Journal articles on the topic 'Health facilities Complaints against Victoria'

Abstract This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs with complete data (n = 691). Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and CMS Automated Survey Processing Environment Complaints/Incidents Tracking System. Four quartiles were created to compare NHs on their CNA retention rates: low (0-48%), medium (49-60%), high (61-72%), and very high retention (73-100%). Negative binomial regressions were estimated on total, substantiated, and unsubstantiated counts of allegations and complaints. All regressions controlled for facility and county-level factors and clustered facilities by county. Controlling for other factors, NHs in the top 50% (high and very high) of retention received 1.92 fewer allegations than those in the bottom 50%, representing a 19% difference; this trend was significant and negative across all outcomes. Using quartiles revealed a non-linear pattern: high retention NHs received the fewest number of allegations and complaints. The difference between high and low retention on total allegations, substantiated allegations, and unsubstantied allegations were 33% (3.73 fewer), 34% (0.51 fewer), and 32% (3.12 fewer) respectively. Unexpectedly, very high retention NHs received more unsubstantiated allegations than high retention NHs controlling for other variables. Research, policy, and practice efforts are critical to increase CNA retention for better consumer experiences by substantively improving CNA job quality through career advancement, high wages, and benefits. Given some turnover is desirable, effective strategies for recruitment are also needed.

Abstract Consumer voices are often left out from assessments of nursing home (NH) quality. For this reason, consumer allegations and complaints against nursing homes were studied in relation to facility rates of nurse aide retention. Analyses involved means and frequencies, correlations, ANOVAs with Tukey correction to examine the independent and dependent variables (N=690). Four quartiles of retention were created. In the final models, medium, high, and extremely high retention facilities are compared to the low retention facilities. Negative binomial regressions were estimated on total, substantiated, and unsubstantiated counts of allegations and complaints. All regressions controlled for the same characteristics, including nurse aide empowerment, consistent assignment, administrator turnover, director of nursing turnover, average age of residents, and percent female. The correlation between retention and the dependent variables was negative and statistically significant (r=-0.11, p<.01). The ANOVAs showed that high retention NHs (61-72%) received significantly fewer allegations than low (0-48%) and medium (49-60%) retention NHs; they also received fewer unsubstantiated allegations, and fewer complaints, both substantiated and unsubstantiated. After controlling for other variables, each retention group was significantly related to having fewer allegations and complaints compared to the low retention NHs. Notably, high retention NHs received between 29 and 35% fewer allegations and complaints of all types. Unexpectedly, extremely high retention NHs had more allegations, complaints, and unsubstantiated allegations than high retention NHs. Policy and practice have a role to promote nurse aide retention, improve job quality, and ensure adequate support for this critical, in-demand workforce.

Abstract: Abstract: Ministry of Social Security Agency (BPJS) is the Social Security Agency established by the government to provide for Public Health Insurance, National Health Insurance (JKN) is a public health program to realize the health services in accordance with medical needs. BPJS Health Care not for all Indonesian people. Public complaints against the service based on the results of the study proved to be due for service procedures that are less well applied and also because of the service provided is not using the right people and facilities are also incomplete, although the specified low cost but not efficient in making the community recover of the disease. Keywords: Quality of Service, BPJS

Social and healthcare workers are at high risk of experiencing sexual harassment in the workplace. Although sexual harassment is detrimental to people’s well-being, only a few studies have systematically investigated social and healthcare workers’ experiences of different forms of sexually harassing behaviors by patients, clients, and residents in Germany. This study aimed to address this gap by determining the prevalence rates and frequency of nonverbal, verbal, and physical sexual harassment by patients, clients, and residents against social and healthcare workers. In addition, we examined the associations of sexual harassment with workers’ well-being and described employees’ awareness of offers of organizational support for sexual harassment prevention and aftercare. Data were collected from n = 901 employees working in a total of 61 facilities, including inpatient and outpatient care, psychiatric facilities, hospitals, and facilities for persons with disabilities. While the prevalence, frequency, and predominant forms of sexual harassment differed across sectors, the results indicated that nonverbal, verbal and physical sexual harassment were highly prevalent in social and healthcare work, with both men and women being affected. Furthermore, we found that sexual harassment was positively related to impaired well-being (e.g., depressiveness and psychosomatic complaints). In terms of support offers for sexual harassment prevention and aftercare, we found that approximately one-third of social and healthcare workers were not aware of any offers at their facilities. In addition to highlighting the problem of sexual harassment by patients, clients, and residents in social and healthcare settings, this study provides recommendations for the development of interventions and suggests several avenues for future research.

It has been recognized that effective medical record documentation is affected by prevailing factors militating against health institutions in Nigeria. The Ekiti State University teaching Hospital has track record of competent Health Information officers who utilize different documentation methods, the methods in use are assessed while also identifying the problems or factors militating effective documentation in the EKSUTH. . The sampling technique employed was a random sampling which is a sub-group of people chosen by chance in a way that everyone has the chance of being selected. Thirty questionnaires was distributed and retrieved personally. From the data collected it revealed that the Major factor militating against effective MRD in EKSUTH is inadequate resources, funding while also revealing complaints on non-legibility of physicians handwriting, lack of skilled personnel among others. Based on the findings of this research work, it was concluded that inadequate funding and resources is the main factor militating against effective MRD in EKSUTH. Government should make provision for more facilities and electronic medical record equipment to enhance efficient MRD while also making effort to employ more Health Information professionals to further boost effective MRD in EKSUTH.

The Covid-19 pandemic caused a marked increase in admissions to intensive care units. The critically ill patients’ condition from the infection resulted in their deaths. The healthcare facilities have got into trouble because of the pandemic. In fact, they had to create additional beds in a very short time and to protect health workers with personal protective equipment. Healthcare professionals fear that there will be an increase in complaints and medico-legal malpractice claims and hence they have urged politicians to discuss this. The Italian Parliament recently debated the topic of medical liability and passed the Decree-Law no. 18 of 17 March 2020 (DL – so called Cura Italia) by which they want to extend the concept of “gross negligence” to healthcare facilities. Several Extended Care Units have suffered from outbreaks of Covid-19, so the Prosecutor’s Office of several cities initiated investigations against them. This situation has reached Sicily, where the Prosecutor’s Office of Palermo has opened an inquiry against an Extended Care Unit. Simultaneously, the Covid-19 pandemic may change patients’ attitudes towards healthcare professionals, who are risking their lives daily. So the Italian medico-legal community is debating these questions, with one last pending question remaining: is the number of medico-legal claims likely to increase or trend down?

The financial burden of adverse healthcare outcomes in Poland still remains unknown. The objective of the study was to estimate the cost of adverse healthcare outcomes in the Polish healthcare system. Cost calculation was performed on the basis of civil cases completed in Polish courts against doctors and healthcare entities. The research material consisted of 183 civil cases completed by a final judgment in 2011–2013. The case study was conducted in five out of forty-five district courts across the country. Out of 183 reviewed cases, 73 complaints ended up with favorable judgments (39.9%). The average value of the subject matter of the dispute was USD 78,675. The total expected value of lawsuits in the 183 reviewed cases was USD 11,299,020. The total amount awarded in 73 judgments from medical facilities to injured patients was USD 2,653,595, which on average means USD 36,351 per case. The average amount of awarded compensation was USD 33,317 per case. The average compensation amount in the analyzed cases was USD 11,724. The average one-time annuity for a patient was USD 11,788. The estimated costs of negative healthcare outcomes amounted to USD 8,000,000 per year.

Introduction. In July 2011, 29 residential aged care facilities (RACF) located in the Grampians rural region, Victoria, participated in the Grampians healthcare-associated infection (HAI) and antimicrobial use point prevalence study. Methods. On a single day, trained infection control consultants collected data using two surveys. The RACF survey enabled collection of information (e.g. occupancy levels) about each RACF and its residents. The resident survey was completed for eligible high-level care residents who presented with signs and symptoms of a HAI and/or were prescribed an antimicrobial. A literature review was undertaken so comparisons could be made against similar studies. Results. The Grampians prevalence of residents presenting with ≥1 HAI (3.8%) was higher than the pooled prevalence (2.3%) for four international studies (P = 0.01). The Grampians prevalence of residents prescribed ≥1 antimicrobial (8.3%) was higher than the pooled prevalence (5.8%) for eight international studies (P = 0.009). Conclusion. The prevalence of the Grampians residents presenting with ≥1 HAI and residents prescribed ≥1 antimicrobial were both observed to be significantly higher than pooled data from similar international studies. What is known about this topic? RACF residents are vulnerable to HAI for a variety of reasons (e.g. comorbidities and functional disabilities). Inappropriate antimicrobial use for these HAI may lead to the emergence of antimicrobial resistance, adverse drug reactions and excessive costs. The literature does not extensively detail surveillance programs that measure HAI or antimicrobial use in Australian RACF. What does this paper add? In a sample of Australian RACF, the Grampians point prevalence study established a baseline prevalence of HAI and antimicrobial use. The rates calculated were shown to be significantly high when compared with similar studies. What are the implications for practitioners? Quality improvement initiatives that might decrease the prevalence of HAI and antimicrobial use in Australian RACF should be investigated and supported by key stakeholders.

Background and context: Reducing the rate of cancer through awareness and prevention programs as well improvements in screening and treatment techniques is paramount. Citizen especially in rural India tend to neglect health due to routine chores of family life. The nonavailability of facilities worsen the issue. Tobacco habits leads to potentially malignant disorders and oral cancers. There is increasing trend of breast cancer, uterine and cervical cancers and also oral cancers. In India oral cancers are main cancers in males. Member of legislative assembly is public representative to represent state of Maharashtra. Cancer Free Constituency Drive was for creating awareness and screening for villagers. Katol is a rural constituency. There are 288 constituencies in Maharashtra state. Aim: 1) To create public awareness of all types of cancers. 2) To provide diagnosis and investigations and treatment to affected population. 3) Capacity building of young medical and dental professionals in cancer diagnosis and paramedical workers in screening all types of cancers. Strategy/Tactics: 72,056 house visits by 220 Asha workers and 129 nursing students and 30 dental interns to sensitize about 3,00,000 people through well designed brochure for all cancers. Self-Mouth mirror examination was designed for oral cancers and awareness against tobacco. The persons with complaints were told to visit camps on scheduled dates at 10 primary health centers. Program/Policy process: The mammography facilities and Papanicolaou test examination, dental examination in mobile vans and self-mouth mirror examination for oral cancers with trained professional carried out diagnosis in 10 primary health centers with the help of experts in medical and dental professionals. Suspeced cases were referred to tertiary referral medical hospitals. Outcomes: 5100 (males 2216 and females 2954) with complaints visited. Total 813 patients suspected to have cancers were examined by specialists from gynecology(84) general surgery (374) otorhinolaryngology (77) pediatrics (37) dermatology (19) and dentistry (131). 38 abnormal on mammography in 132 females, 55 abnormal reports from Pap smears in 472 females were evaluated, however no cancer detected in three months span. Twelve cases of oral cancers were detected and treated. Six breast cancers were detected and treated. Seven other cancers were reported by medicine and pediatric specialists. 150 cases of potentially malignant disorders were also identified. 90 had the oral submucous fibrosis (inability to open the mouth) caused due to areca quid chewing. The self-mouth mirror examination helped to create awareness against tobacco. What was learned: Awareness of cancer leading to early detection and treatment is possible in rural areas through “Cancer-Free Constituency”. The concept will help to pave the way for improved strategies and policies to better control occurrence and treatment of cancer and to address tobacco related health disparities across cancer care continuum.

