covid positive patients under years of age represent . % of total lab-confirmed cases in the usa ( ) . given the relatively low proportion of covid- pediatric patients, neurological manifestations are very unlikely to be delineated. this pandemic is adversely challenging the health systems, causing stress, fear to healthcare workers, with the pressures of lengthened hours, lack of ppe equipment and systemic changes that are having to be implemented to protect them ( , ) . indeed many healthcare workers have expressed publicly in the media and on social media channels that the risk of infecting their families is a source of constant stress to them and impacting their intimate relationships significantly ( ) . indeed it is also overlooked that the scarcity of resources can impact the management of patients and potentially result in some patient who may have ordinarily fared better having worse outcomes, another key factor in terms of mental health issues and also indeed the morale of healthcare workers, which can have longer terms impacts in terms of the efficiency and drive of health systems ( ) . considering public health ethics, and more specifically the concept of utilitarianism which forms a key part of this, the need to protect our frontline healthcare workers and support their health becomes evident. utilitarianism refers to judging actions based on how much good they will do for the greatest number of people -thereby forming the backbone of ethics and health policy debate underpinning the crisis ( ) . protecting our healthcare workers gives the most benefit. this can, therefore, involve protecting them from contracting the infection, which could then be spread to their families, other patients, and resultantly the community, as well as focusing on their psychological health so they are able to discharge their duties efficiently and effectively. various strategies have been proposed for addressing these issues. it is pivotal that any changes to protocols, such as those related to changes in how to carry out code stroke actions are wellrehearsed, which may include simulation training with the revised protocol ( ) . an extra healthcare worker on the team will be needed to observe the team while at work to try to detect any breach in the covid- precaution protocols and at the end of a procedure to help undress the team and clean their ppes. managing a pandemic of this proportion can undeniably cause stress and fear. as such it has been proposed that healthcare workers, particularly those working with covid- positive cases, be given regular breaks ( ) and encouraged to recognize their limits ( ) . we also propose that healthcare workers be given information pertaining to relaxation and coping strategies; whilst many healthcare workers may already be aware of these, a reminder may be beneficial. the world health organization "mental health and psychosocial considerations during the covid- outbreak" document advocates the role of a "buddy" or peer support system for more experienced clinicians to assist and support their less experienced colleagues, as a means to not only help manage stress but also learn how to efficiently enact the protocols that may be in place in an organization ( ) . this is especially relevant as the health systems are being reorganized and protocols are being revised regularly, sometimes on a daily basis ( ) . online peer-support networks for discussions as well as social media and messaging chat groups may provide a valuable outlet for clinicians. planning how healthcare workers will interact with their families and reorganize their living arrangements can help de-escalate the stressors as reported in the media ( ) . the victorian government in australia has announced that all healthcare workers required to self-isolate or tested positive for covid- will be provided hotel accommodation to minimize risks to them and to their families, with an indication to expand this model to other states and territories ( ) . it is important for these recommendations to be specific to avoid creating further anxiety among healthcare workers ( ) . in the covid- pandemic, acute neurological care is increasingly under stress due to ongoing reorganization and rationing of services to meet the demands of frontline covid- cases. in this article, we have identified and proposed various considerations that may minimize the risk to health systems, healthcare workers, and the patients. the differential diagnosis of severe acute respiratory syndrome cov (sars-cov ) infection should be considered in patients with neurological symptoms during the covid- period ( ). this is important to avoid missed or delayed diagnosis and prevent viral transmission. all patients amidst this pandemic should be screened for covid- and telemedicine could be used to triage these patients and possibly deliver intravenous thrombolysis. for those who may be candidates for endovascular thrombectomy, extra precautions need to be taken to minimize procedural risks associated with the aerosol transmission of the covid- virus and possible exposure to the healthcare staff. an example of reperfusion therapy work-up with ppes in a covid- stroke patient is illustrated in figure . public health campaigns to educate and increase awareness of the community about the need to seek urgent medical attention should acute neurological symptoms occur. special considerations also apply for patients with traumatic brain injury and those requiring urgent aneurysm surgery or carotid endarterectomy. we are alarmed at the rising deaths of healthcare workers who are waging a war against the covid- without the provision of adequate ppe to defend themselves. the cost of adopting the proposed protocol and its impact on the quality of care merits further study. the current consortium is expeditiously working toward rapid adoption of the proposed protocol. further study on the impact and cost these measures may have on the quality of care and its results are envisaged. however, given the nature of the pandemic and emerging situation, the safety of healthcare workers' is paramount and thus justifies the heightened safety measures suggested in our protocol with an anticipation that this would hopefully limit the exposure. minimizing the harm to healthcare workers should be a priority as potential exposure can not only compromise the health systems, expose other workers, and patients to covid- ; but will also have a negative impact on the morale of professional colleagues. written, informed consent was obtained from the individual/legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article. sb devised the project, the main conceptual ideas and proof outline, encouraged ds to investigate and supervised the findings of this work. sb and ds wrote the first draft of the manuscript. all authors discussed the results and recommendations and contributed to the final manuscript. the consortium would like to thank pj for sharing an illustrative case example included in the study. the opinions expressed in this article are those of the authors and do not necessarily represent the decisions, official policy, or opinions of the affiliated institutions. we would like to acknowledge the reprogram consortium members who have worked tirelessly over the last days in contributing to various guidelines, recommendations, policy briefs, and ongoing discussions during these unprecedented and challenging times despite the incredibly short timeframe. we would like to dedicate this work to our healthcare workers who have died due to covid- while serving the patients at the frontline and to those who continue to serve during these challenging times despite lack of personal protective equipment. naming the coronavirus disease (covid- ) and the virus that causes it the neuroinvasive potential of sars-cov may play a role in the respiratory failure of covid- patients available online at neurologic manifestations of hospitalized patients with coronavirus disease loss of sense of smell as marker of covid- infection evidence of the covid- virus targeting the cns: tissue distribution, hostvirus interaction, and proposed neurotropic mechanisms covid- -associated acute hemorrhagic necrotizing encephalopathy: ct and mri features nervous system involvement after infection with covid- and other coronaviruses anesthetic management of endovascular treatment of acute ischemic stroke during covid- pandemic: consensus statement from society for neuroscience in anesthesiology & critical care (snacc)_endorsed by society of vascular & interventional neurology (svin), society of neurointerventional surgery (snis), neurocritical care society (ncs), and european society of minimally invasive neurological therapy (esmint) protected code stroke: hyperacute stroke management during the coronavirus disease (covid- ) pandemic. stroke updated intercollegiate general surgery guidance on covid- . - lincoln's inn fields society of american gastrointestinal and endoscopic surgeons and the european association of endoscopic surgery. sages and eaes recommendations regarding surgical response to covid- crisis society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid- temporary emergency guidance to us stroke centers during the covid- pandemic letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm the battle against coronavirus disease (covid- ): emergency management and infection control in a radiology department a review of screening tests for cognitive impairment quantitative imaging assessment of blood-brain barrier permeability in humans evaluation of the disability determination process for traumatic brain injury in veterans signs and symptoms of patients with brain tumors presenting to the emergency department headache clinic workflows during the covid- pandemic frequent convulsive seizures in an adult patient with covid- : a case report covid- resources for epilepsy clinicians cdc covid- response team. coronavirus disease in children -united states risk of infecting others with covid- key concern for healthcare workers black dog institute. mental health ramifications of covid- : sydney: the australian context black dog institute available online at mental health care for medical staff in china during the covid- outbreak world health organisation. mental health and psychosocial considerations during the covid- outbreak managing mental health challenges faced by healthcare workers during covid- pandemic healthcare workers to be given free accommodation under $ m 'hotels for heroes' plan supporting the health care workforce during the covid- global epidemic the authors declare 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 © bhaskar, sharma, walker, mcdonald, huasen, haridas, mahata and jabbour. 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- -zhk fyfc authors: gerard, françois; imbert, clément; orkin, kate title: social protection response to the covid- crisis: options for developing countries date: - - journal: nan doi: . /oxrep/graa sha: doc_id: cord_uid: zhk fyfc the public health response to covid- in many countries has involved strict restrictions on movement and economic activity which threaten the livelihoods of economically vulnerable households. in response, governments are adopting emergency economic measures to provide households with some safety net. we provide an overview of the policies that could form a comprehensive social protection strategy in low-income and middle-income countries, with examples of specific policies that have been adopted. our core argument is that these countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include expanding their social insurance system, building on existing social assistance programmes, and involving local governments and non-state institutions to identify and assist vulnerable groups who are otherwise harder to reach. covid- has now reached low-income and middle-income countries. the public health response in many countries has involved strict restrictions on movement and economic activity (e.g. closing workplaces, banning gatherings, restricting travel) and others are considering imposing similar policies. domestic measures, as well as similar measures adopted globally, are likely to have an immediate negative impact on household incomes, and might threaten the livelihoods of households who are already vulnerable economically. in response, governments are adopting emergency economic measures to provide households with some safety net. we provide an overview of the policies that could form a comprehensive social protection strategy in developing countries, with examples of specific policies adopted around the developing world in recent days. our core argument is that middle-income and lower-income countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include: . expanding their social insurance system, which typically covers a much smaller share of the labour force than in higher-income countries; . building on existing social assistance programmes, which reach a large share of households in many developing countries; . involving local governments and non-state institutions to identify and assist vulnerable groups who may not be reached by ( ) and ( ). the debate on social protection responses occurs as countries face both a public health and a public finance crisis. first, governments have to design a public health response to mitigate or suppress the virus which balances provision of covid- health care against other health needs and which can be implemented in contexts where strict social distancing is not practical. the strictness and duration of the restrictions imposed on mobility and economic activity will, to a large extent, determine the immediate impact on household incomes, and thus the scale of the social protection response needed to mitigate it. in turn, the support provided to help households could increase compliance with public health policies. second, governments have to finance both health and economic measures, while experiencing shortfalls in tax revenues. many developing countries were already heavily indebted before the crisis, and investors have sold emerging market assets, making borrowing on the open market difficult. without novel solutions to allow governments to borrow internationally and secure additional aid quickly, the scale of their social protection response will be limited, and developing countries may not afford a public health response imposing strict restrictions on their economies. low-income and middle-income countries share features that present specific challenges and opportunities for their social protection response, compared to higherincome countries. . the economic consequences of the crisis for households in developing countries will be severe. a larger share of workers are in occupations and industries less compatible with social distancing (e.g. construction, labour-intensive manufacturing, small retail). households have more limited access to credit and hold limited savings or buffer stock. their usual means of smoothing income shocks, casual work and migration, are not possible when economic activity and mobility are restricted. support from social networks is also more limited when everyone experiences a simultaneous shock, which in the case of a global crisis is true even of the most extended networks (e.g. international remittances). complying with public health guidelines will incur out-of-pocket costs (e.g. access to water in urban slums) that are high as a portion of available income. in this context, households may take short-term decisions out of necessity that leave them in long-term poverty, such as selling assets to finance food consumption. moreover, firms often face more severe liquidity constraints in developing countries, limiting their ability to keep paying their workers during the crisis. the need for government intervention is thus particularly severe in developing countries today. . yet, government programmes insuring against job or earnings loss have more limited scope in developing countries. first, a larger share of workers are in employment categories that are difficult to insure against such risks. many employees work for informal (i.e. unregistered) businesses, which may not contribute to existing social insurance programmes, while others work for formal businesses on informal contracts. the self-employed-whose 'regular' income is more difficult to assess even in richer countries-account for a larger share of employment, and many of them also carry out their activities informally. second, government programmes insuring workers against such risks are more limited in developing countries even for formal (i.e. registered) employees. for instance, the share of developing countries in which these workers are eligible for some form of unemployment insurance is much lower than in higherincome countries (see figure ). existing social insurance programmes will thus be less effective in supporting workers in developing countries. . at the same time, many developing countries can build on large existing social assistance programmes. as figure (a) shows, these cover a sizeable share of the population, including contexts where informal work and self-employment are the norm. these programmes take various forms, such as conditional or unconditional cash transfers, work guarantees, or the direct delivery of food and other necessities (see figure (b)). they target poor households and are not necessarily designed to mitigate job loss or income shocks. they can be made more generous in this time of crisis. they can also provide a base for emergency assistance, e.g. they often rely on detailed registries and effective infrastructure for transferring resources. existing social assistance programmes thus provide invaluable mechanisms to provide emergency relief to many households. . some vulnerable populations are not easily covered by social insurance and are usually outside the populations targeted by social assistance programmes (e.g. informal workers with volatile incomes, migrant workers), making them particularly hard to reach in an emergency. however, local governments in many developing countries are in a good position to assess unmet needs and to deliver direct assistance. the same is true of a range of non-state actors (e.g. ngos, savings and loan associations, mutual insurance organizations), which are active in contexts where state capacity is limited (e.g. remote rural areas or urban slums). involving local actors, especially non-state ones, is an opportunity but also a challenge, as their efforts need to be coordinated, and they need to be monitored by both citizens and national governments. credible partners thus exist for central governments to help 'harder-to-reach' segments of the population, as long as their actions are in line with the national effort and are accountable to the public they serve. despite pervasive informality, formal employees constitute a major employment category in many developing countries, particularly in middle-income countries. moreover, these workers are possibly even less well prepared than their counterparts in richer countries to cope with the economic impact of the crisis. therefore, expanding the social insurance system to provide more support to formal employees could be an important pillar of the social protection strategy of developing countries, even if it will not be sufficient to reach all workers (e.g. informal workers). governments around the world have adopted new job retention schemes in the last few weeks. such schemes already existed in some countries (e.g. germany, italy), including developing countries (e.g. brazil), to help firms cope with temporary shocks (e.g. drop in demand, insolvency issues, natural disasters). they provide subsidies for temporary reductions in the number of hours worked, replacing a share of the earnings forgone by the worker due to the hours not worked, over a maximum period of time (a few weeks or months). their advantage in the current crisis is to avoid the destruction of existing jobs (giupponi and landais, ) , which should be viable again once the public health response is relaxed. subsidizing these jobs could allow firms to continue to operate, even if at some reduced level, without imposing large pay cuts. subsidizing the survival of jobs that must be temporarily suspended could also spare workers and firms the costs of finding a new job and replacing the worker, speeding up the economic recovery. the argument in favour of job retention schemes is strong for developing countries. without such schemes, many workers will be laid off with no unemployment insurance. moreover, setting up a new job retention scheme might be logistically easier than setting up an unemployment insurance programme, as governments could use firms as intermediaries to channel the income support to their workers. job retention schemes are also most valuable in labour markets where search frictions are high. recent research shows (i) that finding the right workers is a major challenge to firm growth in developing countries (hardy and mccasland, ) ; (ii) that workers struggle to find formal employment because of difficulties signalling their skills credibly to firms (abebe et al., , carranza et al., ; and (iii) that displaced formal employees take much longer to find a new formal job than in higher-income countries (gerard and gonzaga, ) . the destruction of existing jobs might thus have severe longer-term impacts on the size and productivity of developing countries' formal sectors, which are a key policy focus (levy, ) . some implementation details might be particularly important in developing countries: • targeting. in thailand, a recent job retention scheme covers a fixed share of workers' monthly earnings; in morocco, a new programme provides a fixed monthly amount to workers whose job must be temporarily suspended; the amount received under the brazilian and south african schemes is not fixed, but the share of forgone earnings that it replaces is lower for higher-wage workers. targeting the income support to low-wage workers can help more workers for a given budget and leave more financial resources to help other worker categories. however, it will require higher-wage workers to make relatively larger adjustments and increase the risk that their jobs will not survive the crisis. additionally, targeting support to low-wage workers may not necessarily target jobs for which search frictions are most important, which may slow down the economic recovery. • payment. in contrast to some pre-existing job retention schemes (e.g. in france), the above-mentioned schemes do not rely on firms advancing the payment of the earnings subsidy. firms in developing countries may not have enough liquidity to make such advances or may not trust the government to reimburse them quickly, disincentivizing participation (see levinsohn et al. ( ) on an earlier wage subsidy in south africa). • other firm contributions. job retention schemes sometimes require firms to contribute towards their workers' compensation beyond the hours actually worked (e.g. for larger firms in the brazil scheme). this could incentivize firms struggling to stay afloat to lay off their workers rather than to participate in the scheme. more generally, firms face other costs than their payroll and helping them cover these costs might be necessary for existing jobs to survive. several countries have implemented a range of policies in this regard, such as low-interest loans, rent moratoriums, or tax relief. even with a job retention scheme, many workers will likely be laid off and developing countries with unemployment insurance programmes will be in a better place to support these workers. however, it might be important to adjust their programmes, such as by relaxing job search requirements and extending eligibility rules. for instance, in south africa, workers are usually eligible for day of unemployment insurance for every days of employment. in brazil, many workers must accumulate up to months of employment to become eligible for any benefits. such rules could leave laid-off workers who have limited job tenure (e.g. less than a year) with little income support throughout this crisis and no other employment options in the short run. a policy that is more common than unemployment insurance in developing countries is mandatory severance payments that firms must pay to workers at layoff. the insurance value of such lump-sum payments is limited when workers cannot find new jobs quickly. moreover, firms facing severe reductions in cash-flow might struggle to pay what they owe to their workers and governments may need to provide firms with low-interest loans to fund severance pay obligations (gerard and naritomi, ) . governments could also consider topping up the severance amount and spreading its payment over time to avoid workers spending it too quickly after layoff. another common component of the social insurance system in developing countries is mandatory contributions by firms or workers to forced (illiquid) savings accounts for long-term objectives, e.g. to fund a complementary severance payment at layoff or a complementary pension at retirement. workers could be allowed to withdraw some amount from these accounts in the current crisis. for instance, the indian government recently allowed formal workers to withdraw up to months' worth of salary (but no more than per cent of the amount in the account) from their employee provident fund. the benefits for workers from such early withdrawals might greatly exceed their costs, particularly for younger workers who will be able to replenish their forced savings accounts in coming years. finally, some countries have considered extending the logic of these social insurance programmes to formal (i.e. registered) self-employed workers. however, it is more challenging to determine (a) their 'usual' earnings level prior to the crisis and (b) the reduction in earnings caused by the crisis. these challenges will only be exacerbated in developing countries, as governments likely have less information about these workers' past or current earnings than in higher-income countries, even for self-employed workers who are formally registered. in this context, developing country governments may be left with fewer options. • one option is to make unconditional monthly transfers of a fixed amount. for instance, the auxilio emergencial in brazil will provide self-employed workers with a monthly payment of per cent of the minimum wage for the next months. it might be possible to design a more fine-grained payment scheme, e.g. based on some presumptive income varying across sectors of activity. however, the costs of designing a more complicated scheme might outweigh its benefits if it leads to long delays in disbursements (as in the uk ). • a complementary option is to provide emergency low-interest credit lines for self-employed workers, allowing them to borrow a maximum amount to pay themselves in the coming months. such policies have been recently implemented in some countries to help small and medium firms pay their workers' wages throughout the crisis, and could be extended to self-employed workers. repayment of loans could be made contingent on self-employed workers' future income or gross revenue crossing above a certain threshold, to mitigate concerns of taking on more debt at this time. social insurance programmes will fail to reach a large share of households in developing countries, in particular those mostly active in the informal sector of the economy. however, many of these households could be reached through social assistance programmes. for example, south africa's child support grant reaches many poor households who are in informal jobs and will not be covered by its job retention scheme. maintaining these programmes throughout the crisis will already provide some minimal support to many affected households, although some of their rules might need to be adapted. these programmes could also be made temporarily more generous to compensate current beneficiaries for income losses. finally, these programmes could be temporarily extended to new households, e.g. to households whose information was collected to target these programmes, and who were deemed ineligible. in practice, these programmes take many forms and their key features determine how they can be used in response to the crisis. the first feature is the type of assistance that these programmes provide. some programmes dispense cash; some provide in-kind assistance (e.g. food, fuel); others subsidize access to essential goods and services (e.g. health services, housing). in cases where supply chains are impacted or prices rise, in-kind provision will be most powerful, and public procurement will support producers as well. for instance, the indian government doubled the monthly foodgrain (wheat and rice) household allowance and added pulses to the ration provided by the public distribution system. when households can buy goods and services at reasonable prices, cash transfers are quicker to implement and more fungible than in-kind transfers. many countries have temporarily topped up the amount received by the current beneficiaries of social assistance programmes. for instance, the indonesian government increased both the benefit amounts of its cash transfer programme (pkh) and the frequency of its payments (from quarterly to monthly). kenya has increased the amount of its pension and orphan and vulnerable children's grant. provision or delay payments, especially for utilities that are publicly owned (e.g. electricity bills or rents). indonesia has recently granted months of free electricity to m customers with low power connections. the second feature is the conditionality of the social assistance. conditional cash transfers (cct) programmes are a popular form of income support in developing countries (e.g. mexico's prospera or brazil's bolsa familia). they make assistance conditional on a particular behaviour encouraged by the state, e.g. enrolling children at school or immunizing them. public works programmes are also often used for antipoverty relief in the developing world (e.g. india's mg-nregs or ethiopia's psnp). these conditions cannot be fulfilled at the time when countries have closed schools and public works sites because of safety, or when hospitals are overwhelmed. to provide social protection in the current crisis, cct and public works programmes need to become temporarily unconditional. removing conditionalities may be legally or politically difficult. for instance, india's relief package increases the wage for mg-nregs workers, but it makes no provision to make public work sites compatible with social distancing. other public works programmes, such as ethiopia's psnp (berhane et al., ) , already provide cash or food for those identified by communities as unable to work and could perhaps extend this feature to all programme recipients. the third feature of social assistance programmes is the population that they target. some programmes help specific socio-demographic groups (e.g. non-contributory social pensions for the elderly or grants for orphans and children). some provide relief to specific occupational groups (e.g. farmer drought relief funds). others are targeted according to economic indicators, such as transfer to households deemed poor based on their assets (e.g. indonesia's conditional cash transfer pkh). developing countries can leverage all their programmes simultaneously to provide assistance to a wide range of vulnerable groups. each of these programmes suffers from inclusion errors, with resources being diverted to non-eligible households or stolen by corrupt bureaucrats, and from exclusion errors, with eligible households deterred from applying (hanna and olken, ) . in these times of emergency, governments will have to rely on social assistance programmes, even if their targeting is not perfect. direct beneficiary payments, and transparency in how much is given to whom, may help keep 'fund leakages' under control (muralidharan et al., ; banerjee et al., ) . using existing programmes to extend assistance to new beneficiaries is possible, but requires both information on potential beneficiaries and payment infrastructure to reach them. some countries have built digital infrastructures linking governments and poor citizens for various programmes that can now be used for emergency payments (see rutkowski et al., ) . for example, chile has a national id-linked basic account for most poor people, which will be used to pay more than m low-income individuals a once-off grant. india also has sent money to jan dhan accounts linked to the adhaar id system, which were created to promote financial inclusion among the poor. other countries have detailed censuses to identify the poorest citizens for social assistance. these censuses can now be used to extend assistance to people who were initially deemed too well-off for assistance. for example, the peruvian programme bono yo me quedo en casa offers an additional transfer equivalent to per cent of the minimum wage to . m poor households identified in a dataset created to target the peruvian juntos cct. beneficiaries can check their availability online, and payments are routed via a national bank. in countries in which no pre-existing databases are available, or where governments would not automatically enrol large parts of the population in emergency assistance programmes, they may prefer to ask people in need of assistance to opt in. for instance, pakistan has announced a relief package with large transfers to the poor, but the emergency programme requires people to self-identify as vulnerable and to text the existing social programme ehsass with their national identification number. enrolling new beneficiaries and paying them is a challenge in many settings. in noncrisis times, enrolling people and checking eligibility may be more effective to target the poorest than automatic enrolment (alatas et al., ) . but enrolment systems set up in times of emergency may not necessarily target the most vulnerable efficiently. for instance, the state of bihar in india has announced a transfer to all migrant workers stranded in other states and plans to perform identity checks through a phone app. households recorded in the cadastro unico-i.e. the brazilian census of the poor-will be eligible for the same auxilio emergencial as formal self-employed workers (see above), but the government also created a new website to extend coverage of this emergency assistance programme to informal workers at large. the use of these technologies may prevent individuals without a computer or smartphone from enrolling, unless complementary systems are set up. even if they successfully enrol, transferring money to these new beneficiaries can be difficult. relying on digital payment infrastructures is quicker and safer in an epidemic, but it might exclude particularly vulnerable households: globally, only per cent of adults have any digital bank or mobile money account; only per cent have received wages or government transfer payments directly to an account (findex, ) . in this context, it will be necessary to set up physical collection points or direct delivery systems for these households while still respecting social distancing measures. in peru, bank branches were overcrowded when recipients of the bono yo me quedo en casa programme came to cash their benefits. a strategy based on expanding social insurance and building on existing social assistance programmes will likely leave important needs unmet. for instance, informal workers with volatile incomes (especially in urban areas) or with weak ties to their place of residence (e.g. migrant workers) are often beyond the reach of social insurance and usually outside the populations targeted by social assistance. a comprehensive social protection response could involve local governments and a range of non-state actors to collect better information on these unmet needs and to deliver targeted assistance. state and municipal governments may play a complementary role to national governments, who often have the main mandate for social insurance and assistance. many developing countries have decentralized extensively over the last decades, and have devolved a range of government functions to lower echelons of government, including responsibilities related to social assistance. for example, the responsibility for implementing india's employment guarantee mg-nregs is devolved from the central government to the state, the district, the block, down to the gram panchayat, a local government of about households. it is common for developing countries to elect or select a large cadre of leaders at very local levels. in kenya, each village of ~ - households has a volunteer village leader who reports to the lowest level of paid civil servant, the assistant chief, adjudicates disputes, and spreads information from the state (orkin and walker, ; walker, ) . these structures can play multiple roles during this crisis. first, local structures can channel information up to decision-making structures, which is important when travel is limited. information could be movements of people, price and availability of food, whether new social protection measures have been successfully implemented, and whether specific groups remain unexpectedly not covered. in food-insecure countries such as malawi and ethiopia, infrastructure has been built to collect local data on food security and channel food or cash to famine-affected areas and public works programmes to food-insecure areas (berhane et al., , beegle et al., . similarly, for public health success against ebola, it was vital that local structures relayed data back to coordinating structures for better decisions. second, local structures could be involved in the identification of individuals in dire need of additional support. they were often involved in the targeting of social assistance programmes pre-crisis, both in the gathering of information on vulnerable populations for higher levels of government and in the prioritization of assistance to the most needed. for example, censuses of the poor used to target cct programmes are typically updated by local administrations in latin american countries. rwanda is using local structures to target in-kind food security packages, which will complement its existing social protection scheme. vulnerable households are identified at the most local (isibo) level, with information on numbers of households relayed up to higher government structures. to avoid exclusion errors, the capital city government set up a toll-free line for households who reported they missed out in the targeting. these institutions have particular strengths that may complement a national government response. they may have funding or staff already in place at local level. local authorities often receive block grant funding to address locally identified needs, with local structures in place to monitor how it is allocated. funding could be temporarily repurposed or these structures could be used to channel any additional funds granted. for example, the indian government allowed state governments to use disaster funds to provide shelter and food to migrant workers. local governments also have networks of employees (e.g. for education, health, welfare) in contact with more remote communities and able to support them in accessing services. for example, south africa's network of early childhood community care givers primarily conducts health promotion and prevention activities; pre-crisis, government tapped this network to assist families in enrolling for child support grants (hatipoglu et al., ) . local governments often have better information on local needs and preferences, so may be more responsive. as a result, their decisions may have more legitimacy. for example, in indonesia, leaders allocating cash transfer benefits via community targeting did reasonably well in terms of targeting the poor. communities were also more satisfied with community targeting than an externally administered proxy means test (alatas et al., ) . they may also be more easily held accountable to communities and may feel pressure to be more responsive, provided the resources and functions devolved to them are clearly communicated to the public (gadenne, ; martinez, ) . for example, the state government of bihar (india) has felt pressure to extend its attention to migrants in this crisis, a segment of the population which it does not usually serve or respond to, and which was excluded from the central government relief package. on the other hand, local structures may be more open to capture. for example, after a serious drought in in ethiopia, community-based food transfers were targeted to households with less access to support from relatives or friends, but were also twice as likely to be targeted to households with close associates in official positions (caeyers and dercon, ) . a range of non-state institutions are also particularly active in giving voice to specific groups or serving populations beyond the reach of the state. depending on the context, these institutions may be in a unique position to gather information on the needs of specific groups, and/or be credible partners for delivering assistance in an emergency. there are a broad range of examples of such institutions. illegal urban settlements sometimes have recognized local leaders who facilitate access to state services and social benefits and are accountable to local populations (e.g. in urban india). recognized local ngos also often provide a range of services and sometimes coordinate their efforts within a geographic area under an umbrella organization (e.g. in urban brazil ); they may have years of experience being accountable to both their donors and their beneficiaries. international ngos (e.g. brac, oxfam) have a strong presence across a range of contexts. there are also private associations with specific purposes, which can, in some instances, have wide coverage. for example, per cent of africans participated in community-organized savings groups (findex, ) . membership may be even higher in rural areas: per cent of a rural kenyan sample were members of a rotating savings group (rosca) (orkin and walker, ) . in ethiopia, over per cent of villagers in two separate samples are members of burial associations (dercon et al., ; bernard et al., ) . another type of private association are professional organizations, which may be active in sectors that employ many informal or poor workers. for example, india's relief package encourages building and other construction worker welfare funds to provide emergency assistance. these institutions could play a range of roles. some will likely repurpose themselves to provide emergency assistance in the current crisis spontaneously, an effort that could be leveraged and complemented by governments. governments could leverage their infrastructure to gather information on the needs of their many beneficiaries. many have a network of workers in remote areas, who are already part of public health responses, e.g. an ngo trained community volunteers, religious leaders, and traditional healers in senegal to monitor for common diseases in their villages. they could be used to recruit people into government programmes in environments where communication about new programmes is difficult. for instance, kenya used roscas to enrol participants into its new health insurance scheme (oraro and wyss, ) . india used national rural livelihood missions and their network of self-help groups (shg) to advertise and enrol people into many development programmes, such as rural sanitation (swachh bharat mission). it may be unusual to involve non-state actors directly in provision of state assistance, but unprecedented times may call for exploring new opportunities. although there may be justifiable concerns about a lack of accountability, institutions with a long history and broad base of membership may be particularly resistant to the capture of transfers (dercon et al., ) . they already need to be locally legitimate to sustain their work, as they have no formal legal authority and are regulated largely by social sanction (olken and singhal, ) . the most important concern is that community institutions remain inclusive in times of crisis and share broadly the emergency resources given to them (gugerty and kremer, ) . for example, rural communities need to provide support to returning migrants rather than banning them from coming home for fear of the contagion. another concern is that non-state institutions enrolled in social protection efforts need also be onboard with governments' public health strategy (e.g. some religious organizations have been promoting alternative ways of dealing with the pandemic ). our analysis highlights that governments in developing countries will have to find creative solutions to build a comprehensive social protection response to the economic impacts of the covid- epidemic. job retention programmes already existed in some countries (e.g. brazil) and could be used more widely to protect employment in the formal sector. some governments, as in chile or india, have leveraged id-linked bank accounts opened for financial inclusion purposes to provide direct support to the poor. even populations that live at the margins of social protection systems, like migrant workers in the informal sector who are not registered where they work, can be reached through associations that work with them (like the aajeevika bureau for internal migrants in india). yet, any government response will be imperfectly targeted, with important inclusion and exclusion errors. government responses based on social insurance programmes may reach many formal employees and registered self-employed (although coarsely), but will miss the informal sector, which is an important part of developing countries' workforce. social assistance programmes allow governments to broaden the base of their response, but their targeting is always specific to a particular dimension of poverty, and their delivery is often plagued with 'leakages'. involving local governments or non-state actors to help provide assistance presents clear opportunities, but also runs the risk of resources being diverted by local elites or used for clientelism. together, these policies may reach some households through several channels at once while leaving others with no direct support. however, in an emergency, the benefits from improving targeting and reducing leakages may not exceed the costs if an improved process leads to long delays in implementation. fortunately, even imperfectly targeted transfers will reach some 'left-behind' households through family, informal, or formal sharing structures. existing social protection transfers are often widely shared in families and extended networks even outside times of crisis. for instance, south african pensions received by grandparents benefit grandchildren (duflo, ) and young adults in the household (ardington et al., ) . households ineligible for progresa cash transfers still get loans and gifts from eligible households in the same village and have higher food consumption (angelucci and di giorgi, ). government could acknowledge explicitly that their emergency response will not reach all households and encourage beneficiaries to share their resources with others whom they identify as being in need, possibly subsidizing means of money transfers (e.g. reducing fees for bank or mobile money transfers ). charitable giving could be encouraged in response to the crisis and channelled to vulnerable populations (e.g. zakat funds in muslim communities in bangladesh before ramadam ). in fact, national funds run by governments and businesses have already raised record amounts in some countries. the challenge of mitigating the economic effects of the pandemic is enormous. any solution will be flawed in many ways because speed is of the essence. but governments, donors, and civil societies have made major gains in the last years in building infrastructure to reach the poorest. if internal and external financing can be found, developing countries can use this to create the economic space for an effective public health response. china has helped firms but does not seem to have protected employment (south china morning post transfer fees for kenya's popular mobile money system were recently waived, although for a public health reason (finextra defusing bangladesh's covid- time bomb thousands of ordinary south africans have contributed to the solidarity fund'). nigeria's similar version, run by the central bank, raised £ m in a week anonymity or distance? job search and labour market exclusion in a growing african city targeting the poor: evidence from a field experiment in indonesia indirect effects of an aid program: how do cash transfers affect ineligibles' consumption? labour supply responses to large social transfers: longitudinal evidence from south africa e-governance, accountability, and leakage in public programmes: experimental evidence from a financial management reform in india direct and indirect effects of malawi's public works programme on food security turning a shove into a nudge? a "labeled cash transfer" for education the implementation of the productive safety nets programme and the household asset building programme in the ethiopian highlands the future in mind: aspirations and forward-looking behaviour in rural ethiopia', working paper political connections and social networks in targeted transfer programmes: evidence from rural ethiopia', economic development and cultural change job search and hiring with two-sided information frictions covid- control in low-income settings and displaced populations: what can realistically be done?', working paper group-based funeral insurance in ethiopia and tanzania grandmothers and granddaughters: old-age pensions and intrahousehold allocation in south africa the global findex database : measuring financial inclusion around the world the global findex database : measuring financial inclusion and the fintech revolution tax me, but spend wisely? sources of public finance and government accountability informal labour and the efficiency cost of social programmes: evidence from the brazilian unemployment insurance programme', nber working paper, . -naritomi subsidizing labour hoarding in recessions: the employment and welfare effects of short time work outside funding and the dynamics of participation in community associations universal basic incomes versus targeted transfers: anti-poverty programmes in developing countries are small firms labour-constrained: experimental evidence from ghana supporting the early childhood workforce at scale: community health workers in south africa wage subsidies and youth employment in south africa: evidence from a randomised control trial', working paper good intentions, bad outcomes: social policy, informality and economic growth in mexico sources of revenue and government performance: evidence from colombia building state capacity: evidence from biometric smartcards in india informal taxation how does membership in local savings groups influence the determinants of national health insurance demand? a cross-sectional study in kisumu cash transfers and community participation in public affairs: a village-level randomized controlled trial in kenya responding to crisis with digital payments for social protection: short-term measures with long-term benefits informal taxation and cash transfers: experimental evidence from kenya key: cord- -tvqpv fp authors: corrin, bryan; nicholson, andrew g. title: occupational, environmental and iatrogenic lung disease date: - - journal: pathology of the lungs doi: . /b - - - - . - sha: doc_id: cord_uid: tvqpv fp nan in practice the term is confined to the effects of mineral dust on the lungs. diseases caused by organic dusts are not included among the pneumoconioses and, in medicolegal practice at least, the presence of dust alone is insufficient to indicate pneumoconiosis: for compensation to be considered, the mineral dust must alter the structure of the lung and cause disability. the british industrial injuries advisory council defined pneumoconiosis as 'permanent alteration of lung structure due to the inhalation of mineral dust and the tissue reactions of the lung to its presence, excluding bronchitis and emphysema' . parkes recommends that cancer and asthma caused by mineral dust should also be excluded from the definition, an opinion with which we concur. to reach the lung, dust particles have to be very small. particle density and shape also affect the aerodynamic properties of dust. host factors such as airflow characteristics, airway branching patterns and airway disease also affect dust deposition. three deposition mechanisms are recognised ( fig. . . ): . inertial impaction: when air streams change direction or velocity, the inertia of the entrained particles causes them to maintain their original direction for a distance that depends upon their density and the square of their diameter. the same rules govern a car approaching a bend too fast: the car crashes into the outside of the bend. . sedimentation (gravitational settlement): under the influence of gravity, particles settle with a speed that is proportional to their density and the square of their diameter. . diffusion: very small airborne particles acquire a random motion as a result of bombardment by the surrounding gas molecules. inhaled dust particles are liable to sediment out in the alveoli if they have a diameter in the range of - µm, are roughly spherical in shape, and in density approximate to that of water. larger or denser particles impact or precipitate on the walls of the conductive airways and are rapidly removed by ciliary action. smaller particles may reach the alveoli but do not sediment so readily and many are therefore exhaled. very small particles are deposited on the walls of alveoli by diffusion but because they are so small the total amount of dust deposited in this way is insignificant compared with that deposited by sedimentation ( fig. . . ). direct measurement shows that most lung dust ( %) has a particle diameter less than . µm. fibrous dust particles behave differently. fibres over µm in length may reach the alveoli if they are very thin and remain aligned with the air stream. fibre penetration is inversely related to path length and the number of bifurcations. tall people have longer conductive airways and experience more deposition in these sites than short people who have greater alveolar deposition for the same level of exposure. slightly more dust is deposited in the right lung than the left, probably because the right main bronchus is more in line with the trachea, and is broader and shorter than the left, and carries % of the inhaled air. , dust clearance from the lung inhaled dust that settles in the conductive airways is removed within a day or two by ciliary action. only dust that reaches the alveoli is liable to cause pneumoconiosis and much of this is also removed, but the clearance rate here is much slower: many coalminers continue to expectorate mine dust years after retirement. alveolar clearance is gravity largely effected by macrophages, principally via the airways to the pharynx but also via lymphatics to the regional lymph nodes. the airway and interstitial routes interconnect at the bronchiolar level where some dust-laden macrophages leave the interstitium for the air space. this interconnection is probably the route utilised by circulating macrophages clearing other parts of the body of endogenous or exogenous particulate matter via the lung. long asbestos fibres present a particular problem to macrophage clearance. some minerals, notably chrysotile asbestos, undergo slow physicochemical dissolution in the lungs. only a small fraction of the inhaled dust gains access to the interstitium, a necessary step if it is to cause pneumoconiosis. some free dust enters through the bronchus-associated lymphoid tissue , and some is taken up by, or pierces, the alveolar epithelium ( fig. . , p. ). [ ] [ ] [ ] some of this is transported within hours to the hilar lymph nodes. so rapid is this translocation that it is thought not to involve most, the lesions are more numerous and better developed in the upper lobes than the bases but the reverse is true of asbestosis. the reasons for this are complex but undoubtedly involve the dust deposition:clearance ratio for the effect of the dust will depend upon both its amount and the duration of its stay in the lungs. there are well-recognised regional differences in the distribution and clearance of inhaled material, which in turn are dependent upon man's upright posture, the consequent gravitational forces being maximal at the apices. when standing at rest, the apices of the lungs are hardly perfused, so that lymph formation and clearance are much better at the bases. [ ] [ ] [ ] similarly, the apices are relatively less well aerated; alveoli in the lower lobes receive more air than those in the upper lobes. , the greater respiratory excursions at the bases are thought to promote macrophage mobility there. it is to be expected therefore that the bases would both receive and clear more dust than the apices, rendering it difficult to predict on theoretical grounds which parts of the lungs carry the heaviest dust burden. in fact, more dust of all types is found in the upper lobes, the part most severely affected by every type of pneumoconiosis except asbestosis. , the predilection of asbestos to affect the periphery of the lower lobes is attributed to the dangerous long asbestos fibres preponderating there. , pulmonary reactions to mineral dust the main tissue reaction to mineral dust is fibrosis. silica is highly fibrogenic and is therefore very likely to cause pneumoconiosis. carbon is non-fibrogenic and therefore, unless there are complications, coal pneumoconiosis causes little disability. tin too is harmless, and stannosis therefore unimportant, although the chest radiograph is highly abnormal because tin is very radiopaque. stannosis is one of several terms that specify pneumoconiosis due to a particular mineral, the best known being silicosis, asbestosis and anthracosis. the blackness of carbon and red-brown colour of iron give ample evidence, both naked-eye and microscopically, of the type and amount of these dusts when they are present in the lung ( fig. . . ), but other inorganic dusts may be more difficult to identify. however, a flick-out substage condenser and polaroid filters to test for refractility and birefringence respectively are useful adjuncts that are too often neglected by the histopathologist. crystalline silica is traditionally regarded as being only weakly birefringent, in contrast to silicates which generally show up brightly with simple crossed polaroid filters. however, with modern microscope lamps, if the light source is set at high intensity when using polaroid filters, both silica and silicates are birefringent. mineralogists use polarising microscopy for analysis, but only by studying large polished crystals with controlled orientation of the light. the small dust particles found in tissue sections are too small to permit analysis by this technique but it is nevertheless very useful for detecting their presence ( fig. . . ) . particle shape gives a useful indication of mineral type but appearances are sometimes deceptive: the plate-like crystals of talc are seldom observed as such, usually being viewed edge-on, when they appear to be needle-shaped. occasionally, stains can be used to identify minerals, e.g. a modified perls' reaction for inhaled iron, and irwin's aluminon stain for aluminium, but these too have largely been replaced by modern analytical techniques. ultrafine dust particles are particularly liable to be transported across the alveolar epithelium. the integrity of the alveolar epithelium is very important to dust translocation from the air spaces to the interstitium. much more dust reaches the interstitium if the epithelium is damaged. , it is widely thought that macrophages that have left the interstitium for the alveolar space never return, , but this is probably untrue. heavily laden macrophages accumulate in alveoli bordering the terminal and respiratory bronchioles, eventually filling them completely. erosion of the alveolar epithelium permits re-entry of these macrophages into the interstitium, very close to foci of bronchial mucosaassociated lymphoid tissue (malt), which are found near the terminal bronchioles. these aggregates guard the mouths of lymphatics, which commence at this point; alveoli are devoid of lymphatics. dustladen interstitial macrophages accumulate in and around the bronchial malt, which macklin therefore referred to as dust sumps. most pneumoconiotic lesions are found in the region of the dust sumps and are therefore focal. asbestosis is diffuse rather than focal because the long asbestos fibres are not readily mobilised and cannot be concentrated in the centriacinar dust sumps. this is also seen on occasion with platy non-fibrous dusts such as talc, mica, kaolinite and feldspar. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] within the dust sumps the dust particles are not static. they are constantly being freed and reingested by interstitial macrophages and, because these cells are mobile, successively inhaled dusts soon become intimately mixed. macrophages play an important role in pneumoconiosis and if the dust is fibrogenic the repeated phagocytosis of indestructible mineral particles results in constant fibroblast stimulation. the zonal distribution of pneumoconiosis pneumoconiosis affects both lungs but seldom evenly and some pneumoconioses show characteristic patterns of lung involvement. in microincineration combined with dark-field microscopy can also be used to demonstrate small particles. incombustible mineral particles that cannot be seen with bright-field or polarising microscopy are rendered visible by this technique and their position on the slide can be compared with tissue reactions evident in a serial section that has not been incinerated. microincineration has, however, also been largely replaced by modern analytical techniques that will now be considered. analytical electron microscopy is very helpful in identifying minerals, whether applied to lung digests or tissue sections. [ ] [ ] [ ] [ ] scanning electron microscopy permits the examination of thicker sections than transmission electron microscopy but does not detect very small particles. however, scanning electron microscopy allows more tissue to be examined and avoids the difficulty of cutting mineral particles with an ultramicrotome. mineral particles in a -µm thick deparaffinised section can be recognised in a scanning electron microscope set to collect the back-scattered electrons. the instrument can then be focused on points of potential interest and switched to x-ray diffraction, which provides information on crystal structure (fig. . . ) . alternatively, elemental analysis may be undertaken with either energy-dispersive or wavelength-dispersive x-ray spectroscopy. with energy-dispersive x-ray spectroscopy, all elements of atomic number above are identified, whilst with wavelength-dispersive x-ray spectroscopy the section can be scanned for one particular element. with the former technique different elements are shown graphically as individual peaks, the heights of which are proportional to the amounts of the different elements within the particle studied, thereby giving information on probable molecular formula ( fig. . . ) . thus, different silicates can be distinguished from each other and also from silica, which registers as pure silicon, oxygen (atomic number ) not being detected. the fact that the elements of low atomic number that constitute organic chemicals are not detected means that any minerals present (except beryllium, atomic number ) can be recognised easily in tissue sections. only particles can be analysed however: elements present in only molecular amounts cannot be detected by x-ray analysis. the detection of trace amounts of substances such as beryllium requires bulk chemical analysis or techniques that are not widely available such as atomic absorption spectrometry, neutron activation analysis and microprobe mass spectrometry. , the last of these techniques can also provide molecular (as opposed to elemental) analysis of organic as well as inorganic particles. another analytical technique of interest is microscopic infrared spectroscopy which provides data on the compound nature of microscopic particles in tissue sections ( fig. . . ) . micro-raman spectroscopy is also useful in this respect. some metals cause hypersensitivity, which can be identified by exposing the patient's lymphocytes to metals and measuring their reaction in vitro. radiological grading of pneumoconiosis a scheme for grading pneumoconiosis radiologically by comparison with standard radiographs has been adopted by the international labour organisation (ilo) and is widely used. small opacities (up to cm diameter) are graded by their profusion, , and indicating increasing numbers, and by their size, increasing through p, q and r if rounded and s, t and u if irregular. type p opacities are described as punctiform and measure up to . mm in diameter; larger lesions up to mm in diameter (type q) are described as micronodular or miliary; and those over mm and up to cm in diameter (type r) are described as nodular. irregular opacities cannot be sized so accurately, s, t and u indicating fine, medium and coarse respectively. large opacities (over cm diameter) are graded by their combined size, increasing through a, an opacity measuring between and cm in diameter; b, one or more opacities whose combined area does not exceed the equivalent of one-third of the area of the right lung field (when they are regrouped in the mind's eye or measured with a transparent ruler); and c, one or more opacities whose combined area exceeds one-third of the area of the right lung field (when similarly regrouped). in coalworkers, small opacities (up to cm diameter) correspond to simple coalworker's pneumoconiosis and large opacities (over cm diameter) to complicated coalworker's pneumoconiosis, which is also known as progressive massive fibrosis. silicotic lesions have been identified in the lungs of egyptian mummies, and the injurious effects on the lungs of inhaling mine dust have been recognised for more than years. as long ago as the sixteenth century in joachimsthal, bohemia (now jachymov, czech republic), diseases of miners' lungs were attributed to the dust the miners breathed. silicosis, tuberculosis and lung cancer are all now known to have been prevalent among the miners in this region, the cancer being largely attributable to the high level of radioactivity in the mines. silicosis was recognised in the uk soon after the discovery in that the addition of calcined flint to the clay from which china is made produced a finer, whiter and tougher ware. the preparation and use of this flint powder were highly dangerous, causing the condition known as potter's rot, one of the first of the many trade names by which silicosis has since been known. aluminium oxide (alumina) now provides a safe, effective substitute for flint in this industry. in it was noted that sheffield fork grinders who used a dry grindstone died early, and amongst other preventive measures it was recommended that the occupation should be confined to criminals: fortunately for them, the substitution of carborundum (silicon carbide) for sandstone was effective enough. however, silicosis still occurs in some miners, tunnellers, quarrymen, stone dressers and metal workers. silica in one form or another is used in many trades -in the manufacture of glass and pottery, in the moulds used in iron foundries, as an abrasive in grinding and sandblasting, and as a furnace lining that is refractory to high temperatures. rocks such as granite and sandstone are siliceous and their dusts are encountered in many mining and quarrying operations. in coal mining in the uk the highest incidence of the disease was in pits where the thinness of the coal seams required the removal of a large amount of siliceous rock, a process known as 'hard heading' . in south africa, silicosis causes a high mortality among the gold miners on the witwatersrand, where the metallic ore is embedded in quartz. slate is a metamorphic rock that contains both silica and silicates, and slateworkers develop both silicosis and mixed-dust pneumoconiosis. , nor are rural industries immune from the disease, particularly if ventilation is inadequate, as it is in certain african huts where stone implements are used to pound meal and the occupants develop mixed-dust pneumoconiosis. silicosis and mixed-dust pneumoconiosis have also been reported in dental technicians. desert sand is practically pure silica but the particles are generally too large to reach the lungs. however, silicosis has been reported in inhabitants of the sahara, libyan and negev deserts and those living in windy valleys high in the himalayan mountains, [ ] [ ] [ ] [ ] [ ] [ ] [ ] whilst in california the inhalation of dust raised from earth has led to silicate pneumoconiosis in farm workers, horses and a variety of zoo animals. the silica in rocks such as granite, slate and sandstone is largely in the form of quartz and this is therefore the type of silica encountered in most of the industries considered above. cristobalite and tridymite, which are possibly even more fibrogenic than quartz, are more likely to be encountered in the ceramic, refractory and diatomaceous earth industries where processing involves high temperatures. many workers with silicosis are asymptomatic. as a general rule, exposure to silica dust extends over many years, often or more, before the symptoms of silicosis first appear: by the time the disease becomes overt clinically, much irreparable damage has been inflicted on the lungs. the initial symptoms are cough and breathlessness. from then onwards, respiratory disability progresses, even if the patient is no longer exposed to silica dust. ultimately, there may be distressing dyspnoea with even the slightest exercise. silicosis sometimes develops more rapidly, perhaps within a year or so of first exposure. such 'acute silicosis' was observed in the scouring powder industry in the s when these cleansing agents consisted of ground sandstone mixed with a little soap and washing soda. , the additives were considered to have rendered the silica in the sandstone more dangerous but it is possible that the rapidity of onset of the disease merely reflected the intensity of the dust cloud to which the packers were exposed. confusingly, the term 'acute silicosis' has since been applied to a further effect of heavy dust exposure in tunnellers, sand blasters and silica flour workers, namely pulmonary alveolar lipoproteinosis (see below), , whilst the terms 'accelerated silicosis' or 'cellular phase silicosis' have been substituted for 'acute silicosis' in referring to the rapid development of early cellular lesions. , the time from first exposure to the development of symptoms (the latency period) is inversely proportional to the exposure level. however, it is evident that a certain amount of silica can be tolerated in the lungs without fibrosis developing, indicating either a time factor in the pathogenetic process or a threshold dust load that has to be reached before fibrosis develops. silica particles that are roughly spherical in shape and of a diameter in the range of - µm sediment out in the alveoli and are concentrated within macrophages at macklin's dust sumps, as explained previously (see p. ). early lesions, as seen in so-called accelerated or cellular phase silicosis, consist of collections of macrophages separated by only an occasional wisp of collagen. the early lesions have been likened to granulomas and on occasion have been mistaken for langerhans cell histiocytosis or a storage disorder, but langerhans cells are scanty and the histiocytes contain dust particles rather than accumulated lipid or polysaccharide. the macrophages of the early lesion are gradually replaced by fibroblasts and collagen is laid down in a characteristic pattern. the mature silicotic nodule is largely acellular and consists of hyaline collagen arranged in a whorled pattern, the whole lesion being well demarcated ( fig. . . ) and sometimes calcified. small numbers of birefringent crystals are generally evident within the nodules when polarising filters are used, but these mainly represent silicates such as mica and talc, inhaled with the silica. silica particles are generally considered to be only weakly birefringent, but fairly strong birefringence is evident in strong light (see above). silicotic nodules develop first in the hilar lymph nodes and are generally better developed there than in the lungs. [ ] [ ] [ ] indeed, silicotic nodules are occasionally found in the hilar lymph nodes of persons who have no occupational history of exposure to silica and whose lungs are free of such lesions, the silica in the nodes being presumed to represent inhaled particles derived from quartz-rich soil. severely affected lymph nodes often calcify peripherally, giving a characteristic eggshell-like radiographic pattern. this is sometimes the only radiological abnormality. such enlarged lymph nodes may occasionally press upon and obstruct adjacent large bronchi or result in a left recurrent laryngeal nerve palsy, so simulating malignancy. sometimes the nodules develop within the walls of major bronchi, occasionally causing a middle-lobe syndrome (see p. ). silicotic nodules are also found along the lines of the pleural lymphatics , where they have been likened to drops of candle wax on the visceral pleura. very rarely, silica-induced fibrosis is more pronounced in the pleura than in the lungs. lung tissue between the nodules is often quite normal and not until the process is very advanced is there any disability ( fig. . . b). in severe cases large masses of fibrous tissue are formed, which may undergo central necrosis and cavitation ( fig. . . ). on close inspection it is evident that these consist of conglomerations of many silicotic nodules closely packed together. in such severe cases cor pulmonale develops. occasionally, silicotic nodules develop in the abdominal as well as the thoracic lymph nodes, and in the liver, spleen, peritoneum and bone marrow. [ ] [ ] [ ] [ ] [ ] in about % of cases, the typical pulmonary nodules that predominantly affect the upper lobes are accompanied by diffuse fibrosis that is maximal in the lower lobes. , , [ ] [ ] [ ] the latter may show 'honeycombing' and closely resemble idiopathic pulmonary fibrosis. the association is too common to be explained by chance and the diffuse fibrosis is therefore regarded as a further manifestation of the pneumoconiosis, possibly due to an interaction between the dust and the immunological factors discussed below. the pathogenesis of silicosis has excited much interest and many different theories have been advanced over the years. an early theory held that the hardness of the silica was responsible, but this was discounted by the observation that silicon carbide (carborundum) is harder than silica but is non-fibrogenic. theories based on the piezoelectric property and on the solubility of silica were successively abandoned although the latter had a long period of popularity. it gained support from kettle's experiments which showed that fibrosis developed about chambers placed in an animal's peritoneal cavity if the chambers contained silica powder sealed in by a collodion membrane through which solutes such as silicic acid could pass. however, it was later shown that the pores in a collodion membrane are quite irregular in size and when the experiments were repeated using chambers guarded by millipore membranes, no fibrosis developed, despite solutes being able to diffuse out. the solubility theory also fails to take account of the differing fibrogenicity of the various forms of silica despite them being of similar solubility. furthermore, if the outer, more soluble layer of the particles is removed by etching, fibrogenicity is increased although solubility is decreased. in line with this, freshly fractured crystalline silica is more pathogenic in every respect than its aged equivalent, which may partly explain the severity of silicosis in trades such as sandblasting. these observations suggest that the fibrogenicity of silica is connected with its surface configuration. it is now known that uptake of the silica by macrophages is necessary for silicosis to develop. if silica and macrophages are enclosed together in peritoneal millipore chambers, a soluble product of the macrophages diffuses out and causes fibrosis. this observation led to the realisation that the fibrogenicity of the various crystalline forms of silica correlated well with their toxicity to macrophages and for a time macrophage death was thought to be necessary. it is now considered that before the macrophages are killed by the ingested silica, they are stimulated to secrete factors that both damage other con stituents of the lung and promote fibrosis. [ ] [ ] [ ] [ ] [ ] [ ] [ ] transforming growth factor-β is one fibrogenic factor that has been implicated in the pathogenesis of silicosis. [ ] [ ] [ ] toxic damage to macrophages is due to silica particles injuring the phagolysosomal membranes, so releasing acid hydrolases into the cytoplasm. it is important in the pathogenesis of the disease indirectly because when the macrophage crumbles, the silica particles are taken up by fresh macrophages and the fibrogenic process continues. it has been suggested that early involvement of the hilar lymph nodes in the fibrogenic process promotes the development of the disease in the lung by delaying dust clearance. immunological factors have been implicated in the pathogenesis of silicosis because many patients with silicosis have polyclonal hypergammaglobulinaemia, rheumatoid factor or antinuclear antibodies, and because there is a well-recognised association between autoimmune diseases such as systemic sclerosis and rheumatoid disease and exposure to silica. , [ ] [ ] [ ] [ ] the relation of immunity to dust exposure appears to be a reciprocal one: on the one hand, the presence of dust results in rheumatoid lesions in the lungs being more florid (see caplan's syndrome, p. ), whilst on the other, non-specific immunisation of rabbits with horse serum results in experimental silicotic lesions being larger and more collagenous. it is doubtful whether pneumoconiosis and autoimmune disease play a causative role in each other but one seems to aggravate the other and may lead to its earlier development. one of the commonest and most feared complications of silicosis is chronic respiratory tuberculosis. once this infection has been added to the silicosis, the prognosis rapidly worsens. it is thought that in the presence of silica, the tubercle bacilli proliferate more rapidly because the ingested silica particles damage phagolysosomal membranes and thereby interfere with the defensive activity of the macrophages. the synergistic action of silica dust has long been held responsible for the inordinately high incidence of respiratory tuberculosis in mining communities. many former south african gold miners now have acquired immunodeficiency syndrome (aids) as well as silicosis and tuberculosis has consequently reached almost epidemic proportions amongst these men. phagocyte damage by ingested dust particles may also cause some cases of chronic necrotising aspergillosis complicating pneumoconiosis. a series of studies suggesting that there might be a link between silica inhalation and lung cancer was reviewed by the international agency for research on cancer in , leading to the conclusion that the evidence for carcinogenicity of crystalline silica in experimental animals was sufficient, while in humans it was limited. subsequent epidemiological publications were reviewed in , when it was concluded that the epidemiological evidence linking exposure to silica to the risk of lung cancer had become somewhat stronger but that in the absence of lung fibrosis remained scanty. the pathological evidence in humans is also weak in that premalignant changes around silicotic nodules are seldom evident. nevertheless, on this rather insubstantial evidence, lung cancer in the presence of silicosis (but not coal or mixed-dust pneumoconiosis) has been accepted as a prescribed industrial disease in the uk since . some subsequent studies have provided support for this decision. in contrast to the sparse data on classic silicosis, the evidence linking carcinoma of the lung to the rare diffuse pattern of fibrosis attributed to silica and mixed dusts is much stronger and appears incontrovertible. , alveolar lipoproteinosis in response to heavy dust exposure a further complication of exposure to silica is the development of alveolar lipoproteinosis (see p. ). , , , very heavy experimental exposure to silica, and indeed other dusts, stimulates hypersecretion of alveolar surfactant to such an extent that the normal clearance mechanism is overwhelmed. [ ] [ ] [ ] [ ] [ ] [ ] [ ] alveolar macrophages are enlarged by numerous phagolysosomes distended by lamellar bodies that represent ingested surfactant. the alveoli are filled by such cells and, having a foamy cytoplasm, they produce the appearances of endogenous lipid pneumonia, similar to that more usually encountered as part of an obstructive pneumonitis distal to a bronchial tumour. the macrophages gradually disintegrate and the free denatured surfactant slowly becomes compacted, during which time its staining with both eosin and the periodic acid-schiff reagents intensifies until the appearances are finally those of alveolar lipoproteinosis. this process prevents the aggregation and concentration of the dust in the usual foci and thereby hinders the development of silicosis. lipoproteinosis and silicosis may be seen in conjunction but, more often, different areas of the lung show one or the other. the lipoproteinosis has its own severe impact on lung function, but, unlike silicosis, is potentially reversible (by massive alveolar lavage). occasional patients exposed to silica develop renal disease. [ ] [ ] [ ] [ ] two mechanisms appear to operate. first, translocation of silica particles from the lungs leads to their deposition in the renal interstitium with resultant nephrotoxity. second, silica stimulates an autoimmune response characterised by the formation of various antibodies, notably rheumatoid factor and antinuclear antibodies, which leads to the development of immune complex-mediated glomerulonephritis. , amorphous silica manmade submicron forms of silica, variously known as amorphous, vitreous, colloidal, synthetic or precipitated silica, are widely used in industry. they consist of pure non-crystalline silicon dioxide. particle size ranges from to nm but aggregates of the particles measure from to µm. industrial surveys suggest that inhalation of such dust is harmless, observations that are in accord with the results of animal experiments. an amorphous silica is the principal component of the fossilised remains of diatoms that constitute the sedimentary rock, diatomite ( fig. . . ). this is generally obtained by open-cast mining, following which the rock is crushed and calcined. the calcined product is used in filters, insulation material and as a filler. being amorphous, the silica in diatomite is harmless, but calcining (> °c) results in its conversion to crystalline forms of silica. diatomaceous earth pneumoconiosis is unusual and its risk appears to be related to the amount of cristobalite and tridymite (two forms of crystalline silica) produced in the calcining process. the silicates are complex compounds in which silicon and oxygen form an anion combined with cations such as aluminium and magnesium: talc, for example, is a hydrated magnesium silicate with the formula mg si o (oh) . silicates include fibrous forms (asbestos and the zeolites), plate-like forms (talc and mica) and clays (kaolinite and fuller's earth). in histological sections, the platy talc and mica particles are generally cut tangentially and therefore appear needleshaped (see fig. . . ). they are strongly birefringent whereas the clays are only weakly so. talc particles in the lung exceeding µm in length should arouse suspicion of intravenous drug abuse. of the fibrous silicates, zeolite is used as a building material in certain communities, notably in central turkey. pneumoconiosis is not a problem but zeolites are of medical interest because, like asbestos, they present a mesothelioma risk. asbestos is dealt with separately (see below). pneumoconiosis has been described with various non-fibrous silicates, notably in the rubber industry, which uses talc and, less commonly, mica as lubricants. other occupations posing a risk include the extraction of kaolinite from china clay (kaolin), , , and in the open-cast and underground mining of fuller's earth (montmorillonite, bentonite and attapulgite clays, which were originally used in 'fulling' (degreasing) wool). , however, all these substances are commonly contaminated with silica, asbestos or both, and it has been questioned whether in pure state they are at all fibrogenic. the modifying effect of inert substances such as iron on that of silica is well known (see mixed-dust pneumoconiosis, below) and it has been suggested that talc, mica and fuller's earth act in a similar way in regard to their more fibrogenic contaminants, the pneumoconioses attributed to them in reality representing mixed-dust pneumoconiosis or asbestosis. contrary evidence comes from reports of pulmonary fibrosis in persons heavily exposed to pure talc, mica or kaolin. all these silicates are evident in the tissues as plate-like birefringent crystals which often provoke a foreign-body giant cell reaction (see fig. . . ) and may result in fibrotic nodules. large focal lesions resembling the progressive massive fibrosis of coalworkers may be produced, and also a diffuse 'asbestosis-like' form of pneumoconiosis, the latter attributed to poor macrophage mobilisation of the plate-like particles. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] it would appear therefore that silicates are indeed fibrogenic if enough is inhaled; they appear to vary in fibrogenicity but in all cases they are less fibrogenic than silica. inert dusts are non-fibrogenic and therefore of little clinical consequence, although elements of high atomic number can give rise to a striking chest radiograph. it should be noted however that inert or lowly fibrogenic materials may be associated with substances of medical importance, for example, kaolin, bentonite and barytes (barite) may all be contaminated with silica , , and talc may be contaminated with asbestos. the best known of the inhaled inert mineral dusts is carbon while, of the remainder, iron is the most widespread. others include tin and barium. with all these dusts, particles retained in the lung are gathered at macklin's dust sumps by heavily laden macrophages which are lightly bound together there by a few reticulin fibres. collagen is not formed and the worker suffers no ill-effects. the lungs take on the colour of the dust and in siderosis assume a deep brick-red hue. carbon deposition is commonly found in the lungs, particularly those of city dwellers and tobacco smokers. it is also the principal constituent of coal, which is dealt with separately below, and large amounts of pure carbon may be inhaled by workers involved in the manufacture of carbon black, carbon electrodes and charcoal. [ ] [ ] [ ] [ ] although carbon is regarded as being non-fibrogenic, the very heavy lung burdens encountered in industries such as these may lead to the complicated form of pneumonconiosis known as progressive massive fibrosis that is more commonly encountered in coal workers (see p. ). heavy pure carbon deposition may also be acquired domestically when wood is burnt in buildings devoid of a chimney, so-called 'hut lung', a term that is also applied to the domestic acquisition of carbon mixed with silica or silicates, resulting in forms of mixeddust pneumoconiosis. , , anthracofibrosis is a term introduced by chinese bronchoscopists for bronchial stenosis or obliteration associated with carbon pigmentation of the mucosa. although the original description incriminated tuberculosis, mixtures of various mineral dusts acquired at work or domestically are a more likely cause. [ ] [ ] [ ] [ ] iron dust in the lungs was first described by zenker in , when he also introduced the terms siderosis and pneumonokoniosis. zenker was describing a woman who coloured paper with iron oxide powder ('rouge'), a substance which is still encountered by some workers engaged in polishing silver, glass, stone and cutlery. siderosis is also found in welders, iron foundry fettlers, steel workers, boiler scalers and haematite miners and crushers. iron dust particles are reddish-brown but in the lung may be masked by carbon : when evident, or revealed by microincineration, they resemble haemosiderin and generally give a positive perls' reaction, but particularly with haematite, heat ( - o c) and concentrated ( n) hydrochloric acid may be necessary. haematite miners in both the uk (cumbria) and france (lorraine) have an increased risk of bronchial carcinoma, but radon gas rather than haematite is the suspected carcinogen. radon is a decay product of uranium. minute amounts are present in all rocks but local concentrations occur and these are liable to build up in mines if ventilation is limited. silver, as well as iron, is found in the lungs of silver polishers, where it stains elastin in alveolar walls and pulmonary vessels grey. such argyrosiderosis is as harmless as siderosis. tin miners are subject to silicosis but not stannosis because the ore, which is found in association with siliceous rocks, contains only low concentrations of the metal. tin smelters, on the other hand, and factory workers exposed to high concentrations of tin dust or fume, are liable to inhale large amounts of this inert metal and develop the striking chest radiograph of stannosis. they remain in good health however for tin is completely non-fibrogenic. tin particles in the lung resemble carbon but are strongly birefringent and remain after microincineration: microprobe analysis provides positive identification. other inert dusts include barium, which also has a high atomic number and is therefore radiopaque, and minerals of low radiodensity such as limestone, marble and cement (all chiefly composed of calcium carbonate) and gypsum (hydrated calcium sulphate). however, the extraction of barium ore (almost entirely in the form of barium sulphate, which is known as barytes in europe and barite in the usa) may entail exposure to silica and silicates. pure baritosis resembles stannosis and siderosis. the term 'mixed-dust pneumoconiosis' refers to the changes brought about by inhaling a mixture of silica and some other less fibrogenic substance such as iron, carbon, kaolin or mica. , , [ ] [ ] [ ] the proportion of silica is usually less than %. typical occupations include foundry work and welding and the mining of coal, haematite, slate, shale and china clay. the action of the silica is modified and, although fibrotic nodules are formed, they lack the well-demarcated outline and concentric pattern of classic silicosis. the lesions are found in a centriacinar position and are stellate in outline with adjacent scar emphysema. they are firm and generally measure no more than mm in diameter. they closely resemble the fibrotic nodules of simple coal pneumoconiosis (see below). confluent lesions also occur on occasions. these resemble the progressive massive fibrosis of coalworkers and appear to represent a single large lesion rather than a conglomeration of individual nodules, as in advanced silicosis. abundant dust is generally evident in lesions of all sizes; this consists of black carbon or brown iron mixed with crystals of varying degrees of birefringence, silicates generally being strongly birefringent and silica weakly so. calcification is unusual. mixed-dust pneumoconiosis carries an increased risk of pulmonary tuberculosis, but not to the same degree as silicosis. in some cases the stellate nodules are accompanied by diffuse fibrosis, as in silicosis and again possibly involving interactions between the dust and immunological factors. involvement of the bronchi with consequent stenosis (so-called anthracofibrosis) is described above. the term 'anthracosis' was initially applied to changes observed in a coalminer's lung but is now often extended to include the common carbon pigmentation of city dwellers' lungs, and the term 'coal pneumoconiosis' is more appropriate to a special form of pneumoconiosis to which coalworkers are subject, particularly those who work underground. the principal constituent of coal, carbon, is non-fibrogenic, so suspicion has naturally fallen on the ash content of mine dust, some of which derives from the coal, some from adjacent rock strata and some from stone dust laid in the roadways to minimise the risk of coal dust explosions. coal itself appears to be the responsible agent because coal-trimmers, working in the docks and not exposed to rock dust, also develop the disease. coalminers encountering siliceous rock are, of course, also liable to develop silicosis like other underground workers. coal consists largely of elemental carbon, oxygen and hydrogen with traces of iron ore and clays such kaolinite, muscovite and illite, but no silica. the mineral content varies with the type and rank (calorific value) of the coal. all coal derives from peat, the youngest type being lignite and the oldest anthracite, with bituminous (house) coal in between. as it ages, the oxygen and mineral constituents diminish and the coal hardens. lignite is soft and said to be of low rank, anthracite hard and of high rank, with bituminous coal intermediate. although high-rank coal is of low mineral content, its dust is more toxic to macrophages in vitro and is cleared more slowly in vivo. this observation may explain why, in the uk, high-rank coal is associated with a higher prevalence of coal pneumoconiosis. the low mineral content of high-rank coal is reflected in the mineral content of the lungs of those who hew such coal in the uk, but in the ruhr, in germany, and in pennsylvania, in the usa, anthracite miners' lungs contain more silica than those who hew bituminous coal, the silica presumably deriving from other sources. not surprisingly, the presence of silica is reflected in the tissue reaction to the inhaled dust, resulting in a more fibrotic reaction very analogous to mixed-dust pneumoconiosis. a spectrum of changes is therefore encountered in coalminers' lungs, ranging from coal pneumoconiosis through mixeddust pneumoconiosis to silicosis; the findings in any individual depend upon the nature of the coal being mined and the type of work undertaken. in high-rank british collieries the development of coal pneumoconiosis appears to depend on the total mass of dust inhaled, whereas in low-rank british collieries the mineral content of the lung dust appears to be more important. this may explain apparently contrary data drawn from different coalfields -data based on coals of different composition that are not strictly comparable. some workers have stressed the importance of silica in the dust whereas others, particularly in the high-rank coalfields of south wales, have been unable to detect any association between silica and the level of pneumoconiosis. both findings may be correct, but only for the particular group of miners examined in each case. the lesions of coal pneumoconiosis are generally focal and fall into one or other of two major types, simple and complicated, depending upon whether the lesions measure up to or over cm; simple corresponds to categories - of the ilo grading system (see p. ) and complicated, which is also known as progressive massive fibrosis, to ilo categories a-c. more diffuse interstitial fibrosis has been reported in about % of welsh and west virginian coalminers, usually involving those carrying a particularly heavy dust burden; it runs a more benign course than non-occupational interstitial fibrosis (idiopathic pulmonary fibrosis). similar findings have been reported from france. simple coal pneumoconiosis consists of focal dust pigmentation of the lungs, which may be associated with a little fibrosis and varying degrees of emphysema. its clinical effects are relatively minor. some degree of black pigmentation (anthracosis) of the lungs is common in the general urban population, especially in industrial areas, but much denser pigmentation is seen in coalminers, whose lungs at necropsy are black or slate-grey. black pigment is evident in the visceral pleura along the lines of the lymphatics and on the cut surface where it outlines the interlobular septa and is concentrated in macklin's centriacinar dust sumps ( fig. . . ). the dust is generally more plentiful in the upper parts of the lungs and in the hilar lymph nodes, possibly due to poorer perfusion and consequently poorer lymphatic drainage there (see p. ). two forms of coal dust foci are recognised, macules and nodules, the former being soft and impalpable and the latter hard due to substantial amounts of collagen. both lesions are typically stellate but the more fibrotic the nodules, the more rounded they become, until it is difficult to distinguish them macroscopically from those of silicosis. in these circumstances reliance has to be placed on the whorled pattern of the collagen that is evident microscopically in silicosis. the stellate nodules are analogous to those seen in mixed-dust pneumoconiosis caused by mixtures of silica and inert dusts other than carbon (see above). with polarising filters, small numbers of birefringent crystals may be seen in both macules and nodules, usually representing mica or kaolinite derived from rock that bordered the coal. macules consist of closely packed dust particles, free or within heavily laden macrophages, so that the lesion appears black throughout ( fig. . . ). appropriate stains show that the dust-laden macrophages and free dust are lightly bound by reticulin. very little collagen is evident. although striking in their appearance, dust macules are thought to have little effect on lung function. nodules contain substantial amounts of collagen and are thought to have an adverse, but limited, effect on respiration. they vary from a heavily pigmented, stellate lesion, which apart from its collagen content resembles the dust macule ( fig. . . ), to one that is less pigmented and more circumscribed. the stellate, heavily pigmented type of nodule is seen in lungs that have a relatively low ash content whilst the more rounded and less pigmented nodule is seen in lungs with relatively high ash loads. radiologically (see p. ), p-type opacities correspond to macules, q-type opacities to the stellate nodules that resemble those of mixeddust pneumoconiosis and r-type opacities to the rounded nodules that resemble those of silicosis. , thus, the radiological changes of simple coalworker's pneumoconiosis are due to the dust and the small amount of collagen present and do not reflect any emphysema that may also be present. however, pulmonary dust foci are often associated with emphysema ( fig. . . ) and the severity of the emphysema appears to correlate with the dust load. the prevalence of chronic bronchitis and emphysema is high in the coal industry and it has long been debated whether occupation or cigarette smoking is the major factor contributing to emphysema in coalminers. [ ] [ ] [ ] [ ] as well as mineral dust, nitrous fumes from shot-firing form another occupational hazard of coal mining. heppleston made a special study of the emphysema found in coalminers, claiming that it differs from centriacinar emphysema, as seen in smokers in the general population, and attributing it to the dust. he introduced the term 'focal emphysema of coalworkers' to describe this special process. others find it very difficult to identify any convincing difference between the emphysema of coalworkers and that encountered outside the industry but heppleston based his claims on the study of serial sections. by this means he showed that, although both forms affect respiratory bronchioles, the focal emphysema of coalworkers affects more proximal orders of these airways and is not associated with the bronchiolitis seen with centriacinar emphysema. furthermore, focal emphysema is a dilatation lesion whereas coniosis, also known as progressive massive fibrosis, can have very serious consequences. particularly when the lesions are large, it is associated with productive cough, breathlessness, significant impairment of lung function and premature death. the major factor accounting for the development of progressive massive fibrosis appears to be the sheer bulk of coal dust in the lung, rather than coal rank or the silica content of the mine dust. progressive massive fibrosis has occasionally been recorded in dockers loading silica-free coal into the holds of ships and in workers exposed to pure carbon in the manufacture of carbon black and carbon electrodes. [ ] [ ] [ ] progressive massive fibrosis is characterised by large (over cm) black masses, situated anywhere in the lungs but most common in the upper lobes. the lesions may be solitary or multiple and very large, occupying most of the lobe and even crossing an interlobar fissure to involve an adjacent lobe (figs . . b, . . ). they cut fairly easily, often with the release from a central cavity of black fluid flecked by cholesterol crystals. for many years it was believed that the condition was the result of synergism between mycobacterial infection and dust but the failure of the attack rate to decrease as tuberculosis declined negated this view. today, more emphasis is placed on total dust load for the lesions tend to affect lungs that carry an unduly heavy dust burden. if the remainder of the lung shows little evidence of dust accumulation, the possibility of the masses representing caplantype lesions (see below) should be considered. centriacinar emphysema involves destruction of adjacent alveolar walls. by definition, therefore, focal emphysema is not a true emphysema at all (see p. ). however, it has been shown that mineral dusts cause elastin and collagen breakdown in the rat lung. focal emphysema may progress to the destructive centriacinar form and this has strengthened claims that mine dust plays a causal role in centriacinar emphysema. , [ ] [ ] [ ] [ ] [ ] [ ] in the uk, these claims have been accepted and chronic bronchitis and emphysema in coalminers and metal production workers have been accepted as prescribed industrial diseases since . in germany too, chronic obstructive pulmonary disease is now compensatable as an occupational disease. the conditions for compensation in the uk were initially: • underground coal mining for a minimum of years in aggregate • forced expiratory volume in second at least litre below that expected or less than litre in total • radiological category of at least / . however the last of these criteria has now been dropped. the inclusion of a time element and the omission of some estimate of dust load (such as radiological category) have been criticised, with some justification. as with lung cancer caused by chromates benefit is paid irrespective of smoking habits. whereas simple coal pneumoconiosis, particularly the macular variety, has little effect on lung function, complicated coal pneumo- microscopically, the lesions consist of dust and connective tissue intermixed in a random fashion. central necrosis and cavitation commonly occur. the necrosis is thought to be ischaemic. it is amorphous or finely granular, and eosinophilic apart from abundant dust particles and cholesterol crystal clefts. the fibrotic component in a complicated pneumoconiotic lesion is rich in fibronectin, with collagen only more abundant at the periphery. two types of progressive massive fibrosis are recognisable, corresponding to the two types of nodule described in simple coal pneumoconiosis. the first appears to have arisen by enlargement of a single nodule, whereas the second is a conglomeration of individual lesions, each of which corresponds to the more circumscribed type of nodule seen in simple coal pneumoconiosis. the ash content of the lungs bearing these two types of progressive massive fibrosis varies in the same way as with the two types of simple pneumoconiotic nodules, the enlarged single lesion being found in lungs with a relatively low ash content, and the conglomerate lesion in lungs with a relatively high ash content. the second type resembles the conglomerate nodules of large silicotic lesions but lacks the characteristic whorled pattern of the latter. the diffuse interstitial fibrosis found in a minority of coalworkers is associated with heavy dust deposition. it may progress to honeycombing but, as with the focal forms and unlike idiopathic interstitial fibrosis, it is better developed in the upper zones, the reasons for which are discussed above (see the zonal distribution of pneumoconiosis, p. ). the pathogenesis of coal pneumoconiosis has much in common with that of silicosis, and indeed many other pneumoconioses. it involves the promotion of fibrogenic factor synthesis and release by cells phagocytosing the inhaled dust. several such factors have now been identified, the degree of fibrosis produced varying with the amount of dust inhaled and the ability of its constituents to promote the production of the responsible cytokines. these include plateletderived growth factor, insulin-like growth factors and , transforming growth factor-β and tumour necrosis factor-α. , , as with other minerals, the indestructability of the dust perpetuates the process. as in silicosis, immunological factors appear to be involved, for there is an increased prevalence of rheumatoid arthritis and of circulating autoantibodies [ ] [ ] [ ] in miners with coal pneumoconiosis. rheumatoid factor has also been demonstrated within the lung lesions. these abnormalities are generally more pronounced in miners with complicated pneumoconiosis but are also found in those with the simple variety. it is also possibly pertinent to the immunological basis of coal pneumoconiosis that some of the pulmonary manifestations of rheumatoid disease are more pronounced in coalminers. this was first pointed out by caplan and will be considered next. caplan described distinctive radiographic opacities in the lungs of coalminers with rheumatoid disease, and it is now recognised that similar lesions may develop in rheumatoid patients exposed to siliceous dusts. the development of such rheumatoid pneumoconiosis does not correlate with the extrapulmonary or serological activity of the rheumatoid process. nor is there a strong relation to dust burden: caplan lesions are characteristically seen in chest radiographs that show little evidence of simple coal pneumoconiosis. pathologists recognise the lesions as particularly large necrobiotic nodules similar to those seen in rheumatoid patients who are not exposed to dust (fig. . . ) . however, because of their large size (up to cm diameter) they may be confused with progressive massive fibrosis undergoing central ischaemic necrosis (see above) or silicosis complicated by caseating tuberculosis. such errors will be less likely if the radiological evolution of the lesions is considered for they tend to cavitate and undergo rapid remission, only to be succeeded by others. they are also well demarcated radiologically. pathologically, they resemble rheumatoid nodules in showing peripheral palisading but differ in their large size and the presence of dust. the dust accumulates in circumferential bands or arcs within the necrotic centres of the lesion (fig. . . ), an arrangement that suggests periodic episodes of inflammatory activity. caplan lesions differ from tuberculosis in lacking satellite lesions and tubercle bacilli, and from progressive massive fibrosis in showing characteristic bands of dust pigmentation (table . asbestosis is defined as diffuse interstitial fibrosis of the lung caused by exposure to asbestos dust. , it does not cover asbestos-induced carcinoma of the lung or asbestos-induced pleural disease. the development of asbestosis depends on the presence of fairly large dust burdens: this is in contrast to mesothelioma and other forms of asbestos-induced pleural disease, which, although also dose-related, occur following the inhalation of far smaller amounts of asbestos dust. asbestos is a generic term for more than naturally occurring fibrous silicates, fibre being defined as an elongated particle with a length-tobreadth (aspect) ratio of at least . asbestos fibres have a high aspect ratio, generally over . based on their physical configuration they can be divided into two major groups, serpentine and amphibole. the physical dimensions and configuration of asbestos fibres are strongly linked to their pathogenicity. chrysotile (white asbestos) is the only important serpentine form. it accounts for most of the world production of asbestos of all types ( being a serpentine mineral, chrysotile consists of long, curly fibres that can be carded, spun and woven like cotton ( fig. . . ). the curly chrysotile fibres are carried into the lungs less readily than the straight amphibole asbestos fibres, and once there undergo physicochemical dissolution and are cleared more readily. they readily fragment into short particles that are easily ingested by macrophages and in the acidic environment of the macrophage phagolysosome they are particularly unstable. the half-life of chrysotile in the lungs is estimated to be in the order of only a few months. , not surprisingly therefore chrysotile is the least harmful type of asbestos in respect of all forms of asbestos-induced pleuropulmonary disease. [ ] [ ] [ ] it may nevertheless cause pulmonary fibrosis if sufficient is inhaled. , in contrast to chrysotile, amphibole forms of asbestos consist of straight rigid fibres that are stable within the lung. they do not fragment, they are insensitive to chemical attack and their clearance halflives are in the order of decades rather than months. the main amphibole forms of asbestos of commercial importance are crocidolite (blue asbestos) and amosite (brown asbestos). crocidolite, reputedly the most dangerous in regard to all forms of asbestos-related disease, was formerly mined in western australia (wittenoom) and south africa (cape province and the transvaal); it was the principal amphibole used in the uk. amosite, the name of which derives from the acronym for the former asbestos mines of south africa company in the transvaal, was the principal amphibole used in north america. amphiboles are no longer imported by the developed countries but much remains in old lagging and presents a considerable dust hazard when this is removed. tremolite, a further amphibole asbestos, contaminates quebec chrysotile deposits, montana vermiculite and many forms of commercial (non-cosmetic) talc and is responsible for much of the asbestos-related disease in chrysotile miners and millers. another amphibole asbestos, anthophyllite, was formerly mined in finland. it causes pleural plaques (see p. ) but not lung disease, possibly because its fibres are relatively thick ( fig. . . ) . erionite is a zeolite rather than a type of asbestos but is comparable in form to amphibole asbestos and is also biopersistent. it is found . these coated structures are termed 'asbestos bodies' . because other fibres may gain a similar coat, the non-specific term 'ferruginous body' has been advocated. however, coated carbon fibres (so-called coal bodies) are easily recognised as such by their black core. in practice, ferruginous bodies with the appearance of asbestos bodies almost always prove to have an asbestos core. , long fibres are more likely to be coated than short ones, which are cleared more quickly: in one study few fibres less than µm in length were coated and few fibres over µm in length were uncoated. amphiboles form bodies more readily than chrysotile. a comparison of light and electron microscopic fibre counts found that . % of chrysotile, % of crocidolite and . % of amosite formed bodies. nevertheless, sufficient chrysotile fibres are coated to permit recognition of asbestosis by standard histological criteria (diffuse fibrosis and asbestos bodies), even if chrysotile is the only asbestos present. despite the biodegradability of chrysotile, asbestos body numbers do not materially diminish with time. very occasionally however a patient with diffuse pulmonary fibrosis and a history of asbestos exposure has no evident asbestos bodies but analysis shows a fibre burden within the range found in asbestosis, justifying fibre analysis in such cases. a there is evidence that alveolar macrophages are involved in the coating of asbestos fibres to form asbestos bodies and that the bodies are less harmful to the macrophages than uncoated fibres. asbestos bodies give a prussian blue reaction for iron when stained by perls' method and their yellow-brown colour makes them easily recognisable in unstained films of sputum or in unstained histological sections. sections may be cut µm thick to increase the yield and help identify bodies that lie at an angle to the microtome blade. there is a good correlation between the numbers of asbestos bodies seen in lung sections and those in tissue digests. , the bodies may be found singly or in irregular clumps or stellate clusters. they are unevenly distributed but in well-established asbestosis they are easily found. if they are not evident, asbestos burden may be assessed quantitatively in tissue digests (see below). their presence in lung tissue, sputum or bronchoalveolar lavage fluid merely confirms exposure, not the presence of disease. however, the number of asbestos bodies in lavage fluid correlates well with lung asbestos burden , and the number in sputum correlates with the duration and intensity of exposure. [ ] [ ] [ ] fibre counts , , [ ] [ ] [ ] [ ] [ ] quantitation is desirable in certain circumstances (box . . ), in which case it is best effected on -cm blocks of fixed or fresh lung tissue obtained from three different sites, avoiding tumour and thickened pleura. the tissue blocks are digested with caustic soda or bleach, following which the fibres may be collected on a millipore membrane or viewed in suspension in a red blood cell-counting chamber. if phase contrast optics are used both coated and uncoated fibres can be assessed. alternatively, dark ground illumination can be used to demonstrate uncoated fibres. however, electron microscopy is to be preferred as it detects far more fibres than are visible by light microscopy and can also provide information on fibre type. it is important that the laboratory is well practised in fibre analysis and has established its own control range for the general population as well as asbestosis as most lungs contain some asbestos. ambient fibres are generally shorter than µm and some workers therefore confine their counts to fibres that are at least as long as this. justification for this comes from animal experiments demonstrating that long fibres cause more inflammation, chromosomal damage, fibrosis, lung tumours and mesotheliomas than short fibres, [ ] [ ] [ ] [ ] and from studies in humans suggesting that long fibres in parts of central turkey where it causes both mesothelioma and a pattern of interstitial pulmonary fibrosis that is comparable to asbestosis. , asbestos use and exposure exposure to asbestos occurs in countries where it is extracted ( asbestos is used particularly for fireproofing, in heat and sound insulation and for strengthening plastics and cement. thus, unless adequate precautions are taken, exposure is experienced by dockers unloading asbestos in the close confines of a ship's hold, by thermal insulation workers (laggers and strippers) in shipyards, power stations, train maintenance depots, factories and other large buildings, by construction workers such as carpenters cutting asbestos building panels, and by workers making asbestos products such as fireproof textiles, brake and clutch linings, and specialised cement. as well as such direct exposure, exposure may also be: • indirect, as experienced by the families of asbestos workers • paraoccupational, as experienced by those working alongside an asbestos worker • neighbourhood, as experienced by those living downwind of an asbestos works or mine • ambient, as experienced by those living or working in a building containing asbestos. exposure to asbestos incorporated in the structure of a building carries a negligible health risk if the asbestos material is well maintained to prevent shedding of dust. stripping asbestos out is more dangerous than maintaining it in situ, but maintenance is sometimes neglected. the near indestructibility of asbestos accentuates the health problems that its ubiquity poses. because of their aerodynamic properties, fibres of µm or more in length may reach the finer bronchioles and alveoli. once impacted, the sharp asbestos fibres become coated with a film of protein that is rich in iron. the coating is thickest at the ends of the fibres, giving a other human studies have shown that, although asbestos load is maximal in the upper lobes, more long fibres are found at the bases, where fibrosis is most marked. , a further reason for limiting attention to the longer fibres is that the shorter ones are cleared more easily and their number therefore varies with the time lapsed since last exposure. for these reasons asbestos regulations in many countries now limit attention to fibres that are over µm in length and have a length-to-diameter (aspect) ratio greater than : such fibres have become known as regulatory or world health organization (who) fibres. values are best expressed as fibres/g dry lung. by light microscopy, normal values range up to : over is seen with mesotheliomas, and over in asbestosis (table . . ). , , , however, compared with electron microscopy, light microscopy is relatively insensitive, showing only . % of the amosite, % of the crocidolite and . % of the chrysotile. light microscopic counts correlate poorly with severity of asbestosis and electron microscopy non-asbestos fibres commonly found in the lung include mullite, which derives from fly ash. this may constitute up to % of the total fibre burden (see table . . ) and is thought to be harmless. there is no firm evidence that manmade fibres present a health hazard but in certain localities natural non-asbestos mineral fibres, zeolites for example, are important causes of mesothelioma (see p. ) and also cause interstitial pulmonary fibrosis. in contrast to the first half of the twentieth century, much of the asbestosis encountered today is asymptomatic, identified radiologically or histologically in lungs resected for carcinoma or removed at autopsy. symptomatic cases are characterised by an insidious onset of breathlessness, a dry cough and crackles over the lower lung fields. finger clubbing is a variable feature. lung function tests show a restrictive respiratory defect. radiology initially shows small irregular basal opacities that gradually coalesce to become linear, coarsen and eventually progress to a honeycomb pattern of small cysts. the principal differential diagnosis, both clinically and pathologically, is from idiopathic pulmonary fibrosis. this is aided by the slow progression of asbestosis, which often extends over years, as opposed to an average course of - years from presentation to death for the idiopathic condition. most cases of asbestosis are diagnosed solely on the occupational history and these clinicoradiological features. recourse to histology is unusual but biopsy (preferably as a wedge of lung) may be undertaken if the clinical features are atypical. histology also arises when the pathologist samples lung parenchyma remote from a resected carcinoma (the universal importance of which cannot be overemphasised). asbestosis (established) over over the light microscopic counts include total fibres (coated and uncoated). the electron microscopic counts include only amphibole asbestos. results from different laboratories vary and these figures, derived from several sources, , , provide only a general guide. reliable results depend upon counts being made regularly and the normal range from that laboratory being ascertained. ratios of counts obtained by electron and light microscopy vary greatly but approximate to . is better in this respect. [ ] [ ] [ ] by transmission electron microscopy, values may range up to in controls, with asbestosis generally above and mesotheliomas found at any level down to , all these figures representing amphibole fibres/g dried lung (see table . . ). , , it should be noted that counts from different parts of the same lung may vary widely; , - caution should therefore be exercised in interpreting a count obtained on a single sample. there is also wide discrepancy between laboratories, even when analysing the same sample. results obtained in an individual case therefore have to be evaluated against a standard set of values unique to that laboratory. electron microscopy also provides valuable information on the type of fibre. chrysotile differs physically from the amphiboles in two respects: its fibres are both curved and hollow (figs . . and . . ). with an electron microscope equipped for microprobe analysis, the various forms of asbestos may also be distinguished from other fibres and from each other (box . . ), , an important point as the amphibole forms of asbestos are far more dangerous than chrysotile (table . . ). [ ] [ ] [ ] coroners require autopsy verification of the diagnosis in all suspected cases and this also necessitates hystology. when the lungs from a patient with asbestosis are seen at autopsy, pleural fibrosis is often found, and although this may also be attributable to asbestos exposure it is to be regarded as an independent process and not part of the asbestosis: it is dealt with separately on page . slicing the lung affected by asbestosis shows a fine subpleural fibrosis, especially of the lower lobes ( fig. . . ). in severe cases the fibrosis often extends upwards to involve the middle lobe and lingula, and sometimes the upper lobes also. microcystic change associated with the fibrosis develops in advanced cases and in severe disease there may be cysts over cm in diameter. however, these classic changes are seldom seen in developed countries today. following decades of dust suppression in asbestos factories, current patients have mild to moderate asbestosis and are dying of related cancer or of non-pulmonary disease. in some of these cases the asbestosis is only detectable microscopically. fixation of the lungs through the bronchi and the use of heard's barium sulphate impregnation technique facilitate demonstration of the fibrosis (see p. and fig. . . ). the mild degree of asbestosis currently encountered is of little functional significance but is often critical in determining whether an associated carcinoma of the lung should be attributed to asbestos exposure (see below). the histological diagnosis of asbestosis requires an appropriate pattern of interstitial fibrosis associated with the presence of asbestos bodies. both components must be present. the fibrosis is paucicellular, lacking any significant degree of inflammation and being collagenous rather than fibroblastic. it is generally considered that asbestosis begins about the respiratory bronchioles and alveolar ducts where most of the asbestos fibres impact. alveolar walls attached to these bronchioles show fine interstitial fibrosis. however, this early lesion has to be interpreted with caution because it is not specific to asbestos, being found with other inhaled mineral dusts , and even in many cigarette smokers who have not been so exposed. it more likely represents a non-specific reaction to a variety of inhaled particles. it may cause mild airflow obstruction but is not associated with the radiographic, clinical or restrictive changes of classic asbestosis. as the disease progresses, the focal changes join up so that the basal subpleural regions show widespread interstitial fibrosis and eventually complete destruction of the alveolar architecture. in severe cases there may be honeycombing and metaplastic changes in the alveolar and bronchiolar epithelium. apart from the presence of asbestos bodies the changes resemble those of non-specific interstitial pneumonia, or more rarely usual interstitial pneumonia. fibroblastic foci may be found but they are uncommon. there is often an increase in alveolar macrophages but the desquamative interstitial pneumonia that has been reported in association with asbestos , is not to be regarded as a variant of asbestosis ; concomitant smoking is a more likely cause. a variety of other non-specific inflammatory processes such as organising pneumonia have been reported in asbestos workers and if localised some have been suspected of representing malignancy until biopsied. several schemes have been proposed for grading the extent and severity of asbestosis. these are of value in epidemiological studies but should only be applied to cases meeting the histopathological criteria for a diagnosis of asbestosis. one such scheme is shown in box . . . , , in well-established asbestosis asbestos bodies are numerous and easy to find, aggregates of them sometimes forming clumps ( fig. . . ) . in earlier lesions a detailed search may be necessary, in which fibrosis confined to the walls of respiratory bronchioles and the first tier of adjacent alveoli b extension of fibrosis to involve alveolar ducts and/or two or more tiers of alveoli adjacent to the respiratory bronchiole, with sparing of at least some alveoli between adjacent bronchioles fibrotic thickening of the walls of all alveoli between at least two adjacent respiratory bronchioles honeycomb change a an average score is obtained for an individual case by adding the scores for each slide ( - ), then dividing by the number of slides examined b grade and, to a lesser extent, grade need to be distinguished from smoking-induced peribronchiolar fibrosis and mixed-dust pneumoconiosis. case the examination of unstained or perls-stained sections facilitates their identification. minimum criteria for the diagnosis of asbestosis require the identification of diffuse interstitial fibrosis in well-inflated lung tissue remote from a lung cancer or other mass lesion and the presence of either two or more asbestos bodies in tissue with a section area of cm or a count of uncoated asbestos fibres that falls in the range recorded for asbestosis by the same laboratory. , there are marked variations in the concentration of asbestos fibres between samples from the same lung , and it is therefore recommended that at least three areas be sampled, the apices of the upper and lower lobes and the base of the lower lobe. the equivalent of mallory's alcoholic hyalin of the liver has been described in the lungs in asbestosis, , and subsequently in other [ ] [ ] [ ] [ ] it is seen as small eosinophilic cytoplasmic inclusions within hyperplastic type ii alveolar epithelial cells (fig. . . a ). electron microscopy shows that the inclusions consist of a tangle of tonofilaments ( fig. . . b ) and by immunocytochemistry a positive reaction is obtained with antibodies to cytokeratin, both these features being typical of mallory's hyalin in the liver. the inclusions also react for ubiquitin, the accumulation of which is indicative of cellular damage, in particular faulty proteinolysis. the differential diagnosis of asbestosis includes pulmonary fibrosis due to many other causes, any of which may of course affect an asbes-tos worker as much as members of the general population. the proportion of diffuse pulmonary fibrosis in asbestos workers that is not attributable to asbestos has been estimated to be as high as % and likely to rise as the risk of asbestosis diminishes with better industrial hygiene. the principal differential diagnosis of asbestosis is from idiopathic pulmonary fibrosis. both diseases affect the bases and periphery of the lungs predominantly. in the late stages, cystic change is more evident in idiopathic pulmonary fibrosis but this criterion is not totally reliable. nor is the presence of pleural fibrosis, although it is usually present in asbestosis and is seldom found in idiopathic pulmonary fibrosis. asbestosis seldom progresses or does so very slowly after exposure ceases , whereas idiopathic pulmonary fibrosis typically proves fatal within - years from onset. the fibrosis of asbestosis is generally paucicellular: inflammation is not a feature and the fibroblastic foci that characterise the usual interstitial pneumonia pattern of fibrosing alveolitis are seldom observed in asbestosis. very often the distinction from idiopathic pulmonary fibrosis has to be based on the amount of asbestos in the lung and, if asbestos bodies are not readily identifiable, this has to depend on fibre counts. errors are made both by overlooking substantial numbers of asbestos bodies completely and by ascribing undue importance to scanty bodies. if considering the possibility of minimal asbestosis (to justify attributing carcinoma of the lung to asbestos, for example) it should be remembered that a little peribronchiolar fibrosis is also characteristic of smokers' lungs, centriacinar emphysema and early mixeddust pneumoconiosis. [ ] [ ] [ ] as described above, at least two asbestos bodies/cm in the presence of interstitial fibrosis distant from any lung cancer or other mass lesion is required for a diagnosis of asbestosis. although the causes of asbestosis and idiopathic pulmonary fibrosis are very different, they resemble each other in several ways, suggesting that similar pathogenetic mechanisms may operate. , [ ] [ ] [ ] in both these diseases there is degeneration of the alveolar epithelium and capillary endothelium, with patchy loss of the former, and bronchoalveolar lavage shows an increase in macrophages that might perpetuate the damage by releasing lysosomal enzymes, nitric oxide and hydroxyl radicals. , [ ] [ ] [ ] both diseases are also characterised by an increased prevalence of circulating non-organ-specific autoantibodies. experimentally, asbestos exposure leads to the activation of a variety of fibrogenic cytokines at sites of lung injury. , [ ] [ ] [ ] [ ] [ ] [ ] inhaled asbestos activates a complement-dependent chemoattractant for macrophages and macrophage stimulation involves the secretion of fibroblast stimulating factors, [ ] [ ] [ ] asbestos being intermediate between haematite and silica in regard to macrophage-mediated fibrogenicity. the epithelial damage could be mediated directly by the needle-like asbestos fibres or indirectly through enhanced phagocyte generation of free radicals (which is much greater with amphibole asbestos than with either chrysotile or silica). , fibrogenic cytokines released by activated pulmonary phagocytes and regenerating alveolar epithelial cells in asbestosis include tumour necrosis factor-α and transforming growth factor-β, as in idiopathic pulmonary fibrosis. as a result of better industrial hygiene, asbestosis is less severe today than in earlier years when it followed much heavier exposure, with the consequence that death from respiratory failure and cor pulmonale is less common and sufferers are surviving longer. there is therefore now a greater risk of asbestos-related cancer eventually developing. asbestos exposure predisposes to two varieties of malignant neoplasm, carcinoma of the lung and mesothelioma of the pleura and peritoneum. the risk of malignancy increases with dose but the relative risk of carcinoma is much smaller than that of mesothelioma. for example, with heavy exposure, as in lagging, the risk of mesothelioma is increased -fold whereas it is increased only fivefold for lung cancer. hence, with light exposure there is a substantial risk of mesothelioma but only a small risk of lung cancer. asbestosis requires heavy exposure and in one group of patients with asbestosis, % died of pulmonary carcinoma, % of mesothelioma and % of other respiratory diseases. although there were many earlier reports, the link with carcinoma of the lung may be considered to have been firmly established by , that between crocidolite asbestos and mesothelioma by , and that between amosite asbestos and mesothelioma by . mesothelioma is considered on page . in regard to carcinoma of the lung, asbestos is not such a potent pulmonary carcinogen as cigarette smoke but together their effects are multiplicative rather than additive (table . . ). , however, the risk attributable to asbestos is the same regardless of smoking history, being increased fivefold in both smokers and non-smokers. there is usually a latent period in excess of years between first exposure to asbestos and the development of lung cancer and the risk increases the greater the cumulative exposure. the increased risk involves carcinomas of all the histological types encountered in the lung, although adenocarcinoma has been disproportionately overrepresented. , [ ] [ ] [ ] [ ] [ ] [ ] it is uncertain whether the increased risk of carcinoma is caused by the asbestos , [ ] [ ] [ ] [ ] [ ] [ ] or the asbestosis. