Journal articles on the topic 'New York (State). Psychiatric Institute of the State Hospitals'

IntroductionEffective, brief, low-cost interventions for suicide attempt survivors are essential to saving lives and achieving the goals of the National Strategy for Suicide Prevention and Zero Suicide. This study aims to examine the effectiveness of the Attempted Suicide Short Intervention Program (ASSIP) in averting suicide reattempts in the United States healthcare system, its psychological mechanisms as predicted by the Interpersonal Theory of Suicide, and the potential implementation costs, barriers and facilitators for delivering it.Methods and analysisThis study is a hybrid type 1 effectiveness–implementation randomised controlled trial (RCT). ASSIP is delivered at three outpatient mental healthcare clinics in New York State. Participant referral sites include three local hospitals with inpatient and comprehensive psychiatric emergency services, and outpatient mental health clinics. Participants include 400 adults who have had a recent suicide attempt. All are randomised to ‘Zero Suicide-Usual Care plus ASSIP’ or ‘Zero Suicide-Usual Care’. Randomisation is stratified by sex and whether the index attempt is a first suicide attempt or not. Participants complete assessments at baseline, 6 weeks, and 3, 6, 12 and, 18 months. The primary outcome is the time from randomisation to the first suicide reattempt. Prior to the RCT, a 23-person open trial took place, in which 13 participants received ‘Zero Suicide-Usual Care plus ASSIP’ and 14 completed the first follow-up time point.Ethics and disseminationThis study is overseen by the University of Rochester, with single Institutional Review Board (#3353) reliance agreements from Nathan Kline Institute (#1561697) and SUNY Upstate Medical University (#1647538). It has an established Data and Safety Monitoring Board. Results will be published in peer-reviewed academic journals, presented at scientific conferences, and communicated to referral organisations. Clinics considering ASSIP may use a stakeholder report generated by this study, including incremental cost-effectiveness data from the provider point of view.Trial registration numberNCT03894462.

Harvey S. Levin obtained his Bachelor’s degree from City College of New York, in New York city, Ph.D. in Clinical Psychology from the University of Iowa, in Iowa City, completed his internships in Clinical Neuropsychology and Pediatric Psychology at the University of Iowa Hospitals in Iowa City and Clinical Psychology, Psychiatry and Pediatrics at the Illinois Masonic Medical Center in Chicago, and his fellowship in Neuropsychology at University of Iowa Hospitals in Iowa City.Dr. Levin started his career in 1972 as Instructor with the Department of Psychology at the University of Iowa and transitioned to The University of Texas Medical Branch (UTMB) in Galveston, Texas, in 1974, where he began an internationally renowned career in clinical work, teaching, and, most of all, pioneering research on traumatic brain injury (TBI). He ultimately became the Chela and Jimmy Storm Distinguished Professor in Surgical Research, Division of Neurosurgery, Department of Surgery in 1987. After leaving Texas for two years to take a position with the University of Maryland Medical System and Shock Trauma Institute in Baltimore, he moved back to Houston Texas in 1995 and established the Cognitive Neuroscience Laboratory (CNL) within the Department of Physical Medicine & Rehabilitation at Baylor College of Medicine, which was supported by federal grants, including funding from the National Institutes of Health, Department of Defense, Department of Veterans Affairs, and Centers for Disease Control and Prevention, and numerous private foundations. The CNL integrated rehabilitation and neuroplasticity research with multimodality brain imaging, clinical and neuropsychological assessment, and fluid biomarkers. Dr. Levin was Professor with the Departments of Physical Medicine and Rehabilitation where he served as Director of Research (1995-2014), Pediatrics, and Neurosurgery at Baylor College of Medicine. He was also a Research Scientist and the Director of the Center of Excellence for Traumatic Brain Injury at the Michael E. DeBakey Veterans Affairs Medical Center (2008-2013), and Adjunct Professor with the Department of Psychology at Rice University in Houston, Texas.Dr. Levin’s research focused on investigating both acute and long-term outcomes of mild to severe TBI in civilian and military populations, including cognitive and behavioral sequelae in relation to neuropathology using advanced brain imaging modalities. He began prospective, longitudinal studies of adults and children who had sustained TBI associated with closed head trauma upon joining UTMB and developed, in collaboration with Drs O’Donnell and Grossman, the Galveston Orientation and Amnesia Test (GOAT). The GOAT was the first measure to assess post-traumatic amnesia and orientation following moderate to severe TBI, is still most widely used by the clinicians and researchers, and it has been translated to 16 languages. The original publication, “Levin HS, O’Donnell VM, Grossman RG. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J Nerv Ment Dis. 1979 Nov;167(11):675-84. doi: 10.1097/00005053-197911000-00004. PMID: 501342”, has over 1200 citations. This work continued with participation in the NINDS Traumatic Coma Data Bank and the organization of outcome assessments for NINDS-funded clinical trials of hypothermia to treat severe TBI. To monitor the quality of outcome data across performing sites, Dr. Levin and colleagues developed a code for the reliability of data collected and implemented the role of an outcome monitor who evaluated adherence to protocol across sites. Following establishment of the CNL, he pursued investigation of TBI outcomes across the lifespan using multimodality brain imaging and biomarkers, errorless learning, translational studies in collaboration with neuroscientists using animal models, and clinical trials of methylphenidate, progesterone, CDP-choline. Dr. Levin spent over 30 years researching neurobehavioral outcomes of head injury in children, starting with a small pilot study funded by the Shriners Hospital in 1991 and continuing with several cycles of a multicenter R01 grant funded by the National Institute of Health. In later years, he used his expertise as a member of several large consortiums, including the Long-term Impact of Military-Relevant Brain Injury Consortium \ Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) funded by the VA and DoD and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) funded by the NINDS.During his career, Dr. Levin authored and coauthored more than 400 articles in scientific journals and over 100 books, with one of them, “Levin, H. S., Benton, A. L., & Grossman, R. G. (1982). Neurobehavioral consequences of closed head injury. Oxford University Press, USA”, having over 1100 citation, as well as book chapters that advanced knowledge of TBI, epilepsy, neurodegenerative diseases, and other illnesses that affect brain functioning. He was also very active as a reviewer on federal grant panels and as an editor and reviewer for the Journal of Neurotrauma, Journal of Clinical and Experimental Neuropsychology, Archives of Physical Medicine & Rehabilitation, Neuropsychology, Journal of the International Neuropsychological Society, Lancet, JAMA, Pediatrics, and other top-cited journals. He served as president of the International Neuropsychological Society in 1989-1990. Dr. Levin was a recipient of numerous prestigious awards, including the Javits Neuroscience Investigator Award, the Jennett-Plum Award for Research on Traumatic Brain Injury, the Distinguished Career Award by the International Neuropsychological Society, the American Congress of Rehabilitation Gold Key Award, the Distinguished Lifetime Contribution to Neuropsychology Award from the National Academy of Neuropsychology, as well as awards from other head injury and psychological organizations, including the International Brain Injury Association, the National Head Injury Foundation, the North American Brain Injury Society, Texas Psychological Association, and the Defense and Veterans Brain Injury Center. In addition to his stellar scientific accomplishments, Dr. Levin trained, mentored, and provided supervision to interns, fellows, postdocs, residents, medical and psychology students. He was the Director of an NCMRR/NIH T32 Postdoctoral Research Program, and training supervisor in neuropsychology for Baylor College of Medicine and for the Memorial Hermann TIRR Neuropsychology Postdoctoral Fellowship Programs. A passionate educator, he taught classes at Baylor College of Medicine, the University of Houston, and the National and Kapodistrian University of Athens Medical School in Greece and served as an evaluator for the American Board of Clinical Neuropsychology/American Board of Professional Psychology. He was often invited as a lecturer at numerous scientific organizations.The main objective of this symposium is to provide an overview of the current state of research in TBI while highlighting Dr. Levin’s contributions to this field. The symposium will start with a brief overview of Dr. Levin’s career (Dr. Randall S. Scheibel), followed by presentations focused on the assessment of adult TBI, including posttraumatic amnesia (Dr. Felicia C. Goldstein), the current state of pediatric TBI (Dr. L. Ewing-Cobbs), and novel imaging in TBI (Dr. Erin D. Bigler). There will be a brief discussion session at the end lead by Dr. Elisabeth A. Wilde.