Violence in children is one of the issues that is most often found in news through electronic media and print media. Based on the results of the 2018 National Survey on Child and Youth Life Experience (SNPHAR) released by the Ministry of Women's Empowerment and Child Protection, showed that 6% of boys and 9% of girls had experienced sexual violence. 50% of boys and 60% of girls have experienced emotional abuse. Furthermore, 33% of boys and 20% of girls experience physical violence. The rise of various types of violence requires P2TP2A to be more proactive to reduce the number of violence against children in Mandailing Natal Regency. The purpose of this study is to find a picture of the strategy carried out by P2TP2A in Mandailing Natal Regency in preventing cases of violence against children. The method used is descriptive qualitative by interviewing respondents who come from P2TP2A devices Mandailing Natal Regency. The results showed that P2TP2A Mandailing Natal Regency had carried out its duties and functions based on the Standard Operating Procedures established by the Chairman of the Mandailing Natal P2TP2A Technical Team. The strategy undertaken is to conduct socialization to schools and villages to report acts of violence so that services can be provided in accordance with the needs of victims of good advocacy services, rehabilitation, health, counseling as well as complaints and assistance. The strategy carried out by P2TP2A in Mandailing Natal District has shown results but requires cooperation from various parties due to the limited facilities owned by P2TP2A

The purpose of the study was to analyze and generalize recommendations regarding the actions of medical workers when documenting the facts of sexual violence and providing medical and psychological assistance to persons affected by sexual violence related to the armed conflict in Ukraine. Results and discussion. As a result of the international armed conflict on the territory of Ukraine, caused by the aggression of the Russian Federation, a large number of crimes against the civilian population were recorded. At the present time, one of the difficult challenges of society is sexual violence in the conditions of armed conflict. Sexual violence during an armed conflict is not only a criminal offense, but also a violation of international humanitarian law and human rights. According to the United Nations, the facts of sexual violence in wartime are difficult to detect and investigate. Responding to sexual violence in armed conflict requires coordination of international and national institutions and an interdisciplinary approach to providing legal and medical assistance, social and psychological support to victims of sexual violence during armed conflict. The modern tool for combating violence against women and preventing violence against women is the Istanbul Convention. An important aspect is that the right of victims of sexual violence during armed conflicts to appeal to state bodies, human rights organizations, medical workers, psychologists for help is a personal decision of each victim. A victim of sexual violence in the context of an armed conflict has the right to receive qualified free medical care. Medical assistance to persons affected by conflict-related sexual violence is provided in health care facilities as needed at all levels of medical care, both outpatient and inpatient. The purpose of providing medical assistance to the victim is to overcome the negative consequences and effects of conflict-related sexual violence on the physical and psychological health of the victim. The injured person has the right to freely choose a health care facility, a doctor, and a method of treatment in accordance with the doctor's recommendations. Medical assistance to persons affected (or likely to be affected) by conflict-related sexual violence is provided in accordance with the Protocols for the provision of medical assistance. When seeking medical help from victims or their legal representatives, medical workers must record their complaints (appeals), collect anamnesis, conduct a medical examination with an assessment of the condition of a victim of conflict-related sexual violence and, if necessary, additional instrumental and laboratory examination and measures to prevent the consequences of sexual violence. Conclusion. We recommend an algorithm of actions for medical professionals in cases of recording and documenting the fact of conflict-related sexual violence. In order to prevent psychological traumatization of the victim, it is recommended to use modern methods of recording (photographing, video recording) during the collection of anamnesis and subsequent examination of the victim in order to enable the parties to the criminal proceedings/court to use the obtained data. It is emphasized that the timely conduct of forensic medical examinations in order to detect the presence of injuries with the subsequent recording of the facts of the conflict-related sexual violence will help the side of the criminal proceedings/court to take effective measures of a criminal or other nature against the offender

Introduction. The process of raising a child can be associated with a significant number of chronic stressors that lead to the depletion of parents' mental resources. Parents of a child with disabilities, in addition to the usual stressors associated with the upbringing process, often bear an additional stress load due to the need to implement specialized measures aimed at maintaining the child's health and ensuring normal socialization. This dramatically increases the risk of parental burnout. At the moment, there is an acute shortage of specialized methods for assessing burnout for this contingent. Aims and objectives. The purpose of this study was to assess the psychometric characteristics of this technique “Level of Parental Emotional Burnout” (LPEB/PV), designed with reference to the family relationship context. Materials and Methods. The study involved 138 parents (mean age 36.5; SD = 7.01) of chronically ill children. The assessment of convergent and divergent validity of LPEB/PV was carried out using the methodology for diagnosing attitudes towards a child's illness, a questionnaire of symptomatic complaints (SCL-90-R), a family environment scale (FSS), and the Scale of basic beliefs in adaptation by M.A. Padun and A.V. Kotelnikova. Results. The conducted research showed that the scales of the LPEB/PV methodology corresponded to the developed theoretical construct, that is, it confirmed the construct validity of the methodology. The presented results demonstrate good psychometric characteristics of the LPEB/PV methodology in all studied parameters: re-test reliability and reliability of content samples, internal construct, convergent and divergent cross-validity. It is apparent for the necessity of additional study of the phenomenon from the highly personal engagement of the fight against the child's illness by parents. The scales reflecting this phenomenon found a correlation between the scales diagnosing manifestations of distress in parents with the situation of a child's chronic illness. Conclusion. Based on the results of the primary psychometric test, it can be said that the LPEB/PV method can be used to study emotional burnout in parents of chronically ill children, both in specialized counseling centers and in healthcare facilities where children with disabilities are treated.

The article discusses the proof of improper performance of professional duties by a medical worker. It is noted that rare cases of criminal prosecution of medical workers for failure to perform or improper performance of their professional duties, which are reflected in judicial statistics against the background of numerous complaints of victims in health facilities, are caused by the lack of evidence for the prosecution. According to the verdicts, evidence of the commission of these crimes are testimonies, documents and conclusions of examinations. The originals of medical documents are especially important, which, in order to be admissible in proof, should appear on the side of the prosecution in accordance with the law, including the one that regulates medical activities, storage and access to documentation, which may contain information that constitutes medical confidentiality. It is recommended to involve specialists in the field of medicine to participate in procedural actions, as they expertly help the investigator to collect traces of the use of medicines and find out other issues. Commission forensic medical examination in cases of professional activity violations by medical workers is mandatory, as it solves the issue of the presence of defects in their actions. It is noted that the Rules for the Commission of Forensic Medical Examinations, approved by the Ministry of Health of Ukraine in 1995, provide for the possibility of inclusion in the commissions, along with experts, specialists of other specialties, which was allowed by the Criminal Procedure Code of Ukraine in 1960. Since the Criminal Procedure Code of Ukraine of 2012 does not provide such an opportunity, the conclusions obtained by such commissions should not be used in making procedural decisions. To solve this problem, it is proposed to fix in the Code of Criminal Procedure of Ukraine the procedure for attracting to conduct comprehensive and commission forensic examinations necessary to ensure their objectivity and completeness of specialists from among those who are not forensic experts. The proposed changes to the law, as well as the recommended approach of the investigator and the prosecutor to determine the means of evidence will contribute to a better and faster investigation of the non-fulfillment or improper performance of medical duties by medical workers and will strengthen the prosecution’s position in court when considering cases of this category.

Abstract Purpose To provide an overview of compounding under sections 503A and 503B of the Federal Food, Drug, and Cosmetic Act, and to describe the pharmacist’s role within the US Food and Drug Administration’s (FDA’s) Compounding Incidents Program, whose efforts are aimed at protecting the public against poor-quality compounded drugs through surveillance, review and response to adverse events and complaints. Summary Compounded drugs may serve an important medical need for patients who cannot be treated with medications approved by FDA; however, compounded drugs are not approved by FDA and are not subject to premarket review for safety, efficacy, or manufacturing quality; thus, they may pose safety risks to patients. Prompt reporting of adverse events or complaints related to compounding is important in identifying these risks and implementing safeguards to protect the public. FDA’s Compounding Incidents Program consists of a team of pharmacists dedicated to the surveillance and review of adverse events and complaints and follow-up actions related to safety risks associated with compounded drugs. Pharmacists are a vital component of FDA’s Compounding Incidents Program, utilizing their clinical skill set and regulatory knowledge to review and act on safety issues that affect public health. Conclusion As FDA continues to expand the Compounding Incidents Program and its efforts to protect the public against poor-quality compounded drugs, we encourage the continued submission of adverse event reports by healthcare professionals and consumers to FDA’s MedWatch reporting system in addition to adverse event reporting compliance by outsourcing facilities.

ABSTRACT Objective: analyze the prenatal nursing consultation from the perspectives of pregnant women and nurses. Method: qualitative and descriptive study, involving 20 pregnant women and four nurses, at a primary health care service located in the city of São Luís/Maranhão (Brazil). The data were collected through semistructured interviews, participant observation and a focus group and analyzed based on the premises of thematic analysis. Results: the pregnant women expressed their satisfaction with the physical examination, highlighting that the welcoming. Complaints were made on the nurses’ technical competence, specifically regarding counseling on urinary tract infection. Some facilities were highlighted after the implementation of the Estratégia Rede Cegonha, mainly in the scheduling of appointments. The following difficulties were mentioned: lack of some prescribed drugs and long terms for carrying out and receiving preventive examinations. Conclusion: the pregnant women assessed the nursing consultation as very good, but they tend to attribute the logistic difficulties at the Health Center (lack of inputs) and even the forwarding to the medical professional (prescription of drugs to obtain outside the Health Center) to the nurses. Based on the research, relevant points could be identified that can influence positive criticism against the nursing consultation, as it constitutes more than half of clinical prenatal care in Brazil and can also change the conditions sensitive to hospitalization in primary care.

Abstract Background In recent years there have been reports of viral haemorrhagic fever (VHF) epidemics in sub-Saharan Africa where malaria is endemic. VHF and malaria have overlapping clinical presentations making differential diagnosis a challenge. The objective of this study was to determine the prevalence of selected zoonotic VHFs and malaria co-infections among febrile patients seeking health care in Tanzania. Methods This facility-based cross-sectional study was carried out between June and November 2018 in Buhigwe, Kalambo, Kyela, Kilindi, Kinondoni, Kondoa, Mvomero, and Ukerewe districts in Tanzania. The study involved febrile patients seeking health care from primary healthcare facilities. Blood samples were collected and tested for infections due to malaria, Crimean-Congo haemorrhagic fever (CCHF), Ebola virus disease (EVD), Marburg virus disease (MVD), Rift Valley fever (RVF) and yellow fever (YF). Malaria infections were tested using rapid diagnostics tests while exposure to VHFs was determined by screening for immunoglobulin M antibodies using commercial enzyme-linked immunosorbent assays. The Chi-square test was used to compare the proportions. Results A total of 308 participants (mean age = 35 ± 19 years) were involved in the study. Of these, 54 (17.5%) had malaria infection and 15 (4.8%) were positive for IgM antibodies against VHFs (RVF = 8; CCHF = 2; EBV = 3; MBV = 1; YF = 1). Six (1.9%) individuals had both VHF (RVF = 2; CCHF = 1; EVD = 2; MVD = 1) and malaria infections. The highest co-infection prevalence (0.6%) was observed among individuals aged 46‒60 years (P < 0.05). District was significantly associated with co-infection (P < 0.05) with the highest prevalence recorded in Buhigwe (1.2%) followed by Kinondoni (0.9%) districts. Headache (100%) and muscle, bone, back and joint pains (83.3%) were the most significant complaints among those infected with both VHFs and malaria (P = 0.001). Conclusions Co-infections of VHF and malaria are prevalent in Tanzania and affect more the older than the younger population. Since the overlapping symptoms in co-infected individuals may challenge accurate diagnosis, adequate laboratory diagnosis should be emphasized in the management of febrile illnesses.