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the latter view envisages the carcinoma arising in the foci of alveolar epithelial hyperplasia and dysplasia that commonly accompany any interstitial fibrosis (see carcinoma complicating idiopathic pulmonary fibrosis, p. ). however, most carcinomas complicating asbestosis arise in the bronchi rather than the alveolar tissue. on the other hand, more arise in the sites worst affected by asbestosis, the lower lobes and the periphery of the lung, than in the general population ( fig. . . ) . , , [ ] [ ] [ ] [ ] [ ] the majority view has been that asbestosis is a necessary precursor of the carcinoma but evidence to the contrary is finding increasing support (table . . ). in the uk, industrial compensation was formerly only awarded to an asbestos worker for carcinoma of the lung if there was also asbestosis or diffuse pleural fibrosis but new rules were introduced in . asbestosis remains a sufficient criterion but diffuse pleural thickening is not and asbestosis is no longer a necessary criterion: asbestos is deemed to have been responsible if the patient worked in asbestos textile manufacture, spraying, lagging or gas mask manufacture for at least years before or years after . the basis for these changes is the premise that heavy asbestos exposure is sufficient in itself to account for carcinoma of the lung. together, these factors have a multiplicative rather than additive effect mortality ratio non-smoking controls non-smoking asbestos workers cigarette-smoking controls cigarette-smoking asbestos workers asbestosis associated with carcinoma of the lung. the asbestosis has been highlighted by barium sulphate impregnation and is seen as a grey subpleural band to the right of the picture. although the carcinoma has arisen in the same lobe as the asbestosis it has not obviously arisen in an area affected by asbestosis. . asbestosis diagnosed clinically, radiologically or histologically or a minimum count of asbestos bodies per gram dry lung tissue (/g dry), or an uncoated asbestos fibre burden of million amphibole fibres more than µm in length/g dry, or million amphibole fibres more than µm in length/g dry or estimated cumulative exposure to asbestos of at least fibres/ ml-years or an occupational history of year of heavy exposure to asbestos (e.g. manufacture of asbestos products, asbestos spraying) or - years of moderate exposure (e.g. construction or ship-building) and . a minimum lag time of years lung fibre counts in the asbestosis range (see table . . ) provide valuable evidence of such exposure. compensation standards for asbestos-associated lung cancer in different countries are shown in box . . . , asbestos-induced airway disease although asbestosis causes a restrictive respiratory defect, airflow limitation is also seen in this disease. much of the airflow limitation is attributable to cigarette smoking but it is also seen in non-smoking asbestos workers and is worse in those with asbestosis. the pathological basis of this appears to be small-airways disease (see p. ). it is possibly a non-specific reaction to inhaled dust or cigarette smoke. because it is not established that this lesion progresses to interstitial alveolar fibrosis (asbestosis) the term 'asbestos airways disease' is suggested. fibrosis limited to the bronchioles is specifically excluded from the definition of asbestosis in the latest guidelines (although these retain grade for fibrosis limited to the bronchiolar walls). it should also be noted that, although emphysema is considered to be a destructive rather than fibrotic condition, a little focal the presence of asbestos-related bilateral pleural plaques or asbestos-related bilateral pleural thickening and occupational exposure and a lag time of at least years the presence of asbestosis or pleural plaques or diffuse pleural thickening or fibre-years of exposure only fibre-years of exposure are taken into account exposure, at least years' latency and asbestos-related pleural or parenchymal changes asbestosis is not required but smoking is taken into consideration attempts are made to quantify separately the attributability to asbestos, smoking and other factors (e.g. radon) fibrosis is generally evident in this common condition and does not necessarily indicate early asbestosis. aluminium has been implicated in the development of respiratory disease during the refining of its principal ore, bauxite, to yield various aluminium oxides (aluminas), in the preparation of the metal by smelting alumina, in the production of corundum abrasive and in the production of special aluminium powders used in explosives. bauxite is a mixture of various aluminium oxides, hydroxides and silicates, iron oxide and titanium dioxide. the oxides of aluminium are obtained by differential heating of the ore and the respiratory effects of this work appear to be no more than mild airway irritation. it is generally accepted that aluminium oxide is inert. aluminium is prepared by the electrolytic reduction of its oxide dissolved in sodium aluminium fluoride (cryolite), a process releasing a considerable amount of fluoride-rich effluent. exposed workers have complained of what is termed pot-room asthma. the pathology of this condition is not well described but the pathogenesis is thought to involve irritation rather than allergy. the abrasive corundum is formed from bauxite mixed with coke and iron heated in an electric arc furnace, a process in which workers may be exposed to the fumes of alumina and free silica. in the past some of these workers developed diffuse pulmonary fibrosis (shaver's disease) and, although this was initially attributed to the aluminium, it is now agreed that the free silica was the responsible agent. the exposure to free silica has been reduced and the disease is now regarded as historic. aluminium powder holds a paradoxical position in regard to lung disease. in certain industries it has caused very severe pulmonary fibrosis, yet in others it has proved harmless. indeed, at one time canadian miners breathed aluminium dust before work, in the belief that this would reduce the danger of silica in the mine dust and more recently silicosis has been treated by such means in france. it is questionable whether this practice is effective but it at least appears to cause no harm. the explanation for these contradictory observations probably lies in differing methods of manufacture of aluminium powder. aluminium metal appears to be an inert substance but this is only because it has a high affinity for oxygen and the surface layer of aluminium oxide so formed is firmly bound to the underlying metal, unlike ferric oxide which permits further rusting of iron. granular aluminium powders, produced in a ball mill or from a jet of molten aluminium, therefore acquire a protective coat of surface oxide and are inert. with stamped aluminium powders, however, surface oxidation is prevented by lubricants added to aid the separation of these flake-like particles. the usual lubricant (stearin) contains stearic acid and this polar compound combines with the underlying metal, which is thereby protected from both atmospheric oxidation and the action of body fluids when such dust is inhaled. in certain circumstances, however, non-polar lubricants in the form of mineral oils have been substituted for stearin. this happened in germany during the second world war when munition production was stepped up but stearin was difficult to obtain, , and in the uk in the s to make the powder darker for purely commercial reasons. in vitro, oil-coated stamped aluminium powder reacts with water to produce aluminium hydroxide, which affords the underlying metal no protection against further attack, so that aluminium hydroxide continues to be formed. this substance is a protein denaturant, once used in the tanning industry, and it is believed that this property underlies the very ex ceptional cases of severe pulmonary fibrosis that have occurred in connection with stamped aluminium powder produced with mineral oil rather than stearin. , the fibrosis has a very characteristic pattern, affecting the upper lobes and progressing rapidly, the interval from onset of symptoms to death being as short as years. there is marked shrinkage of the lungs with gross elevation of the diaphragm and buckling of the trachea (fig. . . ). the lungs are grey ( fig. . . ) and microscopically, numerous small black jagged particles are seen. these can be shown to contain aluminium with irwin's aluminon stain or by microprobe analysis. what appears to be a different pathological effect of aluminium dust on the lungs is the rare development of granulomatous disease resembling sarcoidosis and berylliosis. , this represents hypersensitivity to the metal, amenable to confirmation with a lymphocyte transformation test similar to that used to diagnosis berylliosis (see below). rare cases of desquamative interstitial pneumonia and pulmonary fibrosis have been reported in aluminium welders. , elements with atomic numbers from (lanthanum) to (lutetium) are known as the lanthanides or rare earth metals. they are used in many manufacturing processes, including the production of hightemperature ceramics and the grinding of optical lenses. carbon arc lamps used in reproduction photography emit appreciable quantities of oxidised lanthanides, particularly cerium oxide, and there are reports of pneumoconiosis in exposed individuals. the pathological changes reported have varied from granulomatous nodules to diffuse interstitial fibrosis indistinguishable from the idiopathic variety except for the presence of rare earth elements (usually cerium) detected by polarising light microscopy and electron microprobe analysis. hard metal is a tungsten alloy containing small amounts of cobalt, titanium, molybdenum and nickel. it is exceptionally tough and once formed can only be worked with diamond. it is used in the tips of drill bits, on abrasive wheels and discs, and in armaments. interstitial lung disease is liable to arise in its manufacture or in those using hard metal as an abrasive. experimental work suggests that cobalt is the dangerous constituent but this element is soluble and, unless industrial contact has been recent, analysis of lung tissue usually shows tungsten and titanium but no cobalt. the role of cobalt is also indicated by the development of similar interstitial lung disease in diamond polishers using high-speed polishing discs made with a diamond-cobalt surface that lacked tungsten carbide and the other constituents of hard metal. , hard-metal lung disease and cobalt lung take two forms, an industrial asthma and interstitial fibrosis. the latter has a diffuse lower zonal distribution and the appearances mimic idiopathic pulmonary fibrosis. however, an unusual feature is the presence of moderate, or perhaps only small numbers, of giant cells (fig. . . a, b) . , not only are there multinucleate alveolar macrophages but syncytial cell forms develop in the alveolar epithelium. electron microscopy confirms that these are multinucleate type ii pneumocytes (fig. . . c ). such epithelial changes are well known in measles pneumonia but the viral inclusion bodies that characterise this infection are not found in hard-metal pneumoconiosis. the changes are those initially described as a particular pattern of idiopathic interstitial pneumonia termed giant cell interstitial pneumonia or gip (see p. ). elemental analysis shows that many, but not all, cases of gip represent hardmetal disease. the exceptions seldom give a history of cobalt exposure and must be presumed to represent true idiopathic cases. conversely, epithelial giant cells are not always found in hard-metal pneumoconiosis and so their presence, although highly characteristic, is neither totally specific nor totally sensitive. beryllium is the lightest of metals. it has an atomic weight of and special properties that make it especially useful in many applications. it is more rigid than steel, has a high melting point and is an excellent conductor of heat and elecricity. unfortunately, the inhalation of beryllium dust or fume is exceedingly dangerous. , those who worked with beryllium compounds before precautionary measures were taken suffered a high morbidity and mortality. sometimes, the escape of dangerous fumes from the factories was on such a scale that people living in nearby houses, downwind from the places in which these materials were being worked, contracted and occasionally died from berylliosis ('neighbourhood cases'). alternatively, contamination of a beryllium worker's clothes might lead to berylliosis in a temperatures. the alloys of beryllium are also now widely used, especially those with copper, on which it confers elasticity and resistance to fatigue. alloy manufacture and the machining of beryllium alloys are therefore further activities that entail a risk of berylliosis, as is the recovery of the metal in the recycling of scrapped electronic and computer parts. seemingly innocuous occupations such as dental laboratory technician are not without risk of chronic berylliosis. there are good grounds for regarding chronic berylliosis as being an allergic condition. many of those affected react strongly to skin tests with dilute solutions of beryllium salts, although these must be undertaken with care: occasionally in a highly sensitised person even so small an exposure may evoke a systemic reaction. the skin reaction is of the delayed type, occurs in only % of exposed individuals, is not associated with a clear-cut dose-response curve and represents a granulomatous response. further evidence for the disease having an allergic basis derives from bronchoalveolar lavage, which demonstrates an excess of t-helper lymphocytes that proliferate in vitro on exposure to beryllium salts. a positive transformation test given by these lymphocytes is a more reliable indicator of disease than in vitro blood lymphocyte transformation testing, which is safe but not wholly reliable and indicates only sensitization, rather than berylliosis. susceptibility to berylliosis varies widely from person to person and it is notable that chronic pulmonary disease is strongly associated with the hla antigen dpβ and the glu gene. , the importance of genetic factors is supported by a report of the disease in identical twins. chronic berylliosis is thought to be initiated by the metal binding to tissue proteins and acting as a hapten to initiate a delayed hypersensitivity response characterised by a proliferation of t-helper lymphocytes. these sensitised cells in turn secrete a variety of cytokines (e.g. interleukin- , tumour necrosis factor-α and interferon-γ) that recruit and activate macrophages, which mature into epithelioid cells. the resultant epithelioid cell granulomas destroy the lung tissue and lead to pulmonary fibrosis. if beryllium enters the subcutaneous tissues through a cut or abrasion, as often happened in the earlier days of fluorescent lamp manufacture, a sarcoid-like granuloma soon appears at the site; in time, the overlying epidermis may break down to form an ulcer. even more serious are the lesions produced by the inhalation of beryllium. chronic pulmonary berylliosis takes the form of a widespread granulomatous pneumonia with a histological picture identical to that of sarcoidosis (fig. . . a ). both berylliosis and sarcoidosis affect the upper lobes more than the lower (fig. . . b ) and in both diseases the granulomas are preferentially distributed along lymphatics and may involve adjacent blood vessels. in neither condition is there widespread necrosis but in both diseases the granulomas occasionally display a little central necrosis or hyalinisation. as in sarcoidosis, the hilar lymph nodes may be involved but, unlike sarcoidosis, not in isolation. over a period of many years, the sarcoid-like granulomas gradually undergo progressive fibrosis, with consequent impairment of pulmonary function. in the later stages, when the disease has become chronic, dispersal of beryllium from its site of initial absorption may lead to generalisation of the disease and to the appearance of similar granulomas elsewhere, particularly in the liver, kidneys, spleen and skin, but this is unusual. relative. beryllium compounds may also cause contact dermatitis and conjunctivitis. beryllium is also classified as a probable pulmonary carcinogen, but this is controversial. two forms of berylliosis are recognised, acute and chronic. acute berylliosis was first reported in germany in and is now largely of historical interest, being only encountered as a result of rare accidental or unexpected exposure. it follows the inhalation of a soluble beryllium salt and represents chemical injury, the pathology being that of diffuse alveolar damage (see p. ). further consideration will be confined to chronic berylliosis, which is allergic in nature. chronic berylliosis was first reported in in the fluorescent lamp industry. beryllium has now been replaced in this application but it has since proved to be of great value in the nuclear, electronic, computer and aerospace industries and the production of refractory materials and crucibles that are to be subjected to particularly high and there is a lifelong risk of disease. progression often entails alternating exacerbations and remissions, long after exposure has ceased. in keeping with the view that berylliosis is a hypersensitivity reaction, very little beryllium is necessary to cause the disease. particulate beryllium is so scanty in the affected tissues and the atomic number of beryllium so low that electron microprobe analysis is generally unsuitable for its detection. furthermore conventional detectors are protected by a beryllium window. however, the substitution of a polymeric window has enabled beryllium to be detected by electron microprobe analysis, presumably in a patient with fairly heavy exposure. ion or laser microprobe mass spectroscopy can also detect very small amounts of beryllium in tissue sections but these techniques are not widely available. the differential diagnosis of chronic berylliosis is from sarcoidosis, to which it is identical morphologically. [ ] [ ] [ ] however, as noted above, it is unusual for berylliosis to cause significant hilar lymphadenopathy in the absence of pulmonary disease, which is a common feature of sarcoidosis. extrathoracic granulomas, erythema nodosum and uveitis, which are all common in sarcoidosis, are unusual in berylliosis. however, one group found that % of patients initially diagnosed as having sarcoidosis actually had chronic berylliosis. similar findings have been reported by others. , any patient thought to have sarcoidosis who has worked with or near metals should be offered a beryllium lymphocyte transformation test. a list of laboratories performing this test can be found at www.dimensional. com/~mhj/medical_testing.html. although polyvinyl is not a mineral and the reaction of the lungs to its presence is therefore not a true pneumoconiosis, it is generally so termed and is dealt with here for convenience. workers are exposed to polyvinyl chloride dust in the milling and bagging of this plastic and micronodular opacities may be detected in their lungs radiologically. however, the material is non-fibrogenic and histology merely shows a foreign-body reaction to the dust particles. the radiological opacities may abate when exposure ceases. nevertheless, one polyvinyl chloride worker developed systemic sclerosis, which is a recognised complication of silicosis (see p. ). polyvinyl chloride is produced from vinyl chloride monomer, which has a causal association with angiosarcoma of the liver and probably other forms of cancer, including carcinoma of the lung (see p. ). in the late s a characteristic lung disease was identified in workers at several factories producing plush material by spraying nylon flock on to an adhesive backing material. [ ] [ ] [ ] [ ] the flock fibres are too large to be inspired but may be mixed with smaller nylon shards of respirable size. the workers complained of cough and breathlessness and were found to have a restrictive ventilatory defect with interstitial markings on radiography. their symptoms improved on removal from the workplace but relapsed on return to work. pathologically, there was lymphocytic bronchiolitis and peribronchiolitis with widespread lymphoid hyperplasia represented by lymphoid aggregates. chronic berylliosis is characterised by the gradual onset of cough, shortness of breath, chest pain, night sweats and fatigue. these symptoms may develop within a few weeks of exposure or many years later. once the worker is exposed, the beryllium is retained in the tissues granulomas were not identified. the histological appearances suggest a severe immunological reaction and raise possibilities such as rheumatoid disease and sjögren's syndrome but consideration of the clinical and serological setting and the occupation should permit recognition of the cause. the industrial production of popcorn and other foodstuffs appears to carry a risk of obstructive airway disease. [ ] [ ] [ ] [ ] biopsy of affected workers has shown peribronchiolar fibrosis and granulomas and air sampling has identified many volatile organic compounds, of which the flavouring agent diacetyl ( , -butanedione) is suspected of being responsible for the bronchiolitis. it is difficult to continue paint spraying (air brushing, aerographics) without adequate respiratory protection but in the early s several small aerographic factories operated in the neighbourhood of alicante, southeastern spain without any concern for the workers' health. the workers were required to paint patterns on textiles using a hand-held spray gun. the atmospheric pollution was intense but complaints of respiratory difficulties were met with reassurances and the workers urged to continue. this they did because of the otherwise poor economy, often returning to work when disabling breathlessness had settled down. a change of paint (to acramin f) may have contributed because the worst-affected workers were employed at two plants that had made this switch. their illness has been described as the 'ardystil syndrome' after the name of one of these factories. some workers were left with permanent respiratory disability. one required a lung transplant and others died. [ ] [ ] [ ] [ ] transbronchial biopsy showed organising pneumonia, which in the fatal cases had progressed to irreversible interstitial fibrosis. a similar outbreak of respiratory disease was subsequently reported in algerian textile factories where acromin f was applied by the same technique. , acromin f is marketed as a paste and used as such without ill-effect. its use in heavy spray form appears to be responsible for the 'ardystil syndrome' . workers in engineering workshops may be exposed to the prolonged inhalation of fine sprays or mists of the longer-chain hydrocarbons that constitute many mineral oils. this may result in exogenous lipid pneumonia, which is described on page , or extrinsic allergic alveolitis. [ ] [ ] [ ] the vapour of shorter-chain hydrocarbons such as paraffin oil (kerosene: c - ) and petrol (gasoline: c - ) and gaseous hydrocarbons such as propane may act as acute asphyxiants or central nervous system depressants but have negligible pulmonary toxicity. however, if they are ingested or aspirated in their liquid form they are acutely toxic to the lungs, producing a chemical pneumonitis with the features of diffuse alveolar damage. ingestion may be accidental or deliberate (see fig. . , p. ) whereas aspiration is generally inadvertent, occurring in siphoning accidents, such as those experienced by fairground operatives who 'breath or eat fire' ('fire-eater's lung'). , animal experiments involving the intratracheal injection of kerosene resulted in acute pulmonary exudates, which cleared except for residual bronchiolitis. welder's pneumoconiosis, first recognised in , essentially represents the fairly harmless deposition of iron in the lungs (siderosis -see p. ). however, welders may suffer various ill-effects from the inhalation of substances other than iron (table . . ). some of these are para-occupational risks, that is, encountered by welders because they work near another process and are inadvertently exposed: thus, shipyard welders may be exposed to asbestos, and those in foundries to silica. welders may therefore develop a mixed-dust pneumoconiosis (see p. ), rather than just siderosis. however, one analytical investigation identified excess amounts of iron alone in association with pulmonary fibrosis; the silicon content did not differ from that in controls. more directly, welders may be exposed to asbestos insulation that they themselves use, while welders of special steel alloys run the risk of metal-induced asthma, metal fume fever, polymer fume fever and the consequences of toxic metal fume inhalation, all of which are described separately in this chapter, as is lung disease in aluminium welders. chronic bronchitis has been attributed to the inhalation of low concentrations of irritants such as ozone and nitrogen dioxide by welders but this risk is unproven and the subject of much controversy. welders may also inhale carcinogenic hexavalent chromium compounds in the course of their work and therefore develop lung cancer. the term 'welder's lung' is often applied indiscriminately to any of these diseases and, as it has no specific meaning, is best avoided. dust, fume and gas are some of the terms used to describe different physical forms of respirable agents. they are defined in table . . on the finely divided fume of several metals is highly toxic to the lungs and capable of producing severe acute and chronic damage to both the conductive airways and the alveoli, resulting in acute tracheobronchitis and bronchiolitis, diffuse alveolar damage, obliterative bronchiolitis and pulmonary fibrosis. important metal fumes in this respect include aluminium, which is released together with silica fume in bauxite smelting (see shaver's disease, above), cadmium from welding or cutting special steels, chromium from cutting its alloys or in the manufacture of chromates, cobalt released in the production and use of its alloys (see hard-metal disease, above), mercury released in various industries and in the home, nickel carbonyl released during the purification of metallic nickel or the manufacture of nickel alloys and beryllium (see above). many irritant gases cause severe acute and chronic damage to both the conductive airways and alveoli. the changes are non-specific and similar to those wrought by toxic metal fumes (see above) and viruses amongst other agents. they consist of acute tracheobronchitis and bronchiolitis, obliterative bronchiolitis, diffuse alveolar damage and pulmonary fibrosis. the gases liable to produce such damage include oxides of nitrogen, sulphur dioxide, ozone, phosgene, chlorine, ammonia and various constituents of smoke, notably acrolein. some of these are also touched upon in chapter . because they are of general as well as occupational importance, although there is no rigid difference between general and occupational pollution. ozone, sulphur dioxide and nitrogen dioxide are oxidising gases that may be found together as industrial atmospheric pollutants. each is capable of producing diffuse alveolar damage by means of its oxidising properties and the release of free active radicals. in addition, they cause damage to distal airways, particularly terminal and respiratory bronchioles, with resulting bronchiolitis. oxides of nitrogen may be encountered with fatal consequences by farmhands seeking to free a blockage in a silo when they encounter pockets of this gas that have accumulated on top of the fermenting silage: the term 'silo-filler's disease' is generally applied to the initial haemorrhagic oedema or the obliterative bronchiolitis that develops in those who survive the initial chemical injury. [ ] [ ] [ ] [ ] asphyxia due to the farmhand encountering pockets of carbon dioxide is a further hazard within agricultural silos. other farmhands have suffered from the inhalation of toxic gases or bacteria when handling liquid manure. [ ] [ ] [ ] [ ] welding, which is considered below, may also involve exposure to toxic gases such as oxides of nitrogen. ozone, the principal oxidant gas of photochemical smog, produces pulmonary changes at relatively low levels and may be encountered at higher concentrations in various industries. potentially dangerous levels of ozone are produced from atmospheric oxygen by ultraviolet radiation given off in welding while ozone is used in industry to sterilise water, bleach paper, flour and oils, and mask the odour of organic effluents. the damage wrought by ozone is predominantly centriacinar in distribution, affecting terminal and respiratory bronchiolar epithelium and proximal alveolar epithelium. [ ] [ ] [ ] there is loss of cilia and necrosis of centriacinar alveolar type i epithelial cells. the changes are dose-dependent and, in one study, the youngest animals were most sensitive. in long-term experiments, hyperplastic bronchiolar clara and ciliated cells extended peripherally to line alveolar ducts. the role of granulocytes is stressed in some experimental studies and it is notable that neutrophil migration is prominent when the human lungs are damaged by ozone. aldehydes such as acetaldehyde, formaldehyde and acrylic aldehyde (acrolein) are widely used in the plastics and chemical industries. the first is a liquid and the others are water-soluble gases. pathologists are of course familiar with formaldehyde solution from its use as a disinfectant and histological fixative. all these aldehydes are intensely irritant and their acute effects generally prevent prolonged exposure to high concentrations. chronic effects include skin sensitivity and asthma, and in rats nasal carcinoma. however, the doses to which these experimental animals were exposed far exceed any that are likely to be encountered by humans, in whom there is no convincing evidence of aldehyde-induced cancer. ammonia gas is extensively used in industry as a raw material, notably in the manufacture of nitrogenous products such as fertilisers and plastics. it is highly soluble and its acute irritative effects are mainly felt in the eyes, nose and throat, but high levels affect the major airways, possibly leading to them being blocked by exudates. survival usually brings full recovery but bronchiectasis and obliterative bronchiolitis have been described. chlorine gas is widely used in the chemical industry. it is transported and stored under pressure in liquid form. heavy exposure through its accidental release or use as a war gas has proved fatal through its acute toxicity causing exudative airway occlusion and pulmonary oedema. survivors usually recover completely but, as with nitrogen dioxide and ammonia, there is a risk of obliterative bronchiolitis. phosgene (carbonyl chloride, cocl ) is a poisonous, colourless gas that was responsible for thousands of deaths during world war i, when it was used in chemical warfare. it is used industrially in the preparation of some organic chemical compounds and is formed, perhaps inadvertently, by the combustion of methylene chloride in products such as paint strippers. phosgene causes injury to terminal bronchioles and alveoli, with resulting oedema and hyaline membrane formation. the mechanism of cell damage is uncertain but it may depend on inactivation of intracellular enzymes by the gas. longterm problems are rare but chronic bronchitis and emphysema have been described in survivors. mustard gas (bichloroethyl sulphide, c h cl s) is a further agent that has been used in chemical warfare. it is primarily a skin vesicant but when inhaled it results in widespread epithelial destruction and pulmonary oedema. survivors may be left with irritant-induced asthma (reactive airways dysfunction), chronic bronchitis, tracheobronchomalacia, bronchiectasis and bronchiolitis obliterans. [ ] [ ] [ ] thionyl chloride is used in the manufacture of lithium batteries where it is liable to result in the release of sulphur dioxide and hydrochloric acid fumes. workers in such factories have developed lung injury varying from mild, reversible interstitial disease to severe obliterative bronchiolitis. hydrogen sulphide is the principal chemical hazard of natural gas production. high levels of the gas also buid up in sheds housing large numbers of pigs, the source here being the pig manure. once inhaled the gas is rapidly absorbed into the blood stream. the effects are therefore widespread but include the usual respiratory effects of irritant gases, varying from sneezing to pulmonary oedema and acute respiratory distress, depending upon the exposure. in alberta cases were identified over a -year period. the overall mortality was %; % of victims were dead on arrival at hospital. most required admission to hospital but the survivors experienced no long-term adverse effects. a the danger of asphyxia from the inhalation of gases devoid of oxygen is fairly widespread in industry. it generally arises from the use of inert gases, which, being non-toxic, give a false sense of security. pockets of these gases tend to form in confined spaces. anoxic death from the accumulation of methane is well known in mines and has also occurred in slurry pits and sewers. anoxic asphyxia in diving (and anaesthesia) has resulted from the incorrect connection of gas cylinders or failure to notice that a mixed gas contains insufficient oxygen. deaths have occurred in welding when argon or carbon dioxide has been used to shield the weld and prevent oxidation of the metals at the high temperatures employed. deaths have also resulted from inadvertent entry to discharged oil tanks filled with nitrogen to reduce the risk of explosions, or from the formation of pockets of nitrogen gas applied in liquid form to freeze the contents of damaged pipes so that they can be repaired without the necessity to drain down. the respiration of a gas devoid of oxygen causes loss of consciousness within seconds because it not only fails to provide oxygen but removes that present in the pulmonary arterial blood. the changes at autopsy are those common to cellular hypoxia. they include cerebral and serosal petechiae and pulmonary congestion and haemorrhage but these features are not specific and are not always present. the cause of death can generally only be surmised from the circumstances surrounding the death. occupational asthma is the commonest cause of work-related respiratory disease in many western countries (table . . ). [ ] [ ] [ ] the reported incidence ranges from per million workers in south africa to per million workers in finland. , it occurs in many industries (table . . ) and occupational factors can be identified as contributing to asthma in about % of adult cases. over aetio- in the uk a third are organic, a third chemical, % metallic and the rest miscellaneous. the commonest, in descending order, are isocyanates, flour and grain, laboratory animals, glutaraldehyde, solder or colophony and hardening agents. atopy appears to predispose to occupational asthma when the allergen is of high molecular weight but not when it is of low molecular weight. for example, atopic individuals are particularly prone to develop asthma if employed in the manufacture of biological detergents, whereas atopy does not increase the risk of asthma from sensitisation to toluene di-isocyanate, which is a serious health problem in the manufacture of polyurethane. similarly, platinum salts are such potent sensitising agents that nearly all those exposed to them develop asthma. asthma-provoking metals other than platinum include chromium, cobalt, nickel and vanadium, all of which are used in steel alloys, and possibly aluminium (see pot-room asthma, p. ). other asthma-inducing factors encountered in industry include grain and flour dust, certain wood dusts, soldering fluxes containing colophony (pine resin), epoxy resin hardeners such as phthallic anhydride, isocyanate-containing foams and paints, formaldehyde and the excreta of laboratory animals. contaminated humidifiers may cause occupational asthma as well as humidifier fever and extrinsic allergic alveolitis. pathologically, occupational asthma is identical to nonoccupational asthma (see p. ). byssinosis is a further form of occupational asthma, one encountered in the cotton industry. the sensitising agent is a component of the cotton bract, which is the part of the cotton harvest other than the cotton fibre. bract consists of dried leaf, other plant debris and soil particles and contains a variety of fungal and bacterial residues, including lipopolysaccharide endotoxin, but the exact nature of the sensitising agent remains unknown. the endotoxin is unlikely to be responsible for byssinosis but may be the cause of so-called mill fever, a self-limiting illness characterised by malaise, fever and leukocytosis that is experienced by many people on first visiting a cotton mill. dust levels and the risk of byssinosis are particularly high in the carding rooms where the raw cotton is teased out before it is spun. affected workers are worse when they return to work after the weekend break, a feature attributed to antibody levels having built up during this brief respite from the cotton dust. there is no link with atopy and the fluctuating antibodies are precipitins of the immunoglobulin g class. complement activation by both arms of the complement cascade has been reported. , when the lancashire economy was largely cotton-based, necropsies on workers suffering from byssinosis generally showed gross emphysema, and this came to be accepted as evidence of byssinosis. however, it is now realised that in this heavily industrialised part of the uk, emphysema is as common in the general population as in cotton workers and it can no longer be considered a component of byssinosis. other findings in byssinosis are more commensurate with asthma, namely an increase in bronchial muscle and mucous cells. no granulomas or other evidence of extrinsic allergic alveolitis are found. fever may be the predominant feature in a variety of occupational illnesses and the unifying term 'inhalation fever' has been proposed. however, the individual occupations are of interest and these conditions will therefore be considered separately. mill fever has been mentioned above under byssinosis. humidifier fever is an acute illness characterised by malaise, fever, myalgia, cough, tightness in the chest and breathlessness, all of which are worse on monday mornings if the humidifier responsible is at work rather than home. the chest complaints, and their aggravation on return to work after the weekend, are features shared with byssinosis (see above) but the general complaints fit better with extrinsic allergic alveolitis (see p. ). humidifier fever develops in circum-stances that also lead to the development of a form of extrinsic allergic alveolitis, and not surprisingly the same name has been extended to this latter condition, with inevitable confusion. both diseases are caused by microbiological contamination of humidifiers or air conditioners so that a fine spray of microorganisms is emitted into the office, factory or home. investigations have generally shown the baffle plates of the air conditioner to be covered with a slime of bacteria, fungi or protozoa (mainly amoeba and ciliates), and extracts of this have been used to identify precipitins in the patient's sera, as in extrinsic allergic alveolitis. however, unlike extrinsic allergic alveolitis, humidifier fever resolves within a day and leaves no permanent injury. for this reason there is seldom the opportunity to study the tissue changes, and partly for this reason it remains unclear whether the disease is mediated by immune complexes, as in extrinsic allergic alveolitis, or by endotoxins derived from the contaminants. a febrile illness occurring in precipitin-negative farm-workers after heavy exposure to fungi in their silos was attributed to inhaled fungal toxins and named pulmonary mycotoxicosis. it is also known as precipitin test-negative farmer's lung and organic dust toxic syndrome. the condition is generally self-limiting and is seldom biopsied but desquamative interstitial pneumonia and diffuse alveolar damage have been reported. , metal fume fever this is a self-limiting acute illness characterised by fever, sweating, myalgia, chest pain, headache and nausea, that comes on monday mornings when occupational exposure is experienced after a weekend's respite, as with bysinnosis and humidifier fever; during the week tolerance develops. , the disease involves the release of cytokines such as tumour necrosis factor and is presumed to have an allergic basis. the metals involved are chiefly zinc, copper and magnesium, and, to a lesser extent, aluminium, antimony, iron, manganese and nickel. occupations at risk include any that generate such metal fumes, but particularly welding. it is most commonly associated with welding zinc-coated surfaces. if the symptoms persist, alternative diagnoses, such as acute cadmium poisoning and other specific toxic metal fume diseases, should be suspected: these are not self-limiting and may cause severe bronchiolitis or diffuse alveolar damage (see above). this illness resembles metal fume fever except that it occurs without regard to previous exposure: no tolerance develops and there is therefore no particular susceptibility on mondays. the polymers concerned are quite inert, except when heated to produce fume: polytetrafluorethylene (ptfe, teflon, fluon, halon) is a notable example. as with other self-limiting diseases, little is known of the tissue changes. environmental irradiation chiefly affects the skin but in some parts of the world rocks near the surface release significant amounts of radon gas. this carcinogen is liable to accumulate in buildings and be inhaled, so subjecting the occupants to an increased risk of lung cancer. the installation of underfloor ventilation is therefore advocated in such areas. this subject is explored more fully on page . the body is vulnerable to both increases and decreases in pressure and it is the lungs that often bear the brunt of the damage. increased pressure may result in blast injury or crushing of the chest while decreased pressure may result in the lungs literally bursting or dissolved gases being released within the blood (caisson disease), or the vascular alterations that underlie mountain sickness developing. some of these pressure changes entail a risk of pneumothorax and it is essential that this is properly investigated postmortem by the chest being opened under a water seal. loud music has been incriminated as a specific form of air pressure change causing pneumothorax and metereologists have shown that 'spontaneous' pneumothoraces tend to occur in clusters associated with natural drops in atmospheric pressure. , explosions may cause injury by the body being violently thrown against a less moveable object, by objects being thrown against the body or by the blast wave hitting the body. these mechanisms often act together but sometimes there is only blast injury, to which the lungs are particularly vulnerable. for a time it was considered that the damage was direct, the blast wave travelling down the airways to injure the lungs. however, at the start of the second world war, experiments conducted in the uk showed that the lungs were injured indirectly, the blast wave being transmitted to them through the chest wall: pulmonary blast injury is worst on the side of the body towards the explosion, and can be reduced by protective clothing. underwater explosions are particularly dangerous because water is incompressible. there may be severe internal injury but no external evidence of damage other than a trickle of blood from the mouth or nose. this is because the injury is rate-dependent. quite small thoracic deform-ation may produce severe pulmonary damage if peak compression is attained very quickly, typically in less than ms. conversely, severe chest wall distortion may produce only minor pulmonary contusion if this time is extended beyond ms. at necropsy, the lungs are contused, with blood evident in the airways and parenchyma. depending on the force of the blast, the haemorrhage may be pinpoint, patchy or confluent. it tends to follow the lines of the ribs and may be accompanied by pleuropulmonary lacerations having the same distribution. in this case there will also be haemothorax, pneumothorax and possibly air embolism. patchy pulmonary haemorrhages cuff the blood vessels. , in patients who survive for a few days, the lungs resemble the liver macroscopically and histologically show chronic interstitial inflammation and fibrosis as well as haemorrhage. other injuries are often present and fat embolism, aspiration pneumonia, fluid overload and infection may all be added to the effects of the blast wave. 'chest squeeze' is another form of barotrauma caused by high pressure but here the body is compressed rather than subject to a sudden wave of pressure as in blast injury. it is experienced by divers who descend very deeply, thereby subjecting their bodies to such high pressure that their chest walls are literally crushed, so that their ribs break and their lungs are severely compressed. more common mishaps experienced by divers include drowning and decompression sickness, both of which are dealt with below, and neurological syndromes such as nitrogen narcosis, which will not be considered further. 'burst lung' is the most acute form of decompression sickness. it is experienced by divers and submariners making rapid ascents from depth and by aviators who ascend too rapidly in unpressurised aeroplanes, experience failure of a plane's pressure system or have to eject at high altitudes. injury to the lung is caused by trapped alveolar gas expanding so rapidly that it exceeds total lung capacity before it can escape through the trachea. the lungs literally burst: the alveolar walls rupture and blood mixes directly with alveolar air. the victim experiences chest pain and there may be blood-stained froth at the mouth or frank haemoptysis. air may enter the alveolar walls to cause interstitial emphysema or air embolism. asthmatics may be at particular risk because of regional air-trapping. . diving mammals such as porpoises and whales are protected from such dangers of peripheral air-trapping by cartilage extending far out into the finest conductive airways so that these passages never close, even at the end of full expiration (fig. . . ) . , patients requiring positive-pressure artificial respiration are also at risk of burst lung, but the complications of the resultant interstitial emphysema differ from those experienced by divers. in divers, the chest wall is buttressed by the surrounding water and air in the interstitium is liable to track towards the hilum of the lungs and enter pulmonary veins, with resultant cerebral and coronary air embolism, either of which may prove fatal. iatrogenic burst lung, on the other hand, takes place in patients whose chest wall is not so buttressed, and then outward rupture of the interstitial air is more likely, resulting in pneumothorax. extension of the interstitial emphysema to the mediastinum, neck and chest wall is also more likely in such patients, resulting in surgical emphysema at these sites. however, there are exceptional cases marked by both cerebral embolism and extensive air tracking. the same circumstances that lead to burst lung may also cause decompression sickness, which is also known as caisson disease. in this condition there is a sudden release of nitrogen gas that has gone into solution in the lipids of adipose tissue and of myelinated nervous tissue at the higher pressure: the released nitrogen gains access to the blood stream in which it forms bubbles. doppler ultrasound techniques show that this is quite customary when divers ascend from depth, but the lungs generally provide an effective filter so that there are no untoward systemic effects, although there may be sudden chest pain on deep inspiration ('the chokes'). gradual decompression permits the nitrogen to diffuse across the alveolar membranes and be exhaled. if, however, substantial amounts of nitrogen are released from solution, sufficient pulmonary arteries may be blocked to cause pulmonary hypertension, with resultant opening of arteriovenous communications or a patent foraman ovale, so permitting the gas to enter the systemic circulation. this is often followed by limb pains ('the bends') and perhaps cerebral symptoms ('the staggers'). fatal cases are characterised by gas bubbles within blood vessels throughout the body and froth in the heart chambers. delayed effects include ischaemic necrosis of bones and other tissues. deep-diving mammals are protected by the same mechanism that prevents them suffering from burst lung. they exhale before diving and during the dive the chest is compressed to the extent that virtually all the gas in the lungs passes into the cartilage-buttressed nonrespiratory airways (see fig. . . ) , resulting in very little to be absorbed by the blood. the pulmonary collapse also serves to reduce buoyancy. the distribution of the little gas that is absorbed is minimised by bradycardia. many viscera experience anaerobic respiration but hypoxia is minimised in the heart and musculature by high levels of haemoglobin and myoglobin. the brain is further protected by the supplying arteries drawing on oxygen stored in an unusual spongelike cervical organ known as the rete mirabilis. mountain sickness is due to reduced atmospheric pressure brought about more slowly than that responsible for decompression sickness . , it may be acute or chronic. acute mountain sickness is likely to be experienced by anyone who ascends above - m without a period of acclimatisation at intermediate levels. symptoms are as liable to occur in people born at high altitude who return after a few weeks spent at sea level as in those who go to the mountains for the first time: acclimatisation is obviously short-lived and is therefore necessary whenever an ascent is to be made. the ill-effects are commonly precipitated by exercise. in the susceptible, acute mountain sickness commonly appears within days of ascent. the basis of acute mountain sickness is tissue hypoxia. it results in deteriorating intellectual and psychological function, headache, nausea, vomiting, and more rarely pulmonary and cerebral oedema. high-altitude pulmonary oedema is characterised by increasing dyspnoea, cyanosis and a dry cough, and later the production of copious, frothy sputum, which sometimes becomes blood-stained. the pulmonary artery pressure is markedly raised but wedge pressures are normal, indicating that the left side of the heart is unaffected and that pulmonary venous constriction is unlikely to be an important contributory factor. the pulmonary oedema fluid has a high protein content and the condition has been characterised as a non-cardiogenic high-permeability oedema associated with excessive pulmonary hypertension. , hypoxia is a well-known cause of pulmonary arteriolar constriction but in acute mountain sickness the vascular response appears to be exaggerated for the pulmonary artery pressure is considerably higher than is usual for the altitude. an association with certain hla complexes (hla-dr and hla-dq ) suggests that this has a genetic basis. although arteriolar constriction only tends to protect the pulmonary capillaries, it could explain the oedema if the process was patchy -as is the resultant oedema -for patchy arteriolar constriction would subject the rest of the lung to abnormally high pressures and lead to capillary stress failure in these areas (see pp. and ). , measurements of capillary pressure suggest that this is indeed the case. furthermore, vasodilators such as calcium channel blocking agents and inhaled nitric oxide gas , , have been used with success to counter acute mountain sickness, supporting the idea that hypoxic vasoconstriction plays a central role. autopsy shows the lungs to be heavy and firm. the cut surface weeps oedema fluid, which is often blood-stained, but a striking feature is the patchy distribution of the changes. areas of haemorrhagic oedema alternate with others that contain clear oedema fluid and others that are normal apart from overinflation. pulmonary arterial thrombi are commonly found. microscopy confirms the presence of haemorrhagic oedema and may show neutrophils and hyaline membranes in the alveoli. the alveolar capillaries are congested and may contain thrombi. there may also be an increase in mast cells and rarely pulmonary infarction. the right ventricle is commonly dilated whereas the left ventricle is normal. highlanders generally show right ventricular hypertrophy and increased muscle in their pulmonary arteriesm, changes that are not apparent in lowlanders. , chronic mountain sickness prolonged residence at high altitude leads to hypoxic pulmonary hypertension (see p. ), an increase in red cell mass and cor pulmonale. livestock taken from lowland plains to high-altitude pastures suffer similarly but the natural stock of the himalayas and ethiopian highlands are apparently immune. so too are other species long established at high altitude such as the llama and yak. these species are said to have adapted to their climate, that is, the forces of natural selection have bred out the pulmonary vasoconstrictive response to hypoxia. cattle of european origin and humans acclimatise to high altitude by processes such as increasing their red cell mass but generally they are not adapted like native species and suffer hypoxic pulmonary hypertension at altitudes in excess of m. certain himalayan highlanders may be an exception to this in that their small pulmonary arteries are reported not to show the muscularisation that characterises hypoxic pulmonary hypertension. in cattle of european origin, the dependent oedema of right-sided cardiac failure caused by hypoxic pulmonary hypertension affects the breast (brisket) particularly and in the rocky mountains of north america such cattle are said to have 'brisket disease' . a human counterpart of this has been described in children of chinese ancestry who have been taken to reside in tibet and who have developed a fatal form of subacute infantile mountain sickness. a small minority of permanent residents in the andes develop the changes of chronic mountain sickness to a marked degree and are said to suffer from monge's disease. the basis of this is alveolar hypoventilation, which leads to a progressive fall in systemic arterial oxygen saturation and elevation of haemoglobin concentration to an unusually severe degree. the latter averages about g/dl, which exceeds even the g/dl found in healthy high-altitude residents. patients with monge's disease are so deeply cyanosed that their lips are virtually black. their pulmonary artery resistance is also markedly raised. the cause of the alveolar hypoventilation is uncertain but the only cases of monge's disease that have come to necropsy had conditions such as kyphoscoliosis that predispose to alveolar hypoxia. drowning is defined as suffocation by submersion, and usually occurs in water. it is the commonest cause of accidental death among divers but % of drowning accidents do not involve deep descents. falling into quite shallow water is a particularly common cause of drowning in young children. in adults, men outnumber women by to . more die in fresh water than the sea, not because it is more hazardous to the lungs than sea water, but because unguarded inland waters and swimming pools are visited more frequently. alcohol consumption contributes to many deaths by drowning. drowning is not simply a matter of being unable to keep one's head above water. this may be merely a secondary event. for example, the entry dive may result in underwater head injury, or the exertion of swimming may precipitate a heart attack. furthermore, the struggling swimmer going down for the third time ('drowning not waving') is the exception: most drowning is characterised by the swimmer failing to surface or quietly dropping beneath the surface without anyone noticing. swimming underwater can be extremely hazardous if it is preceded by hyperventilation, a danger that needs to be more widely appreciated. hyperventilation results in undue loss of carbon dioxide so that instead of hypercapnia forcing the swimmer to surface to breathe, progress under water may be continued until hypoxia causes sudden loss of consciousness. panic contributes to many swimming accidents and is often precipitated by the inadvertent aspiration of just a little water. most people are naturally buoyant, but only slightly so. with the lungs fully expanded the average adult has a positive buoyancy of about . kg, which is sufficient to keep the head out of the water if the rest of the body is submerged. if an arm (weight about kg) is raised to wave for help, the head will go down. if the swimmer shouts, exhalation reduces buoyancy to neutral at normal end-expiration and to negative at residual volume. buoyancy cannot be regained when the head is submerged and unless able to swim to the surface, the person will continue to sink. autopsy generally shows that the lungs are full of water, but some victims die of 'dry drowning' due to laryngospasm. events may also be modified by the temperature of the water. sudden immersion in cold water may result in tachycardia, hypertension and hyperventilation, making it difficult for the victim to keep the airways free of water. it may also result in sudden death due to ventricular fibrillation. even a good swimmer loses consciousness within an hour of immersion in very cold water. drowning is then inevitable unless a correctly fitted life jacket is worn, in which case there is a danger of death from hypothermia. however, as in open heart surgery, cold prolongs the interval before there is irreversible brain damage. if the person is rescued, water in the lungs is quickly absorbed, even if it is saline, and therefore hyperosmolar:aspirated sea water is quickly equilibrated by pure water joining it from the blood but the alveolar epithelial barrier remains impermeable to protein and once osmotic equilibrium is reached, all is quickly reabsorbed. [ ] [ ] [ ] fresh water is absorbed even more quickly. it is unnecessary to tip the patient to hasten this process. any water recovered in this way comes from the stomach and time that should be devoted to mouth-to-mouth breathing and cardiac massage is lost. these resuscitative efforts may need to be prolonged as fresh water in particular inactivates alveolar surfactant, leading to alveolar collapse which persists until the surfactant is replenished. very few victims who are resuscitated on site fail to survive, and very few who cannot be resuscitated on site recover later. interchange of fluid between the blood and air spaces may cause major fluctuations in plasma volume with consequent changes in ionic concentrations and haemolysis. hypervolaemia may cause circulatory problems but hyperkalaemia consequent upon the haemolysis is not thought to be as important as was formerly believed: ventricular fibrillation following submersion is more likely to be a complication of hypothermia than of electrolyte imbalance. circulatory collapse may ensue shortly after rescue. this is due to loss of the circulatory support provided by the pressure the water exerts on the body, which results in a considerable increase in cardiac output while the body is immersed. on leaving the water the loss of this support results in a tendency to venous pooling. although this is countered by baroreceptor responses, these are reduced by prolonged immersion in cold water. circulatory collapse is believed to be the cause of death in many persons who perish within minutes of rescue. to counter this effect, patients should be lifted out of the water in the prone position. it can be seen that, in fatal cases, the pathologist is faced with several possibilities. thus, death may have been due to: • natural causes before the body entered the water • unnatural causes before entry, the body merely being disposed of in the water • natural causes in the water • injuries received in the water from impact with rocks, a boat or a ship's propeller, or in tropical waters from predators such as a crocodile or a shark (any of which may also be incurred after death, as may disfigurement by fish and rats) • 'dry drowning' • true drowning • hypothermia • circulatory failure after rescue. true drowning is indicated by froth in the airways and heavy waterfilled lungs. both fresh and salt water contain numerous microscopic algae known as diatoms and those representative of the water in which the drowning occurred are found in the lungs. unless death occurred before submersion, diatoms are also found in other viscera because these tiny life forms easily enter the circulation. thus, the presence of diatoms in digests of organs such as the kidneys, liver, brain and bone marrow suggests that death was due to drowning. because they have a siliceous capsule, diatoms are resistant to putrefaction as well as digestion and can be identified in the body long after death. however, a positive test is not always accepted as proof of drowning and a negative test does not exclude drowning. the various physical forms in which respirable environmental agents may be encountered are defined in table . . . some effects of inhalant lung injury are recognised as distinct disease entities and are dealt with elsewhere: for example, the pneumoconioses on page , extrinsic allergic alveolitis on page , chronic bronchitis on page and lung cancer on page . other respirable agents, such as lead fume and carbon monoxide gas, exert their harmful effects elsewhere in the body and will not be considered further. this section is concerned with toxic substances that may be inhaled by the general public. those that are more likely to be encountered in the workplace or in war zones are considered on page . the lungs have a rather stereotyped pattern of response to inhaled toxins, displaying degenerative changes and inflammation of varying degree, the former sometimes amounting to necrosis. in general, the site of maximal absorption or injury is related to solubility (for gases and vapours) and particle size (for aerosols such as dusts, fog, fumes, mists, smog and smoke): the less water-soluble and the smaller the particle size, the further down the respiratory tract the agent will penetrate ( fig. [ ] [ ] [ ] thus, ammonia produces intense congestion of the upper respiratory passages and laryngeal oedema whereas phosgene has little effect on these sites but causes pulmonary oedema. air pollution [ ] [ ] [ ] [ ] [ ] the toxic (as opposed to allergenic) air pollutants thought to pose the greatest threat to the lungs comprise smoke particles, sulphur dioxide, oxides of nitrogen, various aldehydes and ozone. smoke and sulphur dioxide derive particularly from the combustion of fossil fuels in domestic fires and power stations, nitrogen dioxide is an important car exhaust and domestic gas appliance pollutant and ozone is the principal photochemical product of smog. aldehydes such as formaldehyde and acrylic aldehyde (acrolein) also contribute to general air pollution because they are released in the combustion of diesel oil and petrol. collectively, these pollutants have been incriminated in the exacerbation (rather than causation) of asthma. they also predispose to respiratory infection and result in airway inflammation and hypersecretion. , their effect on children is of particular concern because development of the lungs is known to continue well into childhood and damage to the lungs before their growth is complete is likely to be irreparable. at the other extreme of life episodes of severe air pollution are known to hasten the deaths of many patients with chronic airway disease. particularly high concentrations of the agents responsible for air pollution may be encountered in industry and their effects are therefore also considered in chapter . , on occupational diseases of the lung. many of the polycyclic hydrocarbons found in polluted air are carcinogenic (see p. ) and it is therefore not surprising that urban air pollution has been found to be associated with excess mortality from lung cancer. domestic air pollution is rife in many of the poorer parts of the world due to the burning of biomass (wood, dried cow dung, bagasse, straw) in unventilated living rooms for heating and cooking. the women are particularly at risk of developing chronic bronchitis while their children have an increased incidence of acute respiratory infections. , , a volcanic ash (tephra) irritates the eyes, skin and respiratory tract and in some eruptions may contain much free silica (e.g. montserrat in and mount st helens, washington state, usa in ) or be associated with the release of radon gas (e.g. the azores in ). the destruction of the world trade center in caused massive air pollution of new york city that had lasting respiratory effects on survivors, rescue workers and local residents. [ ] [ ] [ ] at the time of the disaster there was much smoke from combustion of aeroplane fuel and flammable materials in the building while the collapse of the twin towers released dust from cement and dry-wall partitions that was highly alkaline. [ ] [ ] [ ] this caused considerable irritation of the eyes and the conductive airways. a year later many victims were still suffering from bronchial hyperreactivity and poor ventilatory function, in a so-called reactive airways dysfunction syndrome , and there was continuing spirometric decline years later. the respirable portion of the dust formed only a small fraction of the whole but given the level of exposure its future effects cannot be discounted, particularly as it contained substances such as asbestos. unusual effects attributed to the disaster include acute eosinophilic pneumonia and granulomatous pneumonitis. , allergenic air pollutants are dealt with in detail in the sections on asthma (see p. ) and extrinsic allergic alveolitis (see p. ). allergenic air pollution is generally occupational or domestic but periodic widespread air pollution was responsible for the epidemics of asthma seen in barcelona in the s, which were eventually traced to ships discharging cargoes of soya flour (see p. ). smoking-related diseases figure large throughout this book and in this section they are merely summarised collectively. of the greatest importance, both in the number of patients they affect and in their clinical effects on the individual, are the various forms of chronic obstructive lung disease and lung cancer, but there are many other respiratory diseases associated with smoking, and a few that are less common in smokers (box . . ). not surprisingly, these diseases are often encountered in combination and sometimes one may obscure another. for example, a cigarette smoker may have emphysema in the upper lobes and idiopathic pulmonary fibrosis in the lower lobes. , alternatively, langerhans cell histiocytosis and desquamative interstitial pneumonia may affect the same parts of the lungs, in which case the focal lesions of the former may be masked by the latter condition. the term 'smoking-related interstitial lung disease' has been introduced to cover a spectrum of interstitial diseases related to smoking , , as well as being used in a more restricted sense to describe a combination of air space enlargement and interstitial fibrosis predominantly affecting the lower lobes. , , a quite advanced interstitial fibrosis has been reported in smokers with no clinical evidence of interstitial lung disease. b early changes detectable in smokers include chronic bronchiolitis, fibrosis of the bronchiolar wall and mild peribronchiolar interstitial fibrosis. , even earlier changes are detectable at the molecular level: as many as smoking-responsive genes that are significantly up-regulated or down-regulated have been identified in normal cigarette smokers. there is marked individual variation, which may explain why many lifelong heavy smokers experience no respiratory problems. histological evidence that a patient smokes is provided by an increase in the number of alveolar macrophages and a characteristic brown discoloration of cytoplasm due to the phagocytosis of tar and other particulate matter derived from tobacco smoke (fig. . . ) . cigarette smokers are at greater risk of lung disease than cigar and pipe smokers, probably because they inhale more deeply. they do this because cigarette smoke is more acid than cigar and pipe smoke and its nicotine content is therefore absorbed more easily through the lungs than the buccal mucosa. smokers obviously put their own health at greatest risk but the lesser hazards of passive smoking are now well recognized (see p. ). passive smoking involves both the smoke exhaled by others and that coming from smouldering tobacco between puffs, the latter being known as sidestream smoke. the harmful effects of maternal smoking on the unborn child also come in this category. they include increased airway responsiveness and reduced lung function during the neonatal period and an increased risk of sudden infant death syndrome. reduced numbers of alveolar attachments to the bronchioles have been demonstrated in such infants. smoking is also associated with disease of other organs (e.g. carcinoma of the oesophagus and bladder) but these are outwith the remit of this text. tobacco smoking by waterpipe (shisha, hubble-bubble) is enjoying a rise in popularity, both in its heartland, the middle east, and western countries, and wherever it is practised it is widely perceived as being less dangerous than smoking cigarettes. this is probably a mis conception. what evidence there is suggests that waterpipe tobacco smoking is just as harmful as cigarette smoking, if not more so. the lungs may be injured in burned patients in many ways (box . . ) , but an important consideration when a body is recovered from a fire is whether death was due to the fire or took place beforehand, the latter raising the possibility of foul play. a vital reaction to the skin burns and the presence of soot in the lower airways provide evidence that death occurred in the fire but an absence of soot from the airways may be due to death occurring rapidly, from asphyxia or poisoning by gases released in the conflagration. soot is cleared rapidly and if the patient survives a few days an absence of soot from the airways is to be expected. lung injury may result directly from heat and smoke inhalation or indirectly from the release of mediators associated with blast injury or shock. although air temperature in a fire may reach very high temperatures thermal injury seldom extends beyond the carina but more extensive injury from heat alone was seen in men exposed to steam escaping from a fractured boiler pipe. those dying immediately showed coagulative necrosis of the respiratory mucosa down to the level of the alveolar ducts and alveolar congestion and oedema, while those surviving a little longer exhibited diffuse alveolar damage. the diffuse alveolar damage probably represented a manifestation of shock from their extensive cutaneous scalding whereas the mucosal necrosis is directly attributable to heat. diffuse alveolar damage is extrinsic allergic alveolitis sarcoidosis blast injury asphyxia poisoning by combustion products (e.g. carbon monoxide, cyanide) direct thermal injury (largely limited to the trachea) irritant smoke, fume and gas (e.g. oxides of nitrogen, ammonia, acrolein, sulphur dioxide) hypovolaemic shock secondary to skin loss septicaemic shock from: infected skin burns infected central lines secondary viral and bacterial pneumonia fluid overload tracheostomy complications, including tracheobronchitis, pneumonia and barotrauma oxygen toxicity absorption of toxic topical disinfectants thromboembolism uraemia usually part of systemic multiorgan failure in these patients, and is the leading cause of death in burns. the ubiquity of plastics today means that smoke contains numerous irritants, including isocyanates, aldehydes and fluorinated organic chemicals. irritant smoke products have two principal effects. firstly, they cause an immediate painful stimulation of the eyes and respiratory tract which at low concentrations may prevent escape and at high concentrations may cause laryngeal spasm and death. secondly, they cause bronchopulmonary injury some hours after exposure. burned patients dying within - days often show tracheobronchial necrosis and diffuse alveolar damage with prominent hyaline membranes. , , secondary herpesvirus infection is often present. , the respiratory changes caused by heat and smoke are non-specific and careful consideration of the many causes of lung injury in burned patients listed in box . . and of the clinical circumstances and management is generally required. often it will be concluded that the cause of the lung injury is multifactorial. long-term consequences of smoke inhalation include bronchiectasis and obliterative bronchiolitis. methyl isocyanate, the chemical released at bhopal the bhopal catastrophe of was caused by the accidental release of tons of methyl isocyanate gas (ch -n=c=o) from a pesticide plant. over people were exposed, of whom died, mostly within hours of exposure, and were seriously injured. the victims complained of intense ocular and respiratory irritation. some survivors were left with persistent respiratory impairment, which was thought to be due to obliterative bronchiolitis. , methyl isocyanate is an extremely potent respiratory irritant, destroying the epithelium throughout the conducting airways, with comparatively less parenchymal injury. in survivors, epithelial regeneration, often involving squamous metaplasia, quickly commences, but not before endobronchial granulation tissue projections have developed, resulting in obliterative bronchiolitis. tear gases are chemical irritants delivered as an aerosol for the purpose of riot control. they react with mucocutaneous sensory nerve receptors causing intense irritation of the eyes, mucous membranes and skin. the respiratory effects are mainly concentrated on the upper tract so that there is violent sneezing, severe rhinorrhoea and cough but there may also be tracheobronchitis and rarely pulmonary oedema. patients with pre-existent asthma or chronic obstructive pulmonary disease are most severely affected while others may be left with reactive airways dysfunction. toxins reaching the lungs via the blood stream may be drugs, food contaminants, metabolites produced elsewhere in the body, or chemicals ingested intentionally or accidentally, either in the home or the workplace. the lungs are selectively damaged by certain blood-borne toxins for a variety of reasons. for example, the herbicide paraquat is preferentially taken up by the lungs because of its molecular homology with certain endogenous substances. as detailed below, the type i alveolar epithelial cells are the cells that bear the brunt of the damage in paraquat poisoning. on the other hand, the alveolar capillary endothelium has its own selective uptake mechanisms (see metabolic functions of the pulmonary endothelium, p. ) which may be responsible for it being selectively damaged by other chemicals. the bronchiolar clara cells are selectively injured by some ingested chemicals because they are equipped to deal with inhaled xenobiotics, but occasionally this activity results in metabolites that are extremely toxic. an example of this from veterinary medicine is provided by the furan-derivative -ipomeanol, which is found in mouldy sweet potatoes and results in acute pulmonary oedema in cattle fed such a diet. when this chemical is injected into mice, the bronchioles are denuded of clara cells whereas the intervening ciliated cells are completely unaffected. the selective damage to the bronchiolar clara cells appears to stem from the oxidative efficiency of their p- cytochromes, which is much higher than those of the liver. chemicals having a similarly selective effect on bronchiolar clara cells include -methylfuran, carbon tetrachloride, naphthalene and , -dichloroethylene, the last of which is a volatile compound that is widely used in the plastics industry. procarcinogens may be activated in the airways by similar mechanisms. paraquat is a dipyridylium compound that is widely used in agriculture as a herbicide. it kills all green plants but is inactivated on contact with the soil. it is applied as a spray and if the manufacturer's instructions are followed there is no danger to health. most fatal cases of paraquat poisoning, both accidental and suicidal, have been due to ingestion of the % aqueous solution gramoxone. the less concentrated granular form weedol is unlikely to be ingested accidentally but may be taken suicidally. paraquat is not absorbed by the intact skin but repeated or prolonged application damages the epidermis so that absorption into the blood stream with consequent systemic effects is possible, but rare. although paraquat has toxic effects on the liver, kidneys and myocardium, these are transient and attention has centred on the pulmonary changes, which are usually fatal. following suicidal ingestion of large amounts of paraquat, death from multiorgan failure and pulmonary haemorrhage occurs within a few days, whereas most victims of accidental paraquat poisoning die from progressive pulmonary fibrosis between and days after ingestion. in those who survive longer, a honeycomb pattern of pulmonary fibrosis may be apparent. paraquat is a powerful oxidant and owes its toxicity to the production of active oxygen radicals. the lungs are particularly susceptible because paraquat is concentrated there by an active uptake mechanism in the alveolar epithelium. the inadvertent uptake of paraquat probably stems from a similarity between the molecular arrangement of its quaternary nitrogen atoms and the amine groups of endogenous oligoamines such as putrescine, spermidine and spermine, which are concerned in alveolar epithelial cell division and differentiation (fig. . . ) . this results in paraquat levels being - times higher in the lung than in the plasma. once taken up by the lung, paraquat is not metabolised but participates in redox cycling so that superoxide radicals are constantly produced. epithelial injury is proportional to the concentration of paraquat, while it is lessened by hypoxia and antioxidants such as superoxide dismutase, and potentiated by increased concentrations of oxygen. [ ] [ ] [ ] [ ] the high concentration of oxygen in the alveoli is a further reason why the lungs are particularly vulnerable to paraquat. knowledge of the toxic effects of paraquat comes from observations on autopsy series , , and from experimental studies that have enabled the sequence of pulmonary changes to be observed. [ ] [ ] [ ] [ ] in accordance with paraquat being taken up by the alveolar epithelium, electron microscopy shows that these cells suffer more profound damage than the endothelium. type i epithelial cells swell and undergo necrosis (fig. . . ), whilst type ii cells, although remaining capable of proliferation, show ultrastructural evidence of damage with derangement of cell organelles. , histological changes in the lungs follow the pattern of diffuse alveolar damage, with a characteristic feature of the early exudative phase being intense vascular congestion and alveolar haemorrhage. , , hyaline membranes are most clearly seen by about days (fig. . . ) and epithelial proliferation and fibrosis are conspicuous by about days. the pattern of pulmonary fibrosis in paraquat poisoning has been disputed. some authors have stressed its interstitial position, whereas others have clearly demonstrated that it is intra-alveolar. , , [ ] [ ] [ ] [ ] however, as described on page , it generally assumes an obliterative pattern of intra-alveolar fibrosis in which the lumina of several adjacent alveoli are totally effaced, rendering them completely airless (see fig. . , p. ). a new multisystem disease appeared abruptly in the environs of madrid in . [ ] [ ] [ ] over people were affected and about in died. the disease was initially thought to be mycoplasma pneumonia but was soon found to be associated with the use of adulterated oil sold illicitly by door-to-door salesmen. although it was sold for culinary purposes the oil had been produced for industrial use in steel manufacture. it consisted of rapeseed and olive oil mixed with liquified animal fat, aniline and other organic chemicals. it has not been possible to identify the exact chemical responsible for the disease or to reproduce the changes in other species but the later induction of similar pathological changes by another substance contaminated with an aniline derivative is possibly relevant (see l-tryptophan-induced eosinophilia-myalgia syndrome, p. ). some clinical and pathological features of the disease suggest that immune mechanisms may also be involved. the initial clinical features included fever, respiratory distress, cough, haemoptysis, skin eruptions and marked eosinophilia. radiographs suggested pulmonary oedema and sometimes showed pleural effusion. about % of patients died at this stage but most recovered quickly. however, within a few weeks many were readmitted to hospital with nausea, vomiting, diarrhoea and abdominal pain. about a quarter then proceeded to develop weakness, myalgia, weight loss, scleroderma-like skin signs and pulmonary hypertension. , many of these patients died after a long, wasting illness or are permanently disabled with neurological and hepatic disorders. in the early phase the lungs showed the most severe changes, which consisted of a combination of diffuse alveolar damage, eosinophilic infiltrates and arterial luminal narrowing by endothelial swelling and vacuolation, intimal foam cell infiltration and a non-necrotising vasculitis. , , there was also capillary thrombosis, which later extended into arteries and veins, culminating in fibrosing obliteration of these blood vessels. in some patients dying of haemoptysis, dilated thin-walled blood vessels were identified in the mucosa of major blood-filled airways. late features in the lungs included plexogenic arteriopathy (see p. ), possibly secondary to changes in the liver. similar inflammatory and vascular changes were seen in many other tissues. notable extrapulmonary features included fasciitis, vasculitis, neuronal degeneration, perineuritis, hepatic injury and tissue eosinophilia. sauropus androgynus is a vegetable that is widely cultivated for the table in many south-eastern asian countries. it is apparently harmless when cooked but recently there has been a vogue in taiwan for consuming large amounts of its unprocessed juice, blended with that of guavas or pineapple, because of its supposed efficacy as a slimming aid and in blood pressure control. coincident with this fad there has been an upsurge in patients with symptoms of obstructive lung disease. within a -month period more than such patients were seen at one hospital. [ ] [ ] [ ] they had four features in common: recent consumption of uncooked s. androgynus juice, fixed ventilatory obstruction, radiological evidence of bilateral bronchiectasis and an absence of any previous chronic respiratory disease. four patients agreed to undergo open-lung biopsy. this showed chronic bronchiolitis or obliterative bronchiolitis of constrictive pattern. the lymphocytes were mainly t cells but immunofluorescent and electron microscopy showed no evidence of an immune process. four patients underwent single-lung transplantation. the excised lungs showed sclerotic obliteration of bronchial arteries in the walls of bronchi - mm in diameter with segmental necrosis of bronchi - mm in diameter. the changes were considered to fit best with segmental ischaemic necrosis of bronchi at the watershed zone of the bronchial and pulmonary vasculature. further patients have required lung transplantation but public education of the dangers of this herbal medicine now appears to have been successful. alcohol and nicotine outstrip all other recreational drugs in popularity and their effects are of course well known. those of tobacco smoking are summarised above and dealt with in detail in the chapters on obstructive lung disease (chapter ) and carcinoma of the lung (chapter . ). less well known is the lung disease that results from smoking blackfat tobacco, a practice popular with guyanese indians. blackfat is the trade name of a type of tobacco that is flavoured with mineral oil, some of which vaporises and is inhaled when the tobacco is smoked, to cause exogenous lipid pneumonia (see p. [ch ] ). in recent years the smoking of two other substances, marijuana and cocaine, has gained in popularity. it would not be surprising if the long-term effects of smoking these substances were similar to those of cigarette smoking but as yet it is too early to judge. however, the short-term effects are similar to those of tobacco smoking and this bodes badly for their ultimate effects. marijuana consists of the dried leaves of the cannabis plant, also known as hemp, as opposed to hashish, which is the plant's resin, and a further extract known as 'weed oil' . all these substances are smoked because they contain cannabis alkaloids which have psychoactive effects. however, this habit also exposes the lungs to many of the same respiratory irritants that are found in tobacco smoke. initial exposure to marijuana smoke often results in coughing while habitual smokers produce black sputum. bronchial biopsy shows inflammation and squamous metaplasia and bronchoalveolar lavage demonstrates increased numbers of cells, which are predominantly macrophages but also include neutrophils. [ ] [ ] [ ] [ ] [ ] these changes are virtually identical to the short-term effects of tobacco smoke and are therefore likely to be similarly followed by the development of chronic obstructive lung disease and lung cancer. indeed, the dangers of smoking marijuana are probably greater than those of smoking tobacco as compared with tobacco smoking it is associated with a fivefold greater increase in blood carboxyhaemoglobin and a threefold increase in the amount of tar inhaled. it is estimated that three cannabis cigarettes result in the same degree of bronchial damage as tobacco cigarettes. there is also evidence that the effects of smoking marijuana and tobacco are additive. not surprisingly therefore, epidemiological studies report a doserelated impairment of large-airway function in marijuana smokers. there are also several reports attributing pneumothorax to marijuana smoking ( fig. . . ) . , the pneumothorax may be spontaneous or develop during the deep, sustained inspiratory effort involved in smoking marijuana (or cocaine), which may be enhanced by a partner applying positive ventilatory pressure by mouth-to-mouth contact. thoracoscopy in such cases has shown predominantly apical, irregular bullous emphysema, while lung biopsy has demonstrated widespread alveolar filling by heavily pigmented macrophages. , evidence is also beginning to accumulate that long-term cannabis use increases the risk of lung cancer. smoking cannabis in the form of weed oil is also reported to result in exogenous lipid pneumonia. cocaine cocaine hydrochloride is a fine white powder derived from the leaves of the plant erythroxolon coca by a complex chemical process. it is heat-labile and therefore cannot be smoked. users inject it intravenously or inhale it unheated through the nose, the latter practice being known as 'snorting' . however, a heat-stable free-base form that can be smoked is easily prepared from the hydrochloride with baking powder and a solvent such as ether. this process results in a crystalline deposit that is known as 'rock' because of its appearance or 'crack' because of the crackling sound it emits when heated. when smoked, the cocaine is readily absorbed and an intense surge of euphoria is experienced within seconds. the intravenous route takes twice as long and 'snorting' several minutes. the hard addict therefore prefers to smoke 'crack' . a variety of pulmonary complications of smoking free-base cocaine has been reported. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] acute effects include cough, shortness of breath, chest pain and haemoptysis. asthma may be aggravated, black sputum is produced, and pneumothorax and interstitial emphysema have resulted from valsalva manoeuvres undertaken in the belief that they promote even more rapid absorption. biopsy has shown pulmonary congestion and oedema, organising pneumonia, haemorrhage, haemosiderosis, diffuse alveolar damage and interstitial pneumonia or fibrosis. less common effects include eosinophilic pneumonia, extrapulmonary eosinophilic angiitis, medial thickening of pulmonary arteries and the barotrauma described above (see fig. . . ) . severe burning of the airways has also been seen due to 'crack' being smoked before all the ether used in its preparation has evaporated. 'snorting' unheated cocaine has its own complications: substances such as cellulose or talc with which the drug is 'cut' (mixed as a diluent) are liable to provoke a foreign-body giant cell reaction in the lungs (fig. . . ). however, particles of foreign material larger than those in the usual respirable range (allowing for the fibrous shape of substances such as cellulose) should suggest intravenous use (see 'filler embolism', below). heroin is usually injected, but it may be smoked, when, as with marijuana, it is liable to lead to a very pronounced macrophage response. intravenous heroin abuse sometimes causes the sudden onset of a potentially fatal high-permeability pulmonary oedema (fig. . . ). intravenous abuse of heroin and other drugs is also liable to cause 'filler embolism', which will now be considered. 'filler embolism' is the result of illicit drug usage in which compounds designed for oral use are injected intravenously to heighten their effects. oral preparations consist largely of fillers such as talc or starch and this insoluble particulate matter accumulates in the pulmonary capillaries. it provokes a foreign-body giant cell reaction, thrombosis and fibrosis and may cause pulmonary hypertension ( fig. this 'designer' drug, taken for its central stimulant activity (street names 'ice' or 'u- -e-uh', pronounced euphoria), is related to the appetite suppressor aminorex, discussed on page , and has similarly been associated with pulmonary hypertension. assessing whether a particular clinical manifestation represents an adverse drug reaction considers previous experience with the drug, alternative aetiological agents, the timing of events, drug levels, and the effect of withdrawing the drug and rechallenge with the drug. it is worth bearing in mind that: • one drug may cause several patterns of disease. • one pattern of disease may be produced by a variety of drugs. • a drug reaction may develop long after the drug has been withdrawn. • a drug reaction may develop suddenly even though the dose of the drug has not been altered. • drug effects may be augmented by factors such as age, previous radiotherapy and elevated oxygen levels. • drug reactions may be localised. • many drugs cross the placenta to affect the fetus. an alternative classification of adverse drug reactions, which is more appropriate to pathology practice and which will be followed here, is one based on the pattern of disease. some pathological patterns of drug-induced lung disease are shown in table central depression of respiration occurs as a side-effect of barbiturates, morphine and its derivatives, and even mild sedatives, and may be particularly troublesome in patients suffering from chronic obstructive lung disease. ventilation in such patients may be largely dependent on hypoxic respiratory drive and treatment with oxygen may therefore also have an adverse effect on respiration by lowering the degree of hypoxia and so diminishing the stimulation of the respiratory centre. peripheral impairment of the respiratory drive may be brought about by aminosides and other antibiotics, while corticosteroids may result in a myopathy affecting the respiratory muscles. other iatrogenic hazards affecting the peripheral nerves controlling respiration include nerve root disease complicating immunisation and surgical damage to the spinal and phrenic nerves. asthmatic patients are particularly susceptible to exacerbations of their disease by drugs (box . . ). this effect may occur either as a predictable pharmacological side-effect of the drug or as an idiosyncratic response. examples of the former include β-adrenergicic antagonists and cholinergic agents while examples of the latter include sensitivity to the colouring agent tartrazine, for which reason many manufacturers have eliminated tartrazine from their red, orange and yellow tablets. allergic bronchoconstriction also forms part of generalised anaphylactic reactions induced by vaccines and antisera and occurs as a localised response to penicillin, iodine-containing contrast media, iron dextran and other medicaments. bronchospasm may also be initiated by the non-specific irritant effect of inhaling nebulised drugs if they are prepared as a hypotonic solution, a side-effect that is prevented by using isotonic solutions. aspirin and other non-steroidal anti-inflammatory agents aspirin-induced asthma has been recognised for many years and more recently several of the newer anti-inflammatory drugs have been found to exacerbate asthma in certain sensitive individuals. the basis for this is uncertain but the likelihood of an individual antiinflammatory drug provoking an asthmatic response is related to its potency as an inhibitor of prostaglandin cyclooxygenase pathway, resulting in the production of leukotrienes. [ ] [ ] [ ] as well as asthma being exacerbated by drugs, the disease has been caused by occupational exposure in the pharmaceutical industry to certain drugs which can be inhaled during manufacture, notably penicillin, cephalosporin, methyldopa, cimetidine and piperazine. obliterative bronchiolitis of the constrictive type has been reported with penicillamine , and gold , but in many cases it is possibly the underlying condition rather than the drug that is res ponsible (see p. ). this is often rheumatoid disease, which is sometimes complicated by bronchiolitis obliterans whether the patient is under treatment or not. organising pneumonia extending into peripheral bronchioles (see p. ) may be seen with a variety of drugs but results in a restrictive rather than obstructive lung defect and is to be regarded as a cytotoxic effect of the drug acting primarily at the alveolar level (see below). raw sancropus androgyns taken as a slimming aid causes severe obliterative bronchiolitis (see p. ). the cytotoxic effects of drugs may be acute or chronic, leading to changes as varied as pulmonary oedema, diffuse alveolar damage, pulmonary haemorrhage and haemosiderosis, organising pneumonia, interstitial pneumonitis and interstitial fibrosis. , some of the most severe acute effects are seen with the chemotherapeutic agents used in malignant disease but they are also recorded with drugs that are not traditionally thought to be cytotoxic, e.g. desferrioxamine administered as a prolonged intravenous infusion in acute iron poisoning. pulmonary toxicity due to busulphan was first described in , and has been the subject of several subsequent studies. [ ] [ ] [ ] [ ] it remains the mainstay of treatment for chronic myeloid leukaemia. like other alkylating agents, it acts by cross-linking dna strands. clinical estimates of the incidence of pulmonary toxicity vary around % but subclinical damage is thought to be much more common. although not strictly dose-dependent, toxicity is rarely seen with a total cumulative dose of less than mg. synergy with radiation and other cytotoxic drugs occurs. similar effects have been reported for most cytotoxic agents, particularly bleomycin. pulmonary toxicity is seen less commonly with other alkylating agents, such as cyclophosphamide and melphalan. [ ] [ ] [ ] [ ] bleomycin is a cytotoxic antibiotic derived from streptomyces species. it is widely used in the treatment of neoplasms such as lymphomas and germ cell tumours, and is thought to produce its therapeutic and toxic effects by altering the normal balance between oxidants (active oxygen radicals) and antioxidant systems. bleomycin produces superoxide radicals when incubated with oxygen and iron in vitro. oxygen enhances its effects, a fact well known to anaesthetists who accordingly take care to limit concentrations of inspired oxygen to % in patients on bleomycin who are undergoing surgery. [ ] [ ] [ ] radiotherapy and cytotoxic agents such as bleomycin are also synergistic. bleomycin is preferentially concentrated in the lungs and pulmonary fibrosis can be produced in animals when it is administered intravenously, intraperitoneally or by intratracheal instillation. electron microscopy shows that the early changes consist of swelling and vesiculation of endothelial cells, interstitial oedema and type i epithelial cell necrosis. , the reported incidence of bleomycin toxicity varies from to % depending on the type of patient being treated and on dosage. in general, toxic effects increase with age and cumulative dose: above a total dose of about units they rise significantly. the acute morphological changes attributable to drugs include pulmonary oedema and diffuse alveolar damage. acute pulmonary oedema is seen in heroin addicts who die while injecting themselves intravenously but it is also seen in patients administered a variety of drugs therapeutically, for example hydrochlorothiazide, salicylate, opiates, vinorelbine,and desferrioxamine. the oedema is of the high permeability type (see p. ), rich in protein, and is occasionally haemorrhagic or accompanied by the hyaline membranes of diffuse alveolar damage. diffuse alveolar damage has alveolar epithelial necrosis as its basis (figs . . and . . ). however, the continuing action of many cytotoxic drugs affects the regeneration process so that atypical type ii epithelial cells develop, a characteristic feature that was first described with busulphan and subsequently with bleomycin. , these two drugs differ chemically but both act (by different mechanisms) on dna. the atypical cells have abundant deeply eosinophilic or amphophilic cytoplasm and large nuclei, which may be multiple but are usually single. the nuclei measure up to µm and are densely stained throughout or contain either large homogeneous deeply eosinophilic inclusions or clear vacuoles (fig. . . ) . electron microscopy distinguishes the inclusions from nucleoli and shows them to consist of tubular aggregates derived from the internal nuclear membrane. airway epithelium shows similar nuclear changes and often undergoes squamous metaplasia. the presence of such cells in sputum specimens submitted for cytology can lead to a misdiagnosis of malignancy. fibrosis may follow diffuse alveolar damage or develop insidiously, perhaps many years after drug therapy ceased (fig. . . ) . it may be both interstitial and intra-alveolar. the interstitial component is often accompanied by a non-specific chronic inflammatory infiltrate. the proportions of inflammation, which is potentially reversible, and fibrosis, which when collagenous is irreversible, obviously bear on the prognosis. however, most case reports antedate the recent classification of interstitial pneumonia described in chapter and it is uncertain how their pathological appearances would now be classified. the majority lack the classic features of usual interstitial pneumonia and fibrotic non-specific interstitial pneumonia. many show overlapping patterns of intersitital pneumonia and this alone should arouse suspicion that a drug may have been responsible. however, some cytotoxic drugs result in pulmonary changes by more than one mechanism: for example, methotrexate may produce hypersensitivity reactions with granuloma formation [ ] [ ] [ ] [ ] or pulmonary eosinophilia as well as diffuse alveolar damage. pulmonary toxicity is also occasionally seen in patients undergoing treatment with gold salts for rheumatoid disease: in addition to diffuse alveolar damage, there may be eosinophilia and dermatitis in these cases, again indicating possible hypersensitivity. nitrofurantoin is another example of a drug resulting in a variety of patterns of alveolar injury: diffuse alveolar damage, desquamative interstitial pneumonia, giant cell interstitial pneumonia, organising pneumonia and eosinophilic pneumonia have all been recorded in association with this drug. [ ] [ ] [ ] it should also be noted that in patients with neoplastic disease, clinical features suggestive of a pulmonary drug reaction may be due to factors other than drugs. in leukaemic patients, for example, these include direct infiltration of the lungs by leukaemic cells, opportunist infection and, if bone marrow transplantation has been undertaken, the effects of irradiation and possibly graft-versus-host disease. phospholipidosis is encountered with drugs such as the antidysrhythmic agent amiodarone, which block lysosomal enzymes involved in the breakdown of complex lipids. this leads to their accumulation throughout the body but the effect is most marked in tissues that take up the drug and contain cells rich in lysosomes. the lung fulfils both these requirements through its rich complement of alveolar macrophages. these cells accumulate the enzyme substrate (phospholipid) in their cytoplasm with the result that large foam cells fill the alveoli (fig. . . ). the appearances are those of endogenous lipid pneumonia, similar to that seen in obstructive pneumonitis. however, with amiodarone cytoplasmic vacuolation is also seen in epithelial and interstitial cells. the phospholipid inclusions contained within the vacuoles are particularly well seen in unstained frozen sections viewed by polarised light. identical changes to those induced by amiodarone were seen in the lungs of rats exposed to very high levels of the antidepressant drug iprindole and the anorectic drug chlorphentermine. these three compounds, iprindole, chlorphentermine and amiodarone, all belong to the amphiphilic group of drugs which block lysosomal phospholipase and sphingomyelinase. although their pharmacological actions are very different, a molecular homology is apparent (fig. . . ) . it is likely that all patients receiving substantial amounts of amiodarone develop phospholipidosis throughout the body, but this is generally well tolerated. only a minority experience respiratory impairment and in these there is also evidence of pulmonary inflammation and fibrosis, which is possibly mediated immunologically. these patients generally have a restrictive lung deficit, the onset of which may be acute or chronic. bronchoalveolar lavage shows foamy macrophages but these cells indicate exposure to the drug rather than drug toxicity; nor are they specific to amiodarone, being observed on occasion with other drugs. lymphocytes of suppressor type may also be detected on lavage. histologically, amiodarone toxicity is diagnosed on a combination of phospholipidosis and interstitial pneumonia and fibrosis. occasionally the hyaline membranes of diffuse alveolar damage are superimposed on the interstitial changes (see fig. . . ) . [ ] [ ] [ ] in some patients the fibrosis is intraalveolar rather than interstitial and the appearances are those of organising pneumonia. the process may be localised and mimic a neoplasm radiologically. , amiodarone toxicity is probably dose-dependent but there is considerable individual variation in the amount required, , which appears to be under genetic control. amiodarone toxicity is uncommon in patients taking daily doses of mg or less whereas the there are drugs that undoubtedly cause a usual interstitial pneumonia pattern, for example the chemotherapeutic agents and nitrofurantoin (fig. . . ), while others, for example the statins, are recorded as having induced a non-specific interstitial pneumonia pattern. a drug history is therefore imperative when assessing any patient with diffuse parenchymal lung disease. organising pneumonia similar to the cryptogenic condition described on page , and probably similarly reversible with steroids, has been encountered with a variety of drugs, including amiodarone, sulphasalazine and pencillamine. penicillamine has also been incriminated in the development of both diffuse alveolitis and bronchiolitis obliterans, but both these changes could well be due to the underlying rheumatoid disease for which the pencillamine is administered. in busulphan lung there may be an organising intraalveolar fibrinous exudate, which at its most extreme results in irreversible effacement of the alveolar architecture by sheets of loose connective tissue (see p. ). with continued experimental administration of the drug iprindole mentioned above, the phospholipidosis it produced gradually evolved into alveolar proteinosis (more properly called lipoproteinosis; see p. ), but this has not been reported as a drug effect in humans. alveolar proteinosis has however been recognised in a number of patients receiving chemotherapy for conditions such as leukaemia. the mechanism here is probably based on the cytotoxic action of the drug and the material filling the alveoli may represent the detritus of degenerate alveolar cells rather than excess pulmonary surfactant, as in the primary auto-immune form of alveolar proteinosis. eosinophilic pneumonia, the pathology of which is described on page , may be caused by several drugs, including nitrofurantoin, para-aminosalicylic acid, sulphasalazine, phenylbutazone, gold compounds, aspirin and penicillin (see box . , p. ). , it may also follow radiation to the chest. the tissue eosinophilia is generally accompanied by a rise in the number of eosinophils in the blood. the clinical picture varies from transient asymptomatic opacities on a chest radiograph to a life-threatening illness with severe respiratory distress and hypoxaemia, so-called acute eosinophilic pneumonia (see p. ). the reaction is often associated with a florid rash. withdrawal of the drug may be all that is required to effect resolution but corticosteroids are usually given as they produce a marked improvement. this syndrome of necrotising granulomatosis, vasculitis and eosinophilia in asthmatic patients, which is described more fully on page , has been reported when leukotriene receptor antagonists have been used to treat asthma. however, it is likely that the syndrome has been merely unmasked by the antileukotriene permitting a reduction in corticosteroid dose rather than representing a direct effect of the antileukotriene. , mesalazine has also been implicated in inducing a vasculitis during treatment for inflammatory bowel disease. the eosinophilia-myalgia syndrome was identified in the usa in and quickly identified as being due to the ingestion of ltryptophan from one particular japanese supplier. withdrawal of this substance led to the virtual elimination of the disease, but not before patients had been affected, in fatally. [ ] [ ] [ ] [ ] [ ] cases were subsequently described in europe where there were further fatalities. l-tryptophan is an essential amino acid that is freely available to the public: its purchase does not require a medical prescription. it has been promoted as a dietary supplement and as an agent against insomnia and premenstrual tension. women in the reproductive years preponderated in the patients affected by the resultant eosinophiliamyalgia. the clinicopathological features of the syndrome are similar to those of the spanish toxic oil syndrome (see p. ) and differ more in degree than type. the discovery of an aniline-derived contaminant in the tryptophan-induced condition is a further link connecting these two syndromes. an immune basis is suggested by the identification of t lymphocytes activated against fibroblasts in the eosinophilia-myalgia syndrome. the illness is a multisystem disorder and besides blood eosinophilia and myalgia there may be arthralgia, fever, rash and involvement of the lungs, liver and central nervous system. as in the toxic oil syndrome, there is fasciitis, wasting and muscle pain associated with blood and tissue eosinophilia. the lungs are affected in % of cases. pulmonary symptoms have included cough, dyspnoea and chest pain. radiographs have shown diffuse bilateral infiltrates and pulmonary hypertension has been documented in a few cases. histology of the lungs shows an oedematous myxoid intimal thickening affecting small pulmonary blood vessels and a diffuse interstitial lymphocytic and eosinophilic infiltrate. , , , , these cells may also be seen within the walls of the thickened blood vessels (fig. . . ) . , massive ingestion of l-tryptophan has resulted in the appearances of an organising pneumonia. as an adverse drug reaction, granulomatous alveolitis is best exemplified by the extrinsic allergic alveolitis of pituitary snuff-takers, but it is also encountered on rare occasions with cytotoxic and other drugs, including methotrexate, bacille calmette-guérin (bcg) immunisation, interferons, ciprofloxacin, antiviral therapy and tumour necrosis factor antagonists. [ ] [ ] [ ] , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the histological appearances may suggest extrinsic allergic alveolitis or sarcoidosis but the centri-acinar or lymphangitic concentration of these conditions is usually lacking. however, unless an infective agent can be demonstrated the diagnosis generally requires consideration of the clinical and environmental details, including any drug regimen. exogenous lipid pneumonia may result from the unintentional aspiration of various fat-based medicaments such as liquid paraffin, oily nose drops and petroleum jelly or of fat-rich dietary supplements in the form of ghee. [ ] [ ] [ ] [ ] [ ] [ ] [ ] the consumption of liquid paraffin as an aperient is common in some countries and may be taking place without the knowledge of the patient's medical practitioner. regurgitation and aspiration of ingested oil are especially likely to happen during sleep in the presence of a hiatus hernia or when the oesophagus fails to empty completely into the stomach because of achalasia of the cardia. the aspiration of vegetable oil occurred in the past from the use of menthol in olive oil for the treatment of tuberculous laryngitis, and occasionally from the use of iodinated vegetable oils for bronchography. [ ] [ ] [ ] [ ] more recently exogenous lipid pneumonia has developed from the constant sucking of lollipops formulated for the administration of the analgesic fentanyl but also containing a stearate component. the treatment of epistaxis by nasal packing with paraffin gauze has also led to exogenous lipid pneumonia. the pathology of exogenous lipid pneumonia is described on page . other medicines may also be aspirated unwittingly, for example a ferrous sulphate tablet may cause brown iron staining and necrosis of the bronchus at the point of impact, progressing to bronchial stenosis. [ ] [ ] [ ] distal infection is then likely, as with any foreign body. barium sulphate aspiration may complicate gastrointestinal radiography. large amounts may impair ventilation but being inert there is no permanent injury to the lungs, although the striking changes are evident on the chest radiograph. an outbreak of pulmonary hypertension affecting many swiss, austrian and german patients in the period - was probably due to the anorectic drug aminorex, which was accordingly withdrawn with regression in the number of new cases. the pathology in these patients was identical to that of primary pulmonary hypertension (see p. ) and it proved impossible to reproduce the condition in laboratory animals but the epidemiological evidence that aminorex was to blame is very strong. fenfluramine and phentermine, further anorectic drugs that are chemically similar to aminorex, have also been associated with such plexogenic pulmonary hypertension, [ ] [ ] [ ] [ ] [ ] and with fibroproliferative plaque on the tricuspid valve and pulmonary arteries. pulmonary hypertension due to pulmonary veno-occlusive disease has sometimes complicated the use of cytotoxic chemotherapeutic agents or followed bone marrow transplantation. non-steroidal anti-inflammatory agents such as indomethacin and diclofenac cross the placenta and, if given in late pregnancy, may cause premature closure of the ductus arteriosus, resulting in severe neonatal pulmonary hypertension. , pulmonary hypertension is a well-recognised association of human immunodeficiency virus (hiv) infection but until recently has been unexplained. now, however, evidence is emerging that the highly active antiretroviral therapy administered to hiv-positive patients might be responsible for the pulmonary hypertension. the older high-oestrogen contraceptive drugs carried a slight risk of thromboembolism but this is not seen with the newer preparations. pulmonary thromboembolism has also occurred with a drug-induced lupus syndrome associated with anticardiolipin antibodies. chemotherapeutic drugs such as mitomycin may cause widespread smallvessel thrombosis resulting in the haemolytic-uraemic (thrombotic microangiopathic) syndrome. there is prominent involvement of pulmonary vessels and patients often suffer from respiratory as well as renal insufficiency, and pulmonary hypertension. the syndrome can develop during treatment or up to several months after the drug has been withdrawn. pulmonary thromboembolism is also recorded as a complication of immunoglobulin infusion. non-traumatic fat embolism has resulted from the agglutination or 'creaming' of fat emulsions administered intravenously as a source of calories to debilitated patients. [ ] [ ] [ ] [ ] [ ] [ ] the agglutinated liposomes occlude fine blood vessels throughout the body, causing effects such as priapism, osteonecrosis and pancreatitis. they may be demonstrated in the pulmonary capillaries but the lungs have considerable vascular reserve and it is uncertain what effect the vascular occlusion has on pulmonary function. agglutination of these fat emulsions is particularly common in severely ill patients and this has been attributed to the elevated blood levels of acute-phase proteins, especially c-reactive protein, that are found in the very ill. the agglutination is also induced by calcium and may be brought about by administering calcium and other mineral supplements through the same venous line as the fat. once agglutinated, the fat is less soluble and may be demonstrated in paraffin sections. sudan black is especially useful for this purpose (fig. . . ). microvascular crystal embolism is a further risk of parenteral nutrition, the crystals representing various calcium salts that may precipitate in the circulation. transient diffusion abnormalities attributed to oil embolism are very common in patients undergoing lymphangiography but serious respiratory impairment is limited to those patients with pre-existing lung disease or in whom substantial amounts of contrast medium are injected rapidly. [ ] [ ] [ ] [ ] other emboli of an iatrogenic nature described in pulmonary arteries include the broken-off ends of intravenous catheters and cannulas, particles from dialysis tubing, prosthetic implants of substances such as teflon and silicone , [ ] [ ] [ ] [ ] and various materials injected to occlude abnormal blood vessels. , diffuse pulmonary haemorrhage diffuse pulmonary haemorrhage may result from interference with the clotting mechanism by anticoagulants or from widespread pulmonary capillaritis, the latter reported in leukaemic patients treated with retinoic acid. pulmonary haemorrhage has also been reported as an idiosyncratic reaction to lymphangiography media and as a complication of immunoglobulin infusion, while the development of anti-basement membrane antibodies resulting in goodpasture's syndrome has been attributed to penicillamine. a infection is a common pulmonary hazard in any patient receiving corticosteroids, chemotherapy or any other immunosuppressant drug. viral, bacterial, fungal and protozoal infections, often in combination, may all develop in the lungs of such patients and tissue reactions may be atypical. pneumocystis jiroveci, for example, may elicit a granulomatous reaction or cause diffuse alveolar damage rather than the usual foamy alveolar exudate (see p. ). metastatic calcification, described on page , may result from any drug causing hypercalcaemia, e.g. high doses of vitamin d, calcium and inorganic phosphate or excessive alkali intake in the treatment of peptic ulceration. carcinoma of the lung may be promoted by drugs. arsenicals cause squamous metaplasia of the bronchi and occasionally squamous carcinoma, while peripheral scar cancers, usually adenocarcinomas, have developed in lungs showing fibrosis due to drugs such as busulphan. drugs may result in a variety of pleural diseases. common examples include effusions, chronic inflammation and fibrosis. these are usually encountered in isolation but may be associated with chronic interstitial pneumonia or fibrosis. sometimes there is also serological evidence of systemic lupus erythematosus: many drugs, including hydantoin, practolol, procainamide, hydralazine and sulphonamides, are associated with the development of a syndrome resembling systemic lupus erythematosus that includes pleural disease. whether the drugs are directly responsible for the syndrome or merely promote the development of latent natural disease is uncertain. ergotamine derivatives such as methysergide and bromocriptine are notable for the production of pleural fibrosis, which is sometimes associated with mediastinal and retroperitoneal fibrosis large amounts or prolonged treatment are generally required to produce this effect. [ ] [ ] [ ] in patients given practolol, pleural thickening has become evident several years after the drug was discontinued. this shows the need for a careful drug history in any patient with unexplained pleural fibrosis. reports of radiation-induced lung damage began to appear soon after ionising radiation became widely used in the treatment of malignant disease. [ ] [ ] [ ] despite refinements in radiotherapy techniques it is often impossible to avoid irradiating small areas of lung when treating cancer of the lung, breast, spine, thymus and oesophagus. parts of the lungs are also included in 'mantle' irradiation of mediastinal lymph nodes affected by lymphoma. occasionally, the whole of both lungs is irradiated, as in the treatment of widespread pulmonary metastases or as part of whole-body irradiation prior to marrow transplantation for the treatment of leukaemia. radiation pneumonitis, usually localised, is estimated to affect about % of patients. therapeutic irradiation is given as divided doses over several weeks in order to minimise damage to adjacent tissue. the effects of such fractionated treatment are cumulative. in the lungs an early exudative phase soon passes and progressive damage becomes apparent only after months or even years. , the changes are generally confined to the area of lung that is irradiated but are widespread when the whole body is irradiated prior to bone marrow transplantation or there is accidental whole-body irradiation. however, localised irradiation of the lung has been followed by abnormalities in non-irradiated areas. these include bilateral alveolar exudates, migratory organising pneumonia affecting both lungs , and fulminant bilateral interstitial pneumonia. the likelihood of lung injury is increased by the simultaneous use of cytotoxic drugs and oxygen therapy. furthermore, chemotherapy following irradiation may result in exacerbation of the injury in areas previously irradiated, a phenomenon termed 'recall pneumonitis' . , in the long term, irradiation also results in an increased incidence of lung carcinoma. this was seen in patients given therapeutic irradiation to the spine for ankylosing spondylitis and is still encountered on occasion following irra diation for breast cancer. the pathogenesis of radiation injury is described on page . radiation damage to the lung is traditionally separated into fulminant acute injury coming on within days, subacute pneumonitis developing within several weeks (typically - months) and interstitial fibrosis slowly evolving from the subacute stage or making itself apparent years later. the migratory organising pneumonia referred to above is an unusual further effect, as is chronic eosinophilic pneumonia. in the pleura, radiation causes fibrinous effusions and adhesions. pleural effusion and pulmonary oedema may be augmented by the long-term effects of radiation on the heart. fulminant acute injury is an unusual and unexpected effect of therapeutic radiation but one that is likely to come to the attention of the pathologist as an autopsy is often requested. the clinical features are those of acute lung injury and the pathological changes are those of diffuse alveolar damage. the cause is likely to be accidental overdosage, augmentation of the radiation damage by accompanying oxygen therapy or treatment with cytotoxic drugs. occasionally however these factors can be excluded, in which case the damage has to be ascribed to 'hypersensitivity' . subacute radiation pneumonitis is encountered more commonly. after an interval of about - months the patient complains of shortness of breath and a non-productive cough. the chest radiograph shows hazy opacification proceeding to more dense consolidation. lung biopsy shows alveolar and interstitial oedema, possibly with residual hyaline membranes, proliferation of atypical alveolar epithelial cells and interstitial fibroblasts and organising thrombosis. later, as the process advances, there is widespread fibrosis comparable to that illustrated in figure . on page and ultimately dense scarring (fig. . . ) . tracheal and aortic injury may complicate radiation treatment of tracheal lesions, sometimes resulting in an aortotracheal fistula. patients requiring mechanical ventilation are liable to suffer lung injury in a number of ways. in addition to effects of barotrauma such as pneumothorax and surgical emphysema, they often develop diffuse alveolar damage. the high oxygen tension that is often combined with mechanical ventilation is a major factor - but mechanical forces other than the high pressures responsible for barotrauma can also contribute to this form of lung injury, notably by resulting in excessive end-expiratory stretch and repeated collapse/recruitment of the alveolar walls. , low tidal volume ventilation is therefore a fundamental part of the management of diffuse alveolar damage. although oxygen is necessary to life, it is cytotoxic in high concentrations. severe hyperoxia damages dna, inhibits cellular proliferation and ultimately kills cells. its toxicity is thought to be due to the intracellular production of active oxygen radicals, some of which derive from activated neutrophils attracted to the site of injury. [ ] [ ] [ ] [ ] under normal conditions most of the oxygen is reduced to water by cytochrome oxidase, and any active radicals produced are eliminated by superoxide dismutase, catalase and other antioxidants. however, these defence mechanisms may prove inadequate when active radicals are produced in excess. problems are likely to arise in clinical practice when lung disease necessitates the concentration of oxygen in the inspired air being raised in order to maintain normal blood levels of oxygen and prevent cerebral hypoxia. [ ] [ ] [ ] a 'safe' level for oxygen administration is not firmly established and, because of species differences in susceptibility to oxygen, caution is needed in extrapolating from animal studies. however, animal experiments have shown that previous damage to the lungs renders them unduly sensitive to oxygen , and conversely that prior exposure to high levels of oxygen confers some resistance to subsequent oxygen exposure. clinical studies suggest that less than % oxygen (at atmospheric pressure) can be tolerated for long periods without ill effect. little, if any, serious lung damage results from administration of % oxygen for up to hours but concentrations between % and % carry a risk of damage if this period is exceeded. , extracorporeal oxygenation of the blood circumvents the problem but if it is to be prolonged it becomes a major undertaking that poses its own hazards; it is therefore generally reserved for patients who remain hypoxaemic despite other measures. intravenous blood oxygenators are employed to minimise the supplementation of inspired oxygen and partial liquid ventilation utilising perfluorocarbon has also been used. experimentally, disruption of cd binding to reduce the release of proinflammatory cytokines has shown promising results in blunting oxygen-induced lung injury. none of the morphological changes attributable to oxygen toxicity is specific. the earliest ultrastructural change in experimental oxygen poisoning is swelling of endothelial cells, the cytoplasm of which becomes grossly oedematous and vacuolated. swelling and fragmentation of type i epithelial cells follow and these cells become separated from their basement membrane, which is then coated by thin strands of protein. this coating is replaced by proliferating type ii cells by the th day. with recovery in room air the lungs practically return to normal. the full clinical picture of oxygen poisoning is the acute respiratory distress syndrome and the corresponding pathological changes are those of diffuse alveolar damage, as described on page . patients with hypovolaemic shock or undergoing major surgery often require massive blood transfusions and this provides another possible cause of pulmonary damage. although hypervolaemia is the commonest cause of pulmonary oedema after blood transfusion, transfusion-related acute lung injury is more often fatal. platelet and white cell aggregates are known to develop in stored blood, but a relationship between the number of microaggregates transfused and the degree of respiratory impairment has not been convincingly demonstrated. leukocyte antibodies are a more likely cause of lung injury in these patients. such antibodies are often found in multiparous female donors as a result of sensitisation by fetal white cells during pregnancy. alternatively, the recipient may have developed them during pregnancy or as a result of previous blood transfusions. the implicated antibodies are thought to initiate alveolar capillary damage within hours of transfusion by stimulating granulocyte aggregation. , electron microscopy has shown capillary endothelial damage with activated granulocytes in contact with alveolar basement membranes. cardiopulmonary bypass entails oxygenation and circulation of the blood by extracorporeal devices, so permitting major heart surgery. in the early days of such surgery it was not unusual for patients to develop fatal respiratory insufficiency in the postoperative period. this led to the term 'postperfusion lung' . electron microscopic studies showed alveolar damage with degranulation of neutrophils in pulmonary capillaries. , the syndrome is now less common but infants remain susceptible. the most likely explanation is that the synthetic materials with which blood comes into contact during the bypass procedure are able to activate complement. this is mediated by hageman factor (factor xii) and the alternative pathway. aggregation of neutrophils leads to their sequestration in the lungs and damage results from their release of lysosomal enzymes and active radicals. [ ] [ ] [ ] the process is delayed by hypothermia. a postcardiac injury syndrome develops after a variety of myocardial or pericardial injuries: it has been described after cardiac surgery (postpericardiotomy syndrome), myocardial infarction (dressler's syndrome), blunt trauma to the chest, percutaneous puncture of the heart and implantation of a pacemaker. there is a delay of anything between a few days and a few months between the cardiac injury and the onset of symptoms, which comprise chest pain, breathlessness, dyspnoea and fever. examination usually reveals haemorrhagic pleural or pericardial effusions and pulmonary infiltrates. the syndrome usually resolves spontaneously and few pathological studies have therefore been conducted. however, the changes of diffuse alveolar damage have been reported, principally hyaline membrane formation and type ii pneumocyte hyperplasia. the pathogenesis is obscure. antibodies reacting with myocardial antigens often develop after cardiac surgery but there is no relationship between these and the development of the syndrome. [ ] [ ] [ ] this minimally invasive technique is used to destroy lesions as varied as pulmonary metastases and the connection between the left atrium and ectopic foci in the muscular sleeves that surround the terminations of the pulmonary veins (see p. ). the former may be complicated by pneumothorax and the latter by pulmonary vein stenosis. , central venous cannulation (synonym: catheterisation) is widely used in treating seriously ill patients and may give rise to serious complications. the commonest early complications related to the respiratory tract are caused by local trauma: they include pneumothorax, subcutaneous emphysema, haemothorax and air embolism. infection occurs later, causing endocarditis, septic emboli and lung abscesses. thrombosis is another common late complication: one autopsy study of patients with central venous lines showed that % had major pulmonary emboli and % had microscopic emboli in their pulmonary arteries. pulmonary artery cannulation, for example with a swan-ganz catheter, may result in pulmonary infarction or any of the traumatic complications of central venous catheterisation mentioned above. , tracheotomy entails a small immediate risk of haemorrhage from damaged subthyroidal arteries, while an endotracheal tube predisposes to infection, as with all foreign bodies. infection is also promoted by the filtering action of the upper respiratory air passages being bypassed. the latter factor also necessitates humidification of the inspired air and on occasion the humidifier or ventilator has become contaminated so that an aerosol of bacteria is introduced directly into the lower respiratory tract. high-pressure ventilation may also lead to interstitial emphysema, pneumothorax and surgical emphysema. asphyxia may follow an endotracheal tube becoming blocked by secretions or through it being badly positioned. secretions need to be constantly removed yet repeated suctioning to achieve this has led to cardiac dysrrythmia and even cardiac arrest. if the balloon on the endotracheal tube is too near the tracheostomy it may act as a fulcrum, causing the tip of the tube to press into the tracheal wall. pressure necrosis and perforation may follow, leading to mediastinitis, tracheo-oesophageal fistula or erosion of a large blood vessel. these are also complications of tracheobronchial laser therapy. pressure from the balloon may lead to a tracheal diverticulum and after the tube is withdrawn the trachea may become narrowed at either the site of the incision or further down where the balloon on the tracheal tube causes pressure. small, shallow ulcers generally heal quickly but deeper ulcers cause necrosis of the tracheal cartilage, and healing is then often accompanied by fibrous stenosis (fig. . . ) or web formation. this results in wheezing and dyspnoea but not before the trachea has narrowed to % of its original size, which may take months. earlier narrowing may be caused by oedema or a fibrinous pseudomembrane. , sometimes the stenosis takes the form of a large mass of granulation tissue at the tracheostomy site, a so-called granuloma ball. in children especially, intubation may lead to tracheomalacia so that after the tube is removed the airway collapses. necrotising sialometaplasia is a further complication of prolonged intubation. the incidence of such posttracheostomy complications can be minimised by careful placement of the stoma and tube, avoidance of large apertures and high cuff pressures, elimination of heavy connecting equipment and meticulous care of the tracheostomy. nasogastric feeding tubes may of course lead to aspiration lesions in the lungs and even fatal asphyxia if they are inadvertently allowed to enter the trachea rather than the oesophagus. bronchoscopy is generally a safe, almost routine procedure. a review of patients who underwent bronchoscopy identified severe complications in ( . %), of whom three died. the fatal cases comprised a -year-old with coronary heart disease who developed cardiac arrest and two patients who had had tracheal transplantation for oesophageal cancer and required bronchoscopic laser treatment but died of airway obstruction. the pleural cavity is intubated in the treatment of pneumothorax and pleural effusions the tube being placed anteriorly to drain air and posteriorly to drain fluid. complications include laceration of an intercostal artery or vein, the lung, the diaphragm and the heart. pneumonectomy has been practised since the s, since when the mortality associated with this operation has dropped from over % to near zero in the best hospitals. risk factors include underlying lung disease, other medical conditions and more extensive procedures such as pleuropneumonectomy and pneumonectomy combined with chest wall resection. the anatomical changes that take place soon after pneumonectomy have been extensively studied by radiologists who describe the air-filled postpneumonectomy space gradually filling with fluid and contracting as the mediastinum shifts and the ipsilateral dome of the diaphragm rises. much of the space is filled by fluid within weeks but complete opacification may take up to months. rapid filling in the immediate postoperative period suggests haemorrhage or chylothorax. however, fluid accumulation is normally rapid after pleuro-pneumonectomy and may compromise the function of the other lung. pathologists conducting autopsies long after the operation may find complete fibrous obliteration of the postpneumonectomy space, coupled with mediastinal shift and elevation of the hemidiaphragm, but often there is persistent brown fluid, which may be clear, cloudy or occasionally purulent. the remaining lung is generally enlarged, with its volume greater than predicted. animal studies have shown that if one lung is excised early in life the enlargement is partly due to enhanced growth but later it represents only dilatation of existing air spaces. hepatocyte growth factor is thought to be involved in the proliferation of residual lung cells following pneumonectomy. pulmonary complications include those typically seen after other thoracic procedures, such as haemorrhage and infection, and those unique to the postpneumonectomy state, namely anastomotic dehiscence and postpneumonectomy pulmonary oedema. the latter presents as the acute respiratory distress syndrome and represents the early stages of diffuse alveolar damage. it follows severe shift of the heart and mediastinum, which is commoner in children and young adults, in whom the tissues are more compliant. [ ] [ ] [ ] [ ] the condition complicates up to % of lung resections , and is commoner following excision of the right lung when severe herniation of the left lung into the postpneumonectomy space stretches the trachea and left main bronchus and the latter is compressed between the left pulmonary artery in front and the arch of the aorta behind. in the long term the compression can result in bronchomalacia and postobstructive bronchiectasis. if postpneumonectomy oedema develops the immediate postoperative mortality is high - % following pneumonectomy, % following lobectomy and % following sublobar resections. , the pathogenesis is probably multifactorial but apart from factors such as fluid overload and high inspired oxygen concentrations there is probably an element of alveolar wall injury, induced by oxidant generation secondary to lung stretching and general surgical trauma. , occupational dust exposure and chronic obstructive pulmonary disease -a systematic overview of the evidence occupational exposures and the risk of copd: dusty trades revisited the origin of the term 'pneumonokoniosis' industrial injuries advisory council. pneumoconiosis and byssinosis. london: hmso; aerosols: their deposition and clearance human lung parenchyma retains pm . airway branching patterns influence asbestos fiber location and the extent of tissue injury in the pulmonary parenchyma and lymph nodes in infants' lungs pulmonary sumps, dust accumulations, alveolar fluid and lymph vessels candida lung abscesses complicating parenteral nutrition a diffuse form of pulmonary silicosis in foundry workers inhalation of china stone and china clay dusts: relationship between mineralogy of dust retained in the lungs and pathological changes talc pneumoconiosis. a report of six patients with postmortem findings diffuse 'asbestosis-like' interstitial fibrosis of the lung pulmonary pathology in workers exposed to nonasbestiform talc talc pneumoconiosis -a pathologic and mineralogic study diffuse interstitial fibrosis in nonasbestos pneumoconiosis -a pathological study the disposal of coal and haematite dusts inhaled successively vertical gradient of alveolar size in lungs of dogs frozen intact apical localization of phthisis distribution of blood flow and ventilation perfusion ratio in the lung, measured with radioactive co apical localization of pulmonary tuberculosis, chronic pulmonary histoplasmosis, and progressive massive fibrosis of the lung effect of inspiratory flow rate on the regional distribution of inspired gas apical scars and their relationship to siliceous dust accumulation in non-silicotic lungs topographic distribution of asbestos fibres lung structure as a risk factor in adverse pulmonary responses to asbestos exposure. a case-referent study in quebec chrysotile miners and millers particle deposition in casts of the human upper tracheobronchial tree differences in particle deposition between the two lungs pulmonary retention of ultrafine and fine particles in rats experimental study of the dust-clearance mechanism of the lung the lung: an excretory route for macromolecules and particles phagocytic potential of pulmonary alveolar epithelium with particular reference to surfactant metabolism chrysotile asbestos inhalation in rats: deposition pattern and reaction of alveolar epithelium and pulmonary macrophages the uptake of mineral particles by pulmonary epithelial cells translocation of particles to the tracheobronchial lymph nodes after lung deposition: kinetics and particle-cell relationships patterns of particle deposition and retention after instillation to mouse lung during acute injury and fibrotic repair silica deposition in the lung during epithelial injury potentiates fibrosis and increases particle translocation to lymph nodes the permeability of lung parenchyma to particulate matter the migration of bronchoalveolar macrophages into hilar lymph nodes etude au microscope electronique du granulome pulmonaire silicotique experimental the postnatal development of lymphoreticular aggregates in human lung in relation to occupational and non-occupational exposure the distribution of amosite asbestos in the periphery of the normal human lung diseases associated with exposure to silica and nonfibrous silicate minerals detection of silica particles in lung tissue by polarizing light microscopy a practical method for the identification of particulate and crystalline material in paraffin-embedded tissue specimens particles in paraffin sections demonstrated in the backscattered electron image quantitative analysis of inorganic particulate burden in situ in tissue sections microanalysis in histopathology ion microprobe mass analysis of beryllium in situ in human lung: preliminary results laser probe mass spectrometry (lamms) analysis of beryllium, sarcoidosis and other granulomatous diseases molecular identification of foreign inclusions in inflammatory tissue surrounding metal implants by fourier transform laser microprobe mass spectrometry value of beryllium lymphocyte transformation test in chronic beryllium disease and in potentially exposed workers radiographic and pathologic correlation of coal workers' pneumoconiosis slateworker's pneumoconiosis transkei silicosis three cases of dental technician's pneumoconiosis related to cobaltchromium-molybdenum dust exposure: diagnosis and follow-up deposition of silicosis dust in the lungs of the inhabitants of the sahara regions sulla possibilita e sulla frequenza della silicosi pulmonare tra gli abitanti del deserto libico simple siliceous pneumoconiosis of bedouin females in the negev desert simple siliceous pneumoconiosis in negev bedouins silicosis in a pakistani farmer silicosis in a himalayan village population -role of environmental dust non-occupational pneumoconiosis at high altitude villages in central ladakh silicate pneumoconiosis of farm workers silicate pneumoconiosis and pulmonary fibrosis in horses from the monterey-carmel peninsula comparative pathology of silicate pneumoconiosis two cases of acute silicosis -with a suggested theory of causation acute silicosis silicose aigue fatale par inhalation volontaire de poudre à recurer acute silicosis in tombstone sandblasters accelerated silicosis in scottish stonemasons the relation between fibrosis of hilar lymph glands and the development of parenchymal silicosis distribution of silicotic collagenization in relation to smoking habits silicosis presenting as bilateral hilar lymphadenopathy silicotic lymph node lesions in nonoccupationally exposed lung carcinoma patients obliterative central bronchitis due to mineral dust in patients with pneumoconiosis left recurrent laryngeal nerve palsy associated with silicosis anthracotic and anthracosilicotic spindle cell pseudotumors of mediastinal lymph nodes: report of five cases of a reactive lesion that simulates malignancy right middle lobe atelectasis associated with endobronchial silicotic lesions pleural pearls following silicosis: a histological and electronmicroscopic study silicainduced pleural disease: an unusual case mimicking malignant mesothelioma factors associated with massive fibrosis in silicosis silicosis of systemic distribution hepatosplenic silicosis hepatic silicosis silicotic lesions of the bone marrow: histopathology and microanalysis peritoneal