The subject of this paper is to make closer clarification of the role and the specificities of services in transporting medicine by caring of vulnerable populations, or individuals who are in an emergency condition or critical situations. The field of medical transport presents a few legal questions and challenges. The aim is to research the rate of legal regulation and whether the legal and other regulation should be revised for reasons of achieving better health care of endangered. Issues of performing different types of transport of patients are observed in cases where the transport emergency and when it is not an emergency but is done on the orders of a doctor, be it on intrahospital moving the patient, moving within health facilities, or at home treatment. Each hospital should have a formalized plan for intra- and interhospital transport that addresses: a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process. Each transport of critically ill patients carries inherent risks. So equally important is a commitment to providing high-quality, compassionate clinical care in a team-based environment with excellent documentation and communication. The results of the legal analysis and the illustrated example from the foreign jurisprudence are that when it comes to transport some of the patients' rights can be suspended under the condition of keeping a medical record properly. The urgency of transport is the reverse of the merits of enjoyment of the corresponding rights. The conclusion is that the regulations Serbia in the field of healthcare under-cover transportation problems of patients. Some amendments to the regulations and draft decisions regarding the current work of emergency services are of more recent date and insufficiently implemented. There is no doubt that groups or individuals in transport deserve a better quality of transport services, as well as the effective protection of the complaints against the department. Developed countries, experiencing and legislation in this regard can be a good model for the Law of Serbia. This is very important because today some aspects of transport, the case of the so-called. air ambulances in the health care, have given international situation.

Objective: The objectives of this study are to (1) create a mental health syndrome definition for syndromic surveillance to monitor mental health-related ED visits in near real time; (2) examine whether CC data alone can accurately detect mental health related ED visits; and (3) assess the added value of using Dx data to detect mental health-related ED visits.Introduction: Between 2006 and 2013, the rate of emergency department (ED) visits related to mental and substance use disorders increased substantially. This increase was higher for mental disorders visits (55 percent for depression, anxiety or stress reactions and 52 percent for psychoses or bipolar disorders) than for substance use disorders (37 percent) visits [1]. This increasing number of ED visits by patients with mental disorders indicates a growing burden on the health-care delivery system. New methods of surveillance are needed to identify and understand these changing trends in ED utilization and affected underlying populations.Syndromic surveillance can be leveraged to monitor mental health-related ED visits in near real-time. ED syndromic surveillance systems primarily rely on patient chief complaints (CC) to monitor and detect health events. Some studies suggest that the use of ED discharge diagnoses data (Dx), in addition to or instead of CC, may improve sensitivity and specificity of case identification [2].Methods: We extracted a de-identified random sample of 50,000 ED visits with CC from the National Syndromic Surveillance Program (NSSP) for the period January 1—June 30, 2017. NSSP’s BioSense Platform receives ED data from >4000 hospitals, representing about 55 percent of all ED visits in the country [3]. From this sample we extracted 22868 ED visits that included both CC and Dx data. We then applied our mental health syndrome case definition which comprised mental health-related keywords and ICD-9-CM and ICD-10-CM codes. We queried CC text for the words “stress,” “PTSD,” “anxiety,” “depression,” “clinical depression,” “manic depression,” “unipolar depression,” “agitated,” “nervousness,” “mental health,” “mental disorder,” “affective disorder,” “schizoaffective disorder,” “psycoaffective disorder,” “obsessive-compulsive disorder,” “mood disorder,” “bipolar disorder,” “schizotypal personality disorder,” “panic disorder,” “psychosis,” “paranoia,” “psych,” “manic,” “mania,” “hallucinating,” “hallucination,” “mental episode,” and “mental illness.” We queried Dx fields either for ICD-9- CM codes 295-296; 300, 311 or for ICD-10-CM codes F20-F48. The ICD-9- CM and ICD-10-CM codes used to identify mental health-related ED visits are based on the mental health disorders most frequently seen in EDs. Alcohol and substance use, suicide ideation, and suicide attempt were excluded from this study because they are included in alternate syndromes [2]. We manually reviewed the CC text to validate the search terms. Sensitivity, specificity, and positive predictive value will be calculated based on agreement of coding mental health against the human review of mental health visits.Based on our case definition, the sample of 22868 ED visits with CC and Dx data was further stratified into two groups: (1) mental health identified in either CC or Dx, and (2) no mental health identified in CC and Dx. Group 1 was further stratified into three groups: (a) mental health identified only in CC, (b) mental health identified in both CC and Dx, and (c) mental health identified only in Dx. The sample of 27132 ED visits with CC and no Dx data was further stratified into two groups: (1) mental health identified in CC, and (2) no mental health identified in CC (Figure).Results: Of the 50,000 sample of ED visits with CC data, 22868 visits had both CC and Dx data. Of the 22868 visits, we identified 1560 mental health-related ED visits using the mental health syndrome case definition. Of those visits, 241 were identified by a CC only, 226 were identified by both CC and Dx, and 1093 by a mental health-related Dx. Of the 27132 ED visits without Dx data, 421 had mental health identified in CC.Conclusions: Based on our preliminary analysis these findings suggest potential benefits of including Dx data in syndrome binning for mental health. Mental health terms are more likely to be found in Dx data than in the CC (1093 vs. 662). Using CC alone may underestimate the number of mental health-related ED visits. This study had several limitations. Not all facilities reporting to NSSP provide chief complaint data in the same manner, some provide CC as a drop down menu with predefined terms while others include the full text of CC. Not all records contained a Dx code which limited our ability to examine the added value of Dx code for that subset.