silicosis pulmonary fibrosis in non-ferrous foundry workers irregular opacities in coalworkers' pneumoconiosis -correlation with pulmonary function and pathology pneumoconiosis-related lung cancers -preferential occurrence from diffuse interstitial fibrosis-type pneumoconiosis the effects of dusts on peritoneal cells within diffusion chambers freshly fractured quartz inhalation leads to enhanced lung injury and inflammation: potential role of free radicals an examination of the cytotoxic effects of silica on macrophages activity of macrophage factor in collagen formation by silica fractionation of connective-tissue-activating factors from the culture medium of silica-treated macrophages effect of sio -liberated macrophage factor on protein synthesis in connective tissue in vitro the regulation of lung fibroblast proliferation by alveolar macrophages in experimental silicosis the ability of inflammatory bronchoalveolar leucocyte populations elicited with microbes or mineral dust to injure alveolar epithelial cells and degrade extracellular matrix in vitro cytokines and cytokine network in silicosis and coal workers' pneumoconiosis activation of murine macrophages by silica particles in vitro is a process independent of silica-induced cell death localization of type i procollagen gene expression in silica-induced granulomatous lung disease and implication of transforming growth factor-beta as a mediator of fibrosis transforming growth factor-beta (tgfbeta) in silicosis mechanisms in the pathogenesis of asbestosis and silicosis changes in the composition of lung lipids and the 'turnover' of dipalmitoyl lecithin in experimental alveolar lipo-proteinosis induced by inhaled quartz case report: pulmonary alveolar proteinosis and aluminum dust exposure induction of surfactant protein (sp-a) biosynthesis and sp-a mrna in activated type ii cells during acute silicosis in rats silicon nephropathy: a possible occupational hazard rapidly progressive silicon nephropathy silica and glomerulonephritis: case report and review of the literature rapidly progressive crescenteric glomerulonephritis in a sandblaster with silicosis diatomaceous earth pneumoconiosis particle size for differentiation between inhalation and injection pulmonary talcosis kaolin pneumoconiosis. a case report kaolin pneumoconiosis. radiologic, pathologic and mineralogic findings silicosis in wyoming bentonite workers pneumoconiosis due to fuller's earth pulmonary disease caused by the inhalation of cosmetic talcum powder talc dust pneumoconiosis mica-associated pulmonary interstitial fibrosis baritosis: a benign pneumoconiosis silicosis in barium miners scleroderma in gold-miners on the witwatersrand with particular reference to pulmonary manifestations immunological factors in the pathogenesis of the hyaline tissue of silicosis mini-review -immunologic aspects of pneumoconiosis adverse effects of crystalline silica exposure chronic necrotizing pulmonary aspergillosis in pneumoconiosis -clinical and radiologic findings in patients silica and some silicates. monographs on the evaluation of the carcinogenic risk of chemicals to humans occupational lung disease: . exposure to crystalline silica and risk of lung cancer: the epidemiological evidence do silica and asbestos cause lung cancer? report by the industrial injuries advisory council in accordance with section of the social security administration act on the question whether lung cancer in relation to occupational exposure to silica should be prescribed. london: hmso; crystalline silica exposure, radiological silicosis, and lung cancer mortality in diatomaceous earth industry workers acute silicoproteinosis acute silicolipoproteinosis atypical reaction to inhaled silica alveolar proteinosis. its experimental production in rodents experimental endogenous lipid pneumonia and silicosis pathogenesis of experimental pulmonary alveolar proteinosis pneumoconiosis in carbon electrode makers graphite pneumoconiosis of electrotypers case report: a case of wood-smoke-related pulmonary disease hut lung. a domestically acquired particulate lung disease bronchial stenosis due to anthracofibrosis anthracofibrosis attributed to mixed mineral dust exposure: report of three cases anthracofibrosis, bronchial stenosis with overlying anthracotic mucosa: possibly a new occupational lung disorder occupational anthracofibrosis pneumoconiosis and other causes of death in iron and steel foundry workers histochemical study of certain iron ore dusts mixed-dust pneumoconiosis proposed criteria for mixed-dust pneumoconiosis: definition, descriptions, and guidelines for pathologic diagnosis and clinical correlation chronic interstitial pneumonia in silicosis and mix-dust pneumoconiosis: its prevalence and comparison of ct findings with idiopathic pulmonary fibrosis proposed criteria for mixed-dust pneumoconiosis: definition, descriptions, and guidelines for pathologic diagnosis and clinical correlation coal pneumoconiosis coal workers' pneumoconiosis pneumoconiosis in coal trimmers dust exposure, dust recovered from the lung, and associated pathology in a group of british coalminers the relationship between the mass and composition of coal mine dust and the development of pneumoconiosis interstitial fibrosis in coal miners -experience in wales and west virginia coal worker's pneumoconiosis: ct assessment in exposed workers and correlation with radiographic findings variations in the histological patterns of the lesions of coal workers' pneumoconiosis in britain and their relationship to lung dust content comparison of radiographic appearances with associated pathology and lung dust content in a group of coalworkers small airways disease and mineral dust exposure. prevalence, structure and function coal mining, emphysema, and compensation revisited coal mining, emphysema, and compensation revisited -reply coal mining and chronic obstructive pulmonary disease: a review of the evidence the pathogenesis of simple pneumokoniosis in coal workers mineral dusts cause elastin and collagen breakdown in the rat lung: a potential mechanism of dust-induced emphysema emphysema in coal workers' pneumoconiosis pulmonary disability in coal workers' pneumoconiosis quantified pathology of emphysema, pneumoconiosis, and chronic bronchitis in coal workers emphysema and dust exposure in a group of coal workers coal worker's lung: not only black, but also full of holes contributions of dust exposure and cigarette smoking to emphysema severity in coal miners in the united states report by the industrial injuries advisory council in accordance with section of the social security administration act on the question whether bronchitis and emphysema in coal miners and metal production workers should be prescribed. london: hmso; the new prescription: industrial injuries benefits for smokers? exposure to respirable coalmine dust and incidence of progressive massive fibrosis the attack rate of progressive massive fibrosis ischemic necrosis in anthracosilicosis the composition of massive lesions in coal miners mechanisms of fibrosis in coal workers' pneumoconiosis: increased production of platelet-derived growth factor, insulin-like growth factor type i, and transforming growth factor beta and relationship to disease severity secretion and mrna expression of tnf alpha and il- in the lungs of pneumoconiosis patients a broader concept of caplan's syndrome related to rheumatoid factors differential agglutination test in rheumatoid arthritis complicated by pneumoconiosis circulating antinuclear antibody and rheumatoid factor in coal pneumoconiosis serologic changes in pneumoconiosis and progressive massive fibrosis of coal workers immunological investigations of coalworkers' disease certain unusual radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis pathological studies of modified pneumoconiosis in coal-miners with rheumatoid arthritis (caplan's syndrome) asbestos, asbestosis, and cancer: the helsinki criteria for diagnosis and attribution report of the asbestosis committee of the college of american pathologists and pulmonary pathology society the asbestos cancer epidemic rapid short-term clearance of chrysotile compared with amosite asbestos in the guinea pig persistence of natural mineral fibers in human lungs: an overview a pathological and mineralogical study of asbestos-related deaths in the united kingdom in correlation between fibre content of the lungs and disease in naval dockyard workers correlation between fibre content of the lung and disease in east london asbestos factory workers the effects of the inhalation of asbestos in rats mass and number of fibres in the pathogenesis of asbestos related lung disease in rats fiber burden and patterns of asbestos-related disease in chrysotile miners and millers carcinogenesis and mineral fibres lung diseases due to environmental exposures to erionite and asbestos in turkey prospective study of mesothelioma mortality in turkish villages with exposure to fibrous zeolite analysis of ferruginous bodies in bronchoalveolar lavage from foundry workers analysis of the cores of ferruginous (asbestos) bodies from the general population fiber counting and analysis in the diagnosis of asbestos-related disease concentrations and dimensions of coated and uncoated asbestos fibres in the human lung comparison of the results of asbestos fibre dust counts in lung tissue obtained by analytical electron microscopy and light microscopy asbestos bodies and the diagnosis of asbestosis in chrysotile workers asbestos fiber content of lungs with diffuse interstitial fibrosis: an analytical scanning electron microscopic analysis of cases comparison of phagocytosis of uncoated versus coated asbestos fibers by cultured human pulmonary alveolar macrophages numbers of asbestos bodies on iron-stained tissue sections in relation to asbestos body counts in lung tissue digests asbestos content of lung tissue in asbestos associated diseases: a study of cases analysis and interpretation of inorganic mineral particles in 'lung' tissues asbestos bodies in bronchoalveolar lavage in relation to asbestos bodies and asbestos fibres in lung parenchyma asbestos bodies in the sputum of asbestos workers: correlation with occupational exposure the optical and electron microscopic determination of pulmonary asbestos fibre concentration and its relation to human pathology reaction assessment of mineral fibres from human lung tissue detection of asbestos fibres by dark ground microscopy analysis of lung asbestos content guidelines for mineral fibre analyses in biological samples: report of the ers working group relationship between occupations and asbestos-fibre content of the lungs in patients with pleural mesothelioma, lung cancer, and other diseases inflammation-generating potential of long and short-fibre amosite asbestos samples asbestos-stimulated tumour necrosis factor release from alveolar macrophages depends on fibre length and opsonization the pathogenicity of long versus short fibre amosite asbestos administered to rats by inhalation and intra-peritoneal injection cytogenetic and pathogenic effects of long and short amosite asbestos exposure and mineralogical correlates of pulmonary fibrosis in chrysotile asbestos workers quantitative assessment of inorganic fibrous particulates in dust samples with an analytical transmission electron microscope fibre distribution in the lungs and pleura of subjects with asbestos related diffuse pleural fibrosis malignant mesothelioma in women observations on the distribution of asbestos fibres in human lungs analysis of asbestos fibres and asbestos bodies in tissue samples from human lung: an international interlaboratory trial distribution and characteristics of amphibole asbestos fibres in the left lung of an insulation worker measured with the light microscope the identification of asbestos dust with an electron microprobe analyser symposium on man-made mineral fibres mortality in cases of asbestosis diagnosed by a pneumoconiosis medical panel small-airway lesions in patients exposed to nonasbestos mineral dusts small airways disease and mineral dust exposure relation of smoking and age to findings in lung parenchyma: a microscopic study electron microscopic studies in desquamative interstitial pneumonia associated with asbestos desquamative interstitial pneumonia associated with chrysotile asbestos fibres localized inflammatory pulmonary disease in subjects occupationally exposed to asbestos criteria for the diagnosis and grading of asbestosis report of the pneumoconiosis committee of the college of american pathologists and the national institute for occupational safety and health cytoplasmic hyalin in asbestosis further observations on cytoplasmic hyaline in the lung lung pathology of severe acute respiratory syndrome (sars): a study of autopsy cases from singapore lung pathology of fatal severe acute respiratory syndrome immunohistochemical detection of ubiquitin-positive intracytoplasmic eosinophilic inclusion bodies in diffuse alveolar damage idiopathic pulmonary fibrosis in asbestosexposed workers mortality of workers certified by pneumoconiosis medical panels as having asbestosis radiographic evidence of asbestos effects in american marine engineers chronic airflow obstruction in lung disease. philadelphia: saunders fine structural changes in cryptogenic fibrosing alveolitis and asbestosis pulmonary asbestosis and idiopathic pulmonary fibrosis: pathogenetic parallels crocidoliteinduced pulmonary fibrosis in mice hydroxyl radicals are formed in the rat lung after asbestos instillation invivo asbestos fibers and interferon-gamma up-regulate nitric oxide production in rat alveolar macrophages oxidant sand antioxidant mechanisms of lung disease caused by asbestos fibres antibodies in some chronic fibrosing lung diseases asbestos causes translocation of p protein and increases nf-kappa b dna binding activity in rat lung epithelial and pleural mesothelial cells rapid activation of pdgf-a and -b expression at sites of lung injury in asbestos-exposed rats upregulation of the pdgf-alpha receptor precedes asbestos-induced lung fibrosis in rats tnf-alpha receptor knockout mice are protected from the fibroproliferative effects of inhaled asbestos fibers alveolar cell stretching in the presence of fibrous particles induces interleukin- responses the molecular basis of asbestos induced lung injury inhaled asbestos activates a complementdependent chemoattractant for macrophages alveolar macrophage stimulation of lung fibroblast growth in asbestos-induced pulmonary fibrosis cellular and molecular basis of the asbestos-related diseases up-regulated expression of transforming growth factor-α in the bronchiolar-alveolar duct regions of asbestos-exposed rats a study of macrophage-mediated initiation of fibrosis by asbestos and silica using a diffusion chamber technique enhanced generation of free radicals from phagocytes induced by mineral dusts mortality from lung cancer in asbestos workers diffuse pleural mesotheliomas and asbestos exposure in northwestern cape province carcinogenicity of amosite asbestos asbestos exposure, cigarette smoking and death rates smoking, exposure to crocidolite, and the incidence of lung cancer and asbestosis pathology of carcinoma of the lung associated with asbestos exposure a study of the histological cell types of lung cancer in workers suffering from asbestosis in the united kingdom lung cancer cell type and asbestos exposure histological type of lung carcinoma in asbestos cement workers and matched controls incidence of lung cancer by histological type among asbestos cement workers in denmark lung cancer in asbestos cement workers in denmark asbestos and lung cancer in glasgow and the west of scotland exposure to crocidolite and the incidence of different histological types of lung cancer asbestos and lung cancer asbestos and lung cancer: is it attributable to asbestosis or to asbestos fibre burden? in: corrin b, editor. pathology of lung tumours asbestos fibreyears and lung cancer: a two phase case-control study with expert exposure assessment the quantitative risks of mesothelioma and lung cancer in relation to asbestos exposure is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? relation between asbestosis and bronchial cancer in amphibole asbestos miners asbestosis as a precursor of asbestos related lung cancer -results of a prospective mortality study asbestos exposure, asbestosis, and asbestosattributable lung cancer asbestos and lung cancer -reply criteria for attributing lung cancer to asbestos exposure asbestosis: a marker for the increased risk of lung cancer among workers exposed to asbestos asbestos, asbestosis, and lung cancer: a critical assessment of the epidemiological evidence airway function in lifetime-nonsmoking older asbestos workers severe diffuse small airways abnormalities in long term chrysotile asbestos miners morphology of small-airway lesions in patients with asbestos exposure does aluminum smelting cause lung disease? the treatment of silicosis by aluminum powder silicose aigue. caractéristiques cliniques, radiologiques, fonctionnelles et cytologiques du liquide bronchoalveolaire. a propos de observations pathologie and pathogenesis der aluminiumlunge die aluminiumlunge -eine neue gewerbeerkrankung. z f d ges pulmonary fibrosis in workers exposed to finely powdered aluminium aluminium pneumoconiosis i. in vitro comparison of stamped aluminium powders containing different lubricating agents and a granular aluminium powder effect on the rat lung of intratracheal injections of stamped aluminium powders containing different lubricating agents and of a granular aluminium powder desquamative interstitial pneumonia in an aluminum welder sarcoidlike lung granulomatosis induced by aluminum dusts aluminum induced pulmonary granulomatosis aluminum welding fume-induced pneumoconiosis rare earth (cerium) pneumoconiosis rare earth (cerium oxide) pneumoconiosis: analytical scanning electron microscopy and literature review hard metal disease interstitial lung disease and asthma in hard-metal workers: bronchoalveolar lavage, ultrastructural, and analytical findings and results of bronchial provocation tests the biological action of tungsten carbide and cobalt: studies on experimental pulmonary histopathology cobalt lung in diamond polishers rapidly fatal progression of cobalt lung in a diamond polisher hard metal pneumoconiosis and the association of tumor necrosis factor-alpha the pulmonary toxicity of beryllium beryllium and lung disease recent chronic beryllium disease in residents surrounding a beryllium facility nonoccupational beryllium disease masquerading as sarcoidosis -identification by blood lymphocyte proliferative response to beryllium beryllium disease international agency for research on cancer. an evaluation of carcinogenic risk to humans. overall evaluation of carcinogenicity: an updating of iarc monographs vols - uber eine apparatur zur erzeugung niedriger staubkonzentrationen von grosser konstanz und eine methode zur mikrogravinctrischen staubbestemmung. anwendung bei der untersuchung von stauben aus der berylliumsgewinnung delayed chenical pneumonitis occurring in workers exposed to beryllium compounds chronic beryllium disease in a dental laboratory technician maintenance of alveolitis in patients with chronic beryllium disease by berylliumspecific helper t cells hla-dpb glutamate : a genetic marker of beryllium disease immunogenetic basis of environmental lung disease: lessons from the berylliosis model beryllium disease in identical twins beryllium detection in human lung tissue using electron probe x-ray microanalysis diagnostic criteria for chronic beryllium disease (cbd) based on the uk registry - united kingdom beryllium registry: mortality and autopsy study lung disease and the lightest of metals misdiagnosis of sarcoidosis in patients with chronic beryllium disease diagnoses of chronic beryllium disease within cohorts of sarcoidosis patients the pathology of interstitial lung disease in nylon flock workers flock worker's lung: broadening the spectrum of clinicopathology, narrowing the spectrum of suspected etiologies polyethylene flock-associated interstitial lung disease in a spanish female popcorn workers' lung clinical bronchiolitis obliterans in workers at a microwave-popcorn plant clinical bronchiolitis obliterans in workers at a microwave-popcorn plant bronchiolitis obliterans syndrome in popcorn production plant workers popcorn worker's lung' in britain in a man making potato crisp flavouring toxicity in textile airbrushing in spain outbreak of organising pneumonia in textile printing sprayers epidemic outbreak of interstitial lung disease in aerographics textile workersthe 'ardystil syndrome': a first year follow up organizing pneumonia in textile printing workers: a clinical description outbreak of pulmonary disease in textile dye sprayers in algeria five-year follow-up of algerian victims of the ''ardystil syndrome mineral oils and petroleum . skorodin ms, chandrasekhar aj. an occupational cause of exogenous lipoid pneumonia machine operator's lung. a hypersensitivity pneumonitis disorder associated with exposure to metalworking fluid aerosols metalworking fluid-associated hypersensitivity pneumonitis: a workshop summary an outbreak of hypersensitivity pneumonitis at a metalworking plant: a longitudinal assessment of intervention effectiveness stenius-aarniala b. fire-eater's lung fire-eater's lung: seventeen cases and a review of the literature pulmonary mechanics in dogs given different doses of kerosene intratracheally x-ray appearance of the lungs of electric arc welders the health of welders in naval dockyards: the risk of asbestosrelated diseases occurring in welders welders' pneumoconiosis: tissue elemental microanalysis by energy dispersive x ray analysis the respiratory health of welders toxic fumes and gases . nemery b. metal toxicity and the respiratory tract lung changes associated with the manufacture of alumina abrasives acute inorganic mercury vapor inhalation poisoning nickel poisoning ii. studies on patients suffering from acute exposure to vapors of nickel carbonyl silo-filler's disease -a syndrome caused by nitrogen dioxide silo-filler's disease: nitrogen dioxide-induced lung injury silo filler's disease silo-filler's disease in new york state dung lung: a report of toxic exposure to liquid manure death caused by fermenting manure acute toxic exposure to gases from liquid manure slurry lung': a report of three cases pulmonary lesions in rats exposed to ozone pathology of adult respiratory distress syndrome response of macaque bronchiolar epithelium to ambient concentrations of ozone ultrastructural alterations of alveolar tissue of mice differentiated bronchiolar epithelium in alveolar ducts of rats exposed to ozone for months ozone-induced acute tracheobronchial epithelial injury -relationship to granulocyte emigration in the lung ozone-induced airway inflammation in human subjects as determined by airway lavage and biopsy a cohort study of workers exposed to formaldehyde in the british chemical industry -an update pulmonary toxicity following exposure to methylene chloride and its combustion product, phosgene the diversity of the effects of sulfur mustard gas inhalation on respiratory system years after a single, heavy exposure: analysis of cases tracheobronchomalacia and air trapping after mustard gas exposure an international collaborative pathologic study of surgical lung biopsies from mustard gas-exposed patients thionyl-chloride-induced lung injury and bronchiolitis obliterans hydrogen sulfide poisoning: review of years' experience anoxic asphyxia anoxic asphyxia -a cause of industrial fatalities: a review sword ' : surveillance of work-related and occupational respiratory disease in the uk occupational asthma as identified by the surveillance of work-related and occupational respiratory diseases programme in south africa incidence of occupational asthma by occupation and industry in finland sword ' : surveillance of work-related and occupational respiratory disease in the uk american thoracic society statement: occupational contribution to the burden of airway disease aetiological agents in occupational asthma reported incidence of occupational asthma in the united kingdom, - occupational asthma in a factory with a contaminated humidifier the pathology of byssinosis byssinosis: a review in vitro alternative and classical activation of complement by extracts of cotton mill dust: a possible mechanism in the pathogenesis of byssinosis antibody independent complement activation by card-room cotton dust occupational fevers . raskandersen a, pratt ds. inhalation fever -a proposed unifying term for febrile reactions to inhalation of noxious substances humidifier fever pulmonary mycotoxicosis organic dust toxicity (pulmonary mycotoxicosis) associated with silo unloading desquamative interstitial pneumonitis and diffuse alveolar damage in textile workers: potential role of mycotoxins pulmonary mycotoxicosis: a clinicopathologic study of three cases pulmonary involvement in zinc fume fever cytokines in metal fume fever music: a new cause of primary spontaneous pneumothorax atmospheric pressure influences the risk of pneumothorax: beware of the storm experimental study of blast injuries to the lungs biophysics of impact injury to the chest and abdomen histologic, immunohistochemical, and ultrastructural findings in human blast lung injury histologic, immunohistochemical, and ultrastructural findings in human blast lung injury the ultrastructure of rat lung following acute primary blast injury disorders associated with diving decompression disorders in divers intrapulmonary air trapping in submarine escape training casualties airway structure and alveolar emptying in the lungs of sea lions and dogs the structure and function of the small airways in pinniped and sea otter lungs mechanisms of death in shallow-water scuba diving pulmonary barotrauma in submarine escape training the pathophysiology of decompression sickness hemodynamic changes induced by recreational scuba diving dysbaric osteonecrosis: aseptic necrosis of bone deep diving mammals: dive behavior and circulatory adjustments contribute to bends avoidance current concepts: high-altitude illness illnesses at high altitude high altitude pulmonary edema high altitude pulmonary oedema; characteristics of lung lavage fluid prevention of high-altitude pulmonary edema by nifedipine pulmonary circulation at high altitude association of high-altitude pulmonary edema with the major histocompatibility complex pathogenesis of high-altitude pulmonary oedema: direct evidence of stress failure of pulmonary capillaries high-altitude pulmonary edema: current concepts high-altitude pulmonary edema is initially caused by an increase in capillary pressure when lungs on mountains leak -studying pulmonary edema at high altitudes inhaled nitric oxide for high-altitude pulmonary edema lung pathology in high-altitude pulmonary edema pathological features of the lung in fatal high altitude pulmonary edema occurring at moderate altitude in japan lack of smooth muscle in the small pulmonary arteries of the native ladakhi -is the himalayan highlander adapted? aspects of hypoxia pulmonary blood vessels and endocrine cells in subacute infantile mountain sickness the human pulmonary circulation: its form and function in health and disease pulmonary edema associated with salt water near-drowning -new insights the effect of salt water on alveolar epithelial barrier function near-drowning: clinical course of lung injury in adults haggard hw. action of irritant gases upon the respiratory tract regional respiratory tract absorption of inhaled reactive gases respiratory irritants encountered at work health effects of outdoor air pollution committee of the environmental and occupational health assembly of the committee of the environmental and occupational health assembly of the fine particulate air pollution and mortality in us cities, - health effects of diesel exhaust emissions respiratory changes due to long-term exposure to urban levels of air pollution: a histopathologic study in humans chronic glandular bronchitis in young individuals residing in a metropolitan area an association between air pollution and mortality in united states cities chronic bronchitis in women using solid biomass fuel in rural peshawar indoor air pollution: a poverty-related cause of mortality among the children of the world risk of copd from exposure to biomass smoke human health impacts of volcanic activity persistent hyperreactivity and reactive airway dysfunction in firefighters at the world trade center the world trade center residents' respiratory health study: new-onset respiratory symptoms and pulmonary function pulmonary function after exposure to the world trade center collapse in the new york city fire department characterization of the dust/smoke aerosol that settled east of the world trade center (wtc) in lower manhattan after the collapse of the wtc chemical analysis of world trade center fine particulate matter for use in toxicologic assessment longitudinal assessment of spirometry in the world trade center medical monitoring program acute eosinophilic pneumonia in a new york city firefighter exposed to world trade center dust granulomatous pneumonitis following exposure to the world trade center collapse smoking-related interstitial lung diseases: a concise review concomitant upper-lobe bullous emphysema, lower-lobe interstitial fibrosis and pulmonary hypertension in heavy smokers: report of eight cases and review of the literature heterogeneity in combined pulmonary fibrosis and emphysema smoking-related interstitial lung diseases challenges in pulmonary fibrosis : smoking-induced diffuse interstitial lung diseases combined pulmonary fibrosis and emphysema: a distinct underrecognised entity smoking-related changes in the background lung of specimens resected for lung cancer: a semiquantitative study with correlation to postoperative course clinical assembly contribution to the celebration of years of the ers. smoking-related lung diseases: a clinical perspective clinically occult interstitial fibrosis in smokers: classification and significance of a surprisingly common finding in lobectomy specimens bronchiolar inflammation and fibrosis associated with smoking -a morphologic cross-sectional population analysis relation of smoking and age to findings in lung parenchyma: a microscopic study variability in small airway epithelial gene expression among normal smokers airway alveolar attachment points and exposure to cigarette smoke in utero patterns of global tobacco use in young people and implications for future chronic disease burden in adults tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic pathology of the lung in fatally burned patients respiratory tract pathology in patients with severe burns heat injuries to the respiratory system death in the burn unit: sterile multiple organ failure pulmonary interstitial edema and hyaline membranes in adult burn patients herpesvirus infections in burn patients pulmonary herpes simplex in burns patients long-term course of bronchiectasis and bronchiolitis obliterans as late complication of smoke inhalation disaster at bhopal: the accident, early findings and respiratory health outlook in those injured chronic lung inflammation in victims of toxic gas leak at bhopal respiratory morbidity years after the union carbide gas leak at bhopal: a cross sectional survey management of the effects of exposure to tear gas ingested toxic agents . boyd mr. evidence for the clara cell as a site of cytochrome p -dependent mixed-function oxidase activity in lung pulmonary histological appearances in fatal paraquat poisoning pulmonary damage due to paraquat poisoning through skin absorption paraquat induced pulmonary fibrosis in three survivors kinetics and cellular localisation of putrescine uptake in human lung tissue enhancement of oxygen toxicity by the herbicide paraquat hypoxic protection in paraquat poisoning the effects of variable o tension and of exogenous superoxide dismutase on type ii pneumocytes exposed to paraquat paraquat-induced injury of type ii alveolar cells the changing pattern of paraquat poisoning in man remodeling of the alveolar structure in the paraquat lung of humans: a morphometric study experimental paraquat poisoning the pathogenesis and structure of paraquatinduced pulmonary fibrosis in rats pulmonary ultrastructure after oral and intravenous dosage of paraquat to rats patterns of pulmonary structural remodeling after experimental paraquat toxicity experimental models of interstitial pneumonia: paraquat, iprindole fine structure of the lung lesion in a case of paraquat poisoning fatal pulmonary intra-alveolar fibrosis after paraquat ingestion paraquat lung: a reappraisal an immunohistochemical study of the fibrosing process in paraquat lung injury toxic-allergic syndrome caused by ingestion of rapeseed oil denatured with aniline pathology of a new toxic syndrome caused by ingestion of adulterated oil in spain clinical epidemiology of toxic oil syndrome -(phenylamino)alanine, a novel aniline-derived amino acid associated with the eosinophilia-myalgia syndrome -a link to the toxic oil syndrome pulmonary hypertension due to toxic oil syndrome. a clinicopathologic study pulmonary hypertension in patients with eosinophilia-myalgia syndrome or toxic oil syndrome pulmonary vascular lesions in the toxic oil syndrome in spain outbreak of bronchiolitis obliterans associated with consumption of sauropus androgynus in taiwan histopathological study of sauropus androgynus-associated constrictive bronchiolitis obliterans: a new cause of constrictive bronchiolitis obliterans sauropus androgynus-constrictive obliterative bronchitis/bronchiolitishistopathological study of pneumonectomy and biopsy specimens with emphasis on the inflammatory process and disease progression segmental necrosis of small bronchi after prolonged intakes of sauropus androgynus in taiwan sauropus bronchiolitis -reply the lipoid pneumonia of blackfat tobacco smokers in guyana a morphometric analysis of the male and female tracheal epithelium after experimental exposure to marijuana smoke differential examination of bronchoalveolar lavage cells in tobacco cigarette and marijuana smokers tracheobronchial changes in habitual, heavy smokers of marijuana with and without tobacco airway inflammation in young marijuana and tobacco smokers an unusual cause of patchy ground-glass opacity pulmonary hazards of smoking marijuana as compared with tobacco british lung foundation. a smoking gun? tracheobronchial histopathology in habitual smokers of cocaine, marijuana, and/or tobacco effects of cannabis on pulmonary structure, function and symptoms large lung bullae in marijuana smokers the pulmonary pathology of illicit drug and substance abuse bong lung: regular smokers of cannabis show relatively distinctive histologic changes that predispose to pneumothorax cannabis use and risk of lung cancer: a case-control study exogenous lipid pneumonia related to smoking weed oil following cadaveric renal transplantation a review of the respiratory effects of smoking cocaine medical complications of cocaine abuse blackened bronchoalveolar lavage fluid in crack smokers -a preliminary study pulmonary histopathology in cocaine abusers pulmonary complications of crack cocaine: a comprehensive review cocaine-induced churg-strauss vasculitis pulmonary artery medial hypertrophy in cocaine users without foreign particle microembolization crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings effects of 'crack' cocaine on pulmonary alveolar permeability pulmonary hemorrhage and antiglomerular basement membrane antibody-mediated glomerulonephritis after exposure to smoked cocaine (crack): a case report and review of the literature cellulose granulomas in the lungs of a cocaine sniffer intravenous injection of talc-containing drugs intended for oral use. a cause of pulmonary granulomatosis and pulmonary hypertension autopsy findings in drug addicts pulmonary 'mainline' granulomatosis: talcosis of intravenous methadone abuse self induced pulmonary granulomatosis. a consequence of intravenous injection of drugs intended for oral use the pulmonary vascular lesions of intravenous drug abuse microcrystalline cellulose pulmonary embolism and granulomatosis talc granulomatosis: laboratory findings similar to sarcoidosis postmortem findings of pulmonary lesions of older datum in intravenous drug addicts. a forensic-pathologic study recreational use of aminorex and pulmonary hypertension fatal drug reactions among medical inpatients drug-related hospital admissions: a review of australian studies published - incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies (see comments) the quality in australian health care study adverse reactions to drugs drug-induced pulmonary disease -an update an algorithm for the operational assessment of adverse drug reactions. ii. demonstration of reproducibility and validity aspirin idiosyncrasy and tolerance aspirin-sensitive asthma: abnormal platelet response to drugs inducing asthmatic attacks; diagnostic and physiopathological implications mechanism of aspirin sensitivity bronchiolitis and bronchitis in connective tissue disease. a possible relationship to the use of penicillamine bronchiolitis obliterans in a patient with localized scleroderma treated with d-penicillamine constrictive bronchiolitis obliterans following gold therapy for psoriatic arthritis gold-induced pulmonary disease: clinical features, outcome, and differentiation from rheumatoid lung disease progressive airway obliteration in adults and its association with rheumatoid disease drug-induced infiltrative lung disease drug-induced and iatrogenic infiltrative lung disease interstitial lung disease associated with drug therapy pulmonary toxic effects of continuous desferrioxamine administration in acute iron poisoning interstitial pulmonary fibrosis following busulfan therapy busulphan lung report of a case and review of the literature busulfan lung: report of two cases and review of the literature a -year-old man with pulmonary infiltrates after a bone marrow transplantation -busulfan pneumonitis drug-induced pulmonary disease lung parenchymal injury induced by bleomycin pathology of high dose intermittent cyclophosphamide therapy cyclophosphamide pneumonitis pulmonary histopathologic changes associated with melphalan therapy melphalan-induced pulmonary interstitial fibrosis potentiation of bleomycin-induced lung injury by exposure to % oxygen factors influencing postoperative morbidity and mortality in patients treated with bleomycin bleomycin therapy and anaesthesia risk factors of anesthesia and surgery in bleomycin-treated patients the pathogenesis of bleomycin-induced pulmonary damage in mice experimentally induced bleomycin sulfate toxicity origin and significance of intranuclear tubular inclusions in type ii pulmonary alveolar epithelial cells of patients with bleomycin and busulfan toxicity late bcnu lung -a light and ultrastructural study on the delayed effect of bcnu on the lung parenchyma statin-induced fibrotic nonspecific interstitial pneumonia bronchiolitis obliterans organizing pneumonia during treatment with acebutolol and amiodarone methotrexate-induced pneumonitis (baltimore) bronchoalveolar lavage findings suggest an immunologic disorder pneumonitis complicating low-dose methotrexate therapy for rheumatoid arthritis -discrepancies between lung biopsy and bronchoalveolar lavage findings methotrexate pneumonitis: review of the literature and histopathological findings in nine patients the pulmonary toxicity of antineoplastic agents relationship of gold and penicillamine therapy to diffuse interstitial lung disease desquamative interstitial pneumonia following long-term nitrofurantoin therapy two unusual pathological reactions to nitrofurantoin: case reports bronchiolitis obliterans organising pneumonia associated with the use of nitrofurantoin amiodarone lung toxicity: a human and experimental study effect of amiodarone on the lung shown by polarized light microscopy fine structural alterations in the lungs of iprindole-treated rats effects of chlorphentermine on the rat lung amiodarone-induced hypersensitivity pneumonitis. evidence of an immunological cell-mediated mechanism amiodarone pneumonitis: three further cases with a review of published reports amiodarone-associated pulmonary toxicity. a clinical and pathologic study of eleven cases amiodarone lung: pathologic findings in clinically toxic patients amiodarone-induced bronchiolitis obliterans organizing pneumonia (boop) amiodarone-related pulmonary mass and unique membranous glomerulonephritis in a patient with valvular heart disease: diagnostic pitfall and new findings nodular amiodarone lung disease amiodarone pneumonitis: no safe dose amiodarone pneumonitis: no safe dose susceptibility to amiodarone-induced pulmonary toxicity: relationship to the uptake of amiodarone by isolated lung cells acute amiodarone-induced pulmonary toxicity following lung resection pulmonary alveolar proteinosis developing from desquamative interstitial pneumonia in long term toxicity studies of iprindole in the rat eosinophilic lung diseases mesalazine-induced eosinophilic pneumonia chronic eosinophilic pneumonia after radiation therapy for breast cancer churg-strauss syndrome in patients receiving montelukast as treatment for asthma inhaled corticosteroids and churg-strauss syndrome: a report of five cases pulmonary migratory infiltrates and pachypleuritis in a patient with crohn's disease immunodeficiency virus-infected patients receiving antiretroviral therapy ciprofloxacin-induced acute interstitial pneumonitis pulmonary granulomas after tumour necrosis factor alpha antagonist therapy pulmonary sarcoidosis developing during infliximab therapy sarcoid-like granulomatous disease following etanercept treatment for ra pneumonia due to liquid paraffin: with chemical analysis a case of chronic paraffin pneumonitis liquid paraffin pneumonia -with chemical analysis and electron microscopy paraffinoma confirmed by infrared spectrophotometry foreign body granulomata of the lungs due to liquid paraffin exogenous lipoid pneumonia due to nasal application of petroleum jelly reaction of human lungs to aspirated animal fat (ghee): a clinicopathological study clinical reactions following bronchography the reaction of pulmonary tissue to lipiodol experimental study of bronchographic media on lung a method for the identification of lipiodol in tissue sections of lungs, lipids, and lollipops bronchial necrosis and granuloma induced by the aspiration of a tablet of ferrous sulphate syndrome of iron pill aspiration pulmonary disease associated with l-tryptophan-induced eosinophilic myalgia syndrome. clinical and pathologic features a case of the eosinophilia-myalgia syndrome associated with use of an l-tryptophan product an investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use l-tryptophan and the eosinophiliamyalgia syndrome: pathologic findings in eight patients histopathologic features of the l-tryptophan-related eosinophilia-myalgia (fasciitis) syndrome -(phenylamino)alanine, a novel aniline-derived amino acid associated with the eosinophilia-myalgia syndrome -a link to the toxic oil syndrome immunemediated mechanisms and immune activation of fibroblasts in the pathogenesis of eosinophilia-myalgia syndrome induced by l-tryptophan pulmonary hypertension in patients with eosinophilia-myalgia syndrome or toxic oil syndrome tryptophan-induced lung disease -an immunophenotypic, immunofluorescent, and electron microscopic study bronchiolitis obliterans organizing pneumonia associated with massive l-tryptophan ingestion pulmonary disease complicating intermittent therapy with methotrexate case records of the massachusetts general hospital. a -year-old man with increasing dyspnea, dry cough, and fever after chemotherapy for lymphoma interferon-alpha therapy associated with the development of sarcoidosis proliferation and differentiation in mammalian airway epithelium sarcoid-like pulmonary disorder in human review of the literature severe barium sulfate aspiration into the lung: clinical presentation, prognosis and therapy aminorex and the pulmonary circulation pulmonary hypertension and fenfluramine irreversible pulmonary hypertension after treatment with fenfluramine dietary pulmonary hypertension appetite-suppressant drugs and the risk of primary pulmonary hypertension fatal pulmonary hypertension associated with short-term use of fenfluramine and phentermine autopsy findings of heart and lungs in a patient with primary pulmonary hypertension associated with use of fenfluramine and phentermine pulmonary veno-occlusive disease following therapy for malignant neoplasms pulmonary veno-occlusive disease in an adult following bone marrow transplantation: case report and review of the literature indomethacin in the treatment of premature labor. effects on the fetal ductus arteriosus prenatal diagnosis of intrauterine premature closure of the ductus arteriosus following maternal diclofenac application roles and mechanisms of human immunodeficiency virus protease inhibitor ritonavir and other anti-human immunodeficiency virus drugs in endothelial dysfunction of porcine pulmonary arteries and human pulmonary artery endothelial cells pulmonary embolism after intravenous immunoglobulin fat embolism in infancy after intravenous fat infusions pulmonary fat accumulation after intralipid infusion in the preterm infant intralipid microemboli the pathogenesis of fat embolism pulmonary lipid emboli in association with long-term hyperalimentation the impact of intravenous fat emulsion administration in acute lung injury microvascular pulmonary emboli secondary to precipitated crystals in a patient receiving total parenteral nutrition -a case report and description of the high-resolution ct findings pulmonary complications following lymphangiography with a note on technique changes in pulmonary function due to lymphangiography pulmonary complications of lymphangiography respiratory distress syndrome from lymphangiography contrast medium spallation and migration of silicone from blood-pump tubing in patients on hemodialysis acute pneumonitis after subcutaneous injections of silicone in transsexual men pulmonary granulomas secondary to embolic prosthetic valve material pulmonary teflon granulomas following periurethral teflon injection for urinary incontinence acute pneumonitis after subcutaneous injections of silicone for augmentation mammaplasty a pathological study following bronchial artery embolization for haemoptysis in cystic fibrosis isobutyl- -cyanoacrylate pulmonary emboli associated with occlusive embolotherapy of cerebral arteriovenous malformations hemorragie alveolaire diffuse secondaire a l'utilisation d'anticoagulants oraux diffuse alveolar hemorrhage with underlying pulmonary capillaritis in the retinoic acid syndrome intrapulmonary hemorrhage with anemia after lymphangiography alveolar hemorrhage as a complication of treatment with abciximab d-penicillamine induced goodpasture's syndrome in wilson's disease drugs and the pleura pleuropulmonary changes induced by ergoline drugs pleuropulmonary disease as a side-effect of treatment with bromcriptine pleuropulmonary disease due to pergolide use for restless legs syndrome fibrosis of the lung following roentgen-ray treatments for tumor radiation reaction in the lung radiation pneumonitis: experimental and pathologic observations radiation pneumonitis following combined modality therapy for lung cancer: analysis of prognostic factors the pathogenesis of radiationinduced lung damage radiation pneumonitis: a review adult respiratory distress syndrome after limited thoracic radiotherapy migratory bronchiolitis obliterans organizing pneumonia after unilateral radiation therapy for breast carcinoma migratory organizing pneumonitis 'primed' by radiation therapy hamman-rich syndrome 'primed' by radiation? recall' pneumonitis: adriamycin potentiation of radiation pneumonitis in two children recall lung pneumonitis due to carmustine after radiotherapy pulmonary radiation injury mortality from cancer and other causes after radiotherapy for ankylosing spondylitis increased risk of lung cancer after breast cancer radiation therapy in cigarette smokers aortotracheal fistula secondary to bacterial aortitis respirator lung -a misnomer pathology of adult respiratory distress syndrome pulmonary morphology in a multihospital collaborative extracorporeal membrane oxygenation project lung injury caused by mechanical ventilation ventilator-induced lung injury oxygen radicals mediate endothelial cell damage by complement-stimulated granulocytes in vitro damage of rat lungs by oxygen metabolites intercellular adhesion molecule- contributes to pulmonary oxygen toxicity in mice -role of leukocytes revised intercellular adhesion molecule- expression on the alveolar epithelium and its modification by hyperoxia normobaric oxygen toxicity of the lung oxygen pneumonitis in man pathology of pulmonary oxygen toxicity diffuse alveolar damage -the role of oxygen, shock and related factors diffuse interstitial pulmonary fibrosis. pulmonary fibrosis in mice induced by treatment with butylated hydroxytoluene and oxygen potentiation of diffuse lung damage by oxygen: determining values resistance and susceptibility to oxygen toxicity by cell types of the gas-blood barrier of the rat lung ultrastructural observations on the development of the alveolar lesions extracorporeal membrane oxygenation for adult respiratory failure pulmonary pathology of patients treated with partial liquid ventilation disruption of the cd -cd ligand system prevents an oxygen-induced respiratory distress syndrome pathogenesis and reversibility of the pulmonary lesions of oxygen toxicity in monkeys. ii ultrastructural and morphometric studies diffuse alveolar damage, respiratory failure and blood transfusion pulmonary injury -secondary to extracorporeal circulation fine structural changes in the lungs following cardiopulmonary bypass complement and the damaging effects of cardiopulmonary bypass acute lung injury during cardiopulmonary bypass: are the neutrophils responsible? inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies the pleuropulmonary manifestations of the postcardiac injury syndrome the postmyocardial infarction syndrome. the nonspecificity of the pulmonary manifestations the postcardiac injury syndromes antiheart antibodies following open heart surgery: incidence and correlation with postpericardiotomy syndrome analysis of the factors associated with radiofrequency ablation-induced pneumothorax irreversible intrapulmonary vascular changes after pulmonary vein stenosis complicating catheter ablation for atrial fibrillation pulmonary venous stenosis after treatment for atrial fibrillation right sided infective endocarditis as a consequence of flow directed pulmonary artery catheterisation complications and consequences of endotracheal intubation and tracheotomy. a prospective study of critically ill adult patients pathologic changes of the trachea after percutaneous dilatational tracheotomy pseudomonas aeruginosa respiratory tract infections in patients receiving mechanical ventilation cardiac arrhythmias resulting from tracheal suctioning obstructive fibrinous tracheal pseudomembrane -a potentially fatal complication of tracheal intubation -h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial tracheobronchomalacia in children necrotizing sialometaplasia (adenometaplasia) of the trachea severe complications of bronchoscopy the postpneumonectomy state evaluation of post-pneumonectomy space by computed tomography the postpneumonectomy space: factors influencing its obliteration hepatocyte growth factor stimulates proliferation of respiratory epithelial cells during postpneumonectomy compensatory lung growth in mice severe airway obstruction caused by mediastinal displacement after right pneumonectomy in a child. a case report postpneumonectomy syndrome: diagnosis, management, and results treatment of left pneumonectomy syndrome with an expandable endobronchial prosthesis postpneumonectomy syndrome: another twist acute lung injury and acute respiratory distress syndrome after pulmonary resection the mortality from acute respiratory distress syndrome after pulmonary resection is reducing: a -year single institutional experience prevalence and mortality of acute lung injury and ards after lung resection lung injury following pulmonary resection in the isolated, blood-perfused rat lung the pathogenesis of lung injury following pulmonary resection it is estimated that % of all hospital admissions are due to effects of therapeutic drugs, that - % of inpatients experience a drug reaction and that % of deaths in hospital may be related to drug therapy. [ ] [ ] [ ] [ ] the lungs are often involved in these adverse reactions. the mechanism of an adverse drug reaction may be based on:• overdosage: toxicity linked to excess dose, or impaired excretion, one classification of adverse drug reactions is that based upon the type of drug (box . . ). this is not adopted here but in passing it is worth noting that pharmacists are generally very helpful in supplying details of adverse reactions to specific drugs. alternatively, information on the long list of potentially pneumotoxic drugs may be obtained at http://www.pneumotox.com. a useful scheme for chapter key: cord- - jgusov authors: dignard, caroline; leibler, jessica h. title: recent research on occupational animal exposures and health risks: a narrative review date: - - journal: curr environ health rep doi: . /s - - - sha: doc_id: cord_uid: jgusov purpose of review: in the last year, an increasing number of studies have reported on methicillin-resistant staphylococcus aureus (mrsa) transmission in africa and asia and in migrant workers. we reviewed original research on occupational health and safety of animal workers published from january , , through june , , with a targeted focus on infectious disease studies published in these populations. recent findings: studies focused on occupational exposures to infectious agents, dust and allergens, pesticides, and occupational injury. research on zoonotic mrsa used whole genome–sequencing technologies to evaluate transmission in africa and asia. swine worker exposure to porcine coronavirus and emerging influenza a viruses was documented in china. s rna amplicon sequencing identified distinct microbiota compositions in households with active animal farmers. multiple bioaerosol exposures were assessed for industrial dairy workers. occupational injury studies highlighted the struggles of latino animal workers in the usa. summary: these studies highlighted the global expansion of zoonotic antibiotic resistance and identified novel occupational zoonoses of concern. the integration of microbiome assessment and compound mixtures into the evaluation of dust and endotoxin exposures for animal workers marks a new direction for this work. occupational exposure to animals is associated with a myriad of health and safety risks, including zoonotic infections, occupational injury, respiratory disease, and cancer [ ] [ ] [ ] [ ] . in the usa, food animal workers have elevated workplace mortality and injury rates compared with workers in other industries, highlighting the occupational risks involved in the profession [ ] . in the last years, research on zoonotic infection risk has dominated the occupational health literature on the animal workforce, highlighting in particular exposure risk to drugresistant bacteria and influenza viruses and subsequent transmission from workers to the general public [ ] [ ] [ ] . in the last years, industrialization and corporate consolidation have characterized the food animal production industry, first in the usa and europe and then globally [ , ] . these trends have fundamentally altered occupational exposures for the food animal workforce, by increasing and intensifying specific occupational exposures that impart health risks [ ] . for workers, the intensity of animal exposures has increased, as industrial farms can hold tens of thousands of animals on site. the dramatic increase in the number of animals housed together in confinement contributes to intensified worker exposure to animals and animal products, including allergens and fecal materials [ , ] . notably, the introduction of antibiotics into animal production-in an effort to facilitate the higher carrying capacity of industrial farms-has resulted in worker exposures to antibiotic-resistant bacterial infections [ ] . since , research on zoonotic methicillin-resistant staphylococcus aureus (mrsa), particularly the livestock-associated mrsa strains st and cc , have identified important public health concerns stemming from the misuse and overuse of these antibiotics in agriculture [ ] [ ] [ ] . likewise, the h n epidemic in poultry in asia in the mid- s and the h n swine flu human pandemic, highlight the role of industrial systems in the ecology of pandemic influenza [ ] [ ] [ ] . the emergence and re-emergence of zoonotic pathogens with potential to infect humans remains a critical public health issue, and animal workers are at the front lines [ ] [ ] [ ] . the demographics of this workforce have also changed significantly in recent decades, with latino and immigrant workforce currently dominating the worker population in the usa. this change has resulted in additional challenges for the workforce, including language barriers, immigration status concerns, stagnant and falling wages, and other socioeconomic and political stressors [ ] . the relationship between these stressors and occupational injury and mental health has been documented in recent years [ ] [ ] [ ] [ ] . many animal workers experience occupationally induced respiratory disease, including allergies, asthma, and rhinitis [ , ] . high levels of inhalable dust and endotoxins are considered the primary exposures of concern in regard to respiratory disease; however evaluating these often complex mixtures-including animal products, dust, pathogens, and chemicals-is typically limited to single-compound analyses. as a result, much remains unknown about the etiology of occupational respiratory disease among animal workers. across agricultural industries, the use of pesticides is associated with a variety of health risks, including reproductive, dermatological, and neurological problems as well as cancer [ ] [ ] [ ] [ ] . pesticide use is common among animal facilities, particularly those that engage in both crop and livestock production, yet pesticide exposures have received limited scrutiny to date in research on animal workers. on both industrial and small-scale animal farms, chemical disinfectants are used to prevent transmission of infectious agents and may result in health concerns for workers [ , ] . while the biosecurity literature has promoted the use of disinfectants to prevent disease transmission, health risks associated with worker exposure to these compounds are largely unstudied. in this manuscript, we review occupational health studies published in the last months in the peer-reviewed literature focused on the health and safety of animal workers. our intention was to highlight important findings and new directions for this research area. we searched pubmed, web of science, and google scholar for terms and keywords relating to occupational health and animal exposure, including combinations of the following worker and health-specific terms: "food animal worker", "animal worker", "industrial animal worker", "animal farmer", "occupational injury", "occupational health", "health and safety", and "occupational safety". a date range of january , , through june , , was included so as to maximize identification and in-depth discussion of recent research. a total of distinct manuscripts were identified upon initial search. following review by two researchers (c.d., j.h.l.), these papers were reduced to manuscripts of relevance to the current topic. these papers included three review manuscripts and original research studies. we included the reviews in our analysis because they provide important insight and expert consensus as to the direction of important fields (biosecurity for live bird market workers; respiratory exposures and disease among food animal workers; and effectiveness of health and safety trainings and interventions for latino animal workers). the manuscripts were organized in an excel spreadsheet and read by two researchers. a narrative synthesis approach was used to extract central themes, findings, and conclusions. based on our a priori knowledge of the field and an assessment of other recent manuscripts in the literature, we identified manuscripts we believed to be of elevated significance to readers engaged in animal worker health and safety work and research, and we discuss those studies in greater detail. the manuscripts published during this -month period were predominantly in the following topic areas: infectious disease and pathogen exposures; respiratory disease and irritants; pesticide and chemical exposures, including neurological toxicants and carcinogens; and occupational injury. below, we summarize the key findings from manuscripts published in each of these topic areas, highlighting the papers that in our opinion are of greatest importance for the field. the majority of manuscripts identified in our review ( / ; %) were focused on animal worker exposure to infectious agents, zoonotic pathogen carriage or infection within this workforce, or pathogen contamination of the work environment. the infectious disease papers are summarized in table . the reviewed manuscripts documented the identification of livestock-associated mrsa in animals and humans in regions around the world and in animal-exposed professions in which mrsa had not previously been assessed. a study in nigeria identified low prevalence of la-mrsa among abattoir workers ( . %) and distinguished a diversity of s. aureus spa types in the work environment, including a novel spa type (t ) [ ] . the first published study of la-mrsa among workers and livestock in trinidad identified a low prevalence among animals (< %) and no worker carriage, indicating limited transmission in this country [ ] . a case study of mrsa among swine and workers on an australian swine farm where workers were affected by skin lesions identified high odds of mrsa nasal carriage among the workers (or . ) and a dose-response relationship of mrsa nasal carriage in association with duration of time spent working with pigs [ ] . a study in italy reinforced the elevated prevalence of st among industrial swine (approx. %) and swine workers ( %) in that country and highlighted a component of the production cycle (fattening) in which workers had higher risk of exposure [ ] . cuny and colleagues assessed mrsa nasal colonization among butchers and food preparers in germany to evaluate whether these persons with contact with raw meat were colonized with livestock-associated mrsa, and found limited evidence of colonization (< %) [ ] . these studies continue to expand our knowledge of the distribution of livestock-associated mrsa, both by industry and by geographic region. whole genome-sequencing (wgs) technology was used to elucidate transmission pathways in two studies conducted in africa. amoako and colleagues took a comprehensive approach and used wgs to evaluate mrsa along the "farm to fork" continuum in the intensive poultry industry in south africa [ ] . the authors evaluated samples collected from the farms, transport vehicles, slaughterhouses, and retail outlets, as well as fecal and nasal specimen from workers along the production process. the authors document the widespread distribution of mrsa clone st -cc _t -sccmec_type_ivd ( b) throughout the production cycle. they hypothesize that the multidrug resistance of this clone is mediated by mobile genetic elements, due to the similarity of resistance patterns between the human and animal specimen. the identified prevalent clone is considered both nosocomial and community-associated, highlighting the public health risks associated with the poultry industry in south africa. this work and the study in cameroon, detailed below, are of relevance due to the rapid intensification and expansion of industrial food animal production into africa and the limited research to date on the public health consequences of this industrial growth. a second study in africa used wgs to identify the genetic lineage of mrsa isolates from swine slaughterhouses in south africa and cameroon [ ] . these authors found approximately % prevalence in pigs in south africa but a low prevalence in cameroon (< %), with no workers colonized in either country. all isolates were st , a distinction from the amoako study. these findings highlight potential differences in mrsa carriage by species and/or region and also suggest that production or environmental containment practices may differ among countries and corporations in relevant ways for public health. chen et al. used wgs to identify whether cc , the predominant livestock-associated mrsa strain in asia, was associated with pathogenicity in humans [ ] . the authors screened mrsa isolates from a national database in taiwan and found cc had a low prevalence ( . %); however, these isolates were associated with invasive disease, including bacteremia leading to death and osteomyelitis in four of the eight identified cases. the remaining four cases were associated with mild disease or colonization without disease. of note, only two of the eight cases had documented exposure to pigs, considered the main cc reservoir in the region. this important paper highlights two core concepts: ( ) while rare in humans, cc may be associated with significant pathogenicity in humans, including death and ( ) nosocomial or community transmission for this pathogen should be considered. like the african studies, this paper elucidates the public health risks from animal work and highlights the potential role of animal workers at the front lines of exposure to zoonotic pathogens of broader health concern. other antibiotic-resistant bacterial infections escherichia coli (e. coli) recovered from swine workers and pigs in northern vietnam, a region characterized by rapid growth in industrial swine production and heavy agricultural antibiotic usage [ ] . esbls are of particular concern because these genes are encoded by plasmids that are easily transferred across bacterial species, potentially resulting in widespread antibiotic resistance. the authors observed high prevalence of ctx-resistant e. coli among both workers and pigs ( % of pig workers and % of pigs) on farms studied. esblproducing e. coli was detected from more than % of both pigs and farms. this paper highlights significant concern regarding potential spillover of drug-resistant bacteria from swine to humans in this region, as well as the likelihood of dissemination of the esbl mges. research during this period focused on zoonotic influenza of multiple subtypes, including the emerging influenza d virus. ma et al. published findings from a longitudinal study of swine workers, swine, and environmental sampling in china [ ••] . notably, in this study, workers were monitored for influenza-like illness along with surveillance sampling, so as to identify active symptoms associated with infection. approximately % of workers with ili were positive for influenza a virus, with more than % of those infected with a putative swine lineage virus. additionally, high concordance was noted between a(h n )pdm -like h n viruses isolated from workers with ili and iav circulating among swine, indicating species crossover. a second study, led by borkenhagen et al. identified influenza b and influenza d viruses in swine worker nasal passages during a surveillance study in malaysia [ ] . the authors also recovered porcine circovirus in worker nasal specimen as well as in pig specimen, indicating zoonotic concern associated with this viral pathogen of growing concern in asia. we would also direct readers interested in zoonotic influenza emergence to two valuable review papers published in the last year this topic, by zhou et al. and bailey et al [ , ] . animal worker exposure to hepatitis e virus (hev) was explored in two notable papers, both of which extended the prior paradigm of hev research to include new populations or production specifics. a study in hubei, china, identified elevated seroprevalence among rabbit slaughterhouse workers compared with community controls and observed a doseresponse relationship between increasing seroprevalence associated with duration of employment [ ] . khounvisith and colleagues evaluated hev seroprevalence among commercial pig workers in laos, a region with hev endemicity among swine [ ] . the authors observed % of workers were hev seroprevalent, compared with % of controls, and workers exposed to piglets during the growth process were at elevated risk. other authors highlighted additional emerging zoonotic viral pathogens in the food animal workforce, including a report of brucellosis among sheep farmers in egypt and knowledge and biosecurity practices among indian animal farmers about rabies [ , ] . msimang and colleagues reported on rift valley fever seroprevalence among animal farmers and veterinarians in south africa, concluding that infection with this re-emerging pathogen is likely notably higher than previously recognized and under-diagnosed in the region [ ] . we identified eight original research papers and one review study focused on topics related to respiratory disease, exposure to allergens and dust, and airborne bacteria among animal workers. these papers expanded the literature in two core ways: ( ) a focus on combined and interacting respiratory exposures, rather than single-exposure assessments and ( ) the use of s rna amplicon sequencing technology to evaluate house microbiota in farmer's homes and correlating these data to endotoxin levels. key papers are discussed below. davidson et al. conducted personal exposure monitoring of bioaerosol exposures, including inhalable dust, endotoxin, -hydroxy fatty acids, muramic acid, ergosterol, and ammonia among workers at large dairies in the western usa [ •] . this paper marks one of the early studies to consider multiple, and interacting, respiratory exposures in this population. the authors conclude that a majority of these workers were exposed to endotoxin concentrations that exceed recommended guidelines ( %). workers were also exposed to inhalable dust and ammonia at levels above guidelines. the authors also evaluated the correlation between pairs of these exposures by different dairy tasks, another novelty of this work. lee et al. used s rna amplicon sequencing to evaluate bacterial composition of dust samples recovered from households of active and former farmers recruited in the agricultural lung health study, a nested study of the agricultural health study in north carolina and iowa [ ••] . current farming was a significant predictor of the composition and diversity of house dust microbiota. animal farming was uniquely associated with firmicutes and proteobacteria phyla, with bacillaceae, bacteroidaceae, xanthomonadaceae, streptococcaceae, and lactobacillacae also identified in dust specimen from homes with animal farmers. the authors identified taxa associated with endotoxin concentration. asthma status was not associated with bacterial diversity or composition. this paper is notable for its integration of traditional exposure assessment approaches to endotoxin and s rna amplicon sequencing technology for evaluating microbiota, and for contributing detail to our understanding of household-level exposures experienced by animal workers and their families. other notable manuscripts this year included: a study of bacterial and fungal exposures among portuguese veterinarians, exposures to ammonia, vocs, and fungus among swine workers during the summer and winter seasons in poland, and a study from australia of worker exposure to asthmagens derived from animals or fish/shellfish (el zaemey et al.) [ ] [ ] [ ] . the latter study was notable for its large sample (n = ) and its comparison of farmers and animal workers to community controls in a national agricultural study. additionally, an excellent consensus paper published by the european academy of allergy and clinical immunology highlights the state of the literature on respiratory disease and animal workers, specifically food processing workers, in europe, focusing on all elements of the food production chain [ ] . studies of pesticide and chemical exposures among animal workers highlighted pesticides usage in livestock production may increase the risk of parkinson's disease (pd) among farmers. while this relationship has been previously assessed in crop farmers, the identification of animal farmers as a population at risk due to shared exposures is a notable contribution of work from this year. pouchieu and colleagues evaluated the risk of pd among both livestock and crop farmers in france exposed to pesticides in the agrican cohort [ ] . the crop matrix pestimat was used to evaluate exposure to active ingredients and duration of lifelong use, and the implementation of this matrix again reinforces the interest in evaluating complex and realistic mixture scenarios for worker exposures. in this study, cattle workers in particular had an elevated risk of pd, with dithiocarbamate fungicides, rotenone and the herbicides diquat and paraquat identified as compounds of concern for this occupational group. additionally, further studies elucidate carcinogenic compounds beyond pesticides that animal workers may be exposed to, highlighting cancer research as an underexplored area for consideration in this population. darcey and colleagues conducted a cross-sectional study to evaluate exposure to solar radiation, diesel engine exhaust, and solvents among australian farmers [ ] . exposure to these carcinogens was highest for farmers with mixed livestock and crop production, again highlighting unique risk profiles for workers who engage in multiple agricultural activities. hoffman et al. evaluated serum immune markers in a subset of ahs participants who were swine farmers to consider an immunological explanation for the inverse relationship between swine farming and lung cancer, which is hypothesized due to endotoxin exposure [ ] . the authors observed that macrophage-derived chemokine (ccl ), which is believed to contribute to lung carcinogenesis, was lower in swine farmers compared to cattle farmers with a % reduction in levels among farmers at the largest farms (> head), suggesting a dose-response relationship. these manuscripts highlight the complex health effects associated with occupational animal exposure and indicate how emerging technologies and personal monitoring can inform the biological basis of epidemiologic observations. reviewed manuscripts largely focused on the experiences of latino immigrant and migrant farmworker populations in the usa, who comprise a majority of the us food animal workforce. we note a limited number of peer-reviewed original research publications on occupational injury during the short period of our review. we identified four published epidemiological studies of occupational injury in the animal workforce as well as three studies evaluating effectiveness of injury prevention training. a small study conducted in missouri examined self-reported injury and health status among latino immigrant workers. their results indicated a high prevalence of workers rating their health as fair or poor, along with high prevalence of occupational injury [ ] . clouser and colleagues found that occupational injury was more likely for latino farmworkers in the usa if they self-reported work stress, supervisor unfairness, or supervisor inability to speak spanish [ ] . these findings reinforce that immigrant latino and migrant workers in the animal industry need additional resources and supports to successfully mitigate injury risk. bush and colleagues evaluated the causes of missed work among a sample of latino horse workers in the usa in an attempt to evaluate the causes of occupational illnesses [ ] . the authors found that having at least one child, poor selfrated health, and elevated stress were associated with missed work, highlighting the intersecting role of personal and workrelated factors for these workers. an assessment of osha's dairy-focused local emphasis programs (leps) in wisconsin and new york by liebman et al. found that the osha's recent initiative to reduce injury and hazard in the dairy industry improved farmers' ability to recognize occupational hazards [ ] . the authors found that the leps motivated participating dairy producers in these two states to address hazards, such as correct signage, repairs and fit for ppe, and manure management and also encouraged workers to advocate for health care needs. rodriguez et al. evaluated the effectiveness of delivering health and safety training using mobile platforms to us dairy workers with limited english proficiency [ ] . this method was successful, with workers enrolled (n = ) demonstrating a % mean increase from pre-to post-test knowledge of workplace safety practices (p < . ). this paper is of particular note given the proliferation of smartphones and the increasing proportion of the food animal workforce with limited english proficiency. rodriguez and colleagues noted that more than / of the participants in their study spoke a central american indigenous language and were able to receive training through smartphone applications and translation, highlighting the power of this technology to reach many workers with necessary education. caffaro and colleagues conducted a literature review on occupational safety and health training programs addressing migrant farmworkers, including animal workers, to determine the effectiveness of the standard programs in place [ ] . the majority of the reviewed studies found the training programs to be ineffective, with no or little difference in injury outcomes with or without the standard training programs. the authors recommended an increase in participatory approaches and multilingual offerings so as to improve the effectiveness of these programs for migrant workers. continued efforts to evaluate the effective means of developing and delivering injury prevention and health promotion training to the changing and diverse food animal workforce is an important theme of study. research in and early on occupational health and safety topics involving animal workers highlighted the risks and interventions associated with infectious disease, respiratory disease, chemical exposure, and occupational injury. in the realm of infectious disease, these studies identified an expanding, and concerning, geographical distribution of mrsa as well as novel transmission pathways. the expansion of mrsa into africa is of particular note, as the continent has witnessed rapid intensification of food animal production and demand for industrial meat products in recent years. given the known consequences of unregulated antibiotic usage in animal production for public health and the emergence of la-mrsa, surveillance, and regulation of la-mrsa in this region is a critically important direction for future research. in the absence of antibiotic stewardship, interventions to protect workers from zoonotic antibiotic resistant infections-building on the experiences in europe and the usa-would improve african worker health. likewise, the discovery of mrsa strain cc among human patients in taiwan, and the association of this strain with severe illness and death, signifies an important direction for future research. while highly prevalent in livestock populations in asia, cc has not been considered a human pathogen of significance. chen et al.'s paper should reignite interest in this strain as an important, if rare, contributor to severe illness in humans, with surveillance targeting food animal workers at the front lines of exposure. research on zoonotic influenza viruses identified species spillover from swine farming into the food animal workforce, highlighting the importance of this pathway, and this industry for surveillance and pandemic influenza prevention. bailey and colleagues nicely highlight the recent expansion of zoonotic influenza research, notably the discovery of zoonotic influenza d virus, in their review on this topic [ ] . continued research on influenza transmission at the humananimal interface in food animal production remains a critically important area for continued work. likewise, research on behaviors and practices that affect worker exposure, as well as intervention evaluation studies, are central. studies of respiratory irritants and disease integrated new technologies into multi-exposure assessments, including s rna amplicon sequencing technology. the incorporation of metagenomics approaches will likely mark exposure assessment studies in the future, given the relevance of these techniques in other research areas and the opportunities to shed new light on existing occupational health problems. in particular, microbiome analyses have the potential to highlight the relationship between occupational exposures and chronic conditions, such as cancers and respiratory diseases, whose etiology has remained elusive. gene expression studies could elucidate pathways of respiratory irritation among highly exposed workers, with relevance for both the food animal workforce and also the general population. as whole genome sequencing techniques have clarified the role of zoonotic pathogens in the emergence of novel pathogens, such as livestockassociated mrsa and zoonotic influenza viruses, genetic, and genomic techniques hold significant power to clarify pathways of occupational disease for the food animal workforce. this is an important area for future research. consideration of pesticide exposures in animal workers, and multiple exposures between crop and animal farmers, also reflects the emerging interest in complex mixtures analyses in occupational exposure assessment. while studies reviewed here did not formally engage mixtures analytic approaches (such as weighted quantile sum regression or lagged kernel machine regression) davidson and colleagues illustrated the value of combined metrics in exposure assessment studies for food animal workers. given the complex mixtures of pathogens, allergens, toxicants, and other compounds that food animal workers are exposed to on the job, the application of mixtures methods to occupational health studies of food animal workers is an important next step for the field. these techniques may hold specific relevance for cancer endpoints of relevance to this workforce, whose etiologies are potentially multifactorial and have remained rather elusive to date. the predominance of research on latino and migrant worker injury and safety reflect changing demographics in the animal industry over the last years. food animal production in the usa, including both live animal production as well as processing, remains in a period of demographic transition, with the industry increasingly facing a reckoning between the needs and demands of the immigrant and us-born workforce. as segments of the workforce become increasingly immigrant-based, the specific training needs, and injury experiences of these workers become central. studies on the effectiveness of safety training and intervention that target the specific needs and experiences of this segment of the workforce are critically important to reducing morbidity in this industry. likewise, future research that highlights the health experiences and needs of us-born food animal workers, who currently experience wage stagnation and significant social stressors in many regions of the usa, should also be at the forefront. the occupational injury implications of the industry's interests in increased line speeds and also automation also remain an important area for future work, so as to inform regulations and protect workers. food animal work remains a complex and often dangerous occupation. research in and beyond would best suit the needs of this workforce by continuing to highlight pathogens of concern, identify regulatory and intervention opportunities to reduced occupational pathogen exposure, integrate emerging microbiome and genomic technologies to more fully elucidate occupational disease pathways, and evaluate injuryprevention techniques specific to the demands and realities of the industry. funding information support for this work was provided by cdc/ niosh k oh (jhl) and williams college center for environmental studies (cd). antimicrobial-resistant bacteria: an unrecognized work-related risk in food animal production particulate matter, endotoxin, and worker respiratory health on large californian dairies environmental exposure and health effects from concentrated animal feeding operations lung cancer risk in workers in the meat and poultry industries-a review incidence rates of nonfatal occupational injuries and illnesses by industry and case types the animal-human interface and infectious disease in industrial food animal production: rethinking biosecurity and biocontainment. public health rep wash dc swine workers and swine influenza virus infections tackling antibiotic resistance: the environmental framework chickenizing farms and food: how industrial meat production endangers workers, animals, and consumers industrial livestock production and global health risks. food agric organ u n -poor livest policy initiat res rep industrial food animal production and global health risks: exploring the ecosystems and economics of avian influenza microbial ecology, bacterial pathogens, and antibiotic resistant genes in swine manure wastewater as influenced by three swine management systems public health implications related to spread of pathogens in manure from livestock and poultry operations animal antibiotic use has an early but important impact on the emergence of antibiotic resistance in human commensal bacteria an overview of livestock-associated mrsa in agriculture food-animal production and the spread of antibiotic resistance: the role of ecology staphylococcus aureus cc : host adaptation and emergence of methicillin resistance in livestock avian influenza virus (h n ): a threat to human health persistence of highly pathogenic avian influenza h n virus defined by agro-ecological niche diversity of influenza viruses in swine and the emergence of a novel human pandemic influenza a (h n ). influenza other respir viruses pandemic influenza planning: shouldn't swine and poultry workers be included? vaccine methicillin-resistant staphylococcus aureus (mrsa) strain st is present in midwestern u.s. swine and swine workers multidrug-resistant and methicillin-resistant staphylococcus aureus (mrsa) in hog slaughter and processing plant workers and their community in north carolina (usa) sweat and fear: workers' rights in us meat and poultry plants measuring job characteristics and mental health among latino farmworkers: results from cognitive testing migrant farmworker stress: mental health implications. j rural health off j am rural health assoc natl rural health care assoc systematic review of respiratory health among dairy workers stress, depression, and occupational injury among migrant farmworkers in nebraska lifetime allergic rhinitis prevalence among us primary farm operators: findings from the farm and ranch safety survey pesticides and their metabolites in the homes and urine of farmworker children living in the salinas valley. ca noncancer health effects of pesticides: systematic review and implications for family doctors rotenone, paraquat, and parkinson's disease dietary fat intake, pesticide use, and parkinson's disease the health and safety of workers in a confined animal system respiratory illness in agricultural workers staphylococcus aureus in two municipal abattoirs in nigeria: risk perception, spread and public health implications genomic analysis of methicillin-resistant staphylococcus aureus isolated from poultry and occupational farm workers in umgungundlovu district clinical and molecular features of mdr livestockassociated mrsa st with staphylococcal cassette chromosome mecxii in humans genome analysis of methicillin-resistant staphylococcus aureus isolated from pigs: detection of the clonal lineage st in cameroon and south africa mrsa in swine, farmers and abattoir workers in southern italy emergence of highly prevalent ca-mrsa st as an occupational risk in people working on a pig farm in australia prevalence of methicillin-resistant staphylococcus aureus (mrsa) in broilers and workers at "pluck shops" in trinidad cephalosporin-resistant escherichia coli isolated from farm workers and pigs in northern vietnam surveillance for respiratory and diarrheal pathogens at the human-pig interface in sarawak. malaysia the authors identified cross-species transmission of human-adapted h n viruses and swine-adapted h n viruses in both swine and swine workers in china, highlighting continued pandemic influenza risk from swine production in this region. the authors also noted symptomatic influenza-like illness among workers using a longitudinal design sero-diagnosis of brucellosis in sheep and humans in assiut and el-minya governorates. egypt challenges to human rabies elimination highlighted following a rabies outbreak in bovines and a human in high seroprevalence of hepatitis e virus in rabbit slaughterhouse workers high circulation of hepatitis e virus in pigs and professionals exposed to pigs in laos rift valley fever virus exposure amongst farmers, farm workers, and veterinary professionals in central south africa methicillin susceptible staphylococcus aureus (mssa) of clonal complex cc , t from infections in humans are still rare in germany effectiveness of market-level biosecurity at reducing exposure of poultry and humans to avian influenza: a systematic review and meta-analysis the continual threat of influenza virus infections at the human-animal interface: what is new from a one health perspective the authors conducted personal exposure monitoring for multiple airborne irritants and toxins among dairy workers in the western us, and considered exposureby-exposure mixtures, setting the stage for future work the authors evaluated microbial composition of household dust using s technology and compared findings to endotoxin levels. this study marks an early foray into microbiome research for understanding health effects associat organic dust exposure in veterinary clinics: a case study of a small-animal practice in portugal occupational exposure level of pig facility workers to chemical and biological pollutants prevalence of occupational exposure to asthmagens derived from animals, fish and/or shellfish among australian workers food processing and occupational respiratory allergy-a eaaci position paper pesticide use in agriculture and parkinson's disease in the agrican cohort study prevalence of exposure to occupational carcinogens among farmers industrial hog farming is associated with altered circulating immunological markers self-reported occupational injuries and perceived occupational health problems among latino immigrant swine confinement workers in missouri associations of work stress, supervisor unfairness, and supervisor inability to speak spanish with occupational injury among latino farmworkers missed work due to occupational illness among hispanic horse workers an overview and impact assessment of osha large dairy local emphasis programs in new york and wisconsin using mobile technology to increase safety awareness among dairy workers in the united states effectiveness of occupational safety and health training for migrant farmworkers: a scoping review nasal colonization of humans with occupational exposure to raw meat and to raw meat products with methicillin-susceptible and methicillin-resistant staphylococcus aureus publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations human and animal rights this article does not contain any studies with human or animal subjects performed by the authors. the authors declare that they have no conflict of interests. papers of particular interest, published recently, have been highlighted as: key: cord- -t zfhdf authors: tufts, steven title: hospitality unionism and labour market adjustment: toward schumpeterian unionism? date: - - journal: geoforum doi: . /j.geoforum. . . sha: doc_id: cord_uid: t zfhdf abstract this paper proposes a conceptual model for understanding emerging changes in a north american labour union. unite-here, largely representing textile and hospitality workers, has been at the forefront of debates on union revitalization in the us and canada. unite-here is often characterized as a successful example of north american union renewal, but i argue that this often oversimplifies many complex and contradictory labour strategies. much of the labour union renewal literature remains prescriptive and is only beginning to escape false binaries such as business versus social unionism, the servicing versus organizing model, or ‘top-down’ versus ‘bottom-up’ administration. in this paper, i attempt to conceptualize the strategies adopted by the union as they exist in relation to the changing political economic landscape. i characterize the current labour practices as ‘schumpeterian unionism’, a model which captures the shifting, contradictory, and multi-scalar relationships labour has with the broader community, capital and the state. the model is illustrated with a case study of unite-here local ’s response to the sars outbreak through their establishment of a hospitality workers resource centre to service unemployed workers. for over two decades, economic restructuring in advanced capitalist economies has challenged organized labour and with the rare exception of a few northern european countries, labour union density in many advanced capitalist economies has been in a prolonged period of stagnation or decline (moody, ; fantasia and voss, ; visser, ) . in canada, the percentage of workers covered by unions is double that of the united states but has slowly declined to less than a third of the labour force (akyeampong, ) . the central question for many labour activists and researchers continues to be how labour can revitalize itself to maintain a capacity to shape economic landscapes. there has been no shortage of commentary on these questions as an entire literature on labour union renewal has been dedicated to the project for well over a decade (bronfenbrenner, ; fairbrother and yates, ; kumar and schenk, ) . geographers have also weighed in on these debates, although the approach has focussed largely on the question of the how labour can (re)organize at scales compatible to that of contemporary capital (herod, (herod, , castree et al., ; tufts, a) . for many, union revitalization involves a shift toward a social justice or 'social movement unionism' which organizes communities around a range of issues beyond the workplace as a means of challenging the operation of the market (see fletcher and gaspasin, ) . this departure is antithetical to the narrow 'bread and butter' business unionism which typified much of the post-war compromise industrial relations in anglo-american economies. even the staunchest advocates of social movement unionism, however, recognize it remains an ideal rather than actual practice. moody ( , p. ) argues that social movement unionism has lost much of its 'unique meaning' as it now refers to any effort where the union reaches out to the community in an issue based campaign. for this reason, kumar and murray ( ) speak of 'social unionism' as a midway point between business and social movement unionism to characterize unions who adopt some of the more innovative strategies, but remain very much integrated into capitalist production. in this paper, i too propose an understanding of union renewal which is located between the binaries of business and social movement unionism, but i theoretically embed such union strategy in larger processes of economic and political transformation. i argue that many of the labour renewal strategies currently observed can be interpreted as not only a reaction to, but also constitutive of neoliberalism and the re-scaling of capital and the state (see jessop, ; brenner, ) . as an entry point into this discussion, the paper proposes a model of 'schumpeterian unionism' juxtaposing the ideal-types of 'defensive atlantic unionism' and 'ideal renewed social movement unionism'. i compare four areas of union activity: intra-institutional organizing; extra-institutional organi-zation; labour-management relations; and labour-state relations. here, schumpeterian unionism is defined as a model of labour organization that preserves working-class agency by adapting to successive rounds of economic 'creative destruction' (see peck and jones, ) . in keeping with traditional marxist interpretations of trade unionism, these practices are neither transformative nor revolutionary, but they may sustain labour as a viable economic agent within harsher variants of neoliberalism. aside from the labour union renewal literature itself, the conceptual framework is developed from two sources. its first theoretical inspiration is largely drawn from jessop's ( ) political economy of evolving capital-state relations. in a groundbreaking article, jessop ( ) forwarded the schumpeterian workfare state (sws) as a model of state-capital relations displacing the keynesian welfare state established in post-war atlantic fordist economies. at its core, the sws model characterized a number of national policies aimed at implementing the neoliberal project (e.g., labour market flexibility, innovation). the sws model is inspired by schumpeter's ( , p. ) treatise on economic evolution that centred the process of 'creative destruction' as 'the essential fact about capitalism' that must be understood in order to understand overall economic development. over a decade, jessop ( ) refined his initial model to where he speaks of schumpeterian workfare post-national regimes (swpr) as the successor to the keynesian state. the swpr's focus is on: economic policies which increase competitiveness in global markets; downward pressure on social wages with limited welfare; the rise of networks of public-private governance; and re-scaled state policy above and below the nation. from a geographical viewpoint, the most significant evolution of jessop's model is the integration of how capitalist states re-scale economic policy to global (e.g., policies allowing capital to flow to low wage regions) and sub-national levels (e.g., policies enhancing regional metropolitan competitiveness rather than national economic development). indeed, it was the initial aspatiality of jessop's model that inspired a number of geographers to explore how restructuring of the welfare state was being played out across space at different scales (see peck, peck, , . brenner ( ) has built upon jessop's work to define how the re-territorialization of state policies from the national-global and national-local has created a number of contradictory new state spaces. in particular, national policy supporting cities and the decentralization of power has shifted the governance and reconfigured state-capital formations toward the urban. it is the re-territorialization of the state to a number of scales which have proliferated the variations of neoliberalisms on the ground and requires researchers to now look at neoliberal policies as they 'actually exist' (brenner and theodore, ) . the swpr model and the work it has inspired have contributed significantly to our understanding of the evolution of the capitalist state and the complex ways local, regional and national governments have recast their relationships with capital and citizens in order to restore conditions of profitability in the midst of crisis. for labour unions, the implications of these policies must not be understated as they shape the quantity and quality of jobs delivered by capital and in some cases, challenge the rights of workers to organize effectively (panitch and swartz, ; fantasia and voss, ) . while in most cases organized labour has been the target of swprs, it is problematic to conceptualize labour as outside processes shaping variations of capitalist states. another approach is to explore how organized labour is changing in response to shifting policies of swpr and how these responses are in many cases enabling neoliberal state projects operating at multiple scales. while many emergent labour union renewal strategies can still be discussed as a reaction to neoliberal restructuring and the regulatory environment imposed by swprs, other emerging union structures and practices can also be viewed as an integral part of contemporary capitalist economies. in other words, it is consistent to consider how unions are implicated in various formations of neoliberal regimes since schumpeterian economies will inevitably require the consent of schumpeterian labour. it is within this theoretical framework, that the following discussion of labour union renewal is situated. second, the model has been conceptualized through its grounding in a larger empirical project on hospitality sector unionism in toronto, specifically the experience of unite-here local (see tufts, tufts, , tufts, , tufts, , a tufts, , b . while a number of campaigns and initiatives of local may be characterized as schumpeterian unionism, here i present an examination of the unions response to the outbreak of severe acute respiratory syndrome (sars) in toronto which adversely affected the city's hospitality sector. the specific case study is the hospitality workers resource centre (hwrc), a service developed as a response to workers displaced from work by the crisis. the case study demonstrates how the choices unions make can contribute to neoliberal agendas while simultaneously reproducing labour as viable institutions. further, it demonstrates how 'schumpeterian' unions are rescaling their strategies in the midst of global challenges. grounded theoretical approaches are a huge strength of contemporary economic geography (see yeung, ) and any new theoretical work must remain grounded in real political circumstances of workers' lives. abstracting organized labour's practices too far from the realities of everyday political struggles leads to analyses which are far removed from unionism as it 'actually exists'. following an elaboration and definition of schumpeterian unionism, i present local 's response to the sars outbreak to exemplify the model. i conclude with some broader implications for the model with respect to union renewal and the broader labour geography project. for some time researchers have recognized the need to transcend false binaries characterizing discussions of union renewal such as servicing versus organizing models or business versus social movement unionism. for example, fletcher and hurd ( ) recognized the limits of juxtaposing servicing versus organizing in discussions of union renewal almost from the initial conception. many studies of labour union renewal also remain largely prescriptive and often 'idealize' labour transformation as an antithesis to the stagnant and defensive actions of retrenched business unionism. as a result, labour union renewal as it 'actually exists' remains hidden as the emphasis is on capacities to achieve an ideal form, such as a renewed social movement unionism. labour union renewal, however, contains both complex and contradictory processes with uneven outcomes. in some instances, so-called 'renewed' unionism actually aids the neoliberal project while actions deemed 'business as usual' unionism may forestall its advancement. i address these contradictions by introducing the concept of 'schumpeterian unionism' as one way of characterizing the current transformation of segments of anglo-american labour movements. a further aim of the model is to integrate labour union renewal into explanations of local variations of capitalism as labour union renewal itself is largely a geographical phenomenon. it is now widely accepted that local labour markets influence successive rounds of accumulation and reproduction. but labour union renewal is much more than a function of previous 'layers' of labour mobilization as the ability to make unions vibrant is largely dependent on the multi-scalar organization of workers and the ability of unions to 're-scale' their activities in ways which are compatible with contemporary capital and capitalist states (tufts, a (tufts, , b savage, ) . schumpeterian unionism therefore addresses the 'geographical dilemma' (see castree et al., ) facing workers who are forced to compete for international investment and jobs by establishing both permanent and temporary networks and coalitions. similar to the approach taken by jessop ( ) to discuss changes in the capitalist states, i present the model of schumpeterian unionism as an 'ideal-type', by juxtaposing the model against two other antithetical ideal-types: defensive atlantic unionism, associated with the rise and decline of atlantic fordism; and renewed social movement unionism, currently discussed in the literature. for each ideal-type i compare four elements of union activity: intra-institutional organizing; extra-institutional organizing; labour-management relations; and labour-state relations (summarized in table ). at the core of any discussion of labour union transformation is the ability of unions to organize new members in traditionally non-union sectors (e.g., consumer services) as they experience declines in their core membership (e.g., manufacturing workers). defensive unionism attempts to maintain its power largely through servicing collective agreements and protecting the jobs of existing members. when new organizing does take place it is often in the form of blitzing' worksites (i.e., signing the minimal cards required for a certification vote as quickly as possible) in the union's core sector and does not guarantee a successful union drive or prepare workers for the difficult task of obtaining the first collective agreement. throughout the s, particular attention was paid to models shifting union resources to 'organizing' new members rather than 'servicing' existing members (metzgar, ; bronfenbrenner et al., ) . a simple shift of union resources to the recruitment of new members did not always constitute a significant shift from the defensive unionism. a renewed social movement unionism calls for more intensive organizing strategies (e.g., house calls to new members) that built solidarity for long-term struggle against capital (see bronfenbrenner, ) . further, an ideal renewed unionism is not an abandonment of servicing members. instead, such renewed unionism calls for new approaches to servicing that allow workers to self-organize against an employer through mu-tual-aid (see bacharach et al., ) and shift any surplus resources created by greater membership participation to organizing new members within and beyond traditional industrial relations frameworks into a broader labour movement (e.g., representing workers by pressuring employers prior to any formal certification). schumpeterian unionism, however, is much more grounded in traditional approaches to representing and organizing workers. first, schumpeterian unions do not adopt a broad-based framework as advocated by commentators arguing that low-wage service workers require new frameworks for bargaining entire occupations and communities rather than the industrial model based on the large single factory worksite (see clawson, ; wial, ; fudge and tucker, ) . instead, organizing campaigns are strategic and specific targets are identified. servicing by paid staff is not abandoned, but collective bargaining efficiencies are developed and linked to organizing. for example, collective bargaining is used to exert demands for greater employer recognition of unions and to facilitate organizing (e.g., neutrality agreements with employers). most important, campaigns and bargaining are increasingly multi-scalar as local initiatives are linked to global struggles in complex ways. geographers have contributed their own theoretical and empirically assertions as debates are largely focussed on the appropriate scale to organize workers (see tufts, a tufts, , b sadler and fagan, ) . as savage ( , p. ) succinctly notes, however, the mechanisms creating multiple scales of organizing are rarely painless transitions: ''these successes, however, have raised important questions concerning matters of union structure-for instance, should the power to devise strategies rest at the local level so that organizers can develop locally sensitive campaigns, or does it need to be coordinated at a national level so as to be able to match the organizational structure of employers who are increasingly national and/or international in scope, and what kinds of intra-union tensions do such questions spawn?" in other words, schumpeterian unionism's 'creative destruction' of the geographical scale of defensive unionism through shifts of strategic and other organizing resources to new sectors (e.g., office cleaning, hospitality) is just as painful as the processes of 'creative destruction' in neoliberal economies which have restructured through technological innovation and regional and global outsourcing. the re-scaling of union practices is not only a response to the broad-based, centred at the margins sectoral, management of dissent re-scaling of economic practices but also constitutive of these strategies. in terms of organizing beyond the union itself, defensive atlantic unions largely retreat to insular strategies where coalitions are rare and strictly managed, international solidarity is symbolic at best (or at worst a means of disciplining communist unions in other countries), mergers and raids are carried out for survival, and national and regional central labour bodies are largely irrelevant. in contrast, the success of recruiting and building power over employers is often directly linked to union engagement with other labour and non-labour organizations in order to build a broad 'social movement unionism' around diverse communities. again, such broad-based multi-issue coalitions are rarely achieved. and while 'global unions' are deemed crucial for organizing large scale neoliberal transnational employers such as wal-mart (see bronfenbrenner, ; gordon and turner, ) , transferring resources to institutions which can negotiate and enforce effective global agreements with employers remains a challenge (stevis and boswell, ) . the power of national and sub-national central labour bodies to marshal resources from several unions is uneven as national labour movements differ in history and structure. in the case of the us, there are now two national central labour bodies following the split of the change to win coalition from the afl-cio in , creating greater, if temporary, solidarity among some unions and divisions among others. schumpeterian unions' approach to extra-local organizing is much more flexible and contingent on specific challenges. first, all unions exercise caution when entering coalitions. it is better to characterize many of these relationships as ephemeral coalitions rather than a sustainable community unionism (see tufts, ; wills and simms, ) . these alliances are often campaign specific and labour's superior financial and political power is not easily surrendered to create equal coalitions (see tattersall, ) . similarly, while an ideal social movement unionism works toward establishing powerful global unions rather than symbolic bureaucratic lobbying bodies a healthy scepticism must be levied at the new labour internationalism (see also waterman and wills, ; munck, ) . recent efforts to build new global unions are embryonic and there is little evidence to suggest that they will escape the 'geographical dilemmas' that historically plague unions (see castree et al., ) as the local aspirations of workers in real communities often collide. nevertheless, labour is forming a range of new relationships that transcend national borders. it is often more accurate, however, to describe the emerging formations as situated networks where actors exchange information that can be put into action at a number of different scales rather than formal institutions able to leverage power against transnational capital (see wills, ) . while a defensive unionism views central labour bodies (e.g., local labour councils, national federations) as irrelevant, many commentators calling for a renewed social movement unionism would lend a formative role to such organizations. in terms of national central labour bodies, a renewed social movement unionism has called for more active roles of central institutions in organizing, but relative power of central labour bodies varies greatly from na-tion to nation and region to region. schumpeterian unions only reimagine the role of such institutions in terms of what they can offer to multi-scalar campaigns and practices. cooperative organizing campaigns, the mediation of jurisdictional disputes, and the economies of scale gained through joint lobbying and educational efforts are part of this re-imagined but still limited role for central labour bodies. schumpeterian unions may surrender power and resources if it is in the strategic interests of a cooperative campaign, they do not surrender resources to the point where centralized bodies become formative and threaten overall union sovereignty. in fragmented labour movements with many small unions, mergers are viewed as a means of rationalizing necessary resources. while a defensive unionism enters mergers for 'growth' and survival (see chaison, ) , a renewed social unionism views mergers as a fundamental reorientation toward a general unionism reminiscent of one big union. a more balanced approach to the question of mergers explains these developments in terms of unions seeking to increase their strategic capacity to organize in new sectors (see yates and ewer, ) . in the case of unite-here's troubled merger, the financial resources of one union in a declining sector (i.e., unite) combined with a poor union established in a growing sector (i.e., here) to increase the capacity to organize workers in immigrant communities. in sum, for schumpeterian unions, extra-local organizing is crucial, but such alliances are most often ephemeral and driven by the practical requirements and the specific scale of its struggle with employers. clearly, unions in a defensive position with capital and the state have engaged in concessionary relationships with employers. lower wages and increased labour flexibility in terms of job security and the production process are the central pillars of capital's challenge to the regulated labour market (vosko and stanford, ) . in order to secure institutional survival and the jobs of members, unions have actively participated in the workplace restructuring. in many cases, concession bargaining has been the norm as workers struggle to maintain jobs in industries facing significant competitive pressures. such concessions are counter to social movement unionism's commitment to a significant reassertion of workplace democracy where workers have a significant control in the implementation of new technologies and work practices, the distribution of work, the management of working time, and the development of life-long learning and class-based education for all workers (see livingstone and sawchuk, ) . for unions, cooperation remains controversial and uneven as the degree to which labour cooperates with employers in securing state support of the implementation of new technologies is quite varied from full acquiescence to militant resistance (see bacon and blyton, ) . schumpeterian unions, however, do continue to cooperate with employers on a daily basis, but the relationship is better characterized as one of 'limited trust' where cooperation is often ephemeral and lent for competitive support under specific conditions. recent research in the canadian auto sector has found that unions play a role in facilitating information flows among competing firms within 'clusters' suggesting that restructuring through outsourcing to non-union firms can impede such knowledge transfer (rutherford and holmes, ) . some unions have adopted strategies which engage new labour-management partnerships as new trade-offs are made between increasing productivity and maintaining job security. 'social partnerships' are argued to strengthen labour's position by 'trapping' capital investment in local markets through 'high road' strategies that emphasize training and increased productivity in the workplace (kelly, ) . it is the 'high road' model of labour market investment which is advocated by schumpeterian unions which are less con- the change to win coalition was formed when a number of unions (which included the service employees international union (seiu), teamsters, ufcw, unite-here and others) left the afl-cio reportedly over philosophical differences concerning organizing and american labour's relationship to the democratic party (see fletcher and gaspasin, ) . given current conflicts between unite-here and seiu, key members of the coalition, it is likely that several of these unions will reaffiliate with the afl-cio in the near future. cerned with class-based education. here, human capital investment through vocational training is advocated for as a means of increasing local competitiveness and preparing workers for future rounds of creative destruction. increasingly, labour cooperates with capital in lobbying for state subsidies to support economic development initiatifves (e.g., auto assembly plants, training) that have been devolved from national to local strategies placing cities and regions in direct competition. cooperation with the state was a hallmark of competitive defensive atlantic unionism. economic development strategies often found labour and the state in a tight tri-partite relationship with local capital to attract international investment through civic boosterism (harvey, ; hudson and sadler, ) . union leadership was also implicated in the coercive management of dissent against neoliberal states' restructuring of social contracts as they (paternalistically) defended against capital flight. at the same time, labour surrendered labour market regulation exclusively to the state, failing to organize workers outside of industrial relations regimes which were increasingly hostile to union expansion (panitch and swartz, ). an ideal renewed social movement unionism emphasized greater social democratic control over investment decisions which will better manage industrial (over) capacity and the creative destruction process. further, social movement unionism defines union membership in broad terms which are centred on the needs of workers in the margins rather than exclusive formal membership. for example, the living-wage campaigns which emerged in the s in the de-industrialized us, pressured the state and employers to improve working standards for all workers in specified low-wage sectors, not only unionized workers (luce, ) . schumpeterian unionism is more than willing to enter uneven tri-partite relationships with the state and capital. there are however, two main differences between its approach to economic development and more defensive unionism. first, there is recognition of the unevenness of the partnerships and for this reason they are often temporary initiatives based on specific issues rather than a long-term cooperative framework. second, schumpeterian unions are engaged in a process of seeking out and exploiting new state spaces created by the re-territorialization of states in an increasingly global economy (brenner, ) . such unions re-territorialize their relationship with the state, increasingly to the local level as they look to identify the new points of leverage created by re-scaled state accumulation strategies. for example, schumpeterian unions are perhaps less concerned with national electoral politics and more concerned with finding new ways to exploit the slippages created when states download responsibilities to scales such as the urban. for unions such as unite-here, participation in left political parties at the national and sub-national scale is not abandoned, but there is encouragement to build relationships with municipal politicians (left and right) to influence processes such as urban development. similarly, in terms of labour market regulation, schumpeterian unions explore new ways of regulating the labour market below the national and regional scale. for example, schumpeterian unionism will engage with the state in terms of securing human capital investment to enhance local competitiveness. in most cases, this is focused on one or a small number of economic sectors. in this respect, unions situate themselves inside the process of 'creative destruction' rather than profound economic transformation. schumpeterian unions do not, however, launch campaigns for broad policy reform beyond their sector. instead, benefits are secured for workers in specific sectors, which can manage the negative effects of restructuring and suppress dissent from marginalized workers who are fortunate enough to belong to unions who can elicit support from the state (e.g., subsidies for training, tax subsidies for employers). while what is presently occurring in unions is not transformative at the level of the economic system, unions are adapting to, and in some cases shaping, economic sectors with innovative and rediscovered strategies under extremely difficult conditions. in part, the above conceptualization is derived from practices of significant segments of contemporary organized labour. as a specific case study, i look at how unite-here local , responded to the outbreak of sars and the rapid decline of tourism activity in the city through the rise and fall of the hospitality workers resource centre established to aid unemployed workers. data on the use of the hwrc was supplied from the centre's client registration database and a series of interviews with clients, peer counsellors and hwrc board members, those community leaders who participated in the founding, administration, and eventual closure of the hwrc. on february , a woman returned to canada from a hong kong wedding where she was infected by another guest (a doctor from southern china). on march , the first case of sars was identified at scarborough grace hospital in north york. six days later, the -year old son of the woman who attended the wedding died in hospital. the disease spread through the hospital and a travel advisory for toronto was issued by the world health organization (who) on april , . the first travel advisory was lifted april , and by may , toronto was removed from the list of areas with a recent local transmission. but a patient exposed at scarborough grace infected north york general on may and two days later canada informed the who of new clusters. the breakouts were commonly referred to as sars i and sars ii (table ) . toronto was not removed from list of regions with a recent local transmission until july . by that time, over deaths and cases were documented in toronto. healthcare workers were perhaps the most greatly affected as they accounted for over % of the infections, including nelia laroza, the first healthcare worker who died on june , (see tufts, ) . the outbreak and the travel advisory devastated the local tourism industry. while the numbers of the total economic impact varied, short to medium term economic losses have been estimated at between $ . and $ billion (all figures $cdn, table ). in april , statistics canada reported that ontario lost , jobs in foodservices alone. for hotels, occupancy rates declined to unprecedented seasonal levels. the epicentre of the outbreak, toronto and niagara falls, were hit particularly hard as seasonal occupancy rates fell by as much as % from the same period a year earlier and revenue per available room (revpar, a indicator combining occupancy and daily room rates) fell significantly and did not recover until (hvs international, . in terms of accommodation services employment, for the entire province of ontario (for which data is more readily available), quarterly employment compared to the same previous annual period fell by % in and did not begin to show same quarter growth until two years later (fig. ) . it is, however, crucial to recognize the context of the outbreak which increased the impact on workers. in , trips into canada by non-residents from the us declined by %, but this trend had only been exacerbated as travel peaked in the pre- / period. the interviews with clients were conducted by peer counsellors following an interview training seminar with the primary researchers. (the training of peer counsellors in evaluative research techniques was part of hwrc's mandate.) the interviews were confidential and participant anonymity was guaranteed. the impact of / itself on tourism along with the iraq-us war, the rapid appreciation of the canadian dollar, a breakout of bse (i.e., 'mad-cow' disease) and the august blackout in northeastern north america together created what was repeatedly referred to as a 'perfect storm' decimating the local tourism industry. most important, however, was the timing of the sars breakout. it occurred during the early spring, a time of year when seasonal tourism-related industry workers are heading back to work after exhausting employment insurance (ei) benefits received over the winter months. in the case of hotel workers who were quickly running to the end of their benefits, there was simply no job to return to. while most of the large hotels in toronto are unionized, the sector is still regarded as a low-wage sector which employs large numbers of women and recent immigrants located in the margins of the labour market. the impact of sars on hospitality workers is not reducible to only levels of employment. in interviews with hotel workers facing prolonged periods of underemployment in and major themes were identified in their experiences. first, there were a number of hangover effects of underemployment. the most noted of these were: financial difficulties ranging from the accumulation of debt to eviction; stress associated with re-entry into the job market and changing companies and/or occupations (e.g., interview anxiety); and increased work in other jobs (e.g., two or more part-time low wage jobs as a substitute for lost hospitality employment). second, when workers did return to hotels (often on a parttime basis) there was significant restructuring of work which included: intensified workloads as employers were hesitant to restore employment levels to pre-sars levels; new flexible work arrangements including multi-tasking and the performance of front-line work by administrative staff; and extended period of reduced work hours. these findings are supported by a survey of workers serviced by the hwrc in august and september . only of the clients surveyed ( . %) reported working hours a week ( . %). at best, the state's response to the needs of hospitality workers was uneven. immediately, local called for direct assistance for workers through special extensions to ei benefits for workers in the sector. the federal government failed to respond with adjustments to the ei program beyond some limited 'work share' arrangements which allow workers to receive partial benefits if they share their employment with others (i.e., only work parttime). the employment insurance system in canada was significantly restructured in the s decreasing overall eligibility for workers resulting in significant surpluses which were used to addresses the federal public fiscal deficit. reversing the neoliberal reforms to the program for a post-industrial sector, which is supposed to absorb rather than displace unemployed workers, was a precedent the canadian government did not wish to set. hospitality workers, many of whom are immigrant women interpreted this policy failure as another example of social exclusion by the state (see tufts, ) . for the most part the canadian federal government limited its response to the tourism crisis to a series of sponsored events and marketing initiatives aimed to boost the industry (table ) . very little was provided in terms of direct relief, but funding was eventually secured for a drop-in centre to assist struggling hospitality workers, largely through co-funding sources from municipal, provincial and federal sources. as the outbreak unfolded in march , immediate discussions were held among local , employers and tourism toronto. at the beginning of the crisis, the union and the industry were able to find a common ground with respect to the need to find assistance for hospitality workers, specifically those in the accommodation sector. it was realized that the structure of the employment insurance program would simply not allow many casual and seasonal workers to weather the crisis given that benefits collected in the slow winter months would soon expire. other forms of assistance would be needed. in order to lobby effectively for government support joint labour-management efforts would be necessary. in the words of one board member, ''we pretty much came to a meeting of the minds that the industry and the union had to work together here to assist employees." in may , the union involved the metro labour education centre (mlec), a labour friendly and administered training service, in the proposal process for a resource centre. in june and july, informal discussions were held with all three levels of government and by august a submission of a proposal and meeting was held with jane stewart, then minister of human resources. in september-october , negotiations with all three levels of government were held and a labour market adjustment program (lmap) contract was signed with the hwrc, a local tri-partite service administered by government, employers and the union. in november space was procured, staff recruited and services developed. in january , hwrc was in full operation (a full months after the crisis began). the centre received approximately visits in months of operation prior to its abrupt closure on october , (see timeline in table ). hwrc's mandate included a range of peer support services, job search assistance and vocational training (table ). of all the services, peer support was rated by clients as the most useful given the effects of unemployment. as part of the contract, hwrc had to provide job search assistance, but many workers had difficulty parting with the sector given their experience and the 'lifestyle' nature of the employment (i.e., social networks, working with people etc.). the centre also provided lists to workers from employers hiring in the sector, but there was no formal agreement to hire unemployed hospitality workers between the hotels and hwrc. for the most part the hwrc provided upgrading of 'soft' skills. in interviews with hwrc 'clients', vocational training was the most sought after but weakest service delivered. for some the services delivered were too 'soft' (e.g., english as a second language instruction, computer literacy) or offered at inopportune times. participants stated that first aid training, food handling safety or even courses in culinary art would have allowed them to upgrade their skills during their unemployment. offering 'hard' industry specific upgrades or accreditation training, however, was not specifically the mandate of the centre and the employers claimed that either they or third parties (e.g., colleges) trained hospitality workers. the shortcoming was recognized by one of hwrc's community board members: ''unfortunately, very minimally, it had an impact on training. . ..which really was kind of the dream behind this whole thing -that we'd be able to teach them [hospitality workers] hard and soft skills so that when the industry would rebound we'd have a stronger, more capable workforce" (hwrc board member). aside from the lack of 'real' training offered by hwrc, workers interviewed also wanted the centre to advocate more aggressively for employers to hire unemployed hospitality workers, but this was not supported by the employers' board members. the hwrc did, however, deliver a wide variety of workshops, seminars, and training opportunities. the vision of the centre was to offer a comprehensive range of services for temporally unemployed and underemployed workers. this differed significantly from many labour market adjustment programs aimed at retraining permanently displaced workers for new careers. as stated by a founding board member, ''there's everything. the mental health, the wellness, the financial, the personal, the vocational, the training piece-it's all there and that's the way an adjustment process should be run." members experiencing the pressures of unemployment also appreciated the more holistic approach. when asked which services were most beneficial, clients most often referred to the support services. the availability of emotional support was considered just as important referral services to food and rent banks. for those who stated job search services were most important, the ability to receive assistance with resume writing in english and internet access were particularly valued. interview participants who ranked vocational training as the most important did find english language training and computer classes useful. in analysing the interview transcripts the inability of respondents to list just one service as the 'most beneficial' reveals an important aspect of hwrc's integrative servicing model. it is the ability to receive a range of services in one location provided by peers who understand the sector and the impact of the sars crisis was deeply valued. ''it's [hwrc] a wonderful service. and what most people don't understand is that, when you are in hospitality, when the customer is sitting and he asks for a cup of coffee, he expects to get a cup of coffee right away. but i think some of the offices that try and help you find a job or whatever they do, they don't think anything is urgent, they don't know deadlines because nothing will happen to [them] . . .you see, but if you don't serve a cup of coffee within a minute or two minutes, you will not have a job because the customer won't show up. . .so the urgency is not understood by most of the [other] centres....and it's not only that, you [hwrc] understand everything that has to come together so one can get a job. and you have all of this for me" (hwrc client) according to hwrc records, between january and august , clients visited the centre times. in a telephone survey of clients taken in august and september , support services were ranked as the most important services offered by hwrc by . % of respondents followed by job search services ( . %) and vocational training ( . %). during its less than one year of operation, hwrc managed to service over a thousand clients. registration information tracking clients from january through mid-june allowed a basic profile of clients. the majority of the clients ( ) reported residential addresses within toronto. there were, however, a small number of clients from mississauga, brampton and other greater toronto area municipalities. of those clients reporting their age, over half ( . %) were under the age of . given seniority rules in the accommodation sector, it is not surprising that younger workers were the first to become unemployed. at the same, time the presence of a large number of older workers seeking assistance ( . % were over ), reveals the extent of the crisis. the client profile does indicate that hwrc did manage to reach the most marginal segments of the hospitality labour market. for example, room attendants (almost entirely immigrant women) were the largest group of clients seeking assistance from hwrc. the centre's focus on younger workers and women occupying the lowest paying jobs in the sector must be considered an important part of the centre's rationale and success. there were also secondary benefits to hwrc for workers. first, the use of peer counsellors resulted in substantial capacity building in the approximately one dozen people who were employed by the centre. these workers, unemployed themselves, were trained in a number of different skills during the hwrc's operation ranging from computer training to providing emotional support that will benefit them in their workplace and union activities. second, the centre raised the profile of hospitality workers and the importance of their sector to toronto's economy. on october , , the hospitality workers resource centre closed its doors. the government had initially sought to close down the project in august (one year following the signing of the initial contract), but extended the operation by two months given that the initial funding was not received until the end of october . the decision to close the centre was supported by the employers and contested by the union. the employers supported the state's claim that the sars crisis was over and that other agencies could deliver the same services as hwrc. it is important, however, to consider the different viewpoints regarding the centre's continued operation and the sector's long-term labour market development. during the summer of , it became clear that the employers and government officials had a different vision of the future of hwrc than did its union partners. while the union and hwrc staff felt strongly that there was an overwhelming demand for services, the position of employers and government funding agencies was that the industry was in recovery and that the centre had surpassed its mandate. although, the contract with hrdc was for one year, some stakeholders were perplexed by the government's sense of urgency to close the centre given that there was still money in the budget. hwrc staff aggressively advocated for an extension to hwrc. efforts to extend the life of the centre did manage to get an initial extension (beyond august ) but were ultimately unsuccessful. in interviews with hwrc staff and board members, divergent views on any long-term possibilities for the centre were evident. the divergent views reflected significant ideological differences between the two groups of stakeholders concerning the role of state supported training. employers (and increasingly governments) tend to see a limited part for third party training that occurs beyond the college system and industry controlled associations. union stakeholders and labour educators, however, feel that it is important to invest in human capital on an ongoing basis from a variety of development tools. there was, however, perhaps an even more unarticulated motivation behind the different positions on the future of hwrc. there is a sense of underlying mistrust between unions and employers in toronto's hospitality sector that limits cooperative projects seeking government funding. it is possible that employers fear any inroads unions may gain in sectoral training initiatives. employers may have anxiety toward any integration of union education (e.g., workers' rights, shop steward training) into hospitality service training programs. employers have resisted union attempts to gain control over training in other sectors for similar reasons. in the case of the hospitality sector, any union control over job placement services, such as the establishment of a 'clearing-house' for unemployed workers seeking to be matched with industry postings may appear to employers as efforts to establish a local 'hiring-hall' giving unions control over labour supply. unfortunately, the minimal trust between employers and unions limit initiatives seeking government support, but this is exactly what local is seeking. the sars outbreak was a painful path for local toward its 'high road partnership' vision for the sector. given the success of hwrc during its short period of operation and the need for a long-term development strategy for toronto's hospitality workforce, new models based on the hwrc were and continue to be developed. in the round of collective bargaining, the union advocated for a 'high road partnership' model with employers to improve the quality of jobs and service delivery in the industry. local struck a task force (in which the author participated) under the leadership of janet dassinger, the labour activist seconded from metro labour education centre to administer the hwrc who continues to work local . a report was released in late titled an industry at the crossroads: a high road economic vision for toronto hotels. in the report, a call is made to develop a 'high road' labour-management partnership and longterm labour force development strategy for toronto's hospitality sector. again specific reference was made to the models used in us cities such as the culinary training academy in las vegas. the high road partnership model is largely inspired by a report by working for america institutes on the hotel sector. the 'high road' partnerships practiced and advocated by unite-here and some us employers are aimed are creating and sustaining secure, high-paying jobs and competitive sectors through cooperative and innovative joint labour-management training strategies with public and private funding. the goals of such partnerships are to: strengthen internal labour markets by developing well defined career ladders; upgrade the skills of all workers; provide training for entry level workers; develop the toronto tourism industry; and address the short and long-term labour requirements of the sector. the recommendations in the industry at the crossroads document are indicative of a schumpeterian union's approach to labour market development. there are calls for higher wages and benefits, greater union representation and training and equal opportunity in the workplace. however, the report does go beyond these issues to advocate for social programs which hotel workers require such as daycare, affordable housing and improve public transit. an analysis of the short life of the hwrc and the union's attempts to build on the experience illustrates the contradictions facing unions as they adjust to neoliberal agendas. klein ( ) has recently argued that corporations increasingly practice a 'disaster capitalism' where profits are derived through destruction and neoliberalism is deeply entrenched in the aftermath as local economies rebuild. workers inevitably bear the brunt of disasters as their unequal relationship with capital and state makes them particularly vulnerable when communities are destroyed (as witnessed in post hurricane katrina new orleans). labour unions, as agents within capitalism, can also manage negative events in a way than may assist them in reshaping their institutions and organizing future workers. as an intra-institutional exercise, the hwrc was developed by the union to service all hospitality workers in the community, not just local members (who remained the largest group of clients). in this respect, the hwrc was a servicing innovation which addressed the needs of unemployed workers beyond the immediate workplace (i.e., coping with unemployment and financial uncertainty). the centre demonstrated what unions can do for working people and provided a contact point for non-union workers with the union. through the training of peer counsellors, local also developed its leadership capacity by developing activists with skills (e.g., workshop facilitation) which are applicable to union life. the project was also a multi-scalar initiative that required a local union to negotiate with levels of government beyond the national (which was very late in its delivery of funding). still, hwrc was a highly targeted resource which only addressed sars related unemployment in one-sector and was not accessible to other dislocated workers. in this respect, the union did not reach out beyond hospitality services and remained largely concerned with creative development of its own sector. as for extra-institutional organizing, local and the hwrc were able to raise the profile of low-wage hospitality workers that often remain invisible in the landscape. important alliances were forged with local labour friendly community institutions such as mlec. these alliances were needed to pressure the state and nego-tiate for resources. the toronto and york region labour council also supported displaced workers. the experience of low-wage workers became central to the labour council's 'a million reasons' campaign calling for an overall increase in the minimum wage. the council later initiated 'a million reasons to support hotel workers' campaign as it supported unite-here in its round of bargaining which attempted to establish north american agreements with specific companies (see tufts, a) . local , networked with other locals through its international union, used these networks as it formulated what such a centre might look like over the longer-term (i.e., a las vegas style union culinary training institute). there were, however, some limits to extra-institutional organizing efforts. other unions, historically competitive with unite-here, representing smaller numbers of workers in the sector did not lead or participate in the hwrc project. further, there was some tension at the national scale as a committee of the canadian labour congress (clc) examining employment insurance reform was wary of unite-here's call for special extensions for hospitality workers as this contradicted the clc's position of broad reforms which would restore accessibility and higher benefits to all workers, a goal more typical of social movement unionism. as for labour-management relations, the response of the union to sars was hardly a social democratic partnership. instead a short-term cooperative relationship was struck in order to lobby the state for hwrc financial support. while labour and management did cooperate in a joint effort to manage the destruction the tourism industry and employment, trust remained minimal and the employers ceased the centre's operation at its earliest convenience. who provides training for hospitality workers remains a contentious issue and workers are demanding industry specific vocational skills. exerting control over local industry training, however, remains a long-term project of local . administration over human capital investment will give the union some power in competitive creative destruction processes which characterize the hospitality sector. while the union would undoubtedly include union education in the training curriculum, life-long learning or broad classed-based education deemed crucial to social movement unionism is not envisioned. the changing relationship between the state and unite-here became evident through the hwrc. for the first time, hospitality workers made their demands known to the state which is much more experienced in responding to demands for intervention by industrial unions. for example, during hwrc's operation, the canadian and ontario government announced a joint % subsidy of ford's $ million flexible re-tooling of its windsor assembly plant (lyne, ) . such subsidies (which have only grown in the wake of the collapse of the north american auto sector) are largely facilitated through the joint lobbying efforts of powerful multinational corporations and industrial unions (e.g., the canadian auto workers). such large scale, long-term support for hospitality workers was not secured and the tri-partite hwrc was largely a temporary measure. however, local did manage to exploit the new state spaces created as nation states re-territorialize their accumulation strategies at the urban scale. as states centre economic development strategies around 'creative cities' with well-developed consumer service economies (florida, ) , they must address crises which threaten those related sectors. the investment made by the canadian state in terms of stimulating tourism activity and the (relatively limited) support given to hospitality workers is evidence of re-scaled policy. re-territorialization presents urban service workers, who have been largely ignored, with new spaces to secure state subsidies. in return for this state support, the union will play a role in regulating the labour market by managing dissent by providing material gains and sectoral based training for marginalized workers who are increasingly central to urban accumulation strategies. the culinary training academy in las vegas is a labour-management partnership which trains adults for the las vegas hospitality industry. it is funded through government grants, fee for service training programs and a special contribution fund negotiated among las vegas hotel properties and the members of culinary union local and bartenders local (unite-here affiliated locals). the academy provides training for new entry level workers and incumbent workers through skills upgrading. facilities include 'mock' hotel suites and an onsite restaurant. the above discussion details a model of unionism which is derived from both engagement with theory on capital-state formations and grounding in an empirical case study. as a concept, schumpeterian unionism is not designed to be an all encompassing model. given that the model is partially grounded in the examination of unite-here's response to the sars crisis, it is only expected that the case study illuminates the model (as it was designed). like all models, grounded or not in specific empirical cases, there are limits to general application. but the framework is an entry point to greater understanding of labour's relationship with neoliberal capital and states. it is itself, an ideal-type which is meant to better capture some broad changes in organized labour which remain far removed from other idealized-types of unionism. with other cases, there will be other 'ideal-types' of schumpeterian unionism that vary over space and time. it is, however, a framework for the investigation of other labour union responses which respond to, and in many cases enable, economic and political change that is theoretically and empirically located between other reductive and normative models. there are, however, political and theoretical implications of emergent schumpeterian unionism(s). politically, in the case of unite-here, there are limits to its schumpeterian unionism as practiced. while unite-here in general, and local specifically, have been viewed as successful examples of union renewal (see schenk, ) , it is inaccurate to characterize these efforts as any significant movement toward social movement unionism. instead, union strategies reflect a re-territorialized neoliberal economy and state as they actually exist on the ground. the experience with hwrc did create a space for local to engage with the state and begin to consider new spaces in which it can shape the development of the accommodation sector in toronto. the union is, however, participating in the creative destruction process as it advocates turning crises into a skills upgrading opportunity. while this is common, the local and sector specific nature of the union's demands in this case limit broader social reforms and even the possibility of a shift toward a movement based unionism. unite-here's proposal of limited reforms to address the crisis is in keeping with the neoliberal state's transition away from universal welfare provisions. in the end, these demands for relatively small reforms were not even met and the limited funding for the hwrc was a small investment for the state. establishing a program that fosters flexibility and shifts the responsibility to adapt to crises to workers is simply a variant of neoliberal labour market policy. while the hwrc had some success, it was largely localized resistance. instead of arguing for broad changes or 'why can't canada be more like sweden?', the union settled for 'why can't toronto be more like las vegas?' such a schumpeterian approach by unite-here is expected given that the strategic potential to (re)regulate the local labour market through such a centre and the new spaces for engagement created by the re-scaling of state economic development strategies. such strategies are, however, unlikely to inspire a mass social movement needed for economic transformation (or even much needed national employment insurance reform). at best, unions can engage new state spaces and the contradictions of urban accumulation and even improve the lives of working people in specific sectors and places, but the dominant economic system is inevitably reproduced. theoretically, schumpeterian unionism raises many questions and there are some implications with respect to the production of scale, the agency of labour in capital-state relations, and the broader labour geography project. first, a key aspect of schumpeterian unionism emphasized here is the multi-scalarity of union renewal efforts. schumpeterian unions do not recognize the primacy of any one particular scale, but instead focus on how different scales of worker mobilization or state control can be engaged with to the advantage of workers. in their analysis of the sars outbreak, keil and ali ( ) argue that the same global connectivity which allowed the disease to spread so quickly also allowed international health care professionals to share information and transcended the limits of national based health care systems. similarly, as the epidemic displaced hospitality workers from toronto's migrant and racialized communities, the union similarly marshalled action beyond and below the nation state, soliciting local support to federal officials and integrating 'high road partnerships' practiced in other countries. as ward ( , p. ) reminds us ''. . .the importance of acting at certain scales is always relative and contingent. it does not necessarily become more or less important in the move from the local to the global or from the global to the local." as a concept, schumpeterian unionism captures this fluidity and emphasizes how different scales of worker action and engagement conflict with and strengthen each other. admittedly, the above conceptualization may be uncomfortable for some researchers as it abandons the 'national' as the penultimate scale for understanding the relative success and failure of labour movements (see rutherford ). such an interpretation, however, would conflate the theorization of how workers are producing scale with theorization of the relative importance of particular scales. schumpeterian unions are engaging with the city as a means of leveraging local power, but this does not mean that the nation state or national scale remain unimportant in analyses. in the case of local , the hwrc was a local initiative that engaged the federal government as a key funder and highlighted the inadequacies of the current national employment insurance program. indeed, further research is required to examine what happens when local schumpeterian unionism conflicts with other scales of organized labour (e.g., international head offices, central labour bodies) which are more reflective of defensive or social movement unionism. questions of scale have preoccupied much of labour geography, but perhaps it is now time to expand discussions to highlight the role labour might play in broader processes of capital-state formation. an underdeveloped theme in the literature influenced by jessop's swpr framework is the role organized labour plays in not only challenging but facilitating neoliberal transitions. the hwrc case and the consequent campaign for 'high road' partnerships regulating the local labour market are not incompatible with national economic development strategies which foster urban competitiveness. over the longer-term, local 's schumpeterian unionism may increase the power of the union and even increase standards for workers while enhancing the overall competitiveness of toronto (and canada's) tourism and hospitality industry. labour geography is capable of producing more in-depth models which embed labour union transformation in broader processes of capital-state re-territorialization. lastly, there is a broader theoretical implication of the above approach to understanding labour union renewal for the broader labour geography project. indeed, schumpeterian unionism does integrate significant agency for labour as it addresses broader questions of political-economy. in a recent keynote conference presentation, wills ( ) differentiated labour geography, a project which emphasizes the agency of workers and their institutions in producing economic landscapes (see also castree, ; lier, ) , from other research on changing labour markets and relations which focus on oppressive capitalist structures which she defines as the political economy of work. the above conceptualization of schumpeterian unionism may be taken as an example of how labour geography might contribute to broader discussions of labour union renewal and the political economy of work. further, it is an example of how capital-state theory might inform labour geography. if labour geography is to flourish as a viable sub-discipline it will inevitably have to engage with a variety of literatures and approaches to labour studies. excavating labour agency will remain central to the project, but rigidly applying an agency (an elusive and chaotic concept) litmus test to define the discipline may prematurely isolate labour geography from other research on work. as labour geographers interested in the emancipatory potential of our research and the power of labour, we must take every opportunity to understand the changing political and economic conditions confronting workers. the union movement in transition mutual aid and union renewal: cycles of logics of action trade union reponses to workplace restructuring: exploring union orientations and actions cities and the geographies of 'actually existing neoliberalism new state spaces -urban governance and the rescaling of statehood global unions: challenging transnational capital through cross-border campaigns the american labour movement and the resurgence of organizing organizing to win. new research on union strategies labour geography: a work in progress spaces of work: global capitalism and the geographies of labour union mergers in hard times the next upsurge: labor and the new social movements trade unions in renewal: a comparative study hard work: remaking the american labor movement solidarity divided: the crisis in organized labor and a new path toward social justice beyond the organizing model: the transformation process in local unions the rise of the creative class and how it's transforming work, life, community and everyday life labour before the law: the regulation of workers' collective action in canada organizing the landscape: geographical perspectives on labor unionism labor geographies: workers and the landscapes of capitalism contesting work closures in western europe's industrial regions: defending place or betraying class? canadian lodging outlook monthly joint publication of hvs-str tracking regional hotel occupancy and daily room rates endorsed by the hotel association of canada towards a schumpeterian workfare state? preliminary remarks on post-fordist political economy social partnership agreements in britain: labor cooperation and compliance governing the sick city: urban governance in the age of emerging infectious disease the shock doctrine: the rise and fall of disaster capitalism innovation in canadian unions: patterns, causes and consequences paths to union renewal: canadian experiences places of work, scales of organizing: a review of labour geography hidden knowledge: organized labour in the information age subsidies at last secured, ford unveils $ -million ontario expansion an organizing model of unionism workers in a lean world: unions in the international economy us labor in trouble and transition: the failure of reform from above, the promise of revival from below globalization and labour: the great new transformation from consent to coercion: the assault and trade union freedoms rd edition work-place. the social regulation of labor markets training and enterprise councils: schumpeterian workfare state or what? workfare states states of the unions: labour law and continued divergence in unionization in advanced economies. presentation to the annual meetings of the association of american geographers we simply have to do that stuff for our survival": labour, firm innovation and cluster governance in the canadian automotive parts industry australian trade unions and the politics of scale: reconstructing the spatiality of industrial relations justice for janitors: scales of organizing and representing workers precarious employment: understanding labour market insecurity in canada capitalism, socialism and democracy international framework agreements: opportunities and challenges for global unionism there is power in coalition: a framework for assessing how and when union-community coalitions are effective and enhance union power we make it work'': the cultural transformation of hotel workers in the city building the 'competitive city': labour and toronto's bid to host the olympic games community unionism in canada and labour's (re)organization of space sars & new normals: healthcare and hospitality workers fight back. our times: canada's independent emerging labour strategies in toronto's hotel sector: toward a spatial circuit of union renewal world cities and union renewal union membership statistics in countries challenging the market: the struggle to regulate work and income thinking geographically about work, employment, and society . place, space and the new labour internationalisms the emerging organizational structure of unionism in low wage services keynote speech. developing theoretical approaches in labour geography conference bargaining for the space to organise in the global economy: a review of the accor -iuf trade union rights agreement building reciprocal community unionism in the uk. capital and class us hotels and workers: room for improvement the future of trade unions: international perspectives on emerging union structures critical realism and realist research in human geography: a method or a philosophy in search of a method? key: cord- -dgpfmx o authors: cao, jinya; wei, jing; zhu, huadong; duan, yanping; geng, wenqi; hong, xia; jiang, jing; zhao, xiaohui; zhu, boheng title: a study of basic needs and psychological wellbeing of medical workers in the fever clinic of a tertiary general hospital in beijing during the covid- outbreak date: - - journal: psychother psychosom doi: . / sha: doc_id: cord_uid: dgpfmx o nan dear editor, the coronavirus disease (covid- ) has become a global threat. a fever clinic for triaging patients is a primary strategy against covid- [ ] . on january , , the novel coronavirus was put on highest alert throughout china. on the same day, a special -h fever clinic was set up in the emergency department, peking union medical college hospital (pumch). doctors and nurses for this fever clinic were handpicked by the emergency department based on their experience and their adaptability and tenacity under pressure shown in their past works. psychological support for these medical workers was deemed as essential [ ] . thus, a hotline service was set up by the department of psychological medicine, from a.m. to p.m. every day, to talk with medical workers about their feelings, provide support and understanding, and help them find emotional resources. furthermore, we continuously monitored these medical workers with qualitative and quantitative evaluations, regularly feeding back findings to the emergency department to allow for adjustments. the qualitative interview involved topics as shown below. quantitative questionnaires (table ) included the patient health questionaire- (phq- ) and maslach burn-out inventory (mbi). phq- and mbi were administered at the end of their duty before a -week rest leave. interviews were conducted whenever the medical workers were free, initiated either by us or them, during the a.m. to p.m. hotline service. each medical worker was interviewed several times during their -to -week work time rotation. each interview lasted - min. a total of medical workers were selected as the first batch for the fever clinic. they all agreed to participate in our interviews and provided oral consent (response rate %). the participants comprised doctors, nurses, and clinical technicians; of the workers were male, and were married. the overall mean age was . ± . years. mean working experience was years (range - ). ily members was the most frequently reported coping strategy. talking with colleagues was also useful for most participants. two participants reported that they would rather cope with stress on their own, but they welcomed talks with psychologists through hotline. other coping strategies included sport, singing, writing diaries, watching videos, etc. . bodily discomfort. of the participants, doctors and nurses reported mild bodily discomfort including tiredness, throat pain, cough, neck and shoulder pain, back pain, headache and nausea, frequent urination, and skin rash. no medical worker was infected with covid- . the above-described bodily discomforts may likely have psychosomatic origins. . phq- and mbi (see table ). the higher rate of "personal accomplishment" burnout may be related to the fact there is still no definitely effective medication against covid- . consistent with other similar situations, medical workers in our study were under high stress [ ] [ ] [ ] [ ] [ ] [ ] . however, overall, the emotional distress and burnout levels were not highly elevated. our psychological support and adjustments may help buffer the negative impact of stress. in addition, we have to acknowledge that in such an emergency situation with a shortage of medical staff and resources, many doctors and nurses are overworking extensively. it is a new situation for medical workers [ ] . we suggest monitoring the physical and psychological needs and wellbeing of medical workers in similar situations, and then adjusting their working schedules and formulating psychosocial interventions accordingly. therapeutic and triage strategies for novel coronavirus disease in fever clinics mental health care for medical staff in china during the covid- outbreak national health commission of people's republic of china impact on health care workers employed in high-risk areas during the toronto sars outbreak psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital psychological effects of the sars outbreak in hong kong on high-risk health care workers factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto. psychosom med the mental health of hospital workers dealing with severe acute respiratory syndrome health workers' experiences of coping with the ebola epidemic in sierra leone's health system: a qualitative study different kinds of major incident require different mental health responses we would like to thank all the medical workers for agreeing to participate in our study and for their great work in the fever clinic. we would also like to thank qing chang from the department of medical affairs, pumch, and hong kang from the labor union, pumch, for their help with logistics and organization. the trial protocol was approved by the ethics committee for peking union medical college hospital, chinese academy of medical sciences (s-k ). all participants gave their oral consent. the authors have no conflicts of interest to declare. j.c. and j.w. received funding support from pumch (pumch- - . and zc , respectively). j.w. and h.z. contributed equally to the conception of the study design and coordination. data collection was carried out by y.d., x.z., w.g., and j.j. data analysis and interpretation was done by j.c., w.g., y.d., and h.x. j.c. and y.d. wrote the first draft of the paper. j.w., h.z., and b.z. provided a critical revision of this draft. all authors gave their final approval of the version to be published. key: cord- - cjm c authors: muller, a. e.; hafstad, e. v.; himmels, j. p. w.; smedslund, g.; flottorp, s.; stensland, s.; stroobants, s.; van de velde, s.; vist, g. e. title: the mental health impact of the covid- pandemic onhealthcare workers, and interventions to help them: a rapid systematic review date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: cjm c background: the covid- pandemic has heavily burdened, and in some cases overwhelmed, healthcare systems throughout the world. healthcare workers are not only at heightened risk of infection, but also of adverse mental health outcomes. identification of organizational, collegial and individual risk and resilience factors impacting the mental health of healthcare workers are needed to inform preparedness planning and sustainable response. methods: we performed a rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid- pandemic on healthcare workers. on may , we utilized the norwegian institute of public health's live map of covid- evidence, the visualization of a database of , screened studies, to identify studies for inclusion. we included studies reporting on any type of mental health outcome in any type of healthcare workers during the pandemic. we described interventions reported by the studies, and narratively summarized mental health-related outcomes, as study heterogeneity precluded meta-analysis. we assessed study quality using design-specific instruments. results: we included studies, reporting on a total of , healthcare workers. the prevalence of general psychological distress across the studies ranged from - % (median %), anxiety - % (median %), depression - % (median %), and sleeping problems - % (median %). seven studies reported on implementing mental health interventions, and most focused on individual symptom reduction, but none reported on effects of the interventions. in most studies, healthcare workers reported low interest in and use of professional help, and greater reliance on social support and contact with family and friends. exposure to covid- was the most commonly reported correlate of mental health problems, followed by female gender, and worry about infection or about infecting others. social support correlated with less mental health problems. discussion: healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, sleep problems, and distress during the covid- pandemic, but most studies do not report comparative data on mental health symptoms. before the pandemic. there seems to be a mismatch between risk factors for adverse mental health outcomes among healthcare workers in the current pandemic and their needs and preferences, and the individual psychopathology focus of current interventions. efforts to help healthcare workers sustain healthy relationships to colleagues, family and friends over time may be paramount to safeguard what is already an important source of support during the prolonged crisis. expanding interventions' focus to incorporate organizational, collegial and family factors to support healthcare workers responding to the pandemic could improve acceptability and efficacy of interventions. other: the protocol for this review is available online. no funding was received. healthcare workers in the current pandemic and their needs and preferences, and the individual psychopathology focus of current interventions. efforts to help healthcare workers sustain healthy relationships to colleagues, family and friends over time may be paramount to safeguard what is already an important source of support during the prolonged crisis. expanding interventions' focus to incorporate organizational, collegial and family factors to support healthcare workers responding to the pandemic could improve acceptability and efficacy of interventions. other: the protocol for this review is available online. no funding was received. what is already known on this topic • during viral outbreaks such as covid- , healthcare providers are at increased risk of infection and negative physical and mental health outcomes • covid- is a particular challenge to healthcare systems and workers • healthcare workers' mental health problems correlate with organizational factors such as workload and exposure to covid- patients • healthcare workers are more interested in occupational protection, rest, and social support than in professional psychological help • interventions focus more on addressing individual psychopathology, which points towards a mismatch between what workers want and need, and the services available to them needed to save lives and prevent a serious impact on physical and mental health of healthcare workers . previous viral outbreaks have shown that frontline and non-frontline healthcare workers are at increased risk of infection and other adverse physical health outcomes . furthermore, mental health problems putatively associated with healthcare workers' occupational activities were reported during and up until years after epidemics, including symptoms of post-traumatic stress, burnout, depression and anxiety [ ] [ ] [ ] . likewise, reports of the mental toll on healthcare workers have persistently appeared during the current global health crisis [ ] [ ] [ ] . several reviews have already been conducted on healthcare workers' mental health in the covid- pandemic, with search dates up to may . pappa et al. identified thirteen studies in a search on april and pooled prevalence rates; they reported that more than one of every five healthcare workers suffered from anxiety and/or depression; nearly two in five reported insomnia. vindegaard & benros' review, searching on may , identified twenty studies of healthcare workers in a subgroup analysis, and their narrative summary concluded that healthcare workers generally report more anxiety, depression, and sleep problems compared with the general population. in the face of a prolonged crisis such as the pandemic, sustainability of the healthcare response fully relies on its ability to safeguard the health of responders: the healthcare workers , . yet, the recent findings of psychological distress among healthcare workers might indicate that the healthcare system is currently unable to effectively help the helpers. understanding the risks and mental health impact(s) that healthcare workers experience, and identifying possible interventions to address adverse effects, is invaluable. our main aim was to perform a rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid- pandemic on healthcare workers and on healthcare workers' understandings of their own mental health during the pandemic. our second aim was to describe the interventions assessed in the literature to prevent or reduce negative mental health impacts on healthcare workers who are at work during the covid- pandemic. all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint we conducted a rapid systematic review according to the methods specified in our protocol, published on our institution's website . we included any type of study about any type of healthcare worker during the covid- pandemic, with outcomes relating to their mental health. we extracted information about interventions aimed at preventing or reducing negative mental health impacts on healthcare workers. we had no restrictions related to study design, methodological quality, or language. we identified relevant studies by searching the norwegian institute of public health's (niph's) live map of covid- evidence (https://www.fhi.no/en/qk/systematic-reviews-hta/map/) and database on may , as described in our protocol . the live map and database contained , references screened for covid- relevance containing primary, secondary, or modelled data. two researchers independently categorized these references according to topic (seven main topics, subordinate topics), population ( available groups), study design, and publication type. we identified references categorized to the population "healthcare workers", and to the topic "experiences and perceptions, consequences; social, political, economic aspects". in addition, we identified references by searching (title/abstract) in the live map's database, using the keywords: emo*, psych*, stress*, anx*, depr*, mental*, sleep, worry, somatoform, and somatic symptom disorder. we screened all identified references specifically for the inclusion criteria for this systematic review. the protocol of the live map of covid- evidence describes the methodology of the map and database . the methodology, including the search, has developed dynamically since march . we performed our first search for the map . . and we have identified references published since . . by searching: • pubmed (national library of medicine), from . . - . . • embase (ovid), between . . - . . • centers for disease control and prevention (cdc), . . - . . all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint the last included search for this review was conducted on may . the search strategy is presented in appendix . we developed a data extraction form to collect data on country and setting, participants, exposure to covid- , intervention if relevant, and outcomes related to mental health. we extracted data on prevalence of mental health problems as well as correlates (i.e. risk/resilience factors); strategies implemented or accessed by healthcare worker to address their own mental health; perceived need and preferences related to interventions aimed at preventing or reducing negative mental health consequences; and experience and understandings of mental health and related interventions. one researcher (aem) extracted data and another checked her extraction. two researchers independently assessed the methodological quality of systematic reviews using the amstar tool and of qualitative studies using the casp checklist . one researcher (aem, sf) assessed the quality of cross-sectional studies using either the jbi prevalence or the jbi cross-sectional analytical checklist, and longitudinal studies using the jibi cohort checklist . results of these checklists are presented in appendix in the standard risk of bias format. we summarized outcomes narratively. for figures without numbers, we extracted numbers using an online software (https://apps.automeris.io/wpd/). we describe interventions and outcomes based on the information provided in the studies. median prevalence rates were presented as box-and-whisker plots. we decided not to perform a quantitative summary of the associations between the various correlates and mental health factors, due to a combination of heterogeneity in assessment measures and lack of control groups, and an overarching lack of descriptions necessary to confirm sufficient homogeneity. our included studies not only varied greatly from one another, they most often did not report sufficient information regarding inclusion criteria, population, setting, and exposure to assess potential clinical heterogeneity. we graded the certainty of the evidence using the grade approach (grading of recommendations assessment, development, and evaluation) . all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint fifty-nine studies were included. table displays their summarized characteristics, while appendix displays characteristics of the individual studies. thirty-nine studies were conducted in or included participants from china; four in iran; three in the usa; two each in france, india, and singapore; and one each from australia, germany, italy, malaysia, and taiwan. two studies reported results of international online surveys; one included respondents from countries and the other from countries. the majority of studies ( ) were cross-sectional surveys, four were other cross-sectional designs; two studies reported surveys administered twice over time; three were qualitative studies; and one study searched within a database of existing online surveys. we also identified two systematic reviews , , which identified five primary studies , , , , . the studies reported on healthcare workers working in different settings: studies reported on health care workers in hospitals, two studies were conducted in specialist health services outside hospitals, and three studies in other settings, while studies did not specify the healthcare setting or only partially described multiple settings. no studies reported on nursing homes or primary care settings. in studies, participants were frontline workers, while studies reported on non-frontline workers. frontline or non-frontline activities were unclear in ten studies. six studies reported on interventions to reduce mental health problems. more than half of the studies included nurses ( ) and/or doctors ( ) . studies reported on a total of , healthcare workers, ranging from a case study with three participants to a survey of , participants. 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 (which this version posted july , . all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint appendix displays the methodological quality assessments of individual studies. overall assessments are displayed in appendix , the description of included studies. twenty-five studies were assessed as having low methodological quality (including eleven of crosssectional studies that provided only prevalence data), twelve medium, and sixteen high. the most common methodological weaknesses across all studies arose from insufficient reporting: samples, settings, and recruitment procedures were often not described thoroughly. while both systematic reviews had low scores on the amstar, all three qualitative studies were assessed on the casp checklist as valuable. four studies had designs that we did not assess for quality: jiang et al. , and schulte et al. six studies reported on the implementation of interventions to prevent or reduce mental health problems caused by the covid- pandemic among healthcare workers. these interventions can be loosely divided into those targeting organizational structures, those facilitating team/collegial support, and those addressing individual complaints or strategies. two interventions involved organizational adjustments. the first intervention was reported on by two studies , . hong et al. called it a "comprehensive psychological intervention" for frontline workers undergoing a mandatory two-week quarantine in a vocational resort, following two-to three-week hospital shifts. the quarantine itself was also described as part of the intervention, explicitly intended "to alleviate worries about the health of one's family". other elements included shortened shifts; involvement of the labor union to provide support to healthcare workers' families; and a telephone-based hotline that allowed healthcare workers to speak to trained psychiatrists or psychologists. this hotline had already been available to healthcare workers for four hours per week prior to the pandemic, but was made available for twelve hours, seven days a week. chen et al. reported a second intervention that attempted to address individual complaints and facilitate collegial support. a telephone hotline was set up to provide immediate psychological support, along with a medical team that provided online courses to help healthcare workers handle psychological problems, and group-based activities to release stress. however, uptake was low, and when researchers conducted interviews with the healthcare workers to understand this, healthcare workers reported needing personal protective all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint equipment and rest, not time with a psychologist. they also requested help addressing their patients' psychological distress. in response, the hospital developed more guidance on personal protective equipment, provided a rest space, and provided training on how to address patients' distress. schulte et al. targeted collegial support and building individual strategies through one-hour video "support calls" for healthcare workers called in from their homes, to describe the impact of the pandemic on their lives, to reflect on their strengths, and to brainstorm coping strategies. this intervention was implemented as a response to the hospital redeploying pediatric staff to work as covid- frontline staff, and reorganizing pediatric space to accommodate more pediatric and adult covid- patients. lv et al. surveyed healthcare workers before and during the outbreak, reporting no further information about the timeline. the study included both those working on the frontline and those with unclear exposure to covid- . however, it is unclear whether respondents were the same at both time points. the prevalence of anxiety, depression, and insomnia increased over time, all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint whether mild, moderate, moderate to severe, or severe (see figure ). during the outbreak, one out of every four healthcare workers reported at least mild anxiety, depression, or insomnia. even if i try hard, and i've been smoking or drinking a lot lately." the authors presented the changes per item after two weeks, rather than answers at both time points, and the answer scale was not reported. worry worsened for % of participants, anxiety for %, fidgeting for %, fear for %, feeling nervous and uneasy for %, not thinking one can succeed for %, and an increase in smoking and drinking for only %. the proportion reporting improvement was similar for fidgeting, fear, and feeling nervous and uneasy, and more improved in not thinking one can succeed and for a reduction in smoking and drinking. two cross-sectional studies reported healthcare workers' self-reported changes in mental health; both were also of low methodological quality due to insufficient reporting. in benham et al. , twelve iranian psychiatry residents were re-deployed to work one frontline shift. half of the residents reported that they experienced more distress after this shift. abdessater et al. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint studied urology residents not working on the frontline. when asked to report the level of stress caused by covid- , % reported a medium to high amount of stress, and the remaining reported none to low. less than % had initiated a psychiatric treatment during the pandemic. a third cross-sectional study , also of low methodological quality, surveyed healthcare workers in china in february, during the "outbreak period". a different cohort of healthcare workers were surveyed in march, during the "non-epidemic outbreak period". the healthcare workers in to the second phase of the survey reported less symptoms of anxiety and depression, and higher health-related quality of life. twenty-nine studies reported prevalence data of mental health variables as proportions or percentages. (seventeen additional studies reported data as average scores on various instruments, and we did not extract this data.) we present box-and-whisker plots in figure to show the distribution of anxiety, depression, distress, and sleeping problems among the healthcare workers investigated in the studies, using the authors' own methods of assessing these outcomes for anxiety, there were data from studies. the percentage of healthcare workers with anxiety ranged from - % with a median of %. for depression, there were data from studies. the percentage with depression ranged from - %, with a median of %. for sleep problems, there were data from six studies. the percentage with sleeping problems ranged from - %, with a median of %. for distress, there were data from studies. the percentage with distress ranged from - %, with a median of %. only one study reported prevalence of somatic symptoms, including decreased appetite or indigestion ( %) and fatigue ( %). all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint 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 (which this version posted july , . t a b l e : s u m m a r y o f f i n d i n g s t a b l e p a t i e n t o r p o p u l a t i o n : h e a l t h c a r e w o r k e r s , b o t h f r o n t l i n e a n d n o n -f r o n t l i n e s e t t i n g : c h i n a ( s t u d i e s ) . g e r m a n y ( s t u d y ) , i n d i a ( s t u d y ) , s i n g a p o r e ( s t u d y ) , f r a n c e ( s t u d y ) , i r a n ( 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint the most commonly reported protective factor associated with reduced risk of mental health problems was having social support , , , . two studies directly measured self-perceived resilience. bohlken et al. asked their sample of psychiatrists and neurologists to assess how resilient they were on a likert scale from - ("not applicable" to "completely applicable"), and % selected the two highest categories. cai et al. compared experienced frontline workers with inexperienced frontline workers, and found that inexperienced workers scored lower on total resilience on the connor-david resilience scale as well as within each of three subscales, and had more mental health symptoms. inexperienced workers were also younger and had less social support available to them. ten studies reported that healthcare workers utilized other resources or had individual strategies to address their own mental health during the pandemic, separate from formal interventions. six studies reported healthcare workers' utilized support from family/friends during the pandemic. "family" was the most common stress coping mechanism utilized by louie et al. 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 (which this version posted july , . kang et al. found slightly higher levels of interest in professional resources. when asked from whom they prefer to receive "psychological care" or "resources", % answered psychologists or psychiatrists, % answered family or relatives, % answered friends or colleagues, % answered others, and % said they did not need help. the authors found that preferred sources of psychological resources were related to the level of psychological distress. in a structural equation model that uncovered clusters of healthcare workers with different distress all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint levels (subthreshold, mild, moderate, and severe), those with moderate and severe distress more often preferred to receive care from psychologists or psychiatrists, while those with subthreshold and mild distress more often preferred to seek care from family or relatives. in two studies, participants specified that they had a greater need for personal protective equipment than for psychological help. chung et al. reported this in a survey that allowed healthcare workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse. while % requested such contact, nearly half of those who answered the free text question about their psychiatric needs wrote that they needed personal protective equpiment instead, and % said they were worried about infection. chen et al.'s study was to understand why uptake of their psychological intervention was so low, and findings were identical to chung et al.'s: "many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies" (p. e ). only one study explored how healthcare workers would be willing to provide mental health services to other healthcare workers: twelve psychiatry residents were re-deployed as frontline workers for one shift in benham et al.'s study. after that shift, none were willing to provide face-to-face mental health services to other healthcare workers, although % said they would provide online services. they identified healthcare workers of deceased patients as possible target populations for online services. three qualitative studies assessed as valuable were included. two interconnected themes across all three studies were distress stemming both from concern for infecting family members, and from being aware of family members' concern for the healthcare workers. wu et al. explored reasons for stress during interviews with healthcare workers at a psychiatric hospital. while these healthcare workers were not on the frontline, they felt they were at higher risk of exposure than healthcare workers at a general hospital. their wards were crowded, and several patients were admitted from emergency rooms with aggressive behaviors that made social distancing difficult or that posed direct challenges to healthcare workers' use of personal protective equipment (such as tearing masks). healthcare workers felt unprepared because all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint psychiatric hospitals had no plans in place. at the same time, they also felt that their peers on the frontline were providing more valuable care. an additional source of stress was knowledge of their own risk of infection and transmission to family members, particular to elderly parents in their care, and to children who were at home and whose schoolwork had to additionally be managed. the disruption of the pandemic to nurses' personal lives and career plans was another stressor. sun et al. interviewed twenty frontline nurses about their psychological experiences of frontline work. similar themes as wu et al.'s sources of stress were reported, particularly the fear of infecting friends and family. elderly parents and children at home were again mentioned, and concern was great enough that several respondents did not tell their family they were working on the frontline, while others did not live at home during this period. as with wu et al.'s nonfrontline workers, these healthcare workers also reported fear and anxiety of a new infectious disease that they felt unprepared to handle on a hospital-level, unprepared to treat on a patientlevel, and from which they were unable to protect themselves. the first week of training and the first week of actual frontline work was characterized by these negative emotions, which were then joined -not necessarily replaced -by more positive emotions such as pride at being a frontline nurse, confidence in the hospital's capacity, and recognition by the hospital. yin et al. used a framework of existence, relatedness, and growth theory to analyze nurses' psychological needs. they reported nurses' identification of existence needs as primarily health and security: their own physical and mental health, personal protective equipment, and emotional stability for their family. their need for relatedness was represented by needs for relationships and affection, as well as for care, help, and support from colleagues and bosses, as well as from outside the hospital. finally, growth needs referred to needing knowledge of covid- infection prevention and control, particularly from the authorities. motivation, as could emotional support. affecting them negatively were fears of infecting their families, particularly because their families would suffer more financially from needing to be quarantined than they already were suffering under the lockdown; fears of using personal protective equipment incorrectly; and feeling unequipped to handle patients' non-medical needs. healthcare workers reported that stigma suppressed patients' provision of accurate travel and all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint quarantine history. this was an issue they were ill-equipped to help patients address when they returned to the community. healthcare workers also reported that they were stigmatized, because they were potential sources of infection. this systematic review identified heterogeneous studies that examined the mental health of healthcare workers during the covid- pandemic. the total of , participants included mainly frontline nurses and physicians, but also other healthcare workers who provided clinical care, administration, or other clinical tasks. studies reported a variety of outcomes and situations, including the implementation of interventions to prevent or reduce mental health problems, other resources and strategies utilized by healthcare workers, and on healthcare workers' mental health responses to re-deployment as frontline workers. while the majority of studies were cross-sectional and assessed as having high risk of bias, several patterns in their findings were evident: more healthcare workers were interested in social support to alieve mental health impacts, only a minority were interested in professional help for these problems, and yet interventions described in the literature largely seemed to focus on relieving individual symptoms. the current study reveals a mismatch between the likely organizational sources of psychological distress, such as workload and lack of personal protective equipment, and how healthcare systems are attempting to relieve distress at an individual level. between one and two of every five healthcare worker reported anxiety, depression, distress, and/or sleep problems. only one study reported on somatic symptoms such as changes in appetite. these findings comport with much of the existing literature; healthcare workers in general, and particularly intensive care nurses and physicians, are known for elevated levels of distress compared to the general population [ ] [ ] [ ] [ ] [ ] . findings from the two studies following healthcare worker over two timepoints during the pandemic indicate that these complaints increased from the first timepoint to the next. thus, there is reason to believe that the pandemic and working conditions during the pandemic negatively affects healthcare workers, although more longitudinal studies are needed to confirm this hypothesis. all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . research may hinder the discovery of underlying organizational faults, which could be more appropriate targets of intervention. this focus on the individual rather than system-level factors is also common in interventions for healthcare worker burn-out before the pandemic . the most striking illustration of this was the finding shared by two studies , that healthcare workers said personal protective equipment would benefit their mental health more than professional help. on the other hand, it is possible that healthcare workers could benefit from professional mental health interventions more than they recognize or report, and that under-recognition is related to occupational culture, fear of stigma or weakness, or simply cultural differences, as the two studies in question both reported on chinese healthcare workers. the possible risk and protective/resilience factors reported by our included studies are similar to those identified in other recent reviews of healthcare workers' mental health during other novel all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint viral outbreaks such as sars, mers, ebola, and h n . these factors, not related to individual psychopathology, could be areas for healthcare settings to proactively address: junior status, higher exposure, longer quarantine time, having an infected family member, lack of practical support, stigma, and younger age were risk factors of distress in kisely et al's pandemic. our quality assessment of qualitative and quantitative studies should help other researchers in the evidence synthesis process, if they wish to use methodological quality in their inclusion criteria. we followed the norwegian institute of public health's rigorous methodological standards for systematic reviews, such as two researchers screening and assessing eligibility. an additional methodological strength is our utilization of the live map of covid- evidence, one of the first reviews to do so (see also two reports , and one diagnostic accuracy study . by using our map, we quickly identified studies that had already been categorized to our topic and population of interest, without having to search in academic databases and screen again. while not being able to conduct a meta-analysis is unfortunate, it was appropriate not to assume that poorly reported studies were homogenous enough. the principle of homogeneity tends to be overlooked by systematic reviewers eager to produce a summary estimate, but if all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint met, means that all studies included were similar enough that their participants can be considered participants of one large study . the result, however, is that the prevalence data about mental health problems does not provide a summary estimate that can be generalized. other weaknesses are those common to rapid reviews due to time pressure, such as fewer details about the included studies' populations being presented than normally reported. the covid- pandemic has resulted in a flood of studies, many of which have been pushed through the peer-review process and published at speeds hitherto unseen (see glasziou for a discussion). it is therefore not surprising that the majority of our included studies were assessed as having a high risk of bias or being of low methodological quality. lack of information on samples or procedures was a common limitation, leading to serious implications to the generalizability and validity of findings. we also call on journals and researchers to balance the need for rapid publication with properly conducted studies, reviews and guidelines . healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, distress, and sleep problems during the covid- pandemic. causes vary, but for those on the frontline in particular, a lack of opportunity to adequately rest and sleep is likely related to extremely high burdens of work, and a lack of personal protective equipment or training may exacerbate mental health impacts. provision of appropriate personal protective equipment and work rotation schedules to enable adequate rest in the face of long-lasting disasters such as the covid- pandemic seem paramount. over time, many more healthcare workers may struggle with mental health and somatic complaints. the six studies exploring mental health interventions mainly focused on individual approaches, most often requiring healthcare workers to initiate contact. proactive organizational approaches could be less stigmatizing and more effective, and generating evidence on the efficacy of interventions/strategies of either nature is needed. as the design of most studies was poor, reflecting the urgency of the pandemic, there is also a need to incorporate high-quality research in disaster preparedness planning. all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint gev conceived of this review and conducted the grade assessments. ss and sØs wrote the first drafts of the introduction and discussion. aem identified the studies within the map for this review. jpwh and evh wrote the first draft of the methods. aem, sv, gs, gev, sf, evh, and jpwh developed the methods of the live map of covid- evidence. sØs contributed to identifying outcomes. aem, sf, and gev extracted data and assessed study quality. aem and gs conducted the analyses. all authors contributed to the protocol and design of this review. all authors have read and approved the final draft of this manuscript. the corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license (or non exclusive for government employees) on a worldwide basis to the bmj publishing group ltd to permit this article (if accepted) to be published in bmj editions and any other bmjpgl products and sublicenses such use and exploit all subsidiary rights, as set out in our license. competing interest: all authors have completed the unified competing interest form (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. transparency: the lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. funding: no funding was received. ethical approval: no ethical approval was required for this systematic review. patient and public involvement: this rapid systematic review did not seek involvement of the population of interest (healthcare providers) due to time constraints. healthcare providers will instead receive direct dissemination of results. all rights reserved. no reuse allowed without permission. 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 (which this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint the italian health system and the covid- challenge critical care crisis and some recommendations during the covid- epidemic in china covid public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap mers and covid- among healthcare workers: a narrative review prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak long-term psychological and occupational effects of providing hospital healthcare during sars outbreak mental health of nurses working at a governmentdesignated hospital during a mers-cov outbreak: a cross-sectional study mental health survey of medical staff in a tertiary infectious disease hospital for covid- covid- pandemic and its impact on mental health of healthcare professionals the experiences of health-care providers during the covid- crisis in china: a qualitative study prevalence of depression, anxiety, and insomnia among healthcare workers during the covid- pandemic: a systematic review and meta-analysis covid- pandemic and mental health consequences: systematic review of the current evidence covid- and italy: what next? protect our healthcare workers no reuse allowed without permission. 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 (which this version posted the impact of the covid- pandemic on mental health of health care workers: protocol for a rapid systematic review a systematic and living evidence map on covid- amstar : a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both casp checklist for qualitative research grade guidelines: . introduction-grade evidence profiles and summary of findings tables addressing faculty emotional responses during the covid pandemic anxiety and depression survey of chinese medical staff before and during covid- defense assessment of iranian nurses′ knowledge and anxiety toward covid- during the current outbreak in iran assessment of the mental health of front line healthcare workers in a covid- epidemic epicenter of china at the height of the storm: healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of covid- brief psychotic disorder triggered by fear of coronavirus? comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease (covid- ) outbreak in february covid pandemic impacts on anxiety of french urologist in training: outcomes from a national survey covid- and mental health: a review of the existing literature covid- and paediatric health services: a survey of paediatric physicians in australia and new zealand covid- associated psychiatric symptoms in healthcare workers: viewpoint from internal medicine and psychiatry residents covid- outbreak situation and its psychological impact among surgeon in training in france covid- -related information sources and psychological well-being: an online survey study in taiwan a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china emergency responses to covid- outbreak: experiences and lessons from a general hospital in nanjing evaluation of the level of anxiety among iranian multiple sclerosis fellowships during the outbreak of covid- factors associated with mental health outcomes among health care workers exposed to coronavirus disease fear and practice modifications among dentists to combat novel coronavirus disease (covid- ) outbreak the immediate mental health impacts of the covid- pandemic among people with or without quarantine managements the impact of covid- pandemic on spine surgeons worldwide impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study investigation and analysis of the psychological status of the clinical nurses in a class a hospital facing the novel coronavirus pneumonia issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid patients mental health and psychosocial problems of medical health workers during the covid- epidemic in china mental health care for medical staff in china during the covid- outbreak. the lancet psychiatry mental health status of doctors and nurses during covid- epidemic in china mental health, risk factors, and social media use during the covid- epidemic and cordon sanitaire among the community and health professionals in wuhan multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak novel coronavirus and related public health interventions are negatively impacting mental health services online mental health services in china during the covid- outbreak. the lancet psychiatry perceived social support and its impact on psychological status and quality of life of medical staffs after outbreak of sars-cov- pneumonia: a cross-sectional study prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against the covid- in gansu prevalence of self-reported depression and anxiety among pediatric medical staff members during the covid- outbreak in guiyang, china psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in shanghai psychological effects of covid- on hospital staff: a national cross-sectional survey of china mainland psychological impact and coping strategies of frontline medical staff in hunan between psychological impact and predisposing factors of the coronavirus disease (covid- ) pandemic on general public in china psychological impact of the covid- pandemic on adults and their children in italy psychological impact of the covid- pandemic on health care workers in singapore psychological impact on women health workers involved in covid- outbreak in wuhan: a cross-sectional study psychological status of medical workforce during the covid- pandemic: a cross-sectional study psychological status of surgical staff during the covid- outbreak psychological stress of icu nurses in the time of covid- psychological stress of medical staffs during outbreak of covid- and adjustment strategy a qualitative study on the psychological experience of caregivers of covid- patients screening for chinese medical staff mental health by sds and sas during the outbreak of covid- staff mental health self-assessment during the covid- the stress and psychological impact of the covid- outbreak on medical workers at the fever clinic of a tertiary general hospital in beijing: a cross-sectional study stressors of nurses in psychiatric hospitals during the covid- outbreak a study of basic needs and psychological wellbeing of medical workers in the fever clinic of a tertiary general hospital in beijing during the covid- outbreak a study on the psychological needs of nurses caring for patients with coronavirus disease from the perspective of the existence, relatedness, and growth theory survey of insomnia and related social psychological factors among medical staffs involved with the novel coronavirus disease outbreak symptom cluster of icu nurses treating covid- pneumonia patients in wuhan vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid- control work stress among chinese nurses to support wuhan for fighting against the covid- epidemic working in the emergency and inpatient covid- special wards: a different experience for iranian psychiatric trainees amid the outbreak: running title: experience of iranian psychiatric trainees in covid- special wards psychosocial work environment and mental health--a meta-analytic review prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis dysfunctional psychological responses among intensive care unit nurses: a systematic review of the literature %j revista da escola de enfermagem da usp the sleep-deprived human brain job decision latitude, job demands, and cardiovascular disease: a prospective study of swedish men health workforce burn-out occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors affecting mental health of health care workers during coronavirus disease outbreaks: a rapid systematic review should healthcare personnel in nursing homes without respiratory symptoms wear facemasks for primary prevention of covid- ? -a rapid review social and economic vulnerable groups during the covid- pandemic antibody tests for identification of current and past infection with sars-cov- mixed and indirect treatment comparisons. evidence synthesis for decision making in healthcare waste in covid- research using grade in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the covid- pandemic, now more than ever and no matter what key: cord- - t q ba authors: rani, uma; dhir, rishabh kumar title: platform work and the covid- pandemic date: - - journal: indian j labour econ doi: . /s - - -y sha: doc_id: cord_uid: t q ba platform business models emerged with the growth of the internet in the s and are conceptualized as two- or multi-sided markets, as they facilitate exchange between service providers, clients (business) and workers. this article focuses on the impact of covid- on digital labour platforms, such as freelance online web-based platforms and location-based platforms (transportation and delivery platforms), which have grown exponentially over the past decade. the covid- pandemic exposed immediately some of the vulnerabilities that the workers in the platform economy were facing as they were declared as part of the ‘emergency services’, and this note explores their conditions during the pandemic. platform business models emerged with the growth of the internet in the s. platform businesses are conceptualized as two-or multi-sided markets, and they facilitate exchange between service providers, clients (business) and workers (unc-tad ; teece ; evans and gawer ) . for instance, the most widespread two-sided markets are transportation platforms, where customers (riders) are matched with drivers, and freelance or microtask or competitive programming platforms, wherein clients (firms) are matched with workers or a crowd of programmers. the common three-sided market is the delivery platform, wherein the three parties-business partners (grocery or restaurants), the delivery worker and the customers-interact with each other, and the platform facilitates this exchange. these models feature a peculiar governance structure and a set of standards and protocols that facilitate interactions between the different users (clients, customers and workers) which are different from traditional business. the interactions between users on the platform are controlled and coordinated by the rules and standards that are laid down in platforms' terms of service agreements that are unilaterally determined by the platforms, which allows them to scale so as to unleash network effects (hagel ) . this strategy allows them to have a dominant position in the market, as is evident from uber which operates in countries. in this short piece, we will focus on the impact of covid- on digital labour platforms, such as freelance online web-based platforms and location-based platforms (transportation and delivery platforms), which have grown exponentially over the past decade. the covid- pandemic exposed immediately some of the vulnerabilities that the workers in the platform economy were facing, and this note explores their conditions during the pandemic. the transportation and delivery platforms played a key role in providing essential services to consumers during the lockdowns, as people were restricted to their homes across the globe. in india, some food delivery platforms, such as swiggy, also started to deliver groceries and essential items. these services were increasingly vital for those in quarantine, while also providing an important option to those particularly vulnerable to covid- to access food, groceries, goods and even medical services. the workers providing such services also played an important role in connecting consumers with enterprises, including small and medium enterprises (smes), and contributed towards meeting demands and ensuring business continuity. as there are no data available on the number of workers engaged in these platforms, it is difficult to estimate their size, but in most countries across the globe these workers were declared as part of the 'emergency services' during covid- lockdown. at the same time, there was an increase in online web-based work, such as freelancing and software programming during the pandemic. the online labour index (oli), which tracks workers and all the projects and tasks posted on the five largest english-language online web-based labour platforms, shows that since the covid- pandemic outbreak, the demand for such tasks declined globally in march before picking up by the end of april (see fig. ). the global decline from mid-march to mid-april in was quite steep compared to - , and it is possible that due to the uncertainty caused by covid- pandemic, firms were postponing the outsourcing of tasks or projects. stephany et al. ( ) posit that due to declining revenues firms might be reducing their non-essential spending, including outsourcing. the demand for online work globally is dominated by the usa ( %). however, the demand for online work was quite uneven across different parts of the world during the covid- pandemic. it increased in the uk, australia, canada, india and germany, but declined in the usa. the decline in demand in the usa was observed in activities such as creative and multimedia, clerical and data entry, and writing and translation. india and the uk observed an increase in online work demand, which was largely in the software development and technology activities. the labour supply for online work is dominated by india ( %), followed by bangladesh, pakistan, philippines and ukraine, apart from the usa and the uk. the share of total supply of workers coming from india increased during the covid- pandemic, and a marginal increase was also observed in the uk and ukraine, while it declined in other countries. to further examine the changing landscape of online platforms during covid- , we focus on two countries-the usa and india, as they have a large presence in both demand for online work and supply of labour on these platforms. both online work demand and labour supply in the usa declined between march and april , and it then picked up. the drop in the demand for online work was largely in creative and multimedia, and sales and marketing support (see fig. a , b). however, demand for software development and technology remained quite stable and increased since the beginning of april. stephany et al. ( ) based on their interviews with freelancers in the usa found that companies are probably cutting their non-essential expenditures related to marketing and sales campaigns, while continuing their business outsourcing related to software development and other technology support, in the context of remote teleworking. on the labour supply side, there was a decline in labour supply across all occupations except software development, and since april the supply of labour increased quite steeply, in particular in the software development and technology category and at a slow pace for clerical and data entry work (see fig. a, b) . in india, in contrast, both online work demand and labour supply increased in april , after a slight decline during mid-march (see fig. a , b). compared to earlier years, there was a spike in both demand and supply from april to early june. the increase in the demand for online labour was largely driven by software development and technology in mid-march, which took off immediately, and as mentioned earlier the need for finding software solutions related to remote and teleworking could have led to an increase in these activities (see fig. c ). in mid-april, there was also a rise in professional services, and sales and marketing activities. other occupations such as creative media and clerical activities picked up in mid-may. it is possible that with the decline in revenues many companies in india are looking at online labour platforms as a substitute for on-site work (stephany et al. ) . with the increasing online work demand in india, there is also an increase in the number of registered workers, as it provides opportunities for replacing lost incomes either due to layoffs or insecurities related to their existing working situations. the occupations that have observed the biggest increase in labour supply are software development and technology, for which demand continues to grow, unaffected by the seasonal patterns that were observed in the earlier years clearly indicating that there is an increase in such work locally within the country (see fig. d ). while this trend is not surprising, it raises questions about the transformations in the world of work and what it means for both businesses and workers. there is a very clear indication that with the ict revolution and the proliferation of the internet, platform work will continue to grow. if the pandemic continues, the pace at which the world of work might transform can be even more rapid, and the increasing insecurities exposed by the pandemic need to be resolved. platform work is often heralded for the flexibility it offers, the freedom to choose work, its income generation potential and the autonomy available to those performing the work. research in recent years has raised concerns about low and unstable pay, inadequate access to regular work, lack of paid time off or sick leave, as well as poor or no access to social protection, particularly due to the classification of workers as 'independent contractors' or 'freelancers' (berg et al. ; huws et al. ; rosenblat and stark ) . since the covid- outbreak, these concerns have magnified. workers engaged in location-based platforms such as those providing delivery or taxi services are particularly at risk due to the nature of their work as they cannot always ensure social distancing. many workers depend entirely on task-based work for their earnings without paid sick leave, and they cannot afford to self-quarantine even if covid- symptoms were to appear, posing risks to both themselves and others. at the same time, with the lack of health insurance coverage for platform workers in many countries, even getting tested for covid- may be challenging. this could lead to a scenario wherein not only is the platform worker engaged in work while being sick, but also risks spreading the virus to the customers or businesses involved. while risks of contracting covid- is less for workers engaged in online platforms when compared to those engaged in location-based platforms, limited access to social protection creates challenges for them too. as the levels of unionization among these platform workers are low, there are limited avenues for collective bargaining in the platform economy. despite that, many of them have formed informal groups or associations and are fighting for their rights, especially related to 'mis-classification' as they are classified as 'independent contractors', 'self-employed' or 'freelancers', which excludes them from getting any labour or social protection. the lack of such protections are exposing workers to additional risks in the context of covid- pandemic, as the workers are often not provided with personal protective equipment, or sick pay or hazard pay for performing tasks. in the absence of institutionalized mechanism for collective bargaining, some workers have also resorted to strike actions to demand for basic protections such as provision of personal protective equipment (ppe) and hazard pay, among others. in addition, workers have also been demanding platform companies to provide access to their administrative data to public authorities not only to process unemployment benefits, but also to ensure that workers are not crowding at certain pick points so as to avoid the spread of the virus. these workers have also been demanding government authorities to provide them with unemployment and social protection benefits, as they are included as 'essential workers', and to expand the coverage of other benefits such as access to credits with low interest rates, the easing of educational debts, payment of cash transfers, among others. platform app companies have been responding in various ways, depending upon the company and the country to the workers' demands, for instance, using the app to effectively communicate the measures adopted by the company and by the regulatory authorities, including global guidelines to prevent the spread of the virus. they have also tried to provide hand sanitizer, masks or air sprays to prevent workers and consumers from infecting or spreading the virus. moreover, they have also set up special places for disinfecting vehicles, motorbikes, bikes, backpacks or food containers, either by their own initiative, in consultation with platform workers' associations, or in coordination with public authorities. however, several reports and press chronicles have shown that many workers are not receiving this equipment, due to logistic difficulties or problems of shortage. some app companies have set up emergency funds and other forms of sick pay to assist workers infected with the virus or that have been medically ordered to self-isolate. however, these sick pay schemes are considered to be insufficient to cover the loss of income and even distant from minimum wages available in different countries. public authorities have responded across the world with preventive health and safety measures such as providing information and training in relation to covid- and providing protective equipment (such as brazil, chile, colombia, valencia in spain, peru). some countries such as peru have also provided paid sick leave for those infected with virus or in close contact with infected people from the common fund and special private insurance and most importantly have passed a bill which also provides for sharing of data to prevent agglomeration. while these are important measures, they are not sufficient to address the risks that these platform workers face. the covid- pandemic has also exposed the sustainability of platform business, as many of these companies were already struggling to be profitable. for instance, uber reported losing us$ . billion in its second quarterly earnings in , http://www.lepar isien .fr/econo mie/uber-comme nce-a-equip er-ses-chauff eurs -de-masqu es- - - - .php. https ://www.munis tgo.cl/munic ipali dad-de-santi ago-y-didi-reali zan-sanit izaci on-gratu ita-para-taxis -en-santi ago/. https ://thewi re.in/busin ess/covid - -food-deliv ery-worke rs. https ://www.uber.com/blog/updat e-covid - -finan cial/; https ://fair.work/fairw ork-relea ses-repor t-onplatf orm-respo nses-to-covid - / (nearly half the of the platforms surveyed by fairwork launched some form of sick pay, although they 'do not typically label the financial support provided as "sick pay"' but instead describe it as "a one-time pay adjustment" or as "a support payment"'.); https ://www.jorna da.com.mx/ultim as/mundo / / / /didi-crea-fondo -de-emerg encia -para-condu ctore s-conta giado s-decovid - - .html. https ://fair.work/fairw ork-relea ses-repor t-on-platf orm-respo nses-to-covid - /. https ://www.theve rge.com/ / / / /uber- -billi on-quart er-loss-profi t-lyft-traffi c- . swiggy's losses grew sixfold to ₹ crore in the financial year , and zomato posted us$ millions in losses for the financial year . despite their non-profitability, venture capitalists continue to heavily subsidize them and they are betting on these platforms to dominate the market with network effects, which will lead to significant returns for their investments, the popular 'winner-takes-all' argument (kenney and zysman , pp. - ) . these companies seem to have used the pandemic to also cut costs by laying off workers; for instance, swiggy laid off employees and ola employees, which also helps them to restructure their companies. some companies such as uber are also using this crisis as an opportunity to change their business model, shifting from a specific economic activity to a more massive scale and coordinating gig work. uber has launched a new 'work hub' that enables its drivers to find alternative gig work, in such areas as customer service, food production and logistics. through this hub, app-based drivers can connect with other uber platforms, such as uber eats (food deliveries), uber freight (trucking) and uber works (blue-collar shifts), and with a growing number of companies that have entered in agreements with uber. as put by a recent press report, uber is '… becoming a platform for organising all kinds of casual, temporary and gig work. and by extension, it's becoming a platform for transforming work in general, for making work more casual and temporary, and for making labour more flexible'. the regulation of digital platforms has been under discussion in several countries, with debates underway particularly regarding the role of regulatory frameworks for ensuring labour protections on digital labour platforms. recognizing these difficulties, the ilo's global commission on the future of work called for the 'development of an international governance system for digital labour platforms (and their clients) to respect certain minimum rights and protections' (ilo , p. ). it could set minimum standards as well as develop the infrastructure necessary for facilitating payments to social security systems, and it could also establish a representative board to adjudicate disputes between platforms, clients and workers. given the critical role of social dialogue, access to healthcare, income stability, paid leave and sick leave, and social protection more broadly in combating the spread of covid- , the evolving world of work under the platform economy model requires an urgent and serious transformation for ensuring both short-and long-term economic stability and sustainability. https ://www.livem int.com/compa nies/news/swigg y-s-losse s-rise-six-fold-to-rs- - -crore -in-fy - .html. https ://econo micti mes.india times .com/small -biz/start ups/newsb uzz/zomat o-posts -usd- -mn-lossfor-fy -reven ue-up- -fold-to-usd- -mn/artic lesho w/ .cms. https ://www.forbe s.com/sites /simon chand ler/ / / /coron aviru s-turns -uber-into-gig-platf ormfor-all-work/# fb d b . digital labour platforms and the future of work the rise of the platform enterprise: a global survey the power of platforms work in the european gig economy: research results from the uk online labour index: measuring the online gig economy for policy and research work and value creation in the platform economy algorithmic labor and information asymmetries: a case study of uber's drivers distancing bonus or downscaling loss the changing livelihood of us online workers in times of covid- dynamic capabilities and (digital) platform lifecycles value creation and capture: implications for developing countries. unctad/der/ key: cord- -cmeociax authors: jay miller, j.; niu, chunling; moody, shannon title: child welfare workers and peritraumatic distress: the impact of covid- date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: cmeociax whilst there is broad consensus that covid- has had a pernicious impact on child welfare services, in general, and child welfare workers, specifically, this notion has not been thoroughly examined in the literature. this exploratory study examined covid- related peritraumatic distress among child welfare workers (n= , ) in one southeastern state in the united states (u.s.). findings suggest that the study sample was experiencing distress levels above normal ranges; . % of participants were experiencing mild or severe distress. sexual orientation, self-reported physical and mental health, relationship status, supervision status, and financial stability impacted distress levels experienced by child welfare workers. overall, data suggest that covid- is impacting child welfare workers and there is a need to conceptualize, implement, and evaluate initiatives aimed at assuaging distress among child welfare workers. coronavirus (covid- ) pandemic has fundamentally altered child welfare practice. distancing guidelines, evolving regulatory edicts, and substantial significant restrictions in legal operations (e.g., court processes) have significantly impacted workers' abilities to perform seminal child welfare duties. indeed, as jerry milner, associate commissioner at the children's bureau, aptly concluded in a letter to child welfare leaders: "the covid- pandemic has created unprecedented challenges for our health and human services systems in serving our most vulnerable families, children, and youth" ( , para ). indubitably, these circumstances have taken a toll on child welfare workers. whilst a plethora of local, state, and federal entities have proffered strategies to assist workers in assuaging the impact of covid- , personal and professional challenges associated with the pandemic persist. this paper examines the impacts of these challenges. this exploratory study examined peritraumatic distress among child welfare workers (n= , ) in one southeastern state in the united states (u.s.). to collect primary data, researchers deployed the covid- peritraumatic distress index (cpdi; qiu, shen, zhao, wang, xie, & xu, ) . cpdi is a self-report instrument designed to measure covid- specific distress. this is the first known empirical study to explicitly examine this topic among child welfare workers. after a brief review of pertinent background literature, this paper will explicate results, discuss findings, and proffer salient practice, policy, and research implications. background a well-functioning child welfare system is essential to wellbeing. per the child welfare information gateway ( ), child welfare workers carry out an array of tasks aimed at child and family safety, permanency, and wellbeing. barth ( ) explained that the impact of the work performed by child welfare workers reverberates for generations and extends beyond an individual child or family, but to society as a whole. in short, the importance of the work that child welfare workers perform cannot be overstated. in general, there is a host of problematic occupational concerns related to child welfare practice. suggested that child welfare workers experience higher rates of compassion fatigue and occupational stress, when compared to other social service providers. miller et al made similar assertions ( ) . kim, ji and kao ( ) and blome and steib ( ) reported that child welfare workers experience high caseloads and lower perceptions of personal accomplishment, when juxtaposed with workers in other contexts. lizano, hsiao, barak, and casper ( ) explained that the work-related strain experienced by child welfare workers negatively impacted overall worker wellbeing. others have discussed a host of inimical physical and psychological conditions experienced by child welfare workers (e.g., salloum et al., ; griffiths, royse, culver, piescher, & zhang, ; schelbe, radey & panisch, ) . indeed, even in the best of times, child welfare practice can be challenging. to be clear, empirical research examining the impact of covid- among the child welfare workforce is in the nascent stages. however, research conducted in other areas illustrate the impact of covid- on an array of practitioners. for instance, in a cross-sectional study of physicians, advanced practice providers, residents/fellows, and nurses, shechter et al. ( ) found that nearly % of participants reported acute stress and nearly half of the sample exhibited symptoms for depressive disorder related to covid- . lai et al. ( ) and xiao, zhang, kong, li, and yang ( ) reached similar conclusions. in a broader review of six articles published about the impact of covid on healthcare workers, spoorthy, pratapa, and mahant ( ) concluded that factors such as gender, age, and lack of social support, among others, were linked to stress, anxiety, and depressive symptoms among study participants. in assessing literature about the impacts of covid- on the public, torales, o'higgins, castaldelli-maia, and ventriglio ( ) found that the pandemic has contributed to a host of problematic circumstances. in addition to those noted by spoorthy, pratapa, and mahant ( ) , torales and colleagues ( ) discussed denial, anger, and fear that has been brought about by the pandemic. these authors went on to discuss the impact that these issues may have on prevention and decisionmaking related to the pandemic. empirical studies notwithstanding, several outlets have made assertions about the impact of covid- on the child welfare system, more broadly, and workers, more specifically. for example, the national conference on state legislatures ( ) asserted that court restrictions have dramatically slowed child welfare processes and impacted workers' abilities to navigate seminal functions associated with performing their duties. kelly ( ) maintained that these restrictions have presented difficulties in managing child welfare cases. merritt and simmel ( ) explained that many workers experienced abrupt transitions to virtual and/or remote work and service environments. in some instances, child welfare workers, particularly child protective service workers, have continued to initiate and conduct home visits, etc. akin to those in traditional healthcare settings (e.g., hospitals), these workers have been concerned about the availability of adequate personal protective equipment (ppe) and exposure to covid- (see fadel, ) . given the sweeping impact of the pandemic, it is probable that covid- has exacerbated the challenges for engaging in child welfare work. these negative impacts can be felt not only by the child welfare workers, but the children and families they seek to serve. whilst the impact of the pandemic has been explored among other practitioner groups (such as healthcare professionals, etc.), works that examine this impact among child welfare workers is nominal, at best. a thorough review of relevant databases revealed no such studies. this paper seeks to contribute to addressing that limitation in the current literature. the overarching purpose of this exploratory study was to examine covid- peritraumatic distress among child welfare workers. this is the first work known to the authors to examine the impact of covid- on distress among this population. in so doing, this study offers insight for how to allay distress among child welfare workers during covid- . specifically, this study was guided by three ( ) research questions: research question : what are covid- related peritraumatic distress levels among child welfare workers? research question : are there group differences in covid- related peritraumatic distress by participant demographic/professional characteristics? research question : what demographic/professional characteristics predict covid- related peritraumatic distress? this study employed a cross-sectional design. primary data were collected via an electronic survey administered via an online survey management program (e.g., survey monkey). researchers sought, and were granted, institutional review board (irb) approval and a waiver of documentation of informed consent. all data were collected during summer . to recruit participants for this study, researchers circulated the approved study invitation to statewide child welfare groups and professional membership associations. in turn, participants were asked to forward the invitation to other potential participants. this approach does not permit for the calculation of a response rate. those who participated in the survey were offered a chance to enter a $ incentive drawing. researchers did utilize features that disabled ip and email address tracking. the incentive link was not connected to the primary survey link. all participants self-identified as a public or private child welfare worker at the time of the survey. primary data pertaining to distress were collected using the covid- peritraumatic distress index (cpdi; qiu, shen, zhao, wang, xie, & xu, ) . cpdi is a -item scale designed to examine covid- specific peritraumatic distress. for clarity, peritraumatic distress refers to the physiological and/or emotional distress experienced by an individual during a traumatic event. bunnell, davidson, and ruggiero ( ) explained that peritraumatic distress is related to the development of posttraumatic stress disorder (ptsd). cpdi entails parameters associated with stress, as outlined in the international classification of diseases ( th rev.). each item is anchored at indicating never and indicating most of the time example items include: "compared to usual, i feel more nervous and anxious" and "i feel insecure and bought a lot of masks, medications, sanitizer, gloves and/or other home supplies." in terms of scoring, the cpdi scores range from - , with higher scores indicating more distress. cut scores are as follows: - (normal distress); - (mild distress); and, - (severe distress). the cronbach's alpha of cpdi for this study was . (p< . ). in addition to the cpdi, researchers collected demographic and professional data necessary to adequately describe the sample. variables of interest included: gender; age; years of practice experience; hours worked per week; sexual orientation; race; relationship status; education level; and professional membership group status, among others. participants were asked to self-report their physical health status and mental health status, respectively. response options for both of these variables included excellent, very good, good, fair, or poor. participants were also asked about their current financial situation. response categories included: i cannot make ends meet; i have just enough money to make ends meet; i have enough money, with a little left over; or, i always have money left over. remote work status was operationalized by asking participants if they had worked primarily remotely since march , , the date covid- was declared a pandemic. participant responses to the instrument are summarized in table . all data were analyzed via spss . once data were cleaned, researchers initiated descriptive, bivariate and multivariate inferential analyses. descriptive analysis showed frequency and mean distribution of main variables. bivariate examination included correlation analyses, robust one-way analyses of variances (brown-forsythe tests) or independent sample t-tests. multivariate inferential analysis included hierarchical multiple ordinary least squares regression. a total of , (n= , ) child welfare workers participated in this study. of the participants, of them were employed by a private child welfare agency; , of them were employed by a public child welfare agency. typical survey respondents were aged . (sd= . ) years and had been practicing in child welfare for . (sd= . ) years. additional demographic information is included in table . the mean cpdi score for participants was . (sd= . ); with a range of . at an individual level, . % of the sample had cpdi scores within the normal range; . % in the mild range; and, . % in the severe range. correlation analyses between the total distress scores and various continuous demographic variables yielded one significant relationship. specifically, age (r = -. , p < . ) was significantly correlated with cpdi scores, whereby older participants tended to have lower cpdi scores. due to the exploratory nature of the study, anovas were initiated to assess group differences in cpdi scores. analyses detected significant differences in mean total scores for the following variables: sexual orientation, physical health, mental health, supervision status, current financial status, and current relationship status. table contains a summary of results for these analyses. for sexual orientation, participants were put into two categories for the purpose of analysis: "heterosexual or straight" vs. "not heterosexual or straight" (e.g., gay or lesbian and bisexual). analysis for the purpose of analyses, current marital status was categorized as "married" or "not lastly, differences were detected by financial status. to reduce the sample imbalance across the four levels, those who reported "i cannot make ends meet," and "i have just enough money to make ends meet," were combined into one level. a one-way robust anova (brown-forsythe test) was used to compare mean total distress scores between the different financial status and was found to be statistically results revealed that seven variables significantly predicted total distress: married (p < . ), financial status (p < . ), physical health (p < . ), mental health (p < . ), age (p < . ), and sexual orientation (p < . ). the older and married social workers tended to have lower distress scores by . and . points, respectively. identifying as "heterosexual or straight" seemingly predicted lower total distress scores by . points. compared to those who reported "excellent physical health", child welfare workers who reported "very good," "good," or "fair/poor" physical health were inclined to score higher on the total covid distress scale by . , . , and . points, respectively. likewise, those who reported "excellent mental health", when compared to those who reported "very good," "good," or "fair/poor" mental health, scored . , . , and . points higher, respectively. for those who reported "i cannot make ends meet," "i have just enough to make ends meet," or "i have enough with a little left over" impacted distress scores by . and . points respectively, after controlling for all other variables. table for the results of the regression analysis. this study is likely the first to examine covid- related distress among child welfare workers. overall, data indicates that child welfare workers in this sample were above normal ranges and fall into the mild distress category. nearly half of all participants scored in a range indicating mild or severe peritraumatic distress stress related to covid- . in many ways, these findings may not be surprising. in a national examination of the general public, palsson, ballou, and gray ( ) concluded that over half of their sample reported having higher stress levels as a result of covid- . as well, these findings are somewhat consistent with the aforereferenced literature related to other professional groups, such as healthcare professionals (e.g., shechter et al., ) . in addition to professional challenges, child welfare practitioners may be coping with personal challenges, such as homeschooling, caregiving, economic uncertainty, and the like, that may impact their professional roles. these conditions, plus an uncertain prospect for improved conditions in the immediate future, can certainly cause distress among those experiencing them. covid- related distress among child welfare workers can be disconcerting for an array of reasons. for example, this distress may lead to professional burnout, which in turn, may contribute to retention issues (lizano, hsiao, barak, & casper, ) . as well, it is possible, that covid- distress may impact practice decisions. miller, donohue-dioh, niu, and shalash ( ) and suggested that wellness factors, or lack thereof, can negatively impact child welfare workers' abilities to adroitly manage caseloads. that in mind, the level of distress among participants in the current study, specifically, and in the larger child welfare workforce, more broadly, certainly warrants more critical examination and response. that said, the fact that the sample is not experiencing more distress is noteworthy. to be clear, any level of distress among child welfare workers is concerning. however, . % of participants in this study did fall within a "normal" range of distress. while there are no published examinations of peritraumatic distress related to covid- among child welfare workers, a recent study of secondary traumatic stress among child welfare workers in three states, rienks ( ) concluded that nearly % of the sample experienced moderate, high, or severe stress. given the attention that the impact of the pandemic has had on child welfare, one might have surmised higher levels of distress among the participants in the current study. there are a number of additional factors that may be impacting distress, or lack thereof, among child welfare workers. for example, several outlets have discussed the fact that calls to child protective services have slowed during the pandemic (e.g., welch & haskins, ) . moreover, much of the work has shifted to virtual/remote tasks. interestingly, these dynamics may have offered some temporary reprieve associated with high caseloads, volumes, etc. that may cause stress among child welfare workers. among participants in this sample, age did appear to significantly impact distress. age was correlated with distress such that older participants experienced less distress and being older significantly predicted decreases in distress. this is consistent with other research, in general, about age and stress. for instance, jorm, windsor, dear, anstey, christensen, and rodgers ( ) examined generalized psychological distress, by age. these researchers concluded that distress tended to decrease as one got older. it is also possible that older participants may be better able to cope with distress as a result of more financial stability, etc. have better coping skills as it relates to distress (e.g., schieman, van gundy & taylor, ) . still yet, age may be related to other factors, such as parenting young child(ren), etc. that may be especially relevant during the pandemic. all told, these findings affirm cursory notions that different age groups may be experiencing covid- differently. analyses revealed that several demographic variables impacted covid- distress. individuals who were married experienced less distress than did those who were not; marital status was a significant predictor of less distress. several authors have discussed the importance of connectedness and romantic/social relationships to overall wellbeing. for instance, fincham and beach ( ) concluded that marriage is associated with better mental wellbeing and miller, lianekhammy, and grise-owens ( ) found that individuals who are married tend to engage in more frequent self-care practices, when compared to those who are not married. as well, many states, including the one in which this study occurred, implemented strict distancing and isolation mandates. being married may provide additional support, in a time when others are isolated from their social networks. this support can be integral to addressing covid- related distress. interestingly, supervisors experienced less distress than did non-supervisors. this is somewhat counter to previous assertions that child welfare supervisors may experience more stress than other child welfare professionals (e.g., dill, ) . it is possible that being a supervisor is a proxy for other variables, such as financial status, as supervisors may typically earn more salary. additionally, supervisors may be better informed about agency dynamics and responses associated with the pandemic. or still yet, supervisors' experience may permit them to better navigate or cope with distress specifically associated with covid- , such as not having to initiate home visits, conduct face-to-face interviews, etc. all of these factors may contribute to less distress for child welfare supervisors. perhaps not surprisingly, physical and mental health appear to impact covid- distress. in short, analyses indicate that participants with better physical or mental health, respectively, experience less covid- related distress. this finding is consistent with a line of research inquiry linking physical/mental health to overall wellbeing (e.g., perales, del pozo-cruz, & del pozo-cruz, ). there are a number of factors associated with physical/mental health that may impact current findings. for example, many physical and mental wellbeing routines may be disrupted during covid- . due to community health guidelines, most gyms and health facilities were closed at periods during the pandemic and counseling/therapy sessions may have been limited or have transitioned to virtual/tele delivery options. veritably, accessibility to resources, and facilities, can impact covid- related distress. financial status also seems to be linked to lower distress associated with covid- . in summary, those reporting more financial stability appear to experience lower distress. intuitively, these findings may be expected. finances are often a life stressor. previous research pertaining to child welfare workers has linked financial status to self-care and wellness practices (miller, donohue-dioh, niu, grise-owens, & poklembova, ) . covid- has likely exacerbated that stressor. in terms of sexual orientation, identifying as heterosexual or straight appeared to significantly decrease distress. given previous literature about lgbtq* professionals, these findings may not be surprising. evidence suggests lgbtq* individuals face an array of challenges that exacerbate stressors. lgbtq* practitioners must also face issues associated with role encapsulation, tokenism, homophobia, heterosexism, heterocentrism, hostile workplaces, inadequate access to formal and professional mentorship opportunities, professional isolation, and loneliness, (lasala, jenkins, wheeler, & fredriksen-goldsen, ; dentato et al., ) , among others. this study has several strengths. notably, this is the first known study to explicitly examine covid- distress among child welfare workers. the cdc ( ) has discussed the importance of understanding covid- associated stressors as a way to better address those stressors. in addition, though exploratory, the study has a more than adequate sample size of child welfare workers and examines the concept of peritraumatic distress related to the pandemic. data from the current study may provide valuable information for child welfare employers to more adeptly support workers during covid- and other disasters. this work must also be considered within the context of several limitations. for example, all participants self-selected into the study and self-identified as a public child welfare worker. the sample was overwhelmingly female and white, which may not be reflective of larger child welfare worker populations. a more diverse sample may have yielded different responses, which might have impacted the results. given the nature of this study, and the population, a social desirability bias may be impacting data associated with the current study. the instrument utilized for this study is relatively new. though this is to be expected given the quickly emerging science associated with covid- , this instrument should be further assessed for use among broader populations, to include child welfare workers. additionally, this study did not examine a number of job-specific factors, such as caseload, etc. given these limitations, assertions based on this study must be made carefully and critically. given that confirmed cases of covid- are on the rise in the u.s., it is imperative to conceptualize approaches to supporting child welfare workers in dealing with challenges, and associated consequences, of covid- . nearly half of the participants in this study were experiencing distress associated with the pandemic. as such, studies that examine the impact of the pandemic on child welfare should identify pragmatic strategies for assuaging distress. the following paragraphs briefly outline salient implications derived from the afore-referenced findings. to be clear, to deal with covid- related distress among child welfare workers, responses from both the individual and organizations (e.g., employer) may be necessary. for individual child welfare workers, attention should be focused on developing self-care practices conducive to assuaging distress. several entities (e.g., centers for disease control, ; national child traumatic stress network, ) have discussed the importance of self-care during the pandemic. this importance has also been discussed in previous research works associated with child welfare workers (e.g., . typical steps in this regard include establishing robust self-care plans, delineating implementation strategies for said plans, and evaluating progress (grise-owens, miller, & eaves, ) . from an organizational standpoint, consideration should be given to conceptualizing and implementing broader initiatives aimed at supporting child welfare workers in dealing with the distress associated with covid- . a host of authors have discussed the importance of workplace culture, to include offering support, for child welfare workers (e.g., ellett, ellis, westbrook, & dews, ; madden, scannapieco, & painter, ) . there are several ways in which organizations can actualize such initiatives. for example, organizations may look to foster interactions among child welfare workers that extend beyond traditional work spaces. this may take the form of virtual accountability, check-in, and support groups. findings from the current study suggest that certain employee groups (e.g., lgbtq*) experience higher levels of distress. as such, targeted or specialized groups may be impactful in helping to address distress. such initiatives should be conceptualized in a participatory fashion -that is -with the input of child welfare workers. certainly, membership organizations can be helpful in achieving supportive aims for child welfare workers. groups such as the child welfare league of america (see https://www.cwla.org/coronavirus/) and prevent child abuse america (see https://preventchildabuse.org/coronavirus-resources/) have provided web pages, documents, and guidelines to assist workers in dealing with the pandemic. other entities, such as the children's bureau (see https://www.acf.hhs.gov/cb/resource/covid- -resources) have proffered resource pages. from a macro perspective, it is imperative that regulatory entities continue to promulgate policies directed at providing relief during covid- . for instance, remote work arrangements may be an ideal approach to assuaging stress among child welfare workers, even absent a pandemic. other edicts related to ppe requirements, virtual visits, etc. should be assessed and weighed as a necessary response to ensure the safety of workers. research implications abound. most importantly, researchers should continue to examine the impact of covid- on a variety of stakeholders, including child welfare workers, service recipients, and foster parents, to name a few. what's more, researchers should assess practices and policies, such as remote work arrangements, etc., for efficacy and efficiency. other areas include the impact of age and how covid- may impact underrepresented groups, such as lgbtq* and practitioners of color, other jobrelated factors, such as caseload, and how these variables may mediate/moderate distress, to name a few. the critical mission of child welfare workers is laudable and essential. if the wellbeing of children and families served by these workers is to be actualized, the needs of the practitioners must be assessed and addressed. this is particularly true during a pandemic, that by any measure, has had a profound impact on the child welfare system. though this exploratory study fills a unique gap in the current child welfare research literature, it is in no way a definitive work. to understand the true impact of covid- on child welfare services, and those who perform those services, workers, employers, researchers, and policy makers must continue to examine the short, medium, and long-term impacts of covid- . this study can serve as a starting point for that work. after safety, what is the goal of child welfare services: permanency, family continuity or social benefit? the organizational structure of child welfare: staff are working hard, but it is hardly working the peritraumatic distress inventory: factor structure and predictive validity in traumatically injured patients admitted through a level i trauma center employees: how to cope with job stress and build resilience during the covid- pandemic department of health and human services homophobia within schools of social work: the critical need for affirming classroom settings and effective preparation for service with the lgbtq community impact of stressors on front-line child welfare supervisors. the clinical supervisor a qualitative study of child welfare professionals' perspectives about factors contributing to employee retention and turnover child welfare services and caretakers grapple with covid- effects marriage in the new millennium: a decade in review the a-to-z self-care handbook for social workers and other helping professionals unheard voices: why former child welfare workers left their positions who stays, who goes, who knows? a state-wide survey of child welfare workers age group differences in psychological distress: the role of psychosocial risk factors that vary with age feds lay out minimum expectations for child welfare courts during coronavirus. the chronicle of social change burnout and physical health among social workers: a three-year longitudinal study factors associated with mental health outcomes among health care workers exposed to coronavirus disease lgbt faculty, research, and r