Historians of Modern Architecture have cultivated the image of the architect as a temperamental genius, unconcerned by issues of politeness or pragmatics—a reading reinforced in cultural representations of Modern Architects, such as Howard Roark, the protagonist in Ayn Rand’s 1943 novel The Fountainhead (a character widely believed to be based on the architect Frank Lloyd Wright). The perception of the Modern Architect as an artistic hero or genius has also influenced the reception of their work. Despite their indisputable place within the architectural canon, many important works of Modern Architecture were contested on pragmatic grounds, such as cost, brief and particularly concerning issues of suitability and effectiveness in relation to climate and weather. A number of famed cases resulted in legal action between clients and architects, and in many more examples historians have critically framed these accounts to highlight alternate issues and agendas. “Complaints about the weather,” in relation to architecture, inevitably raise issues regarding a work’s “success,” particularly in view of the tensions between artistry and functionality inherent in the discipline of architecture. While in more recent decades these ideas have been framed around ideas of sustainability—particularly in relation to contemporary buildings—more traditionally they have been engaged through discussions of an architect’s ethical responsibility to deliver a habitable building that meets the client’s needs. This paper suggests these complaints often raise a broader range of issues and are used to highlight tensions inherent in the discipline. In the history of Modern Architecture, these complaints are often framed through gender studies, ethics and, more recently, artistic asceticism. Accounts of complaints and disputes are often invoked in the social construction (or deconstruction) of artistic genius – whether in a positive or negative light. Through its discussion of a number of famed examples, this paper will discuss the framing of climate in relation to the figure of the Modern Architect and the reception of the architectural “masterpiece.” Dear Monsieur Le Corbusier … In June 1930 Mme Savoye, the patron of the famed Villa Savoye on the outskirts of Paris, wrote to her architect, Le Corbusier, stating: “it is still raining in our garage” (Sbriglio 144)—a persistent theme in their correspondence. This letter followed another sent in March after discovering leaks in the garage and several bedrooms following a visit during inclement weather. While sent prior to the building’s completion, she also noted that rainfall on the bathroom skylight “makes a terrible noise […] which prevents us from sleeping in bad weather” (Sbriglio 142). Claiming to have warned Le Corbusier about the concern, the contractor refused to accept responsibility, prompting some rather fiery correspondence between the two. This problem, compounded by issues with the heating system, resulted in the house feeling, as Sbriglio notes, “cold and damp” and subject to “substantial heat loss due to the large glazing”—a cause for particular concern given the health problems of the clients’ only child, Roger Savoye, that saw him spend time in a French Sanatorium (Sbriglio 145). While the cause of Roger’s illness is not clear, at least one writer (albeit with a noticeable lack of footnotes or supporting evidence) has linked this directly to the villa (de Botton 65). Mme Savoye’s complaints about dampness, humidity, condensation and leaking in her home persisted in subsequent years, prompting Benton to summarise in 1987, “every autumn […] there were cries of distress from the Savoye family with the first rains” (Villas 204). These also extended to discussion of the heating system, which while proving insufficient was also causing flooding (Benton, "Villa" 93). In 1935 Savoye again wrote to Le Corbusier, wearily stating: It is raining in the hall, it’s raining on the ramp and the wall of the garage is absolutely soaked [….] it’s still raining in my bathroom, which floods in bad weather, as the water comes in through the skylight. The gardener’s walls are also wet through. (Sbriglio 146-7) Savoye’s understandable vexation with waterproofing problems in her home continued to escalate. With a mixture of gratitude and frustration, a letter sent two years later stated: “After innumerable demands you have finally accepted that this house which you built in 1929 in uninhabitable…. Please render it inhabitable immediately. I sincerely hope that I will not have to take recourse to legal action” (Sbriglio 147). Paradoxically, Le Corbusier was interested in the potential of architecture and urban planning to facilitate health and well-being, as well as the effects that climate may play in this. Early twentieth century medical thought advocated heliotherary (therapeutic exposure to sunlight) for a diverse range of medical conditions, ranging from rickets to tuberculosis. Similarly the health benefits of climate, such as the dryness of mountain air, had been recognised for much longer, and had led to burgeoning industries associated with health, travel and climate. The dangers of damp environments had also long been medically recognised. Le Corbusier’s awareness of the health benefits of sunshine led to the inclusion of a solarium in the villa that afforded both framed and unframed views of the surrounding countryside, such as those that were advocated in the seventeenth century as an antidote to melancholy (Burton 65-66). Both Benton and Sbriglio present Mme Savoye’s complaints as part of their comprehensive histories of an important and influential work of Modern Architecture. Each reproduce excerpts from archival letters that are not widely translated or accessible, and Benton’s 1984 essay is the source other authors generally cite in discussing these matters. In contrast, for example, Murphy’s 2002 account of the villa’s conversion from “house” to “historical monument” cites the same letters (via Benton) as part of a broader argument that highlights the “undomestic” or “unhomely” nature of the work by cataloguing such accounts of the client’s experience of discomfort while residing in the space – thus revisiting a number of common criticisms of Modern Architecture. Le Corbusier’s reputation for designing buildings that responded poorly to climate is often referenced in popular accounts of his work. For example, a 1935 article published in Time states: Though the great expanses of glass that he favors may occasionally turn his rooms into hothouses, his flat roofs may leak and his plans may be wasteful of space, it was Architect Le Corbusier who in 1923 put the entire philosophy of modern architecture into a single sentence: “A house is a machine to live in.” Reference to these issues are usually made rather minimally in academic accounts of his work, and few would agree with this article’s assertion that Le Corbusier’s influence as a phrasemaker would rival the impact of his architecture. In contrast, such issues, in relation to other architects, are often invoked more rhetorically as part of a variety of historical agendas, particularly in constructing feminist histories of architecture. While Corbusier and his work have often been the source of intellectual contention from feminist scholars—for example in regard to authorial disputes and fractious relationships with the likes of Eileen Gray or Charlotte Perriand – discussion of the functional failures in the Villa Savoye are rarely addressed from this perspective. Rather, feminist scholars have focussed their attention on a number of other projects, most notably the case of the Farnsworth House, another canonical work of Modernism. Dear Herr Mies van der Rohe … Mies van der Rohe’s Farnsworth House, completed in 1951 in Plano Illinois, was commissioned as a country weekend residence by an unmarried female doctor, a brief credited with freeing the architect from many of the usual pragmatic requirements of a permanent city residence. In response Mies designed a rectilinear steel and glass pavilion, which hovered (to avoid the flood levels) above the landscape, sheltered by maple trees, in close proximity to the Fox River. The refined architectural detail, elegant formal properties, and poetic relationship with the surrounding landscape – whether in its autumnal splendour or covered in a thick blanket of snow – captivated architects seeing it become, like the Villa Savoye, one of the most revered architectural works of the twentieth century. Prior to construction a model was exhibited in the Museum of Modern Art in New York and, upon completion the building became a pilgrimage site for architects and admirers. The exhibition of the design later fuelled debate about whether Dr Farnsworth constituted a patron or a client (Friedman 134); a distinction generating very different expectations for the responsibilities of the architect, particularly regarding the production of a habitable home that met the client’s brief versus producing a design of architectural merit. The house was intended as a frame for viewing and contemplating nature, thus seeing nature and climate aligned with the transcendental qualities of the design. Following a visit during construction, Farnsworth described the building’s relationship to the elements, writing: “the two horizontal planes of the unfinished building, floating over the meadows, were unearthly beautiful under a sun which glowed like a wild rose” (5). Similarly, in 1951, Arthur Drexler described the building as “a quantity of air caught between a floor and a roof” (Vandenberg 6). Seven years later the architect himself asserted that nature “gained a more profound significance” when viewed from within the house (Friedman 139). While the transparency of the house was “forgiven” by its isolated location and the lack of visibility from neighbouring properties, the issues a glass and steel box might pose for the thermal comfort of its occupant are not difficult to imagine. Following the house’s completion, Farnsworth fitted windows with insect screens and blinds (although Mies intended for curtains to be installed) that clumsily undermined the refined and minimalistic architectural details. Controversy surrounding the house was, in part, the result of its bold new architectural language. However, it was also due to the architect-client relationship, which turned acrimonious in a very public manner. A dispute between Mies and Farnsworth regarding unpaid fees was fought both in the courtroom and the media, becoming a forum for broader debate as various journals (for example, House Beautiful), publicly took sides. The professional female client versus the male architect and the framing of their dispute by historians and the media has seen this project become a seminal case-study in feminist architectural histories, such as Friedman’s Women and the Making of the Modern House of 1998. Beyond the conflict and speculation about the individuals involved, at the core of these discussions were the inadequacies of the project in relation to comfort and climate. For example, Farnsworth describes in her journal finding the house awash with several inches of water, leading to a court session being convened on the rooftop in order to properly ascertain the defects (14). Written retrospectively, after their relationship soured, Farnsworth’s journal delights in recounting any errors or misjudgements made by Mies during construction. For example, she described testing the fireplace to find “the house was sealed so hermetically that the attempt of a flame to go up the chimney caused an interior negative pressure” (2). Further, her growing disenchantment was reflected in bleak descriptions aligning the building with the weather. Describing her first night camping in her home, she wrote: “the expanses of the glass walls and the sills were covered with ice. The silent meadows outside white with old and hardened snow reflected the bleak [light] bulb within, as if the glass house itself were an unshaded bulb of uncalculated watts lighting the winter plains” (9). In an April 1953 article in House Beautiful, Elizabeth Gordon publicly sided with Farnsworth as part of a broader campaign against the International Style. She condemned the home, and its ‘type’ as “unlivable”, writing: “You burn up in the summer and freeze in the winter, because nothing must interfere with the ‘pure’ form of their rectangles” (250). Gordon included the lack of “overhanging roofs to shade you from the sun” among a catalogue of “human qualities” she believed architects sacrificed for the expression of composition—a list that also included possessions, children, pets and adequate kitchen facilities (250). In 1998 excerpts from this article were reproduced by Friedman, in her seminal work of feminist architectural history, and were central in her discussion of the way that debates surrounding this house were framed through notions of gender. Responding to this conflict, and its media coverage, in 1960 Peter Blake wrote: All great houses by great architects tend to be somewhat impractical; many of Corbu’s and Wright’s house clients find that they are living in too expensive and too inefficient buildings. Yet many of these clients would never exchange their houses for the most workable piece of mediocrity. (88) Far from complaining about the weather, the writings of its second owner, Peter Palumbo, poetically meditate the building’s relationship to the seasons and the elements. In his foreword to a 2003 monograph, he wrote: life inside the house is very much a balance with nature, and an extension of nature. A change in the season or an alteration of the landscape creates a marked change in the mood inside the house. With an electric storm of Wagnerian proportions illuminating the night sky and shaking the foundations of the house to their very core, it is possible to remain quite dry! When, with the melting snows of spring, the Fox River becomes a roaring torrent that bursts its banks, the house assumes a character of a house-boat, the water level sometimes rising perilously close to the front door. On such occasions, the approach to the house is by canoe, which is tied to the steps of the upper terrace. (Vandenberg 5) Palumbo purchased the house from Farnsworth and commissioned Mies’s grandson to restore it to its original condition, removing the blinds and insect screens, and installing an air-conditioning system. The critical positioning of Palumbo has been quite different from that of Farnsworth. His restoration and writings on the project have in some ways seen him positioned as the “real” architectural patron. Furthermore, his willingness to tolerate some discomfort in his inhabitation has seen him in some ways prefigure the type of resident that will be next be discussed in reference to recent owners of Wright properties. Dear Mr Wright … Accounts of weatherproofing problems in buildings designed by Frank Lloyd Wright have become the basis of mythology in the architectural discipline. For example, in 1936 Herbert Johnson and J. Vernon Steinle visited Wright’s Richard Lloyd Jones house in Oklahoma. As Jonathan Lipman wrote, “Steinle’s most prominent recollection of the house was that there were scores of tubs and canning jars in the house catching water leaking through the roof” (45). While Lipman notes the irony that both the house and office Wright designed for Johnson would suffer the same problem, it is the anecdotal accounts of the former that have perhaps attracted the most interest. An oft-recounted story tells of Johnson telephoning Wright, during a dinner party, with regard to water dripping from the ceiling into his guest-of-honour’s soup; the complaint was reportedly rebuffed unsympathetically by Wright who suggested the lady should move her chair (Farr 272). Wright himself addressed his reputation for designing buildings that leaked in his Autobiography. In reference to La Miniatura in Pasadena, of 1923, he contextualised difficulties with the local climate, which he suggested was prone to causing leaks, writing: “The sun bakes the roof for eleven months, two weeks and five days, shrinking it to a shrivel. Then giving the roof no warning whatever to get back to normal if it could, the clouds burst. Unsuspecting roof surfaces are deluged by a three inch downpour.” He continued, stating: I knew all this. And I know there are more leaking roofs in Southern California than in all the rest of the world put together. I knew that the citizens come to look upon water thus in a singularly ungrateful mood. I knew that water is all that enables them to have their being there, but let any of it through on them from above, unexpectedly, in their houses and they go mad. It is a kind of phobia. I knew all this and I have taken seriously precautions in the details of this little house to avoid such scenes as a result of negligible roofs. This is the truth. (250) Wright was quick to attribute blame—directed squarely at the builder. Never one for quiet diplomacy, he complained that the “builder had lied to [him] about the flashing under and within the coping walls” (250) and he was ignorant of the incident because the client had not informed him of the leak. He suggested the client’s silence was undoubtedly due to her “not wishing to hurt [his] feelings”. Although given earlier statements it might be speculated that she did not wish to be accused of pandering to a phobia of leaks. Wright was dismissive of the client’s inconvenience, suggesting she would be able to continue as normal until the next rains the following year and claiming he “fixed the house” once he “found out about it” (250). Implicit in this justification was the idea that it was not unreasonable to expect the client to bear a few days of “discomfort” each year in tolerance of the local climate. In true Wright style, discussions of these problems in his autobiography were self-constructive concessions. While Wright refused to take responsibility for climate-related issues in La Minatura, he was more forthcoming in appreciating the triumphs of his Imperial Hotel in Japan—one of the only buildings in the vicinity to survive the 1923 earthquake. In a chapter of his autobiography titled “Building against Doomsday (Why the Great Earthquake did not destroy the Imperial Hotel),” Wright reproduced a telegram sent by Okura Impeho stating: “Hotel stands undamaged as monument of your genius hundreds of homeless provided perfectly maintained service. Congratulations” (222). Far from unconcerned by nature or climate, Wright’s works celebrated and often went to great effort to accommodate the poetic qualities of these. In reference to his own home, Taliesin, Wright wrote: I wanted a home where icicles by invitation might beautify the eaves. So there were no gutters. And when the snow piled deep on the roofs […] icicles came to hang staccato from the eaves. Prismatic crystal pendants sometimes six feet long, glittered between the landscape and the eyes inside. Taliesin in winter was a frosted palace roofed and walled with snow, hung with iridescent fringes. (173) This description was, in part, included as a demonstration of his “superior” understanding and appreciation of nature and its poetic possibilities; an understanding not always mirrored by his clients. Discussing the Lloyd Lewis House in Libertyville, Illinois of 1939, Wright described his endeavours to keep the house comfortable (and avoid flooding) in Spring, Autumn and Summer months which, he conceded, left the house more vulnerable to winter conditions. Utilising an underfloor heating system, which he argued created a more healthful natural climate rather than an “artificial condition,” he conceded this may feel inadequate upon first entering the space (495). Following the client’s complaints that this system and the fireplace were insufficient, particularly in comparison with the temperature levels he was accustomed to in his workplace (at The Daily News), Wright playfully wrote: I thought of various ways of keeping the writer warm, I thought of wiring him to an electric pad inside his vest, allowing lots of lead wire so he could get around. But he waved the idea aside with contempt. […] Then I suggested we appeal to Secretary Knox to turn down the heat at the daily news […] so he could become acclimated. (497) Due to the client’s disinclination to bear this discomfort or use any such alternate schemes, Wright reluctantly refit the house with double-glazing (at the clients expense). In such cases, discussion of leaks or thermal discomfort were not always negative, but were cited rhetorically implying that perfunctory building techniques were not yet advanced enough to meet the architect’s expectations, or that their creative abilities were suppressed by conservative or difficult clients. Thus discussions of building failures have often been invoked in the social construction of the “architect-genius.” Interestingly accounts of the permeability of Wright’s buildings are more often included in biographical rather that architectural writings. In recent years, these accounts of weatherproofing problems have transformed from accusing letters or statements implying failure to a “badge of honour” among occupants who endure discomfort for the sake of art. This changing perspective is usually more pronounced in second generation owners, like Peter Palumbo (who has also owned Corbusier and Wright designed homes), who are either more aware of the potential problems in owning such a house or are more tolerant given an understanding of the historical worth of these projects. This is nowhere more evident than in a profile published in the real estate section of the New York Times. Rather than concealing these issues to preserve the resale value of the property, weatherproofing problems are presented as an endearing quirk. The new owners of Wright’s Prefab No. 1 of 1959, on Staten Island declared they initially did not have enough pots to place under the fifty separate leaks in their home, but in December 2005 proudly boasted they were ‘down to only one leak’ (Bernstein, "Living"). Similarly, in 2003 the resident of a Long Island Wright-designed property, optimistically claimed that while his children often complained their bedrooms were uncomfortably cold, this encouraged the family to spend more time in the warmer communal spaces (Bernstein, "In a House"). This client, more than simply optimistic, (perhaps unwittingly) implies an awareness of the importance of “the hearth” in Wright’s architecture. In such cases complaints about the weather are re-framed. The leaking roof is no longer representative of gender or power relationships between the client and the uncompromising artistic genius. Rather, it actually empowers the inhabitant who rises above their circumstances for the sake of art, invoking a kind of artistic asceticism. While “enlightened” clients of famed architects may be willing to suffer the effects of climate in the interiors of their homes, their neighbours are less tolerant as suggested in a more recent example. Complaints about the alteration of the micro-climate surrounding Frank Gehry’s Walt Disney Concert Hall in Los Angeles prompted the sandblasting of part of the exterior cladding to reduce glare. In 2004, USA Today reported that reflections from the stainless steel cladding were responsible for raising the temperature in neighbouring buildings by more than 9° Celsius, forcing neighbours to close their blinds and operate their air-conditioners. There were also fears that the glare might inadvertently cause traffic problems. Further, one report found that average ground temperatures adjacent to the building peaked at approximately 58° Celsius (Schiler and Valmont). Unlike the Modernist examples, this more recent project has not yet been framed in aid of a critical agenda, and has seemingly been reported simply for being “newsworthy.” Benign Conversation Discussion of the suitability of Modern Architecture in relation to climate has proven a perennial topic of conversation, invoked in the course of recurring debates and criticisms. The fascination with accounts of climate-related problems—particularly in discussing the work of the great Modernist Architects like Le Corbusier, Mies van der Rohe and Frank Lloyd Wright—is in part due to a certain Schadenfreude in debunking the esteem and authority of a canonical figure. This is particularly the case with one, such as Wright, who was characterised by significant self-confidence and an acerbic wit often applied at the expense of others. Yet these accounts have been invoked as much in the construction of the figure of the architect as a creative genius as they have been in the deconstruction of this figure—as well as the historical construction of the client and the historians involved. In view of the growing awareness of the threats and realities of climate change, complaints about the weather are destined to adopt a new significance and be invoked in support of a different range of agendas. While it may be somewhat anachronistic to interpret the designs of Frank Lloyd Wright or Mies van der Rohe in terms of current discussions about sustainability in architecture, these topics are often broached when restoring, renovating or adapting the designs of such architects for new or contemporary usage. In contrast, the climatic problems caused by Gehry’s concert hall are destined to be framed according to a different set of values—such as the relationship of his work to the time, or perhaps in relation to contemporary technology. While discussion of the weather is, in the conversational arts, credited as benign topic, this is rarely the case in architectural history. References Benton, Tim. The Villas of Le Corbusier 1920-1930. New Haven: Yale UP, 1987. ———. “Villa Savoye and the Architects’ Practice (1984).” Le Corbusier: The Garland Essays. Ed. H. Allen Brooks. New York: Garland, 1987. 83-105. Bernstein, Fred A. “In a House That Wright Built.” New York Times 21 Sept. 2003. 3 Aug. 2009 < http://www.nytimes.com/2003/09/21/nyregion/in-a-house-that-wright-built.html >. ———. “Living with Frank Lloyd Wright.” New York Times 18 Dec. 2005. 30 July 2009 < http://www.nytimes.com/2005/12/18/realestate/18habi.html >. Blake, Peter. Mies van der Rohe: Architecture and Structure. Harmondsworth: Penguin, 1963 (1960). Burton, Robert. The Anatomy of Melancholy, vol. II. Eds. Nicolas K. Kiessling, Thomas C. Faulkner and Rhonda L. Blair. Oxford: Clarendon, 1995 (1610). Campbell, Margaret. “What Tuberculosis Did for Modernism: The Influence of a Curative Environment on Modernist Design and Architecture.” Medical History 49 (2005): 463–488. “Corbusierismus”. Art. Time 4 Nov. 1935. 18 Aug. 2009 < http://www.time.com/time/magazine/article/0,9171,755279,00.html >. De Botton, Alain. The Architecture of Happiness. London: Penguin, 2006. Farnsworth, Edith. ‘Chapter 13’, Memoirs. Unpublished journals in three notebooks, Farnsworth Collection, Newberry Library, Chicago, unpaginated (17pp). 29 Jan. 2009 < http://www.farnsworthhouse.org/pdf/edith_journal.pdf >. Farr, Finis. Frank Lloyd Wright: A Biography. New York: Charles Scribner’s Sons, 1961. Friedman, Alice T. Women and the Making of the Modern House: A Social and Architectural History. New York: Harry N. Abrams, 1998. Gordon, Elizabeth. “The Threat to the Next America.” House Beautiful 95.4 (1953): 126-30, 250-51. Excerpts reproduced in Friedman. Women and the Making of the Modern House. 140-141. Hardarson, Ævar. “All Good Architecture Leaks—Witticism or Word of Wisdom?” Proceedings of the CIB Joint Symposium 13-16 June 2005, Helsinki < http://www.metamorfose.ntnu.no/Artikler/Hardarson_all_good_architecture_leaks.pdf >. Huck, Peter. “Gehry’s Hall Feels Heat.” The Age 1 March 2004. 22 Aug. 2009 < http://www.theage.com.au/articles/2004/02 /27/1077676955090.html >. Lipman, Jonathan. Frank Lloyd Wright and the Johnson Wax Buildings. Introduction by Kenneth Frampton. London: Architectural Press, 1984. Murphy, Kevin D. “The Villa Savoye and the Modernist Historic Monument.” Journal of the Society of Architectural Historians 61.1 (2002): 68-89. “New L.A. Concert Hall Raises Temperatures of Neighbours.” USA Today 24 Feb. 2004. 24 Aug. 2009 < http://www.usatoday.com/news/nation/2004-02-24-concert-hall_x.htm >. Owens, Mitchell. “A Wright House, Not a Shrine.” New York Times 25 July 1996. 30 July 2009 . Sbriglio, Jacques. Le Corbusier: La Villa Savoye, The Villa Savoye. Paris: Fondation Le Corbusier; Basel: Birkhäuser, 1999. Schiler, Marc, and Elizabeth Valmont. “Microclimatic Impact: Glare around the Walt Disney Concert Hall.” 2005. 24 Aug. 2009 < http://www.sbse.org/awards/docs/2005/1187.pdf >. Vandenberg, Maritz. Farnsworth House. Ludwig Mies van der Rohe. Foreword by Lord Peter Palumbo. London: Phaidon Press, 2003. Wright, Frank Lloyd. An Autobiography. New York: Duell, Sloan and Pearce, 1943.