esearchers: risks and rewards support in the workplace: buffering the deleterious effects of work-family conflict on child welfare workers' wellbeing and job burnout an examination of retention and length of employment among public child welfare workers barriers to child protection during covid- : considering the impact on child maltreatment. the chronicle of social change exploring the self-care practices of child welfare workers: a research brief examining self-care among individuals employed in social work capacities: implications for the profession examining the selfcare practices of child welfare workers: a national perspective letter on child welfare leaders as level emergency responders. children's bureau, administration for children and families impact of physical activity on psychological distress: a prospective analysis of an australian national sample a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations an exploration of child welfare caseworkers' experience of secondary trauma and strategies for coping the role of self-care on compassion satisfaction, burnout and secondary trauma among child welfare workers satisfactions and stressors experienced by recently-hired frontline child welfare workers status, role, and resource explanations for age patterns in psychological distress psychological distress, coping behaviors, and preferences for support among new york healthcare workers during the covid- pandemic mental health problems faced by healthcare workers due to the covid- pandemic-a review the outbreak of covid- coronavirus and its impact on global mental health child welfare: hhs could play a greater role in helping child welfare agencies recruit and retain staff what covid- means for america's child welfare system the effects of social support on sleep quality of medical staff treating patients with coronavirus disease key: cord- - jtd ytz authors: zhang, wen-rui; wang, kun; yin, lu; zhao, wen-feng; xue, qing; peng, mao; min, bao-quan; tian, qing; leng, hai-xia; du, jia-lin; chang, hong; yang, yuan; li, wei; shangguan, fang-fang; yan, tian-yi; dong, hui-qing; han, ying; wang, yu-ping; cosci, fiammetta; wang, hong-xing title: mental health and psychosocial problems of medical health workers during the covid- epidemic in china date: - - journal: psychother psychosom doi: . / sha: doc_id: cord_uid: jtd ytz objective: we explored whether medical health workers had more psychosocial problems than nonmedical health workers during the covid- outbreak. methods: an online survey was run from february to march , ; a total of , chinese subjects participated. mental health variables were assessed via the insomnia severity index (isi), the symptom check list-revised (scl- -r), and the patient health questionnaire- (phq- ), which included a -item anxiety scale and a -item depression scale (phq- ). results: compared with nonmedical health workers (n = , ), medical health workers (n = ) had a higher prevalence of insomnia ( . vs. . %, p < . ), anxiety ( . vs. . %, p < . ), depression ( . vs. . %; p< . ), somatization ( . vs. . %; p < . ), and obsessive-compulsive symptoms ( . vs. . %; p < . ). they also had higher total scores of isi, gad- , phq- , and scl- -r obsessive-compulsive symptoms (p ≤ . ). among medical health workers, having organic disease was an independent factor for insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms (p < . or . ). living in rural areas, being female, and being at risk of contact with covid- patients were the most common risk factors for insomnia, anxiety, obsessive-compulsive symptoms, and depression (p < . or . ). among nonmedical health workers, having organic disease was a risk factor for insomnia, depression, and obsessive-compulsive symptoms (p < . or . ). conclusions: during the covid- outbreak, medical health workers had psychosocial problems and risk factors for developing them. they were in need of attention and recovery programs. the coronavirus disease (covid- ) outbreak is a pandemic [ ] in which a coronavirus has been identified as the cause of an outbreak of respiratory illness. it was first detected in wuhan, china [ ] , but covid- is becoming an increasing public event being a rapid epidemic [ , ] . according to the official website of the world health organization [ ] , as of march , , more than , people have been confirmed to have a covid- infection globally. many accomplishments on covid- , including virus information, clinical features, and diagnosis have been achieved, but no effective treatment is available yet [ , [ ] [ ] [ ] . medical health workers are first-line fighters treating patients with covid- . every day, they face a high risk of being infected and are exposed to long and distressing work shifts to meet health requirements. in brief, they are exposed to a protracted source of distress which may exceed their individual coping skills, being, according to a clinimetric definition [ ] , in allostatic load, which is likely to result in overload with protracted time [ ] . despite messages mentioning that medical health workers' mental health should be emphasized during the campaign against covid- [ ] [ ] [ ] , no research on mental health problems in medical health workers after the maximum point of the covid- epidemic in china has been reported. since chinese medical health workers have been exposed to a persistent source of distress, the aim of the present research was to outline its psychological manifestations. for this purpose, the prevalence and potential factors contributing to insomnia, anxiety, depression, obsessive-compulsive symptoms, somatization symptoms, and phobic anxiety were detected. design, participants, and procedure this is a cross-sectional study performed via an online survey run from february to march , . the study was performed weeks after the covid- epidemic outbreak in wuhan [ ] . this survey period corresponded to the reducing stage after the maximum point of the covid- epidemic outbreak in china [ ] , i.e., the highest vulnerability period after the great distress. persons in the nation with at least years of age were welcome to join in the online survey via the wenjuanxing platform (https:// www.wjx.cn/m/ .aspx). the online survey included questions on sociodemographic and clinical variables. a simple math question (i.e., - = ?) was added at the end for ensuring the quality and completeness of the questionnaire. thus, participants who had not completed the survey received from the online platform a warning on unanswered questions when they did the math question. the online platform did not give warnings to those who gave up. as a result, participants were those who completed all questions of the online survey. demographic data, i.e., sex, age, occupation (medical health workers, i.e., medical doctors and nurses, and nonmedical health workers, excluding nonmedical personnel working in hospitals/ medical institutions), marital status (i.e., married, unmarried, divorced, and widowed), living area (i.e., urban and rural), living with families (yes or no), education status (≤ years, i.e. junior high school and lower, > years, i.e. senior high school and higher) were collected via ad hoc questions as well as the information of a risk of contact with covid- patients in hospitals. participants were also asked whether they have had insomnia or psychiatric disorders prior to covid- (those who replied positively were automatically excluded by the platform) and whether they were having organic diseases (the question was "do you currently have any organic disease? [diagnosed by medical examination in the hospital]"). in addition, insomnia, anxiety, depression, somatization, obsessive-compulsive symptoms, and phobic anxiety were assessed. insomnia was assessed via the insomnia severity index (isi), a -item self-report index assessing the severity of initial, middle, and late insomnia [ ] . an isi total score > indicates that insomnia is present [ ] . the item "since the outbreak, how long (in minutes) did you usually take to fall asleep each night?" was added to assess the degree of sleep onset latency in medical health workers. this item was rated as , , , and (i.e., ≤ , - , - , and > min, respectively). anxious and depressive symptoms were assessed via the patient health questionnaire- (phq- ) [ ] , which is an ultra-brief self-report questionnaire with a -item anxiety scale, named generalized anxiety disorder -item (gad- ), and a -item depression scale, named patient health questionnaire -item (phq- ). in screening of depression and anxiety, a cutoff ≥ in gad- and phq- is recommended [ ] . somatic symptoms, obsessive-compulsive symptoms, and phobic anxiety were measured via the symptom check list- revised (scl- -r) [ , ] , a -item self-report scale with items rated on a -point likert scale (from "not at all" to "extremely"). subscale scores ≥ indicate potential psychological issues [ ] . the chinese versions of isi [ ] , phq- [ ] , gad- [ ] , and scl- -r [ ] were used; they were validated and showed excellent psychometric properties. statistical analyses χ tests were used to compare group differences of categorical variables. mann-whitney tests were used to compare independent groups on continuous variables nonnormally distributed. psychother psychosom doi: . / multivariate logistic regression analyses were performed using stepwise variable selection, and all variables were entered into the model to explore independent influence for different risk dimensions, such as insomnia, anxiety, depression, somatization, obsessive-compulsive symptoms, and phobic anxiety. subgroup analyses were performed for medical and nonmedical health workers. all hypotheses were tested at a significance level of . . data analyses were run via sas statistical software, version . (sas institute inc.). nationwide, a total of , participants from china (see online supplement ; for all online suppl. material, see www.karger.com/doi/ . / ) completed the survey. table presents sociodemographic features of the whole sample and compared medical health workers ( medical doctors and nurses) to , nonmedical health workers. medical health workers showed higher prevalence rates of insomnia ( . vs. . %, p < . ), anxiety ( . vs. . %, p < . ), depression ( . vs. . %; p = . ), somatization ( . vs. . %; p < . ), and obsessive-compulsive symptoms ( . vs. . %; p < . ) than nonmedical health workers. medical health workers also had higher total scores of isi (p < . ), gad- (p < . ), phq- (p = . ), and on the scl- -r obsessive-compulsive symptom scale (p < . ) than nonmedical health workers. each item of isi (p < . or p < . ), gad- (p < . ), and phq- (p = . ) was significantly elevated in medical health workers compared with nonmedical health workers. on the scl- -r obsessive-compulsive symptom scale, of the items had higher scores in medical health workers than in nonmedical health workers. in the scl- -r somatization symptoms scale, of items, including questions (headaches) (p = . ), (faintness or dizziness) (p < . ), and (trouble getting your breath) (p < . ), had higher scores in medical health workers than in nonmedical health workers. no difference on phobic anxiety between both groups was found ( table ) . the multivariate logistic regression analyses ( medical health workers during the covid- epidemic had high prevalence rates of severe insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms. they also had risk factors for developing insomnia, anxiety, depression, obsessive-compulsive symptoms, and somatization. thus, the presence of these symptoms in addition to the life status of daily fighting against covid- suggests that they must cope with psychological distress and are at risk of allostatic overload [ ] . indeed, according to clinimetric criteria, allostatic overload can be diagnosed in the presence of a current identifiable source of distress in the form of recent life events and/or chronic stress; the stressor is judged to tax or exceed the individual coping skills when its full nature and full circumstances are evaluated. in addition, the stressor is associated with difficulty in falling asleep, restless sleep, early morning awakening, lack of energy, dizziness, generalized anxiety, irritability, sadness, demoralization; significant impairment in psychother psychosom doi: . / social or occupational functioning; and feeling overwhelmed by the demands of everyday life [ ] . the reasons for the psychological distress to which medical health workers were exposed might be related to the many difficulties of being safe at work, such as the initially insufficient understanding of the virus, the lack of prevention and control knowledge, the long-term workload, the high risk of exposure to patients with covid- , the shortage of medical protective equipment [ , ] , the lack of getting rest [ ] , and the exposure to critical life events [ ] , such as death. exemplifications of such a distress are: ( ) of the nurses at the pohang medical center in north gyeongsang province resigned due to overwork among the covid- epidemic [ ] ; ( ) > , medical health workers in (wuhan) hubei province were infected with covid- at a very early stage (before and in january of ). later, with continuously updated guidelines on how to handle the patients with covid- [ ] , with rest in shifts for medical staff, with rapid supply of medical protective items (including masks, glasses, and suits), and with training on the novel coronavirus infection pneumonia diagnosis and treatment plan for all medical staff [ ] , no doctors have been infected with covid- among about , medical personnel from the nation supporting hubei medical services [ ] ; and ( ) as of the th march, medical health workers in one hospital of wuhan died due to being infected with covid- [ ] . our report found potential risk factors for medical health workers to develop insomnia, anxiety, depression, obsessive-compulsive symptoms, and somatization. undoubtedly, these risk factors might endure allostatic overload and favor the development of psychopathology, including chronic insomnia [ ] . independent factors (i.e., currently having organic disease, living in rural areas, being at risk of contact with covid- patients in hospitals, or being female) were common risk factors for insomnia, anxiety, depression, and obsessive-compulsive symptoms among medical health workers. when faced with the same covid- during the fight against the epidemic, medical health workers in rural areas might worry about being infected due to a different working place involving different medical skills and medical conditions. in contrast, the medical conditions in urban areas were often much better. thus, different directions on caring for the medical health workers might be possible. adequate working conditions and recovery programs, i.e., programs favoring activities required to ensure the best physical, mental, and social conditions so that medical workers may progress towards an optimal state of health [ ] , seem necessary. this may support medical staff in adapting to the working environment quickly and maintain a better mental and health balance to be able to work. lowering job demands and workload [ ] , while increasing job control and reward might help to protect medical health workers. individual interventions adequate for medical staff in the current situation, where they wear medical protective equipment which cannot be removed during work time, are still unknown. story sharing [ ] would be important as well as reinforcing the positive assets of persons [ ] . simple, easy, practical methods are needed. electronic devices, such as mobile phones and computers, may help. the present study has limitations. first, a cross-sectional design was applied although a longitudinal approach might help verifying whether allostatic overload develops (exhaustion may ensue after some time) and whether psychiatric disorders, especially posttraumatic stress disorder, might occur with the covid- progression. second, psychological assessment was based on an online survey and on self-report tools. the use of clinical interviews is encouraged in future studies to draw a more comprehensive assessment of the problem. third, it is not possible to assess the participation rate since it is unclear how many subjects received the link for the survey. in conclusion, a higher prevalence of psychological symptoms was found among medical health workers during covid- as well as risk factors for them. medical health workers are in need of health protection and adequate working conditions, e.g., provision of necessary and sufficient medical protective equipment, arrangement of adequate rest, as well as recovery programs aimed at empowering resilience and psychological well-being [ ] . world health organization who characterizes covid- as a pandemic early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia covid- : too little, too late? lancet covid- : surge in cases in italy and south korea makes pandemic look more likely world health organization who statement on cases of covid- surpassing china medical treatment expert group for covid- . clinical characteristics of coronavirus disease in china a pneumonia outbreak associated with a new coronavirus of probable bat origin remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro clinical characterization of allostatic overload. psychoneuroendocrinology -ncov epidemic: address mental health care to empower society the mental health of medical workers in wuhan, china dealing with the novel coronavirus online mental health services in china during the covid- outbreak beijing: central steering group: over , medical staff in hubei were infected in the early stage of the epidemic, currently no infection reports among medical aid staff the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. sleep (basel) comparing the effects of mindfulness-based cognitive therapy and sleep psycho-education with exercise on chronic insomnia: a randomised controlled trial a -item measure of depression and anxiety: validation and standardization of the patient health questionnaire- (phq- ) in the general population symptom check list (scl- ) re-testing reliability, validity, and norm applicability of scl- psychological results of patients with persisting gastroesophageal reflux disease symptoms by symptom checklist -revised questionnaire the effect of e-aid cognitive behavioral therapy in treating chronic insomnia disorder: an open-label randomized controlled trial. zhonghua jing shen ke za zhi value of patient health questionnaires (phq)- and phq- for screening depression disorders in cardiovascular outpatients reliability and validity of gad- and gad- for anxiety screening in cardiovascular disease clinic world health organization shortage of personal protective equipment endangering health workers worldwide hubei had more than , medical infections, and the wuhan health and medical committee reported "none" for half a month evaluating life events and chronic stressors in relation to health: stressors and health in clinical work london: coronavirus: doctors collapse from exhaustion as virus spreads through south korea beijing: two departments issue the novel coronavirus infection pneumonia diagnosis and treatment plan wuhan central hospital, infected with covid- , died, totally five died in the hospital effect of transcranial alternating current stimulation for the treatment of chronic insomnia: a randomized, doubleblind, parallel-group, placebo-controlled clinical trial rehabilitation in endocrine patients: a novel psychosomatic approach a systematic review including meta-analysis of work environment and burnout symptoms sharing a traumatic event: the experience of the listener and the storyteller within the dyad well-being therapy: treatment manual and clinical appliatios current psychosomatic practice the authors would like to thank all participants for their time and excellent cooperation. the authors declare that they have no conflicts of interests. all participants provided their online informed consent. the study was approved by the local ethics committee on human research. key: cord- -upnqi f authors: platt, lucy; elmes, jocelyn; stevenson, luca; holt, victoria; rolles, stephen; stuart, rachel title: sex workers must not be forgotten in the covid- response date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: upnqi f nan as countries maintain or adjust public health measures, emergency legislation, and economic policies in response to the covid- pandemic, there is an urgent need to protect the rights of, and to support, the most vulnerable members of society. sex workers are among the most marginalised groups. globally, most direct sex work has largely ceased as a result of physical distancing and lockdown measures put in place to halt transmission of severe acute respiratory syndrome coronavirus (sars-cov- ), potentially rendering a frequently marginalised and economically precarious population more vulnerable. most sex workers, even those who can move their work online, have been financially compromised and some are unable to stop in-person services. it is imperative that sex workers are afforded access to social protection schemes as equal members of society. as with all aspects of health, the ability of sex workers to protect themselves against covid- depends on their individual and interpersonal behaviours, their work environment, the availability of community support, access to health and social services, and broader aspects of the legal and economic environment. , stigma and criminalisation mean that sex workers might not seek, or be eligible for, government-led social protection or economic initi atives to support small businesses. police arrests, fines, violence, disruption in aid by law enforcement, and compulsory deportation have been reported by sex workers across diverse settings, fuelling concerns that the pandemic is intensifying stigma, discrimination, and repressive policing. , sex workers who are homeless, use drugs, or are migrants with insecure legal or residency status face greater challenges in accessing health services or financial relief, which increases their vulnerability to poor health outcomes and longer-term negative economic impacts. , increased prevalence of underlying health conditions among sex workers might increase risk of covid- progressing to severe illness. demand for shelter and supported housing has increased as sex work venues have been shut down or rental payments default through loss of income. existing mental health problems are likely to be exacerbated by anxiety over income, food, and housing, alongside concerns about infection from continuing to work in the absence of social protection. risk of infection with sars-cov- is heightened for those who share drug paraphernalia for drug use. alternative ways of maintaining or extending treatment and drug substitute prescribing are important to save lives in places where services are closed or restricted or there are staff shortages due to sickness. there is scarce reliable evidence of the risk of infection or complications of covid- among people living with hiv, although the risk could be greater among those who are immunocompromised and not on hiv treatment. review evidence suggests, on average, use of antiretroviral therapies is already low among sex workers who are hiv positive in high-income and low-income settings. it is crucial that disruption to health services does not further reduce access to hiv treatment and prevention or to vital services addressing domestic or other forms of violence. , mathematical models suggest that even with widespread testing and contact tracing, in the absence of a covid- vaccine, physical distancing will be a key intervention to prevent community transmission globally. early modelling that informed physical distancing policies did not account for the needs of all interventions and services must be designed and implemented in collaboration with sex-worker-led organisations. illegal or uncertain residency status • immediate cessation of arrests, raids, and prosecutions for sex work and minor drug-related offences, and long-term reform of policies and laws that have been shown to be harmful to health • provision of emergency housing to those who are homeless, moratorium on evictions, and assistance with rent or mortgage repayments for those in need vulnerable populations, or their access and adherence to official guidance. population-level gains, such as a reduction in hospital admissions and mortality, are likely to be intangible for marginalised populations for whom the immediate negative effects of physical distancing could be substantial. the inability to work, reduced access to health services, and increased isolation are likely to result in poorer health outcomes and increased inequalities, particularly where individuals are largely excluded from formal social protection schemes. sex worker organisations have rapidly responded to covid- by circulating hardship funds; helping with financial relief applications; advocating for governments to include sex workers in the pandemic response; calling for basic labour rights to facilitate safer working conditions; and providing health and safety guidance for those moving online or unable to stop direct services. worldwide, government initiatives have included supplying food packages to sex workers in bangladesh, the provision of emergency housing in england and wales, and the inclusion of sex workers in financial benefits in thailand, the netherlands, and japan. yet these schemes often exclude the most marginalised, including those who are homeless, transgender, or migrants. , there is a critical need for governments and health and social care providers to work with affected communities and front-line service providers to co-produce effective interventions. examples of necessary interventions are described in the panel. existing sex worker organisations provide an essential foundation for community health work and in collaboration with health services they can facilitate, and ensure the appropriateness of, community testing and contact tracing as well as maximising the uptake of potential future covid- vaccines or treatments. achieving healthier communities and controlling covid- requires a collective and inclusive response. resources and support for sex workers need to be prioritised. involvement of communities in social protection schemes, health services, and information will enable sex workers to protect their health during this pandemic as equal citizens, in line with principles of social justice. reforms of social and legal policies, including decriminalisation of sex work, can reduce discrimination and marginalisation of sex workers and enable provision of vital health and social services. this need becomes more acute as existing health and social challenges are exacerbated by the covid- crisis. we declare no competing interests. transform drug policy foundation, bristol, uk (sr); and school of social policy sex workers rights advocacy network. swan statement on covid- and demands of sex workers. sex workers rights advocacy network, . unaids. covid- responses must uphold and protect the human rights of sex workers associations between sex work laws and sex workers' health: a systematic review and meta-analysis of quantitative and qualitative studies hiv infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed refugee and migrant health in the covid- response regional updates covid- migrant sex workers and sex worker responses. the european network for the promotion of rights and health among migrant sex workers testing for latent tuberculosis infection using interferon gamma release assays in commercial sex workers at an outreach clinic in birmingham active or latent tuberculosis increases susceptibility to covid- and disease severity burden and correlates of mental health diagnoses among sex workers in an urban setting emcdda update on the implications of covid- for people who use drugs (pwud) and drug service providers who. q&a on covid- , hiv and antiretrovirals antiretroviral therapy uptake, attrition, adherence and outcomes among hiv-infected female sex workers: a systematic review and meta-analysis covid- strategy update special report: the simulations driving the world's response to covid- individuals and populations: the strategy of preventive medicine transcending the known in public health practice sex-workers' resilience to the covid crisis: a list of initiatives rights in the time of covid - . lessons from hiv for an effective, community-led response project viva: a multilevel communitybased intervention to increase influenza vaccination rates among hard-toreach populations in new york city examining and challenging the everyday power relations affecting sex workers' health key: cord- - lady pc authors: callander, denton; meunier, Étienne; deveau, ryan; grov, christian; donovan, basil; minichiello, victor; kim, jules; duncan, dustin title: investigating the effects of covid- on global male sex work populations: a longitudinal study of digital data date: - - journal: sex transm infect doi: . /sextrans- - sha: doc_id: cord_uid: lady pc objectives: recommendations of ‘social distancing’ and home quarantines to combat the global covid- pandemic have implications for sex and intimacy, including sex work. this study examined the effects of covid- on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work. methods: this study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. website engagement metrics were calculated for the periods before (september to december ) and during covid- (january to may ); poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus. results: data were collected from profiles representing individuals. in the ‘before’ period, the number of active profiles was stable (inter-rate ratio (irr)= . , % ci . to . , p= . ) but during covid- decreased by . % (irr= . , % ci . to . , p< . ). newly created profiles also decreased during covid- ( . %; irr= . , % ci . to . , p< . ) after a period of stability. in total, unique profiles explicitly referenced covid- ; ( . %) evoked risk reduction strategies, including discontinuation of in-person services ( . %), pivoting to virtual services ( . %), covid- status disclosure ( . %), enhanced sanitary and screening requirements ( . %) and restricted travel ( . %). some profiles, however, seemed to downplay the seriousness of covid- or resist protective measures ( . %). conclusions: these findings support the contention that covid- has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. targeted education and outreach are needed to support male sex workers grappling with covid- , including around the most effective risk reduction strategies. those involved with the sex industry must have access to state-sponsored covid- financial and other aid programmes to support individual and public health. objectives recommendations of 'social distancing' and home quarantines to combat the global covid- pandemic have implications for sex and intimacy, including sex work. this study examined the effects of covid- on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work. methods this study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. website engagement metrics were calculated for the periods before (september to december ) and during covid- (january to may ); poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus. results data were collected from profiles representing individuals. in the 'before' period, the number of active profiles was stable (inter-rate ratio (irr)= . , % ci . to . , p= . ) but during covid- decreased by . % (irr= . , % ci . to . , p< . ). newly created profiles also decreased during covid- ( . %; irr= . , % ci . to . , p< . ) after a period of stability. in total, unique profiles explicitly referenced covid- ; ( . %) evoked risk reduction strategies, including discontinuation of in-person services ( . %), pivoting to virtual services ( . %), covid- status disclosure ( . %), enhanced sanitary and screening requirements ( . %) and restricted travel ( . %). some profiles, however, seemed to downplay the seriousness of covid- or resist protective measures ( . %). conclusions these findings support the contention that covid- has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. targeted education and outreach are needed to support male sex workers grappling with covid- , including around the most effective risk reduction strategies. those involved with the sex industry must have access to state-sponsored covid- financial and other aid programmes to support individual and public health. the global covid- pandemic has dramatically reshaped awareness of and approaches to public health, with health institutions around the world recommending measures like social distancing and self-isolation to slow spread of the virus. the exact mechanisms of covid- transmission are still being clarified and while it has not, in any official sense, been classified as an sti, the intimate physical contact associated with much sexual activity has implications for transmission of the virus. as a result, a number of public health bodies have published guidelines recommending that, among other precautions, individuals limit sex with new and casual partners to reduce covid- transmission risk. while these recommendations have implications for people's personal sexual and romantic lives, social distancing and self-isolation also have implications for sex workers; no empirical work has yet examined the effects of covid- on populations involved with sex industry. although research has yet to examine the effects of covid- on sex work, numerous journalistic and opinion pieces in mainstream media (many of them written by sex workers themselves) have sought to highlight challenges facing the industry, most notably serious economic hardship. [ ] [ ] [ ] [ ] [ ] further, brothels and sex on premises venues have been closed in many parts of the world -with reports of some facing fines for remaining open affecting working arrangements and opportunities for some sex workers. in what has been characterised as a reaction to diminishing opportunities for in-person sex work, journalists have documented rising popularity of virtual sex work services like webcamming. although some have advocated for sex work to be considered an 'essential service' and, therefore, excluded from restrictions on movement and work, given the risks that physical intimacy poses for the transmission of covid- , from a health perspective it seems dangerous for sex workers to provide in-person services while the pandemic continues to threaten public health in many parts of the world. a major challenge to sex workers enacting social distancing and self-isolation, however, is that in many countries they have been excluded from large financial stimulus and support packages proposed in support of individuals and businesses. [ ] [ ] [ ] it seems likely that such exclusions are driven or at least compounded by the criminalisation of sex work in many parts of the world. further, some behaviour have also speculated that covid- -related job loss and economic strife may lead people to try making money through sex work. although journalists and media pundits seem eager to write about sex work as it relates to covid- , data are needed to better understand the pandemic's effects on the industry. this information is essential for highlighting the ways in which government policies, healthcare and other services can best support sex workers who may be at increased risk of the virus as well as economic strain; there are covid- prevention implications for the clients of sex work as well. in most of the world, sex work is criminalised and endures considerable social stigma. as such, direct research with sex workers is rare, usually qualitative and involves small samples in limited geographies. for the male sex industry, online data offer an opportunity to investigate sex work indirectly but with incredible breadth, which is afforded by the hundreds of thousands of individual men in every part of the world who advertise sexual services online. the online profiles of male sex workers provide a powerful source of data that can be used to investigate the sociobehavioural effects of covid- , building on existing methods developed to study hiv and sti-related behaviours and norms among those involved with sex work. this paper documents the findings of a mixed methods longitudinal analysis of the effects of covid- on male sex work internationally. for the period september to may , a longitudinal study of ecological digital data pertaining to sex work was undertaken. in august , a database comprising deidentified data extracted from online profiles maintained by male sex workers on a large, international website was established. on the first day of each month, customisable digital data 'scraping' software known as import. io automatically extracts, standardises, deidentifies and archives information contained within each profile's categorical fields (eg, age, location, services offered), automatically generated profile details (eg, creation date, visit count) and free-text sections (eg, headline, 'about me' section) (import. io, california, usa, ). no contact details or photographs were extracted, and all profile text was cleaned of any potentially identifiable information prior to analysis. no eligibility or restriction criteria were placed on profile data. to assess the effects of covid- on male sex work online, the following measures were calculated for each month of data collection: ( ) number of active profiles, ( ) number of new profiles, ( ) number of inactive profiles, ( ) the average number of visits per profile per day, and ( ) proportion of profiles offering virtual sexual services (eg, webcamming, phone sex). the number of 'inactive' profiles was defined as the number of profiles active in a month but not the month following, while the average number of visits per profile was calculated as a rate per day for the prior month (ie, 'visits' reported in april actually reflect the march period). for these reasons, indicators were calculated from september to may to allow a month grace period during which to calculate the retrospective measures. profiles were identified over time using their uniquely assigned profile codes and url addresses. two distinct analyses were conducted, combining qualitative and quantitative methods. changes over time to each measure of online activity were assessed via poisson regression analyses with month fitted as an independent variable; inter-rate ratios (irr) and confidence intervals (ci) were calculated for each. poisson regression is a robust and efficient statistical test for working with frequency data. for mean-based and proportional measures we used linear regression analyses with month as the independent variable. for each measure, the analysis was separated into two time periods relative to the covid- pandemic: before (september to january ) and during (january to may ). further, the free-text sections of male sex work profiles were analysed for any references to covid- ; a content analysis using the techniques of thematic analysis was employed to define profile users' engagement with the virus and conduct frequency analyses. for profiles referencing covid- and appearing in multiple monthly extractions, those with unchanged text over time (ie, duplicates) were treated as a single profile while profiles with language related to covid- that changed from month to month were treated separately. this approach recognised that male sex workers can adjust their profiles and, given the ongoing nature of the pandemic during the study period, may have altered their response to covid- over time. this analysis relied on publicly accessible data that were deidentified; as such, it was exempt from review by the institutional review board of columbia university. stakeholders representing communities of sex workers, however, were consulted on the design of this study and interpretation of the results. to further protect the online identities of male sex workers, quotations shared in this paper have been modified slightly to ensure that search engines cannot be used to identify individual profiles. during the months of study data, data points were collected representing individual profiles. at each profile's first appearance during the study period, the selfreported age of users ranged from to years old (m= . , sd= . ). male sex workers included in our analysis were based around the world but primarily in north america ( . %), europe ( . %) and asia ( . %) and, to a lesser extent, the oceania ( . %), south american ( . %) and african ( . %) regions. in terms of race and ethnicity, male sex workers used the website's fixed categorical options to self-describe as 'caucasian' ( . %), 'latin' ( . %), 'asian' ( . %), 'mixed' ( . %), 'black' ( . %), 'mediterranean' ( . %), 'other' ( . %), 'arab' ( . %) and 'native american' ( . %). our primary outcome measures are presented in figure and reported in online supplementary appendix a, all of which demonstrated changes that appeared to be associated with covid- . the total number of active profiles remained stable in the 'before' period (ie, september to january ; irr= . , % ci . to . , p= . ) but decreased by . , p< . ). the average number of views per profile per day also decreased during the covid- period after a period of stability in the months prior, decreasing by . % from january to may (f= . , β=− . , p< . ; figure ). similarly, while no trends were observed in the proportion of male sex work profiles offering virtual services (eg, webcamming, phone sex) before covid- (f= . , β= . , p= . ), this measure increased from . % in january to . % in may (f= . , β= . , p< . ). in march , only three profiles contained any reference to covid- ( . %) but this increased to profiles ( . %) in april and profiles ( . %) in may. after removing profiles duplicated across months and also profile content (ie, profiles with references to covid- that were unchanged from month to month), a total of unique profiles referenced covid- at some point during the study period. individual male sex workers based in the regions of north america ( . %) and oceania ( . %) were more likely than others to reference the virus (p< . ) while the average age of male sex workers who explicitly referenced covid- was higher than those without any reference ( . vs . years, p< . ). analysing the content of profiles that referenced covid- , we defined two themes of engagement: ( ) risk reduction and ( ) social reactions (table ). . risk reduction strategies were outlined in of the unique profiles that referenced covid- ( . %), which mainly focused on describing the ways in which male sex workers were enacting public health recommendations and trying to minimise transmission risk for themselves or their clients. most commonly, . % of profiles advised of discontinued in-person services. 'social distancing is sexy', as one profile headline read. some profiles advised of virtual services on offer specifically because of covid- concerns ( . %), including . % of men who chose to discontinue behaviour in-person work (eg, 'because of social distancing and selfisolation, only phone and video meetings at this time'). other profiles self-disclosed covid- status as 'negative' ( . %) with some every providing the date their test was carried out, while several profiles ( . %) described enhanced protocols for clients, which included requirements like temperature checks, the provision of hand sanitiser and even one profile that claimed to offer, 'on-site covid- testing', despite such technologies not being available to the general public during the study period. in other cases, male sex workers referenced enhanced screening protocols but provided no further details. a number of profiles also advised that male sex workers were restricting or cancelling any work-related travel ( . %), for example: 'due to corona virus all future travel is cancelled, and clients will be refunded their deposits' (table ). . social reactions were displayed on unique profiles ( . %) maintained by male sex workers, which mainly involved some kind of comment on covid- reflecting the circumstances generally or specific to sex work. as outlined in table , several profiles voiced solidarity for the sex work and broader communities ( . %; eg, 'unavailable until the covid- crisis is resolved: stay safe, stay strong'). other profiles ( . %) shared sentiments that seemed to resist the public discourse of the time that stressed the seriousness of covid- . such dismissals manifested through humour (eg, 'hit me up boys, i'll take a salt and lime with my corona'), discounted rates, and offerings of pandemic-tailored services (eg, 'i'm here if you need a good shag in your quarantine'). following the rise of covid- as a global pandemic in the early months of , there was a significant decline in global activity on one of the world's largest and most popular english-language websites for male sex work. particularly in north america and europe, since the start of the pandemic the number of male sex workers advertising on a popular and highly trafficked website decreased substantially as did the amount of visitor traffic to the profiles that remained. we observed some male sex workers engaging directly with covid- via their online profile. most commonly, men used their profile text to advise of discontinued in-person sex work services while pivoting to the provision of virtual options and the overall proportion of profiles offering virtual services increased slightly during the covid- period. aside from the discontinuation of in-person sex work, some profiles shared other approaches to covid- risk reduction. notably, we observed male sex workers disclosing their covid- status and, in some cases, providing the date of test, a finding that calls to mind practices around hiv status disclosure. hiv prevention efforts have long promoted regular testing and status disclosure as important health initiatives among populations of sex workers and others and the fact that male sex workers would seek to adapt these kinds of strategies to face the emerging threat of covid- suggests their attention to and engagement in public health issues. indeed, previous work has suggested that sex workers are often more engaged with public health concerns than the general population. [ ] [ ] [ ] while it is promising that sex workers were engaged in finding ways of protecting themselves and their clients, it is unclear if some of the strategies described (eg, temperature checks) would be sufficient to prevent covid- transmission. the deployment of potentially ineffective risk reduction strategies likely reflects uncertainty and confusion among the general public amid an ongoing public health emergency. given the intimate contact associated with sex work, however, targeted resources and outreach efforts to help sex work communities understand the most effective risk reduction strategies in the face of viral pandemics such as covid- should be made available to support better preparedness now and into the future. there is evidence that sex work support organisations have already started to distribute targeted educational resources, but ongoing effort is required to ensure meaningful dissemination of the most recent and evidencebased information. as mentioned, many sex workers globally rely on sex work as a form of income. although the number of active profiles decreased significantly during the study period, as of april the total number remained relatively high. while it was clear from the text of several profiles that some male sex workers were maintaining their profiles to only accept future bookings or provide virtual services, for others it may be that they could not do without the income generated by sex work. along with declining profile views, men who continue selling sex during the covid- pandemic may be doing so because of few economic alternatives, a contention that aligns with much reporting in mainstream media to date. [ ] [ ] [ ] [ ] [ ] further, given that we documented a decline in newly established male sex work profiles, media reports that other forms of economic hardship may be driving an uptick in those involved in sex work seem unfounded. this analysis provides an assessment of the effects of covid- on male sex work globally. our findings, however, are limited by the fact that the website from which data were drawn is predominantly english language. although data were extracted from profiles in every region of the world, care should be taken in generalising our results; it is also possible that male sex workers operating on other websites may have had different reactions to covid- . similarly, male sex workers who operate online often have different practices and needs than those who operate in other spaces; given that street-based sex workers typically face greater substance use and financial hardship than their peers online, [ ] [ ] [ ] their needs in terms of covid- are likely greater and more complex. specific research on and attention to street-based sex workers and covid- is needed. further, at the time this analysis was conducted covid- remained a serious and ongoing public health emergency, which means that ongoing health surveillance of behaviours and norms is needed to monitor future effects of covid- on sex work. the economic hardships faced by male sex workers are likely compounded by the criminalisation of sex work (enca, ). criminalisation and explicit policy directives currently work to exclude sex workers from opportunities for state-sponsored financial aid, [ ] [ ] [ ] which would in turn make it very difficult for some to reduce or discontinue in-person services. given that intimate physical contact significantly increases the risks of covid- transmission, it is alarming that some sex workers may be forced to choose between their health and their income. while it may be tempting to pass judgement or think harshly of male sex workers who continue to work while the pandemic endangers public health and causes considerable social turmoil, it seems logical that social distancing and self-isolation can only be implemented if these men have access to the financial and social support programmes offered to workers in other industries. attention must also be paid to the immediate and long-term effects of social distancing programmes-active already for several months in some areas and mired with uncertainty about if, how and when they will be discontinued-on male sex workers behaviour and others involved in the sex industry. along with the economic effects hinted at through our analysis, extended social distancing may give rise to mental health challenges for sex workers who, due to fears of social stigma and criminalisation, are unable to access the kinds of social support that can help alleviate depression, anxiety and other challenges. in the longer term, a plan is desperately needed to help sex workers return to in-person work in a way that accounts for the risks posed by covid- . to be effective, such planning must involve sex workers in its design and implementation and should be complemented by the expansion of existing financial and other aid programmes alongside targeted education and outreach campaigns to support sex work communities during and after the covid- pandemic. ► male sex work activity on a highly popular website decreased significantly during the covid- pandemic. ► male sex workers displayed numerous covid- risk reduction strategies, including the discontinuation of inperson services and promotion of virtual forms of sex work. ► targeted covid- outreach is needed to support sex workers in employing only the most rigorous risk reduction strategies. ► decreases in visitor traffic suggest that male sex workers are likely facing considerable economic hardship; programmes of state-sponsored aid must include sex work communities. world health organization. coronavirus disease (covid- ) advice for the public. geneva, switzerland: who new york city department of health. sex and coronavirus disease (covid- ). new york, ny: department of health and mental hygiene sex in the era of covid- . sydney, nsw: aids council of new south wales coronavirus fears are decimating the sex industry. new york, ny: huffpost how covid- is driving sex workers like me into crisis. new york, ny: huffpost anonymous. i'm a sex worker & coronavirus is destroying my business. new york, ny: refinery, sex workers face ruin amid virus fears, brothel closures sex workers are stressed, anxious and depressed amid covid- pandemic. new york, ny: salon coronavirus crisis: sex workers impacted, brothels told to shut unemployed legal sex workers in nevada struggling during coronavirus closures. reno, nevada: reno gazette journal sydney brothel fined for staying open. sydney, nsw: newslimited ltd sex work comes home: more of us are making and watching sexual performances online now. fewer of us are paying covid- : sex workers want to be part of 'essential service brown eus. sex workers and 'prurient' businesses excluded from disaster loans. los angeles, ca: reason porn union leader to trump: why are you screwing us out of our coronavirus stimulus check? new york, ny: the daily beast, thai government screws sex workers over , baht stimulus. phuket, thailand: the thaiger some tipped employees consider sex work amid covid- closures. peoria, il: wcbu. org wild guesses and conflated meanings? estimating the size of the sex worker population in britain a global overview of male escort websites you need a cash buffer": male sex work and condom use in the era of hiv pre-exposure prophylaxis content analysis: an introduction to its methodology disclosure of hiv status, hiv risk reduction tool kit. atlanta, ga: centers for disease control and prevention (cdcp) the use of the internet by gay and bisexual male escorts: sex workers as sex educators the incidence of sexually transmitted infections among frequently screened sex workers in a decriminalised and regulated system in melbourne rising chlamydia and gonorrhoea incidence and associated risk factors among female sex workers in australia covid- and risk reduction for sex workers. sydney, nsw: scarlet alliance australian sex workers association street workers and internet escorts: contextual and psychosocial factors surrounding hiv risk behavior among men who engage in sex work with other men client demands for unsafe sex: the socioeconomic risk environment for hiv among street and off-street sex workers you can do it from your sofa': the increasing popularity of the internet as a working site among male sex workers in melbourne the authors acknowledge the contribution of alicia singham goodwin in helping code and organise the qualitative data. the authors also acknowledge taylor harrington, ryan mcnally and the staff of import.io for their assistance in establishing the profile database extraction processes. contributors dc conceived this analysis along with em. dc, vm, bd and rd conceived the idea for the database. rd developed and oversaw the processes of data extraction. data analysis was conducted by dc with support from em and dd. cg, vm and bd provided topical guidance, while jk guided interpretation of the study's implications from a policy and practice perspective. all authors contributed to the manuscript's creation, providing numerous reviews and signing off on the final version.funding funding for the database from which this study draws was provided by a project grant from the australian research council (dp ). patient consent for publication not required.ethics approval this study used publicly-available, de-identified data. as such, it was classified as non-participant research and exempt from ethical review.provenance and peer review not commissioned; externally peer reviewed. data availability statement data are available upon reasonable request.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. denton callander http:// orcid. org/ - - - Étienne meunier http:// orcid. org/ - - - key: cord- -hz qj fw authors: viterbo, lilian monteiro ferrari; costa, andré santana; vidal, diogo guedes; dinis, maria alzira pimenta title: workers’ healthcare assistance model (wham): development, validation, and assessment of sustainable return on investment (s-roi) date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: hz qj fw the present study aimed to present and validate the worker´s healthcare assistance model (wham), which includes an interdisciplinary approach to health risk management in search of integral and integrated health, considering economic sustainability. through the integration of distinct methodological strategies, wham was developed in the period from to , in a workers’ occupational health centre in the oil industry in bahia, brazil. the study included a sample of workers, . % of which were men, with a mean age of . years (age ranged from to years). the kendall rank correlation coefficient and hierarchical multiple regression analysis were used for the validation of wham. the assessment of sustainable return on investment (s-roi) was made using the wellcast roi™ decision support tool, covering workers with heart disease and diabetes. wham can be considered an innovative healthcare model, as there is no available comparative model. wham is considered robust, with % health risk explanatory capacity and with an . % s-roi. it can be concluded that wham is a model capable of enhancing the level of workers’ health in companies, reducing costs for employers and improving the quality of life within the organization. more than ever, life, as we know, will never be the same. the world is currently experiencing the coronavirus pandemic (covid- ) [ ] , an unforeseeable health development that is affecting the entire global population, and consequently healthcare assistance models across the globe. there is now an urgent need to look at human health through the "one health" lens [ ] , to design and implement programs, policies, legislation, and research in a cooperative manner among all sectors of society to achieve better public health outcomes. in addition to the recognition of the success of the current healthcare models in the relief of pain and the treatment of multiple pathologies, several criticisms are gaining support, pointing out the limitations relating to the attention to patient health. these issues include approaches that take an undifferentiated view of the individual, which is focused exclusively on the part of the body that is sick; the focus on the curative actions of diseases, injuries, and damages; the advancement of medicalization; and the generalization of hospital care using technology. in the past, if a medical doctor was seen as a figure possessing the knowledge necessary to cure the patient, nowadays that figure is seen as one part of a team, with the patient being the final decision-maker in their health outcomes. the world health organization has chosen to strengthen people-centred care and integrated health services as priority strategies to transform health services to meet the health challenges of the st century [ ] . this favours the emergence of integrated care models, which are seen as possible solutions to the growing demand for improvement in the patient experience, especially in patients with chronic conditions. considering economic sustainability in the search for integral and integrated health, this study aims to present and validate a model of workers' healthcare, the workers´healthcare assistance model (wham), which embraces an interdisciplinary approach towards health risk management. in light of the literature review, the following three research hypotheses were formulated: hypotheses (h ). wham promotes integral and integrated care; hypotheses (h ). wham is robust and has greater explanatory capacity for workers' health risks; hypotheses (h ). wham is economically sustainable and provides a significant return on investment. a review of the literature in the field of occupational health highlights discussions relating to "assistance models", a term that varies based on the conceptualization, which can include "assistance modalities or technological models" [ , ] ; "ways to promote health" [ ] ; "assistance models" [ , , ] ; "technical, techno-assistance, and technical assistance models" [ , ] ; "modes of intervention" [ ] ; "attention models" [ ] [ ] [ ] ; and "care models". the result of this diversity of terms is the already identified difficulty in conceptualizing assistance models. healthcare assistance models are understood as technological combinations with different purposes, which are used to solve problems and meet needs within a given context and population and in a given territory (individuals, groups, or communities), to organize health services or to intervene in situations, depending on the epidemiological profile and investigation of health problems and risks [ ] . these logical systems organize the functioning of care networks, articulating the relationships between network components and health interventions. in turn, these are defined according to the prevailing view of health, demographic and epidemiological situations, and social determinants of health at a given time and in a given society and place [ ] . according to campos [ , ] , the conceptualization of an assistance model, technological model, or assistance modality must go beyond mere organizational and technical design, showing a new way of producing assistance actions anchored in the organization of the state. according to silva [ ] , biomedicine has become the hegemonic model in the provision of health services in brazil and other countries around the world, influenced by accumulated knowledge and the paradigm of science. in this process, the daily requirements in the health sector stand out, such as the relationships between people; the involvement and co-responsibility of managers, health professionals, and patients in healthcare; as well as the bond, reception, and humanization of healthcare assistance practices [ ] . from a technological point of view, there is a predominance of the use of the so-called "hard technologies" (equipment), to the detriment of light technologies (professional-patient relationships) [ , ] . thus, diagnostic tests are a priority, but patients are not necessarily considered in terms of their suffering. this approach has been the target of criticism at the international level, starting from the s and gaining greater importance in the second half of the s [ , ] . in terms of the biomedical model, there is a certain neglect of the importance of the determinants of the health-disease process; that is, the focus on the disease and not on the elements that contribute to health promotion, underestimating that cultural, ethical, and social aspects condition lifestyles and that these are also determinants in the same process [ , , ] . merhy [ ] contributes to the debate about the need to change the hegemonic assistance model, arguing that it is necessary to impact the core of care. in this sense, it is necessary to invest in relational-type light technologies, focusing on the needs of users and reversing the investment in hard or light-hard technologies, which can be translated into standards, equipment, and materials. thus, light technologies are used and combined with people and resources to achieve certain objectives, which are gathered in an organized manner and consolidated as essential elements of health services [ ] . regardless of the scope, health services are always complex. the processes are standardized by regulatory bodies, service providers, and class representatives, among others. they have highly specialized and qualified workers who, belonging to different class councils, have interests that do not always converge [ ] . team composition characteristics in health services must be highlighted, recognizing these team members as the main actors responsible for the implementation of technologies aligned to a healthcare assistance model. faria [ ] draws attention to the fact that actions performed in a given place to deal with a certain problem may not apply to other situations, considering the historical-political context that influences a situation. therefore, the use of healthcare assistance models invariably requires the selection of certain constructs that support them. thus, they can be used in an alternative or adapted way, as long as they enable the achievement of similar results. to incorporate new health needs, healthcare assistance models can be considered to have influenced the organization of care models, being more focused on specific populations, such as the chronically ill. a comprehensive care model defines how health services are offered, providing the best care and service practices for a person or population group as they evolve through a condition, injury, or event, aiming for people to receive the right care, at the right time, by the right team, and in the right place [ ] . the field of occupational health is a fertile environment for the development of interdisciplinary practices [ ] [ ] [ ] [ ] , as it encompasses knowledge from different disciplines, requiring constant and complex interactions between professionals in the fields of epidemiology, the environment, engineering, and healthcare, among others. the framing of occupational health in a biomedical healthcare assistance model favours the development of disjointed and ineffective interventions regarding the needs presented by workers, while the biopsychosocial model is often used in their work environments. according to annadale [ ] , the biomedical healthcare assistance model only focuses on the physical processes, i.e., the pathology, biochemistry, and physiology of a disease, neglecting the roles of social factors or individual subjectivity. in this context, it is necessary to discuss a model of assistance in occupational health that is capable of reviewing the central characteristics of the biomedical healthcare assistance model, including: (i) organization of practices focused on the identification of signs and symptoms and the treatment of diseases, with health promotion not being a priority; (ii) assistance is organized based on individual spontaneous demand, with an emphasis on specialization and the use of hard technologies; (iii) the work is developed in a fragmented, hierarchical manner and with inequality across different professional categories; (iv) difficulty in implementing the integrated care due to the lack of understanding of the individual as a multidimensional human being, as well as the lack of communication and integration between the services involved; (v) health planning is seldom used as a management tool; (vi) the training of health professionals is specialized, based on the hegemony of scientific knowledge; and (vii) themes such as interdisciplinary, people-centered care, attachment, and welcoming are not prioritized. another aspect of great relevance in the current global context of scarcity of resources, particularly in the current context of covid- , is the prioritization of investments ineffective, integral, and integrated interventions, which can be achieved through a model that contemplates the management of occupational health risks, considering the social health determinants [ , ] , global disease burden [ ] , environmental aspects [ , ] , sustainable development goals [ , ] and in particular, working conditions that affect an individual's health [ ] . in the current context, the effectiveness of a healthcare assistance model must include economic sustainability in addition to health gains, to know how much the company has earned due to investments made in a certain area, with the sustainable return on investment (s-roi) being a very important metric for this assessment. measuring the s-roi [ ] [ ] [ ] of preventive programs is not an easy task, due to the large number of variables that influence this calculation. the main variable is patient health, which can improve or worsen unpredictably. analyzing the s-roi in preventive programs identifies the financial impact a program generates concerning the amount invested, which must be considered in the long term. disease prevention actions bring future returns, mainly to the reduction of healthcare assistance costs. if the individual participates in preventive programs, the probability of developing diseases or discovering them in advanced stages decreases. over the past years, several studies [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] have addressed this issue and there is growing evidence that workplace programs can generate acceptable financial returns for employers investing in them. a study of johnson and johnson employees [ ] showed a difference in the increase in the average annual costs of internment between workers involved and not involved in lifestyle improvement programs and changes in the workplace, representing $ and $ , respectively, thus representing a considerable increase in percentage terms. the study by munir et al. [ ] aimed to conduct a cost-benefit analysis of the stand more at work (smart) workplace intervention, designed to reduce sitting time. a net saving of $ . ( % ci; $− . ; $ . ) per employee was found as a result of productivity increase. peik and others [ ] applied the research and development (rand) europe model, a program designed to expand access to up to evidence-based clinical preventive services for all employees and eligible family members, as part of a unique global health initiative at the country level to estimate the return on investment over a five-year timeframe. the study concluded that this program generates a global return of $ . -$ . (after investment cost). gao and co-workers [ ] assessed the economic performance of a workplace-delivered intervention to reduce sitting time among desk-based workers. the incremental cost-efficacy ratios ranged from $ . /minute reduction in workplace sitting time to $ . /minute reduction in overall sitting time. the intervention was cost-effective over the lifetime of the cohort when scaled up to the national workforce, and provides important evidence for policy-makers and workplaces regarding the allocation of resources to reduce workplace sitting. the present study was carried out from to , in a workers' occupational healthcare centre in the oil industry in bahia, brazil. it involved the integration of distinct methodological strategies for the development of wham, such as the development of a conceptual model, action research, statistical validation, and s-roi analysis. the study involved two experts who had been working in the field of occupational health for fifteen years, with an emphasis on ergonomics and health management, an interdisciplinary approach, and a database composed of a population group and sample of workers, numbering and individuals, respectively (table ) . data analyses were carried out using spss version for windows (ibm corporation, new york, ny, usa). diagnostics and intervention prevalence were presented as absolute and relative frequencies. correlations among modifiable health risk factors and health outcomes were performed through the kendall rank correlation coefficient. correlations among health indicators and the interdisciplinary risk coefficients were also performed using the kendall rank correlation coefficient. hierarchical multiple regression analysis was used to calculate the independent contributions of occupational medicine interdisciplinary, dentistry interdisciplinary, physical education interdisciplinary, nursing interdisciplinary, and nutrition interdisciplinary risk coefficients, to provide an estimate of incremental variance accounting for the workers' health risk index (whri) [ ] . this index had already been published, resulting from the classification of workers into three risk ranges-"low", "moderate", and "high". the durbin-watson test was applied to detect the presence of autocorrelation at lag in the residuals (prediction errors), through which the hierarchical multiple regression analysis multicollinearity was verified. to lead the application of the wham, the "guidelines for implementing the workers' healthcare assistance model (wham)" were developed, which are presented in the supplementary materials (word s ). the "workers' healthcare assistance model" is understood as the organization of the conditions necessary to carry out a person-centred care process, about the method, staff, and instruments. the term "process" used in the context of healthcare makes it possible to identify, understand, describe, explain, and predict the needs of a person, family, or community at a given moment in the health and disease process, demanding professional care by health specialists. therefore, wham presupposes a set of actions, through certain means of action, regulated by a course of thinking; that is, through a conception of workers' health, wham's origin and its potential to transform itself or to be transformed. to compose the wham, the interdisciplinary workers' health approach instrument (iwhai) [ ] , a tool that had already been published, was used as a data collection instrument, aiming to collect data from health indicators. to map the diagnoses, the health taxonomies were used, while the whri [ ] was used to prioritize the health risks of the workers. figure shows the main stages of integrating the wham. int. j. environ. res. public health , , x of through the kendall rank correlation coefficient. correlations among health indicators and the interdisciplinary risk coefficients were also performed using the kendall rank correlation coefficient. hierarchical multiple regression analysis was used to calculate the independent contributions of occupational medicine interdisciplinary, dentistry interdisciplinary, physical education interdisciplinary, nursing interdisciplinary, and nutrition interdisciplinary risk coefficients, to provide an estimate of incremental variance accounting for the workers' health risk index (whri) [ ] . this index had already been published, resulting from the classification of workers into three risk ranges-"low", "moderate", and "high". the durbin-watson test was applied to detect the presence of autocorrelation at lag in the residuals (prediction errors), through which the hierarchical multiple regression analysis multicollinearity was verified. to lead the application of the wham, the "guidelines for implementing the workers' healthcare assistance model (wham)" were developed, which are presented in the supplementary materials (word s ). the "workers' healthcare assistance model" is understood as the organization of the conditions necessary to carry out a person-centred care process, about the method, staff, and instruments. the term "process" used in the context of healthcare makes it possible to identify, understand, describe, explain, and predict the needs of a person, family, or community at a given moment in the health and disease process, demanding professional care by health specialists. therefore, wham presupposes a set of actions, through certain means of action, regulated by a course of thinking; that is, through a conception of workers' health, wham's origin and its potential to transform itself or to be transformed. to compose the wham, the interdisciplinary workers' health approach instrument (iwhai) [ ] , a tool that had already been published, was used as a data collection instrument, aiming to collect data from health indicators. to map the diagnoses, the health taxonomies were used, while the whri [ ] was used to prioritize the health risks of the workers. figure shows the main stages of integrating the wham. the data collection stage aimed to identify health problems, as well as the efficient and targeted recording of the workers' needs in its broadest sense. for this, the iwhai [ ] was chosen. it allows structured data collection, covering the disciplines of medicine, dentistry, nursing, nutrition, and physical education, as well as environmental, occupational, behavioural, personal, and metabolic the data collection stage aimed to identify health problems, as well as the efficient and targeted recording of the workers' needs in its broadest sense. for this, the iwhai [ ] was chosen. it allows structured data collection, covering the disciplines of medicine, dentistry, nursing, nutrition, and physical education, as well as environmental, occupational, behavioural, personal, and metabolic factors. it is composed of in dimensions with indicators, totalling sub-indexes with closed response coding, where zero represents non-existent or inadequate control of risk and four represents optimal control of risk, arranged in the following scale: = non-existent or inadequate; = tolerable; = reasonable; = good; = excellent. for the diagnostics mapping stage, it was necessary to define taxonomies that encompass the complexity of the workers' health field, especially those related to the health, environment, and work triad. the following codes were used for medical, dental, nursing, nutritional, and physical education factors: (i) international classification of diseases (icd ) [ ] ; international classification of nursing practice (cipe ® ) [ , ] ; international dietetics and nutritional terminology (idnt) [ ] ; and the international classification of functioning, disability, and health (icf) [ ] . for the intervention design stage, it was necessary to define classifications that encompass proposals for interventions, which include ecological and occupational care. for each mapped diagnosis, an intervention must be associated. during the attendance of the worker, priority is given to diagnoses for health indicators that are classified as control or health conditions: = non-existent or inadequate; = poor; = reasonable. this consists of a discussion amongst the interdisciplinary health team to validate the perceptions [ ] raised by professionals in each area during the attendance of workers, sharing the diagnoses and interventions proposed by each discipline. the iwhai [ ] was used as a guiding instrument for data collection. for support of the team decisions regarding the hierarchy of priority interventions, the whri [ ] was used, allowing multidisciplinary (by dimension) and interdisciplinary (association of all dimensions) risk classifications. the classifications comprise three ranges: "low", "moderate", and "high". since % of the sample age is above years and the gender proportion of male to female is very high, the effects of these factors were controlled in this step by the whri [ ] assessment. as the workers' ages increase, the risk indicator also increases; the same happens for male and female workers for some sex-related diseases, such as the higher susceptibility by men to develop cardiovascular diseases and alcohol abuse. for this reason, when whri [ ] is applied, each worker will have two risk indicators influencing the indicators of health behaviours and outcomes: a risk indicator related to the workers' age, whereby the older the worker, the higher their risk indicator; and another risk related to their sex, whereby female or male gender will have different impacts on health behaviours and outcomes. the final whri [ ] score is mediated by the workers' age and sex. the whri [ ] dimension that has the greatest weight in the interdisciplinary context is designated as the worker case manager (wcm) and will assume technical responsibility concerning care management. the care plan (cp) is an interdisciplinary document, composed of relevant iwhai indicators with their respective diagnoses and associated interventions, in addition to the definitions of the implementation and deadline. for the implementation of the cp, the wcm must bring together the interdisciplinary intervention team (iit), ratify the cp, and proceed with the treatment of the proposed actions through interdisciplinary assistance, group work, and collective and environmental interventions. after validation of the cp by the iit, the workers are involved in discussing the cp and implementing it at the individual level. the assessment stage deals with the follow-up and monitoring of the workers to the effectiveness of the implemented health interventions. for this, it is necessary to systematically reassess the whri [ ] . the attendance took place in a single period (shift) by each member of the interdisciplinary team, with an average time of min for each consultation and a total time of . h for each worker in the health service. to validate the wham, the data collected in were used in a representative sample of the population of workers, where attendance by the interdisciplinary team occurred at the same time. through statistical tests, the intention was to identify the prevalent diagnoses and interventions, how the modifiable factors are related to health outcomes in this sample, and the impact each dimension has on the whri [ ] , i.e., if the joint use of these dimensions contributes to greater robustness and explanatory capacity of the wham. to assess the cost-benefit (cb) relationship of implementing wham, interventions directed at workers with coronary heart disease (chd) and diabetes in the period ranging from to were analyzed. the effectiveness of the intervention was based on the results of epidemiological studies over this period. brazilian national data were used to estimate the average annual benefits of preventing direct medical costs for diseases. the analytical tool wellcast roi™ [ ] , developed to justify the approval of disease prevention and management programs, was used to calculate the s-roi. for this, the following steps were taken: (i) determine the incidence of the pre-program disease; (ii) determine all costs associated with the disease, either medical costs (for chd patients, the framingham model [ ] was used to calculate incidence pre and post-program for a period of years, assuming changes in low-density lipoprotein (ldl) cholesterol, and systolic and diastolic pressure risk factors; for patients with diabetes mellitus, the reduction in the progression of diabetes comorbidities over years was calculated, based on the reduction of glycemia, considering the retinopathy, kidney disease, neuropathy, and microangiopathy comorbidities) or economic costs (monthly salary data, loss of daily productivity, medical inflation rate, among other rates estimated by wellcast roi™); (iii) define the program and its cost; (iv) determine the effectiveness of the program in reducing costs; (v) subtract post-program costs from pre-program costs to determine reductions; and (vi) apply the concepts of net present value (npv), internal rate of return (irr), and cb to determine the s-roi. in all stages of the study, the recommendations and guidelines of resolution / [ ] of the brazilian ministry of health on ethical aspects regulating research with human beings, approved by the research ethics committee of the bahia school of medicine and public health and certificate of presentation for ethical consideration (caae) . . . , were followed. all subjects gave their informed consent for inclusion before participating in the study. the prevalent diagnoses and their respective interventions by dimension are presented in detail in table . in the physical education dimension, the most prevalent diagnosis is "regular aerobic capacity" ( . %), with the most prevalent intervention being "encourage thinking about starting a physical activity program, warning about the harm of physical inactivity" ( . %). in the field of nursing, the "impaired ability to perform leisure activities" ( . %) stands out as the most prevalent diagnosis, followed by the need to "promote ergonomic comfort" ( . %) as the most necessary intervention. in the field of medicine, "primary essential hypertension" emerges as the diagnosis with the highest prevalence among workers ( . %), preceded by "encourage health-seeking behaviour" ( . %) as the intervention with the greatest application within this sample. at the nutritional level, "excessive alcohol intake" is the most prevalent ( . %), with the intervention with the greatest application focusing on the need for "adequate macronutrients" ( . %). finally, in the field of dentistry, the most prevalent diagnosis is identified as "other somatoform disorders related to stressful events-bruxism" ( . %), with the predominant intervention being "guide to restorative treatment with external dentist" ( . %). table shows the statistically significant correlations between modifiable health behaviours and health outcomes. moderate correlations in table (τb ≥ . ) are identified as follows: between diabetes mellitus and altered blood glucose (τb = . ), energy balance intake (τb = . ), and the level of food knowledge (τb = . ); between arterial hypertension and the contemplation stage for physical activity (τb = . ); between the musculoskeletal pathology and the feeling of pain (τb = . ); between psychiatric pathology and energy balance intake (τb = . ); between triglycerides and energy balance intake (τb = . ); between caries and oral hygiene quality (τb = . ); between periodontal disease and periodontal condition (τb = . ), oral hygiene quality (τb = . ), level of food knowledge (τb = . ), altered blood glucose (τb = . ), energy balance intake (τb = . ), and simple carbohydrate intake (τb = . ). the results are shown in table show which indicators are most correlated with each coefficient of each dimension of interdisciplinary risk. the values presented in table make it clear which indicators are most correlated with multidisciplinary risk; the worse an indicator is, the more the risk increases. thus, in the field of physical education, it appears that the indicator of the contemplation stage for physical activity is the one that is most strongly correlated (τb = . ). in nursing, the physical aspects of ergonomic risks have the most significant correlation (τb = . ). in the field of medicine, diabetes mellitus is the most disturbing indicator (τb = . ). in nutrition, alcohol consumption presents the strongest correlation (τb = . ). finally, the highest correlation of all is for oral lesion on soft or hard tissue, which is the most significant indicator in the field of dentistry (τb = . ). hierarchical regression analysis was applied to understand whether the variables or dimensions under analysis explain a statistically significant amount of the variance of the dependent variable to be tested-in this case, the whri [ ] ( table ) . a comparison of stages is made by gradually adding each independent variable in each stage, to understand if the combination of the dimensions explains more than considering them separately. table . hierarchical multiple regression analysis scheme. step step step step step after analyzing the robustness of wham, its economic sustainability was assessed using the wellcast roi™ tool. for the analyzed time period and based on the npv of usd , . /per worker, the irr of . %, and the cb of . : , the s-roi was determined, suggesting that wham is economically sustainable. given its complexity, the field of healthcare requires the mobilization of specialists from different areas, with the aim of promoting comprehensive and integrated care for workers. based on an approach aimed at changing behaviors and adopting healthier lifestyles, going beyond the mere medicalization or treatment of diseases, the interdisciplinary care on which the wham model is based resulted in the data presented in table . in view of the most prevalent diagnoses identified for each of the integrated dimensions, an intervention was generated that promotes worker autonomy and the maintenance of healthy lifestyles and behaviors, such as physical activity, healthy eating, non-consumption of alcohol and tobacco, good oral hygiene, balanced social and environmental relations, and decent work habits [ ] . at this level, hypertension or diabetes mellitus diagnosis is highlighted, suggesting healthy behaviors or healthier eating habits interventions. as eng and collaborators [ ] state, the workplace is a key space for guidance around healthy behaviors and the reduction of non-communicable diseases (ncds), such as diabetes mellitus and arterial hypertension. viterbo and co-authors [ ] report that long-term interdisciplinary practice has had very positive and significant effects on reducing ncds. hochart and lang [ ] also mention in their study that the implementation of a comprehensive care program in the workplace with the aim of modifying health risk behaviors resulted in a decrease in workers in the high and medium risk ranges and in the maintenance of health for those that were in the low risk range. the same is true for the issue of oral health, a problem that is related to other serious diseases [ , ] , and which is solved through the implementation of regular programs for the adoption of oral hygiene behavior among workers, as reported by viterbo and collaborators [ ] . supporting these results, and in order to reinforce the importance of an integral look at workers' health, table presents the results between the behaviors (modifiable factors) and the results for workers' health. an overview of these results makes the connections between behaviors and health outcomes even more evident, as well as between the results themselves. in this case, an individual look at a worker would not allow one to understand them as a whole, contributing to fragmentation. certain associations exemplify this idea, namely between the level of food knowledge and the type of food, identified by the energy balance intake, altered blood glucose, and diabetes mellitus. a similar relationship was identified in a review by sami and co-authors [ ] , in which guidance towards healthier eating practices reduced the level of diabetes and prevented associated complications. the study by holynska and colleagues [ ] showed that the level of food knowledge is effectively related to nutrient intake, as this study also demonstrated. in line with this, breen et al. [ ] argued that the level of food knowledge enhances the choice of food, thus optimizing the quality of life of people with diabetes. table shows the results of the indicators that are most correlated with the risk of each analyzed dimension, making it possible to identify those that contribute most to the increased risk in that dimension. the strongest correlation belongs to the field of dentistry, more specifically for oral lesions increasing the health risk of these workers. according to warnakulasuriya et al. [ ] , conducting screening programs using valid visual inspection method to detect potentially malignant oral disorders within a workplace is not only feasible, but also effective. in terms of physical activity, the indicator that has the strongest correlation is that of the contemplation stage for physical activity; that is, the predisposition to start a physical activity. in the review by jirathananuwat and pongpirul [ ] , the studies analyzed demonstrated that the workplace can play an important role in promoting regular physical activity among workers. ergonomic risks in the workplace are, in this context, assumed to be the most correlated with risk in the field of nursing. this has been documented in several studies, namely by skovlund et al. [ ] and welch et al. [ ] . since workers spend long hours of their day at the workplace, an additional concern regarding workplace ergonomics must be considered, as correct adaptation will result not only in promoting the well-being of workers, but also in reducing medical costs for employers, as reported by munir et al. [ ] , gao et al. [ ] , and welch et al. [ ] . in terms of pathologies, diabetes mellitus is the indicator that most contributes to risk in the dimension of medicine. in the reviews by hafez [ ] and gan [ ] , the workplace is an important space for effective reduction of diabetes mellitus. some of the results in this study will have a direct implication in the workplace context, thus a more detailed specific analysis is necessary. the results regarding the wham robustness (table ) make it clear that the combination of technical and scientific knowledge in the work context results in a better understanding of the workers' global health. this result makes it possible to effectively verify that the interdisciplinary approach translates into gains in health, and that it must be adopted as a matrix in all work contexts, particularly those referring to a higher exposure risk and greater number of employees, as already identified in the studies by viterbo et al. [ ] , clark et al. [ ] , and costa et al. [ ] . considering that health promotion and prevention actions can influence the health habits and behaviors of workers, they can also reduce health costs. the literature review [ , [ ] [ ] [ ] suggests that programs based on behavior change theory and using personalized communication and individualized counselling for high-risk individuals are likely to produce a positive return on the amount invested in these programs. the assessment of s-roi in the specific model under investigation (wham) corroborates other studies carried out in the workplace [ , , , ] , showing positive financial results and reinforcing the advantages of applying wham, which in addition to directing investment in health strategies that are proven to be a priority, enables the optimization of financial resources, resulting in an s-roi of . % for interdisciplinary, integral, and integrated interventions for the community of workers with a high risk level. the search for a healthcare model for workers that is oriented towards integrated care, expanded health needs, economic sustainability, and which overcomes the problems arising from the hegemony of the biomedicine paradigm, such as the excessive use of technologies and focus on curative actions of diseases, is one of the great challenges of the brazilian health system today. this scenario is strongly present in brazilian scientific production and is reflected in national and international policies through legislation and public initiative. the results obtained with the practical application of wham in the oil industry in bahia, brazil, demonstrated the potential of the model, where the articulated and hierarchical management of the various indicators of workers' health makes it possible to direct practices aimed at the cause and not at the effect or symptom. at the individual level, the model presented an interdisciplinary diagnosis of the health conditions of each worker, correlating the modifiable health factors and their respective impacts. the presentation of information to individuals promoted autonomy and empowered workers to change behaviors that negatively interfere with health conditions. at the collective level, the application of the model demonstrated the correlation between health indicators and interdisciplinary risk in the studied context, encouraging the creation of strategies aimed at the most critical conditions, as well as the design of preventive interventions. the robustness of the model highlights this same potential, in addition to the related optimization of financial resources of . % for interdisciplinary interventions. the absence of a similar model in occupational health is a limitation of this study since comparative analyses in the context of this work are not possible. the application of wham in different healthcare contexts is suggested in future studies, as well as carrying out analyses of the model's effectiveness by comparing the population's epidemiological results and studying the s-roi. the different theoretical contributions to the theme of this study, as well as the results found, lead to the understanding that wham can be considered as a model capable of encompassing the complexity of the field of occupational health, considering the interdisciplinary approach, risk management, and comprehensive and integrated care, in addition to accounting for economic sustainability for companies investing in healthcare. the proximal origin of sars-cov- the one health concept-the health of humans is intimately linked with the health of animals and a sustainable environmen health services delivery programme division of health systems and public health duas faces da mesma moeda: microrregulação e modelos assistenciais na saúde suplementar. in [national agency for supplementary health. two faces of the same coin: microregulation and care models in supplementary health modelos assistenciais e unidades básicas de saúde: elementos para debate [care models and basic health units: elements for debate modelos de atenção e vigilância da saúde [health care and surveillance models cartografia do trabalho vivo modelos de atenção e a saúde da família [models of care and family health programa saúde da família: a construção de um novo modelo de assistência [family health program: the construction of a new care model modelos de atenção à saúde no brasil [health care models in brazil in políticas e sistema de saúde no brasil communication on health and safety risk control in contemporary society: an interdisciplinary approach. ciência saúde coletiva saúde coletiva cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família [the care of chronic conditions in primary health care: the imperative of consolidating the modelos assistenciais em saúde: desafios e perspectivas [health care models: challenges and perspectives the health care model: concepts and challenges for primary health care in brazil technology of relations as device of humanized attendance in basic attention to health in the perspective of access, sheltering and attachment modelos tecnoassistenciais em saúde: o debate do campo da saúde coletiva [techno-health care models: the debate in the field of public use of light technologies as a strategy for changing the health profile of workers with chronic conditions in the oil industry administração em saúde: autogestão de consultórios e clínicas dos modelo assistencial e atenção básica à saúde [care model and primary health care understanding the process to develop a model of care: an. aci framework; agency for clinical innovation implementation of an interdisciplinary approach to promote workers global health status in the oil industry, brazil ( - ) interdisciplinarity: an articulating movement in the field of worker's health significados e limites das estratégias de integração disciplinar: uma reflexão sobre as contribuições da saúde do trabalhador resgatando conhecimentos e práticas sobre as relações trabalho-saúde [the field of occupational health: rescuing knowledge and practices about work-health relations the sociology of health and medicine: a critical introduction the social determinants of health: developing an evidence base for political action final report to world health organization commission on the social determinants of health; national institute for health and clinical excellence social determinants and lifestyles: integrating environmental and public health perspectives fatores de risco relacionados à carga global de doença do brasil e unidades federadas [risk factors related to the global burden of disease in brazil and federated units environment and human health health monitoring and intervention plan on oil industry workers: results from a case-study. in occupational and environmental safety and health ii sustainable development goals indicators: a methodological proposal for a multidimensional fuzzy index in the mediterranean area desenvolvimento sustentável e saúde do trabalhador nos estudos de impacto ambiental de refinarias no brasil impact of working environment on job satisfaction a cost-benefit analysis of three older adult fall prevention interventions a review and analysis of the health and cost-effective outcome studies of comprehensive health promotion and disease prevention programs the health and cost benefits of work site health-promotion programs impact of worksite health promotion on health care costs and utilization. evaluation of johnson & johnson's live for life program worksite health promotion: its evolution and the johnson & johnson experience a return on investment evaluation of the citibank, n.a., health management program building program participation: strategies for recruitment and retention in worksite health promotion programs health spending projections through : modest changes obscure part d's impact. health aff. (millwood) impacts of workplace health promotion and wellness programs on health care utilization and costs: results from an academic workplace a cost and cost-benefit analysis of the stand more at work (smart work) intervention projected return on investment of a corporate global health programme economic evaluation of a randomized controlled trial of an intervention to reduce office workers' sitting time: the "stand up victoria health risk assessment in oil industry in bahia, brazil: the worker's health risk index (whri) development and validation of an interdisciplinary worker's health approach instrument (iwhai) world health organization icd- -international classification of diseases th revision. the global standard for diagnostic health information sistematização da assistência de enfermagem em unidade de terapia intensiva classificação internacional para a prática de enfermagem: instrumental tecnológico para a prática profissional [international classification for nursing practice: technological instrument for professional practice academy of nutrition and dietetics. international dietetics and nutritional terminology (idnt) reference manual: standard language for the nutrition care process world health organization. international classification of functioning, disability and health; world health organization health behaviors as a mediator of the association between interpersonal relationships and physical health in a workplace context the framingham heart study and the epidemiology of cardiovascular disease: a historical perspective approves regulatory norms of research involving human beings; national health council resolution no of december impact of a workplace health promotion program on employees' blood pressure in a public university impact of a comprehensive worksite wellness program on health risk, utilization, and health care costs periodontitis and diabetes: a two-way relationship the association between oral hygiene and periodontitis: a systematic review and meta-analysis. int effectiveness of an oral health program among brazilian oil workers. in occupational and environmental safety and health ii effect of diet counseling on type diabetes mellitus the level of nutrition knowledge versus dietary habits of diabetes patients treated with insulin diabetes-related nutrition knowledge and dietary intake among adults with type diabetes is workplace screening for potentially malignant oral disorders feasible in india? promoting physical activity in the workplace: a systematic meta-review association between physical work demands and work ability in workers with musculoskeletal pain: cross-sectional study process evaluation of a workplace-based health promotion and exercise cluster-randomised trial to increase productivity and reduce neck pain in office workers: a re-aim approach workplace interventions to prevent type diabetes mellitus: a narrative review shift work and diabetes mellitus: a meta-analysis of observational studies developing and evaluating an interdisciplinary clinical team training program: lessons taught and lessons learned communication of environmental risks to potentially exposed workers: an experience in the oil industry, bahia, brazil. in occupational and environmental safety and health ii financial impact of health promotion programs: a comprehensive review of the literature meta-evaluation of worksite health promotion economic return studies: update a review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: update vi - key: cord- - iwo tlb authors: vieira, tiago title: the lose-lose dilemmas of barcelona’s platform delivery workers in the age of covid- date: - - journal: social sciences & humanities open doi: . /j.ssaho. . sha: doc_id: cord_uid: iwo tlb the abrupt lockdown experienced by a big part of the world population due to the covid- pandemic has bestowed upon home delivery services an unexpected importance. officially considered amongst “essential services”, their workers circulate freely while most people are advised (when not forced) to stay in their homes. the present paper explores how this context helps to shed light on the precarious situation of the majority of the platform delivery workers (pdw). this is done through in-depth, semi-structured interviews and digital ethnography of the interactions within a whatsapp group. the main finding is that the covid- context deepened the precarization of the pdw confronting them with four dilemmas from which there is no way out. the uncontrolled spread of the covid- in spain led the government to enforce a nation-wide lockdown on march . amidst critics from autonomous communities' leaders, opposition parties and even members of the government itself, the enforcement of the lockdown dictated a staggering breakdown of the everyday routines of the spanish people(s). as has been the case almost everywhere else, the main aim of the lockdown was to prevent the proliferation of the virus, through the refraining of human contact. in order to achieve such a goal, all activities considered less than essential for facing this unprecedentedly critical moment were first advised and, later on, forced to come to a stop. on top of this, the very ways in which people interacted became the subject of scrutiny from the authorities: any form of not strictly functional social engagement was deemed unwelcomed -even the once overcrowded supermarkets were now vast empty corridors, as people queued by the door in long, -m-of-distance-between-each-person-please lines. as millions of other people in the city of barcelona followed the protocols, i also did my best to follow the rules, only leaving my thirty square meter flat every other day, and only to buy bread and some groceries. thirty minutes of freedom and, if lucky, some sunlight. while i briefly strolled the never-to-be-seen-so-empty-streets of the up-untilrecently bustling streets of raval, the only few other freedom companions i'd get would be: police officers (dozens of!), dog walkers, fellow groceries' purchasers, and bike riders floating around with huge, fully colored backpacks on their backs. all the three former categories were expected, they all had a reason to be where they were. however, the latter posed me an intriguing puzzle: in a moment where the majority of the population was notably (and perhaps justifiably) afraid of contagious contacts with other human beings, why and under which circumstances (incentives, if you will) would these workers, who are formally free to choose the extent of their availability to work, expose themselves to the possibility of hitting the covid- infected list? in the present paper, i explore the situation of the platform delivery workers (hereafter, pdw) in the peak of the covid- crisis in spain. the pdw form part of broader group of workers whose activities are performed directly and/or mediated by a digital platform, commonly known as platform workers. in the case of the pdw, the platform ensures the liaison between the users/clients, the sellers (restaurants, retailers, etc.) and the pdw who receives the task of having the delivery made. in very simple terms, they are the pizza delivery boy/girl of the smartphone era. the present research is done through the combination of a digital ethnographical approach to a whatsapp group of pdw of barcelona and the conduction of semi-structured interviews to some members of the group. informed by the existing literature on precarity, my qualitative approach aims at unveiling to what extent the workers of this very specific activity are faced with a series of dilemmas from which there is no good way out -essentially they are trapped by their extremely precarious position. the interactions described in the following sections of this paper intentionally overlook any aspects that do not fall under the scope of the purpose of this research: grasping the relation between precarity and exposure to hazardous situations by pdw. other results notwithstanding, my expectation by doing this paper is that those whose voice is so scarcely heard, might have attention drawn to their situation, for unlike the gurus of one of most prominent companies of the platform economy (airbnb), i don't see "people as businesses" (kaplan & nadler, ) , but rather people as people. the deep changes brought about by the hegemony of neoliberalism as a global mantra (harvey, ) produced effects on the life of all human beings on the planet, rendering the organization of societies a process in which stability and predictability were gradually, more and more, nothing but fading memories of a not-so-distant, yet apparently very far away time. while addressing this matter, bourdieu (bourdieu, ) played a decisive role unveiling the "insecurity-inducing strategies" promoted by employers to render the working class more dependent and less demanding -which is synthetized by the word precarit e (precarity ). contributions following bourdieu's notwithstanding, standing's precariat (standing, ) stood out as a particularly important expansion for the research on the topic of precarity. the author developed a seven-axis framework of analysis of labor security, which absence (individually considered or as a whole) led to precarity. his findings seconded those of bourdieu, as he observed that in the post-fordist era workers are increasingly exposed to circumstances making them precarious. since then, namely throughout the last decades, the fact is that this phenomenon has been greatly expanding. not only is it evolving into an increasing share of the labor force, precarity is impacting the lives of workers in increasingly diversified ways (armano et al., ) . bauman's (bauman, ) "liquid modernity" is rapidly turning into a very "age of precarity" (lazar & sanchez, ) . in fact, the changes occurring in the labor market are deeply intertwined with further changes taking place in societal discourses and perceptions (gilbert, ; valas & prener, ) . this "structural precarity" (antunes, ) stems from the multidimensional nature of insecurity and vulnerability (herrmann & kalaycioglu, ) , both cause and consequence of increasing levels of inequality (piketty, ) . unsurprisingly, the substantial technological developments of the last decade -mainly owned by the biggest capitalist corporations -have only further enhanced the critical precarization of labor relations. "labour power comes to be transformed into a commodity in a context where the encounter between supply and demand of work is mediated by a digital platform, and where feedback, ranking and rating systems serve purposes of managerialization and monitoring of workers." (gandini, ) . insofar as this topic seems to be currently very trendy, which has led to rapid expansion of the existing scholarship, the in-depth descriptions provided by srnicek (srnicek, ) and scholz (scholz, ) on how these new labor forms are shaped still stand as seminal works. they shed light on how "the emergence of labor flexible forms has produced a new type of self-employed worker, one that even if autonomous in many aspects as his predecessor (schedule, low social protection) is, indeed, much closer to the temporary worker: precarious, involuntary, dependent." (jansen, ) . building upon this legacy, de groen et al. (de groen et al., ) provide an insightful -to the best of my knowledge, the most developed to this day -account on how "platform workers" are exposed to intense and highly sophisticated forms of precarity. by scrutinizing the work and employment conditions through the lens of a four dimensional scale -the "adjusted wes" -which, in turn, unfolds into different indicators, this paper stands as a landmark for a comprehensive understanding of the challenges faced by the workforce forming part of this emerging, apparently unstoppable new shape of labor relations. all the angles from which labor relations of platform workers and their employer counterparts are looked at by the existing literature notwithstanding, the ways in which precarity penetrates platform work is far from exhausted. among eventually others, one issue that stands outmost notably amidst the pdw -is that of platform workers renting their accounts, thereby emerging rather as subcontractors than as wageearners. the ways in which this unfolds -to be briefly explained in following sections of this paper -has been vastly documented by the media (e.g. (bbc, ; crispino, ; ponte & moya, ) ,), however, surprisingly, it has been overlooked by the scholarship produced by academic researchers. as hereafter observed, the workers hired by this sort of platform's "subcontractors" are served the worst of two worlds: on the one-hand, they operate as illegal, undeclared workers, who not only are deprived any form of social protection, as also, if caught working illegally, are likely to face legal consequences; on the other hand, they are forced to pay all the taxes their sub-contractor has to pay to public institutions, and still need to comply with the control mechanisms entailed in the so-called "application-based management" (ivanova et al., ) . it stands out that this specific issue can hardly be disentangled from the vast precarity web where workers of platforms often find themselves trapped. indeed, it should be seen more as an additional thread of the web than a stand-alone matter -more often than not, although not exclusively, closely related with situations of undocumented immigration. this intertwined thread stands as the central axis of this paper, in which the exposure of both "regular" and "sub-hired" platform workers to the covid- pandemic and subsequent societal context of unexpected and unprecedented measures of confinement is analyzed. the constraints provided by the lockdown made it particularly challenging for any research to be conducted beyond the limits of my desk. while attempting to successfully attain the goals of myself set endeavor, i played to my advantage the increasing "ubiquitous computing" (elwell, ) of human existence as an undisputed advantage. in fact, acknowledging that the "materiality of the digital (…) should be at the forefront of theories attempting to understand contemporary practices" (duggan, ) can only play to this research agenda's advantage, more so if taking for granted the quasi teleological proneness of the pdw for digital engagements (leonardi et al., ) . all this rendered digital ethnography an indisputably valuable methodological approach. provided the term can lead to different interpretations (dicks et al., ) , this is precisely what was done: while analyzing the content of the interactions of a whatsapp group of pdw, i stood as non-participant observer of the life dynamics of this group, grasping as much as possible given the existing limitations their perceptions, concerns, attitudes and praxis. this process was implemented from march to april , (the first four weeks of an unprecedented lockdown for most the people to be fair, the actual translation would be "precariousness". for how, to describe precarit e at labor level, one has evolved from precariousness to precarity see the cambridge encyclopedia of anthropology (cambridge encyclopedia of, ). social sciences & humanities open ( ) walking the earth), in a group to which access is publicly advertised on one of the several existing facebook pages of pdw, and to which no prior conditions of admission are established, so there was no need for a formal introduction to the group or its moderator from my side to ensure access. however, i ended up doing it somehow, given that a big percentage of my interviewees were assembled by individually approaching each one of the group members -to whom i introduced myself as a researcher, explaining i had joined the group looking for interviewees for a research project related to the life of the pdw. this strategy also allowed me to ensure that all group members knew that there was one among them that was not a pdw, but rather a social researcher, thereby ensuring there were no ethical obstacles to my research. this was perceived as unproblematic by group members, since most of them simply ignored me, and those who actually answered (even if not made available to be interviewed) shared words of encouragement. as for the actual analysis, as an initial step, i coded each of the entries according to the topic they referred to -a proof of how active the group, was with a daily average of messages exchanged. each category would receive one point for each entry that fell under its topic. in the not so common case that one entry would cover two different topics (e.g., requests for information on labor rhythm and police controls), both categories received a point (results are presented in the next section). the code construction was inductive, i.e., i developed it after a global content analysis of the interactions, as this allowed to a have a better look at what was going at the level of interactions -the results of this process are presented as part of the findings' section. although the literature review had drawn my attention to the main trademarks of precarity, such as matters of income and managerial control techniques implemented in the framework of "platform work", the general overview of interactions made it clear that more dimensions of analysis had to be explored. in line with that, it was thus necessary to address how labor precarity was closely related to other forms of broader insecurity, namely the exposure to dangers arising from either their legal status or the impossibility to control the content of the packages delivered. sequentially, valuable as the interactions on the whatsapp group were, making sense of them and having more in-depth information on daily routines was only truly possible when the interviews were accomplished and successful analyzed. in other words, my rapport towards the group interactions was only built a posteriori, for it was in the interviews that the most pressing issues of the pdw lives became clear to me. this was particularly important for me as a researcher, given that i have never had the professional experience of working as a pdw, on the one hand, and that all i knew about these workers until now was essentially based on media reports describing their often precarious work and employment conditions. in total, interviews were done, all under anonymity. they were all done by videocall and, in average, lasted for min. they were all conducted in spanish, which i speak fluently as second language, and which allowed all interviewees to express themselves in their mother tongue. all interviews were recorded having the informed consent of the interviewees that the disclosure of the information retrieved would be anonymized. the flexible nature of the interviews made them the most relevant part of this research. as hereafter observed, the information collected confirmed the validity of this technique as a means to have a wider perspective of the existing constellation of visions of the same phenomenon (mason, ) . following kvale's (kvale, ) approach, the interviews were a mix of an unpreoccupied conversation among two acquaintances and an investigation. the script underlying these semi-structured interviews was thus quite loose, aiming mostly at having the interviewees relating their broader experience as pdw with the one of the present moment -even for cases in which they have decided to stop working, in order to protect their health. i dedicated a substantial amount of the interviews' time to understand how the work and employment conditions unfolded for the pdw, and how -in these particular circumstances -this was lived by each one of them. i focused on elements that could present themselves as hazardous, such as excessive work rhythm, overwork, absence of or difficult access to individual protection equipment, lack of alternatives in face of infection, and access to social welfare mechanisms. in both cases -those who continued to work and those who decided to stop -the interviewees' discourses shed light on the adaptations and justifications adopted by the subjects to navigate the current broader cultural framework -that of precarity. all this said, one should not understimate the limits posed by a context in which this research process unfolded. the very strict lockdown imposed by the spanish authorities made it completely impossible to grasp important information and its inclusion in the findings sequentially presented. this fact surely doesn't undermine the results altogether, but it has certainly prevented me from having access to broader dimensions of the precarious lives of the pdw. those which i consider future research would benefit from grasping are: physical living conditions; social capital; mental and physical strategies to cope with the workers' immensly precarious situation. undoubtedly, the conduction of presential (rather than merely digital) ethnography and of focus group interviews, would have made the results of the present research even deeper. the current section presents the main findings retrieved from the combined information of the interactions in the whatsapp group and the interviews. an insightful presentation deems useful the splitting of the information by topic, disregard their intertwined nature. a general overview of the trends of the interactions of the whatsapp group is followed by a specific approach of the topics. the whatsapp group hereafter analyzed was created on january , . it was composed of members when i joined it (march ) and kept on growing steadily until the last day of my research (april ), when it counted with participants -however not all participants were active, many of them stood as mere "observers". the group founder and moderator, himself also a pdw (assuming his profile photo is actually of himself), was one of such silent members -not even once has he interacted publicly within the group. the participants were mainly pdw who worked in barcelona, although there were a very small number of exceptions -people from other spanish cities looking for info or technical information. although most of the interactions referred to glovo, there were pdw who worked for other companies such as deliveroo, uber eats and stuart. some pdw had accounts open in more than one platform. elements like age and country of origin are impossible to account for. however, admitting that the photo provide by the profile picture is, most of the times, from the owner of the whatsapp identity, it was from the beginning clear that this group where young adults are the overwhelming majority (something that was later confirmed by the pool of interviewees, whose age ranged from to ). the same rationale applies for gender. based on the whatsapp profile photos and on the usernames -admitting they were reliable -i could only count seven women. notably, one was a fellow social researcher performing digital ethnography as i was doing, another was the wife of a pdw (it was unclear whether she, herself, was also a pdw) -the remaining others were actual pdw. this does not mean that all other members of the group were men: in the case of at least members, neither their usernames, nor their photos allowed to make a solid prediction on their gender. be as it may, during the two female interviewees confirmed that women were extremely rare in the pdw world. as for the content of the interactions, after a global reading, i deemed to code the information retrieved from the group in the following manner: company -dealing with aspects of the relation with the companies (mainly doubts and complaints shared among peers, before/instead of addressing the company itself); labor rhythm -related to the ongoing movement of demands made by clients (usually to assess if low levels of requests were an individual situation or a broader issue); police/security -shared information about (past or present) police controls and other aspects that could jeopardize the security of pdw, such as requests for delivery of illicit substances; rented accounts -information on accounts to be rented (essentially from people procuring them, but also some advertising and some doubts' clarification); state -discussion all aspects related to the relation of pdw with the state, mainly: the decision of the state of emergency, its renewal and its implications, and clarification of doubts on issues related with taxes and social security; covid -information and debate of news and concerns directly related to covid- (the evolution of numbers, who is to blame, what measures to take to reduce of the possibility of being infected); services -advertisement, sharing or procurement of services, disregard how work-related they are: second-hand backpacks, bikes' workshops, flats for rent, cigarettes, fuel, videogames or even direct requests to workers seeking to avoid the fees charged by the apps; other -jokes, memes, motivational messages of various sorts. as shown by fig. , throughout this period, the main concern of the dpw was related with the action of the police and other aspects related to security, taking up almost one third of all the interactions. most notably, concerns with covid- itself were extremely rare ( %). in fact, direct work-related worries were by far the most pressing, adding up to an aggregated result of % of the interactions. even if the services category is not considered as necessarily work-related -although a large number of the interactions that form part of it indeed are -, one would still observe that % of interactions refer to the need to deal with aspects that are connected to work. the "others'" category -which altogether added up to % of the interactions -was the locus of empathy among the pdw par excellence. inasmuch as these were not directly work-related contents, it was clear that group members found in this type of message a way to mutually motivate one another, expressing individual and collective resilience before such complex context as that of the covid- . undoubtedly, most messages were or religious (or related to them), even if, seldom, some jokes, memes and gifs would be posted, particularly as reaction to some previous message, as a way to provide feedback. the rest of this section is highly informative to why this is and how each of the different dimensions is, one way or another, related to the specific circumstances brought up by the covid- pandemic. if there is one thing that seems consensual among the interviewees is that working as pdw provides a low monthly income. most have noted that work is exhausting, allowing to obtain an amount with which one can "pay your food, your rent, and not more" (juan). of those interviewed the declared net income ranged from to euro per fortnight, all highlighting that reaching these amounts deemed necessary a very intense work rhythm, with no more than one day per week to rest. an important element of instability stems also from the inexistence of a minimum guaranteed wage, rendering it pure luck that there will be enough movement to allow one to earn enough to pay their bills. this is arguably why almost % of the interactions group are dedicated to understanding how rhythm of demands is at each day. the randomness of this possibility to make money is well expressed by the following statement of a member of the whatsapp group: april : wg# "one has to be patient, that i learnt from [name of company] … one just has to get out soon and have faith in god that a request drops." furthermore, the situation of the pdw is of people who live on the edge, renting rooms by the day, with no security at all, exposed to the arbitrariness of those with more power -something that became even more critical during the pandemic, leading one to believe that the covid- crisis may just be the tip of the iceberg of much deeper crisis, where job, food, shelter and medicines' scarcity may lead up to a not so distant perfect storm. take as examples: although the jokes and gags could, altogether, be a strand of this research on its own -following the steps of, among others, 't hart (t hart, ) -their scarcity and discontinuity rendered this possibility unattainable. march : wg# "i could not go out to work because the person who is renting me [a room], told me to look for another place to live, that they did not want to expose to the possibility of me taking the virus to the flat …" march : wg# "if you know of any bicycle account recommend it friends, maybe having some money it is easier to find a place to sleep, this night one good person let spend the night so i don't get frozen with the cold of the last days. i have a bike to work. if you know of any account please i'm very unsettled" beyond income, a decisive element to understand the whole context lived by most pdw is the way the apps are run, commonly known as application-based management. although each platform (which tangible expression is the application) has its specific features, the outline is similar for all. in a nutshell, the odds of a pdw having possibility to work (and, necessarily, obtaining income) is directly related to a mathematical combination of factors, such as: the availability to work in the hours deemed necessary by the platform (most notably in the evenings and weekends), the speed of delivery, the review the given by the customer who gets the order (and, in case it is food, also from the restaurant producing the food). when accomplished within the goals set by the platform, the pdw obtain points. when that is not the case -no matter whose fault it is -the pdw loses points. this extremely important since it is the amount of points one has that determine one's ability to "catch" hours of work. the more points one has, the more hours one will be able to reserve -hence, the more money one can make. diego pointed out how the lockdown was a special period, since "in this period they let you choose the hours you want, something that never happened", which stems from the huge demands received in these days, particularly for food orders. juan reported that the company he delivers for was now increasing the income rate to attract workers to work for more hours, something that had been done in the past only in rainy days or special holidays. be as it may, there still are the "hours of high demand" (defined by the platform and the restaurants), in which "if you don't work, your score will be lowered" (juan). in a context like that emerging from the covid- pandemic, it should come as no surprise that many people have tried to desperately find solutions to economically survive. in the month of march alone, more than thousands of workers were affected either by unemployment or by their companies making use of lay-off mechanisms (gomez, ) . one way or another, the financial stability of hundreds of thousands of families was directly affected, rendering them more prone to searching solutions where there might be potential for fresh and fast income. if one goes back to fig. , the fact that more than in every interactions are related to this topic provides evidence of its relevance. however, to fully grasp the meaning of this number it is important to keep in mind that these are interactions about performing an illegal action held in an open forum, in which everyone can be easily traced by their mobile number. this renders highly likely that many more interactions take place in non-public spaces. from the reports in the media and the interviews had, it is relatively easy to understand how this unfolds. in a nutshell: individual a signs-up for working in one platform, providing the required paperwork to be granted a license; once that is obtained, individual a procures someone who is willing to work but cannot/is not willing to sign-up for working in the platform; once that person is found (hereafter individual b), an oral agreement is celebrated: individual a grants access to his/her account to individual b, provided that the latter concedes the former a percentage of the income earned by working to the platform, plus all taxes. in all cases, individual a is in control at all times: the bank account where the money is deposited by the platform is his/hers; the mechanisms for password change are in his/her hand. the situation reported by jos e speaks for itself in terms of the vulnerability to which people renting accounts are exposed: "in of those payments he decided not to give me a thing, not to pay me … making excuses, that he wasn't making any money with that account and i don't know what else … and he stole that fortnight from me. that was a great problem, i had to pay the rent, and to eat also and, well, that time we even had to put up with hunger, because we lived very poorly …" a side, but important note to take here is: traditionally, this is a situation in which undocumented migrants are more likely to be found both the existing literature and the interviews made confirm it. however, in the pandemic context, it is likely that spanish nationals and documented migrants are drawn by the perks of renting an account: skip all the (although light, time consuming) bureaucracies to become a legal pdw and start making money "right away". while some companies only deal with distribution of food, there are others who provide delivery of packages of any sort (as long as they fit in the backpacks of the workers), including items between two addresses of two private individuals. the second half of this paper's research period was marked by the emergence of cases related to drug traffickers making use of these platforms' services to have their products distributed around the city -thus avoiding having themselves or their customers exposed by walking around the highly patrolled streets of barcelona. an example: april : wg # "well not long ago, a super beautiful blondie asked me to take a box of chocolates … and when she passed it onto my hands … and weighted nothing … that made me curious … and when was coming in the lift i found it suspicious and i felt like smelling it, and it was pure marijuana in the box of chocolates …" unsurprisingly, the lockdown was enforced by the action of police. practically empty, the streets and avenues of barcelona became constantly patrolled by police officers enquiring the purposes of people going around, no matter if they were on foot, riding their bikes or cars. allowed by the governmental decision on "essential activities" to keep on working, the pdw were not unexposed to trouble with the authorities -reason for which % of the interactions on the whatsapp group was about the police controls. as expected, the topic also came up in which case the account owner has an additional power over the individual renting it: that of, at any moment, denouncing him/her to the authorities. those renting an account for this purpose will not be caring for the last, but not least problem stemming from running a rented account: the absence of any form of social protection or benefit. this became outstandingly important when the spanish government announced a series of measures to support the selfemployed workers (which, in theory, is the legal category of the pdw) and those running rented accounts could not enroll for having access to such mechanisms. this was, by far, what occupied the % of the interactions above categorized as "state". in the first two weeks alone, there were more than . detentions and . fines for unjustified violation of the lockdown in the whole of spain. notably, from that the day on it is not possible to find overall data. in most of the interviews, although not with such relevance. indeed, the three reasons behind the concerns with the police controls are deeply intertwined with the previous four dimensions of precarity. even if, in most cases, an overlapping of issues is observed, they are hereafter split for a more comprehensive description. the systematic disrespect for traffic rules has very few (if anything) to do with the covid- context, however the huge reduction in traffic and having "police coming out of every corner" (march , wg # ) made the situation more hazardous. as noted by some, even when not fined, a pdw will necessarily be doubly harmed by a police control: the time spent while having his backpack and documentation checked will necessarily lose him precious hours of work and, simultaneously, impact the evaluation given by the client who will receive his package later than expected -something particularly critical in the case of food coming from restaurants. the words of jos e provide a clear picture of why pdw are so eager to avoid the police: "i cross a lot of red lights. and why do i do it? one is working with the hours given by [name of company], so one has to do what is possible to answer more requests in that hour, and so one goes as fast as possible to work more. sometimes i am afraid, because as much as one is careful, there is always risk" b) rented accounts although they are paying taxes to the account owner (rendering this slightly different from other forms of undeclared work), renting an account is an illegal action and, as noted above, it is often performed by undocumented immigrants. this deems police controls particularly unwelcome for many pdw, with consequences ranging from fines to severe legal complications. this widespread shared concern informs much of the interactions in the whatsapp group, as well as it emerges in several interviews. it is an undisputed source of anxiety: juan: "now they are also asking for documentation, and i will present the documents of my country and they will see that the account is someone else's … and things get complicated …" march : wg # "if one has a rented account, and besides it one doesn't have a passport, then you will have to take a lot of precaution, take latex gloves if possible, mask, lights on the bike, that way we avoid drawing attention." c) transport of illicit substances. it goes without saying that no one will want to be found by the police carrying illicit substances. scrutinizing the information retrieved from the whatsapp group (by the times the interviews took place this wasn't yet an issue), it stands clear that the pdw faced an unprecedented situation, which rendered many of them anxious. the discussion floated around how to avoid being used by drug dealers as carriers, and simultaneously, how to act in order to ensure the police would believe that -when they did carry drugs -they belonged to the client, and the pdw was unaware of what was being carried: april : wg# "guys, the best is not to take packages, there are already many cases of these, i know we are here to earn money but we can't risk, so even if we take a thousand photos, if the police will stop us, it is enough that it is in our package to have us being the harmed ones" against all odds, the issue of the covid- deserved very scarce attention from the pdw, particularly in the whatsapp group (only % of the interactions were directly related with it!). in fact, most of the references to it were purely instrumental and referred to how it connected with other dimensions of the pdw life, namely whether the state of emergency would interfere with their possibility to keep working. this statement should not, however, overlook the direct impact that covid- had on the life of several pdw. for instance, afraid of becoming sick jos e and maria reported having stopped working, while juan spoke of being extra careful -not afraid of the disease itself, but rather of, by becoming sick, not being able to work and, therefore, having no means of survival. despite different approaches to the topic, one aspect seemed to be consensual: the answer of the corporations that own the platforms was seem as scarce and perceived with disbelief by the pdw: march : wg # "they don't give you even a glass of water, let alone a mask. i came from there. and they don't even thank you" wg # "i saw some guy asking for it and they give them [masks], as well as gloves. obviously, when they run out, they won't give you … and you have to ask for it, it's not like they will be announcing it … their obligation would be to even notify us through the app, but we already know how it is …" to a large extent, the pandemic brought up the already existing precarious situation of the pdw. although the pool of interviewees does not stand as a representative sample -nor was that ever the intention -, it is clear that the pdw are mass of people who could not make their way into the world of standardized wage-earning decent jobs. either due to their situation of undocumented migrant, or simply because youth unemployment is massive in spain, working as a pdw forms part of the "precarity trap" in which millions of workers increasingly find themselves (fumagalli, ) . having this in mind, it is of the essence to the latter understanding of the emergence of a set of dilemas that, in a different context, could have assumed substantial different shapes, or not have surfaced at all. as aforementioned, the interviewees and the interactions in the whatsapp group made clear that there were different levels of concern regarding the possibility of being infected (and possibly killed) by the covid- . nonetheless, it stood crystal clear that, even for those exhibiting less fear, the decisive driver of their decision to work (in the case of those who did) was their impossibility to have reach out to any sort of alternative whatsoever. as per the definition of the merriam-webster dictionary ("dilemma." merriam-webste, ) a dilemma is "a usually undesirable or unpleasant choice". provided the above-mentioned circumstances in which pdw find themselves, i consider that, in the present context, they face critical dilemmas -which are hereafter systematically exposed: by far the most critical of all, the survival dilemma stands as a trademark of this particular time. on the one hand, by working and contacting dozens of other people (restaurant workers, clients, police officers, random people on the street), pdw are highly exposed to the highly contagious covid- . on the other hand, the absence of mechanisms of social support (such as unemployment or health benefits) and the possibility of having their account renting agreement unilaterally cancelled (for not being as productive as the original owners of the accounts expect/demand), impels them to continue work. over the period of research, i found two highly informative accounts, which i believe to efficiently summarize this dilemma: pablo: "of course there is a widespread fear … but even more fearsome is not to eat or having to stay on the street. you may get the virus and heal when it's over, but if you don't have anything to eat, you or your family, the death is of starvation. so, the fear is from hunger and that's it. i mean, the delivery workers, we are not fighting against one virus, we are fighting against several." march : wg # "i understand all that, but i have my daughter and the rent won't be forgiven. and my fear is to bring the virus to my house, to my wife and daughter. it is being between the sword and the wall. i'm desperate." . . the cost minimization dilemma: fines versus absence of income particularly for those not having an account under their name, the existence of a higher level of police control in the streets raises yet another dilemma. while going out is decisive to earn income to pay for their basic expenses, pdw caught using other people's accounts without documentation risks being severely fined -which would, of course, render completely useless all the efforts for gathering money. jos e: "i decided not to go out because this is a serious problem. what's more, i heard that the police was in the streets asking the delivery workers to show their working license and the social security documentation. from my side, i have no way to deliver that because my account is rented, so there is a risk i'm fined, and i've been told it can go up to euro. this fortnight i haven't earned a single euro." april : wg # "partners i have a rented account and i am about to run out of euros, what do you recommend, get out or can i get even more screwed with a fine?" wg # "with the fine or with virus, any of the two." wg # "of course you can get more screwed but you have to work. get out from to . whatever you do then is good. i go out everyday and i'm like that" . . the algorithmic dilemma: red signs versus police attention the third dilemma is not specific to this period, however the ubiquitous presence of the police in the streets makes it rather more pressing than in the recent past. the quotes provided in previous sections stand as the most significant to shed light on this issue, reason for which no new quotes are provided here. nonetheless, this dilemma's underlying rationale is the following: on the one hand, the only way to "please the algorithm" which lies at the foundation of the app is to work with high pace, since that will improve the odds of having good reviews, which, in turn, will allow the pdw to have more hours available to work and, thus, earn more income. even if the results of a high rhythm of deliveries doesn't have immediate algorithmic impact -although far from only long term, since the score of each pdw is updated on a daily basis -, as noted by some of the interviewees, the fact that the pdw get one delivery done, allow them to move on to the next one within the available hours. this will be particularly critical to those start to work as pdw, since they will have both fewer hours available and, within those, fewer odds of having a delivery requested to them. notably, this seems to confirm that technology is not, on its own, a form of control or exploitation: the ways in which it is designed and implemented rather mirrors the social relations it embodies (moore et al., ) in the case of the pdw, the absence of human (visible) interference in the decision-making process, allows managerial control to be perceived as computational and, thus, non-biased towards the boss or the employee (gillespie, ) , thus impelling workers to incur in hazardous behaviors, although keeping the appearance (in some cases some sort of fetishicized illusion) that it was their choice all alongand not the companies' perverse algorithmic design inducing them to adopt such praxis (veen et al., ) . on the other hand, to ensure that this very high rhythm is accomplished demands to not always act according to the laws, particularly traffic rules. such an attitude may, however, entail a series of negative consequences, all of them steaming from having the police attention drawn to oneself. the first, and most obvious, is that being stopped by the police will mean losing time, thus rendering the risks and the efforts to make a fast delivery useless. the second, almost as likely in case is not respecting traffic rules, is that one may be fined, which will obviously impact on the available income as soon as the fine is paid. third and most seriously, particularly for those using rented accounts, having the police checking their situation will probably lead to even heavier sanctions, ranging from bigger fines to serious legal complications (particularly for undocumented immigrants, which, as above mentioned, is many times the case). ironically enough, given the more precarious one's situation isspecifically in the case of account renters -, the more one will feel compelled to violate the laws, given that the net income retrieved from working as pdw will be even lower. as noted in the previous section, a problem that has been emerging for the pdw is that there seems to be a sudden increase in cases of drug traffickers making use of them to ensure the distribution of their product. such fact poses a series of problems that dialogue directly with several critical features of the pdw activity and the way it is designed. on the one hand, pdw afraid and/or suspicious of being used as involuntary carriers of drugs may choose to take one of three different actions, all of which may have important consequences: (i) refusing the request for deliver packages from private senders: the immediate consequence is that the earnings that would be obtained from that service will be missed, without the pdw knowing when will he/she be able to have another service; beside that, rejecting services is very likely to have negative impact on one's score, thus affecting his/hers possibility to earn money in the future. (ii) requesting the sender to open the package to ensure it's drugsfree: by asking something that does not comply with any recommendation of the platforms and is, most likely, illegal, pdw risk being sanctioned, either by having a bad review and/or if denounced by the sender to the main company; furthermore, even if this is not at all negatively interpreted by the sender, the fact that the pdw is losing time will already stand as an indirect sanction, for as noted in the previous dilemma it will likely harm the total income earned. (iii) voluntarily asking the police to check a package: particularly under the ongoing circumstances, the police has the authority to open a package and provide a legal document that the pdw may attach to it, thus defending him/herself from any accusation of violation of privacy, thus rendering this the safest option; however, this option will make the pdw lose time of eventually scarce available hours to work, which will have the impacts described above; furthermore, for an account renter (let alone an undocumented migrant!), voluntarily stop at a police control will most probably mean having documentation checked, which, for what has been exposed previously, will hardly stand as a true option on the other hand, not taking any of these three actions poses a serious risk of being stopped by the police anyway, except in this scenario, beyond any other eventual illegalities performed, carrying drugs (or even throwing it away, as some proposed in the whatsapp group). while the pdw may argue that this was being done as part of the job, proving it may be far more complicated -notably, this will be particularly more complex for undocumented immigrants. a relevant excerpt would be: april : wg # "how heavy it is with this thing of the deliveries. even if you reject it because you know its drugs and report it, you lose points …" wg # "my husband asked the client to open the boxes in front of him and the man didn't want to. he obviously didn't take it. and told him all sorts of things but his security is first, since he is already risking by going out because he rents an account. of course that for the police you are an accomplice and that's it." all things considered, exceptions notwithstanding, the pdw options are everything but true choices. the insecurity to which they are exposed deems necessary to incur in ever-growing risks (inter alia, exposure to disease and security risks, high degree of probability of being fined by of the police, or even worse) -which renders these as practically false dilemmas: at the end of the day, there is no choice but to comply with the companies' rules and go to work. as i write the last lines of this paper the developments of the covid- are still very much unpredictable. be that as it may, out of the many conclusions that can already be extracted from this health crisis -and which may prove of the essence for the more than likely upcoming economic crisis -, one is surely that there is no such thing as everyone being on the same boat. if anything, the covid- crisis has exposed the multiple-fold consequences of precarity. not that the immunity of some human beings is stronger than others just because of their job and/or economic security, however, the exposure to health and other risks, the way one cope's with temporary economic scarcity, the very ways in which one goes by a period such as this (for now) one month of quarantine, are not the same for everybody. as part of his precariat, guy standing (standing, ) drew attention to how the expansion of precarity has meant the reemergence of the ancient denizenry, i.e. a mass of people whose absence of many rights denied them the entitlement to a full citizenship. while this has always been the case of vulnerable layers of society, such as the undocumented migrants, as this paper has confirmed, these are far from the only ones falling onto this dark category. inasmuch as the existing constraints to circulation and the rapid unfold of events posed some limitations to the elaboration of this papernamely the possibility to have a larger pool of interviewees -, it still stands as a contribution for a broader understanding that the modernization of the labor process does not necessarily entail progress or social justice. nonetheless, still further research on how the covid- crisis impacted the life of precarious layers of societies is needed. among others, two critical aspects stand out as not possible to have been fully grasped by the research hereby entailed: i) to what extent the pdw were exposed to health risks to ensure they would fulfill their mission, and what did the corporations they work for do to actually tackle those risks. ii) disregard the public discourses surrounding the pdw's importance, in a moment when many people are forced (by law and/or by risk) to not to leave their homes, at least one of the companies -most notably the biggest in spain -has decided to lower the retribution per delivery ("dilemma." merriam-webste, ); beyond the outstanding contradiction, both the justifications and consequences of this decision remain unpredictable, but of the utmost interest from a sociological standpoint. as a final word, the present paper seems to underline that unless policies are designed to reconcile the development of technology, justice and human development altogether, the odds are that groundbreaking innovations are appropriated by those already concentrating wealthusing them to their advantage to further improve their already privileged situation -even if that means voting those around them to indecent living conditions. if ever there were any doubts this is the way unregulated capitalism works, the situation of the pdw in the age of covid- leaves very few room for doubts any sort. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. credit authorship contribution statement tiago vieira: conceptualization, methodology, software, data curation, writing -original draft, visualization, investigation, validation, supervision, writing -review & editing. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. humour and social protest: an introduction o privil egio da servidão introduction vida líquida o mercado ilegal das contas de app de entrega alugadas por brasileiros em londres acts of resistance: against the new myths of our time caporalato digitale tra rider, account italiani venduti a migranti irregolari: «dammi il % e ti cedo l'account study to gather evidence on the working conditions of platform workers qualitative research and hypermedia: ethnography for the digital age questioning "digital ethnography the transmediated self: life between the digital and the analog cognitive biocapitalism, the precarity trap, and basic income: postcrisis perspectives labour process theory and the gig economy common ground the relevance of algorithms la crisis del coronavirus provoca la p erdida de . empleos desde el inicio del estado de alarma. el país a brief history of neoliberalism precarity -more than a challenge of social security or: cynicism of eu's concept of economic freedom the app as a boss? control and autonomy in application-based management. arbeit | grenze | fluss -work in progress self-employment as atypical or autonomous work: diverging effects on political orientations airbnb: case study in occupancy regulation and taxation det kvalitative forskningsintervju understanding labour politics in an age of precarity the ambivalence of logistical connectivity: a co-research with foodora riders. work organisation qualitative researching humans and machines at work. monitoring, surveillance and automation in contemporary capitalism capital in the twenty-first century el mercado negro de los «riders» de glovo en madrid: alquilan sus licencias a «sin papeles uberworked and underpaid: how workers are disrupting the digital economy platform capitalism dualism, job polarization, and the social construction of precarious work platform capital's 'app-etite' for control: a labour process analysis of food-delivery work in australia this paper would not have been possible with the insights and incentive of mireia bolíbar, without the comments of daniel romero-portillo and adam tash, and without the contributions and companionship of my quarantine and life partner, ana oliveira. all of them deserve may utmost gratitude. key: cord- - tc ksf authors: schaap, andrew; weeks, kathi; maiguascha, bice; barvosa, edwina; bassel, leah; apostolidis, paul title: the politics of precarity date: - - journal: contemp polit theory doi: . /s - - -z sha: doc_id: cord_uid: tc ksf nan forms that political agency and solidarity might take in response to it, and the appropriate site within which precarious social conditions can be contested and transformed, is controversial. precarity refers to a situation lacking in predictability, security or material and social welfare. importantly, this condition is socially produced by the development of post-fordist capitalism (which relies on flexible employment practices) and neoliberal forms of governance (which remove social protections) (see azmanova, ) . precarity entails social suffering, which is manifested in the declining mental and physical health of both working and 'out of work' people and compounded by the attribution of personal responsibility to individuals for their politically induced predicament (apostolidis, , pp. - ) . precarity leads to social isolation as workers find themselves segregated and alienated by work processes while the capacity to sustain community is undermined (pp. - ). moreover, precarity leads to temporal displacement with precarious workers finding they have no time to do much else than work: they must constantly make time to find and prepare for work and, in doing so, become out of sync with the normal rhythms of social life (pp. - ) . precarity involves social dislocation as people are forced to relocate to adapt to precarious situations at the same time as their movements are constrained and policed (pp. - ). importantly, precarity is distributed unequally, with people of colour, women, low-status workers and many in the global south experiencing its most devastating effects. at the same time, however, some of its aspects penetrate all social strata. as apostolidis ( , p. ) puts it, 'if precarity names the special plight of the world's most virulently oppressed human beings, it also denotes a near-universal complex of unfreedom'. recognizing that anti-capitalist struggle has always been a fight for time, apostolidis ( , p. ) reflects on how this fight should be adapted to our present political conjuncture. to develop this vision of radical democratic politics, he turns to the experience of migrant day labourers to both diagnose contemporary social pathologies and envision alternative social possibilities. the research for the book is based on apostolidis's involvement in the activities of two worker centres located in seattle, washington, and portland, oregon. in addition to participating in various activities of the centres (such as staffing phones and running occupational health and safety sessions), the research team conducted interviews with migrant day labourers. through interpreting the interviews, apostolidis practices a kind of political theory inspired by paulo freire, which he characterises as 'critical-popular analysis' (p. ). by attending to the self-interpretations of the research participants, apostolidis characterises precarity and considers the possibility of its transformation in terms of four generative themes around which the book is structured. the first three themes speak to the experience of precarity: 'desperate responsibility', 'fighting for the job' and 'risk on all sides, eyes wide open'. the fourth theme envisions an anti-precarity politics in terms of a 'convivial politics'. as apostolidis acknowledges, there is an ethnographic dimension to this project since it provides a thick description of the everyday experiences and practices of migrant day labourers. however, it also entails critical-popular analysis since apostolidis aims to co-create political theory with the research participants. he does so by staging a constructive dialogue between the self-interpretations and practical insights of day labourers and the systematic and defamiliarized perspective afforded by critical theory. the fight for time not only provides insight into how some of the most vulnerable people in society experience, negotiate and resist precarity: from this social perspective, it aims to generate a wider understanding, of what agency all working (and 'out of work') people have to challenge the precaritisation of social life. as such, the book pivots on a fundamental distinction between day labour as exception and day labour as synecdoche. as kathi weeks explains below, this paradigmatic understanding of the precarity of day labouring, enables a perspectival shift from the singular experiences and ideas of migrant day labourers to the more general social condition of precarity and the possibility of its transformation. on the one hand, apostolidis considers those exceptionalising forms of precarity that dominate day labourers' lives, differentiating them from other members of society. on the other hand, however, apostolidis considers the significance of day labour as synecdoche for how precarity permeates social relations on a much broader social scale. a synecdoche is a figure of speech in which a part represents the whole. an often remarked on synecdoche in political language is that of the people, whereby the poor (those who do not participate in politics) speak in the name of the citizenry (the people as a whole). similarly, apostolidis treats day labour as synecdoche, according to which the exceptional forms of precarity experienced by labourers might make visible the precarity that increasingly conditions all social relations. in the final chapters, apostolidis explores how worker centres might also function synecdochally insofar as the purpose of association is construed not only instrumentally, as protection against the risks associated with precarity, but in terms of their constitutive potential to sustain convivial networks of political possibility for more mutually supportive, creative and pluralistic forms of solidarity than those afforded by traditional unionised spaces. it is in these spaces, which are both mundane and potentially extraordinary, that apostolidis discerns a nascent form of radical democratic politics that consists in a struggle against precarity. this entails three key elements: first, the refusal of work, i.e. the refusal to allow one's life to be consumed according to one's role as worker within capitalist social relations; second, the constitution of spaces for egalitarian social interaction that resist the imperatives of neoliberal governance, and; third, the reclamation of people's time from capitalist and state powers (p. ) . this recuperation of time (the time robbed from people's lives, which is symptomatic of alienated labour) is fundamental to understanding how day labour might function as synecdoche both of the wider social condition of precarity and the possibility of its transformation. as apostolidis explains, 'working people are running out of time and living out of time ' (p. ; emphasis in original) . in this context, he suggests, day labourers' socialized activities within the 'time-gaps' of the precarious work economy indicate how the 'time of everyday precarity' might be remade into 'novel, unpredictable, and politically generative temporalities ' (p. ) . the contributors to this critical exchange engage with two key aspects of the politics of precarity. the first relates to the subject of an anti-precarity politics and the extent to which the exceptional but inevitably partial experiences of day labourers can function as a synecdoche for the precarity of all. edwina barvosa questions whether identification with precarity provides an adequate basis for an emancipatory politics, given that it may condition unreflexive modes of action. bice maiguashca suggests that an intersectional politics would require attending to multiple exceptions, each with their own set of experiences and aspirations, as the basis for a coalitional anti-precarity politics. leah bassel similarly advocates building a politics of migrant justice from the knowledge experiences that are generated by a matrix of oppression, which requires acknowledging struggles against patriarchy and racism as well as capitalist domination. in this context, she emphasises the political imperative of making settler colonialism visible in any analysis of migrant justice, including acknowledging the social position of migrants as settlers. in contrast, kathi weeks highlights how certain appropriations of the marxian category of lumpenproletariat resonate with apostolidis's synecdochal interpretation of day labour. as such, it can be interpreted as a conceptual articulation of a heterogenous -rather than a homogenizing -political subject. indeed, in his response, apostolidis clarifies that the use of the term synecdoche indicates that the perspectival shift from the experience of day labour to the general social condition of precarity is intended as a contingent act of representationrather than a reductive empirical truth. the second issue relates to the mode and site of political organizing against precarity, encapsulated in apostolidis's demand of 'workers' centres for all'. weeks emphasises the urgency of politicizing workplace death and injury, which is obscured by the managerial appropriation of discourses of health and well-being with increased productivity of workers. yet, she is concerned that workers centres might be susceptible to co-optation. moreover, she wonders whether workers centres require embodied social interaction to be effective or might also be realised in virtual spaces. bassel highlights how such anti-precarity spaces are both sustained by affective labour of women and may reproduce other forms of oppression. maiguashca wonders what the visionary pragmatism that apostolidis ascribes to day laborers has in common with the principled pragmatism that she and catherine eschle observed among feminist activists involved in the global justice movement. barvosa questions the assumption that global inequality is most effectively redressed through the mobilization of oppressed groups according to a salt-of-the-earth script. she invokes instead to an alternative keep-only-a-competency script, according to which social inequality might be more effectively reduced by the voluntary giving of the wealthy. in response, apostolidis elaborates on the benefits of the critical-popular approach he adopts in the book. while the practical focus of the fight for time supports a coalitional politics as a key mode of struggle, apostolidis highlights the limits of a 'coalitional epistemology', which would require a cumulative assemblage of particularised knowledges prior to envisioning a desirable form of mass solidarity. lois mcnay ( ) has rightly highlighted how radical democratic theory risks becoming 'socially weightless' to the extent that it treats the social world as contingent, devoid of any significance of its own and able to be reshaped in limitless ways through political action. radical democrats tend to over-estimate the agency of members of oppressed groups when they neglect the mundane experiences of social suffering, which undermine individuals' capacity to participate in politics (mcnay, , pp. , - ) . as this critical exchange demonstrates, the fight for time challenges theorists of radical democracy to recognise the weight of the world while reflecting on how political agency is shaped, constrained and enabled by the conditions that it seeks to transform. moreover it challenges us to reflect on how political solidarity is possible across the differences and inequalities that are currrently being exacerbated and intensified by the social production of precarity in response to the covid- pandemic. andrew schaap the future of anti-precarity politics the discussion that follows is constructed around three insights gleaned from the fight for time about how to formulate an anti-precarity politics in the u.s. today. the first concerns one target for such a politics, the second its political subject, and the third considers one of its organizational sites. all three draw on apostolidis's approach to day labouring as both singular and paradigmatic, as at once an exceptional case and an exemplar of precarious work in the contemporary economy. i will begin with one of the targets of an anti-precarity politics apostolidis identifies that seems critically important today: publicizing and politicizing the incidents of work-related death and injury. this is one of the aspects of day labouring, which might be distinctive insofar as it is more hazardous than many other jobs, but is also appallingly common to precarious work under postfordism more generally. (if we include the household as a site of unwaged work as well, the rate of workplace injury and death increases dramatically.) apostolidis mentions briefly an encounter with a nurse who talked about the dangers of working intimately with bodies in need, and this certainly squares with the literature on other forms of care work, especially of home health aides (one of the fastest growing jobs in the u.s.), whose privatized places of work, and complex as well as under-regulated employment relations, can easily render workers unsafe. publicizing this issue is difficult because, as apostolidis notes, the problem of workplace death and injury is strangely absent from popular consciousness. public awareness is only occasionally peaked when massive disasters are reported: 'intervallic evocations of shock enable an overall scheme of normalization' (p. ). the anarchist polemicist bob black, in his essay 'the abolition of work', speaks to this normalization -using his own inimitable brand of sarcasm in a bid for attention to the issue -by claiming that we have made homicide a way of life: 'we kill people in the six-figure range (at least) in order to sell big macs and cadillacs to the survivors' (black, , p. ) . in her book on emma goldman, i was struck by the effort with which ferguson ( ) attempts to make visible the violence that capital and the state used against workplace organizing in the late th and early th centuries, which was rarely reported at the time and remains largely absent from our history books. ferguson ( , p. ) even offered, to powerful effect, a visual aid in the form of a six-page list, a 'bloody ledger', of what she could find of the documented instances of violence levied by public and private armies against striking or resistant workers. for the most part, this spectacular, overt wielding of force and violence over workers by the state and capital has been replaced by brutality meted out through the tools and within the routines of the labour process, such that the perpetrators are typically less directly involved or clearly identifiable. i agree with apostolidis when he argues that anti-precarity political activism requires 'a self-conscious, strategically eclectic, affectively inventive politics of the body' (p. ). the trick, as i see it, is how not only to publicize but also to politicize the issue of bodily harm, given how extensively the idiom of health has been rendered amenable to the logics and aims of biopolitical management. what vocabulary can be used when the seemingly most obvious and most legible candidate, the language of health, has become so tightly sutured to measures of productivity and complicit with the 'workplace wellness' programs dedicated to its restoration and maximization? although it may still be a language through which the problem of work-related death and injury can be publicized, particularly in light of the ways it is currently deployed to pathologize various modes of indiscipline, i am less certain that the individualizing and biologizing vocabulary of health can be used as a tool of work's politicization. the second aspect of the analysis that i want to consider once again draws on the day labourer as both a specific figure and an archetype of precarious work in order to think further about how to conceptualize a political subject adequate to a broad anti-precarity politics. the case of day labourer activism would seem to lend support to the proposition that the marxist category of the lumpenproletariat is once again resonant. the concept is not offered as a form of self-identification, but rather as a mechanism of conceptual articulation, particularly across lines of gender, race, and citizenship, that might serve as alternatives to the analytical and political categories of proletariat and working class. famously disparaged by marx and engels as the sub-working class, or, more precisely, a de-classed and disparate collection that includes vagabonds, former prisoners, pickpockets, brothel keepers, porters, tinkers, and beggars (marx, , p. ) , the lumpenproletariat was negatively contrasted to the upstanding 'labouring nation' exemplified by the economically and socially integrated -hence, powerful and politically reliableindustrial proletariat. (although it should be noted that marx and engels include some discards from other classes as well, including the bourgeoisie.) even the unemployed members of the industrial reserve army were posited as fully inside capitalist relations, as opposed to the surplus population relegated to the outside: that subaltern, disorganized, and politically untrustworthy non-class of people 'without a definite occupation and a stable domicile' (engels cited in draper, draper, , p. . engels included day-laborers in his list of the lumpenproletariat, and those who have since tried to reclaim and revalue the category -most notably, bakunin, fanon, and the black panthers -have added as well various modes of petty criminality, maids, sex workers, and 'the millions of black domestics and porters, nurses' aides and maintenance men, laundresses and cooks, sharecroppers, unpropertied ghetto dwellers, welfare mothers, and street hustlers' with 'no stake in industrial america' (brown, , p. ) . while i am interested in the category as a way to make particular connections among prison workers, domestic workers, day laborers, sex workers, laborers in various underground economies, and undocumented migrants, it has also been used to identify linkages among a host of precariously employed people (see, for example, bradley and lee, ) . indeed, refusing the original distinction between proletariat and lumpenproletariat, the latter category could serve as the general designation that links the lumpen to the proletariat through the hinge category of the precariat. engels once criticized kautsky for using the label proletariat as inclusive of what engels sought to set apart as the lumpen class; kautsky's proletariat was a 'squinty-eyed' concept because it looks in both directions, thereby blurring an important distinction (draper, (draper, , p. . perhaps today the lumpenproletariat could serve as a squinty-eyed, broad category, more adequate to a u.s. political economy where the difference between formal and informal employment, employment and unemployment, work and nonwork are breaking down. the specific advantages of this formulation of the lumpen category include its breadth. stallybrass ( , p. ) notes how the lumpenproletariat is often described in terms of the 'spectacle of multiplicity' it evokes in contrast to the unified sameness of the conception of the proletariat. this heterogeneous breadth would seem especially appropriate to a political economy in which, as apostolidis notes, rather than determine who exactly counts as a precarious worker, 'the better question might be: who does not belong to the vast population of the precaritised?' (apostolidis , p. ; emphasis in original) . another attraction of the concept is how marx and engels's pejorative characterization of the lumpen class betrays some of the ways that the moralized understanding of work and family -recall the description of the lumpen as lacking or marginal to the stabilizing force of both occupation and family -haunts their analyses. for this reason, some, myself included, are interested in how the lumpenproletariat can, as thoburn ( , p. ) notes, be figured as the 'class of the refusal of work'-and, i would add, the refusal of family. finally, i am interested in how it was conceived as politically unreliable in a way that seems more realistic than the tendency for some to posit some kind of special 'wokeness' to the working class, only to be disappointed when they turn out to be politically erratic, sometimes acting against what are taken to be their class interests. the third and last point of particular interest for me in apostolidis's theorizing about the politics of work today was the argument about the worker centre as a mode of labour organizing for precarious workers. in thinking about analogous organizational innovations two examples come to mind. both share some resemblances with the worker centre even if they are associated with more privileged workers. the first is what might be characterized as a dystopian version of the worker centre that goes by the label coworking. interestingly, coworking originated from below as activist projects to create spaces of community and collaboration among elements of the white-collar precariat, but as de peuter et al. ( , p. ) note: 'inside a decade, an innovation from below was drawn out of the margins, harnessed by capital and imprinted with corporate power relations'. today, by way of these global real estate ventures, capital can both appropriate the value waged workers create and charge them rent, just as we pay for the households where so much of our free reproductive labour is enacted. but what might seem quite distant from the worker centres apostolidis describes comes a little closer if we take seriously the contradictory (merkel, ) or ambivalent (de peuter et al., ) status of coworking, which may provide opportunities for the convivial mutualism that apostolidis finds in the worker centre while also interpellating members as entrepreneurial individuals, and which 'is animated by a tension between accommodating precarity and commoning against it' (de peuter et al., , p. ) . i am left with a question that i think might be worth pursuing: is coworking best understood as a specular image against which we can recognize the progressive potential of the worker centre, or is it a cautionary tale about its potential to be co-opted? the second comparison is to a very different model of labour organizing for precarious workers. this is a project based in new york city called wage, an acronym for working artists in the greater economy. it started in as a project committed to help artists to be remunerated for all the work they do with non-profit arts organizations and museums. their 'womanifesto' says they demand payment 'for making the world more interesting' (wage, ) . among other initiatives, wage's efforts involve knowledge production about various arts organizations and the contracts they make with independent artistic workers, the development of a platform that helped artists negotiate fair compensation, and a certification for which arts institutions can apply. this approach to organizing precarious workers is comparable to the model of the worker centre in the sense that each of the projects seeks at once to facilitate work and to acknowledge anti-work critical languages and agendas. one of the questions that the comparison with this project raises is whether the forms of convivial mutualism and politicization apostolidis found in the worker centre require the kind of 'embodied social interaction' (p. ) and faceto-face encounters that platform models of organizing do not necessarily prioritize. kathi weeks in , i co-authored a book with catherine eschle entitled making feminist sense of the global justice movement which sought to make visible, audible and intelligible a strand of feminist anti-capitalist activism that was being consistently ignored in the international relations and social movement literatures (eschle and maiguashca, ) . driven by the conviction that taking the words and deeds of the women engaged in these struggles seriously would yield not only a more intricate and complete empirical map of the movement, but also prompt a re-conceptualisation of its meaning and trajectory, we embarked on fieldwork in several countries as well as interviews with activists over a period of several years. by seeking to expose the gendered power relations that marginalise women within the world social forum process, as well as in the academic literature about this movement, and by choosing to speak to and from the feminist struggles that emerged to confront them, the book was written in solidarity with feminist anticapitalist activists. paul apostolidis' book the fight for time encapsulates a very similar kind of intellectual-political project as it also seeks to capture the self-understandings of migrant day labourers in their everyday struggles, to reflect on how they resonate with contemporary critical theoretical concepts and to learn how, taken together, these empirical and conceptual insights may lead us to a renewed vision of what a left politics might look like for our age. like our book, paul's is unashamedly political in intent and, as such, it embodies a form of 'militant research', which 'activates enlivening moments of contact between the popular conceptions of day labourers and scholars attempts to describe and account for precarity in sociostructural terms' (p. ). like our project, paul's research wants to bring what has been rendered marginal, both politically and academically, to the centre of our scholarship and theorising. and like my own work, more generally, paul's is driven by a commitment to revitalising both the theory and practice of left politics. in my contribution to this critical exchange i will draw out the points of contact between our respective approaches as well as tease out what i take to be our differences. in doing so, i aim to underline not only what is distinctive about paul's efforts, but also the shared challenges that we face as critical theory scholars attempting to chart a path for the theory and practice of a collective, transformative politics. more specifically, i want to highlight two broad lines of inquiry that emerge when undertaking this kind of politicised scholarship. the first line of inquiry seeks to open up a dialogue about the challenges that implicitly accompany the quest of constructing a critical theory that can simultaneously speak to and from 'the exception' and 'the synecdoche', or, to put it otherwise, that can light a path from the particular to the universal. the second theme concerns the role of utopian thinking in galvanising and giving direction to a radical left politics that is inclusive and that is fit for purpose in the st century. turning first to the task of critical theory, understood in marx's terms as the selfclarification of the wishes and struggles of the age, it is imperative that one grounds one's analysis in the practices and aspirations of a particular marginalised subject. elaborating on this point leonard ( , p. ) states, 'without the recognition of a class of persons who suffer oppression, conditions from which they must be freed, critical theory is nothing more than an empty intellectual enterprise'. now, while apostolidis and i agree on this, and both of us have chosen 'addressees' that are subjected to oppressive power relations that undermine their life chances and denigrate their ways of knowing and feeling, the conditions and experiences which give rise to and shape their respective ideas and practices are significantly different. indeed, despite some important overlaps, the radical politics and utopian imagination that emerge from each constituency -precarious labourers, on the one hand and feminist activists, on the other -diverge considerably. so, what are these differences, and what lessons might be drawn from this comparative analysis for those of us seeking to develop a comprehensive critical theory that seeks to move seamlessly from the exception to the synecdoche? apostolidis' chosen addressee is the migrant day labourer living precariously from day to day in a hostile environment in the us. framed as an exploited class, apostolidis' chosen subject wages his struggle for survival and dignity on the terrain of labour relations. while paul rightly recognises that day labourers, as a group, are also gendered and racialised subjects, his study remains primarily focused on the collective efforts of male labourers to resist forms of denigration and harm that mark their lives as workers and to overturn the destructive and exploitative practices of an unregulated capitalist economy, more generally. by contrast, my feminist interlocutors were relatively privileged economically in comparison to other women in their respective societies -and certainly to the day labourers of apostolidis's book. moreover, most of these women were well educated and, although many lived precarious professional lives (e.g. their ngo funding was secured year on year), the women themselves were, in the main, leading comparatively secure lives both materially and socially (they had families and belonged to social movement networks). finally, all of our activists were already politicised and involved in consciousness-raising activities (e.g. our fieldwork in brazil exposed popular education as a common practice) and, to this extent, were engaged in a form of feminist praxis that quite self-consciously and explicitly sought to transform the world they lived in. in sum, pace apostolidis' claim that precarity is a 'near universal complex of unfreedom' (p. ), it is not the obvious starting point for conceptualising the challenges faced by these women. given these different starting points, what kind of politics emerges from each constituency, what utopian visions accompany them, and to whom are they directed? for apostolidis, an anti-precarity politics demands a 'post-work' future, one in which we all refuse to assume the responsibility for facing up to and accepting the consequences of precarity as an inevitable condition of life. instead, we are entreated to engage in a 'politics of demand' that seeks to reclaim our wages and our time ('for what we will') from predatory capitalist powers. more concretely, apostolidis outlines several attendant policies, including the introduction of a universal basic income and the creation of affective spaces of embodied social interaction, including multiple work centres. as he puts it, 'if all working people could gain access to workers centres like those that are inspiring such utopian effulgence … such a politics could well find masses of adherents and assume more fully developed form in our common precarious world' (p. ). this is a resolutely anti-capitalist vision of a transformed world demanded by and imagined for all workers. or, to put it in fraser's ( ) terms, this is a bold call for a social politics of redistribution. turning to the feminist activists of my project, we find an alternative vision of what a better, more just future looks like. and while it is also anti-capitalist in orientation, it refuses to centralise either the realm of 'work' or 'workers' as its central axis of liberation. instead, the politics of demand that emerges from this politicised subject targets, not only capitalism as a systemic power relations but also patriarchy and racism. in this context, all three systems of power are understood as interlinked and pervasive to the extent that they cut across all social realms (economy, society, political, cultural) and are reproduced in both the public and private sphere. each however is also sui generis, and therefore, requires specific strategies to be overturned. moreover, on the affirmative side, our feminist interlocutors articulated their vision for the future in terms of two sets of demands. the first took the form of multiple proposals for policy change that seek to address context specific problems, such as violence against women, reproductive health, labour rights including the women's right to work and environmental degradation. the second was normative and universal in nature and revolved around the identification and defence of a set of ethical values -bodily integrity, equality, fulfilment of basic needs, peace and respect for the environment -that go beyond the concrete wish lists of different groups and pertain to all human beings. thus, the feminist anti-capitalist activism that i explored embodied a self-consciously intersectional politics in which demands for material redistribution and social justice were combined with equally important claims for cultural recognition. thus, here we have different struggles, different self-understandings and different visions of a progressive left politics. but if, as apostolidis suggests, 'we need a politics that merges universalist ambitions to change history, which are indispensable to structural change, with responsiveness to group differences that matter because minimizing them means leaving some people out' ( , p. ; emphasis in original), then how do we knit together these connected and yet distinct visions of emancipation? how do we move from the exception to synecdoche if we have multiple exceptions, each with their own sets of experiences, analyses and aspirations? after all, linking 'universal ambitions' to radical social change requires that we have a shared understanding not only of which structures of power need to be transformed/challenged the most, but also of how we go about building a common struggle. and whatever the intellectual synergies, programmatic overlaps and emotional affinities between the struggles of day labourer in the us and that of women worldwide, their utopian dreams would take us along very different, perhaps even incommensurable, paths. given this challenge, the question becomes one of deciding whether we need multiple critical theories running parallel to each other animated by different kinds of oppressions and degrees of marginality or whether we are still looking for a singular revolutionary subject, the one catalyst for change who is able to be both an exception and a universal exemplar, thereby embodying all the demands of the oppressed? this is not just a quibble about who gets to lead the charge: it is about what radical, progressive change should actually look like. as a feminist scholar seeking to find and defend space for an intersectional politics that refuses to be contained and streamlined in any way, i think it is imperative that critical theorists resist the temptation of elevating one concrete subject to that of a universal one. instead, we must engage in far more patient, painstaking ethnographic work of the kind that apostolidis has undertaken on male migrant day labourers, with a range of other addresses or marginalised subjects (e.g. the experiences of female day labourers are, as apostolidis suggests, one good place to start). it is only once these varied, complex mappings of power and resistance are drawn, with the recognition that they cannot be easily merged, that we can begin to look for connections across them and identify possible sites of bridge building which may lead to a convivial politics of the left and to the emergence of a collective dream. whatever it ends up being, my sense is that it will have to take the form of a coalitional politics, one in which sui generis struggles fight alone and together for radical change. the second theme is the role of utopian thinking in galvanising and giving direction to a radical left politics. despite being burdened by a 'relentless presentism' that does not allow them to think about, let alone strive for, a better future, it is clear that apostolidis believes that the 'demand' politics of day workers is suffused with utopian aspirations (p. ). drawing on coles ( ), apostolidis describes their aspirations in terms of a 'visionary pragmatism' (p. ) that combines an overt disruptive politics, that makes them visible and audible to the wider public, with more mundane, everyday practices of solidarity, mutual aid and self-government. interestingly, this view of utopian thinking as granular, incremental and cumulative, as well as eventful, unruly and confrontational, resonates very strongly with the dreams and impulses of feminist anti-capitalist activists. in fact, we deployed the notion of 'principled pragmatism' as a way of capturing their mode of action, in general and its pre-figurative orientation, in particular. for what became clear to us as researchers is that our feminist activists were concerned with articulating not only the political substance of their alternative future and the values that underpin it, but also an ethos by which this future should be brought into being. in this way, the 'principled' part of principled pragmatism sought to underline the highly ethical nature of both the goals/ends of their mode of action, as well as the means designed to achieve them. moreover, we found that this normative mode of action embodied a specific temporality, which was open ended and processual as well as nonlinear. this is, in part, due to the commitment of feminist activists to enabling women to speak and act for themselves, a project which, by its very nature, is unpredictable. it is nonlinear because its pre-figurative orientation demands that the future be lived out in the present. in this way, principled pragmatism is anchored by the imperative of getting things done in the 'here and now' of everyday life, without giving up the goal of radical change in the future. as a mode of praxis that pursues incremental, context specific change, feminist anticapitalist activism presents us with an inspiring alternative to the clichéd dualism of reformism and revolution. the question here is whether the 'visionary pragmatism' of day workers is generalizable to other forms of contestation and, if not, in what ways it might be different from the 'principled pragmatism' of the feminist activists outlined above and what might be at stake in these differences. whatever our different starting points, what all the contributors to this exchange share is an abiding interest in generating explicitly normative, politicised scholarship or what apostolidis refers to as 'emancipatory scripts'. in other words, we all resist the path of what mcnay calls 'socially weightless' theorising, referred to by andrew schaap in his introduction to this critical exchange, opting instead to grapple with the messy world of politics, the material social conditions that hold it in place, and the suffering it engenders. to this extent, we all believe that what we write about and how we conceptualise it matters, not just intellectually, but also politically. for in the end, the stories we tell about the world and 'politics of resistance' that bubble up within it, can contribute to opening up (or closing down) the spaces of possibility for its realisation. pursuing this intuition is becoming harder, however, not only because academia continues to extol the virtues of scientific knowledge, but also because of changes in the political landscape. with 'populism' now elevated as the threat du jour, all resistance against the status quo is in danger of being discursively contained by politicians and academics alike. moreover, the increasingly trenchant calls to drop the left-right distinction in favour of other political cleavages (e.g. 'people vs elites', 'people from somewhere' vs 'people from nowhere') are making it harder to reclaim a politics for and by the left. in this context, critical theorists of all ilks need to stick together, learn from each other and engage in a form of 'epistemological coalition building'. while it may not be the only route to progressive change, as paul rightly points out, it is one worth sustaining, in my view, and critical exchanges of this sort provide one step in this direction. fighting from fear or creating collaboration across economic divides? in the fight for time paul apostolidis offers readers a powerful meditation on the problem and politics of precarity. he contends that precarity is a global problem shared by virtually all who toil in the global economy. through his study of latino day laborers in the us, apostolidis argues that day laborers present a proxy for the precarity of laborers worldwide (pp. - ). through his portrait of the cruel trials faced by day laborers, apostolidis wisely proposes that work centers for all, popular education practices and consciousness raising, as well as a 'demand politics' for better and safer labor conditions, fair pay, and flexible time are necessary to improve the lot of all laborers everywhere. his valuable work thus provides a vision of collective practices that might, if we are persistent and lucky, ease the plight of billions of precariously placed workers across all walks of life worldwide. along with my admiration, this book's fine and yet familiar tones raise for me two questions that i pose here in the spirit of conversation and in sharing in paul's quest for the best ways to realize global prosperity and peace that recoups the time that all human beings need to explore and express their best qualities and capacities. my first question is whether inviting widespread personal identification with precarity -as opposed to identifying with peace, justice, or other motivating concepts -is a necessary step to ignite awareness and action for economic change that recoups time for all (pp. - )? a recent national public radio/harvard university poll shows that in the us, the majority of both the wealthy ( %) and the poor ( %) already share the view that extreme economic inequality is a widespread and serious problem that presents risks to everyone in the global economy (harvard, ) . while wealth and poverty are facts of a balance sheet, precarity is experienced as a feeling or state of mind. this is acknowledged implicitly by apostolidis in his application of lauren berlant's concept of 'cruel optimism', in which precarity is not considered as economic hardship alone, but is an 'affective syndrome' (p. ). thus while wealth and poverty shape experience in material ways, the feeling of precarity is a choice to embrace and/or identify emotionally with a fearful state of dangerous insecurity. but is the choice to identify oneself with the feelings and fears of precarity wise or helpful? dangerous insecurities may arise for anyone, and even the comparatively well off may feel fear of sudden destitution. yet as frankl ( ) observed in man's search for meaning, the responses that we choose to a threatparticularly one's capacity to choose not to succumb to fear -is a central factor in securing human freedom under any conditions. as frankl himself exhibits, even in the life-threatening conditions of a nazi concentration camp, his humanity and true freedom could not be extracted from him because freedom lies in our capacity to choose our own responses to violent and destructive conditions, even unfathomable extremes. thus, in contrast to berlant's cruel optimism, frankl's observation is that even within the vicissitudes of illness, exposure, and hunger, those who faced the concentration camps with dignity, self-worth, and courage were far more likely to survive, and eventually escape those conditions, than those who surrendered to a mindset of fear-based terror and precarity. in short, our chosen mindsets under hardship also shape our prospects for resolution and escape from extremity for better or worse. thus, to choose to embrace affective fear and precarity may ultimately undermine the strength and survivability of the self. if fear of precarity is widely embraced, this may in turn subvert the capacity for collective action in pursuit of economic justice and the reclaimed time that all workers, as apostolidis deftly shows, so desperately need. beyond frankl's philosophy and experience, neuroscience also illuminates the possible hazards of self-identifying with a precarity mindset. in ledoux's ( ) influential work on the interface of emotion and human physiology, the emotion of fear, particularly mortal fear, triggers neurological subsystems of the body that enable rapid responses by bypassing and making temporarily inaccessible the neocortex -the brain-centers of conscious reflection -which are too slow to address risks to mortal safety. in other words, when humans are in fear, we cannot physically access our capacity for conscious reflection until our fear subsides (ledoux, , p. ) . instead, when in fear, the human body defaults to operating on autopilot through whatever neurologically encoded scripts the emergency systems of a given body happens to have for its fear responses, typically including, fight, flight or freeze. arguably, this can be seen in chapter three of the fight for time, in which paul shows day laborers -fearful of missing out on even an extractive job in their precarious conditions -inflict violent harm on one other in a 'surly wrestling match' as a car approaches (p. ). does such fearbased reaction help? not as much as it endangers people, fosters increasing fear and dissention among laborers, and drives away would-be employers. yet this kind of scrum is not a poor conscious choice. instead it is a scripted embodied impulse that is the anticipated neurological consequence of adopting a fearful approach to experience and thereby hobbling conscious response. on this analysis, choosing a precarity mindset risks disabling physical access to conscious, thoughtful reasoning and response in fearful moments in favor of fear-based impulses and reactions that are attendant to moments of fear. these risks of identifying with precarity raise my second question. what blind spots might exist in the familiar narrative of economic reforms championed in the fight for time? the proposed path to reform invites readers to embrace work centers for all and collective action based in common experiences of deprivation that address intra-group biases and divisions along the way. this is an inherited social script that is long-treasured and often invoked. as a common social inheritance among scholars and activists alike it has been portrayed eloquently before in such powerful retellings as that of salt of the earth, the once blacklisted film narrating a famous new mexico labor strike. in this valuable and familiar approach, echoed here by paul, laborers come together to confront and overcome their mutual biases, and then pursue together demands for better wages and benefits. paul's recruitment into one work center's 'theatre of the oppressed,' intended to help workers address their biases, is an example of this longstanding approach in action (p. ). in this script, rich capitalists appear as universally greedy and cruel hoarders whose victims, the long-suffering poor, must now muster the courage to see their commonalities within divisions of race and gender to demand a fair shake from capitalists. this story is rewarding. and it is true that workers everywhere would be better off if this familiar scenario were consistently fulfilled. yet the gains of this approach over time have been slow, sporadic, labor intensive, and often hobbled by the stubbornly persistent biases, suspicions, and enmities of many laborers -as well as owners -weaknesses to which all of humanity is still often prone. in contrast, from a chicana feminist perspective, such as that of gloria anzaldúa, the enduring problem of economic inequality does not call only for looking within worker's groups for sources of intra-group conflict and dissention. it also calls for searching across polarized social divides -of workers and owners, of the haves and the have nots -to explore and create the conditions for peaceful resolution of economic inequality. although venerated in death, anzaldúa was at times scorned in her lifetime for proposing that true peace and justice required people to eventually come together to work across trenchant social divides: people of color working with whites, women with men, immigrants with non-immigrants, and so on (anzaldúa, ) . this anzaldúan chicana feminist perspective urges us to not overlook the possibility of working generatively across the divides among workers and owners, a possibility in the blind spot of the salt of the earth narrative in which economic benefits must always be fought for and hard won rather than produced through collaborative vision and effort. following this traditional script, the fight for time's focus on work centers and the fight of traditional labor activism implies that attempts to collaboratively bridge the worker-owner divide may be futile, naïve, or at best irrelevant. yet among the ultra-rich, practices of large-scale philanthropy are emerging which suggest that there is more transformative common ground between laborers and some owners than the traditional salt of the earth viewpoint can yet acknowledge. if so, then attending to this common ground may help remedy the lack of time, economic freedom, and financial stability needed by everyone more quickly and effectively than the fights and struggles of work centers, strikes, and direct actions have historically achieved. specifically, in recent years carnegie's ( ) assertion that successful capitalists should ideally end their financial careers by giving away all of their wealth, retaining only a personal competency -defined by carnegie as enough wealth to meet their own life needs and that of one's family -has been gaining a following. reflecting this view, in two of the world's wealthiest billionaires, bill gates and warren buffet, created an organizational structure called the giving pledge ( ), in which ultra-wealthy people across the world pledge to give away the majority, or at least half, of their wealth in their lifetime or upon their death. to date, over ultra-wealthy individuals and families have made this pledge, including five of the top thirteen billionaires on earth (i.e. bill gates, warren buffet, elon musk, mark zuckerberg and mackenzie scott). in july , these five pledgers command a combined total net worth of $ billion usd (bloomberg bi, ), representing an estimated philanthropic giving over time of at least $ billion usd by those five pledgers alone. if a growing number of the ultra-rich are voluntarily committed to giving away their wealth for the benefit others, then -by adopting an anzaldúan perspective on working across economic and other social divides -it becomes valid to explore beyond the familiar salt of the earth script hailed in the fight for time. doing this would involve considering how engagement across social divides of workers and owners may help direct emerging philanthropy into social justice philanthropy that could potentially ease global financial inequities more quickly and resoundingly than the efforts of work centers and traditional labor actions have done to date. such a move could potentially recoup both time and transformative possibilities for the benefit of laborers, as well as owners, and provide sustainability benefits for the planet from a revised economy. by shining an anzaldúan chicana feminist perspective into the blind spots of the fight for time, apostolidis's project is not abandoned, but augmented by bringing unforeseen possibilities into view. new possibilities might arise from organizing with willing and openhearted owners, rather than fighting against them as a class to retrieve the time and financial freedoms precious to all. in moving beyond the view that labor and owners are always divided (rather than only often so), it becomes possible, for example, to imagine efforts in large-scale social justice philanthropy that could, for example, provide everyone on earth with a carnegiesque financial competency. for the sake of discussion let's imagine that such a personal competency would be $ million usd per person worldwide. with . billion people now on earth, the core funding for a $ million dollar safety-trust for each person at present on earth would require . billion usd. that sum seems large, yet it is less than % of the combined minimum pledge, of the five of the signatories to the giving pledge named above. of those five givers, mackenzie scott herself is committed to giving away all of her $ . billion, a sum that alone could handily endow a universal personal competency worldwide. thus at least in terms of core capital resources (even accounting for the illiquidity of many assets of the ultra-wealthy), a universal competency could be funded by a small fraction of the funds already pledged for giving by the world's ultra-rich. in this context, self-identifying with fearful precarity and fighting for traditional reforms through work centers and labor actions for the changes so urgently needed in the (now pandemic-stricken) world may be worthy in our traditional socially inherited script of salt of the earth-style social change. yet this accustomed approach arguably now may be less wise and expeditious than other emerging options. if so, it is worthwhile to explore the limitations of our commonplace labor-related scripts and to confront as needed our own potential blind-spots regarding the diversity among the ultra-rich that could -in an anzaldúan manner -help us to better see new possibilities for bridging economic divides and opening ourselves to collaboratively producing transformations that can benefit all people and the planet upon which we reside together. is resolving the pain of global poverty through philanthropic giving so farfetched? it is not as implausible as so often thought. alongside the kinds of labor actions hailed in the fight for time, in recent months one us billionaire chose to pay the college debt of an entire class of morehouse college totaling over $ million usd. another man paid the college debt of his uber driver, a single mother, thereby enabling her to finish her college degree. by chance, the latter giver is a well-off white man and the recent graduate an african american woman. meeting as strangers by chance, the two have now become friends and their story has gained popular attention. if giving to strangers in need is not merely feasible but also appealing, why is it perhaps emerging more visibly now? it may be because many humans are learning that beyond a meaningful competency, wealth does not necessarily create happiness, but that human connection and giving often do. if so, then a season of transformational giving may be on the near horizon. if these events reveal a nascent turning of the tide, there are still many obstacles on the path of philanthropic giving-for-global-prosperity. if a pathway to funding a universal competency could be created through social justice philanthropy, for instance, this would also need to involve further measures for healing the poverty-related traumas so aptly described in the fight for time. beyond a basic endowment, provisions would be needed to provide for new learning, safeguards, and other supports for recipients in order to truly solve the lingering problems of precarity. why? because those who come into sudden wealth from poverty and lack often risk experiencing poverty once again through missteps, fraud, or other hazards arising from a rapid change in economic conditions. thus even if furnished with a financial competency, in the context of hazardous grafts, frauds and other pitfalls that remain mainstays of us culture (young, ) , latino day laborerslike the vast majority of other workers alluded to in the fight for time -would need additional training to cultivate the skill sets and mindsets needed for living with meaningful wealth after having had little or no prior knowledge or instruction in how to hold, manage, or grow the would-be competency that could furnish them at last with time and freedom from extractive labor. is the idea of philanthropic solutions to global economic inequalities simply another example of 'cruel optimism'? by berlant's ( , p. ) definition, optimism is cruel only if the desired change is truly 'impossible or too possible and toxic'. clearly, however, changes are emerging that make meaningful large-scale social justice philanthropy possible, even if those changes are growing in the shadow of predatory economic practices. with these changes in view, it is worth asking whether paul apostolidis's fine call to 'fight' to retrieve time across all laborers might be best served by extending our willingness to also seek common cause not only among diverse workers, but also among those openhearted wealthy owners who are willing to give back their wealth to benefit the well-being of all humanity. if so, it may be worth our time not to fight for time, but instead to work collaboratively and creatively for time and wealth to become equitably available to everyone in unexpected ways. edwina barvosa whose politics? whose time? traditionally, political theory has not co-theorised. it has spoken from on high among 'male, pale, stale' companions. hence my defection from these ranks. in this dialogue with paul apostolidis' the fight for time, i would like to recognise the attempt to co-theorise. in this work some migrant day labourers' voices, described as latino, are represented through ethnographic moments. bodies, presumably cis-male, are portrayed in struggle. this day labour is proposed as 'synecdoche' -the part that stands for the whole -by which is meant precarity on the grand social scale (p. ). thus, the collective fight for time is staged. demands include: a politics that goes beyond seeking marginal relief from overwork and instead fundamental alternatives; a repudiation of the work ethic that prescribes personal responsibility in the face of desperation; the demand to restore time as well as wages to the people; a refusal of work 'as the axial concept that constricts working people's social and political imaginaries' (p. ). i can only respond from outside of the social and political world the book portrays. i am not latinx/latin@ (hence the unsatisfactory use of terms that are, themselves, the site of struggle), but white, cis female, and belonging to many other privileged social locations. from my vantage point i explore struggles for migrant justice and against austerity and precarity at the intersections, drawing on lessons from black feminism and indigenous scholars writing in the context of the ongoing violence of settler colonialism. i ask: whose politics? whose time? whose politics? whose knowledge counts as the basis for politics? i cannot accept proposals, as in this book, to radiate outwards from some bodies and experiences -people presented as cis-gender latino men, workers -as the part that stands as the whole, the synecdoche. this is a project of inclusion: generative themes are based primarily on these experiences, to which others must then align. this story has been told before. it is of a linear, sequential march toward 'justice'. some are at the centre, in the lead, and others need to wait their turn to then be included. add and stir. who must wait their turn? in this work, this sounds like (presumably cis) women domestic workers who are mentioned but peripheral to this study, as well as those who experience misogyny and harassment at the worker centres (pp. , , ) that are to be the incubators of progressive alternatives and the collective fight for time. we could add here the women who founded and run the worker centres in this book, who are barely visible but are also key protagonists of anti-precarity and antideportation struggles. those who must wait also surely encompass malepresenting others who do not identify with what are referred to in the book as the 'normative' masculinities deployed in the worker centres (p. ). what happens when the political knowledge of queer, non-conforming, differently gendered actors is parked for consideration later on? what politics is generated when these experiences and these intersections are named at the end of a book (pp. - ), after the contours of struggle have been determined against precaritisation 'as the array of social dynamics that structure these settings' (p. )? it becomes possible to call for 'workers centres for all workers'. and thus a space for the resistance of some is built on the oppression of others. theorising this as synecdoche does not name the problem or open up the space for resistance to multiple, intersecting oppressions. it does not centre as part of the theory the messy and vital struggles of workers' centres to change representation on governing boards, to reconfigure resistance to border control in recognition of the specific brutality experienced by lgbtq migrants (p. ) and to bring into focus all forms of work (p. ). this call, 'workers centres for all workers', chills me without scrutiny of all gender relations and all gendered labour -and i mean all, beyond gender binaries, at multiple intersections. what can the 'repudiation of work' mean without naming cis heteropatriarchal relationships of domination, in ableist and racialized capitalist systems that pervade all 'public' and 'private' realms? this book asks how various groups of workers articulate terms of their consent, how regimens and discontinuities of body-time on the job vary between different groups. but this undertaking is impossible without articulating at the same time the terms of consent to cis heteropatriarchal relations in and outside of the workplace. oppressors are not only employers. they are also other workers, community and family members, who are cis men and women embedded in hierarchies that include gender, class, race and legal status. what would it look like to build a politics for migrant justice, against austerity and precarity starting with the knowledge of experiences of a matrix of oppression (hill collins, ) ? this is no synecdoche. it is the challenge of forging justice at the intersections. these are not new lessons to learn and there is no way to do justice here to all the illustrations of this kind of politics in practice. from my past work, one example from france in the s, may provide purchase on us-based challenges. in paris, madjiguene cissé led movements for the regularisation of 'sans papiers' -people 'without papers'. she described the 'struggle within the struggle' by women 'sans papie`res' (the feminised version of 'sans papiers') for gender equality within the movement, as well as regularisation of immigration status. this was a struggle against patriarchy as well as the racism of the french mainstream. the knowledge that sans papie`res women imparted in the struggle meant that they were in charge of their own thought and politics but without excluding others (hill collins, , p. ) , and they did not project separatist solutions to oppression because they were sensitive to how these same systems oppress others (hill collins, , p. s ) . women revitalised the movement and kept it together: 'a role of cement' (cissé and quiminal, ) . cissé explains how women kept the group together particularly when the government attempted to divide them, by offering to regularise 'good files' of some families, but not of single men. sans papie`res very firmly opposed this proposal, arguing that if single men were abandoned, they would never get their papers. migrant justice, anti-austerity and precarity politics look different when built at these intersections. the difference lies in who is present and also in what results. care and self-care are centred as 'an act of political warfare' in a system in which some were never meant to survive (lorde, ). self-help, self-care and selforganising are alternative, sometimes complementary spaces, and an important source of personal support, resilience, information and community, beyond whitedominated, politically raceless, misogynistic anti-austerity/precarity spaces (emejulu and bassel, ) . no part can stand for any whole when other spaces are unsafe and sites of violence rather than a collective fight for time. whose time? in our work exploring the activism of women of colour across europe, akwugo emejulu and i have argued that epistemic justice is about women of colour producing counter-hegemonic knowledges for and about themselves to counter the epistemic violence that defines white supremacy (emejulu and bassel, , p. ). epistemic justice is not a correction or adjustment to 'include' unheard voices, but a break away from destructive hierarchical binaries of european modernity. it is a break away from the 'persistent epistemic exclusion that hinders one's contribution to knowledge production' (dotson, , p. ) and renders women of colour invisible, inaudible and illegitimate to both policymakers and ostensible social movement 'allies'. epistemic justice at the intersections makes settler colonialism visible, whether in the united states of this study or so-called canada, where i grew up. this means going much further than the possibilities briefly flagged in the book: kindling a critical sense of historical time and orientation to the future that is fuelled by an awakened sense of historical injustice (pp. - ). it is necessary to go much further because the fight for time cannot be founded on indigenous erasure. erasure does not create a path toward solidarity 'with other colonised populations who understand their past experiences in somewhat parallel ways' (p. ). this book discusses workers turning a day-labour corner where jobs are fought for in portland into a space of musical performance. these are important moments to explore and co-theorise. but when they are described as transforming the space into a 'site of freedom' (p. ), indigenous struggles are erased. these performances are taking place on stolen land in what is now referred to as 'portland'. tuck and yang's ( ) key work 'decolonisation is not a metaphor' rattles the kind of settler logic that allows for this erasure. they discuss the occupy movement and argue that claiming land for the commons and asserting consensus as the rule of the commons, erases existing, prior, and future native land rights, decolonial leadership, and forms of self-government. occupation is a move towards innocence that hides behind the numerical superiority of the settler nation, which elides democracy with justice and the logic that what became property under the % rightfully belongs to the other %. in contrast to the settler labour of occupying the commons, homesteading, and possession, some scholars have begun to consider the labour of de-occupation in the undercommons, permanent fugitivity, and dispossession as possibilities for a radical black praxis … [that] includes both the refusal of acquiring property and of being property (tuck and yang, , p. ). the fight against precarity and for migrant justice must be reconfigured, if it is to be in solidarity with indigenous struggles. this means changing whose understanding of time and labour are at the centre of analysis. the land where this study took place is not an 'immigrant-receiving country' but a settler colony, founded on indigenous genocide, dispossession and slavery. when time is decolonised, the refusal of work is recast in relation to the refusal of the settler colonial state (simpson, ) and the formations of race, class, gender that it engenders. these formations, rooted in settler colonialism, shape the lives of the migrant day labourers who are 'here' because the united states was 'there' (sivandandan, n.d.) and must contend with entangled colonial legacies from different social locations. this requires a shift in vocabulary, when 'migrants' are in fact settlers. but with this comes also a shift in politics. in undoing border imperialism, walia ( ) shows how movements such as no one is illegal (noii) in what is now called canada have reconsidered their understandings of migrant justice. this has required recognizing the ways in which their actions have been premised on an understanding of sovereignty and territory that perpetuates the colonial legacy that has dispossessed and disenfranchised indigenous peoples (walia, ) . noii activists consequently re-centre ongoing colonialism and reconfigure understandings of land, movement, and sovereignty when claiming that 'no one is illegal'. specifically, activists have tried to consider how their calls for 'no borders' undermine indigenous struggles for title and against land loss, to reclaim land and nation. solidarity means reshaping the political agenda of noii beyond token acknowledgements, to move from a politics of 'no borders, no nation' to 'no one is illegal, canada is illegal' (fortier, ) . and now? i asked two questions here: whose politics? whose time? they remain unanswered. but they are a path to solidarity rather than solutions. so it goes in the messy world of politics, not political theory. leah bassel representing precarity: health, social solidarity, and the limits of coalitional epistemology in her contribution to this critical exchange, kathi weeks poses an unexpectedly timely question about how to politicise precaritisation in the form of heightened bodily risk at work. writing prior to the coronavirus outbreak, weeks echoes my observation in the book that, apart from the temporary rush of reporting when an occupational safety and health (osh) disaster strikes somewhere in the world, 'the problem of workplace death and injury is strangely absent from public consciousness'. how quickly things can change. i am writing this response in april in london, now in its fifth week of 'lockdown'. in this context, weeks's reflections prompt two questions: first, in what specific ways has the covid- crisis made workplace threats to life and health newly legible? second, what ramifications do state and employer responses to the pandemic have for the pressing issue of how 'to politicise the issue of bodily harm given how extensively the idiom of health has been rendered amenable to the logics and aims of biopolitical management', as weeks aptly puts it? i still see the outlines of an answer to the second question in the politics of solidarity around osh matters that day labourers have developed through worker centres. today's work-culture construes the task of sustaining the worker's health as the worker's personal responsibility, which the worker also exercises as a productivity-oriented social duty. many day labourers abet this tendency through their own themes of meeting the 'risk on all sides' by individually keeping their 'eyes wide open'. yet day labourers also demonstrate how health-related language, desires and practices can be cathected with a different figuration of social and individual conscientiousness: responsibility as autonomously collective solidarity. day labourers pose this alternative in three main ways. first, through convivial relations at worker centres, day labourers bolster one another to stand up to abusive employers, to refuse dangerous jobs and to de-throne work and income from their primacy in everyday affairs. second, day labourers contest biopolitical powerknowledge by fusing their own analyses of work-hazards to responsive practices of their own devising, as they teach one another about risky work processes, materials and employer conduct through popular education. third, day labourers are hatching visionary ideas about how distinct working populations can recognise their common stakes in ending the bodily precaritising dimensions of work, such as by organising with, not just against, their middle-class employers. in all these ways, at day labour centres, the talk of putting 'health' first mobilises a complexly social vernacular. one's 'own' health is always a concern, but the worker's understanding of 'health' does not stop with the individual. instead, this idiom positions health as stemming from social interactions that are contingent on power-differences, which are amenable to workers' collective re-formulations, which, in turn, need not be determined by the ideal of productivity. politically, these initiatives by day labourers imply that disentangling health-talk from the corporate wellness apparatus depends on autonomous action from below in tandem with cross-class organising. the role of the wizened welfare state in such efforts, however, is not clear -and that brings us back to the coronavirus. talk about 'biopolitical management'. the crisis has precipitated massive deployments of state resources to expand public health knowledge-systems and to use statistical probability calculations to foster mass populations' biological vigour and protection from disease, albeit in racially selective and gender-unequal ways. must this tidal wave of emergency mobilisation re-sediment personal responsibility and productivism as the norms that regulate occupational safety and health? or, as this surge recedes, could it leave behind institutional beachheads for fighting precarity on the level, and within the sinews, of the working body? even as the present apotheosis of biopolitics applies itself globally and to entire nations, it targets micro-practices in the workplace and affects precarity's configuration of work as a zone of bodily hazard. overall, the covid crisis reduces to the point of vanishing the already quite faint and episodic awareness of how mounting osh threats have made the workplace increasingly dangerous to workers' health for decades, across occupations. the fight for time discusses how these threats principally entail work-environmental hazards, especially poor air quality as more work is done indoors, ergonomically dysfunctional work-processes, and debilitating stress due to corporate downsizing and rising job insecurity. ironically, the pandemic's sudden re-framing of the workplace as replete with health dangers focuses on the work environment. it does so, however, in terms that reproduce the moral individualism of the precaritised osh culture, while occluding the work-environmental systems that generate endemic hazards. thus the exhaled breath of a single co-worker becomes the respiratory threat, rather than the air circulation machinery in the office or warehouse. health-conscious bodily comportment means obeying the individual remonstrance to keep six feet away from any colleague rather than ensuring that the ergonomics of work-procedures avoid forcing workers to contort their bodies and overstrain their tendons. the stress of losing one's job, having work hours reduced, or fearing these things because of the virus's immediate economic effects, normalises the ongoing anxiety that is baked into precarious work-life and linked to heart disease. the hyper-individualisation of osh hazards in the covid- crisis and the fingering of co-workers as those who pose lethal hazards to us also clearly discourage building safer and healthier workplaces through solidarity among workers. such miscasting of fellow workers as the culprits whose irresponsible conduct explains why everyone's health is in jeopardy bedevils many day labourers' attempts to rationalise the contradiction between expectations of personal responsibility and the power-relations governing their work. the pandemic further embeds this thought-habit of precarity. meanwhile, consigning 'essential' workers in some occupations to higher risk exposures while others 'shelter at home' and assemble via zoom aggravates the difficulties of organising across class lines. in all these ways, the pandemic has made it harder to dislodge health discourses from their current ensnarement in norms of productivity and individual responsibility. yet the sheer size and weight of institutional responses to covid- also presents an opportunity to argue that, if states and employers can so speedily muster these titanic responses to this virus, then the capabilities are there, more obviously than ever, to tackle the endemic osh challenges that constitute the bodily mortifying facets of precarity even in 'normal' times. this will only happen, however, if working people redouble their organising efforts. and that makes the project of founding worker centres for all workers even more vital: extending the scaffolding for leadership development and autonomously collective organisationbuilding along with new ventures in state-sponsored redistribution, such as a universal basic income. bice maiguascha correctly observes that she and i share aspirations to pursue critical theory in ways informed by the ideas she cites from marx, leonard and militant research, and i am glad she sees in my book the work of a fellow traveller. for us both, this means doing theoretically evocative social research from positions of active engagement within political struggles against oppression and with the aim of contributing something tangible to those struggles. maiguascha and eschle's research with feminist anti-capitalist activists also illuminates how political agents quite different from those who occupy centre stage in my book can pinpoint 'systemic power relations', including gender, that are fundamental in their own right and need to be contested both as such and via the demands these women raise. in response to maiguashca, let me also underscore that, notwithstanding the near-exclusive focus of my fieldwork on male, latino day labourers, the fight for time affirms, explicitly and in its intellectual practice, the need to theorise politicaleconomic power and contestation in ways that attend to the complex gendered and racialised aspects of work. maiguashca allows that my book 'recognises that day labourers … are gendered and racialised subjects', but the book does more than this. it probes the masculine ideals woven into these workers' themes, explores how the racial state constitutes precarity through policing migrants, distinguishes day labourers' varied renderings of latino identity, and draws on my own supplementary field work and secondary literature to suggest how domestic workers' conceptions would likely both differ from and align with those of day labourers. maiguashca also implies that the book searches 'for a singular revolutionary subject' and anoints the day labourer as 'the one catalyst for change', but the fight for time does neither. if my statements in the book to the contrary do not suffice to show this, then it should still be apparent from the book's premise of basing a critique of capitalism on research with workers who, as weeks notes, resemble marx's disparaged and heterogeneous lumpenproletariat, rather than the traditional proletariat. i stand firmly in sympathy with the efforts of weeks and other theorists influenced by autonomism to widen and complicate the notion of 'the working class', as weeks does by training our attention on women's reproductive labour in households, and as studying day labourers does by foregrounding a liminal and ambiguously gendered realm between productive and reproductive labour. the analytical rubric that positions day labour as both exception and synecdoche in relation to precarity writ large appears to lie at the heart of what most troubles maiguascha and leah bassel. let me thus address further what this interpretive framework means, going somewhat beyond what is already in the book. the exception/synecdoche formulation is intended as a strategy of provocation: a prod to imagine how the critical language of one especially benighted group, which has done a remarkable job of building itself up politically, could shake loose new ways of construing overarching forms of power and domination. such general structures, systems and flows of power and domination exist, and they need to be named in order to be engaged politically. this does not obviate the fact that any act of naming by a situated subject is also bound to yield misnomers because of that person's or group's particularised social location. moreover, as mezzadra and neilson ( ) argue, capital itself regenerates, accumulates and dominates both through systemic processes that integrate the globe and through localised 'operations' that proliferate heterogeneities of experience, identity and activity (including work-activity). this, however, makes it imperative to theorise capital on both levels at the same time, through critical procedures that juxtapose the general and the particular, teasing out their resonances and tensions. one models the whole with the help of closely scrutinising an always-insufficient particular, then re-envisions the systemic through considering other concrete-particulars, and so forth. a synecdoche is a part that stands in for the whole, but this notion's origin in literary theory bespeaks selfawareness that this figuration is a contingent act of representation -rather than a straightforward declaration of truth. furthermore, critical-popular analysis does not simply infer the whole from a part but rather effects mutual mediations between self-expressions of the part and conceptions of general dynamics. the fight for time pursues this path by reading day labourers' themes together with allied concepts from critical and political theory about broad formations of precarity. this is certainly a different way of reaching a provisional sense of society-wide power than that preferred by maiguashca, but it has its virtues. one virtue has to do with the temporality and affectivity of collective action that seeks to confront thoroughly pervasive forms of social, political and economic power. having exhorted readers to pursue with other groups more of the finegrained ethnographic analysis that my book provides, maiguashca then cautions: it is only once these varied, complex mappings of power and resistance are drawn, with the recognition that they cannot be easily merged, that we can begin to look for connections across them and identify possible sites of bridge building which may lead to a convivial politics of the left and to the emergence of a collective dream. this statement conveys a political temporality of postponement as well as an ascetic tinge, and i question both. if capital and other systemic forms of power are perpetually in motion, always mutating, and never ceasing to employ both universalising and particularising modes of operation, then it makes little sense for theory to hold its own generalising capacities in reserve until it has amassed some critical mass of analyses of situated perspectives (and how could a non-arbitrary threshold be specified?). strategically, this appears unwise. affectively, something also seems awry with the gesture of renunciation one must make to defer the invigoration that comes from battling broad-scale domination, while also letting systemically generated suffering endure without being called out as such. the critical-popular approach, in contrast, partakes in the affective spirit of weeks's 'politics of the demand'. this means taking seriously both the re-constituting of desiring subjects in the midst of utopian struggle and the value of fighting for a 'collective dream' that is massive and radical -like 'worker centres for all workers' or 'wages for housework' -but neither totalising, nor conclusive. another virtue of the critical-popular approach to theorising the whole, in comparison to mapping specific differences and then building localised bridges, is that the former offers not just an alternative to the latter, but also a prelude to it. my book not only juxtaposes day labourers' popular themes with academic concepts to theorise precarity writ large and anti-precarity struggle, but also shows how worker centres, the day labour movement and a broader anti-precarity politics all depend on developing popular consciousness and political action-plans through molecular processes and alliance formation. the book's practical contribution to day labour centres' popular education programming, through workshops i conducted, as well as a report i wrote with additional dialogue options, further shows this project's commitment to fostering intersectional interactions of the kind that maiguashca and bassel endorse. the fight for time thus supports coalitional politics as one key mode of struggle needed to define and confront precarity. it takes issue, however, with what we might call a 'coalitional epistemology', or the idea that understanding power on the broadest levels and identifying desirable forms of mass solidarity, can only occur through the cumulative, piece-by-piece assembling of particularised knowledges into progressively larger composites. along these lines, it bears emphasis that the fight for time is one of two inaugural books in my publisher's series 'subaltern studies in latina/o politics', edited by alfonso gonzales and raymond rocco. i am honoured to have my book involved in this effort to support work that brings together latino studies and political theory. the series is also promoting research on latino/latin-american transnationalism (félix, ) , contentious citizenship and gender among salvadorans in the us, and religion, gender and local agency in mexican shelters for central american migrants. colleagues interested in how my book contributes to more wide-ranging discussions of race, ethnicity, migration and gender, and to coalitional politics, should be aware of this context. for the most part, my responses to maiguashca, and defence of the criticalpopular method above, comprise my answer to leah bassel as well. bassel shares with maiguashca a similar orientation toward critique and political action, which bassel describes as embracing 'the challenge of forging justice at the intersections'. bassel argues, however, that rather than either encouraging consideration of other oppressed groups' experiences or incorporating such analysis into the book, the fight for time suppresses and erases such experiences. i strongly disagree. as i have explained, there are good reasons for understanding the logic of the synecdoche as evoking provisional renderings of broad power dynamics in ways that invite -rather than discourage -contestation. readers hoping to join a 'linear, sequential march toward ''justice''' will search in vain for marching orders in my book. bassel also does not mention how the book frames day labour as both exception and synecdoche in relation to precarity writ large. this dual optic makes basic to the book an appreciation for the specificity of day labourers' social experiences. it thus signals clearly that attentiveness to situated subjectivity is a sine qua nonthough not the sole legitimate basis -of critique. in this way, my book underscores how the forms of precarity thematised by day labourers reflect, for instance, their particular position in the urban construction economy and their specific vulnerability to the racialized and gendered homeland security state. this implicitly affirms the value of hearing what other groups of workers, situated distinctly, would say about precarity. at the same time, bassel's commentary neglects a different problem with which my book grapples: the need to challenge the invidious naturalisation of assumed group differences. white middle-class americans, for instance, certainly need to understand better what makes the lives of working-class migrants in the us both different and harder. but the former also need a better grasp of how their own economic, political and bodily fortunes resemble those of the latter much more closely than most would like to admit. anderson ( ) calls for 'migrantizing citizenship' as a tactic for waking britons up to how the shrill demand to save 'british jobs for british workers' has precaritised work for everyone. in a similar spirit, the fight for time appeals for precaritised workers throughout society to recognise their shared stakes in a common struggle, even while observing how the stakes are graver, and different, for some than for others. i do see it as a limitation of my research that, although it delved into the complexities of day labourers' commentaries and traced their interactions with an eclectically convened set of theoretical interlocutors, it did not include substantial fieldwork with other precaritised workers. thus, i could not critically compare such workers' generative themes with the themes spotlighted in the book. the conception of critical-popular research is in its formative stages, and maiguashca's and bassel's comments, have fuelled my interest in exploring how a future project could bring such critical moves into the heart of the inquiry. planning such work with migrant and indigenous subjects (including indigenous migrants) would offer one attractive pathway for doing this, especially given the anti-capitalist trajectories of leading critiques of settler colonialism, which prioritise spatial and temporal politics that may both align and conflict with migrant endeavours (coulthard, ) . in the meantime, i appreciate maiguashca's and weeks's invitations to speculate about how day labourers' themes and organisational spaces might relate to those of other groups. i see an affinity between feminist wsf activists' embrace of an 'ethos' whereby organising processes 'prefigure' radically altered social relations and the day labourers' anticipatory enactment of the 'refusal of work', -even as they desperately pursue jobs, and even though the day labour network takes no stand for such a refusal. as these lines suggest, however, day labourers pursue social change by generating transformation from within, and by virtue of acutely contradictory circumstances. i wonder whether a similar catalysis of power-fromcontradiction plays a role in the wsf activists' undertakings, or whether perhaps these women's class privileges permit a more confident sense that an ethically consistent programme of action is possible in ways that are precluded for day labourers. that said, it would be intriguing to know if the activists in maiguashca's research feel subjected to class-transcending temporal contradictions of precarity, such as the clash between oppressively continuous and jarringly discontinuous patterns of work. even if precarity does not furnish the express 'starting point' for these women's advocacy, it might still provide a basis for solidarity with the day labour movement in the broad fight against capital. barvosa asks whether encouraging people to identify with the timorous mindstate of precarity might be politically counter-productive, given how fear induces corporeal responses that shut down complex thinking, induce self-preserving automatism and impede cooperation. as the book shows, however, the emotions that pervade precarity include not just fear but also guilt, hopefulness, selfsatisfaction, resentment, boredom, numbness and compassion, and more. precisely because precarity is so emotionally plural, it both acquires compelling force and spawns opportunities from within itself for its own contestation. in addition, precarity is more than a 'state of mind'. it is also a socially and politically constituted condition that stems from the convergence of protracted welfare-state austerity with the transformation of employment norms and institutions. precarity, moreover, is a hegemonic formation that relies on working people's consent, which day labourers provide, for instance, through the individualism of their generative themes. yet precisely for this reason and because it is structured in contradiction, especially temporally, precarity can be transformed from within. as my book argues, many workers prefer to see the worker centrecommunity as just a 'workforce' and in this way 'identify emotionally with a fearful state of dangerous insecurity', as barvosa fittingly puts it. yet more day labourers respond to fear -along with confusion, rash self-confidence, impatience and loneliness -by acknowledging these tangled emotions and converting their affective energy into bonds of solidarity. as to gates and buffet, i am glad they are giving away mounds of money and have updated philanthropy's ethical framework, but relying on a programme to broaden beneficent actions does not strike me as a viable response to precarity. as azmanova ( ) argues, in ways complementary to the fight for time, the systemic roots of precarity lie in the competitive pursuit of profit, and precarity's structural foundations abide in the re-organisation of work and de-funding of the welfare state. absent a coordinated and democratic (anti-oligarchic) movement by masses of working people to tackle power on these levels, precarity will persist. the emancipatory script proposed by my book, far from simply pitting poor downtrodden workers against greedy bosses, casts working people at all levels of the economic hierarchy as potential collaborators in the fight against precarity, which must also be a struggle against gargantuan wealth -and a fight for time. paul apostolidis new directions in migration studies: towards methodological de-nationalism now let us shift…the path of conocimiento…inner work, public acts the fight for time: migrant day laborers and the politics of precarity capitalism on edge: how fighting precarity can achieve radical change without crisis or utopia cruel optimism: on marx, loss and the senses the abolition of work a taste of power: a black woman's story ) the gospel of wealth. www.carnegie.org/about/our-history/gospelofwealth visionary pragmatism: radical and ecological democracy in neoliberal times red skin, white masks: rejecting the colonial politics of recognition the ambivalence of coworking: on the politics of an emerging work practice conceptualizing epistemic oppression the concept of the 'lumpenproletariat' in marx and engels the politics of survival. minority women, activism and austerity in france and britain making feminist sense of the global justice movement spectres of belonging: the political life cycle of mexican migrants emma goldman: political thinking in the streets no one is illegal, canada is illegal! negotiating the relationships between settler colonialism and border imperialism through political slogans man's search for meaning justice interruptus: from redistribution to recognition school of public health. ( ) life experiences and income inequality in the united states learning from the outsider within: the sociological significance of black feminist thought black feminist thought: knowledge, consciousness and the politics of empowerment the emotional brain: the mysterious underpinnings of emotional life critical theory as political practice the misguided search for the political freelance isn't free: co-working as a critical urban practice to cope with informality in creative labour markets the politics of operations: excavating contemporary capitalism mohawk interruptus: political life across the borders of settler states marx and heterogeneity: thinking the lumpenproletariat difference in marx: the lumpenproletariat and the proletarian unnameable decolonization is not a metaphor undoing border imperialism the a. sivandandan collection. race & class bunk: the rise of hoaxes, humbug, plagiarist, phonies, post-facts, and fake news key: cord- -g yekx f authors: le, aurora b.; wong, su-wei; lin, hsien-chang; smith, todd d. title: the association between union membership and perceptions of safety climate among us adult workers date: - - journal: saf sci doi: . /j.ssci. . sha: doc_id: cord_uid: g yekx f objectives: an individual’s perceptions of their workplace safety climate can influence their health and safety outcomes in the workplace. even though union membership has been declining in the us, union members still comprise % of the working population and have higher-than-industry average non-fatal illness and injury rates. due to limited research focused in this area, this study examined whether union membership was associated with worker perceptions of safety climate. methods: this was a secondary data analysis study utilizing data from the quality work life module from the general social survey centered on us workers aged and above. propensity-score matching was implemented to reduce potential selection bias between unionized and non-unionized workers. linear regression explored the association between union membership and perceptions of safety climate, controlling for age, sex, education, industry, resource adequacy, supervisor support, co-worker support, and workload. results: for perceived safety climate (on a – scale, the higher the more positive), those in union had a lower mean of perceived safety climate ( . ) compared to those not in a union ( . ). based on the regression results, those who were in a union reported more negative perceptions of their workplace safety climate in a -month period (β = − . , p < . ). conclusions: by demonstrating a commitment to proactive injury prevention and bolstering the business’s overall safety performance indicators, businesses who are open to collaborations with unions may see some long-term benefits (e.g. return on investment, increased job satisfaction) and enhance union workers’ perceptions of safety climate. labor unions have a long and deeply rooted history in the united states since their formation in the mid- s, stemming from the societal and economic impacts of the industrial revolution. labor unions are organizations that hold a critical role in enhancing their members' workplace safety and public health conditions through empowerment, workplace advocacy (i.e., policies, procedures), and collective bargaining (e.g., better wages and benefits) (hagedorn et al., ; kimeldorf, ; morris, ) . today under us labor laws, many unions in different industrial sectors are still recognized as the primary champion for their members' health and safety. according to the bureau of labor statistics, as of , . million wage and salary workers ( . % of all workers) in the us were part of a union-a . % decrease from and continued trend of a centurylong decline in us union membership (bureau of labor statistics, a; mishel, ) . despite this decline in union membership, in , the top five states with the highest union membership and union density had higher employee-reported non-fatal injury and illness rates that were as much as % above the national average of . per employees (bureau of labor statistics, a , b , c . these statistics are congruent with what is found in the literature, as employees in unions compared to non-unionized employees are more likely to self-report injuries and illnesses in the workplace and follow through with filing workers' compensation claims. this also may be attributed to those in unions working more dangerous and laborious jobs (e.g., construction, steel work), working in larger industries, being educated by their union about their employee rights, and their union's contributions to workplace safety culture where self-reporting injuries is encouraged (fenn & ashby, ; freeman & medoff, ; gillen et al., ; hirsch & berger, ; goldenhar et al., ; morse et al., ; worrall & butler, ) . regardless of what the documented reasons were for these non-fatal injuries and illnesses in unions, it is still critical to understand the underlying cause of these elevated rates and determine strategies to mitigate occupational risks. safety climate has been acknowledged as having the potential to reduce workplace injury rates and bolster injury prevention (gillen et al., ; huang et al., ) . safety climate-a construct that is a sub-facet of organizational climate-reflects shared perceptions and beliefs workers hold regarding their safety in their workplace. there are also factors that influence safety climate, which include but are not limited to safety leadership style, supervisor support, communication, organizational support, resource availability, workload, and job demands (barrah et al., ; dejoy et al., ; fernández-muñiz et al., ; flin et al., ; gillen et al., ; neal & griffin, , zohar, ; zohar & tenne-gazit, ) . perceived safety climate, or self-reported safety climate, has been defined in many ways in the literature and a number of scales have been developed to measure the construct (cooper & phillips, ; dejoy et al., ; flin et al., ; neal & griffin, ; seo et al., ; zohar, ) . while no consensus has been developed or standardized instrument has been adapted on how to best measure safety climate, it generally quantifies how workers perceive and describe the importance of safety issues within their organization during a particular point in time by measuring a worker's perceptions of workplace policies, practices and procedures (e.g., supportive environment, safety rules and procedures, communication, management commitment). exploring the relationship between union membership and perceptions of safety climate may highlight areas of improvement when addressing union workers' health and safety. by measuring safety climate, businesses and organizations can better understand the molar perceptions their unionized employees have about workplace safety and obtain safety performance indicators-that go beyond recordable rate. as a result, concrete, organization-specific solutions to predict and prevent workplace injury can be developed and implemented (cooper & phillips, ; guldenmund, ; zohar, zohar, , . previous studies have sought to analyze the associations between perceptions of safety climate, safety attitudes, and/or safety performance in very specific unionized study samples, such as workers in italian manufacturing companies, nuclear decommissioning and demolition industries, construction, australian hospitals, south korean labor industries, and midwestern retail (brondino, silva, & pasini, ; findley et al., ; gillen et al., ; iverson, buttigieg, & maguire, ; lee et al., ; marin, cifuentes, & roelofs, ; sinclair, martin, & sears, ) ; however, none looked across industries or used a nationally representative sample. moreover, when comparing workers who are in a union versus those who are not, it should be noted that individuals in a union might systematically differ from those who are non-unionized. previous studies have indicated that those in a union may have better safety climate scores and reduced injury severity (gillen et al., ) and better union-management relations (findley et al., ; iverson et al., ; lee et al., ) . therefore, unionized workers may be more inclined to have positive safety climate perceptions; this suggests that workers who are in a union and workers who are not in a union (i.e., the treatment and control groups) may not be comparable in terms of perceived safety climate due to differences in observable characteristics. thus, this study sought to address a critical research gap and shortcomings of previous studies by using the propensity-score matching (psm) method to reduce potential selection bias between unionized and non-unionized workers. to our knowledge, this is the first study to utilize a us nationally representative dataset to explore the association between union membership and an individual's safety climate perceptions. given recent events, such as the unprecedented covid- pandemic, attention is being focused once more on workers' safety, health, conditions, and rights, making it all the more important to understand how unions-an advocate for the worker-influence safety climate perceptions (cdc, ; lancet, osha, ) . to address this gap in the literature, the objective of this study was to examine the association between union membership and perceptions of workplace safety climate in us adult workers, using data from the general social survey (gss) quality of worklife (qwl) module. this quasi-experimental design with a control group study implemented psm to reduce potential selection bias between unionized and non-unionized us adult workers. given the evidence that increased illness and injury reporting is a positive aspect of a positive safety culture (shannon, mayr, & haines, ; vredenburgh, ; wu, lin, & shiau, ) , and aforementioned past findings and that states with higher union density also had higher than national average self-reported non-fatal injury and illness rates, it was hypothesized that us adult workers in a union were more likely to have positive perceptions of their workplace safety climate compared to workers that were not part of a union. the gss has gathered data on contemporary american society since and contains a standard core of questions on demographics, behaviors and attitudes, along with special topics modules that are periodically administered (norc, ). the quality of worklife (qwl) module, which is a subset of data from the gss developed by the university of chicago norc group and administered in partnership with the national institute for occupational safety and health (niosh). the qwl measures how work life and work experiences have changed over time and can be used to assess relationships between job/organizational characteristics and employee safety and health in order to identify targets for preventive interventions. qwl data has been previously utilized to find associations on topics such as workplace harassment and occupational injury, occupation and socioeconomic indicators, and long work hours and psychosocial well-being (fujishiro, xu, & gong, ; grosch et al., ; yu et al., ) . the qwl is the only public dataset that measures behaviors and attitudes in the american workplace (niosh, ; smith, ) . data from the gss qwl module and core module from module from , module from , module from , module from , and were extracted. each year contains observations for , - , working adults aged and above, depending on the year. inclusion criteria for this study were adults aged and above who were participants in the , , , , or gss qwl module. data across years were utilized rather than a single year of the gss qwl module to provide a better view over time, as well as to enhance the sample size and statistical power. additionally, as this study assessed perceptions of safety climate, which is an organizational-level construct, those who were self-employed at the time of survey administration were excluded from the study as they may be their own supervisor or predominantly work autonomously. of the original sample from the aforementioned years, , adults aged to without missing values on major variables were included in the analyses. the gss provides a codebook, which specifies which questions correspond to certain constructs and/or measures for the qwl module. the gss adopted items from the niosh management commitment to safety scale (niosh, ) for the qwl to measure safety climate, which included the following four items: ( ) "the safety and health conditions where i work are good"; ( ) "the safety of workers is a high priority with management where i work"; ( ) "there are no significant compromises or shortcuts taken when worker safety is at stake"; ( ) "where i work, employees and management work together to ensure the safest possible working conditions." all four questions' responses were on a four-point ordinal scale from 'strongly agree' to 'strongly disagree' and were reverse coded so that the higher value indicated stronger agreement (strongly agree = , agree = , disagree = , strongly disagree = ). the four recoded variables for the discrete questions above were then summed up into a single variable, "safety climate", on a continuous scale that ranged from to ; a higher scale score is indicative of a more positive perception of safety climate. union membership was determined by the respondent's answer to, "does the respondent or spouse belong to a union?" if "respondent belongs" or "respondent and spouse belongs" was selected, those individuals were included in the study sample as the treatment group. this variable was treated as a binary variable. covariates were selected based on what was supported in the literature as being factors of safety climate and union membership, as well as taking into consideration whether the variable was collected in the qwl. the available literature identifies sex, race, age, education, private vs. public sector, work status, and state of residence being strong indicators of union membership with males, non-whites, those middleaged, individuals who were high school graduates or had some college education, those who worked in the public sector and government, fulltime employees, and individuals from certain states (e.g., hawaii, new jersey, new york, washington), respectively, having greater likelihood of being in a union (bureau of labor statistics, a; benson & griffin, ; hirsch & berger, ; hirsch, macpherson, & vroman, ; hundley, ; kokkelenberg & sockell, ; mishel, ; schur & kruse, ; silverblatt & amann, ; ) . following the literature, individual demographics included in the analysis were: age ( - , - , - , - , and above), sex (male or female), educational level (less than a high school diploma, high school graduate, some college/associate's degree, bachelor's degree, or beyond bachelor's degree), work status (part-or full-time), race/ethnicity (non-hispanic white, non-hispanic black, and other/unclassified), region of residence (northeast, midwest, south, west), and respondent annual income ($ -$ , , $ , -$ , , $ , -$ , , $ , -$ , , or $ , and greater). whether the individual worked in the private or public sector was included, as well as industry-determined by the north american industry classification system . six industry categories were generated based on a fusion of the medical expenditure panel survey's (meps) fiscal year condensing rules for industries and occupations (ahrq, n.d.a,b). these variables were recoded from the dataset as dummy variables into the categories listed in appendix a. factors of safety climate that were both documented in the literature and were captured in the qwl were also included as covariates. these variables were resource adequacy, supervisor support, co-worker support, and workload (brondino et al., ; dejoy et al., ; fernández-muñiz et al., ; gillen et al., ; neal & griffin, ; zohar, ; zohar & tenne-gazit, ) . resource adequacy was determined by summing the respondent's answer to "i receive enough help and equipment to get the job done" and "i have enough information to get the job done" with responses reverse coded so that 'strongly agree' indicated a value of , 'agree' a value of , 'disagree' a value of , and 'strongly disagree' a value of ; values were then totaled into a single, continuous variable that ranged on scale of - , with indicating the highest self-reported resource adequacy. supervisor support was derived from responses to, "my supervisor is concerned about the welfare of those under him or her" and "my supervisor is helpful to me in getting the job done" and was reverse coded in the same manner as resource adequacy into a single, continuous variable on a scale of - , with indicating the highest self-reported supervisor support. co-worker support was determined from responses to, "the people i work with take a personal interest in me" and "the people i work with can be relied on when i need help" reverse coded into a single, continuous variable on a scale of - , with indicating the highest self-reported co-worker support. lastly, workload was determined by the respondent's answers to: "my job requires that i work very fast", "i have too much work to do everything well", and "i have enough time to get the job done." the first two statements were reverse coded so that 'strongly agree' indicated a value of , 'agree' a value of , 'disagree' a value of , and 'strongly disagree' a value of ; the last statement was not reverse coded because the lower value already indicated a decreased workload. after being recoded these three variables were summed into a single continuous scale of - , with indicating the highest self-reported workload. to minimize selection bias between the two study groups (adult workers in a union and adult workers not in a union), a matched sample using psm with nearest-neighbor matching was constructed (rosenbaum & rubin, ) . matching allows an individual from the control group (non-unionized) to be selected as the matched partner for a treated individual (unionized) that is closest in propensity to be treated (caliendo & kopeinig, ; coca-perraillon, ; parsons, ) . the estimate of the likelihood of one subject being in the treatment group, based on a set of characteristics, was the first step conducted in the psm. the study matched participants based on demographic factors (age, sex, education, race/ethnicity, region) and likelihood of being in a union (work status, respondent income, private vs. public sector, industry) as stated above (bureau of labor statistics, a; benson & griffin, ; hirsch & berger, ; hirsch et al., ; hundley, ; kokkelenberg & sockell, ; mishel, ; schur & kruse, ; silverblatt & amann, ) . the study utilized : nearest-neighbor matching so that each treated unit could be matched to more than one control since the unmatched treatment and control group had a notable difference in numbers (n = and n = , ); nearest-neighbor : matching was used because the matched units reached saturation beyond one-to-three matching. the suggested caliper (i.e., propensity range) for the psm was . of the logit of the standard deviation of the predicted propensity scores was used (austin, ; coca-perraillon, ; parsons, ) . after psm, a matched sample of adults in a union and not in a union was created (n = in treatment group and n = in control group). stata . was used for all data analyses, including conducting the imbalance test to corroborate successful matching by reducing the imbalance between the treatment (unionized) and control group (non-unionized) based on the aforementioned covariates (statacorp. . stata statistical software: release , college station, tx: statacorp llc). multicollinearity among covariates in the final model was also assessed; multicollinearity was not present with the variables selected for the models. the descriptive statistics were calculated for both the matched and unmatched samples included weighted and unweighted frequencies or means, as well as percentages or standard errors for all variables used in the statistical models. chi-square tests were conducted to determine group differences between respondents who were part of a union and those who were not for categorical variables and t-test were used for continuous variables. a linear regression model was conducted to examine the associations between union membership and perceived safety climate, controlling for the covariates pertaining to perceived safety climate (resource adequacy, supervisor support, co-worker support, workload) and sociodemographic factors (age, sex, education, industry). to account for disparate selection probabilities, non-response, and post-stratification adjustments, the regression was weighted using the gss survey weight to provide nationally representative estimates. due to the public availability and de-identified nature of the dataset, this study was deemed as a non-human subject study by the institutional review board at the authors' institution. the imbalance test showed that the matched sample was balanced (χ = . , df = , p = . ), indicating enhanced comparability and a reduction in selection bias between us adult workers who were part of a union and those who were not, based on the covariates identified (table ) . table shows descriptive statistics of the study sample (weighted matched n = , , unweighted matched n = , ; weighted unmatched n = , , unweighted unmatched n = , ). the majority of unionized respondents were middle aged ( . % aged - ), there were slightly more males than females ( . %), most had graduated high school or obtained some college education ( . %), a large majority worked full time ( . %), most were non-hispanic white ( . %), the largest percentage of respondents came from the western region ( . %), most made over $ , per year for individual annual income ( . %), slightly fewer union workers were in the public sector compared to those who were not ( . %), and those in public services (i.e. education, health and social services; public administration; military) were the largest industry category ( . %). for perceived safety climate, those in a union had a mean of . (se = . ) compared to . (se = . ) for those not in a union. respondents who were in a union also had smaller means for resource adequacy, supervisor support, and co-worker support, and a higher mean for workload relative to their non-union counterparts. the mean for resource adequacy for those in a union was . (se = . ) compared to . (se = . ); supervisor support was . (se = . ) vs. . (se = . ), and co-worker support was . (se = . ) vs. . (se = . ). those in a union had a higher mean for workload at . (se = . ) vs. . (se = . ) for those not in a union. table displays the results from the linear regression that examined whether union membership was associated with perceptions of safety climate in the matched sample. those who were in a union reported more negative perceptions of their workplace safety climate in the when surveyed (β = - . , se = . , p < . ). on average, workers who were part of a union had . units lower safety climate perception, compared to workers who were not part of a union. the regression results also showed that resource adequacy (β = . , se = . , p < . ), supervisor support (β = . , se = . , p < . ), and co-worker support (β = . , se = . , p < . ) were significant (table ) . on average, workers who were in a union had . units, . units, and . units higher safety climate perception for resource adequacy, supervisor support, and co-worker support, respectively, compared to non-unionized workers. within age groups on average, for those age and above, when compared to those aged - had . units higher safety climate perception (β = . , se = . , p = . ). lastly, union workers in the construction, extraction, and maintenance operations industry on average, had . units higher safety climate perception, compared to people who worked in public services (β = . , se = . , p = . ). this study examined the association between union membership and perceptions of safety climate in us adult workers. a secondary data analysis was conducted using the general social survey quality of worklife module to address the gap on the limited amount of research conducted in this area using a nationally representative sample to explore the relationship between union membership and perceptions of safety climate. moreover, this study utilized a propensity-score matching methodology to reduce potential selection bias in observed characteristics between the treatment (union) and control (non-union) groups. it was hypothesized that those in a union would have more positive perceptions of their workplace safety climate. regression results from the study did not support the hypothesis and showed that unionized workers were more likely to have decreased positive perceptions of safety climate relative to their non-union counterparts. historically, unions and employers have frequently had adversarial relationship due ( ) recommends that b be less than and that r be between . and for the samples to be considered sufficiently balanced. to conflicting interests and ideologies in the workplace (hagedorn et al., ; kimeldorf, ; morris, ) , and unionized employees tend to be more advocacy-and change-driven. findings from previous studies might explain the negative association between union membership and safety climate. for example, it has been suggested that unionized workers are provided greater education and awareness than non-union workers on potential workplace risks and hazards as well as their union organization establishing minimum safety standards; in fact, the presence of elevated risk and hazards might have been the impetus to unionize in the first place, which thereby could result in negative safety climate perceptions (barling, kelloway, & bremermann, ; baugher & roberts, ; fenn & ashby, ; kelloway, ; mishel, ; sinclair et al., ; spigener & hodson, ) . moreover, it has been suggested companies that want to avoid unionization-for various economic and organizational reasons-may make a more concerted effort to keep their employees satisfied and bolster human resource practices so that employees do not feel compelled to form a union (borjas, ; guest, ) . in turn, unionized employees who are less satisfied than non-union members exercise a different "exit-voice" model and are less likely to leave their jobs even though dissatisfied (freeman, ; hirschman, ; premack & hunter, ) . this can have a negative impact on union workers' job satisfaction (bender & sloane, ; bryson, cappellari, & lucifora, ; feldman & scheffler, ; meng, ) and in turn could result in non-unionized employees' positive perceptions of safety climate. recent research has explored how civility norms-the existence of norms for respectful treatment-may also influence an individual's perceptions of safety climate; greater civility and less contention between workers and management can lead to more positive safety climates (mcgonagle et al., (mcgonagle et al., , yang et al., ) organizational change considerations could be derived based on these findings. when job satisfaction is enhanced, it has been found to be protective against the occurrences and direct and indirect costs of nonfatal injury and illnesses in the workplace, as well as decreasing the costs associated with employee turnover (carsten & spector, ; gillen et al., ; huang et al., huang et al., , huang, shaw, & chen, ; li, wolf, & evanoff, ; mobley, ; smith et al., ; zohar, ) . additionally, a more inclusive and civil leadership style (i.e., authentic, transformational), as well as employers and unions working together to agree on what issues should be addressed (i.e., drafting an action plan to be implemented) has also been shown to improve psychosocial and physical safety outcomes (barling, loughlin, & kelloway, ; hasle, hansen, & møller, ; kelloway, mullen, & francis, ; laschinger & read, ; mullen & kelloway, ; zohar & tenne-gazit, ) . while there is no simple singular solution for enhancing unionized employees' satisfaction, businesses who choose to collaborate and have open negotiations with unions to better address union workers' asks might see some long-term benefits (e.g., return on investment, increased job satisfaction) of enhancing these workers' perceptions of safety and demonstrating a commitment to proactive injury prevention and bolstering the business's overall safety performance indicators. the majority of survey respondents for the study sample were non-hispanic whites, worked full-time and made more than $ , per year in annual individual income. resource adequacy, supervisor support, and co-worker had a significantly positive association between union membership and perceived safety climate; no sociodemographic factors from the regression demonstrated significance between union membership and perceived safety climate. while there has been ongoing discourse on the challenges in obtaining consensus and demonstrating high reliability around appropriate scales to measure safety climate, these findings are congruent with what is found in the literature on indicators of individual perceptions on safety climate-generally sociodemographic factors (e.g., sex, race/ethnicity, educational attainment) do not have a demonstrated strong influence on safety climate as contextual factors such as safety commitment and communication, resources and demands, training, supportive environment, leadership, etc. (brondino et al., ; cooper & phillips, ; dejoy et al., ; fernández-muñiz et al., ; flin et al., ; fogarty & shaw, ; neal & griffin, ; seo et al., ; zohar, zohar, , . in the regression results, being age and above, and being in the construction, extraction, and maintenance operations industry also resulted in a positive association between union membership and perceptions of safety climate. previously, it was thought that age and perceptions of the workplace had a linear relationship-as one aged, a person becomes less critical about their job. however, some studies have found the relationship between job satisfaction and age may actually be u-shaped (clark, oswald, & warr, ; dobrow riza, ganzach, & liu, ; kacmar & ferris, ) . those age and above had positive perceptions with safety climate for this age group relative to those aged - . this could be due to the protective factors work has on cognitive aging, and the continued sense of purpose and community employment provides for the elderly. additionally, those who are older and are still in the workforce may compare their current experiences relative to those earlier in life, before the occupational safety and health (osh) act of was passed; this resulted in the creation of the occupational safety and health administration (osha) creating federal regulations for the workplace thereby driving improved workplace conditions that were non-existent several decades earlier (dobrow riza et al., ; occupational safety and health administration osha, n.d.; scott et al., ; thielgen, krumm, rauschenbach, & hertel, ) . those in construction, extraction, and maintenance operations (cemo), which includes mining (i.e., quarrying, oil and gas extraction), and natural resources (i.e., agriculture, forestry, fishing, hunting), had more positive perceptions of safety climate compared to those in public services, which is the industry with the greatest union membership in this study sample. cemo traditionally has a high union denisty in the u. s. relative to other industries. it has been found that greater union density can be positively associated to workers' self-reported quality of work conditions and thereby safety climate (booth, budd, & munday, ; dollard & neser, ; gillen et al., ; mayer, ) . therefore, having a greater number of employees in unions could prove to be beneficial to the employer over time given the long-term benefits of their employees participating in a union (e.g., championing for better working conditions, identifying safety shortcomings). by having a symbiotic relationship with unions and unionized employees rather than adversarial ones, businesses may reap the long-term benefits of an improved safety climate, such as fewer non-fatal injuries and accidents and lost work days (clarke, ; christian et al., ). there were several limitations to this study that should be acknowledged. first, because of the niosh qwl is cross-sectional data, causal or temporal relationships could not be tested. second, the qwl relies on self-reported data, which could lead to acquiescence bias due to the length of the questionnaire and recall biases since respondents were asked to reflect experiences and attitudes over the past months. in the same vein, perceived safety climate, rather than using data from an objective measure, may introduce some response bias. additionally, perceptions of safety climate could have been influenced by other factors that were not captured by the qwl. also, the publicly available qwl datasets do not provide state identifiers-which in the data and literature, union membership and states have a strong relationship (bureau of labor statistics, a; hirsch et al., ; mayer, )therefore making matching union membership and perceptions in safety climate with state-level information not possible. finally, while using psm does reduce selection bias, it does not remove it completely; unobservable differences between the treatment and control groups may exist but cannot be eliminated. despite these limitations, the qwl does provide data spanning nearly two decades, as well as a nationally representative and generalizable sample on us adults' work conditions, work behaviors, and attitudes. to our knowledge, this is the first study examining the association between union membership and perceptions of safety climate using a national representative sample of us adult workers. this study found that those in a union generally had decreased perceptions of safety climate in their workplace relative to us adult workers not in a union. moreover, by implementing propensity-score matching, selection bias was reduced so the significance of the findings are enhanced. the study may provide a piece of evidence to support the associations between union membership and perceptions of safety climate, focusing more on unions as a population or industry. it has been suggested that stronger union connectivity provides feelings of empowerment, fosters a culture of safety, and provides potentially protective health factors (hogler, hunt, & weiler, ; malinowski, minkler, & stock, ; mishel, ) . although union membership nationwide is declining, it is important to recognize they still comprise approximately % of the american workforce-which is larger than certain industrial sectors (e. g., mining, transportation) where safety climate research has been previously focused (bureau of labor statistics, a,b,c) . future studies could utilize longitudinal data to examine perceptions of safety climate or a national cross-sectional study with a larger sample size than what was extracted from the datasets utilized, specifically focused on union members. these studies could , assess attitudes and behaviors for individual-and organizational-level safety behavior factors, such as safety climate, with more questions per construct in the scale than what was available through the qwl to determine if more significant associations can be gleaned in this overlooked but important worker population. for employers or organizations who would like to enhance employee perceptions of safety climate, focusing on unionized employees who may have a tendency towards more negative perceptions of safety climate through bolstering leadership commitment, enhancing collaboration with the union, and addressing other upstream organizational factors could behoove employers and generally improve the organization's workplace health and safety (barling et al., ; hammer, bayazit, & wazeter, ; kelloway et al., ; mullen & kelloway, ; spigener & hodson, ; zohar, ; zohar & tenne-gazit, ) . the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. a. le conceptualized the study, conducted and performed the analyses, and drafted the full manuscript. s. wong provided critical edits to the code and assisted with data analysis. h. lin assisted with refining the statistical models and provided critical edits to the manuscript. t. smith provided subject matter expertise on safety climate and provided critical edits to the manuscript. agency for healthcare research quality (ahrq), n.d. medical expenditure panel survey industry codes codensing rules beginning fy an introduction to propensity score methods for reducing the effects of confounding in observational studies preemployment predictors of union attitudes: the role of family socialization and work beliefs development and test of a model linking safety-specific transformational leadership and occupational safety men's and women's eldercarebased work-family conflict: antecedents and work-related outcomes perceptions and worry about hazards at work: unions, contract maintenance, and job control in the us petrochemical industry job satisfaction, trade unions, and exit-voice revisited gender differences in union attitudes, participation and priorities never say never? uncovering the neverunionized in the united states job satisfaction, wages, and unions multilevel approach to organizational and group safety climate and safety performance: co-workers as the missing link chart : state nonfatal occupational injury and illness incidence rates compared to the national rate, private industry does union membership really reduce job satisfaction? some practical guidance for the implementation of propensity score matching unemployment, job satisfaction, and employee turnover: a meta-analytic test of the muchinsky model centers for disease control and prevention (cdc), . worker safety and support workplace safety: a metaanalysis of the roles of person and situation factors is job satisfaction u-shaped in age? the relationship between safety climate and safety performance: a meta-analytic review paper : local and global optimal propensity score matching, presented at the sas global forum validation of a safety climate measure, presented at the occupational psychology conference of the creating safer workplaces: assessing the determinants and role of safety climate time and job satisfaction: a longitudinal study of the differential roles of age and tenure worker health is good for the economy: union density and psychosocial safety climate as determinants of country differences in worker health and productivity in european countries the union impact on hospital wages and fringe benefits workplace risk, establishment size and union density safety climate in ohsas -certified organisations: antecedents and consequences of safety behaviour safety climate differences among job positions in a nuclear decommissioning and demolition industry: employees' selfreported safety attitudes and perceptions measuring safety climate: identifying the common features individual mobility and union voice in the labor market the impact of the percentage organized on union and nonunion wages safety climate and the theory of planned behavior: towards the prediction of unsafe behavior what does "occupation" represent as an indicator of socioeconomic status?: exploring occupational prestige and health perceived safety climate, job demands, and coworker support among union and nonunion injured construction workers modelling relationships between job stressors and injury and near-miss outcomes for construction labourers long hours of work in the us: associations with demographic and organizational characteristics, psychosocial working conditions, and health the nature of safety culture: a review of theory and research human resource management, corporate performance and employee wellbeing: building the worker into hrm the role of labor unions in creating working conditions that promote public health union leadership and member attitudes: a multi-level analysis agreements between labour unions and employers' associations as a strategy for the prevention of repetitive strain injury union membership determination and industry characteristics estimates of union density by state exit, voice, and loyalty": further reflections and a survey of recent contributions killing unions with culture: institutions, inequality, and the effects of labor's decline in the united states role of workplace safety: a revisit of the relationship between job satisfaction and employment status safety climate and self-reported injury: assessing the mediating role of employee safety control worker perceptions of organizational support and return-to-work policy: associations with post-injury job satisfaction who joins unions in the public sector? the effects of individual characteristics and the law absence culture: the effects of union membership status and union-management climate theoretical and methodological considerations in the age-job satisfaction relationship labor unions and occupational safety: conflict and cooperation divergent effects of transformational and passive leadership on employee safety bringing unions back in (or why we need a new old labor history) union membership in the united states the effect of authentic