IntroductionAustralia is at a particular point in its history where there is a noticeable diaspora of artists and creative practitioners away from the major capitals of Sydney and Melbourne (in particular), driven in no small part by ballooning house prices of the last eight years. This has meant big changes for some regional spaces, and in turn, for the face of Australian cultural life. Regional cultural precincts are forming with tourist flows, funding attention and cultural economies. Likewise, there appears to be growing consciousness in the ‘art centres’ of Melbourne and Sydney of interesting and relevant activities outside their limits. This research draws on my experience as an art practitioner, curator and social researcher in one such region (Castlemaine in Central Victoria), and particularly from a recent interview series I have conducted in collaboration with art space in that region, Wide Open Road Art. In this, 23 regional and city-based artists were asked about the social, economic and local conditions that can and have supported their art practices. Drawing from these conversations and Bourdieu’s ideas around cultural production, the article suggests that authentic, diverse, interesting and disruptive creative practices in Australian cultural life involve the increasingly pressing need for security while existing outside the modern imperative of high consumption; of finding alternative ways to live well while entering into the shared space of cultural production. Indeed, it is argued that often it is the capacity to defy key economic paradigms, for example of ‘rational (economic) self-interest’, that allows creative life to flourish (Bourdieu Field; Ley “Artists”). While regional spaces present new opportunities for this, there are pitfalls and nuances worth exploring.Changes in Regional AustraliaAustralia has long been an urbanising nation. Since Federation our cities have increased from a third to now constituting two-thirds of the country’s total population (Gray and Lawrence 6; ABS), making us one of the most urbanised countries in the world. Indeed, as machines replaced manual labour on farms; as Australia’s manufacturing industry began its decline; and as young people in particular left the country for city universities (Gray and Lawrence), the post-war industrial-economic boom drove this widespread demographic and economic shift. In the 1980s closures of regional town facilities like banks, schools and hospitals propelled widespread belief that regional Australia was in crisis and would be increasingly difficult to sustain (Rentschler, Bridson, and Evans; Gray and Lawrence 2; Barr et al.; ABS). However, the late 1990s and early 21st century saw a turnaround that has been referred to by some as the rise of the ‘sea change’. That is, widespread renewed interest and idealisation of not just coastal areas but anywhere outside the city (Murphy). It was a simultaneous pursuit of “a small ‘a’ alternative lifestyle” and escape from rising living costs in urban areas, especially for the unemployed, single parents and those with disabilities (Murphy). This renewed interest has been sustained. The latest wave, or series of waves, have coincided with the post-GFC house price spike, of cheap credit and lenient lending designed to stimulate the economy. This initiative in part led to Sydney and Melbourne median dwelling prices rising by up to 114% in eight years (Scutt 2017), which alone had a huge influence on who was able to afford to live in city areas and who was not. Rapid population increases and diminished social networks and familial support are also considered drivers that sent a wave of people (a million since 2011) towards the outer fringes of the cities and to ‘commuter belt’ country towns (Docherty; Murphy). While the underprivileged are clearly most disadvantaged in what has actually been a global development process (see Jayne on this, and on the city as a consumer itself), artists and creatives are also a unique category who haven’t fared well with hyper-urbanisation (Ley “Artists”). Despite the class privilege that often accompanies such a career choice, the economic disadvantage art professions often involve has seen a diaspora of artists moving to regional areas, particularly those in the hinterlands around and train lines to major centres. We see the recent ‘rise of a regional bohemia’ (Regional Australia Institute): towns like Toowoomba, Byron Bay, Surf Coast, Gold Coast-Tweed, Kangaroo Valley, Wollongong, Warburton, Bendigo, Tooyday, New Norfolk, and countless more being re-identified as arts towns and precincts. In Australia in 2016–17, 1 in 6 professional artists, and 1 in 4 visual artists, were living in a regional town (Throsby and Petetskaya). Creative arts in regional Australia makes up a quarter of the nation’s creative output and is a $2.8 billion industry; and our regions particularly draw in creative practitioners in their prime productive years (aged 24 to 44) (Regional Australia Institute).WORA Conservation SeriesIn 2018 artist and curator Helen Mathwin and myself received a local shire grant to record a conversation series with 23 artists who were based in the Central Goldfields region of Victoria as well as further afield, but who had a connection to the regional arts space we run, WideOpenRoadArt (WORA). In videoed, in-depth, approximately hour-long, semi-structured interviews conducted throughout 2018, we spoke to artists (16 women and 7 men) about the relocation phenomenon we were witnessing in our own growing arts town. Most were interviewed in WORA’s roving art float, but we seized any ad hoc opportunity we had to have genuine discussions with people. Focal points were around sustainability of practice and the social conditions that supported artists’ professional pursuits. This included accessing an arts community, circles of cultural production, and the ‘art centre’; the capacity to exhibit; but also, social factors such as affordable housing and the ability to live on a low-income while having dependants; and so on. The conversations were rich with lived experiences and insights on these issues.Financial ImperativesIn line with the discussion above, the most prominent factor we noticed in the interviews was the inescapable importance of being able to live cheaply. The consistent message that all of the interviewees, both regional- and city-based, conveyed was that a career in art-making required an important independence from the need to earn a substantial income. One interviewee commented: “I do run my art as a business, I have an ABN […] it makes a healthy loss! I don’t think I’ve ever made a profit […].” Another put it: “now that I’m in [this] town and I have a house and stuff I do feel like there is maybe a bit more security around those daily things that will hopefully give me space to [make artworks].”Much has been said on the pervasive inability to monetise art careers, notably Bourdieu’s observations that art exists on an interdependent field of cultural capital, determining for itself an autonomous conception of value separate to economics (Bourdieu, Field 39). This is somewhat similar to the idea of art as a sacred phenomenon irreducible to dollar terms (Abbing 38; see also Benjamin’s “aura”; “The Work of Art”). Art’s difficult relationship with commodification is part of its heroism that Benjamin described (Benjamin Charles Baudelaire 79), its potential to sanctify mainstream society by staying separate to the lowly aspirations of commerce (Ley “Artists” 2529). However, it is understood, artists still need to attain professional education and capacities, yet they remain at the bottom of the income ladder not only professionally, but in the case of visual artists, they remain at the bottom of the creative income hierarchies as well. Further to this, within visual arts, only a tiny proportion achieve financially backed success (Menger 277). “Artistic labour markets are characterised by high risk of failure, excess supply of recruits, low artistic income level, skewed income distribution and multiple jobholding” (Mangset, Torvik Heian, Kleppe, and Løyland; Menger). Mangset et al. point to ideas that have long surrounded the “charismatic artist myth,” of a quasi-metaphysical calling to be an artist that can lead one to overlook the profession’s vast pitfalls in terms of economic sustainability. One interviewee described it as follows: “From a very young age I wanted to be an artist […] so there’s never been a time that I’ve thought that’s not what I’m doing.” A 1% rule seems widely acknowledged in how the profession manages the financial winners against those who miss out; the tiny proportion of megastar artists versus a vast struggling remainder.As even successful artists often dip below the poverty line between paid engagements, housing costs can make the difference between being able to live in an area and not (Turnbull and Whitford). One artist described:[the reason we moved here from Melbourne] was financial, yes definitely. We wouldn’t have been able to purchase a property […] in Melbourne, we would not have been able to live in place that we wanted to live, and to do what we wanted to do […]. It was never an option for us to get a big mortgage.Another said:It partly came about as a financial practicality to move out here. My partner […] wanted to be in the bush, but I was resistant at first, we were in Melbourne but we just couldn’t afford Melbourne in the end, we had an apartment, we had a studio. My partner was a cabinet maker then. You know, just every month all our money went to rent and we just couldn’t manage anymore. So we thought, well maybe if we come out to the bush […] It was just by a happy accident that we found a property […] that we could afford, that was off-grid so it cut the bills down for us [...] that had a little studio and already had a little cottage on there that we could rent that out to get money.For a prominent artist we spoke to this issue was starkly reflected. Despite large exhibitions at some of the highest profile galleries in regional Victoria, the commissions offered for these shows were so insubstantial that the artist and their family had to take on staggering sums of personal debt to execute the ambitious and critically acclaimed shows. Another very successful artist we interviewed who had shown widely at ‘A-list’ international arts institutions and received several substantial grants, spoke of their dismay and pessimism at the idea of financial survival. For all artists we spoke to, pursuing their arts practice was in constant tension with economic imperatives, and their lives had all been shaped by the need to make shrewd decisions to continue practising. There were two artists out of the 23 we interviewed who considered their artwork able to provide full-time income, although this still relied on living costs remaining extremely low. “We are very lucky to have bought a very cheap property [in the country] that I can [also] have my workshop on, so I’m not paying for two properties in Melbourne […] So that certainly takes a fair bit of pressure off financially.” Their co-interviewee described this as “pretty luxurious!” Notably, the two who thought they could live off their art practices were both men, mid-career, whose works were large, spectacular festival items, which alongside the artists’ skill and hard work was also a factor in the type of remuneration received.Decongested LivingBeyond more affordable real estate and rental spaces, life outside our cities offers other benefits that have particular relevance to creative practitioners. Opera and festival director Lindy Hume described her move to the NSW South Coast in terms of space to think and be creative. “The abundance of time, space and silence makes living in places like [Hume’s town] ideal for creating new work” (Brown). And certainly, this was a theme that arose frequently in our interviews. Many of our regionally based artists were in part choosing the de-pressurised space of non-metro areas, and also seeking an embedded, daily connection to nature for themselves, their art-making process and their families. In one interview this was described as “dreamtime”. “Some of my more creative moments are out walking in the forest with the dog, that sort of