leadership, person-job fit, and civility norms on new graduate nurses' experiences of coworker incivility and burnout perceived discrimination and low back pain among , workers in south korea: effect modification by labor union status use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers labor unions: a public health institution results of a community-based survey of construction safety climate for hispanic workers union membership trends in the united states can civility norms boost positive effects of management commitment to safety? civility norms, safety climate, and safety outcomes: a preliminary investigation the relationship between unions and job satisfaction unions, inequality, and faltering middle-class wages intermediate linkages in the relationship between job satisfaction and employee turnover government and labor in early america the relationship of unions to prevalence and claim filing for work-related upper-extremity musculoskeletal disorders safety leadership: a longitudinal study of the effects of transformational leadership on safety outcomes quality of worklife questionnaire safety climate and safety at work. psychol. workplace saf a study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels the general social survey occupational safety and health adminsitration (osha), . guidance for preparing workplaces for covid- proceedings of the twenty-ninth annual sas users group international conference: performing a : n case-control match on propensity score individual unionization decisions using propensity scores to help design observational studies: application to the tobacco litigation constructing a control group using multivariate matched sampling methods that incorporate the propensity score der differences in attitudes toward unions the effects of stress on cognitive aging, physiology and emotion (escape) project a cross-validation of safety climate scale using confirmatory factor analytic approach overview of the relationship between organizational and workplace factors and injury rates race, ethnicity, union attitudes, and voting predilections labor unions and safety climate: perceived union safety values and retail employee safety outcomes the relationship between safety climate and injury rates across industries: the need to adjust for injury hazards are labor unions in danger of losing their leadership position in safety? older but wiser: age moderates congruency effects between implicit and explicit motives on job satisfaction organizational safety: which management practices are most effective in reducing employee injury rates? health conditions and job hazards: union and nonunion jobs predicting safety culture: the roles of employer, operations manager and safety professional workplace mistreatment climate and potential employee and organizational outcomes: a metaanalytic review from the target's perspective association between workplace harassment and occupational injury among adult workers in the united states safety climate in industrial organizations: theoretical and applied implications the effects of leadership dimensions, safety climate, and assigned priorities on minor injuries in work groups thirty years of safety climate research: reflections and future directions transformational leadership and group interaction as climate antecedents: a social network analysis we would like to thank stephanie andel, phd, in the department of psychology at indiana university-purdue university indianapolis for her feedback and expertise in occupational psychology, and earl blair ed.d. from indiana university school of public health-bloomington safety program and abdulrazak balogun, phd from keene state college for their input on organizational management. key: cord- - obj rs authors: srivastava, ravi title: growing precarity, circular migration, and the lockdown in india date: - - journal: indian j labour econ doi: . /s - - - sha: doc_id: cord_uid: obj rs the paper examines the nature of the migrant crisis in india after the country-wide lockdown in march and brings out the types of labour migrants who were severely adversely affected by the lockdown, leading to their exodus towards their native villages. it further assesses the government’s response and proposes some key policy imperatives. the covid- pandemic has made the position of international migrants even more vulnerable and has exposed the poor living conditions in which international emigrant workers work and live in countries across the globe. however, in the case of india, the lockdown imposed to slow the spread of the pandemic created an unprecedented humanitarian crisis for internal migrants, revealing the vast magnitude of invisible and vulnerable migrants in india's workforce across cities and states. in a public address to the nation on march , the indian prime minister announced a "janata (people's) curfew" on march , from morning to night, which was to be monitored by civil society organisations, and voluntarily observed. at that stage, india had experienced deaths and infections due to the covid- . several trains were cancelled and flights reduced for the janata curfew, but these cancellations continued after the "curfew". on march , at pm, the prime minster announced a country-wide lockdown effective from midnight, to last till april . the lockdown was introduced to ostensibly slowdown and break the transmission cycle of the virus, and people-except those engaged in essential serviceswere advised to stay indoors. the sudden lockdown left tens of millions of people stranded across india. these included students, travellers, pilgrims, and migrant workers. the government and the country were completely unprepared for what followed. within a couple of days of the lockdown, migrants started thronging highways and bus stands, prepared to go home anyhow. between march and , the government responded with a series of directives asking the migrants to return and stay indoors. when the numbers became unmanageable, some state governments stepped in with announcements to facilitate the interstate movement of the migrants. however, the central government came down heavily both on governments, which were seen to facilitate the movement of migrants, and on the migrants. the latter were forced into shelters and quarantines or pushed back to their shelters. on march , in response to a petition in the supreme court, the government of india claimed that "not a single migrant was on the roads". it further claimed that the attempted exodus of migrants was the result of a panic created by fake news that the lockdown would continue for three months. as is well known, the supreme court concurred with this view and expressed satisfaction at the steps taken by the government for relief and immobilisation of the migrants. in its submission to the supreme court on march , the government of india stated that india had . crore migrant workers. a perusal of the census of india shows that this is the figure of all migrants (internal as well as international) in india who gave "employment" as the initial reason for migration whenever they had changed their usual place of residence. it is clear that the government did not have any idea of the numbers or the kind of migrants who were facing distress and who were attempting to return to their homes. in the same year, the census showed that there were crore internal migrants in india, of whom . crores were workers. most migrants in india do not give employment as a reason for migration, but rather marriages and other associational reasons (moving with families). an analysis of all the migrants in india shows that they fall into different streams and segments. most migrants move short distances, within the same district, followed by movement to other districts within the state. only a small percentage ( %) of those recorded in the census move to other states. while the classic migration in development literature is rural-urban, most migrants in india ( %) are in rural areas. studies show that the migrants are more likely to be concentrated in higher consumption quintiles than non-migrants. furthermore, unlike the classical one-way rural-urban movement, a large percentage of rural-urban migrants retain their links with the rural hinterland, returning occasionally to it during spells of unemployment, for holidays, or when work in rural areas peaks. some of them may stay on permanently in urban areas, while others may eventually return to their rural homes. so who were the migrants who were impelled to move back to their homes in villages after the lockdown? these were clearly not the permanent rural-urban migrants who have severed links with their rural origin. they were quite prominently semi-permanent or long-term circular migrants who had retained links with their families homes in rural areas. even more prominently, they were seasonal and short-term circular migrants who do not figure in census and nss statistics and who have no worthwhile place they can call their home in the urban destination areas. delving a little more in the nature of short-term and long-term circular migration, studies have shown that the former are in temporary and seasonal precarious jobs, mostly in wage employment. the latter belong to various socio-economic strata but include a large chunk of precariously placed rural-urban migrants who are either self-employed or wage-employed. unlike the short-term circular migrants, they have acquired a tenuous foothold in urban areas, although acquiring this foothold may have taken a number of years. like the short-term circular migrant, this segment of long-term circular migrants also remains in precarious jobs, vulnerable to shocks. estimates of these three segments of migrant workers and precarious workers among short-term and long-term circular migrant workers are given in fig. and are based on the estimates prepared in srivastava ( b) . our analysis elsewhere shows the growing precarity of the indian workforce engaged in industry and services (srivastava ) . while this workforce has steadily grown, but only matching the decline in the agricultural workforce, or estimates show that between - and - , the percentage share of circular migrants in the precariously employed workforce outside agriculture grew by about ten per cent points-from about % to % (see fig. ). we have argued that precarity and circular migration have grown hand in hand, promoted by macroeconomic and labour policies in india (srivastava ) . the lockdown exposed the vulnerable circular migrants to a range of extreme vulnerabilities, which were felt within a short period of time, ranging from immediate to a few days. first, the lockdown was so severe that all circular migrants, except a handful engaged in essential permitted services, lost access to jobs and incomes. wage workers employed through contractors even lost access to wage and income sus sus & sus , and nso, sus - sus & sus - arrears, as contractors refused to settle dues. second, those circular migrants-and these included a majority of the short-term circular migrants-lost access to shelters which were nothing but their worksites. those who lived in squalid and congested rented accommodation were left with no means to pay rent and started to be pressurised by their landlords within the first few weeks. third, as we show below, government measures for social protection were least likely to reach these workers as few of them had valid registrations in the destination areas, and relief was both scarce and difficult to access. fourth, the distance from kin and family folk was acutely felt by the risk of disease, and government barriers on interstate movement made going back all the more urgent for interstate migrant workers and their families. the government of india announced a package of measures to support poor households and workers on march , immediately after the imposition of the lockdown. this package was called the prime minister garib kalyan yojana and it comprised of measures of cash transfer using the direct benefit transfer (dbt) route, kind support (through the public distribution system), and a set of directions to various statutory funds/welfare funds, and finally a set of directives whose legal backing, if any was derived from the powers that the government derived from the disaster management act, (dm act). the cash transfers comprised of (a) a fast forwarding of the first instalment of the income transfer scheme for farmers under the pm kisan yojana; (b) a cash transfer of rs. each per month for three months to woman account holders of jan dhan yojana bank accounts; and (c) an amount of rs. to each pension holder under the national social assistance programme. as kind assistance, the government offered extra free rations of kg. of cereals and one kg. pulses per person for three months and a provision of free gas cylinders under the ujjwala scheme. the government also involved the employee fund organisation (epfo) and the state welfare & , and nso, - & - funds under the building and construction workers' welfare fund by asking the former to give concessions to workers and employers, and the latter to make ex gratia payments to construction workers. finally, it also issued a directive to employers to pay wages to workers during the lockdown period and asked landlords to exempt workers from payment of rents during that period and increased the wages payable under mgnrega from rs. to rs. . although the total package carried a price tag of rs. . lakh crores, the additional cost to the government exchequer was rs. , crores, or only about . % of gdp. more important, while the meagre assistance amounts were targeted at existing beneficiaries, they could not touch the circular migrants who did not have access to the pds in destination areas, and many did not even have access to bank accounts, leave alone beneficiary accounts. similarly, the directions to pay wages during lockdown and rent remissions by landlords had no practical impact on the migrant workers engaged in informal jobs. in general, as surveys of migrant workers succeeded in bringing out, the limited package announced by the government bypassed most of the circular migrants, exacerbating their condition in the cities. despite the stiff conditions of the lockdown, large number of migrants made it to their homes just before or after the lockdown was announced, but these were mostly intra-state migrants. the government's strict measures stemmed the tide of the exodus which had started soon after the lockdown. but after the announcement of the second lockdown on april , the exodus turned into a tide, with workers and their family members attempting to walk back across thousands of kilometres, even in the face of harassment and worse by government forces. the government of india's policy response continued to treat the movement of the migrants simply as a violation of the lockdown procedures. there was very little acknowledgement of the difficult conditions of the migrant workers and their families. the policy measures that were announced were contradictory and aimed at continued restriction on coordinated interstate movement of migrants. initially, the central government announced (on april ) permission to deploy migrant workers within destination states where they were stranded. then, on april , it permitted interstate movement, subject to protocols but only by buses. on may , trains were permitted to be deployed but through a cumbersome administrative and interstate coordination procedure, and on may , the central government again issued a notification virtually disentitling temporary migrants from interstate movement. but since mid-april, for the next several weeks, the country saw the largest urban exodus ever in its history, with millions of migrants attempting to move back to their home villages on foot, bicycles, cycle carts, and hired vehicles. by the beginning of june, the government estimated that it had been able to facilitate the interstate movement of about a crore of migrants, but several times that number moved on their own under unimaginable conditions. migrants bore significant costs, financial and nonfinancial, both for their autonomous movement, but also the transportation arranged by the states and the railways, with them or their families incurring debts to make this possible. as is well known, several hundred people died in the process, including more than a hundred on trains. since may , the government of india has announced some follow-up measures to support the affected poor and the migrant workers. under the atma-nirbhar package that was elaborated by the finance minister between may and may , the government enhanced the mgnrega budget by rs. , crores. it announced a scheme worth rs , crores by which states could identify and provide free ration ( kg. per month of cereals and one kg. pulses per month for three months) to each migrant workers and her/his family member not covered under the national food security act (nfsa). it also announced concessions through the employees provident fund organisation to employers and workers in some categories. it declared a scheme to provide working capital to street vendors to provide support to a rental housing scheme with an initial outlay of rs. crores. on june , the prime minister announced the prime minister garib rojgar abhiyan in districts in six states, with more than , returnees migrant each as per the government data. under the scheme, the implementation of existing schemes/works, costing about rs. , crores (without any additional financial allocation), was to be frontloaded in these districts in order to provide employment. on june , the prime minister announced the extension of the free gas cylinder and pds ration schemes for another four months (till november ) at an estimated budgetary cost of rs. , crores. taken together with the earlier measures announced in march, the total budgetary outlay on the measures announced is only about % of gdp. in addition, the central several non-budgetary measures also include portability of pds by june . meanwhile, most states were highly ambivalent in their policies towards sending/ receiving migrants for different reasons. states initially responded with tightening the controls on migrant movement and arranging shelter/quarantines and food for them. kerala, by standards of destination states, does not account for a significant percentage of circular migrants, set up the largest proportion of shelters. a number of state governments announced ex gratia payments from the building & construction welfare funds for workers registered under these funds. however, in most states, interstate migrant workers are not registered and among those workers, are a high proportion of those who are not employed in the construction industry. we must note that kerala emerged as an outlier among states by announcing a comprehensive package of rs. , crore for protection of livelihoods of workers, including migrant workers, even before the lockdown. apart from these ex gratia payments, some states followed up with other ex gratia payments and made additional efforts to provide rations to workers, including migrant workers, not registered in the pds. telangana announced an ex gratia payment for migrant workers early on in the second phase of the lockdown, as did kerala. as the migrant crisis escalated, sending states announced measures to support stranded migrant workers. in the beginning, an initiative was taken by jharkhand, followed by bihar which announced an ex gratia payment of rs. per worker. with the return of the migrants, state governments have announced measures for preparing a database of migrants and their skills, and programme to absorb them in the local economies. the odisha government announced a rs. , package to provide support to the msme and rural sectors, and skill training, with the objective of enhancing employment opportunities to migrant returnees. these measures have provided a patchwork of support to migrant workers and their families. at the same time, several state governments have moved ahead to make drastic changes in labour laws, in some cases (as in uttar pradesh and gujarat) almost abolishing the entire framework of labour regulation and social security under the flawed assumption that this will help to revive investment and economic activity. the pandemic and the lockdown have brought to light the extent to which industrial and urban india has grown to depend on the labour of migrant workers. at the same time, it has also exposed the precarity and vulnerability of these workers, in terms of their jobs and employment relations, their living conditions, and lack of social protection. with the passage of time, and as the economy slowly begins to revive, the gap in wages and employment opportunities can be expected to draw many of the migrants back into migration circuits and urban destinations. the moot question is whether the lessons of the crisis during the pandemic are addressed by the state in the short and medium period. the pandemic has given several other clear lessons which are unaddressed in the policies taken by the indian state so far. first, it is undeniable that the migrants claim to constitution rights vis a vis articles , , , and of the constitution as citizens have not been respected, either in the destinations where they work or in their areas of origin. given the integral link between migration and development, there is a need to reflect and strengthen their full rights as citizens. second, the pandemic has again brought home the important fact that public health is an externality and that state and employers need to invest more in workers' health. this also means much higher investment in workers' housing and access to basic amenities. third, the grim situation of the migrant workers reinforces the need to institute an adequate social protection floor for all the workers. there has been an urgent immediate requirement for income transfer for a few months to compensate informal workers for their loss of income during the lockdown. on behalf of the indian society of labour economics (isle), a large number of economists and public figures had demanded a short-term quasi-universal income transfer of rs. to households. in the short to medium term, there is a need to institute universal social security for all workers, including the migrants who are informal workers. the code on social security presented to parliament in does not present a time bound road map for universal social security. fourth, in the interim, there is need to institute portability in existing social protection schemes, some of which have statutory backing and central funding (srivastava a). portability and a universal social security system will require a pan-india system of social security registration, which can guarantee privacy, security, and safety of the registrant's information. fifth, the devastating circumstances of the migrants remind us that the labour market needs to be re-unified with registration and formalisation of the workforce and greater job security being provided for informal workers, including the circular migrants. this would also mean a thorough review of the labour code on occupational safety, health, and working conditions which currently promotes informality, with inadequate provisions for occupational safety and health. this also demands a reversal of the direction of labour law changes which several states have undertaken in the name of increasing the ease of doing business. sixth, the situation requires an institution of an integrated rural-urban and regional planning framework, which can promote rural regeneration, especially in poorer states, on the one hand, and inclusive urbanisation, on the other. in conclusion, the pandemic should provide an opportunity to gear the economy towards more equitable and inclusive development rather than increased inequalities built on the higher precarity of informal workers in general, and circular migrants in particular. vulnerable internal migrants in india and portability of social security and entitlements. centre for employment studies working paper series understanding circular migration in india: its nature and dimensions, the crisis under lockdown and the response of the state. centre for employment studies working paper series. wp / , institute for human development emerging dynamics of labour market inequality in india: migration, informality, segmentation and social discrimination key: cord- - khv kbj authors: cohen, jennifer; van der meulen rodgers, yana title: contributing factors to personal protective equipment shortages during the covid- pandemic date: - - journal: prev med doi: . /j.ypmed. . sha: doc_id: cord_uid: khv kbj this study investigates the forces that contributed to severe shortages in personal protective equipment in the us during the covid- crisis. problems from a dysfunctional costing model in hospital operating systems were magnified by a very large demand shock triggered by acute need in healthcare and panicked marketplace behavior that depleted domestic ppe inventories. the lack of appropriate action on the part of the federal government to maintain and distribute domestic inventories, as well as severe disruptions to the ppe global supply chain, amplified the problem. analysis of trade data shows that the us is the world's largest importer of face masks, eye protection, and medical gloves, making it highly vulnerable to disruptions in exports of medical supplies. we conclude that market prices are not appropriate mechanisms for rationing inputs to health because health is a public good. removing the profit motive for purchasing ppe in hospital costing models and pursuing strategic industrial policy to reduce the us dependence on imported ppe will both help to better protect healthcare workers with adequate supplies of ppe. since early the us has experienced a severe shortage of personal protective equipment (ppe) needed by healthcare workers fighting the covid- pandemic (emanuel et al., ; livingston, desai, & berkwits, ) . in protests covered by the news media, healthcare workers compared themselves to firefighters putting out fires without water and soldiers going into combat with cardboard body armor. medical professionals have called for federal government action to mobilize and distribute adequate supplies of protective equipment, especially gloves, medical masks, goggles or face shields, gowns, and n respirators. n respirators, which have demonstrated efficacy in reducing respiratory infections among healthcare workers, have been in particularly short supply (macintyre et al., ) . without proper ppe, healthcare workers are more likely to become ill. a decline in the supply of healthcare due to worker illness combines with intensified demand for care, causing healthcare infrastructure to become unstable, thus reducing the quality and quantity of care. sick healthcare workers also contribute to viral transmission. hence ill practitioners increase the demand for care while simultaneously reducing health system capacity. this endogeneity makes a ppe shortage a systemwide public health problem, rather than solely a worker's rights or occupational health issue. ppe for healthcare workers is a key component of infection prevention and control; ensuring that healthcare workers are protected means more effective containment for all. we investigate the four main contributing factors behind the us shortage of ppe in and their interaction. first, a dysfunctional budgeting model in hospital operating systems incentivizes hospitals to minimize costs rather than maintain adequate inventories of ppe. second, a major demand shock triggered by healthcare system needs as well as panicked j o u r n a l p r e -p r o o f journal pre-proof marketplace behavior depleted ppe inventories. third, the federal government failed to maintain and distribute domestic inventories. finally, major disruptions to the ppe global supply chain caused a sharp reduction in ppe exported to the us, which was already highly dependent on globally-sourced ppe. market and government failures thus led ppe procurement by hospitals, healthcare providers, businesses, individuals, and governments to become competitive and costly in terms of time and money. the remainder of this article provides detailed support for the argument that the enormous ppe shortages arose from the compounding effects of these four factors. we conclude that because health is a public good, markets are not a suitable mechanism for rationing the resources necessary for health, and transformative changes are necessary to better protect healthcare practitioners. the shortage of ppe was an eventuality that nonetheless came as a surprise. the us experienced heightened demand for ppe in the mid-to late- s following the identification of the human immunodeficiency virus and the release of centers for disease control (cdc) guidelines for protecting health personnel (segal, (hersi et al., ) . although various stakeholders (governments, multilateral agencies, health organizations, universities) warned of the possibility of a major infectious disease outbreak, particularly pandemic influenza, most governments were underprepared. the world economic forum's annual global risks report even showed a decline in the likelihood and impact of a spread of infectious diseases as a predicted risk factor between and (wef, (wef, , . the problems created by lack of preparation were exacerbated by the high transmissibility of covid- and the severity of symptoms. contributing to the inadequate stockpiles of ppe were the trump administration's policies -which included public health budget cuts, "streamlining" the pandemic response team, and a trade war with the country's major supplier of ppeweakening the cdc's capacity to prepare for a crisis of this magnitude (devi, ) . the ppe shortage is reflected in survey data on ppe usage and in data on covid- morbidity and mortality. as of may , % of nurses reported having to reuse a single-use disposable mask or n respirator, and % of nurses reported they had been exposed to confirmed covid- patients without wearing appropriate ppe (nnu, ). as of july , , at least , nurses, doctors, physicians assistants, medical technicians, and other healthcare workers globally, and in the us, have died due to the virus, and many more have become sick (medscape, ) . the cdc aggregate national data of , cases among healthcare personnel and deaths (cdc, b). healthcare workers have died from covid- healthcare worker deaths by state recorded in medscape ( ) are correlated with cdc ( b) covid- cases by state (pearson's r of . , p< . ) and even more strongly correlated with cdc-confirmed covid deaths in the general population (pearson's r of . , p< . ). these correlation coefficients are indicative of healthcare worker exposure to the virus, and of the critical role of ppe and healthcare systems for population health. in other words, population health is a function of the healthcare system and wellbeing of healthcare workers, and the wellbeing of healthcare workers is a function of the healthcare system and ppe. we now turn to our analysis of ppe shortages, which identifies on four contributing factors: the way that hospitals budget for ppe, domestic demand shocks, federal government failures, and disruptions to the global supply chain (figure ). these four factors arose from a number of processes and worked concurrently to generate severe shortages. the first factor the budgeting model used by hospitals is a structural weakness in the healthcare system. the occupational safety and health administration (osha) requires employers to provide healthcare workers with ppe free of charge (barniv, danvers, & healy, ; osha, ) . from the perspective of employers, ppe is an expenditurea cost. ppe is unique compared to all of the other items used to treat patients (such as catheters, bed pans, and medications) which operate on a cost-passing model, meaning they are billed to the patient/insurer. an ideal model for budgeting ppe would align the interests of employers, healthcare workers, and patients and facilitate effective, efficient care that is safe for all. instead, the existing structure puts employers who prioritize minimizing costs and healthcare workers who prioritize protecting their safety and the health of their patients in opposition, leaving governmental bodies to regulate these competing priorities (moses et al., ) . employers, be they privately-owned enterprises, private healthcare clinics, or public hospitals, seek to minimize costs. in economic theory, cost-minimization is compelled through market competition with other suppliers. in practice, cost-minimization is a strategy for maintaining profitability or revenue. therefore, hospital managers adopt cost-effective behaviors by reducing expenditures in the short term to lower costs (mclellan, ) . despite some hospitals' tax-exempt status, hospitals function like other businesses: they pursue efficiency and cost minimization (bai & anderson, ; rosenbaum, kindig, bao, byrnes, & o'laughlin, ) . the pursuit of efficiency means hospitals tend to rely on just-in-time production so that they do not need to maintain ppe inventories. the osha requirement effectively acts as an unfunded mandate, imposing responsibility for the provision of ppe, and the costs of provision, on employers. when it is difficult to pass along the costs of unfunded mandates to workers (in the form of lower wages) or customers (in the form of higher prices), employers resist such cost-raising legal requirements. the tension between healthcare workers and employers over ppe is evident in the way nurses' unions push federal and state agencies to establish protective standards. it is demonstrated by the testimony of the co-president of national nurses united to the committee on oversight and government reform in the us house of representatives in october . she advocated for mandated standards for ppe during the ebola virus while employers were pushing for voluntary guidelines: [o]ur long experience with us hospitals is that they will not act on their own to secure the highest standards of protection without a specific directive from our federal authorities in the form of an act of congress or an executive order from the white house…the lack of mandates in favor of shifting guidelines from multiple agencies, and reliance on voluntary compliance, has left nurses and other caregivers uncertain, severely unprepared and vulnerable to infection (govinfo, ). employer resistance is short-sighted but unsurprising in the existing costing structure. the costing structure for other items, like catheters, allows employers to pass costs on to patients and insurers. the implication is that if employers (hospitals) cannot pass along the cost of the osha mandate to insurance companies, then employers do not have an economic incentive to encourage employees to use ppe, replace it frequently, or keep much of it in stock, at least until any gains from cost-minimization are lost due to illness among employees. the budgeting model is especially problematic when demand increases sharply, such as during the ebola virus in and the h n influenza pandemic in . as the site where new pathogens may be introduced unexpectedly, hospitals are uniquely challenged compared to other employers to provide protection (yarbrough et al., ) . but even during predictable fluctuations in demand, the existing model does not ensure that adequate quantities of ppe are available. however, previous studies have framed these problems as consequences of noncompliance among healthcare workers rather than noncompliance among employers (ganczak & szych, ; gershon et al., ; nichol et al., ; sax et al., ) . hospitals might be incentivized to avoid shortages by passing ppe costs on to patients and insurers, like other items used in care, but that approach is not the norm. this alternative cost-passing model also leaves much to be desired. where the current model induces tension between workers and employers, a cost-passing model would effectively situate practitioners against patients (cerminara, ) . if patients pay the costs of ppe, they might prefer that practitioners are less safe to defray costs. such a model is detrimental to both healthcare workers and patients. introducing tension to a relationship built on care and trust is precisely why the employer, not the patient, should be required to provide ppe to healthcare workers at no cost to j o u r n a l p r e -p r o o f journal pre-proof the worker. practitioners and patients should be allowed to share the common goal of improving patients' well-being. some labor economists argue that employers could (or do) pay compensating wage differentials to compensate healthcare workers for working in unsafe conditions (hall & jones, ; rosen, ; viscusi, ) . they believe that workers subject to hazardous conditions command a higher wage from employers compared to workers in less dangerous employment. higher wages for healthcare workers would then be embedded in the costs of care, which include pay for practitioners, that are passed along to insurance companies. however, this counterargument does not apply to healthcare practitioners because its necessary conditions are not met. workers would need perfect foresight that a crisis would require more protective equipment, knowledge of their employers' stockpile of ppe, perfect information about the hazards of the disease, and how much higher a wage they would need as compensation for these risks. this information is not available for workers who may be exposed to entirely novel pathogens that have unknowable impacts. neither the existing budgeting model nor the cost-passing model align the interests of the employer, healthcare worker, and patient. yet these three agents have a shared interest in practitioners' use of ppe. ppe, like catheters, are inputs to health. but unlike catheters, the primary beneficiary of ppe use is less easily identifiable than that of other inputs. while healthcare practitioners may appear to be the primary beneficiaries of ppe, the benefits are more diffuse. patients benefit from having healthy nurses who are not spreading infections, nurses benefit from their own health, and hospitals benefit from have a healthy workforce. nurses' health is an input to patient health, to the functioning of the hospital, and to the healthcare system. in other words, every beneficiary depends on nurses' health, which depends on ppe. still, employers' short-term profit motive dominates the interests of healthcare workers and patients, which suggests that alternative models that are not motivated by profit-seeking should be explored. the second contributing factor to the us shortage of ppe during the covid- outbreak was the rapid increase in demand by the healthcare system and the general public. in a national survey of hospital professionals in late march close to one-third of hospitals had almost no more face masks and % had run out of plastic face shields, with hospitals using a number of strategies to try to meet their demand including purchasing in the market and soliciting donations (kamerow, ) . american consumers also bought large supplies of ppe as the sheer scale of the crisis and the severity of the disease prompted a surge in panic buying, hoarding, and resales of masks and gloves. as an indicator of scale, in march amazon cancelled more than half a million offers to sell masks at inflated prices and closed , accounts for violating fair pricing policies (cabral & xu, ) . panicked buying contributed to a sudden and sharp reduction in american ppe inventories, which were already inadequate to meet demand from the healthcare system. there were two different kinds of non-healthcare buyers of ppe. a subset sought profits and bought and hoarded ppe items such as n respirators with the intent of reselling them at inflated prices (cohen, forthcoming) . it is likely that the majority, however, were worried consumers. while it may be tempting to blame consumers for seemingly irrational consumption, their decisions are more complex. panic buyers are consumers in the moment of buying ppe, but they are workers as well; people buy ppe because they are afraid of losing the ability to work j o u r n a l p r e -p r o o f and support themselves and their families. put simply, the dependence of workers on wages to pay for basic necessities contributes to panic when their incomes are threatened. this is rational behavior in the short term given existing conditions and economic structures. still, ppe belongs in the hands of those whose health has many beneficiaries: practitioners. eventually both the profiteer and the average, panicked worker/consumer will require healthcare, and contributing to the decimation of the healthcare work force is in no one's interest. underlying consumption behavior was intense fear of not only the disease but also fear of shortages. this panic reverberated throughout the supply chain as manufacturers tried to increase their production capacity to meet the demand for ppe (mason & friese, ) . one can conceptualize this mismatch between ppe demand and supply in an ability-topay framework. in much of economic theory, markets match supply and demand to determine the price of a good or service, and the price operates as a rationing mechanism. market actors choose to buy or sell at that given price. but there are problems with this framework. on the demand side, some people cannot "choose" to buy a product because they cannot afford it; they lack the ability to pay, so the decision is made for them. an example is a potential trip to the doctor for the uninsured. for many americans, whether to go to the doctor, or whether to have insurance, is not a choice; the choice is made for them because they are unable to pay. on the supply side, the ability-to-pay framework remains, except the product in question is an input. in healthcare, the practitioner is the proximate supplier of care and inputs to health are intermediate goods. the supplier's -or their employer'sability (and willingness) to pay for inputs to care, including ppe, determines the quality and quantity of care the practitioner is able to supply. when healthcare workers do not have ppe (e.g. because others bought it and resold it at extortionary prices), they are unable to provide the care patients need. but reselling behavior is j o u r n a l p r e -p r o o f also economically rational, if unethical, at least in the short term. indeed, ability-to-pay works well for the hoarder/reseller, who both contributes to and profits from the shortage. it is in the pursuit of profitsof monetary gainthat the mismatch between ppe demand and supply resides. on the demand side there is a person in need of care who is constrained by their inability to pay, while on the supply side there is a practitioner who is constrained by their inability to access the resources required to provide high quality care safely. the ability-to-pay framework is incompatible with the optimal allocation of resources when the ultimate aim is something other than monetary gain. hence market prices are not a good mechanism for rationing vital inputs to health such as ppe, and the profit motive is ineffective in resolving this mismatch between demand and supply. given the large-scale failure of the market to ensure sufficient supplies of ppe for practitioners, the government could have taken a number of corrective actions: it could have coordinated domestic production and distribution, deployed supplies from the strategic national stockpile, or procured ppe directly from international suppliers (hhs, ; maloney, ). the us government has anticipated ppe shortages since at least when the national institute for occupational safety and health commissioned a report examining the lack of preparedness of the healthcare system for supplying workers with adequate ppe in the event of pandemic influenza (liverman & goldfrank, ) . in a scenario in which % of the us population becomes ill in pandemic influenza, the estimated need for n respirators is . billion (carias et al., ) . however, the actual supply in the us stockpile was far smaller at j o u r n a l p r e -p r o o f million, thus serving as a strong rationale to invoke the defense production act to manufacture n respirators and other ppe (azar, ; friese et al., ; kamerow, ) . further, the ppe in the national stockpile was not maintained on a timely basis to prevent product expiration, forcing the cdc to recommend use of expired n s (cdc, a). adding to the problems of cdc budget cuts before and during the pandemic and their failure to stockpile ppe was the unwillingness of the federal government to invoke the defense production act to require private companies to manufacture ppe, ventilators, and other critical items needed to treat patients (devi, ) . by july , at which time the us already had more covid- cases than any other country in the world, there were still calls from top congressional leaders and healthcare professionals, including the speaker of the house of representatives and the president of the american medical association, for the trump administration to use the defense production act to boost domestic production of ppe (madara, ; pelosi, ; j. rosen, ) . researchers had also begun to publish studies on how to safely re-use ppe as it became clear that shortages would continue (rowan & laffey, ) . hence even five months into the crisis, the profit motive was still inadequate to attract new producers, which indicates that markets do not work to solve production and distribution problems in the case of inputs to health. not only did the government poorly maintain already-inadequate supplies and fail to raise production directly, it also failed to provide guidance requested by private sector medical equipment distributors and the health industry distributors association (hida), a trade group of member companies (maloney, ) . the private sector sought guidance about accessing government inventories, expediting ppe imports, and how to prioritize distribution, as indicated in this communication from hida's president: specifically, distributors need fema and the federal government to designate specific localities, jurisdictions or care settings as priorities for ppe and other medical supplies. the private sector is not in a position to make these judgments. only the federal government has the data and the authority to provide this strategic direction to the supply chain and the healthcare system (m. . moreover, it was not until early april that the trump administration issued an executive order for m, one of the largest american producers and exporters of n respirators, to stop exporting masks and to redirect them to the us market (whitehouse.gov, ) . looking up the supply chain, at least one distributor proposed bringing efforts to procure ppe internationally under a federal umbrella to the trump administration (maloney, , p. ). states-as-buyers confront the same market-incentivized structural issues that individual buyers face. a single federal purchaser would reduce state-level competition for buying ppe abroad, and mitigate the resulting inflated prices and price gouging by brokers acting as intermediaries between states-as-buyers and suppliers. the federal government chose not to take on this role. the profound government failures related to producing, procuring, and distributing ppe effectively, in ways not achievable through markets, are likely to have long-term impacts. the same distribution companies characterized, "the economics of supplying ppe in these circumstances" as "not sustainable" (maloney, , p. ) . they also expressed concern about the ongoing availability of raw materials required to manufacture ppe in the future. hida member companies expressed these concerns about supply chain issues in calls with federal agencies between january and march , specifically with respect to long-term supply chain issues impacting the upcoming - flu season (maloney, , p. ) . in mid-june, fema officials acknowledged that, "the supply chain is still not stable" (maloney, , p. ). a smoothly functioning supply chain has immediate impacts on the ability of governments and health personnel to contain an epidemic. the infectiousness and virulence of the disease affects the demand for ppe, just as the supply chain's functionality impacts the spread of the disease by improving practitioners' ability to treat their patients while remaining safe themselves (gooding, ) . the us domestic supply chain of ppe has been unable to sufficiently increase production to meet the enormous surge in demand. a large portion of the ppe in the us is produced in other countries. excessive reliance on off-shore producers for ppe proved problematic in earlier public health emergencies (especially the h n influenza pandemic and the ebola virus epidemic), and this lesson appears to be repeating itself during the covid- pandemic (patel et al., ) . the incentive for hospitals and care providers to keep costs down has kept inventories low and driven sourcing to low-cost producers, especially in china. china's low production costs combined with high quality have made it the global leader in producing a vast range of manufactured goods, including protective face masks, gloves, and gowns. even with the emergence of other low-cost exporters, china dominates the global market for ppe exports. meanwhile, the us is the world's largest importer of ppe. yet although the us is extremely dependent on the global supply chain, us manufacturers of ppe are also major exporters given the profits available in world markets. the trade data in table show the world's four top exporters of face masks, eye protection, and medical gloves. the data is drawn from the un comtrade database, using trade classifications from the who's world customs organization for covid- medical supplies j o u r n a l p r e -p r o o f (who, ) . in these data, the category "face masks" includes textile face masks with and without a replaceable filter or mechanical parts (surgical masks, disposable face-masks, and n respirators); "eye protection" includes protective spectacles and goggles as well as plastic face shields; and "medical gloves" includes gloves of different materials such as rubber, cloth, and plastic (who, ). we collected data for the - period. because patterns in - were very similar to those of , the china is the world's largest exporter of medical face masks and eye protection, followed not far behind by the us. the fact that the us recently exported such large amounts of a commodity that in early was marked by extreme shortages is indicative of the lack of public health planning and political will. unlike the case of masks and eye protection, the us is not a top exporter of medical gloves. the three largest exporters of medical gloves are all in asia and are well endowed with natural rubber. table also shows that the us is by far the largest importer of face masks, eye equipment, and medical gloves in the world market, followed by japan, germany, france, and the uk. overall, this analysis points to the high vulnerability of the us to disruptions in the global supply chain of face masks, eye protection, and medical gloves, and especially to disruptions in exports from china. the covid- outbreak in china in late led to a surge in demand within china for ppe, especially for disposable surgical masks as the government required anyone leaving their home to wear a mask. in response to demand, china's government not only restricted its ppe exports, it also purchased a substantial portion of the global supply (burki, ) . these shocks contributed to an enormous disruption to the global supply chain of ppe. as the virus spread to other countries, their demand for ppe also increased and resulted in additional pressure on dwindling supplies. in response, other global producers of ppe, including india, taiwan, germany, and france, also restricted exports. by march , numerous governments around the world had placed export restrictions on ppe, which in turn contributed to higher costs. the price of surgical masks rose by a factor of six, n respirators by three, and surgical gowns by two (burki, overall then, with respect to imports, the us is the biggest importer and so is highly dependent on the global supply chain, and with respect to exports, the us failed to prioritize the country's public health needs. after the covid- outbreak, the us was late to restrict ppe exports as other countries did, and the government failed to take the opportunity to order millions of masks in the years leading up to covid- crisis, including the two-month period between when the virus was recognized in china and when local transmission was detected in the us. impacts. hence the seemingly gender-neutral costing model described in our analysis does not have gender-neutral outcomes. by implication, a meaningful change in the way healthcare is funded that incentivizes hospitals to invest in adequate inventories of ppe will disproportionately benefit women workers. the gender differential is even more striking in the case of home-health aides. more research is needed on the extent to which men and women are impacted differently by ppe shortages. another important question is the extent to which gender issuessuch as women's relative lack of bargaining power in hospital administrationcontributed to shortages to begin with. our analysis points to the need for transformative changes and corrective actions to better protect healthcare practitioners. we must consider a full range of tools that not only create incentives for hospitals to protect their care providers with ppe, but also generate effective institutional capacity to ensure that health providers can mobilize quickly to handle pandemics. we have several recommendations: ( ) prepare hospitals to better protect practitioners by removing the profit motive from consideration in the purchasing and maintenance of ppe inventories; ( ) strengthen the capacity of local, state, and federal government to maintain and distribute stockpiles; ( ) improve enforcement of osha's current regulations around ppe, including requirements to source the proper size for each employee; ( ) develop new regulations to reduce practitioner stress and fatigue (cohen & venter, ; fairfax, ) ; ( ) improve the federal government's ability to coordinate supply and distribution across hospitals and local and state governments (patel et al., ) ; ( ) consider strategic industrial policy to increase us production of medical supplies and to reduce the dependence on the global supply chain for ppe; ( ) consider industrial policy to incentivize ppe production using existing technology while encouraging development, testing, and production of higher-quality, reusable ppe. these changes will address the costing-model issue, the demand problem, the federal government failures, and supply chain vulnerability, but they will not be politically palatable. creating the institutional capacity for building and maintaining a viable stockpile of ppe will j o u r n a l p r e -p r o o f contribute to all of these policy options. such shifts will help set the stage for what global health should look like moving forward. covid- was not the first pandemic nor will it be the last, especially given the likely impacts of climate change. congressional testimony: health and human services fiscal year budget request. c-span a more detailed understanding of factors associated with hospital profitability the impact of medicare capital prospective payment regulation on hospital capital expenditures global shortage of personal protective equipment. the lancet infectious diseases seller reputation and price gouging: evidence from the covid- pandemic potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the united states considerations for release of stockpiled n s beyond the manufacturer-designated shelf life contextualizing adr in managed care: a proposal aimed at easing tensions and resolving conflict covid- capitalism: the profit motive versus public health the integration of occupational-and household-based chronic stress among south african women employed as public hospital nurses invisible women: data bias in a world designed for men u.s.-china tariff actions by the numbers us public health budget cuts in the face of covid- fair allocation of scarce medical resources in the time of covid- the occupational safety and health administration's impact on employers: what worked and where to go from here respiratory protection considerations for healthcare workers during the covid- pandemic surgical nurses and compliance with personal protective equipment hospital safety climate and its relationship with safe work practices and workplace exposure incidents a mixed methods approach to modeling personal protective equipment supply chains for infectious disease outbreak response the value of life and the rise in health spending* effectiveness of personal protective equipment for healthcare workers caring for patients with filovirus disease: a rapid review strategic national stockpile. public health emergency covid- : the crisis of personal protective equipment in the us preparing for an influenza pandemic: personal protective equipment for healthcare workers sourcing personal protective equipment during the covid- pandemic efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers letter from american medical association to vice president michael pence memorandum: information provided by medical distribution companies on challenges with white house supply chain task force and project airbridge protecting health care workers against covid- -and being prepared for future pandemics work, health, and worker well-being: roles and opportunities for employers in memoriam: healthcare workers who have died of covid- the anatomy of health care in the united states behind the mask: determinants of nurse's adherence to facial protective equipment new survey of nurses provides frontline proof of widespread employer, government disregard for nurse and patient safety, mainly through lack of optimal ppe employer payment for personal protective equipment; final rule personal protective equipment supply chain: lessons learned from recent public health emergency responses transcript of pelosi interview on cnbc's mad money with jim cramer/interviewer rosen, homeland security committee colleagues demand answers from administration on strategic national stockpile letter from health industry distributors association the theory of equalizing differences. handbook of labor economics the value of the nonprofit hospital tax exemption was $ . billion in challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid ) pandemic -case study from the republic of ireland knowledge of standard and isolation precautions in a large teaching hospital the role of personal protective equipment in infection prevention history the value of risks to life and health global risks report global risks report memorandum on order under the defense production act regarding m company respirator use in a hospital setting: establishing surveillance metrics acknowledgements: the authors thank jacquelyn baugher, rn, bsn, ocn, for providing insight that aided our understanding of occupational relations internal to hospitals. key: cord- -kk iyavj authors: muller, researcher ashley elizabeth; hafstad, senior advisor elisabet vivianne; himmels, senior advisor jan peter william; smedslund, senior researcher geir; flottorp, research director signe; stensland, researcher synne Øien; stroobants, scientific coordinator stijn; van de velde, researcher stijn; elisabeth vist, senior researcher gunn title: the mental health impact of the covid- pandemic on healthcare workers, and interventions to help them: a rapid systematic review date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: kk iyavj the covid- pandemic has heavily burdened healthcare systems throughout the world. we performed a rapid systematic review to identify, assess and summarize research on the mental health impact of the covid- pandemic on hcws (healthcare workers). we utilized the norwegian institute of public health's live map of covid- evidence on may and included studies. six reported on implementing interventions, but none reported on effects of the interventions. hcws reported low interest in professional help, and greater reliance on social support and contact. exposure to covid- was the most commonly reported correlate of mental health problems, followed by female gender, and worry about infection or about infecting others. social support correlated with less mental health problems. hcws reported anxiety, depression, sleep problems, and distress during the covid- pandemic. we assessed the certainty of the estimates of prevalence of these symptoms as very low using grade. most studies did not report comparative data on mental health symptoms before the pandemic or in the general population. there seems to be a mismatch between risk factors for adverse mental health outcomes among hcws in the current pandemic, their needs and preferences, and the individual psychopathology focus of current interventions. the covid- pandemic has heavily burdened, and in many cases overwhelmed, healthcare systems , including healthcare workers. the who emphasized the extremely high burden on healthcare workers, and called for action to address the immediate needs and measures needed to save lives and prevent a serious impact on physical and mental health of healthcare workers . previous viral outbreaks have shown that frontline and non-frontline healthcare workers are at increased risk of infection and other adverse physical health outcomes . furthermore, healthcare workers reported mental health problems putatively associated with' occupational activities during and up until years after epidemics, including symptoms of post-traumatic stress, burnout, depression and anxiety [ ] [ ] [ ] . likewise, reports of the mental toll on healthcare workers have persistently appeared during the current global health crisis [ ] [ ] [ ] . several reviews have already been conducted on healthcare workers' mental health in the covid- pandemic, with search dates up to may . pappa et al. identified thirteen studies in a search on april and pooled prevalence rates; they reported that more than one of every five healthcare workers suffered from anxiety and/or depression; nearly two in five reported insomnia. vindegaard & benros' review, searching on may , identified twenty studies of healthcare workers in a subgroup analysis, and their narrative summary concluded that healthcare workers generally reported more anxiety, depression, and sleep problems compared with the general population. in the face of a prolonged crisis such as the pandemic, sustainability of the healthcare response fully relies on its ability to safeguard the health of responders: the healthcare workers , . yet, the recent findings of psychological distress among healthcare workers might indicate that the healthcare system is currently unable to effectively help the helpers. understanding the risks and mental health impact(s) that healthcare workers experience, and identifying possible interventions to address adverse effects, is invaluable. our main aim was to perform an updated and more comprehensive rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid- pandemic on healthcare workers, including a) changes over time, b) prevalence of mental health problems and risk/resilience factors, c) strategies and resources used by healthcare providers to protect their own mental health, d) perceived need and preferences for interventions, and e) healthcare workers' understandings of their own mental health during the pandemic. our second aim was to describe the interventions assessed in the literature to prevent or reduce negative mental health impacts on healthcare workers who are at work during the covid- pandemic. we conducted a rapid systematic review according to the methods specified in our protocol, published on our institution's website . we included any type of study about any type of healthcare worker during the covid- pandemic, with outcomes relating to their mental health. we extracted information about interventions aimed at preventing or reducing negative mental health impacts on healthcare workers; we were therefore interested in quantitative studies examining prevalence of problems and effects of interventions as well as qualitative studies examining experiences. we had no restrictions related to study design, methodological quality, or language. we identified relevant studies by searching the norwegian institute of public health's (niph's) live map of covid- evidence (https://www.fhi.no/en/qk/systematic-reviews-hta/map/) and database on may , as described in our protocol . the live map and database contained , references screened for covid- relevance containing primary, secondary, or modelled data. two researchers independently categorized these references according to topic (seven main topics, subordinate topics), population ( available groups), study design, and publication type. we identified references categorized to the population "healthcare workers", and to the topic "experiences and perceptions, consequences; social, political, economic aspects". in addition, we identified references by searching (title/abstract) in the live map's database, using the keywords: emo*, psych*, stress*, anx*, depr*, mental*, sleep, worry, somatoform, and somatic symptom disorder. we screened all identified references specifically for the inclusion criteria for this systematic review. the protocol of the live map of covid- evidence describes the methodology of the map and database the last included search for this review was conducted on may . the search strategy is presented in appendix . we developed a data extraction form to collect data on country and setting, participants, exposure to covid- , intervention if relevant, and outcomes related to mental health. we extracted data on prevalence of mental health problems as well as correlates (i.e. risk/resilience factors); strategies implemented or accessed by healthcare worker to address their own mental health; perceived need and preferences related to interventions aimed at preventing or reducing negative mental health consequences; and experience and understandings of mental health and related interventions. one researcher (aem) extracted data and another checked her extraction. two researchers (aem, sf/gev) independently assessed the methodological quality of systematic reviews using the amstar tool and of qualitative studies using the casp checklist . one researcher (aem) assessed the quality of cross-sectional studies using either the jbi prevalence or the jbi cross-sectional analytical checklist, and longitudinal studies using the jibi cohort checklist . results of these checklists are presented in appendix in the standard risk of bias format. we summarized outcomes narratively. we describe interventions and outcomes based on the information provided in the studies. when studies presented prevalence rates out mental health outcomes in figures without numbers, we extracted numbers using an online software (https://apps.automeris.io/wpd/). we presented mean prevalence rates as box-and-whisker plots. we decided not to perform a quantitative summary of the associations between the various correlates and mental health factors, due to a combination of heterogeneity in assessment measures and lack of control groups, and an overarching lack of descriptions necessary to confirm sufficient homogeneity. our included studies not only varied greatly from one another, they most often did not report sufficient information regarding inclusion criteria, population, setting, and exposure to assess potential clinical heterogeneity. we graded the certainty of the evidence using the grade approach (grading of recommendations assessment, development, and evaluation . fifty-nine studies were included. table displays their summarized characteristics, while appendix displays characteristics of the individual studies. a total of , participants were drawn from at least separate countries across the studies (one study reported participants came from countries, but did not specify these). the people's republic of china was the single most common setting ( studies and , participants), followed by iran (four studies). setting was not applicable for the two systematic reviews and the review of online mental health surveys. the majority of studies ( ) were cross-sectional surveys; two studies reported surveys administered twice over time; five were interview studies, of which three were analyzed qualitatively and two quantitatively; and four were other designs, including a case series and a study that searched within a database of existing online surveys. we also identified two systematic reviews , , which included five primary studies , , , , . the studies reported on healthcare workers working in different settings: studies reported on health care workers in hospitals, two studies were conducted in specialist health services outside hospitals, and three studies in other settings, while studies did not specify the healthcare setting or only partially described multiple settings. no studies reported on nursing homes or primary care settings. in studies, participants were frontline workers, while studies reported on non-frontline workers. frontline or non-frontline activities were unclear in ten studies. six studies reported on interventions to reduce mental health problems. more than half of the studies included nurses ( ) and/or doctors ( ) . study sizes ranged from a case study with three participants to a survey of , participants. six studies reported on the implementation of interventions to prevent or reduce mental health problems caused by the covid- pandemic among healthcare workers. these interventions can be loosely divided into those targeting organizational structures, those facilitating team/collegial support, and those addressing individual complaints or strategies. two interventions involved organizational adjustments. the first intervention was reported on by two studies , . hong et al. called it a "comprehensive psychological intervention" for frontline workers undergoing a mandatory two-week quarantine in a vocational resort, following two-to three-week hospital shifts. the quarantine itself was also described as part of the intervention, explicitly intended "to alleviate worries about the health of one's family". other elements included shortened shifts; involvement of the labor union to provide support to healthcare workers' families; and a telephone-based hotline that allowed healthcare workers to speak to trained psychiatrists or psychologists. this hotline had already been available to healthcare workers for four hours per week prior to the pandemic, but was made available for twelve hours, seven days a week. chen et al. reported a second intervention that attempted to address individual complaints and facilitate collegial support. a telephone hotline was set up to provide immediate psychological support, along with a medical team that provided online courses to help healthcare workers handle psychological problems, and group-based activities to release stress. however, uptake was low, and when researchers conducted interviews with the healthcare workers to understand this, healthcare workers reported needing personal protective equipment and rest, not time with a psychologist. they also requested help addressing their patients' psychological distress. in response, the hospital developed more guidance on personal protective equipment, provided a rest space, and provided training on how to address patients' distress. schulte et al. targeted collegial support and building individual strategies through one-hour video "support calls" for healthcare workers called in from their homes, to describe the impact of the pandemic on their lives, to reflect on their strengths, and to brainstorm coping strategies. this intervention was implemented as a response to the hospital redeploying pediatric staff to work as covid- frontline staff, and reorganizing pediatric space to accommodate more pediatric and adult covid- patients. none of the studies that implemented mental health interventions reported on the effects of the interventions on healthcare workers. the only data available to approximate the impact of the pandemic on the mental health of healthcare workers come from two longitudinal survey studies reporting on changes over time, both of low methodological quality. lv et al. surveyed healthcare workers before and during the outbreak, reporting no further information about the timeline. the study included both those working on the frontline and those with unclear exposure to covid- . however, it is unclear whether respondents were the same at both time points. the prevalence of anxiety, depression, and insomnia increased over time, whether mild, moderate, moderate to severe, or severe (see figure ). during the outbreak, one out of every four healthcare workers reported at least mild anxiety, depression, or insomnia. ***insert figure about here *** yuan et al. and an increase in smoking and drinking for only %. the proportion reporting improvement was similar for fidgeting, fear, and feeling nervous and uneasy, and more improved in not thinking one can succeed and for a reduction in smoking and drinking. two cross-sectional studies reported healthcare workers' self-reported changes in mental health; both were also of low methodological quality due to insufficient reporting. in benham et al. , twelve iranian psychiatry residents were re-deployed to work one frontline shift. half of the residents reported that they experienced more distress after this shift. abdessater et al. , studied urology residents not working on the frontline. when asked to report the level of stress caused by covid- , % reported a medium to high amount of stress, and the remaining reported none to low. less than % had initiated a psychiatric treatment during the pandemic. a third cross-sectional study , also of low methodological quality, surveyed healthcare workers in china in february, during the "outbreak period". a different cohort of healthcare workers were surveyed in march, during the "non-epidemic outbreak period". the healthcare workers in to the second phase of the survey reported less symptoms of anxiety and depression, and higher health-related quality of life. twenty-nine studies reported prevalence data of mental health variables as proportions or percentages. (seventeen additional studies reported data as average scores on various instruments, and we did not extract this data.) we present box-and-whisker plots in figure to show the distribution of anxiety, depression, distress, and sleeping problems among the healthcare workers investigated in the studies, using the authors' own methods of assessing these outcomes the most commonly reported protective factor associated with reduced risk of mental health problems was having social support , , , . two studies directly measured self-perceived resilience. bohlken et al. asked their sample of psychiatrists and neurologists to assess how resilient they were on a likert scale from - ("not applicable" to "completely applicable"), and % selected the two highest categories. cai et al. compared experienced frontline workers with inexperienced frontline workers, and found that inexperienced workers scored lower on total resilience on the connor-david resilience scale as well as within each of three subscales, and had more mental health symptoms. inexperienced workers were also younger and had less social support available to them. ten studies reported that healthcare workers utilized other resources or had individual strategies to address their own mental health during the pandemic, separate from formal interventions. six studies reported that healthcare workers utilized support from family/friends during the pandemic. "family" was the most common stress coping mechanism utilized by louie et al. kang et al. found slightly higher levels of interest in professional resources. when asked from whom they prefer to receive "psychological care" or "resources", % answered psychologists or psychiatrists, % answered family or relatives, % answered friends or colleagues, % answered others, and % said they did not need help. the authors found that the preferred sources of psychological resources were related to the level of psychological distress. in a structural equation model that uncovered clusters of healthcare workers with different distress levels (subthreshold, mild, moderate, and severe), those with moderate and severe distress more often preferred to receive care from psychologists or psychiatrists, while those with subthreshold and mild distress more often preferred to seek care from family or relatives. in two studies, participants specified that they had a greater need for personal protective equipment than for psychological help. chung et al. reported this in a survey that allowed healthcare workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse. while % requested such contact, nearly half of those who answered the free text question about their psychiatric needs wrote that they needed personal protective equpiment instead, and % said they were worried about infection. chen et al.'s study was to understand why uptake of their psychological intervention was so low, and findings were identical to chung et al.'s: "many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies" (p. e ). only one study explored how healthcare workers would be willing to provide mental health services to other healthcare workers: twelve psychiatry residents were re-deployed as frontline workers for one shift in benham et al.'s study. after that shift, none were willing to provide face-to-face mental health services to other healthcare workers, although % said they would provide online services. they identified healthcare workers of deceased patients as possible target populations for online services. three qualitative studies assessed as valuable were included. two interconnected themes across all three studies were distress stemming both from concern for infecting family members, and from being aware of family members' concern for the healthcare workers. wu et al. explored reasons for stress during interviews with healthcare workers at a psychiatric hospital. while these healthcare workers were not on the frontline, they felt they were at higher risk of exposure than healthcare workers at a general hospital. their wards were crowded, and several patients were admitted from emergency rooms with aggressive behaviors that made social distancing difficult or that posed direct challenges to healthcare workers' use of personal protective equipment (such as tearing masks). healthcare workers felt unprepared because psychiatric hospitals had no plans in place. at the same time, they also felt that their peers on the frontline were providing more valuable care. an additional source of stress was knowledge of their own risk of infection and transmission to family members, particular to elderly parents in their care, and to children who were at home and whose schoolwork had to additionally be managed. the disruption of the pandemic to nurses' personal lives and career plans was another stressor. sun et al. concern was great enough that several respondents did not tell their family they were working on the frontline, while others did not live at home during this period. as with wu et al.'s nonfrontline workers, these healthcare workers also reported fear and anxiety of a new infectious disease that they felt unprepared to handle on a hospital-level, unprepared to treat on a patientlevel, and from which they were unable to protect themselves. the first week of training and the first week of actual frontline work was characterized by these negative emotions, which were then joinednot necessarily replacedby more positive emotions such as pride at being a frontline nurse, confidence in the hospital's capacity, and recognition by the hospital. yin et al. families, particularly because their families would suffer more financially from needing to be quarantined than they already were suffering under the lockdown; fears of using personal protective equipment incorrectly; and feeling unequipped to handle patients' non-medical needs. healthcare workers reported that stigma suppressed patients' provision of accurate travel and quarantine history. this was an issue they were ill-equipped to help patients address when they returned to the community. healthcare workers also reported that they were stigmatized, because they were potential sources of infection. this systematic review identified heterogeneous studiesincluding three qualitative, fifty quantitative, two narrative reviews, and four other designsthat examined the mental health of between one and two of every five healthcare worker reported anxiety, depression, distress, and/or sleep problems. only one study reported on somatic symptoms such as changes in appetite. our confidence in these broad estimates, assessed using grade, was very low, which leads us to caution that the true prevalence of anxiety, depression, distress, and sleep problems among healthcare workers are likely different than our estimates. at the same time, is also common in interventions for healthcare worker burn-out before the pandemic . the most striking illustration of this was the finding shared by two studies , that healthcare workers said personal protective equipment would benefit their mental health more than professional help. on the other hand, it is possible that healthcare workers could benefit from professional mental health interventions more than they recognize or report, and that under-recognition is related to occupational culture, or fear of stigma or being perceived as weak . while a variety of countries were represented, four of every five participants were chinese, and chinese occupational culture may be a salient mediator of healthcare workers' expressed preferences , although this must be explored further. health's rigorous methodological standards for systematic reviews, such as two researchers screening and assessing eligibility. an additional methodological strength is our utilization of the live map of covid- evidence, one of the first reviews to do so (see also two reports , and one diagnostic accuracy study ). by using our map, we quickly identified studies that had already been categorized to our topic and population of interest, without having to search in academic databases and screen again. while not being able to conduct a meta-analysis is unfortunate, it was appropriate not to assume that poorly reported studies were homogenous enough. the principle of homogeneity tends to be overlooked by systematic reviewers eager to produce a summary estimate, but if met, means that all studies included were similar enough that their participants can be considered participants of one large study . the result, however, is that the prevalence data about mental health problems does not provide a summary estimate that can be generalized. other weaknesses are those common to rapid reviews due to time pressure, such as fewer details about the included studies' populations being presented than normally reported. the covid- pandemic has resulted in a flood of studies, many of which have been pushed through the peer-review process and published at speeds hitherto unseen (see glasziou for a discussion). it is therefore not surprising that the majority of our included studies were assessed as having a high risk of bias or being of low methodological quality. lack of information on samples or procedures was a common limitation, leading to serious implications to the generalizability and validity of findings. we also call on journals and researchers to balance the need for rapid publication with properly conducted studies, reviews and guidelines . healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, distress, and sleep problems during the covid- pandemic. causes vary, but for those on the frontline in particular, a lack of opportunity to adequately rest and sleep is likely related to extremely high burdens of work, and a lack of personal protective equipment or training may exacerbate mental health impacts. provision of appropriate personal protective equipment and work rotation schedules to enable adequate rest in the face of long-lasting disasters such as the covid- pandemic seem paramount. over time, many more healthcare workers may struggle with mental health and somatic complaints. the six studies exploring mental health interventions mainly focused on individual approaches, most often requiring healthcare workers to initiate contact. proactive organizational approaches could be less stigmatizing and more effective, and generating evidence on the efficacy of interventions/strategies of either nature is needed. as the design of most studies was poor, reflecting the urgency of the pandemic, there is also a need to incorporate high-quality research in pandemic preparedness planning. the authors report no conflicts of interest. the protocol for this review is available online. no funding was received. the italian health system and the covid- challenge critical care crisis and some recommendations during the covid- epidemic in china covid public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap mers and covid- among healthcare workers: a narrative review prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak long-term psychological and occupational effects of providing hospital healthcare during sars outbreak mental health of nurses working at a governmentdesignated hospital during a mers-cov outbreak: a cross-sectional study mental health survey of medical staff in a tertiary infectious disease hospital for covid- covid- pandemic and its impact on mental health of healthcare professionals the experiences of health-care providers during the covid- crisis in china: a qualitative study prevalence of depression, anxiety, and insomnia among healthcare workers during the covid- pandemic: a systematic review and meta-analysis covid- pandemic and mental health consequences: systematic review of the current evidence covid- and italy: what next? protect our healthcare workers the impact of the covid- pandemic on mental health of health care workers: protocol for a rapid systematic review a systematic and living evidence map on covid- amstar : a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both casp checklist for qualitative research grade guidelines: . introduction-grade evidence profiles and summary of findings tables covid pandemic impacts on anxiety of french urologist in training: outcomes from a national survey covid- outbreak situation and its psychological impact among surgeon in training in france fear and practice modifications among dentists to combat novel coronavirus disease (covid- ) outbreak working in the emergency and inpatient covid- special wards: a different experience for iranian psychiatric trainees amid the outbreak: running title: experience of iranian psychiatric trainees in covid- special wards psychological impact and coping strategies of frontline medical staff in hunan between a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease a study of basic needs and psychological wellbeing of medical workers in the fever clinic of a tertiary general hospital in beijing during the covid- outbreak mental health care for medical staff in china during the covid- outbreak. the lancet psychiatry prevalence of self-reported depression and anxiety among pediatric medical staff members during the covid- outbreak in guiyang, china multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak staff mental health self-assessment during the covid- outbreak psychological impact of the covid- pandemic on adults and their children in italy covid- and paediatric health services: a survey of paediatric physicians in australia and new zealand covid- associated psychiatric symptoms in healthcare workers: viewpoint from internal medicine and psychiatry residents psychological effects of covid- on hospital staff: a national cross-sectional survey of china mainland the stress and psychological impact of the covid- outbreak on medical workers at the fever clinic of a tertiary general hospital in beijing: a cross-sectional study assessment of the mental health of front line healthcare workers in a covid- epidemic epicenter of china psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in shanghai impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study covid- -related information sources and psychological well-being: an online survey study in taiwan factors associated with mental health outcomes among health care workers exposed to coronavirus disease psychological impact on women health workers involved in covid- outbreak in wuhan: a cross-sectional study vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid- control screening for chinese medical staff mental health by sds and sas during the outbreak of covid- psychological impact and predisposing factors of the coronavirus disease (covid- ) pandemic on general public in china online mental health services in china during the covid- outbreak. the lancet psychiatry perceived social support and its impact on psychological status and quality of life of medical staffs after outbreak of sars-cov- pneumonia: a cross-sectional study mental health status of doctors and nurses during covid- epidemic in china the impact of covid- pandemic on spine surgeons worldwide psychological status of medical workforce during the covid- pandemic: a cross-sectional study anxiety and depression survey of chinese medical staff before and during covid- defense brief psychotic disorder triggered by fear of coronavirus? work stress among chinese nurses to support wuhan for fighting against the covid- epidemic issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid patients evaluation of the level of anxiety among iranian multiple sclerosis fellowships during the outbreak of covid- assessment of iranian nurses′ knowledge and anxiety toward covid- during the current outbreak in iran mental health, risk factors, and social media use during the covid- epidemic and cordon sanitaire among the community and health professionals in wuhan investigation and analysis of the psychological status of the clinical nurses in a class a hospital facing the novel coronavirus pneumonia covid- and mental health: a review of the existing literature addressing faculty emotional responses during the covid pandemic psychological stress of icu nurses in the time of covid- emergency responses to covid- outbreak: experiences and lessons from a general hospital in nanjing novel coronavirus and related public health interventions are negatively impacting mental health services a qualitative study on the psychological experience of caregivers of covid- patients psychological impact of the covid- pandemic on health care workers in singapore stressors of nurses in psychiatric hospitals during the covid- outbreak psychological stress of medical staffs during outbreak of covid- and adjustment strategy the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china psychological status of surgical staff during the covid- outbreak symptom cluster of icu nurses treating covid- pneumonia patients in wuhan a study on the psychological needs of nurses caring for patients with coronavirus disease from the perspective of the existence, relatedness, and growth theory comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease (covid- ) outbreak in february survey of insomnia and related social psychological factors among medical staffs involved with the novel coronavirus disease outbreak at the height of the storm: healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of covid- mental health and psychosocial problems of medical health workers during the covid- epidemic in china prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against the covid- in gansu the immediate mental health impacts of the covid- pandemic among people with or without quarantine managements impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis the sleep-deprived human brain job decision latitude, job demands, and cardiovascular disease: a prospective study of swedish men health workforce burn-out systematic literature review of psychological interventions for first responders stigmatizing attitudes towards mental disorders among non-mental health professionals in six general hospitals in hunan province occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors affecting mental health of health care workers during coronavirus disease outbreaks: a rapid systematic review should healthcare personnel in nursing homes without respiratory symptoms wear facemasks for primary prevention of covid- ? -a rapid review social and economic vulnerable groups during the covid- pandemic antibody tests for identification of current and past infection with sars-cov- mixed and indirect treatment comparisons. evidence synthesis for decision making in healthcare waste in covid- research using grade in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the covid- pandemic, now more than ever and no matter what key: cord- -ef l authors: potter, gregory d. m.; wood, thomas r. title: the future of shift work: circadian biology meets personalised medicine and behavioural science date: - - journal: front nutr doi: . /fnut. . sha: doc_id: cord_uid: ef l shift work is commonplace in modern societies, and shift workers are predisposed to the development of numerous chronic diseases. disruptions to the circadian systems of shift workers are considered important contributors to the biological dysfunction these people frequently experience. because of this, understanding how to alter shift work and zeitgeber (time cue) schedules to enhance circadian system function is likely to be key to improving the health of shift workers. while light exposure is the most important zeitgeber for the central clock in the circadian system, diet and exercise are plausible zeitgebers for circadian clocks in many tissues. we know little about how different zeitgebers interact and how to tailor zeitgeber schedules to the needs of individuals; however, in this review we share some guidelines to help shift workers adapt to their work schedules based on our current understanding of circadian biology. we focus in particular on the importance of diet timing and composition. going forward, developments in phenotyping and “envirotyping” methods may be important to understanding how to optimise shift work. non-invasive, multimodal, comprehensive phenotyping using multiple sources of time-stamped data may yield insights that are critical to the care of shift workers. finally, the impact of these advances will be reduced without modifications to work environments to make it easier for shift workers to engage in behaviours conducive to their health. integrating findings from behavioural science and ergonomics may help shift workers make healthier choices, thereby amplifying the beneficial effects of improved lifestyle prescriptions for these people. simplistically, our species once lived by two "clocks." one of these clocks is the environmental clock, which generates roughly -h changes in the light/dark (ld) cycle. the other clock is the endogenous biological clock, which among other rhythms generates roughly -h (circadian) rhythms in biological outputs such as the sleep/wake cycle. prior to the introduction of artificial light at night, these two clocks were probably tightly synchronised ( , ) . following industrialisation, however, people can more easily work outside of conventional daytime hours, and - % of the working population now work shifts ( ) . the burden of shift work is striking: shift workers are not only at increased risk of accidents ( ) , they are also disposed to developing numerous diseases, including certain cancers, coronary heart disease, stroke, and type-two diabetes ( ) . few studies have explored whether shift work makes individuals prone to neurodegenerative diseases ( , ) , but shift work frequently disrupts biological rhythms and sleep, and such disturbances propagate a slew of pathobiological changes that contribute to neurodegeneration ( ) . while at the time of writing little is known about the effects of the novel coronavirus disease (covid- ) pandemic on the lives of many shift workers, we would be remiss not to mention that many healthcare professionals at the frontlines of the outbreak are currently working long shifts in conditions that dispose them to developing covid- ( ) . many of the chronic conditions associated with shift work are also associated with greater risk of poor outcomes in those with covid- as well as other coronavirus and influenza infections ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . as shift workers often work jobs considered essential during the covid- pandemic, improving the health of shift workers should become a key part of current and future pandemic preparedness. importantly, however, at present there is no strong evidence that people fully adapt to shift work ( ) . and considering that the unconventional schedules of shift workers also interrupt the lives of cohabiting non-shift workers, the burden of shift work is greater still. the purpose of this manuscript is therefore to summarise some ways by which we might be able to reduce this burden. optimising shift work schedules is fundamental to the health and productivity of shift workers. in general, it appears that most shift workers tolerate rapid, forward (clockwise) rotation schedules best ( ) . to support worker wellbeing, these shifts should each last no longer than h, have at least h of recovery between them, and amount to no more than h of work per week ( ) . to hone shift work schedules for individual workers, workers may benefit from having some control of their schedules. this autonomy helps account for differences between people in nonwork responsibilities, tolerance to shift work, and commuting to and from work. chronotype is another tailoring variable that is particularly germane to optimising shift work schedules. chronotype is defined as interindividual differences in the phenotypic expression of behavioural outputs regulated by the circadian system ( ) , the most conspicuous of which is the timing of the sleep/wake cycle, and in industrialised societies there exist large differences between individuals in their chronotypes ( ) . chronotype appears to modify the association between shift work schedules and risk of health problems ( ) , such that the health of early chronotypes may be especially negatively affected by working night shifts ( ) , whereas late chronotypes find working morning shifts particularly problematic ( ) . while it is not clear precisely why this interaction exists, shift workers who have closer alignment between their chronotypes and their work schedules appear to have more robust melatonin rhythms than their fellow shift workers, suggesting that they have better circadian system function ( ) . shift workers who have chronotypes that are better matched to their work schedules may also sleep better ( ) , and it is increasingly clear that circadian system and sleep health are essential to perhaps all facets of human health ( , ) . the period of each individual's circadian system is one determinant of his or her chronotype. in the absence of time cues (zeitgebers), the free-running period of the human circadian system is slightly longer than h, on average ( ) . the circadian system therefore needs to be synchronised (entrained) each day with the -h day, and shift work complicates this process. retinal light exposure is generally regarded as the most important stimulus in entraining the human circadian system ( ) , and changes in patterns of light exposure can rapidly and substantially shift circadian system timing (phase). this is especially true of short-wavelength light, which most potently suppresses melatonin synthesis ( ) . exposure to such light in the biological morning tends to advance circadian phase, whereas exposure to such light in the late biological evening tends to delay circadian phase. the implication of this is that it is possible to bolster how well-shift workers adapt to work schedules through timely use of means to increase exposure to high-intensity, shortwavelength light at specific times of day (e.g., by using lighttherapy lamps) and means to reduce exposure to such light at specific times of day (e.g., "blue-blocking" glasses and blue-light filtering apps on electronic devices). while not all studies that have used interventions to modify exposure to light in shift workers have proven beneficial, this inconsistency likely reflects marked heterogeneity in the methods used by researchers ( ), as well as large variation between people in how they respond to light ( ) . during darkness, retinal photoreceptors no longer register exposure to light, relaying this to the central clock in the circadian system (the suprachiasmatic nucleus), which in turn signals the pineal gland to synthesise melatonin. melatonin therefore acts as an endogenous marker of darkness, agonising its receptors in cells in numerous tissues to signal them to fulfil time-ofday-specific functions. simplistically, when the concentration of melatonin in the blood surpasses a certain threshold in humans who are melatonin-proficient, it is the biological night-time. conversely, when the concentration of melatonin is below this threshold, it is the biological daytime. melatonin supplementation can shift the phase of the circadian system ( ) . melatonin ingestion in the late biological afternoon tends to advance circadian phase, while ingestion in the early biological morning tends to delay it. melatonin is therefore a chronobiotic -an agent that can modify circadian phase. when timed appropriately, light exposure and melatonin ingestion additively shift circadian phase ( ) . a growing body of evidence also shows that exercise can shift circadian phase. early research demonstrated that min of cycling exercise each hour of night shifts helped workers adjust their circadian systems to a -h delay in bedtime ( ) . more recent work has begun to clarify the precise nature of the relationship between exercise and circadian phase, showing that treadmill exercise done in the early biological morning or early biological afternoon advances circadian phase, whereas the same exercise done in the biological evening delays it ( ) . this relationship is therefore similar to how timing of exposure to light affects circadian phase, and timely exposure to both light and exercise can also additively shift circadian phase ( ) . the influence of timing of food availability on patterns of activity in rats was documented as early as a century ago ( ) , and numerous studies of such "food anticipatory activity" have since implicated nutrition as an influence on circadian system timing. whereas the ld cycle is the primary zeitgeber for the suprachiasmatic nucleus, some scientists have hypothesised that the eating/fasting cycle may be the primary time cue for some peripheral clocks in the circadian system. we now know that changing the timing of food consumption rapidly alters the timing of gene transcription in peripheral clocks in mice, for example ( ) . recent work has shown that this may be true of humans too, for changing meal timing independently shifts the expression of some genes in peripheral tissues as well as the timing of the blood glucose rhythm, without changing the phase of the melatonin rhythm ( ) . we acknowledge, however, that lack of control of variables such as ld cycles in most studies of the effects of nutrition on the human circadian system mean that this is arguably the only study of people that fulfils at least one of the criteria for diet to be classified as a zeitgeber ( ) . it could be that entrainment to ld cycles largely nullifies any zeitgeber effects of nutrition ( ) . summarising the above, it is plausible that carefully timed exposure to light, melatonin ingestion, and exercise may result in additive shifts in the phase of the suprachiasmatic nucleus. as eating/fasting cycles appear to affect the phases of some peripheral circadian clocks, we anticipate that coordinated changes in all of these variables could be used to expedite adaptation to new shift work schedules. if one could estimate shift workers' circadian phases in real time and model how subsequent changes in zeitgeber schedules would influence their circadian systems, one could develop tools that use this information to expedite adaptation to shift schedule changes by providing personalised guidance and perhaps even individual-level changes in exposure to light. this may be a particularly fruitful topic for further study. while it is plausible that one could change nutrient timing to accelerate adaptation to new shift work schedules, in many instances shift workers do not seek to fully adjust to their new shifts. this raises the question of whether workers undergoing transient changes in work schedules should adjust their diets accordingly. however, it is also crucial to consider contextual factors that influence when shift workers eat and drink. work schedules, time constraints, timing of breaks within shifts, family commitments, and prioritising behaviours such as sleep over meals all influence diet timing in shift workers, leading to erratic diet timing patterns in these people ( ) . diet timing irregularities are also affected by cultural factors (e.g., ramadan) and the nature of some jobs (e.g., many on-call workers have especially unpredictable work schedules). temporarily putting these complexities to one side, controlled experiments have begun to explore the effects of diet timing during pre-clinical and clinical simulations of shift work. table summarises our dietary and supplementation suggestions for shift workers based on our interpretation of the current literature. beginning with preclinical research, studies of mice have shown that restricting food access to the dark period (the active phase for these nocturnal animals) may protect against the obesogenic effects of repeated -h advances in the ld cycle ( ) . in addition, restricting food access to the active phase may also accelerate adaptation of circadian rhythms in core body temperature and locomotor activity to repeated -h changes in ld cycles ( ) . these findings imply that people would better cope with rotating shift work if they fixed their eating to the daytime, which is somewhat counterintuitive given that fixing eating time during shifting ld cycles might be expected to uncouple circadian rhythms between the suprachiasmatic nucleus and peripheral clocks. it is, however, intuitive that restricting food access to the active phase may be preferable to restricting it to the rest phase, and findings from initial research on humans support this contention. among healthy young men undergoing simulated night shift work for days, those who confined their consumption of calorie-containing foods and drinks (i.e., the caloric period) to between breakfast at : and dinner at : had superior postbreakfast glucose tolerance after the intervention compared to men who had dinner at : , a meal at : , and breakfast at : ( ) . the group that restricted food intake to the daytime also had superior overnight cognitive function ( ) . this is especially salient given that many shift workers redistribute their energy intakes into the night when working shifts ( ) . additional studies using larger sample sizes and investigating the effects of diet composition on a range of round-the-clock postprandial responses will be instructive. studies of adults undergoing time-restricted eating (tre) also indicate that optimising nutrient timing is likely to be important to cardiometabolic health, although the participants in these studies have generally not been shift workers. we arbitrarily define tre as consumption of all calorie-containing items within a period of h or less each day. conversely, we define workers should restrict consumption of all items containing > calories to a -to -h period each day, when possible. they should keep the timing of this period as regular as is feasible from day to day. workers should self-select the timing of this period, and the ideal time for this period may be relatively early in each worker's biological daytime. we therefore recommend that workers select a caloric period that finishes at least h before their most common bedtime. workers who have poor cardiometabolic health should aim to consume at least half of daily energy intake in the first half of the caloric period (e.g., by increasing the size of breakfast and reducing the size of dinner). this is less relevant to people who exercise in the second half of their caloric period. workers should also aim to evenly divide their protein intakes between dietary events. as a starting point, we recommend that workers aim to consume ∼ . g protein per kg bodyweight at each of to evenly-spaced dietary events each day ( ) . workers who have poor glycaemic control should consume carbohydrate-rich foods last at dietary events, when practical (e.g., consuming fibre-and protein-rich salads before meals or eating meat and vegetable foods before carbohydrate-rich foods). when workers feel it would be beneficial to snack outside of the caloric period (e.g., to abate hunger and/or support alertness), they may benefit from consuming relatively small (i.e., ∼ - % daily caloric intake), minimally processed, micronutrient-dense, satiating, easy to digest, convenient snacks. we hypothesise that relatively high-protein, low carbohydrate snacks are ideal at these times (e.g., snack items may include boiled eggs, dairy products, minimally-processed fish jerky or meat jerky, high-protein drinks, nuts, whole vegetables, and/or low-sugar whole fruits such as berries). if their goal is to support cognitive function during shifts, workers may benefit from individual doses of - mg caffeine per kg bodyweight, favouring the upper end of this range if short on sleep ( ) . repeated doses of caffeine every h or so may maximally support cognitive function during extended wakefulness ( ) . as consuming caffeine as gum leads to faster absorption than consuming caffeine as capsules ( ), caffeinated gum may be particularly helpful if the goal is to affect cognition as quickly as possible. since mistimed caffeine intake impairs sleep, workers should also stop consuming caffeine at least h before the main sleep period, if possible ( ) . individuals differ remarkably in their responses to caffeine ingestion, so they should moderate their intakes according to their individual responses. as a starting point, we recommend consuming no more than mg caffeine per kg bodyweight per h. creatine monohydrate consumption may help shift workers cope with sleep loss. during periods of insufficient sleep, we tentatively recommend that shift workers consume . g creatine monohydrate per kg bodyweight per day. because of its potential alertness-boosting properties, we speculate that the ideal time to consume creatine is with the first meal of each day. well-timed melatonin use may help some shift workers adapt to new work schedules and sleep better during these transitions. we tentatively recommend that workers consume a dose of . - mg melatonin at these times, beginning with a dose at the low end of this range and adjusting the dose according to responses. because of its potent chronobiotic properties, the optimal timing of melatonin ingestion depends on variables such as the individual's circadian phenotype and work schedule. we therefore do not offer guidance related to melatonin ingestion timing. intermittent fasting as periodic abstinence from consumption of any calories for at least h. skipping breakfast is one way to implement tre, and doing so leads to late tre. while breakfast-skipping is a controversial topic, epidemiologic studies have tended to associate breakfast consumption with lower risk of developing cardiometabolic diseases such as heart disease and type-two diabetes ( , ) . however, controlled studies have not shown large effects of skipping breakfast on cardiometabolic health ( ) . for example, lean adults who skipped breakfast for weeks inadvertently decreased their daily energy intakes, but this change was compensated by reductions in physical activity energy expenditure, resulting in no changes in energy balance or body composition ( ) . skipping breakfast did not affect most measures of cardiometabolic health -the only noteworthy difference between groups was that afternoon glycaemic variability was higher in adults who skipped breakfast. a subsequent study implemented the same intervention but only included obese adults ( ) . in this study, participants in the breakfast-skipping group expended less energy in the morning, but they did not burn fewer calories over the entire day. daily energy intake was similar in breakfast-skippers and breakfast eaters, and both groups gained weight during the study. people who skipped breakfast did have higher insulinaemic responses to an oral glucose tolerance test, however. these two rigorous studies show that skipping breakfast minimally affects energy balance but may negatively affect glycaemic regulation and some of its determinants. as sleep timing did not differ between groups, breakfast skipping led to a form of late tre, so these studies imply that late tre may not be optimal for some aspects of cardiometabolic health. skipping breakfast imposes a relatively late caloric period, and an alternative is to shorten the caloric period by way of skipping dinner or having an early dinner. several recent carefully controlled experiments have shown that such early tre may exert numerous positive effects on health. the first of these experiments reported that compared with a ∼ -h daily caloric period for weeks, weeks of early tre (∼ -h daily caloric period, finished by : ) improved insulin sensitivity, blood pressure, appetite regulation, and a marker of oxidative stress in men who have prediabetes ( ) . the same group of scientists recently reported that in overweight adults, just days of early tre reduced mean -h blood glucose levels and improved metabolic flexibility, among other benefits ( , ) . these experiments did not compare early tre to later tre while keeping the caloric period fixed, however, and to our knowledge, only one study has done this to date ( ) . the study in question showed that days of both early ( : to : ) and late ( : to : ) tre improved oral glucose tolerance in men at high risk of developing type-two diabetes, although only early tre lowered fasting glucose, suggest a small advantage of early tre ( ) . while this hypothesis needs careful testing, we believe that early tre may also enhance diet composition by reducing intakes of foods and drinks commonly consumed in the evening, such as processed snacks and alcohol. together, these studies support the superiority of relatively early tre in adults who have poor cardiometabolic health. however, non-self-selected tre schedules may interfere with some social activities and be difficult to adhere to in the context of work schedules and family commitments ( , ) . letting people self-select their tre periods helps mitigate these undesirable consequences. indeed, weeks of self-selected tre minimised these issues in adults with metabolic syndrome, also reducing daily energy intake and potently improving numerous aspects of cardiometabolic health including bodyweight, waist circumference, and blood pressure ( ) . moreover, tre led to more regular diet timing, which may independently be beneficial for cardiometabolic health ( ) . interestingly, tre also improved sleep timing regularity and increased how often participants selfreported restorative sleep. however, this study was an unblinded, single-arm study with only participants included in the data analysis ( ) . based on existing studies, tre appears to be a safe strategy that is likely to reduce energy intake, which would be especially beneficial for people who have unavoidably sedentary lifestyles. we hypothesise that fixing the timing of each worker's caloric period within regular hours each day supports metabolic health, and it is plausible that this may be especially important in workers who are subject to unpredictable changes in zeitgebers such as ld cycles (e.g., emergency service workers). we further speculate that each worker's biological daytime is the optimal time at which to fix the individual's caloric period, but self-selection of tre schedules will help people adhere to tre and avoid undesirable effects on social and family life. this said, scheduling tre as early as is practical may maximise the beneficial cardiometabolic effects of tre. while a detailed discussion of this subject is beyond the scope of this review, several recent controlled studies have shown that when daily energy intake is fixed, the distributions of energy and macronutrient intakes within the caloric period strongly influence cardiometabolic health. for example, one study divided overweight and obese women into two groups that consumed isocaloric weight loss diets for weeks ( ). one group consumed half of their daily energy intakes at breakfast, the other group consumed half at dinner. the group that consumed half at breakfast lost more than twice as much bodyweight, more than twice as many centimetres off their waists, and had greater improvements in oral glucose tolerance. subsequent work by the same scientists demonstrated that when energy intake is controlled, concentrating energy and carbohydrate intakes early in the day leads to enhanced appetite regulation, weight loss, and dramatic improvements in glycaemic control in adults with type- diabetes ( ) . this builds on research demonstrating that having carbohydrate-rich meals early in the day reduces -h glycaemia in adults with impaired fasting glucose and/or impaired glucose tolerance ( ) . while these studies highlight the advantages of concentrating energy and carbohydrate intakes relatively early in the caloric period, we note that that intelligent inclusion of physical activity leads to acute improvements in postprandial responses to dietary events such that relatively high energy and carbohydrate intakes late in the biological day may not be so problematic if they bookend exercise ( ) . and staying on the subject of exercise, there is tentative evidence that distribution of daily protein intake affects skeletal muscle protein synthetic responses to resistance training ( ) . as muscle protein synthesis is the main determinant of muscle protein balance, it is reasonable to assume that evenly dividing and spacing protein intakes between and daily dietary events may help maximise fat-free mass, a key determinant of cardiometabolic health ( ) . we would be negligent to not mention that the sequence of macronutrient intakes within dietary events may also meaningfully affect postprandial responses. several studies by one research group have shown that consuming carbohydrate last at a given dietary event (e.g., a full meal) dramatically reduces postprandial glycaemia and insulinaemia in adults who have prediabetes or type-two diabetes ( ) ( ) ( ) . shift workers who have poor glycaemic control may hence benefit from consuming carbohydrate-rich foods last at dietary events, when practical. most shift workers snack during night shifts. the problem is that night shifts often occur during the workers' biological nighttimes, and digestive and metabolic responses to dietary events are impaired during the biological night ( ) . as highlighted earlier, eating and/or drinking during the biological night-time may disrupt peripheral clocks. if workers snack during night shifts, it is therefore important to minimise energy intake and select dietary choices that lead to favourable postprandial responses. these snacks should also be convenient, minimally processed, micronutrient-dense, satiating, easy to digest, and minimally perishable, when applicable. preliminary research has shown that when -h energy and macronutrient intakes are controlled during simulated night shifts, a small snack (containing % of daily energy intake) may support cognitive function and performance in simulated driving compared with no snacking or a larger meal containing % of daily energy intake ( ) . in this instance, the small snack also reduced hunger to a comparable extent to the meal, without leading to significant digestive discomfort ( ) . compared to large night-time snacks, small night-time snacks may also be better for metabolic health. glycaemic control is relatively easy to measure and predictive of many health outcomes, and some researchers have therefore focused on the effects of nocturnal snacking on glycaemic control. compared with a small midnight snack (∼ calories), a large midnight snack (∼ calories) impaired postprandial glycaemic responses at a subsequent breakfast at : during simulated shift work ( ) . research such as this is informative, but we again need additional studies of workers in which the effects of dietary changes on metabolic parameters are measured around the clock. shift workers are not only apt to consume foods and drinks at suboptimal circadian phases, the quality of shift workers' diets is often worse than that of day workers too. many shift workers report consuming few fruits and vegetables while also consuming a variety of processed foods at work, such as biscuits, cakes, chocolates, pastries, sandwiches, and fried foods ( ) . as diet composition affects metabolic health and cognitive function, it is important to help these people make better dietary choices. one way by which diet composition influences health is via effects on the circadian clockwork, and the ketogenic diet (kd) exemplifies this. there has been a resurgence in interest in the kd of late, and while some believe that the restrictive nature of the kd is a barrier to its widespread implementation, certain properties of the kd make it an appealing option for some shift workers who are able to adhere to it. studies of mice have shown that the kd has chronobiotic actions on the clocks in multiple peripheral tissues, including the brain, gut, and liver ( ) ( ) ( ) . interestingly, tognini and colleagues found that a kd induced distinct changes in the liver and gut clocks in mice. compared to a control diet, consumption of a kd produced greater amplitudes of clock gene transcription and their downstream products in the liver, as well as inducing -h oscillations in the transcription of many genes in the gut ( ) . as disruption of the gut clock is associated with increased intestinal inflammation and permeability, as well as endotoxaemia ( , ) , if translatable to humans these results suggest that shift workers who follow a kd may protect themselves against some of the adverse consequences of consuming calories at suboptimal circadian phases. more generally, both the kd and less severe carbohydrate restriction may reduce some negative effects of shift work on metabolic health. shift workers are at an increased risk of impaired glucose tolerance and type-two diabetes, and restricting carbohydrate intake is likely to reduce fasting and postprandial glycaemia, both of which are precursory to numerous chronic diseases (e.g., some cardiovascular diseases, certain cancers, and dementia) ( ) ( ) ( ) ( ) ( ) ( ) . preliminary evidence has shown that a multicomponent lifestyle intervention centred on the kd may also improve subjective sleep quality in adults who have poor glycaemic control ( ) , suggesting that sleep enhancement may mediate some of the reported benefits of the kd. in preclinical studies, ketone bodies themselves have been found to have pleiotropic beneficial physiological effects, including modulation of inflammation, tissue-specific suppression of mtor signalling, and increased production of brain-derived neurotrophic factor ( ) ( ) ( ) . if translatable to humans, these systemic effects of ketone bodies imply that long-term consumption of a kd could reduce risk of certain cancers and neurodegenerative diseases such as alzheimer's in shift workers, particularly those that are already at increased risk ( , ) . increased production of ketone bodies may also account for some benefits of fasting and tre. for example, early tre led to greater morning beta-hydroxybutyrate levels compared to a -h caloric period ( ) . however, there have not yet been any clinical trials of the kd in shift workers, and it will be interesting to explore how the combination of the kd and tre and/or intermittent fasting interact to affect ketosis, metabolic regulation, and circadian biology in these people. in addition to effects of dietary patterns on the circadian system, specific dietary compounds have chronobiotic actions. a multitude of dietary compounds affects the circadian system and sleep ( , ) , and it is beyond the scope of this article to discuss them all. we therefore focus on some of those that we anticipate may be practical and beneficial for shift workers. in the future, screens for novel chronobiotics and hypnotics may yield compounds that support the health and performance of these workers ( ) . identifying agents that counter decrements in health and cognitive function incited by sleep disruption would also benefit shift workers. largely by antagonising adenosine receptors, consumption of caffeine can improve alertness, attention, reaction time, and mood, as well as physical performance in tests of endurance, strength, and power ( ) . studies of caffeine consumption by shift workers have consistently shown beneficial effects on multiple aspects of cognitive function, although whether this results in improved safety is not clear ( ) . the trade-off is that caffeine consumption tends to prolong sleep latency, reduce slow-wave activity during sleep (which is important to numerous restorative processes), shorten sleep duration, fragment sleep, and worsen subjective sleep quality ( ) . consumed late in the day as coffee, caffeine also delays circadian phase ( ) . thus it is clear that while judicious caffeine intake can be used to help shift workers perform at work -especially when sleepy -mistimed caffeine intake may strongly degrade sleep, which is noteworthy given that many of the adverse consequences of shift work appear to relate to its detrimental effects on sleep ( ) . it therefore seems prudent to recommend that shift workers generally stop consuming caffeine several hours before their main sleep period (more specific guidance on caffeine intake is provided in table ). antagonising adenosine receptors is one way to reduce the accumulation of pressure to sleep (sleep homeostasis), but another is to bolster the phosphorylation of adenosine. creatine (creatine monohydrate, specifically), a safe and inexpensive dietary supplement that increases brain phosphocreatine stores, countering the accumulation of extracellular adenosine in the brain during extended wakefulness. a study of rats showed that adding creatine to the rats' chow for weeks reduced the duration and slow-wave activity of the rats' sleep ( ). we do not currently know the effects of creatine supplementation on sleep in humans, however. notably, while shorter sleep would generally be expected to impair health and performance, creatine supplementation has repeatedly been shown to enhance these variables in humans. creatine supplementation routinely improves performance in -and adaptations to -many exercise tasks, and creatine has a number of therapeutic actions, including neuroprotective properties ( ) . interestingly, creatine supplementation may also acutely help protect against the deleterious consequences of sleep loss. after sleep loss, creatine supplementation seems to offset deterioration in executive function, mood, reaction time, balance, and other motor skills ( ) ( ) ( ) . although we expect creatine supplementation to be a useful strategy to help but this people cope with shift work, we are not aware of any research on this topic. we also note that there is some evidence that concurrent consumption of caffeine may reduce some of the ergogenic effects of creatine on physical performance ( ) , and additional studies are needed to better identify how the two compounds interact. several dietary amino acids may influence circadian rhythms and sleep. for instance, l-tryptophan is a precursor to melatonin that researchers have studied with respect to circadian rhythms and sleep. as an example, there appears to be a temporal relationship between consumption of l-tryptophan in breast milk and infant urinary excretion of -sulfatoxymelatonin, the primary metabolite of melatonin ( ) . furthermore, infants fed l-tryptophan-enriched night-time formula seem to experience more consolidated sleep/wake patterns ( ) . many studies of adults have also shown that ∼ g l-tryptophan each day enhances some sleep parameters, although it is not a potent hypnotic ( ) . to our knowledge, there are no rigorously controlled studies demonstrating that l-tryptophan affects circadian phase, however. overall, there has been little research on whether amino acids affect circadian system parameters. in a screen of whether amino acids affect light-induced shifts in the phase of wheel running activity in mice, l-serine increased the magnitude of phase shifts by %. this effect seems to translate to humans, as adults who consumed l-serine before bedtime experienced a greater advance in circadian phase in response to bright light exposure ( ) . another study reported that week of lornithine supplementation delayed the plasma melatonin rhythm by min ( ) . however, ld cycles and meal timing were not fully controlled in these studies. interestingly, there is also preliminary evidence that regular l-ornithine supplementation ( mg per day) may enhance sleep quality during stressful periods ( , ) . l-glycine may too affect sleep. consuming g l-glycine an hour before bedtime appears to shorten sleep latency, increase sleep efficiency, and reduce daytime sleepiness in healthy adults, effects that appear to be mediated via the suprachiasmatic nucleus ( , ) . such supplementation also seems to diminish daytime fatigue and boost vigilance during sleep restriction ( ) , implying that l-glycine may both enhance sleep and the ability to cope with sleep loss. given that l-glycine is safe, inexpensive, and may confer other health benefits ( ) , night shift workers could gain from supplementing with this amino acid. at present, however, there has been little research on effects of this amino acid on sleep. in summary, it is plausible that supplementing with certain amino acids may help shift workers adapt more quickly to changes in their shifts and/or sleep better, but this is based on few studies that did not control zeitgeber cycles or explore whether the circadian timing of amino acid ingestion interacts with the circadian timing of light exposure. going forward, it will be important to address these limitations. it will also be interesting to see whether concurrent consumption of different chronobiotic agents additively boosts circadian phase shifts. we have mentioned several ideas for future studies, and we will end by focusing on additional research avenues that may be worth exploring with respect to improving the health of shift workers. rapid recent advances in the development and uptake of digital technologies such as smartphones, apps, wearables, and artificial intelligence provide scientists with an unprecedented ability to comprehensively assess people's behaviours and health in freeliving contexts. the mycircadianclock app is a salient example of such technology. this app has already been used in multiple studies to monitor the circadian phenotypes of study participants, unveiling interesting insights into the effects of interventions such as tre on human health ( , ) . as data collected from digital devices are time-stamped, it is easier than ever to temporally map behavioural patterns and their biological sequelae, which could provide novel insights into the causes of changes in the health trajectories of shift workers. one could identify the hours of the day in which it is most frequently a shift worker's biological daytime by longitudinally assessing the timing of the individual's biological clock. as it is not currently practical to assess an individual's melatonin rhythm on a daily basis, the integration of data from surrogate markers of circadian phase such as body temperature and sleep/wake cycles could be used to approximate the timing of the biological daytime. these cycles could be monitored ambiently using data from devices such as smartphones, and the data from the devices could then be used to inform individual shift workers about how to best implement tre. where feasible, this process could be refined figure | using digital devices to optimise the health and performance of shift workers by providing personalised guidance, work schedules, and zeitgeber schedules. ( ) digital devices can be used to monitor behaviours and their biological responses, including (i) exposures to variables such as light (e.g., via head-worn wearables), (ii) dietary behaviours (e.g., via food photography and continuous glucose monitoring), and (iii) physical activity (e.g., via smart watches). digital phenotyping using patterns of smartphone use can be used to enrich this analysis. ( ) these data and their interactions can then be analysed in real time and used to ( ) personalise guidance, shift schedules, and zeitgeber schedules of individual workers. guidance can be delivered digitally and in-person, and innovative technologies may eventually allow the automation of adjustments to individual workers' zeitgeber schedules. with the addition of round-the-clock measures of metabolic regulation, such as continuous glucose monitoring. at a small scale, the feasibility of this type of approach has already been shown ( ) . ultimately, implementing such methods at a large scale and including both shift workers and non-shift-working controls may help develop models that forecast transitions in the health of shift workers, as well as how to alter these trajectories. however, the data collection process will need to be relatively frictionless (for participants, at least) to achieve this. this will be facilitated by close collaboration between scientists and workers in the technology sector. with accurate monitoring in place, digital tools could then be implemented to improve the health and productivity of shift workers by optimising variables such as zeitgeber schedules in real time (figure ) . innovative technologies could also provide novel means of generating insightful data while minimising participant burden. for example, sensors commonly built into smartphones can now be used to monitor blood parameters such as haemoglobin that once required invasive testing ( ) . smartphones can also be used to monitor some exposures that are particularly relevant to shift workers, such as patterns of locomotion and exposure to light. one problem, however, is that it would be especially useful to assess exposure to light at the level of the eye. this requires new wearable devices, for smartphones are not suited to this, and many existing wearables that measure light exposure are frequently obstructed by clothing, confounding their data. it is possible to make smart eyewear to estimate retinal light exposure, and such eyewear may be especially useful for another purpose. the utility of all of these monitoring technologies may be enhanced by the addition of the ability to digitally "envirotype" individuals, ambiently tracking information about their environments to better understand the interaction between environment and phenotype ( ) . building camera technology into eyewear is one way to accomplish this. meanwhile, digital phenotyping -assessing changes in people's phenotypes using data from digital devices -has already been used to identify patients' disease trajectories in neurological disorders such as schizophrenia ( ) . such phenotyping can proceed without active user engagement, and it can also be used to assess behaviours such as sleep ( ) . ultimately, use of multimodal novel sensors that analyse biofluids including interstitial fluid (e.g., continuous glucose monitoring), saliva, sweat, and tears may prove particularly useful in monitoring variables such as dietary intakes and associated changes in metabolites ( ) . however, the development of these sensors poses substantial challenges related to biofouling, accuracy, power, usability, calibration, and data security. these tools are promising approaches to forecasting changes in behaviours and health, and we hope they will help healthcare professionals intervene before individuals succumb to disease. we foresee that using sophisticated computational methods such as deep learning to concurrently analyse individuals' behavioural, health, and environmental data from multimodal sources will eventually enhance personalisation of guidance for individual shift workers ( ) . even if shift workers understand precisely which behaviours they should enact to improve their health, they are prone to a variety of factors that impair decision making, such as circadian system misalignment and sleep loss ( , ) . furthermore, knowledge alone is rarely sufficient to support lasting health behaviour change ( ) . it is therefore imperative to support the ability of these people to make smart decisions, and this requires applying principles from behavioural science, particularly at the level of the organisations that employ shift workers. significantly, many new technologies are strikingly habitforming, and this exemplifies the power of applying behavioural science principles to shape behaviour. if scientists and technologists can collaborate to effectively use behavioural science to create engaging, scalable products that deliver tailored health guidance to shift workers, all would benefit. we believe that technologies that deliver adaptive interventions to both help people avoid poor health decisions during states of vulnerability and support good health decisions during states of opportunity will be particularly advantageous ( ) . the built environment also affects health in numerous ways ( ) , and given that shift workers are prone to health problems, it is particularly critical to pay attention to optimising the workplaces of these people. as shift workers commonly experience circadian system disruption and do not gain tolerance to such disruption ( ) , it may be valuable to create workplaces that allow close control over exposure to light, and intelligent use of "smart" lighting systems may benefit these individuals. we also anticipate the development of closed-loop devices that will personalise light exposure at the level of the individual. the built environment influences physical activity. to support job performance and health, workplaces should have designated exercise spaces to encourage physical activity. environmental design is relevant to nutrition too. dietary choices depend strongly on where foods and drinks are sourced from. in work settings such as airplanes, food is provided for shift workers. however, most shift workers are left to source their own food, and when short on time many shift workers buy foods and drinks from vending machines ( ) . it is encouraging that many workers do select healthier dietary choices when they are available in vending machines, providing an opportunity for organisations to positively affect their employees' health decisions ( ) . furthermore, workplace interventions to promote healthier diets, such as offering free fruit and labelling meals, have sometimes been shown to facilitate healthy dietary choices ( , ) . simple changes in the placement of food in eating areas affect food selection too ( ) , and these changes can be leveraged to support the health of shift workers. similarly, if workers are using products such as melatonin supplements and blue-light-blocking glasses to shift the phases of their circadian systems, it makes sense to help them acquire efficacious products. it is also clear that social life is a strong influence on many shift workers' health behaviours, including their diets. the dietary attitudes and preferences of co-workers affect some workers' dietary choices ( ) , so group commitment to healthier dietary choices may aid the adoption of more nutritious diets. as stress strongly affects dietary choices in many people and shift workers often report high stress and abnormal dietary behaviours ( ) , interventions to nurture the resilience of shift workers and to improve workers' self-regulation skills may support their dietary choices. such interventions include mindfulnessbased approaches ( ) . shift workers could also benefit from other types of social support, including provision of additional childcare, as well as groups and events designed to minimise conflicts between their work and non-work activities. educating shift workers about how to sleep better is likely to be pivotal to their well-being, and shift work workplaces should have spaces for sleepy workers to nap. it is of course important to identify workers who have sleep disorders too, and simple screening tools such as brief questionnaires can be used for this ( ) . it may too be useful to screen for people who are simply not suited to certain shift schedules, for people differ substantially in how they tolerate shift work. certain characteristics associate with better shift work tolerance, including robust general health; young age; male sex; not having children; low languidity and neuroticism; high extraversion, flexibility in sleeping habits, and internal locus of control; and a chronotype that is neither very early nor very late ( ) . promisingly, personalising shift work schedules by removing night shifts for early chronotypes and excluding morning shifts for late chronotypes has been shown to prolong selfreported sleep, improve subjective sleep quality, and enhance worker well-being ( ) . to estimate chronotype, a study by vetter and colleagues used a shift work-specific version of the munich chronotype questionnaire ( ) , and this approach may be useful to help personalise work schedules for shift workers. nonetheless, it would be useful to develop additional questionnaires designed specifically to identify appropriate shift schedules, as well as to track how workers respond to these schedules. finally, it is worth noting that many workplace wellness programmes that have been tested have not yielded impressive results ( ) . assessing the effects of workplace interventions is difficult for numerous reasons, not the least of which are enforcing blinding and randomisation of participants. to date, marked heterogeneity between studies has made it challenging to assess the utility of workplace interventions for shift workers ( ) . and as is so often the case, the participants included in many of these studies did not comprise a diversity of ages and races, nor did the scientists attempt to define determinants of which workers responded positively to the interventions. none of this means that it is not possible to implement effective programmes, however, and we hope that lacklustre results to date do not stymie continued efforts to improve on workplace interventions by better incorporating principles from behavioural science. to assess the efficacy of interventions to improve shift-worker health, it may make sense to use alternatives to many of the hitherto-used study designs. recently, studies applying "big data" approaches have contributed to some advances in efforts to personalise medicine. however, it may be advantageous to concurrently carry out studies that use a "small data" paradigmfor example, using n-of- approaches to more rapidly assess how individual workers are responding to a given intervention and to forecast which of them are at risk of health trajectory transitions towards disease ( ). a large proportion of the workforce works shifts, and these individuals are integral to sustaining functional societies. however, the study of how to support the long-term health and well-being of these people has been somewhat neglected, and a relatively small proportion of relevant studies has included shift workers as participants. while the type of personalised interventions to support shift workers that we have discussed in this article are bound to produce logistical headaches for employers, the onus should be on supporting the long-term the health and performance of their employees. the acute difficulties arising from implementing customised shift schedule systems and suchlike may be more than made up for by the lasting benefits of these systems on health, safety, and productivity. we note also that as shift work increases the likelihood of adverse pregnancy outcomes and may lead to epigenetic modifications in parents that could plausibly affect the epigenetics and hence health of their children, supporting the health of shift workers could one day have critical effects on the well-being of future generations ( , ) . scientists now have an unprecedented ability to identify ways of helping shift workers. we hope that this ability is realised in the near future. entrainment of the human circadian clock to the natural light-dark cycle circadian entrainment to the natural light-dark cycle across seasons and the weekend working group on the evaluation of carcinogenic risk to humans. painting, firefighting, and shiftwork shift and night work and long working hoursa systematic review of safety implications health consequences of shift work and insufficient sleep occupational history of night shift work and parkinson's disease in denmark shift work and overall and cause-specific mortality in the danish nurse cohort. scand j work environ health mechanisms linking circadian clocks, sleep, and neurodegeneration when health professionals look death in the eye: the mental health of professionals who deal daily with the coronavirus outbreak presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the new york city area ons. deaths involving covid- , england and wales: deaths occurring in middle east respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission clinical determinants of the severity of middle east respiratory syndrome (mers): a systematic review and meta-analysis short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome (sars) severe acute respiratory syndrome: clinical and laboratory manifestations a novel risk factor for a novel virus: obesity and pandemic influenza a (h n ) h n influenza a in a hospital in norway working time society consensus statements: individual differences in shift work tolerance and recommendations for research and practice circadian disruption: what do we actually mean? epidemiology of the human circadian clock mismatch of sleep and work timing and risk of type diabetes shift work patterns, chronotype, and epithelial ovarian cancer risk sleep and need for recovery in shift workers: do chronotype and age matter shift work, chronotype, and melatonin rhythm in nurses the circadian clock and human health sleep, health, and society stability, precision, and near- -hour period of the human circadian pacemaker physiology of circadian entrainment effect of light wavelength on suppression and phase delay of the melatonin rhythm health-related interventions among night shift workers: a critical review of the literature high sensitivity and interindividual variability in the response of the human circadian system to evening light physiology and pharmacology of melatonin in relation to biological rhythms evening melatonin and bright light administration induce additive phase shifts in dim light melatonin onset phase-shifting human circadian rhythms with exercise during the night shift human circadian phase-response curves for exercise circadian phase-shifting effects of bright light, exercise, and bright light + exercise a behavioristic study of the activity of the rat restricted feeding uncouples circadian oscillators in peripheral tissues from the central pacemaker in the suprachiasmatic nucleus meal timing regulates the human circadian system food as a circadian time cue -evidence from human studies phase-shifting human circadian rhythms: influence of sleep timing, social contact and light exposure the factors influencing the eating behaviour of shiftworkers: what, when, where and why protein "requirements" beyond the rda: implications for optimizing health a review of caffeine's effects on cognitive, physical and occupational performance multiple dose pharmacokinetics of caffeine administered in chewing gum to normal healthy volunteers the rate of absorption and relative bioavailability of caffeine administered in chewing gum versus capsules to normal healthy volunteers caffeine effects on sleep taken , , or hours before going to bed time-fixed feeding prevents obesity induced by chronic advances of light/dark cycles in mouse models of jet-lag/shift work time-restricted feeding improves adaptation to chronically alternating light-dark cycles timing of food intake during simulated night shift impacts glucose metabolism: a controlled study the impact of meal timing on performance, sleepiness, gastric upset, and hunger during simulated night shift. ind health dietary patterns of nurses on rotational shifts are marked by redistribution of energy into the nightshift meta-analysis of relation of skipping breakfast with heart disease breakfast skipping is associated with increased risk of type diabetes among adults: a systematic review and meta-analysis of prospective cohort studies is breakfast the most important meal of the day? the causal role of breakfast in energy balance and health: a randomized controlled trial in lean adults the causal role of breakfast in energy balance and health: a randomized controlled trial in obese adults early time-restricted feeding improves insulin sensitivity, blood pressure, and oxidative stress even without weight loss in men with prediabetes early time-restricted feeding improves -hour glucose levels and affects markers of the circadian clock, aging, and autophagy in humans early timerestricted feeding reduces appetite and increases fat oxidation but does not affect energy expenditure in humans time-restricted feeding improves glucose tolerance in men at risk for type diabetes: a randomized crossover trial a pilot feasibility study exploring the effects of a moderate time-restricted feeding intervention on energy intake, adiposity and metabolic physiology in free-living human subjects a delayed morning and earlier evening time-restricted feeding protocol for improving glycemic control and dietary adherence in men with overweight/obesity: a randomized controlled trial ten-hour time-restricted eating reduces weight, blood pressure, and atherogenic lipids in patients with metabolic syndrome irregular meal-pattern effects on energy expenditure, metabolism, and appetite regulation: a randomized controlled trial in healthy normal-weight women high caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women reduction in glycated hemoglobin and daily insulin dose alongside circadian clock upregulation in patients with type diabetes consuming a three-meal diet: a randomized clinical trial the effect of diurnal distribution of carbohydrates and fat on glycaemic control in humans: a randomized controlled trial. sci rep exercise-stimulated glucose uptake -regulation and implications for glycaemic control timing and distribution of protein ingestion during prolonged recovery from resistance exercise alters myofibrillar protein synthesis the impact of food order on postprandial glycaemic excursions in prediabetes food order has a significant impact on postprandial glucose and insulin levels carbohydrate-last meal pattern lowers postprandial glucose and insulin excursions in type diabetes circadian physiology of metabolism altering meal timing to improve cognitive performance during simulated nightshifts subjective hunger, gastric upset, and sleepiness in response to altered meal timing during simulated shiftwork eating on nightshift: a big vs small snack impairs glucose response to breakfast distinct circadian signatures in liver and gut clocks revealed by ketogenic diet ketogenic diet delays the phase of circadian rhythms and does not affect amp-activated protein kinase (ampk) in mouse liver ketogenic diet and fasting induce the expression of cold-inducible rna-binding protein with timedependent hypothermia in the mouse liver disruption of the circadian clock in mice increases intestinal permeability and promotes alcohol-induced hepatic pathology and inflammation systematic review and meta-analysis of different dietary approaches to the management of type diabetes effects of the mean amplitude of glycemic excursions and vascular endothelial dysfunction on cardiovascular events in nondiabetic patients with coronary artery disease prediabetes and associated disorders associations of prediabetes with all-cause and cardiovascular mortality: a meta-analysis prediabetes and the risk of cancer: a meta-analysis glucose peaks and the risk of dementia and -year cognitive decline. diabetes care improvement in patient-reported sleep in type diabetes and prediabetes participants receiving a continuous care intervention with nutritional ketosis β-hydroxybutyrate: a signaling metabolite a ketogenic diet extends longevity and healthspan in adult mice ketogenic diet improves the spatial memory impairment caused by exposure to hypobaric hypoxia through increased acetylation of histones in rats shift work and risk of incident dementia: a study of two population-based cohorts night shift work, long working hours and dementia: a longitudinal study of the danish work environment cohort study interdependence of nutrient metabolism and the circadian clock system: importance for metabolic health effects of diet on sleep quality regulation of circadian behaviour and metabolism by synthetic rev-erb agonists caffeine for the prevention of injuries and errors in shift workers coffee, caffeine, and sleep: a systematic review of epidemiological studies and randomized controlled trials effects of caffeine on the human circadian clock in vivo and in vitro creatine supplementation reduces sleep need and homeostatic sleep pressure in rats international society of sports nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine creatine supplementation, sleep deprivation, cortisol, melatonin and behavior effect of creatine supplementation and sleep deprivation, with mild exercise, on cognitive and psychomotor performance, mood state, and plasma concentrations of catecholamines and cortisol skill execution and sleep deprivation: effects of acute caffeine or creatine supplementation -a randomized placebo-controlled trial creatine and caffeine: considerations for concurrent supplementation the circadian rhythm of tryptophan in breast milk affects the rhythms of -sulfatoxymelatonin and sleep in newborn improved circadian sleep-wake cycle in infants fed a day/night dissociated formula milk effects of tryptophan loading on human cognition, mood, and sleep l-serine enhances light-induced circadian phase resetting in mice and humans a randomized, double-blind and placebo-controlled crossover trial on the effect of l-ornithine ingestion on the human circadian clock ornithine ingestion improved sleep disturbances but was not associated with correction of blood tryptophan ratio in japanese antarctica expedition members during summer randomised controlled trial of the effects of l-ornithine on stress markers and sleep quality in healthy workers glycine ingestion improves subjective sleep quality in human volunteers, correlating with polysomnographic changes the sleep-promoting and hypothermic effects of glycine are mediated by nmda receptors in the suprachiasmatic nucleus the effects of glycine on subjective daytime performance in partially sleep-restricted healthy volunteers glycine metabolism in animals and humans: implications for nutrition and health a smartphone app reveals erratic diurnal eating patterns in humans that can be modulated for health benefits a pilot characterization of the human chronobiome noninvasive hemoglobin measurement using unmodified smartphone camera and white flash digital envirotyping: quantifying environmental determinants of health and behavior relapse prediction in schizophrenia through digital phenotyping: a pilot study a comparison of passive and active estimates of sleep in a cohort with schizophrenia wearable biosensors for healthcare monitoring high-performance medicine: the convergence of human and artificial intelligence effects of circadian misalignment on cognition in chronic shift workers the sleep-deprived human brain why is changing health-related behaviour so difficult? public health just-in-time adaptive interventions (jitais) in mobile health: key components and design principles for ongoing health behavior support health and the built environment: years after effects of the internal circadian system and circadian misalignment on glucose tolerance in chronic shift workers vending assessment and program implementation in four iowa worksites a workplace feasibility study of the effect of a minimal fruit intervention on fruit intake effectiveness of offering healthy labelled meals in improving the nutritional quality of lunch meals eaten in a worksite canteen nudging consumers towards healthier choices: a systematic review of positional influences on food choice influences on dietary choices during day versus night shift in shift workers: a mixed methods study the association between shift duty and abnormal eating behavior among nurses working in a major hospital: a cross-sectional study an on-the-job mindfulnessbased intervention for pediatric icu nurses: a pilot questionnaires that screen for multiple sleep disorders aligning work and circadian time in shift workers improves sleep and reduces circadian disruption the munich chronotype questionnaire for shift-workers (mctqshift) effect of a workplace wellness program on employee health and economic outcomes: a randomized clinical trial the impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis night shift work before and during pregnancy in relation to depression and anxiety in adolescent and young adult offspring gp conceived the idea and drafted the manuscript. tw edited the manuscript and produced the final draft. all authors approved the final version and performed the literature review. the authors declare 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 © potter and wood. 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- - umby l authors: cai, qi; feng, hongliang; huang, jing; wang, meiyao; wang, qunfeng; lu, xuanzhen; xie, yu; wang, xing; liu, zhenxing; hou, botong; ouyang, keni; pan, jing; li, qin; fu, beibei; deng, yongchao; liu, yumin title: the mental health of frontline and non-frontline medical workers during the coronavirus disease (covid- ) outbreak in china: a case-control study date: - - journal: j affect disord doi: . /j.jad. . . sha: doc_id: cord_uid: umby l background and objective: coronavirus disease (covid- ) is a new infectious disease with high transmissibility and morbidity. it has caused substantial mental distress to medical professionals. we aimed to compare the psychological impact of the covid- outbreak between frontline and non-frontline medical workers in china. methods: this case-control study recruited frontline and age- and sex-matched non-frontline medical workers during the covid- outbreak (february to , ). a set of online questionnaires were used to measure mental problems (i.e., anxiety, insomnia, and depressive symptoms), and help-seeking behavior and treatment for these mental problems. results: frontline medical workers had higher rates of any mental problem ( . % vs . %, adjusted or= . , % ci= . - . ), anxiety symptoms ( . % vs . %, adjusted or= . , % ci= . - . ), depressed mood (marginally insignificant; . % vs . %, adjusted or= . , % ci= . - . ) and insomnia ( . % vs . %, adjusted or= . , % ci= . - . ) than non-frontline medical workers. no significant difference was observed in terms of suicidal ideation ( . % vs . %, adjusted or= . , % ci= . - . ), help-seeking ( . % vs . %, adjusted or= . , % ci= . - . ) or treatment ( . % vs . %, adjusted or= . , % ci= . - . ) for mental problems. limitations: the case-control nature of the data precludes causal inferences, and there is a possibility of bias related to self-reports. conclusions: frontline medical workers had more mental problems but comparable help-seeking behaviors and treatment for these problems than non-frontline medical workers. these findings highlight the timely mental support and intervention for medical workers, especially for those on the frontline. coronavirus disease was first reported in wuhan, hubei province, china, in december (phan, ) , followed by an outbreak throughout the country and beyond. as of february , , a total of , medical workers were infected in china with novel coronavirus (including confirmed cases, suspected cases, clinically diagnosed cases, and asymptomatic infected persons), , medical workers have been confirmed to be infected, with ( . %) critical cases and ( . %) deaths ((epidemiology working group for ncip epidemic response, ). medical workers, especially those who are working in the frontline, may suffer huge amounts of stress during the fight against covid- . several studies have reported that individuals exposed directly or indirectly to life-threatening situations may have a high risk of psychological morbidities (bills et al., ; chan and huak, ; ji et al., ; mak et al., ; ofner-agostini et al., ; sim et al., ; wang et al., ; wu et al., ) . for example, during the outbreak of severe acute respiratory syndrome (sars) in , it was shown that health care workers had a higher rate of sars infection than other people (ofner-agostini et al., ) , and they were emotionally affected and traumatized during the outbreak (chan and huak, ; wu et al., ) . at present, the severe acute respiratory syndrome from coronavirus (sars-cov- ), which has been reported to have more severe transmissibility than sars-cov (liu et al., b) , puts medical workers, especially the frontline medical staff at very high health risk. with an increasing number of patients, long hours of intensive work and less sleep time, inadequate protection from contamination, and the risk of infection at any time, medical workers have a high risk of physical and mental exhaustion, resulting in a variety of mental health problems. the mental health of medical workers has gained tremendous attention. as this outbreak has highlighted the fragility of psychological resilience, we also need to pay attention to the psychological state of health care workers during epidemics (ho cs et al. ). the government and hospitals have formulated a series of measures to address this problem . a recent study found that nearly one-sixth of , medical staff had psychological distress and therefore needed to seek help from psychological or psychiatric professionals. the prevalences of psychological distress, anxious symptoms, and depressive symptoms were . %, . %, and . %, respectively . another study investigating the mental health status of medical staff found that . % of the medical staff that fought against covid- in wuhan had a high score of anxiety compared with medical staff in xian . however, the deficiency lies in the lack of systematic assessment of mental problems between frontline and non-frontline medical workers during the covid- outbreak. since an increasing number of newly infected cases among the medical staff have been observed to date, and since the arduous task of the fight against the covid- might be far from over, timely mental health care for medical staff during the covid- outbreak is urgently needed. the present study attempted to compare the immediate psychological impact of the covid- outbreak on frontline and non-frontline medical workers in china. this case-control study was conducted between february to , , which was approved by the clinical research ethics committee of zhongnan hospital of wuhan university (ref. no.: ) . this study was conducted through a program called questionnaire star. the sample was obtained based on a non-probability sampling design. all medical workers participated in the survey through the link or quick response (qr) code of questionnaire star, which is a bar code that can store the website link of the questionnaire used in this study. once the questionnaire was submitted, the data would be saved on the questionnaire star server, and the questionnaire creator can download or analyze the data. the requirement for written consent from subjects was waived by the research ethics committee. no identifiable information was collected. a set of questionnaires were sent to medical workers working in hospitals in china via the qr code of questionnaire star. the medical workers included physicians, nurses, and other healthcare workers (e.g., medical technicians, respiratory therapists, or emergency room attendants). medical workers dealing with covid- were considered frontline medical workers. otherwise, they were categorized into the non-frontline medical workers group. other inclusion criteria were as follows: ) age to years old and ) chinese-speaking residents of china. a total of , eligible frontline medical workers and , eligible non-frontline medical workers participated in this study. . % of the non-frontline medical workers (n = , ) were selected and matched to frontline medical workers by age and sex. the matching was performed using the "matchit" package in r (version . . ; r foundation for statistical computing, vienna, austria) (ho, d., imai, k., king, g., & stuart, e., ) . the study instrument was a structured questionnaire that comprised demographic details, three main self-reported rating scales that have broad credibility, and information about whether the participant sought help or treatment for mental problems. the detailed explanation is as follows. participants' demographic characteristics, including age, sex, education level, marital status, jobs, annual household income, living status, and geographic origin, were obtained. the epidemic parameters for the covid- of the areas where the subjects stayed were used to estimate the levels of exposure to the epidemic. the epidemic parameters, including the number of cumulative cases, number of new daily cases, prevalence, and daily incidence, were obtained from the official online platform for controlling the covid- epidemic in china (national health commission and provincial health commissions. a). the beck anxiety inventory (bai) was used to measure anxiety symptoms over the last seven days (beck et al., ; chinese version: che et al., ) . this scale has a total of self-report items with responses rated on a -point likert scale ranging from (not at all) to (severely). higher scores reveal a higher level of anxiety. the following cut-off scores were used to assess different levels of anxiety: ) scores between and denote no anxiety; ) scores between and denote mild anxiety; ) - denotes moderate anxiety; ) - denote severe anxiety (ahmed et al., ) . the presence of anxiety was defined as a bai score > in our study. the insomnia severity index (isi) was used to assess participants' perceptions of insomnia over the past two weeks (chahoud et al., ) . it has seven items targeting the subjective symptoms and daytime consequences of insomnia, as well as the degree of distress caused by these difficulties. each item of this scale is rated on a -point likert scale of - , and higher scores indicate greater insomnia severity (morin et al., ; chinese version: li et al., ) . the optimal cut-off point of isi for detecting clinical insomnia in the chinese population was a total score of (chung et al., ) . therefore, an isi score higher than nine was chosen as the cut-off for insomnia for this study. the patient health questionnaire- (phq- ) was used to measure depressive symptoms over the past two weeks (michel et al., ) . all nine items are scored from to , and the total scores range from to , with a higher score indicating more severe symptoms (kroenke et al., ; chinese version: min et al., ) . scores of to indicate no depression, scores of to indicate mild depression, scores of to indicate moderate depression, scores of to indicate moderately severe depression, and scores of to indicate severe depression (xia et al., ) . participants with a phq- > were defined as depressed in our study. the chinese versions of the three abovementioned rating scales have been proven to have satisfactory reliability and validity (chung et al., ; liang et al., ; wang et al., ) . in addition, suicidal ideations were measured by one question: "over the past two weeks, have you ever had suicidal thoughts?" the responses to this question were "once/several times" or "never" (hassan et al., ) . whether participants sought help or received treatment for mental problems, including anxiety symptoms, depressed mood, suicidal ideation, and insomnia, during the covid- outbreak was recorded. the question "have you ever sought help from psychiatrists or clinical psychologists since the outbreak of covid- began?" was used to estimate help-seeking behavior. the question "have you ever received any treatment for psychiatric or psychological problems since the outbreak of covid- began?" was used to measure treatment history for mental problems. mann-whitney u test and t test were used to compare means of two groups of non-normally and normally distributed variables, respectively. chi-square test was used to compare the inter-group differences for categorical variables. univariate and multivariate logistic regressions were performed to evaluate the relationships of frontline medical workers (vs. non-frontline medical workers) with mental problems, and help-seeking behaviors and treatment for mental problems. a value of two-tailed p < . was considered statistically significant. in table , p values for multivariate logistic regressions were further adjusted using a false discovery rate (fdr) method (bernhard, ). an fdr of % using q values would mean that % of results called significant (p < . ) are false-positives (benjamini et al., ) . all statistical tests were performed using spss version . for windows (armonk, ny: ibm corp) and r (version . . ). a total of participants were enrolled in our study, including frontline workers and age-and sex-matched non-frontline medical workers. table presents the demographic characteristics of the participants. there were no differences in education years and unmarried status between non-frontline and frontline medical workers (all p > . ). however, frontline medical workers had a higher proportion of medical staff (mainly including doctors and nurses) than non-frontline medical workers ( . % vs. . %, p < . ). frontline medical workers showed higher proportions of annual household income of < , usd per head ( . % vs. . %, p = . ) and living alone ( . % vs. . %, p < . ) than non-frontline medical workers. compared with non-frontline medical workers, frontline medical workers had higher proportions of participants from wuhan and hubei province (excluding wuhan) (p < . ). in addition, frontline medical workers had higher exposure levels of the covid- epidemic, including larger numbers of cumulative cases and daily new cases, higher prevalence, and higher daily incidence than subjects from other areas (all p < . ). the psychological impact of acute infection outbreaks on medical workers has aroused considerable concern from the government, the public, and medical professionals. the current study has shown that frontline medical workers directly dealing with patients confirmed or suspected of having covid- had a higher level of various mental problems than those non-frontline medical workers. in addition, the two groups had comparable low rates of help-seeking behaviors and treatment for their mental problems. data from the present study showed that the mental health of frontline medical workers was particularly worrying. the rate of mental problems, such as anxiety, depression, and insomnia, was significantly increased in frontline medical workers, compared with non-frontline medical workers. in this study, about . % of enrolled frontline medical workers experienced anxiety symptoms, and the prevalence is lower than the general population during the covid- outbreak ( . % experienced moderate to severe anxiety symptoms) . similarly, about . % of enrolled frontline medical workers experienced depressive symptoms, and the prevalence is slightly lower than the general population during the covid- outbreak ( . % reported moderate to severe depressive symptoms) . the higher prevalence of anxiety and depression in the general public could be due to less access to personal protection equipment as compared to frontline medical workers. a great deal of evidence demonstrates the dramatic psychological impact of the epidemic on healthcare workers, and the importance of dedicated interventions to deal with mental problems, such as stress, anxiety, depressive symptoms samantha et al., ; . our findings are consistent with those reported zhu et al., who found a significant percentage of psychiatric symptoms during the covid- pandemic, . % for stress, . % for depression, and . % for anxiety among healthcare workers (zhu, et al, ) . a recent study indicated poor sleep quality among frontline clinical nurses fighting with the covid- ( . in contrast, a recent study conducted in singapore found that there was a higher prevalence of anxiety among non-medical healthcare workers compared to medical personnel (tan et al., ) . the opposite findings in singapore could be due to the fact that covid- was a less severe problem in singapore as compared to china and frontline healthcare workers encountered lower level of anxiety and depression. compared with non-frontline medical workers, frontline medical workers might be exposed to much more physical and mental stresses, which may contribute to their higher rates of mental problems. for example, frontline medical workers have had to be extra vigilant when working in the fever clinics or infectious wards, ensuring that suspected patients were timely identified and transferred to the designated hospital to reduce exposure risk for others. in addition, the rapid increase of the infected patients and the uncertainty of transmission in the early stage of the outbreak increased the enormous workload and psychological burden of medical workers . during the covid- outbreak, many medical staff were infected , which may have increased the psychological stress of their colleagues. moreover, inadequate protective materials against the virus, negative emotions from the patients, quarantine, and lack of contact with their families also added to the psychological burden of frontline medical workers. furthermore, mental problems could interact with each other. for example, sleep disorders were reported to be related to anxiety (bélanger et al., ; papadimitriou and linkowski, ) . our results showed poor mental health among frontline medical workers, but contrary to our expectation, we did not observe significantly higher rates of seeking help or receiving treatment for mental problems among these subjects. the phenomenon that medical workers have difficulty accepting and disclosing emotions is not unique to the covid- outbreak (fridner et al., ; king et al., ; tyssen et al., ) . emotional distress is common among hospital doctors, many of whom do not seek professional help or support from their colleagues, because they either think they did not need or are embarrassed to seek help and worried about confidentiality (fridner et al., ) . these findings remind future psychological intervention providers should pay more attention to medical workers with mental health problems. the mental health status of medical workers presented in the current study prompts the need for appropriate measures and timely treatment for covid- -related psychological problems. according to previous experience with severe infectious diseases (such as sars and evd), medical workers with a good awareness of the disease developed relatively fewer psychological symptoms (chua et al., ; huang et al., ; ji et al., ) . therefore, authoritative knowledge about covid- should be disseminated among medical workers as early as possible. mental health professionals should be deployed in the medical teams to provide psychological support. furthermore, external material and spiritual support were crucial to confronting psychological symptoms, including virus prevention implementation, living and medical supplies, as well as spiritual support from colleagues, team leaders, family, and friends (nasser and overholser, ) . since the start of the covid- outbreak, the chinese government, hospitals, and psychological and psychiatric centers have taken measurements to address mental health problems (bao et al., ) . a national guideline for psychological crisis intervention during the covid- outbreak, in which psychological protection measures for medical workers were provided, was published by the national health commission of china (national health commission of the people's republic of china, b). psychological intervention teams were set up to deliver mental health services to medical staff. in addition, a variety of online mental health services through communication programs, such as wechat, weibo, and tiktok, were gradually put into practice for people in need (liu et al., a; . as the development of the epidemic, further psychological support and measurements should be provided, especially for frontline medical workers. there were several limitations to our study. first, medical workers participated in the investigation via the internet without random sampling, so the response rate was hard to estimate. however, the relatively large number of participants reduced this potential sampling bias. second, the mental health status of the participants before the covid- outbreak was not available, making it difficult to know whether their pre-existing mental health status also impacted the posttraumatic morbidity of covid- . third, this study did not address other potential confounding factors, such as personality traits, family history of mental disorders, life events, and social support. fourth, the case-control nature of the present study did not allow us to make any conclusions regarding causality. the present study highlighted the mental health problems and unmet needs of medical workers during the covid- epidemic in china, especially among frontline medical workers. further strategies should be provided urgently to alleviate the mental distress of medical workers. long-term surveillance should be provided to monitor the mental health of frontline and non-frontline medical workers. involved in study design, revising the manuscript. municipalities and special administrative regions. b the participants' exposure to the covid- epidemic was estimated by the regional epidemic parameters. would mean that % of results called significant (p values< . ) are false-positives. epidemic of covid- in china and associated psychological problems -ncov epidemic: address mental health care to empower society an inventory for measuring clinical anxiety: psychometric properties insomnia and generalized anxiety disorder controlling the false discovery rate -a practical and powerful approach to multiple testing multiple testing: correcting for alpha error inflation with false discovery rate (fdr) or family-wise error rate? mental health of workers and volunteers responding to events of / : review of the literature psychological impact of the severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore validation of the chinese version of the beck anxiety inventory (in chinese) psychological effects of the sars outbreak in hong kong on high-risk health care workers assessing insomnia in adolescents: comparison of insomnia severity index, athens insomnia scale and sleep quality index the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china why don't academic physicians seek needed professional help for psychological distress? adolescent mental health: connections to the community a study on the differences of emotion and depression between patients as doctor/nurse and others occupation with severe acute respiratory syndrome matching as nonparametric preprocessing for reducing model dependence in parametric causal inference prevalence of psychological symptoms among ebola survivors and healthcare workers during the - ebola outbreak in sierra leone: a cross-sectional study the mental health of medical workers in wuhan, china dealing with the novel coronavirus impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study emotional distress in doctors: sources, effects and help sought the phq- : validity of a brief depression severity measure factor structure and psychometric properties of chinese version of beck anxiety inventory in chinese doctors psychometric property of the insomnia severity index in students of a commercial school online mental health services in china during the covid- outbreak. the lancet psychiatry transmission dynamics of novel coronavirus ( -ncov) mental health status of doctors and nurses during covid- epidemic in china ( / / ) long-term psychiatric morbidities among sars survivors reliability, factor analysis and internal consistency calculation of the insomnia severity index (isi) in french and in english among lebanese adolescents. eneurologicalsci the phq- assesses depression similarly in men and womenfrom the general population clinical application of patient health questionnaire for self-administered measurement (phq- ) as screening tool for depression the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response recovery from major depression: the role of support from family, friends, and spiritual beliefs februrary ). the epidemic of covid- in china the guideline of psychological crisis intervention for -ncov pneumonia updateon the situation of the covid- up to cluster of cases of severe acute respiratory syndrome among toronto healthcare workers after implementation of infection control precautions: a case series sleep disturbance in anxiety disorders novel coronavirus: from discovery to clinical diagnostics the psychological impact of quarantine and how to reduce it: rapid review of the evidence. the lancet psychological impact of the covid- pandemic on healthcare workers in singapore help-seeking for mental health problems among young physicians: is it the most ill that seeks help? -a longitudinal and nationwide study immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan symptoms of posttraumatic stress disorder among adult survivors two months after the wenchuan earthquake reliability and validity of the chinese version of the patient health questionnaire (phq- ) in the general population investigation on sleep quality of first•line nurses in fighting against novel coronavirus pneumonia and its influencing factors the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk reliability and validity of the chinese version of the patient health questionnaire timely mental health care for the novel coronavirus outbreak is urgently needed epidemiological and clinical features of the novel coronavirus outbreak in china recommended psychological crisis intervention response to the novel coronavirus pneumonia outbreak in china: a model of west china hospital a survey on mental health of medical staff fighting novel coronavirus diseases in wuhan covid- in wuhan: immediate psychological impacton we are grateful to professor jihui zhang (sleep assessment unit, department of psychiatry, faculty of medicine, the chinese university of hong kong, shatin, hong kong sar, china) for valuable contributions on data processing and the revision of the article. we also thank all the participants in our study. dr. hongliang feng was supported by the hong kong ph.d. fellowship scheme of the research grants council. the other authors have nothing to declare. key: cord- - z qrq authors: ehrlich, rodney; spiegel, jerry m.; adu, prince; yassi, annalee title: current guidelines for protecting health workers from occupational tuberculosis are necessary, but not sufficient: towards a comprehensive occupational health approach date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: z qrq health workers globally are at elevated occupational risk of tuberculosis infection and disease. while a raft of guidelines have been published over the past years on infection prevention and control (ipc) in healthcare, studies in different settings continue to show inadequate implementation and persistence of risk. the aim of this commentary is to argue, based on the literature and our own research, that a comprehensive occupational health approach is an essential complement to ipc guidelines. such an approach includes a health system framework focusing on upstream or mediating components, such as a statutory regulation, leadership, an information system, and staff trained in protective disciplines. within the classical prevention framework, primary prevention needs to be complemented by occupational health services (secondary prevention) and worker’s compensation (tertiary prevention). a worker-centric approach recognises the ethical implications of screening health workers, as well as the stigma perceived by those diagnosed with tuberculosis. it also provides for the voiced experience of health workers and their participation in decision-making. we argue that such a comprehensive approach will contribute to both the prevention of occupational tuberculosis and to the ability of a health system to withstand other crises of infectious hazards to its workforce. high rates of tuberculosis (tb) in the populations of low-and middle-income countries (lmics) are associated with high rates of latent tb infection (ltbi) and tb disease in health workers [ ] [ ] [ ] . the most recent systematic review reports a pooled incidence rate ratio for active tb disease among health workers of . , and a pooled odds ratio for ltbi of . , relative to control populations [ ] . in high-hiv-burden countries, hiv infection among health workers [ ] sharply increases their risk of tb, while the rise in drug-resistant tb has further intensified the threat associated with the disease [ , ] . there is no shortage of prevention guidelines directed at healthcare settings where a tb hazard to staff and patients exists. international popularisation of the tb infection prevention and control (ipc) triad of administrative, environmental, and respiratory protection controls can be dated to the publication of guidelines in by the u.s. centers for disease control and prevention (cdc) [ ] . the guidelines, updated in , constituted a response to a resurgence of tb in the united states and nosocomial transmission in u.s. hospitals in the wake of the hiv epidemic [ ] [ ] [ ] . in parallel, the world health organization (who) has published a series of guidelines for low-resource settings [ ] [ ] [ ] , as well as several supporting documents on the implementation of ipc [ , ] and provision of healthcare and related services for affected health workers [ ] . ipc in healthcare settings has featured in other international responses. after considerable advocacy effort, including a statement by the international commission for occupational health (icoh) [ ] , the united nations (un) general assembly political declaration of recognised healthcare workers as an occupational group at risk from tb, and called for ipc and tb screening and surveillance for this population [ ] . while the core ipc guidelines were based on public health "first principles", systematic reviews have concluded that evidence of the effectiveness of various protective measures is limited and/or of "low quality" [ , , ] . the inability to provide data conforming to that produced, for example, in drug trials, arises from the practical and ethical difficulty of undertaking randomised controlled trials for prevention in this context. however, as argued in this commentary, successful preventive practices require an enabling system. an omnibus approach to the ipc package has emerged, reflecting the complex nature of such interventions [ , , ] . usefully, recent guidelines, have employed the grading of recommendations, assessment, development and evaluation (grade) rating framework for public health and clinical recommendations which includes other sources of information and judgements-specifically, a balance of benefits and disadvantages, values and preferences, and resource requirements [ , ] . this enables "low quality" evidence on effect size to contribute to a "moderate" or "strong" recommendation if the other criteria are favourable. this approach thus incorporates contextual factors and uses an optimisation approach to applying evidence. however, the need for an approach that goes beyond ipc guidelines is suggested by the growing number of studies across the world that consistently reveal poor or inadequate implementation of tb ipc [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . barriers to ipc implementation vary with the study design and questions asked, but cover the whole gamut: lack of a national regulatory framework and associated budget; lack of management support; unfamiliarity of staff with ipc guidelines; failure to triage or screen patients; insufficient infrastructure and equipment, such as isolation spaces and personal protective equipment (ppe); deficient ventilation; inadequate staffing and training; poor functioning of infection control committees; and neglect of exposed non-clinical staff. qualitative studies, which have a greater capacity to probe health workers' experience, reveal a perception among health workers of a disproportionate focus on individual-level personal protections, particularly n respirators [ ] ; an experience of powerlessness [ ] ; habituation to tb risk or a sense of fatalism [ ] ; and difficulty in understanding patients and securing patient cooperation with ipc [ , , ] . the objectives of this piece are to argue for a comprehensive occupational health approach to the problem of tb in health workers, and to reflect on what such an approach adds to the prospects for improved prevention and practice. we draw on research carried out by our group as occupational health professionals and researchers in recent years [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , plus the experience of two of the authors (r.e. and a.y.) as clinicians and policy advisors to healthcare facilities, as well as provincial and national public sector health departments in south africa and canada, respectively. we argue that a comprehensive approach should conceive of the problem of protecting health workers within the widest possible framework, including legal and ethical considerations, should be multilevel and cross-disciplinary, and should be informed by the experiences of health workers themselves. a schema for making this argument is given in table . each domain is dealt with in the sections that follow. table . components of a comprehensive occupational health approach to the protection of health workers from occupational tuberculosis (tb). primary (control of tb transmission in healthcare settings), secondary (tb screening, early diagnosis of health workers, and effective treatment), and tertiary (rehabilitation, jobs, and social security). health systems framework assessing and strengthening the capacity of the health system to deliver quality healthcare to the whole population, including its own workforce, across all medical conditions, and to respond to crises. law and ethics understanding and use of statutory legal instruments, as well as the management of ethical implications of practices to protect health workers from tb. health worker voice and advocacy extent to which opportunities are provided for the views and experiences of health workers to be raised to influence the organisation of healthcare. figure applies the framework of primary, secondary, and tertiary prevention to consider opportunities for protecting health workers from occupational tb. it directs attention to the number of ways in which health workers can be at risk and protected from tb, and is an antidote to exclusive focus on any one level. a strong health system is both an enabler and a consequence of prevention activities, as discussed further in the next section. table . components of a comprehensive occupational health approach to the protection of health workers from occupational tuberculosis (tb). primary (control of tb transmission in healthcare settings), secondary (tb screening, early diagnosis of health workers, and effective treatment), and tertiary (rehabilitation, jobs, and social security). assessing and strengthening the capacity of the health system to deliver quality healthcare to the whole population, including its own workforce, across all medical conditions, and to respond to crises. understanding and use of statutory legal instruments, as well as the management of ethical implications of practices to protect health workers from tb. extent to which opportunities are provided for the views and experiences of health workers to be raised to influence the organisation of healthcare. figure applies the framework of primary, secondary, and tertiary prevention to consider opportunities for protecting health workers from occupational tb. it directs attention to the number of ways in which health workers can be at risk and protected from tb, and is an antidote to exclusive focus on any one level. a strong health system is both an enabler and a consequence of prevention activities, as discussed further in the next section. primary prevention in the form of ipc receives the lion's share of attention in guidelines, and remains the foundation for protection. however, secondary prevention contributes to primary prevention by aiming to keep health workers unimpaired and non-infectious in their daily work. this includes occupational health services to provide screening for active tb and the management of affected health workers [ ] . an occupational health platform would also be needed for any programme to screen for and treat ltbi. ltbi screening has long been recommended in low-tbincidence countries, such as the united states [ , ] , and appears in the latest who guideline as a (conditional) recommendation for low-tb-incidence countries only [ ] . consensus on what is required and feasible in high-tb-incidence, lmic settings is elusive. while there are many studies of primary prevention in the form of ipc receives the lion's share of attention in guidelines, and remains the foundation for protection. however, secondary prevention contributes to primary prevention by aiming to keep health workers unimpaired and non-infectious in their daily work. this includes occupational health services to provide screening for active tb and the management of affected health workers [ ] . an occupational health platform would also be needed for any programme to screen for and treat ltbi. ltbi screening has long been recommended in low-tb-incidence countries, such as the united states [ , ] , and appears in the latest who guideline as a (conditional) recommendation for low-tb-incidence countries only [ ] . consensus on what is required and feasible in high-tb-incidence, lmic settings is elusive. while there are many studies of ltbi prevalence in these settings, programme implementation research in this area is scarce and is a pressing need. tertiary prevention, by ensuring that health workers with an occupational disease have access to medical care and special sick leave, and to rehabilitation or to supported retirement, should be regarded as a basic labour right and is discussed further in section . although not explicitly presented in figure , hiv-infected health workers need to be considered within this framework as a particularly vulnerable sub-population needing protection. in south africa, estimates of the proportion of health workers infected with hiv are of the order of % [ ] . hiv infection dramatically increases the risk of progression from tb infection to disease [ ] . a programme of voluntary hiv testing, followed by treatment and counselling on job placement, should thus be regarded as part of primary prevention of tb in affected settings. vaccination of health workers against tb also falls into the category of primary prevention. bacille calmette-guerin (bcg) vaccination or revaccination of health workers is not currently a recommendation by either the cdc [ ] or who, and variation in health worker bcg vaccination practice across europe reflects the lack of consensus as to its efficacy [ ] . however, vaccination should remain on the agenda of a comprehensive occupational health approach-for example, revaccination of ltbi-negative health workers or testing and rollout among health workers of one of the new vaccines on the horizon [ , ] . using a health system framework involves a shift in perspective towards one that is cross-cutting and systemic, political as well as technical. it draws attention to the governance and organisation of healthcare that enable disease control and clinical programmes and practices, and which are geared to achieving greater equitability and sustainability in health outcomes. health system assessment and strengthening are conceptualized by who as focused on the performance of six inter-related building blocks: governance and leadership, information, health financing, health workforce, services, and technology [ ] . this is a two-way interaction. adequate performance in respect of all the building blocks is required if ipc and workplace tb prevention programmes are to work, as discussed further below. conversely, investment in protecting health workers from occupational infectious disease has the potential to yield system-wide benefits. these include tb surveillance as an indicator of respiratory disease risk in healthcare settings; "cross-silo" cooperation in the healthcare system; reduced absenteeism and improved staff retention and morale; and greater patient safety, quality of care, and trust in the health system [ ] [ ] [ ] , ] . at their most upstream, structural health system barriers encompass international and national political economy. an example particularly relevant to africa is the imposition on governments of structural adjustment programmes by international lenders that require reducing the size of the public sector, thereby decreasing healthcare expenditures-including on the control of tb [ ] . zelnick [ ] studied the struggles among south african nurses to provide care and protect themselves against bloodborne exposure in the early days of the hiv/aids epidemic. among the causes of this situation, the author identifies the failure of the new south african government, under the pressure of neoliberal macroeconomic policies, to devote sufficient resources to district health facilities, resulting in staff shortages and a hazardous work environment over which nurses felt they had no control. more recently, lispel and fonn have illuminated the relatively unexplored subject of corruption in the health sector, particularly the diversion of health funding through rigged tendering and supply activities, combined with the enabling factor of poor governance [ ] . a little more downstream, we recently used the who health systems framework from an occupational health perspective to explore the perceptions of key informants within the south african health system of barriers to protection of health workers from tb [ ] . such barriers include, inter alia, lack of an information system to produce the necessary intelligence on health and safety; fragmentation of governance across different organisational units within jurisdictions and health facilities; difficulty in maintaining technological components, such as germicidal ultraviolet light air disinfection; and lack of occupational health services trusted by staff. remedying the deficits outlined above involves costs in the form of organisational management, staffing, clinical practice, ancillary services, and procurement. cost within fixed administrative budgets is, however, a major cross-cutting barrier [ , ] . this creates hesitancy among senior health service managers to commit significant resources to occupational health and safety amidst competing priorities, even if the actions are legally mandated, and especially if they believe tb in their staff is not an occupational disease [ , ] . this suggests that a useful starting point for collaboration between occupational health and ipc is an information system able to track and investigate active tb in health workers for the purposes of risk assessment and targeted ipc. an example is the occupational health and safety information system (ohasis), developed through a collaboration of occupational health and ipc professionals at the university of british columbia with the national institute for occupational health in south africa, and applied in the national health laboratory service of south africa [ , ] . those applying generic guidelines need to consider the legal and related institutional environment of their jurisdictions, and whether this environment is sufficiently enabling. in many and perhaps most countries, occupational health and safety is governed by statutory regulation, which provides a framework of requirements and standards, as well as an enforcement mechanism to prevent occupational injuries and disease [ ] . a review across botswana, zambia, and south africa of laws relevant to reduction of tb transmission adopted a systems view by focusing on regulations governing national legal and policy frameworks; facility design, construction, and use; patients' and health workers' rights; and research, as well as the monitoring of infection control measures and tb surveillance among health workers. the authors concluded that the laws and regulations provided a "strong foundation" for these activities [ ] . however, in high-tb-burden countries, particularly in public sector facilities, the competing demands on the healthcare budget may be used as an alibi for the failure to provide sufficient resources to protect staff from tb [ , ] . there may also be resistance to the application of an "industrial" model of regulation, inspection, and enforcement to the healthcare sector. the notion of voluntary acceptance of risk, an old common law defence by employers against liability for occupational injury or disease, and one that has long formed part of the vocational ethos of healthcare, contributes to this resistance [ , ] . legislation by itself is thus no guarantee of adequate preventive practice in healthcare-as indicated, for example, by the number of studies on poor implementation of tb ipc in south africa [ , , , , ] . worker's compensation or broader social security are components of tertiary prevention of occupational tb. as with preventive legislation, practice varies. in south africa, tb suffered by a health worker who has had contact with tb patients is presumed to be occupational. in contrast, in mozambique, tb is not recognised by statute as an occupational disease, an omission identified by local health workers as a major barrier to comprehensive management of occupational tb [ ] . worker's compensation does not cover students unless they are regarded as employee trainees. students, however, are also at risk of workplace tb [ ] . high annual tb infection rates (i.e., new infections) of / person years have been recorded in medical students in johannesburg using the tuberculin skin test (tst) [ ] , and . / person years in nursing students in zimbabwe [ ] . community health workers are another category of health worker who may be vulnerable to weak benefits or protections in their employer-employee relationship and thus lack proper social protection [ , ] . outside of statutory protection, there are ethical considerations applicable to secondary prevention and occupational health generally. two areas of impact are stigma and screening. there is now a large body of literature confirming that stigma looms large in health worker attitudes to tb preventive practices, including unwillingness to self-disclose tb disease or participate in employer provided services where confidentiality is of concern [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the reduction of stigma requires an understanding of its context-specific nature and cultural content, e.g., in south africa, where tuberculosis has a strong association with hiv infection [ ] . however, the need for protection of the privacy of affected workers is in tension with the social need for self-disclosure to serve accurate risk assessment and to protect and educate co-workers. a contrasting strategy used in south africa by a network of health workers affected by tb has been to publicise their status and share their personal experiences as an educational and a mobilising strategy [ , ] . screening programmes, particularly in low-resource settings, need to pay attention to the ethical implications of medically examining workers who have not presented themselves to healthcare professionals. such considerations have long been part of medical surveillance in occupational health practice, and a body of ethical and legally sensitive guidelines have been developed [ ] . these address issues of informed consent and refusal of consent, the reliability of the test, confidentiality, and third-party reporting of results to employers, all of which require an agreed protocol in advance of screening. historically in some countries, labour unions have played an important role in securing recognition of the tb risk to health workers and related action [ ] . this has included efforts to include a labour perspective in early cdc deliberations on preventive guidelines [ ] . however, it is difficult to make a general statement about the current state of labour union involvement globally in the protection of health workers against tb. in south africa, advocacy by health workers themselves has emerged as a prominent voice for health worker rights in the form of tb proof, a voluntary group that includes a number of members who have suffered from tb [ ] . their work is augmented by a network of concerned health workers internationally [ , ] . tb proof activities have a several elements that we believe should be emulated elsewhere. these include engagement with national policy-making on tb; maintaining a website with educative and activist materials; a strong focus on destigmatising tb; the targeting of students and junior healthcare staff to protect themselves, but also to assert their right to be protected; and the effective use of personal narratives and media [ ] . the voice of health workers has found a place in the large number of publications using qualitative research-typically key informant but also arts-based methods-and covering all aspects of occupational tb risk and management [ , , , , , , [ ] [ ] [ ] ] . some of this work throws light on unrecognised deficiencies in health care practice, such as the exposure of community health workers to infective risk [ ] or the failure of patients to accept or understand ipc owing to cultural or language barriers [ ] . guidelines aimed at standardising operational practice to prevent occupational tb are essential. however, implementation takes place in a local setting, characterised by its own legal framework and employee rights regimen, resourcing, co-morbidity (such as hiv), and cultural attitudes. as greenhalgh and papoutsi have argued, the complexity lies in the interaction between an intervention and the pre-existing organisation of health care, and not necessarily in the intervention on its own [ ] . for example, barriers to implementation can be lowered by intensified training of health workers [ , ] , but the argument here is that such training is insufficient for sustainability if the necessary systemic scaffolding is not in place. the experience of two of the authors (a.y. and j.s.) in an occupational health/ipc programme, developed over almost years in one of south africa's poorer provinces, illustrates the value of customized interventions, including new policies and staffing, at the individual, facility, and provincial and national government levels [ , ] . a common approach to improving implementation is auditing, using operational checklists as a basis for expected quality improvement [ , ] . however, what we propose here is that the concept of a checklist be expanded to include the widest perspective possible. it should cover questions such as whether the system includes primary, secondary, and tertiary levels of protection, as well as embracing a health system framework such as the ones we have described here; whether there is explicit commitment of senior leadership to health system strengthening via ipc and occupational health and safety; whether the legal and ethical implications in relation to screening, coverage, and other thorny aspects referred to earlier are being dealt with; and whether channels for worker voice and agency exist and are used. while not easy to achieve, particularly in high-tb-burden, low-resource settings, policies and practices that incorporate this approach are more likely to provide for long-term sustainable protection of the essential human resources needed to fight tb and indeed other infectious hazards at work. this commentary was prepared before the covid- crisis. while there are many differences between tuberculosis and covid, the approach outlined provided a guide in the early phases of the local covid epidemic in south africa. over and above the urgent pressures of ipc, a systems approach has enabled recognition of the need for collaboration across disciplines and organisational units, occupational health coverage of all levels of the health system, a rapid-response information system on health worker infection and attrition, and a properly functioning worker's compensation regimen. as the covid pandemic develops, it is likely that many of the elements identified in this commentary will require closer attention. what has been striking in the scramble worldwide to put the necessary protective systems in place is the vulnerability of health workers even in high-income countries. however, the longer view must be taken. robust systems designed to protect health workers from infectious hazards, whether viral epidemics or tb, are needed as a continuing rather than as a reactive project, to better withstand the further threats to come. this includes making use of the crisis to embed properly functioning occupational health and ipc practices as an essential part of a resilient health system. latent tuberculosis infection in healthcare workers in low-and middle-income countries: an updated systematic review risk of tuberculosis infection and disease associated with work in health care settings risk of tuberculosis infection and disease for health care workers: an updated meta-analysis. open forum infect high incidence of hospital admissions with multidrug-resistant and extensively drug-resistant tuberculosis among south african health care workers spread of mdr tb from tugela ferry guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare facilities preventing the nosocomial transmission of tuberculosis control of tuberculosis in the workplace: toward and integration of occupational health and public health guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings who policy on tb infection control in health-care facilities, congregate settings and households who guidelines on tuberculosis infection prevention and control guidelines on core components of infection prevention and control programmes at the national and acute health care facility level implementing the who policy on tb infection control in health-care facilities, congregate settings and households joint who/ilo policy guidelines on improving health worker access to prevention, treatment and care services for hiv and tb united to end tuberculosis: an urgent global response to a global epidemic. resolution a/res/ / adopted by the united nations general assembly preventing tb among health workers through strengthening occupational safety and health systems and services. icoh statement on preventing tb among health workers effectiveness of control measures to prevent transmission of tuberculosis infection in health care workers: a systematic review grade guidelines: . going from evidence to recommendation-determinants of a recommendation's direction and strength tuberculosis infection control practices and associated factors among health care workers in health centers of west gojjam zone, northwest ethiopia: a cross-sectional study assessing infection control practices to protect health care workers and patients in malawi from nosocomial transmission of mycobacterium tuberculosis health care worker perspectives on workplace safety, infection control and drug-resistant tuberculosis in a high burden hiv setting evaluation of tuberculosis infection control measures implemented at primary health care facilities in kwazulu-natal province of south africa healthcare workers' challenges in the implementation of tuberculosis infection prevention and control measures in mozambique perceived barriers to adherence to tuberculosis infection control measures among health care workers in the dominican republic strengthening tb infection control in specialized health facilities in romania -using a participatory approach tb infection prevention and control experiences of south african nurses-a phenomenological study voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in south africa the efficacy of infection prevention and control committees in lesotho: a qualitative study tuberculosis and blood-borne infectious diseases: workplace conditions and practices of healthcare workers at three public hospitals in the free state. southern afr patient safety-worker safety: building a culture of safety to improve healthcare worker and patient well-being joint health and safety committee education and the value of bipartite cooperation in the healthcare sector in british columbia collaboration between infection control and occupational health in three continents: a success story with international impact occupational health and tb: a feasibility study of participatory theatre with south african healthcare workers tuberculosis as an occupational disease protecting health care workers against occupational tuberculosis. cross-disciplinary or cross-purposes? public health action perceived health system barriers to tuberculosis control among health workers in south africa workers' compensation claims for occupational tuberculosis in south african health workers: outcomes and workers' experiences preventing occupational tuberculosis in health workers in mozambique: state responsibility and worker rights repeat auditing of primary healthcare facilities for occupational health and safety, and infection prevention and control: a longitudinal study of compliance, reliability and impact. safety health work protecting health workers from infectious disease transmission: an exploration of a canadian-south african partnerships of partnerships latent tuberculosis infection: updated and consolidated guidelines for programmatic management pdf; jsessionid= f f e b c f de d a ?sequence= epidemiology of tuberculosis and hiv: recent advances in understanding and responses european policies on tuberculosis prevention in healthcare workers: which role for. bcg? a systematic review bcg and new preventive tuberculosis vaccines: implications for healthcare workers prevention of m. tuberculosis infection with h :ic vaccine or bcg revaccination everybody's business. strengthening health systems to improve health outcomes: who's framework for action keeping health facilities safe: one way of strengthening the interaction between disease-specific programmes and health systems the high-quality health system 'revolution': re-imagining tuberculosis infection prevention and control imf structural adjustment, public health spending, and tuberculosis who is nursing them? it is us?" neoliberalism, hiv/aids and the occupational health and safety of south african public sector nurses exploring corruption in the south african health sector. health policy plan occupational tuberculosis among laboratory workers in south africa: applying a surveillance system to strengthen prevention and control tool, weapon, or white elephant? a realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector protecting health care workers from tuberculosis in china: a review of policy and practice in china and the united states. health policy plan the role of the law in reducing tuberculosis transmission in botswana, south africa and zambia when students become patients: tb disease among medical undergraduates in cape town high incidence of latent tuberculous infection among south african health workers: an urgent call for action nursing and community rates of mycobacterium tuberculosis infection among students in harare consumed in care: healthcare workers in mumbai's tb-control program stigma as a barrier to the use of occupational health units for tuberculosis services in south africa why healthcare workers are sick of tb agents of change: the role of healthcare workers in the prevention of nosocomial and occupational tuberculosis unpacking the dynamics of double stigma: how the hiv-tb co-epidemic alters tb stigma and its management among healthcare workers #unmaskstigma initiative . tb proof, cape town. available online international code of ethics for occupational health professionals germs at work: establishing tuberculosis as an occupational disease in britain, c. - tuberculosis in the workplace: a labour perspective studying complexity in health services research: desperately seeking an overdue paradigm shift preventing tuberculosis among health workers in malawi evaluation of a tb infection control implementation initiative in out-patient hiv clinics in zambia and botswana periodic checklist for periodic evaluation of tb infection control in health-care facilities this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -vd etd authors: tucker, jennifer l.; anantharaman, manisha title: informal work and sustainable cities: from formalization to reparation date: - - journal: one earth doi: . /j.oneear. . . sha: doc_id: cord_uid: vd etd informal workers produce economic, social, and environmental value for cities. too often, policy elites, including those promoting sustainable cities, overlook this value, proposing formalization and relying on deficit-based framings of informal work. in this perspective piece, we bring critical research and community-produced knowledge about informal work to sustainability scholarship. we challenge the dominant, deficit-based frame of informal work, which can dispossess workers, reduce their collective power, and undercut the social and environmental value their work generates. instead, thinking historically, relationally, and spatially clarifies the essential role of informal work for urban economies and highlights their potential for promoting sustainable cities. it also reveals how growth-oriented economies reproduce environmental destruction, income inequality, and poverty, the very conditions impelling many to informal work. rather than formalization, we propose reparation, an ethic and practice promoting ecological regeneration, while redressing historic wrongs and redistributing resources and social power to workers and grassroots social movements. worldwide, about two billion people work informally, more than one-half of non-agricultural employment in most regions of the global south. informal work includes a range of income-generating activities outside of state labor protections and the wagerelation. these workers generate value and contribute to the realization of the sustainable development goals (sdgs). for instance, grassroots recyclers provide essential urban-environmental services, diverting waste from landfills and enabling recycling, while street vendors support food security as they bring life, vibrancy, and protection to urban spaces. , formal economies rely on and appropriate this value. for instance, waste pickers reduce the cost of public waste management services by diverting recyclables away from landfills. informal firms produce goods cheaply, reducing costs for formal, capitalist firms who depend on these inputs. yet, in many places, urban policy frames informal work as problematic or even criminal. desiring reform, policy makers and city officials invest formalization with supercharged powers to reduce poverty, increase productivity, clean and order urban space, and produce self-reliant economic subjects. the international labor organizations' (ilo) centenary declaration for the future of work prioritizes formalization, , whereas the sdgs, particularly sdg , assert that formalizing the informal will produce economic growth and decent work (safe and adequately paid work that respects labor and human rights). but while policy elites push formalization, the economic reality is moving in the opposite direction. the characteristics associated with informal work-low pay, job insecurity, and temporary, contract-based employment without benefits-are becoming generalized, as seen through the ascendance of the gig economy. despite persistent desires for formalization among policy elites, informal work is a permanent feature of contemporary economic life. informal workers produce economic, social, and environmental value for cities, value that is often underestimated or overlooked because informality challenges mainstream assumptions about what work looks like. indeed, informal work is excluded from dominant economic imaginaries, widely shared assumptions of economically productive activity. the dominant economic imaginary associates work with a regular wage paid by an employer in a private establishment, rather than in public space, even as the work of so many looks very different. using the term imaginaries reminds us that core economic assumptions are ideas made up by people. economies are made real in and through social relations in human societies. they are always cultural and contextual. feminist geographer gibson-graham coined this term critiquing the restricted ideas of valuable work and corresponding notions of valuable people that currently dominate. commonly, informal work is defined by what it lacks. this deficit lens of informal work persists because policy elites ignore critical and community-based research on informality and overlook the knowledge and capacities of informal workers. the deficit-based frame of informal work can dispossess workers, reduce their collective power, and undercut the social and environmental value their work generates. new modes of thinking and acting can, in turn, animate new economic imaginaries and relations. building on our research in india and paraguay, amplifying critical informality scholarship and centering the knowledge produced by workers' organizations, we assert that by thinking historically, relationally, and spatially, and redistributing power and resources to workers, we can move beyond formalization to a frame that centers decent work, ecological health, and reparation for uneven legacies of harm. only when it redistributes resources and power to informal workers will formalization help address social and environmental inequities. although we write to sustainability theorists and practitioners, we emphasize that the main protagonists of transformation must be social movements led by frontline communities, that is, the communities who are both most harmed by the crises of climate, covid- , and economic injustice, and therefore have most at stake in realizing alternative worlds. in this article, we analyze why dominant economic imaginaries devalue informal work, assessing the implications for sustainability initiatives. we then outline our proposals about thinking historically, relationally, and spatially. we emphasize that moving toward sustainable cities requires understanding the dynamics of racial capitalism, which produces both poverty and environmental degradation. we offer reparation as a framework to guide the action of development practitioners and scholars, illustrating our argument with existing practices and transformational proposals. we conclude by reflecting on the hard road ahead, underscoring the need to resource, support, and learn from frontline workers' organizations and social movements. indisputably, the st century is characterized by worsening ecological crises alongside a deficit of decent work. although our focus is informal work, we note that waged employment does not necessarily protect against poverty, as million us workers classified as the ''working poor'' can attest. moreover, reducing poverty by expanding decent work has historically intensified environmental exploitation. nearly all countries with national ecological footprints within the sustainability threshold have very high levels of working poverty, indicating that the traditional means of alleviating poverty through economic growth produces environmental degradation. admirably, the sdgs seek to decouple decent work from ecological extraction, promoting both livelihoods and sustainability. however, the transformative potential of the sdgs is compromised by an economic imaginary that misreads the key drivers of both poverty and environmental degradation and ignores empirical and theoretical research demonstrating that economic growth cannot be decoupled from environmental degradation in today's economies of extraction. [ ] [ ] [ ] [ ] studies finding modest success in a few exceptional countries to decouple economic growth from greenhouse gas emissions do not consider other forms of environmental degradation, such as land use change and unsustainable freshwater extraction. indeed, the sdgs remain captive to ''fairytales of eternal economic growth,'' a mindset decried by youth climate activist greta thunberg at the un climate summit. the sdgs privilege technocratic planning and propose win-win scenarios, downplaying the trade-offs between economic growth, social development, and environmental protection. furthermore, the sdgs ignore compelling evidence that redistribution, not growth, is the key. , in their current form, the sdgs are a trojan horse, smuggling in unpopular and problematic neoliberal economic policies, including the erasure and enclosure of informal livelihoods. scholarship over the last years has offered changing perspectives on the nature and value of informal work. , early dualist frameworks proposed that modernization would expand formal employment and starve the informal sector. since then, researchers have documented intense linkages across supply chains that crisscross sectors designated as formal and informal. there is great variation between domains of informal work, from unregistered ''petty commodity producers,'' supplying cheap inputs into capitalist production processes and reducing costs for formal firms ; to own account operators, such as waste pickers and street vendors; to informal employees, such as day laborers or domestic workers. following insights from critical anthropologists, geographers, and planning scholars, we argue that the informal and formal are relational categories whose boundaries are determined by culture and power, pointing to deeply intertwined domains of economic practice. [ ] [ ] [ ] although we find informal and formal to be analytically imprecise categories, we retain them here because of their political significance in policy making to draw lines between valued and devalued economic activities with consequences for both workers and sustainability initiatives. in spite of this research, the dominant economic imaginary devalues informal workers as unproductive and problematic. informal work is compared against the yard-stick of the ''standard employment relationship,'' signifying a unionized, waged worker, despite calls to decenter the wage. , yet secure, well-paid employment with benefits is the exception, not the norm, a form of work limited to so-called developed countries for a few postwar decades. , the deficit-based definition of informal work holds across deep ideological divisions. neoliberal economists see low productivity and ''low levels of human capital,'' labor scholars emphasize the lack of state protections, such as social security or workplace protections, whereas orthodox marxists see the lack of class consciousness and historical agency because of their structural location in economies of ''informal survivalism.'' the tenacity of the deficit definition echoes dynamics that render invisible other value-producing domains, such as women's unpaid household labor, social reproduction more broadly, the essential inputs of nature and noncommodified economies of reciprocity. informal work produces economic, social, and environmental value that sustains lives and urban environments. at the same time, formal economies rely on and appropriate this value. this article explores this central contradiction: the informal is framed as problematic and targeted for reform even as formal economies benefit from and appropriate the value produced by informal workers. to sketch a counter-story, we underscore the considerable creativity of workers facing calamitous state disinvestment in collective wellbeing. at the same time, we do not romanticize these economic words. informal livelihoods are complex and contradictory, combining individualism and community, care and exclusions, competition and collaboration, autonomy and drudgery. , formalization is shorthand for a range of policies seeking to align economic activities with the law, either changing legal codes or reforming behaviors. this can include decriminalizing informal work, licensing businesses, requiring tax compliance, enforcing labor and environmental regulations, promoting certain kinds of spatial order, or eliminating competition from firms or workers with lower costs of business because of noncompliance. however, legalistic formalization projects, rooted in eurocentric urban knowledge, fail to understand the diverse realities of most cities. whereas legalist policy frameworks value rule-following for its own sake, critical researchers demonstrate the anti-poor biases of law, the criminalization of poverty, and tendencies to leave the legal transgressions of elites unpunished. urban life in many cities is marked by dealmaking and provisionality. residents use, sidestep, and transgress legal codes depending on situational exigencies and a ''transversal'' relationship to law. contrary to expectations, formalization does not necessarily solve problems for informal workers, nor make those economic activities more valuable. formalization deriving from a legalistic, deficit-based framing can dispossess workers of livelihoods, reduce workers' collective power, reiterate stigmas associated with informality, and undercut the social and environmental value that informal work generates. if projects devolve risk and responsibility for providing basic services without resourcing worker organizations, formalization can increase the exploitation of informal workers. , the emphasis on formalization in the sdgs reflects the role of powerful, well-funded civil society organizations, largely from rich and middle-income countries , and too often lacking representation of workers. official ''invited spaces of participation'' often limit dissent, discourage critical examination of underlying economic imaginaries, and carry unspoken, exclusionary codes of acceptable behavior that reflect elite norms, values, behaviors, and codes of dress. not uncommonly, policy elites interpret expressions of worker power as illegitimate, such as waste pickers blockading dumps to protect their livelihoods. , yet often, contentious politics are needed to interrupt the status quo and offer alternative political imaginations. to illustrate the importance of informal work, we draw examples from street vending and waste work. in diverse cities, grassroots recyclers toil in difficult conditions while facing intense stigma, quotidian harassment, and even deadly violence. , yet their labors build functioning value chains for recyclables, generating income for themselves and materials for other markets as they also enable environmental behaviors among elites and provide the only opportunity for recycling in many cities. [ ] [ ] [ ] [ ] [ ] [ ] although there is great variability, the informal sector can rival formal sector material recovery rates. informal sector recyclers have irreplaceable knowledge crucial to maximizing value in waste. , [ ] [ ] [ ] [ ] indeed, policy elites now herald informal recycling as already-existing circular economies critical for sustainability transitions. similarly, street vendors enable access to cheap food despite battling a host of ''everyday challenges.'' their work contributes to sdg : making cities and human settlements inclusive, safe, resilient, and sustainable. furthermore, informal livelihoods provide crucial incomes, critical to sdg : zero poverty. worldwide, waste picking sustains some million people, while similar numbers work as street vendors. but informal work means more than an income. informal economies are complex systems of redistribution; community networks that can be tapped in times of need. in contexts of state disinvestment and chronic job scarcity, informal worlds provide a buffer against outright destitution. indeed, against stereotypes, most monetary transfers that keep poor communities afloat occur within poor communities, not between the rich and the poor. for instance, a montevideo recyclers coopera-tive transferred a share of their collective daily earnings to members unable to work due to sickness or care-taking obligations. in times of crisis, informal responses offer ''collective security mechanisms,'' , illustrated by street vendors providing food to communities under a strict covid- curfew in india. while informal care networks help cities recover from disasters-both slow-moving and spectacular-intensifying inequalities are challenging these systems of social provisioning. finally, we emphasize that the conditions of waged work are not universally preferable to informality. the once-a-month payday, inflexible work schedules, and long hours of waged work can clash with the pressing daily needs of those living precariously. in rio's largest dump, waste pickers valued the flexibility, autonomy, and sociability of the dump, cooking together, socializing, and adapting schedules to their needs, working more when necessary and less when possible. building just and sustainable cities requires reexamining how the informal is conceptualized and acted upon by mainstream development actors. we propose decentering formalization as a primary goal of initiatives such as the sdgs and organizations such as the ilo. for formalization to address social and environmental inequities it must redistribute resources and power to informal workers. this can be realized through an ethic and practice of reparation, which seeks to reimagine and recreate socioecological relations from a full acknowledgment of the injustices of the past as they live into the present. , we advocate reparation over justice because dominant, liberal notions of justice center the individual, foreclosing consideration of histories of harm and denying the need for collective redress. we articulate three modes of thinking to reconceptualize informal work and animate an alternative, ethical economic imaginary: thinking historically, thinking relationally, and thinking spatially. yet, it is not enough to think differently. urban economies come into being in and through webs of social relations that tie people to particular modes of laboring, living, creating, and consuming. thus, we also argue for concrete actions oriented toward social and environmental justice: redistributing wealth and power, strengthening worker's organizations, and recovering politics from technocratic capture. this approach underscores the interlinked nature of liberatory thought and action, or praxis. , these ways of thinking and acting are diametrically opposed to dominant academic and policy-making trends in which informal workers are treated as ''passive objects of study'' or which operate through benevolence, a stance which reproduces racial and imperial hierarchies of power. this agenda cannot be designed and executed from the top down and must emerge through an authentic collaboration with workers. such collaborations are only possible by expanding our notions of the agents of urban and sustainable development, which, in turn, requires radical humility on the part of ''experts,'' while valuing workers' knowledge, power, and political forms. without such a reframing, historically marginalized groups might well be excluded, exploited, or expelled from clean and green cities. [ ] [ ] [ ] [ ] thinking historically thinking historically clarifies racial capitalism's core logics of accumulation, appropriation, and exploitation as incompatible with decent work or sustainable societies. decent work and ll one earth , september , clean environments for some have always required oppressions, exclusions, and exposure to harm for others. , racial capitalism as a frame explains how capitalism incorporates and depends on the ''devaluation of nonwhite bodies.'' from its beginning, capitalism tended to ''differentiate-to exaggerate regional, subcultural, and dialectical differences into 'racial' ones.'' , thinking historically with racial capitalism demonstrates the common patterns through which exclusion, exploitation, and disposability are racialized processes, even if racialization works differently for mexican immigrants in the us, members of scheduled castes such as dalits in india, indigenous guatemalans, or afro-brazilians. indeed, racialized groups are more likely to engage in undervalued and invisibilized forms of work (as are women), including care and informal work. today, covid- has launched the term ''essential workers'' into our public vocabularies, making visible how essential work is often underpaid and under-protected. thinking historically shows how capitalist economies treat essential workers as disposable by constructing myths that devalue or render invisible their work. from enslaved africans picking cotton in the us south to reclaimers recycling the waste of consumer capitalism, a core logic twins the essential and the disposable. this lethal logic organizes formal and informal economies. in indian cities, most frontline, essential workers keeping the city clean during covid- lockdowns are dalit, scheduled castes and tribes, or muslims. [ ] [ ] [ ] yet, the state fails to equip them with adequate protective gear. striking amazon workers also report inadequate health protections at facilities with outbreaks, and have responded by organizing over job actions in the us in march to june . meanwhile, amazon ceo jeff bezos amassed an additional $ . billion during weeks in march and april as the pandemic took hold. these examples illustrate that treating people as disposable is not an aberrant behavior of a few bad apples but a common, accepted means to reduce costs and concentrate profits. indeed, in the us, the standard employment relation was made through racial and gendered exclusions. the wagner act-the cornerstone new deal expansion of labor protections-excluded both domestic employees and agriculture workers, legally barring both groups from organizing. these exclusions were a ''proxy to exclude most black employees'' in the south as they also reflected biases devaluing ''women's work.'' congress excluded these workers in an explicit compromise to appease the racism of conservative southern legislators. looking further back, the rise of the waged worker as the presumed norm and aspirational horizon of all has a long, bloody history. early industrial capitalism needed people willing to work for a wage in brutal factories. in england, this required the enclosures movement, two centuries of dispossessing peasants of commonly held lands and criminalizing ''poaching'' and other means of self-provisioning. this long history normalizing the wage also rendered informal work ''invisible to science.'' similarly, self-sufficient indigenous communities steadfastly refused waged work. forcing participation in waged work required centuries of sustained settler violence: land theft, the criminalization of indigenous culture, and attacks on community means of subsistence, for instance, the intentional decimation of buffalo in the us plains states. , indeed, racial capitalism refuses to recognize non-capitalist lifeways as legitimate or pro-ductive. marking these communities as ''uncivilized'' or ''indolent'' helped justify violence and dispossessions. current land grabs and other processes of rural dispossession create mass migration to cities and urban populations seeking a foothold in informal economies. indeed, many waste pickers in bangalore are migrants from bengal, dispossessed of their land-based livelihoods by urban expansion and neoliberal development. capitalist firms also appropriate unpaid or devalued inputs, a processes of ''cheapening'' land, labor, care work, and the fruits of nature, such as food and energy. some appropriations are overtly violent: theft of indigenous land, plantation-based slave economies, or ongoing murders of indigenous land defenders in latin america and beyond. others are harder to see as cheapening rests on abstract ideas of value and its lack. for instance, capitalism appropriates the ''free gifts'' of nature: energy, natural resources, and raw materials. these ecosystem services-uncounted, invisiblized but absolutely necessaryare valued at %- % of global gdp. the free services of nature also partially absorb the wastes of consumer capitalism. the global atlas of environmental justice tracks more than , cases of communities fighting to protect land, water, forests, and livelihood from economies of extraction and privatization. the sdgs, for their part, propose delinking environmental destruction from economic growth, ignoring capitalism's core logics of appropriation and cheapening. furthermore, capitalism insulates markets from public accountability because of the abstract idea that private-sector economic decision making is separate from matters of public concern. cut off from democratic control, the private sector peruses short-term profitably for elites over collective wellbeing and the sustainability of life on earth. relational thinking shifts our practices of study and intervention ''from 'the poor and poor others' to. relationships of power and privilege,'' a framing we borrow from the relational poverty network. it also helps us see the economic, social, and environmental value of informal work and the ways it subsidizes formal economies. the forces that reproduce environmental destruction, inequality, and exclusion are multiscalar and multidimensional: deregulated economies, tax rebellions by the privileged, corporate tax-evasion and off-shoring, and uneven landscapes of investment (and disinvestment). [ ] [ ] [ ] fifty years of neoliberalism-a variant of racial capitalism characterized by austerity, deregulation, and financialization-has undermined the redistributive function of the northern welfare states and hamstrung burgeoning social state capacities across the global south. economist robert reich calls this the ''succession of the successful,'' as rich communities renege on contributing to public goods, turning instead to privatized housing, education, and health that most families cannot afford. the tentative and uneven gains in reducing inequality in the postwar decades have been swept away by the rise of the superrich, in which the top % controls more wealth than the bottom %. yet, from sociological ''cultures of poverty'' research to social entrepreneurship bootstrap schemes aimed at reforming the poor, much scholarship and action persists in blaming the poor for their poverty or focusing interventions in poor communities, leaving ll one earth , september , untouched key domains responsible for inequality and environmental harm. thinking relationally helps show how capitalism predictably produces poverty and inequality, the very forces that make informal economies necessary. given this, generating decent work and building sustainable cities requires transforming structural economic forces that much exceed the bounds of a particular informal economy. relational thinking highlights how informal workers provide ''invisible subsidies'' crucial for the social reproduction of capitalism, from waste pickers metabolizing post-consumer waste to the businesses in dharavi, an informal settlement outside mumbai, recycling plastic, tanning leather, weaving fabrics, and producing pottery worth as much as $ billion each year. relational thinking also demonstrates the connections between spaces of poverty and landscapes of wealth. middle class and rich consumers depend on the cheap, often informal labor of the monetarily poor, who clean homes, build high rises, metabolize waste, and lower consumption costs by lowering the costs of production. thinking relationally draws attention to the resource-hoarding, overconsumption, and disproportionate political power of the rich as major drivers of environmental harm. it also underscores how the modest welfare gains in the post-war era in north atlantic countries relied on massive wealth transfers from the global south (previously colonized) to the global north (in most cases, imperial powers). egyptian economist samir amin tracked one of these transfers, called unequal exchange. in addition to declining terms of trade, workers earning low wages in the global south buy expensive goods produced by higher paid workers in the global north, and vice versa, such that northern countries capture uncompensated value from the global south. in , the estimated value of this south-to-north transfer was $ . trillion, more than times the value of foreign aid moving in the other direction. on a more local level, poor communities are targeted as sources of revenue through official and extra-legal channels. a us department of justice report found that police officers in ferguson-under pressure to meet citation and arrest quotas-targeted black residents for minor, even fabricated infractions in what one anthropologist called a ''shake-down operation.' ' in other cities, street vending necessitates non-compliant activities. in response, officials harass and evict vendors, demanding bribes, imposing fines, and confiscating merchandise. in cochabamba, bolivia, these practices are so common that vendors call police officers ''the hungry ones'' (los hambres). relational thinking exposes how the rule-breaking behavior of state officials (and elites) is often tolerated, whereas the necessary infractions of the poor are criminalized. finally, thinking relationally clarifies the sources of environmental harm, thereby identifying which countries and which social groups bear responsibility for redress and reparation. , environmental justice research demonstrates that political-economic processes concentrate environmental harm in poor, racialized communities, protecting spaces of privilege. emphasizing the scale of environmental harms, ecologists and environmentalists propose we are in a new geologic age, the anthropocene, in which anthropogenic climate change and environmental destruction are earth-transforming features and system-wide threats. but culpability is not evenly distributed. environmental destruction and climate catastrophe result from our political-economic system, not an undifferentiated ''humanity'' or a timeless, unchangeable human nature. it is the consumption of the middle classes and elites that produces dirty cities and a majority of urban greenhouse gas emissions. the consequences of climate catastrophe concentrate in the global south, even as the global north is historically responsible for producing most carbon emissions. instead of the anthropocene, it is more honest and politically enabling to call our era the capitalocene, a frame that names the culprits undermining the conditions for human society. , thinking spatially thinking spatially sheds light on the social processes that allocate authorization and formalized status. elite groups, usually richer and whiter, have more social power to write their interests into law and more power in contests over the best uses of urban space. spatial thinking helps identify the underlying struggles to control space and economy that often drive formalization projects. state officials manage vendors with a range of laws, codes, tacit agreements, and other unofficial strategies. , too often, vendors are viewed as encroachers or criminals while punitive state policies disregard their needs. media accounts and city officials describe vendors as outsiders or as an ''invasion'' from which the city must ''retake'' space, pursing policies which expel the urban poor from desirable urban spaces. exclusionary policies are pervasive and evictions constant and violent. unfortunately, formal recognition does not always protect street vendors. in monrovia, officials harassed vendors even after a memorandum of understanding extended formal recognition. relocating vendors to formalized markets can also have negative effects. , in bogotá , relocated vendors gained better working conditions, but the move weakened their organizations and their incomes fell. in ciudad del este, paraguay, a municipal formalization project divided vendors, demobilized vending associations, and exposed vendors to ''dispossession by formalization.'' behind any campaign to ''clean the streets'' are competing ideas about the best uses of urban space. these visions are not neutral or objective. captive to the growth imaginary, market forces and state policies define ''highest and best use'' as activities that increase property values or create profit opportunities for formal firms. the dominant economic imaginary associates work with private spaces, coding public spaces for recreation, cars, pedestrians, and shoppers. consequently, urban zoning and regulatory practices often fail to support public space as sites of work. however, informal workers often must work in public. when vendors break the rules to work, they then are accused of being predisposed to unlawfulness, an accusation that codes structural inequalities as a question of culture or individual disposition. spatial imaginaries go beyond constructing public work as problematic. in the us, until the early s, sidewalks and streets were multi-use spaces. sidewalks supported working vendors, circulating pedestrians, celebrating residents and politically active citizens. in los angeles, the notion that sidewalks should prioritize pedestrians solidified through anti-immigrant campaigns targeting the livelihoods of chinese vendors. across latin america, colonial spatial imaginaries construct particular racial groups as belonging to particular spaces: cities are for whites and mestizos whereas indigenous communities are imagined as belonging to rural areas. in bolivia, officials racialized space, interpreting popular markets as unruly, rural incursions into cities, a precursor to attempts to remove or criminalize them. in ecuador, similar policies sought to expel indigenous ecuadorians from quito's historic center, ignoring that rural communities needed the income earned by their family members in the city. policing the line between work, nuisance, and crime is also about asserting control over valuable resources. as resourcestrapped cities move to ''modernize'' and formalize recycling, they often privatize waste management, privilege capital-intensive waste management systems, and enclose the materials that are claimed by waste pickers as livelihood inputs. [ ] [ ] [ ] this ''rational-modernist model of urbanization'' can create a ''vicious circle of competition'' for resources. formalization also requires framing trash as valuable, that is, adopting the knowledge work of waste pickers who saw value where officials saw trash. indeed, the discursive construction of the informal as a problematic space in need of reform is a precursor to imagining sites that can be enclosed and privatized. in contrast to official logics, street vendors and waste pickers value urban space by how it sustains life. when vendors and waste pickers carve out spaces for livelihood they are producing important urban commons, claiming urban space for ordinary workers. indeed, the challenge of informal workers in many places is precisely that they question growth and market-driven notions of what public space should be for and who should decide. from formalization to reparation thinking historically, relationally, and spatially clarifies the processes that co-produce both precarious work and ecological harm. decentering formalization, we advocate for reparation as an ethic to orient the actions of development practitioners and policy makers. our debt here is to the black radical tradition, scholars and activists proposing collective redress for the unspeakable violence and thefts of slavery, legacies that live into the present. [ ] [ ] [ ] following w.e.b. du bois, the ethic of reparation activates memory against the forces of willful forgetting that deny history and deep relationality. we are inspired by the black radical tradition's expansive, future-oriented political imagination and its call to remake economic and social relations from the roots up. ''reparation ecologies'' add an imperative to heal the false nature/society divide, locating socio-economic relationships within living ecologies. both lines of thinking emphasize redistribution: of resources, land, work, and the labors of care. although formalization targets workers or the economies that sustain them for reform, the field of action promoted by reparation is much broader, including the forces producing inequality and environmental harm. reparation acts horizontally, centering communities most harmed by fomenting worker power, repairing historic injustices, and redistributing social power and resources to the grassroots. reparation can also help us acknowledge the long history of assent to exploitation that structures scholarship and practice. the moment is ripe for clear thinking and bold action. the convulsions to work and life precipitated by covid- offer a rare opportunity to enact transformational change. of course, entrenched structures of race/class power are invested in extraction economies, wielding considerable resources to push for exclusionary, unsustainable modes of urban development. only empowered social movements led by frontline communities have the force to contest these elite power structures. for this reason, we call on development scholars and practitioners to invest in worker power, embrace contentious politics, relinquish power over knowledge production, and develop accountable relationships with grassroots social movements. against assumptions that informal workers are unorganizable, and despite many challenges, informal worker organizing is powerful. , collective action takes many forms, from member-based organizations (mbos) to workers organizing from other identity roles, such as mothers or migrants. informal workers organize for different demands: protecting access to markets, defending public resources, expanding citizenship rights, demanding social protection, or advocating for infrastructure improvements. , , indeed, collective action by informal workers changes urban policy. in ahmedabad, india, the organization self employed women's association (sewa) helped pass the protection of livelihood and regulation of street vending act while in lima, vendor organizations won pro-vendor policy at the city and national level. organizing by waste pickers forced a sea change in how policymakers understand these workers. once universally viewed as a nuisance or a criminal element, today, the un frames informal waste workers as ''any city's key ally.'' a study of latin american countries found that worker organizing was fundamental to establishing inclusive recycling policies. reversing trends of privatization, several latin american cities have partnered with waste picker organizations for doorto-door waste collection. in brazil, ''solidarity recycling'' includes over worker organizations as partners in the national solid waste policy. the city government in bangalore, india recognizes informal recyclers with occupational identity cards while organizing in durban cut out middlemen and increased income for reclaimers by %. development organizations should resource informal worker organizations, promote supportive regulatory environments, and support the urban commons built by informal workers. this requires resisting the razing instinct of rational-modernist urbanization that tears down informal spaces, instead upgrading in situ, safeguarding community ties, and respecting the rights of the poor to live centrally and participate in urban life. specific action plans must emerge in collaboration with grassroots organizations, such that here we seed ideas for reparative policies, rather than propose blueprints. worker-run cooperatives improve livelihoods whereas mbos build collective power. across levels of government, policy makers should resource these organizations, invest in mbo bargaining capacity, and seize opportunities to open up spaces for negotiations in diverse forums: everyday, ad hoc, and policy and statutory negotiations. , when cities reorganize waste systems, they can meaningfully include grassroots recyclers, pay waste pickers for services, , and provide work spaces. redistribution-across scales-is foundational to reparation, as it recognizes that markets unjustly concentrate wealth, neoliberal policies under-resource public goods while actually existing electoral politics concentrate social power. public budgets are statements of social values. currently, states overinvest in the military, jails, and policing, or in building infrastructures that cater to the consumption desires of elites. we must continue to insist that the resources for just and sustainable cities exist. cities must prioritize public provisioning of systems of care and ''universal basic services'' such as housing, healthcare, childcare, education, and sanitation. , redistribution can help re-value informal and other forms of invisibilized work, reducing inequality. inequality drives unsustainability, both by promoting conspicuous consumption and forcing poor people to over-exploit resources. , thus, addressing inequality through redistribution is critical to achieving environmental sustainability. here, we highlight some bold proposals scaled to the enormity of today's existential challenges: universal basic income, the global green new deal, the red deal, and care incomes. by delinking labor, income, and development, these reparative policies foster more just ways of organizing work, time, and life. in , reverend dr. martin luther king promoted a guaranteed income to further racial justice and activate the creative powers of human labor freed from the compulsions of (low) waged work, a call echoed five decades later by pope francis in his easter address. these ethical injunctions are now backed by evidence from finland, where modest income supports improved wellbeing and life satisfaction. envisioned to emancipate the economy from fossil fuels, the global green new deal offers concrete plans to decarbonize the economy while redressing the historic injustices that concentrate vulnerability to climate harms in poor countries and communities by insisting that climate culprits finance the transition. visionary indigenous organizers go further with a red deal that defunds prisons, policing, and militarism, freeing up the resources for indigenousled visions of ''liberation, life, and land,'' invoking decolonial calls for ''a world where many worlds fit.'' feminist degrowth scholars propose care incomes, payments to recognize and compensate the socially reproductive work that sustains life and community. currently ignored in gdp accounting, care work is largely carried out by women and marginalized social groups and thus care incomes have the potential to redress historical exclusions and benefit informal workers. [ ] [ ] [ ] conclusions today, life-sustaining earth systems are under existential threat. as covid- devastates informal livelihoods worldwide, mass layoffs plunge unprecedented numbers of workers into economic hardship. ethical economic imaginaries undergirding new realities are thus an urgent necessity. sustainable development initiatives such as the sgds admirably seek to promote both environmental sustainability and decent work. yet, promoting poverty alleviation and ecological wholeness through economic growth is like trying to squeeze water from stone. these approaches are seductive. they promise to decouple growth from environmental damage through innovation as they promote policies that leave inequalities in wealth and social power largely untouched. they ignore that inequality is a key driver of environmental harm. thus, we insist, our pathways forward must recognize the co-constitution of poverty, inequality, and unsustainability. the necessary transformations are daunting. challenging entrenched structures of elite power is so difficult that some caution incremental change and propose only band-aid solutions to ameliorate some of the most acute forms of suffering caused by racial capitalism. against this limiting pragmatism, we argue for transformational change and encourage sustainability scholarship and practice to take an active role in promoting reparation. policymakers and sustainability researchers should learn from the critical and community-produced research on informality. we must move beyond formalization and diagnose the shared drivers of decent work deficits and environmental degradation. thinking historically, relationally, and spatially reveals how the value produced by informal workers subsidize urban economies and ecologies, even as racial capitalism predictably reproduces job scarcity, income inequality, and poverty, the very conditions that impel many to informal work. ethical economic imaginaries combined with ethic of reparative action can offer pathways toward sustainable, equitable cities by investing resources in the only social force capable of contesting elite power structures: workers and social movements on the frontlines. women and men in the informal economy: a statistical picture waste pickers and cities sidewalk, st edition (farrar street vending and public policy: a global review informal sector or petty commodity production: dualism or dependence in urban development? decent work and the informal economy (international labour organization) work for a brighter future (international labour organization) informalizing the economy: the return of the social question at a global level workers without employers: shadow corporations and the rise of the gig economy rethinking the informal economy: linkages with the formal economy and the formal regulatory environment (united nations gens: a feminist manifesto for the study of capitalism -cultural anthropology (fieldsights) the end of capitalism (as we knew it): a feminist critique of political economy policylink an overview of america's working poor few countries combine an environmentally sustainable footprint with decent work is green growth possible? managing without growth: slower by design, not disaster is decoupling gdp growth from environmental impact possible? a systematic review of the evidence on decoupling of gdp, resource use and ghg emissions, part ii: synthesizing the insights. environ greening with jobs (international labour office) a postcolonial feminist critique of the agenda for sustainable development: a south african application sustainable development goals and inclusive development global income inequality capital in the twenty-first century politics of 'leaving no one behind': contesting the sustainable development goals agenda the urban informal sector in sub-saharan africa: from bad to good (and back again?) urban informality as a site of critical analysis an exploration into the nature of informal-formal sector relationships unlocking the informal economy: a literature review on linkages between formal and informal economies in development countries (women in informal employment: globalizing and organizing) holistic framework | wiego the informal economy revisited: examining the past, envisioning the future reclaiming the discarded: life and labor on rio's garbage dump urban informality: transnational perspectives from the middle east the precariat: a view from the south beyond the ''proper job:'' political-economic analysis after the century of labouring man precarity as a political concept, or, fordism as exception precarious labor, south and north: an introduction. int. labor work informality revisited planet of slums (verso) sdg : decent work and economic growth -a gendered analysis a history of the world in seven cheap things: a guide to capitalism, nature, and the future of the planet neoliberalism from below: popular pragmatics and baroque economies world class aspirations, urban informality, and poverty politics: a north-south comparison notes on a southern urban practice peripheral urbanization: autoconstruction, transversal logics, and politics in cities of the global south the antinomies of successful mobilization: colombian recyclers manoeuvre between dispossession and exploitation (development and change) garbage citizenship: vital infrastructures of labor in dakar power and the sustainable development goals: a feminist analysis gender and the sustainable development goals insurgency and spaces of active citizenship: the story of western cape anti-eviction campaign in south africa accumulation by dispossession and the informal economy-struggles over knowledge, being and waste at a soweto garbage dump the excess of modernity: garbage politics in oaxaca six theses on waste, value, and commons the landfill has always borne fruit': precarity, formalisation and dispossession among uruguay's waste pickers networked ecological citizenship, the new middle classes and the provisioning of sustainable waste management in bangalore recovering resources -recycling citizenship: urban poverty reduction in latin america emerging trends in informal sector recycling in developing and transition countries serving the unserved: informal refuse collection in mexico the world's scavengers: salvaging for sustainable consumption and production not to be taken for granted: what informal waste pickers offer the urban economy (the global urbanist) informal sector integration and high performance recycling: evidence from cities, (women in informal employment globalizing and organizing (wiego)) comparative analysis of solid waste management in cities waste picker organizations and their contribution to the circular economy: two case studies from a global south perspective. resources building a circular plastics economy with informal waste pickers: recyclate quality, business model, and societal impacts virtuous circle: how the circular economy can create jobs and save lives in low and middle-income countries the circular economy and the global south: sustainable lifestyles and green industrial development promoting food security and livelihoods for urban poor through the informal sector: a case study of street food vendors in madurai street vendors and cities. environ. urban living in landfill (the independent) from waste pickers to street vendors, how can cities expand opportunities for the urban poor? from waste pickers to street vendors, how can cities expand opportunities for the urban poor give a man a fish: reflections on the new politics of distribution we looked after people better when we were informal': the 'quasi-formalisation' of montevideo's waste-pickers natural disaster and development in a globalizing world (routledge) tacit networks, crucial care: informal networks and disaster response in nepal's gorkha earthquake vegetables on wheels in ahmedabad, india: sewa partners with municipality to ensure food access during lockdown (wiego) a paradise built in hell: the extraordinary communities that arise in disaster (penguin) reparation ecologies: regimes of repair in populist agroecology teaching to transgress: education as the practice of freedom (routledge) pedagogy of the oppressed reclaiming reusable and recyclable materials in africa (women in informal employment: globalizing and organizing praxis in the time of empire from landscapes of utopia to the margins of the green urban life: for whom is the new green city? wiped out by the ''greenwave'': environmental gentrification and the paradoxical politics of urban sustainability ecological gentrification: a research agenda exploring justice in the city contradictions of the climate-friendly city: new perspectives on eco-gentrification and housing justice geographies of race and ethnicity ii: environmental racism, racial capitalism and state-sanctioned violence racial capitalism black marxism: the making of the black radical tradition what did cedric robinson mean by racial capitalism waste of a nation: garbage and growth in india the waste-value dialectic: lumpen urbanization in contemporary india from balmikis to bengalis: the 'casteification'of muslims in delhi's informal garbage economy bengaluru: asha workers, bbmp pourakarmikas stage protests for better working conditions, health cover (the indian express) covid- class struggle timeline | sutori american billionaires got $ billion richer during the pandemic (cnbc) the echoes of slavery: recognizing the racist origins of the agricultural and domestic worker exclusion from the national labor relations act caliban and the witch (autonomedia) wageless life an indigenous peoples' history of the united states our history is the future: standing rock versus the dakota access pipeline, and the long tradition of indigenous resistance (verso) to make live or let die? rural dispossession and the protection of surplus populations examining vulnerability in a dynamic urban setting: the case of bangalore's interstate migrant waste pickers slavery's capitalism: a new history of american economic development environmental conflicts and defenders: a global overview nature's 'free gifts' and the ecological significance of value-paul burkett the capitalocene part ii: accumulation by appropriation and the centrality of unpaid work/energy mapping the frontiers and front lines of global environmental justice: the ejatlas neoliberalism resurgent? market rule after the great recession vagabond capitalism and the necessity of social reproduction encountering poverty: thinking and acting in an unequal world reich voices concern over growing economic elitism an economy for the %: how privilege and power in the economy drive extreme inequality and how this can be stopped introduction grounds for a spatial ethnography of labor informal labor, formal politics, and dignified discontent in india unequal development: an essay on the social formations of peripheral capitalism the divide: a brief guide to global inequality and its solutions how to stop the global inequality machine (the guardian) ferguson and the criminalization of american life (gawker) owners of the sidewalk: security and survival in the informal city the debt of nations and the distribution of ecological impacts from human activities scientists' warning on affluence global environmental justice and the environmentalism of the poor municipal solid waste and the environment: a global perspective anthropocene, capitalocene, plantationocene, chthulucene: making kin the capitalocene, part i: on the nature and origins of our ecological crisis ordinary states: everyday corruption and the politics of space in mumbai uncertainty and the governance of street vending: a critical comparison across the north/south divide street vendors in asia: a review street entrepreneurs: people, place, and politics in local and global perspective revanchist urbanism heads south: the regulation of indigenous beggars and street vendors in ecuador where are the inclusive cities? street vendors globally face increasing hostility (women in informal employment: globalizing and organizing informal economy budget analysis in greater monrovia cleaning up the city: a study on the removal of street vendors from downtown belo horizonte, brazil political transitions and vulnerability of street vending in malawi. theor. empirical researches urban manage informal cities and the contestation of public space: the case of bogotá 's street vendors city-stories: narrative as diagnostic and strategic resource in ciudad del este citizenship's place: the state's creation of public space and street vendors' culture of informality in fighting traffic: the dawn of the motor age in the american city constructing the sidewalks: municipal government and the production of public space in poverty as geography: motility, stoppage and circuits of waste in delhi municipalization for privatization's sake (society and business review) contesting urban metabolism: struggles over waste-to-energy in delhi black reconstruction in america: an essay toward a history of the part which black folk played in the attempt to reconstruct democracy in america breaking bread: insurgent black intellectual life the infrastructure of assent: professions in the age of trumpism. (the avery review a conceptual framework on informal work and informal worker organizing organizing in the informal economy: a challenge for trade unions organising women workers in the informal economy collective bargaining by informal workers in the global south: where and how it takes place solid waste management in the world's cities. water and sanitation in the worlds cities aná lisis de políticas pú blicas para el reciclaje inclusivo en amé rica latina the emergence of ''solidarity recycling'' in brazil: structural convergences and strategic actions in interconnected fields ecological routes to urban inclusion: theorizing ecological citizenship through informal waste work urban recycling cooperatives: building resilient communities (routledge) waste pickers' cooperatives and social and solidarity economy organizations postura de wiego sobre el cierre de vertederos (wiego) preparing informal recycler inclusion plans: an operational guide (inter-american development bank) trabajadores por la ciudad: aporte de las mujeres a la gestió n ambiental de los residuos só lidos en amé rica latina the case for universal basic services unpacking the urban infrastructure nexus with environment, health, livability, well-being, and equity inequality and sustainability inequality, cooperation, and environmental sustainability cuarta declaració n de la selva lacandona (the revolutionary clandestine committee) within and beyond the pandemic. demanding a care income and a feminist green new deal for europe. undisciplined environments (undisciplined environments collaborative feminist degrowth: pandemic as an opening for a care-full radical transformation (degrwoth) from pandemic toward care-full degrowth trajectories of the earth system in the anthropocene the authors thank the two anonymous reviewers, as well as john stehlin and lani marina tsinnajinnie for their feedback on the ideas presented in this perspective piece. we also owe a debt of gratitude to the informal workers, grassroots communities, and frontline organizations who have shared their time and insights with us, in both paraguay and india.