semi-daydreamy thing where your mind is taken away by the place you’re in.”Creative HubsAll of our regional interviewees mentioned the value of the local community, as a general exchange, social support and like-minded connection, but also specifically of an arts community. Whether a tree change by choice or a more reactive move, the diaspora of artists, among others, has led to a type of rural renaissance in certain popular areas. Creative hubs located around the country, often in close proximity to the urban centres, are creating tremendous opportunities to network with other talented people doing interesting things, living in close proximity and often open to cross-fertilisation. One said: “[Castlemaine] is the best place in Australia, it has this insane cultural richness in a tiny town, you can’t go out and not meet people on the street […] For someone who has not had community in their life that is so gorgeous.” Another said:[Being an artist here] is kind of easy! Lots of people around to connect—with […] other artists but also creatively minded people [...] So it means you can just bump into someone from down the street and have an amazing conversation in five minutes about some amazing thing! […] There’s a concentration here that works.With these hubs, regional spaces are entering into a new relevance in the sphere of cultural production. They are generating unique and interesting local creative scenes for people to live amongst or visit, and generating strong local arts economies, tourist economies, and funding opportunities (Rentschler, Bridson, and Evans). Victoria in particular has burgeoned, with tourist flows to its regions increasing 13 per cent in 5 years and generating tourism worth $10 billion (Tourism Victoria). Victoria’s Greater Bendigo is Australia’s most popularly searched tourist destination on Trip Advisor, with tourism increasing 52% in 10 years (Boland). Simultaneously, funding flows have increased to regional zones, as governments seek to promote development outside Australia’s urban centres and are confident in the arts as a key strategy in boosting health, economies and overall wellbeing (see Rentschler, Bridson, and Evans; see also the 2018 Regional Centre for Culture initiative, Boland). The regions are also an increasingly relevant participant in national cultural life (Turnbull and Whitford; Mitchell; Simpson; Woodhead). Opportunities for an openness to productive exchange between regional and metropolitan sites appear to be growing, with regional festivals and art events gaining importance and unique attributes in the consciousness of the arts ‘centre’ (see for example Fairley; Simpson; Farrelly; Woodhead).Difficulties of Regional LocationDespite this, our interviews still brought to light the difficulties and barriers experienced living as a regional artist. For some, living in regional Victoria was an accepted set-back in their ambitions, something to be concealed and counteracted with education in reputable metropolitan art schools or city-based jobs. For others there was difficulty accessing a sympathetic arts community—although arts towns had vibrant cultures, certain types of creativity were preferred (often craft-based and more community-oriented). Practitioners who were active in maintaining their links to a metropolitan art scene voiced more difficulty in fitting in and successfully exhibiting their (often more conceptual or boundary-pushing) work in regional locations.The Gentrification ProblemThe other increasingly obvious issue in the revivification of some non-metropolitan areas is that they can and are already showing signs of being victims of their own success. That is, some regional arts precincts are attracting so many new residents that they are ceasing to be the low-cost, hospitable environments for artists they once were. Geographer David Ley has given attention to this particular pattern of gentrification that trails behind artists (Ley “Artists”). Ley draws from Florida’s ideas of late capitalism’s ascendency of creativity over the brute utilitarianism of the industrial era. This has got to the point that artists and creative professionals have an increasing capacity to shape and generate value in areas of life that were previous overlooked, especially with built environments (2529). Now more than ever, there is the “urbane middle-class” pursuing ‘the swirling milieu of artists, bohemians and immigrants” (Florida) as they create new, desirable landscapes with the “refuse of society” (Benjamin Charles Baudelaire 79; Ley New Middle Class). With Australia’s historic shifts in affordability in our major cities, this pattern that Ley identified in urban built environments can be seen across our states and regions as well.But with gentrification comes increased costs of living, as housing, shops and infrastructure all alter for an affluent consumer-resident. This diminishes what Bourdieu describes as “the suspension and removal of economic necessity” fundamental to the avant-garde (Bourdieu Distinction 54). That is to say, its relief from heavy pressure to materially survive is arguably critical to the reflexive, imaginative, and truly new offerings that art can provide. And as argued earlier, there seems an inbuilt economic irrationality in artmaking as a vocation—of dedicating one’s energy, time and resources to a pursuit that is notoriously impoverishing. But this irrationality may at the same time be critical to setting forth new ideas, perspectives, reflections and disruptions of taken-for-granted social assumptions, and why art is so indispensable in the first place (Bourdieu Field 39; Ley New Middle Class 2531; Weber on irrationality and the Enlightenment Project; also Adorno’s the ‘primitive’ in art). Australia’s cities, like those of most developed nations, increasingly demand we busy ourselves with the high-consumption of modern life that makes certain activities that sit outside this almost impossible. As gentrification unfolds from the metropolis to the regions, Australia faces a new level of far-reaching social inequality that has real consequences for who is able to participate in art-making, where these people can live, and ultimately what kind of diversity of ideas and voices participate in the generation of our national cultural life. ConclusionThe revival of some of Australia’s more popular regional towns has brought new life to some regional areas, particularly in reshaping their identities as cultural hubs worth experiencing, living amongst or supporting their development. Our interviews brought to life the significant benefits artists have experienced in relocating to country towns, whether by choice or necessity, as well as some setbacks. It was clear that economics played a major role in the demographic shift that took place in the area being examined; more specifically, that the general reorientation of social life towards consumption activities are having dramatic spatial consequences that we are currently seeing transform our major centres. The ability of art and creative practices to breathe new life into forgotten and devalued ideas and spaces is a foundational attribute but one that also creates a gentrification problem. Indeed, this is possibly the key drawback to the revivification of certain regional areas, alongside other prejudices and clashes between metro and regional cultures. It is argued that the transformative and redemptive actions art can perform need to involve the modern irrationality of not being transfixed by matters of economic materialism, so as to sit outside taken-for-granted value structures. This emphasises the importance of equality and open access in our spaces and landscapes if we are to pursue a vibrant, diverse and progressive national cultural sphere.ReferencesAbbing, Hans. Why Artists Are Poor: The Exceptional Economy of the Arts. Amsterdam: Amsterdam UP, 2002.Adorno, Theodor. Aesthetic Theory. London: Routledge, 1983.Australian Bureau of Statistics. “Population Growth: Capital City Growth and Development.” 4102.0—Australian Social Trends. Canberra: Australian Bureau of Sttaistics, 1996. <http://www.abs.gov.au/ausstats/abs@.nsf/2f762f95845417aeca25706c00834efa/924739f180990e34ca2570ec0073cdf7!OpenDocument>.Barr, Neil, Kushan Karunaratne, and Roger Wilkinson. Australia’s Farmers: Past, Present and Future. Land and Water Resources Research and Development Corporation, 2005. 1 Mar. 2019 <http://inform.regionalaustralia.org.au/industry/agriculture-forestry-and-fisheries/item/australia-s-farmers-past-present-and-future>.Benjamin, Walter. Charles Baudelaire: A Lyric Poet in the Era of High Capitalism. London: NLB, 1973.———. “The Work of Art in the Age of Mechanical Reproduction.” Illuminations. Ed. Hannah Arendt. Trans. Harry Zohn. New York: Schocken Books, 1969.Boland, Brooke. “What It Takes to Be a Leading Regional Centre of Culture.” Arts Hub 18 July 2018. 1 Mar. 2019 <https://www.artshub.com.au/festival/news-article/sponsored-content/festivals/brooke-boland/what-it-takes-to-be-a-leading-regional-centre-of-culture-256110>.Bourdieu, Pierre. Distinction. Cambridge, MA: Harvard UP, 1984.———. The Field of Cultural Production. New York: Columbia UP, 1993.Brown, Bill. “‘Restless Giant’ Lures Queensland Opera’s Artistic Director Lindy Hume to the Regional Art Movement.” ABC News 13 Sep. 2017. 10 Mar. 2019 <https://www.abc.net.au/news/2017-09-12/regional-creative-industries-on-the-rise/8895842>.Docherty, Glenn. “Why 5 Million Australians Can’t Get to Work, Home or School on Time.” Sydney Morning Herald 17 Feb. 2019. 10 Mar. 2019 <https://www.smh.com.au/national/why-5-million-australians-can-t-get-to-work-home-or-school-on-time-20190215-p50y1x.html>.Fairley, Gina. “Big Hit Exhibitions to See These Summer Holidays.” Arts Hub 14 Dec. 2018. 1 Mar. 2019 <https://visual.artshub.com.au/news-article/news/visual-arts/gina-fairley/big-hit-exhibitions-to-see-these-summer-holidays-257016>.Farrelly, Kate. “Bendigo: The Regional City That’s Transformed into a Foodie and Cultural Hub.” Domain 9 Apr. 2019. 10 Mar. 2019 <https://www.domain.com.au/news/bendigo-the-regional-city-you-didnt-expect-to-become-a-foodie-and-cultural-hub-813317/>.Florida, Richard. “A Creative, Dynamic City Is an Open, Tolerant City.” The Globe and Mail 24 Jun. 2002: T8.Gray, Ian, and Geoffrey Lawrence. A Future For Regional Australia: Escaping Global Misfortune. Cambridge: Cambridge University Press, 2001.Hume, Lindy. Restless Giant: Changing Cultural Values in Regional Australia. Strawberry Hills: Currency House, 2017.Jayne, Mark. Cities and Consumption. London: Routledge, 2005.Ley, David. The New Middle Class and the Remaking of the Central City. Oxford: Oxford University Press, 1996.———. “Artists, Aestheticisation and Gentrification.” Urban Studies 40.12 (2003): 2527–44.Menger, Pierre-Michel. “Artistic Labor Markets: Contingent Works, Excess Supply and Occupational Risk Management.” Handbook of the Economics of Art and Culture. Eds. Victor Ginsburgh and David Throsby. Amsterdam: Elsevier, 2006. 766–811.Mangset, Per, Mari Torvik Heian, Bard Kleppe and Knut Løyland. “Why Are Artists Getting Poorer: About the Reproduction of Low Income among Artists.” International Journal of Cultural Policy 24.4 (2018): 539-58.Mitchell, Scott. “Want to Start Collecting Art But Don’t Know Where to Begin? Trust Your Own Taste, plus More Tips.” ABC Life, 31 Mar. 2019 <https://www.abc.net.au/life/tips-for-buying-art-starting-collection/10084036>.Murphy, Peter. “Sea Change: Re-Inventing Rural and Regional Australia.” Transformations 2 (March 2002).Regional Australia Institute. “The Rise of the Regional Bohemians.” Regional Australia Institute 24 May. 2017. 1 Mar. 2019 <http://www.regionalaustralia.org.au/home/2017/05/rise-regional-bohemians-painting-new-picture-arts-culture-regional-australia/>.Rentschler, Ruth, Kerrie Bridson, and Jody Evans. Regional Arts Australia Stats and Stories: The Impact of the Arts in Regional Australia. Regional Arts Australia [n.d.]. <https://www.cacwa.org.au/documents/item/477>.Simpson, Andrea. “The Regions: Delivering Exceptional Arts Experiences to the Community.” ArtsHub 11 Apr. 2019. <https://visual.artshub.com.au/news-article/sponsored-content/visual-arts/andrea-simpson/the-regions-delivering-exceptional-arts-experiences-to-the-community-257752>.

Photo by Hédi Benyounes on Unsplash ABSTRACT The current incarceration facilities for the growing number of women are depriving expecting mothers of adequate care crucial for the child’s mental and physical development. Programs need to be established to counteract this. INTRODUCTION Currently, Diana Sanchez was eight months pregnant when she was arrested for identity theft and put in a prison cell in Denver. At five a.m., two weeks after being incarcerated, she announced to a deputy outside her cell that she was going into labor. Footage from a camera in her cell shows her pacing anxiously or writhing in her bed for the five hours preceding the arrival of her son. She banged on the door and begged for help. All she received was an absorbent pad. She gave birth alone in her prison cell on July 31, 2015, around 10:45 am. At 11:00 am, a prison nurse walked in to cut the umbilical cord and take Sanchez’s newborn baby without offering postnatal care. Sanchez was later sent to a hospital, and her baby was separated from her until she was put on probation. In 2018, on behalf of her three-year-old son, Sanchez sued Denver Health and Denver Sheriff Department and won a $480,000 settlement.[1] Though many more men are incarcerated than women, the rate of growth of female incarceration has exceeded that of male incarceration for decades. One study estimated that 231,000 women are currently incarcerated in the US,[2] 80 percent of whom are mothers, and 150,000 pregnant.[3] Another recent study of 1,396 incarcerated pregnant women found that 92 percent had live births, 6.5 percent had stillbirths or miscarriages, and 4 percent terminated the pregnancy. The authors found that there is no system of reporting pregnancy outcomes in US prisons. There is a noteworthy ethical lapse in mental, emotional, and medical care that threatens the well-being of pregnant women in prison. According to Carolyn Sufrin, “Pregnant incarcerated people are one of the most marginalized and forgotten groups in our country… and women who don't get counted don't count.” [4] Poor documentation, visibility, and transparency contribute to the systemic abuse of incarcerated women. Studies document women giving birth alone in cells and shackles in solitary confinement. Their complaints regarding contractions, bleeding, and other pains of labor are often ignored.[5] l. Prenatal Care in American Prisons Diana Sanchez was not offered any prenatal care after she was incarcerated. And neither she nor her son received appropriate postnatal care.[6] Sanchez was on medication for opioid withdrawal while pregnant, which could have been detrimental to her baby’s health.[7] There is an unacceptable absence of pre- and postnatal care in most US prisons. A lack of regulation makes the availability of perinatal care unpredictable and unreliable. Several studies confirmed that there is not a standard for prenatal care for women incarcerated during pregnancy. [8] Knowledge of the appropriate mental and physical care pregnant women require, addiction support, and support for maternal-infant bonding all exists outside the prison system and ought to be used as a benchmark. At the very least, pregnant women, birthing women, and new mothers should not be placed in solitary confinement or shackled.[9] In the prenatal arena, depriving an individual of adequate healthcare is not appropriate and could be cruel and unusual. Only 18 percent of funding in prisons goes to health care for the prisoners. That is roughly $5.7 thousand per prisoner, according to an NIH study done in 2015.[10] There should be an adequate amount of funding for the health needs of incarcerated pregnant women. By depriving pregnant women of healthcare, the prisons are depriving the fetus of adequate care. ll. Respect for Autonomy During Incarceration Women maintain healthcare autonomy even when incarcerated. The purpose of a prison sentence is retribution for crimes and rehabilitation to prevent reoffending.[11] The separation of a mother and newborn causes significant developmental and psychological harm to the child and the parent. Parent-child separation does not serve the purpose of retribution or rehabilitation and is authorized only due to prisons’ limited space and resources that make it difficult to accommodate children, as well as a state interest in children’s best interests or the custody rights of the other parent. When it is possible to keep a family together, prisons should make every effort to do so for the health of the mother-child relationship. Incarcerated people may become a burden to family or society due to prison medical neglect. For example, diabetes and hypertension, which can occur during pregnancy, can worsen without treatment. The inability to access the care they would otherwise want and need endangers women and poses a burden to the healthcare system after incarceration, Depersonalizing individuals convicted of crimes must be placed in the context of historical eugenics practices. State-sanctioned sterilization and efforts to prevent women from reproducing were widespread during the early 20th century.[12] Cases of coerced and nonconsensual sterilization of incarcerated women and men evidence the history of eugenics.[13]Abortions are offered to some incarcerated women.[14] However, many incarcerated women are denied the right to see healthcare providers to thoroughly discuss abortion or other options.[15] Although the abortions are consensual, the quality of consent is questionable. lll. Prison Nursery Programs, “I need something to live for…” Indiana Women’s Prison (IWP), a max security female prison, has a program called Wee Ones that enables women convicted of nonviolent crimes to spend 30 months bonding with their newborn child. It is one of eight programs in the country that allows pregnant mothers to spend the last few months of their sentence with their children. It is a voluntary program that allows pregnant offenders a private room in a housing unit. It offers parent education, resources that are accessible after release, and career education. The program application process and the rules to which women must adhere to remain in the program are stringent. The programs generally have a zero-tolerance policy. Even simply sleeping in the same bed as the child or arguing with other mothers can result in termination from the program. Kara, a pregnant woman incarcerated for drug possession, had a history of abuse in her family and tended to act out in anger against her peers in the program. She was learning how to have healthy reactions to anger when handling her child, but her temper ultimately led to her removal from the program. Her son was placed in foster care, and Kara returned to the regular cells. In an interview before her transfer, she told the camera that Charlie gave her a purpose. With tears in her eyes, she said, “Charlie was my way of life here [...] I need something to live for [,] and I screwed up.”[16] Pregnancy in prison can be a way to improve quality of life for some women. Studies demonstrate that nursery programs improve mental health of the incarcerated women.[17] The secure attachment of the infant to its primary caregiver promotes healthy development in the child and a bonded relationship with the mother.[18] The close bond between mother and child in prisons has been shown to decrease recidivism and to reduce the burden on the foster care system.[19] Women who do not qualify for these programs, or are incarcerated in prisons without them, are separated from their newborn babies and their other children. The disconnect can lead to the child rejecting the incarcerated mother once she is released.[20] Programs like Wee Ones honor women’s autonomy while they are incarcerated. During interviews, the women expressed that although raising a child in that environment is difficult, it was better than not being with their children. While rocking a baby in her lap, one inmate expressed her frustrations with Wee Ones but then paused to express gratitude and said, “After all, it’s prison. And prison ain’t supposed to be nice.”[21] The ethical issue of autonomy reflects a more difficult dilemma in the prison landscape. lV. Counter Arguments: Do the Nursery Programs Work for the Children and the Women Typically, newborns are taken from their incarcerated mothers within two to three days of birth and sent to live with a relative or placed in foster care. Many women are never reunited with their babies. There is much debate over whether the programs are beneficial to the children. One ethical issue is whether children, as innocents, are being punished either by being in the prison system or by being separated from their mothers. Skeptics, like James Dwyer, have argued against keeping innocent babies in the custody of incarcerated mothers asserting that there is little evidence demonstrating that the programs rehabilitate the women.[22] Dwyer commented on the “reckless” hopefulness the programs provide: "It might, in fact, be the babies distract them from rehabilitation they should be doing instead. […] They're so focused on childcare and have this euphoria — they think they'll be just fine when they get out of prison and they're not. We just don't know."[23] One study showed that 58 percent of incarcerated women are arrested again after release, 38 percent are reconvicted, and 30 percent return to prison within three years.[24] Dwyer uses this data to argue that the programs are not worthwhile. However, the data is not limited to the special population that had the prison nursery experience. The data applies to all incarcerated women limiting its applicability. More importantly, there is compelling evidence to support prison nursery programs.[25] The programs do decrease recidivism[26] and prison misconduct,[27] and they allow women to create stronger bonds with their children.[28] Bev Little argues that allowing mothers to bond with their babies only delays the inevitable separation and will cause trauma and have other ill effects on the baby. [29] But others feel that stronger maternal-fetal attachment is best for both parties. There is evidence that the bond, once formed, is long-lasting. Later in life, there is less drug addiction among children who stayed in the nursery rather than being separated from their mothers.[30] Another counterargument is that the policies in prison nurseries are not as useful for motherhood outside of the facility; thus, an issue with recidivism occurs because the women are less prepared for motherhood upon release from prison. Prison nursery programs establish methods and procedures for successful motherhood that are unique to operation within correctional environments. Yet, fortunately, parenting classes offered by prisons and jails emphasize sacrifice, self-restraint, and dedicated attention to the baby. These classes aptly apply to motherhood outside of prison.[31] One incarcerated mother experiencing addiction, Kima, was described as ambivalent toward her pregnancy. “It’s something about knowing but not knowing that makes me not accountable or makes me think I’m not accountable,” Kima shared.[32] After the nurse confirmed her pregnancy, she acknowledged fear and knew she would be held accountable to the baby. The occurrence of pregnancy ambivalence is common.[33] A study of a population of prisoners from Rhode Island found that 41 percent of the women expressed ambivalent attitudes about pregnancy. 70 of the women from a population in San Francisco expressed ambivalent or negative attitudes towards pregnancy.[34] But the ambivalence of some women toward pregnancy is not a reason to prevent women who feel differently from reaping the full benefits of programs that support them during pregnancy. Another counterargument is that prison is becoming a comfort that women might seek if they are homeless or housing insecure. For example, Evelyn was released from a San Francisco jail after being arrested for using cocaine. She was 26 weeks pregnant and had a four-year-old son in the custody of her aunt. Following her release, she was homeless and using drugs in the streets. She felt that her only hope of keeping her baby safe was to go back to jail. Like Kima, she had been in and out of jail from a young age. She grew accustomed to and dependent on the care provided there. While incarceration can provide a home and a nursery, there is no ethical reason to argue for making prison less comfortable by separating babies and children from incarcerated women. Instead, these facts suggest we are not doing enough for women outside prisons either. CONCLUSION Many experts stress the dearth of research and information on these women and their babies. There is no empirical data to show how big the problem is, but there is evidence that programs providing nursery care for the children of incarcerated women have many benefits. Because the research is not largescale enough, many pregnant women in the prison system are ignored. Many women give birth in unacceptable conditions, and their children are taken from them the moment the umbilical cord is cut. While the US incarcerates too many women, a movement to expand prison nurseries could help new mothers bond with their children. Strong educational programs could aid in lowering the rates of recidivism by providing therapeutic resources for mothers.[35] There is a growing problem of mass incarceration in the US as many women are placed in correctional facilities. Most of these women are convicted of possession or use of illegal substances.[36] Many women come from disadvantaged backgrounds, poverty, and have experienced addiction. Depriving an expectant mother of adequate care is cruel and irresponsible both to the mother and her innocent child. The criminal justice system is harming children both mentally and physically. Reform of the system is needed to provide the basic care those children need. Programs like IWP’s Wee Ones are necessary for physical, psychological, and social development. A program that offers a place for mothers to raise their babies in the community of other mothers would incentivize and facilitate healthy parental habits. Further programs for mothers who are released from prison would give them valuable resources to keep them from returning and encourage healthy relationships between the mother and the baby. - [1] Li, D. K. Video allegedly shows woman giving birth in Denver jail cell alone, with no assistance. Denver: NBC News, 2019. [2] Kajstura, Aleks. “Women's Mass Incarceration: The Whole Pie 2019.” Prison Policy Initiative, 29 Oct. 2019, https://www.prisonpolicy.org/reports/pie2019women.html. (“Including those in prisons, jails, and other correctional facilities.”) [3] Swavola, E, K Riley and R Subramanian. "Overlooked: Women and Jails in an Era of Reform." Vera Institute of Justice August 2016. [4] Sufrin, C. Pregnant Behind Bars: What We Do and Don't Know About Pregnancy and Incarceration Allison Chang. 21 March 2019. Transcript. [5] Sufrin, C., 2019. (Suffrin expressed that she had seen such practices firsthand working as an OB/GYN for incarcerated women.) [6] Padilla, M. “Woman Gave Birth in Denver Jail Cell Alone, Lawsuit Says,” New York Times, Sep. 1, 2019. [7] Li, D. “Video allegedly shows woman giving birth in Denver jail cell alone, with no assistance,” NBC U.S. News, Apr. 29. 2019. [8] Knittel, A. and C. Sufrin. "Maternal Health Equity and Justice for Pregnant Women Who Experience Incarceration." JAMA Network Open 3.8 (2020). A study in Ontario, Canada, coincided with a study done in Australia. [9] Sufrin, C., et al. "Pregnancy Outcomes in US Prisons, 2016–2017." p. 803-804. [10] Sridhar, S., R. Cornish and S. Fazel. "The Costs of Healthcare in Prison and Custody: Systematic Review of Current Estimates and Proposed Guidelines for Future Reporting." Frontiers in Psychiatry 9.716 (2018). [11] Kifer, M., Hemmens, C., Stohr, M. K. “The Goals of Corrections: Perspectives from the Line” Criminal Justice Review. 1 May 2003 [12] Perry, D. M. "Our Long, Troubling History of Sterilizing the Incarcerated." The Marshall Project: Sterilization of Women in Prison 26 July 2017. [13] Rachel Roth & Sara L. Ainsworth, If They Hand You a Paper, You Sign It: A Call to End the Sterilization of Women in Prison, 26 Hastings WOMEN's L.J. 7 (2015); See Skinner v. Oklahoma ex rel. Williamson, 316 U.S. 535 (1942) (procreation considered a fundamental right; fact pattern of male sterilization in prison based on type of crime.) [14] Sufrin, C., M. D. Creinin, J. C. Chang. “Incarcerated Women and Abortion Provision: A Survey of Correctional Health Providers.” Perspectives on Sexual and Reproductive Health. p. 6-11. 23 March 2009. [15] Kasdan, D. “Abortion Access for Incarcerated Women: Are Correctional Health Practices in Conflict with Constitutional Standards?” Guttmacher Institute. 26 March 2009. [16] Born Behind Bars. Season 1, Episode 5, “They Can Take Your Baby Away,” produced by Luke Ellis, Francis Gasparini, & Jen Wise, aired on 15 Nov. 2017 A&E Networks [17] Bick, J., & Dozier, M. (2008). Helping Foster Parents Change: The Role of Parental State of Mind. In H. Steele & M. Steele (Eds.), Clinical applications of the Adult Attachment Interview (pp. 452–470). New York: Guilford Press. [18]Sroufe, L. A., B. Egeland, E. A. Carlson, W. A. Collins. (2005). The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford Press. [19] Goshin, L. S., & Byrne, M. W. “Converging Streams of Opportunity for Prison Nursery Programs in the United States.” Journal of Offender Rehabilitation. 15 Apr 2009. [20] Babies Behind Bars. Dirs. W. Serrill and S. O'Brien. 2015. Another IWP pregnant woman is Taylor. At the time of the show, she was pregnant and expecting twins. In interviews throughout the episode, she expressed how her pregnancies in prison had put her in a better mood and felt beneficial to her. She had tried to sign up for the nursery program for her previous pregnancy, but her sentence was too long to get it. Her child was sent to live with a caregiver, and when Taylor was on probation, Taylor’s daughter didn’t want to be around Taylor. Taylor was so distraught that she messed up and went back, this time, pregnant with twins. After she was reincarcerated, she was able to be accepted into Wee Ones. She expressed to the camera man that the program might help her feel more like a mother so that when she gets out, she will have someone to care for. Taylor, Kara, and many other women depend on their children or their pregnancy for a purpose while behind bars. They relied on their babies to be a boon for them. [21] Babies Behind Bars. Dirs. W. Serrill and S. O'Brien. 2015. [22] Corley, C. "Programs Help Incarcerated Moms Bond with Their Babies in Prison." Criminal Justice Collaborative (2018). [23] Corley, C. "Programs Help Incarcerated Moms Bond with Their Babies in Prison." Criminal Justice Collaborative (2018). [24] Owen, B. & Crow, J. “Recidivism among Female Prisoners: Secondary Analysis of the 1994 BJS Recidivism Data Set” Department of Criminology California State University (2006) p. 28 [25] Prison Nursery Programs: Literature Review and Fact Sheet for CT. Diamond Research Consulting, 2012, www.cga.ct.gov/2013/JUDdata/tmy/2013HB-06642-R000401-Sarah Diamond - Director, Diamond Research Consulting-TMY.PDF. [26] New York Department of Correction Services (NYDOCS). (1993). Profile of Participants: The Bedford and Taconic Nursery Program in 1992. Albany, NY. Department of Correction Services.Rowland, M., & Watts, A. (2007). Washington State’s effort to the generational impact on crime. Corrections Today. Retrieved September 12, 2007, from http://www. aca.org/publications/pdf/Rowland_Watts_Aug07.pdf. [27] Carlson, J. R. (2001). Prison nursery 2000: A five-year review of the prison nursery at the Nebraska Correctional Center for Women. Journal of Offender Rehabilitation, 33, 75–97. [28] Carlson, J.R. [29] Little, B. "What Happens When a Woman Gives Birth Behind Bars?" A+E Networks, 29 October 2019. <https://www.aetv.com/real-crime/what-happens-when-a-woman-gives-birth-in-jail-or-prison>. [30] Margolies, J. K., & Kraft-Stolar, T. When “Free” Means Losing Your Mother: The Collision of Child Welfare and the Incarceration of Women in New York State 1, 9 (Correctional Association of N.Y. Women in Prison Project 2006) [31] Sufrin, C. Jailcare: Finding the Safety Net for Women Behind Bars. Berkeley: University of California Press, 2017. [32] Sufrin, C. Jailcare: p. 155. [33] Peart, M. S. & Knittel, A. 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