For neurologists and psychiatrists, this month's edition of CNS Spectrums contains both original research articles and review papers surrounding a central theme of enormous importance: how the environment can harm brain function and how the brain can repair itself. We are extremely fortunate to have Jeremy Coplan as our guest editor. Dr. Coplan, with whom I have enjoyed years of collaboration on many projects of mutual interest, is professor of psychiatry at the State University of New York (SUNY) Downstate Medical Center in Brooklyn and senior scientist in the Department of Clinical Psychobiology at the New York State Psychiatric Institute in New York City. Let me now summarize why I believe the area covered this month is so vital.

Cannabis is one of the most commonly elicited substances abused. It is easily accessible, inexpensive, and the ultimate gateway drug. Synthetic cannabinoid has been known to be packaged under numerous trade names such as “K2, spice, AK-47, Geeked up, Smacked, and Green Giant..etc”. K2 Abuse has been rising more recently in New York State, especially among lower socioeconomic areas and among younger male individuals. Clinicians should be educated and awareness should be increased regarding patient presentation, treatment, as well as management. Although, treatment is ultimately supportive therapy, long term management to prevent future abuse is of prime importance. Death is rare but there can be serious risks associated with K2 abuse.Case presentationPatient is a 36-year-old male with unknown PMH who presented with bizarre behavior and anxiety. Patient was uncooperative and portraying repetitive tangential thoughts. He was found agitated, screaming “I am king of the world, and I feel good”. The patient admits to waking up this morning and smoking marijuana and his last memory since then was being in the ambulance. The patient denies any psychiatric medical history but is unable to provide any further details. The patient's family reports unusual behavior in the past few days such as religious connotations, nonsensical rantings, and repetitive thoughts causing them to contact emergency medical services. The family also admits to depressive episodes as well as suicidal ideations found in his personal written lyrics. He admits to drinking 1 pint of various types of liquor well as 6+ beers per day for >15 years. He denies any history of smoking, although he does smoke marijuana daily as per family.On physical exam his vital signs were normal. Patient was tearful and exhibiting repetitive thoughts, despite having a somnolent general affect. The rest of the physical exam was within normal limits. Patient received intravenous crystalloid fluids, Haldol 5 mg IV, and Benzodiazepine IV. Pertinent laboratory findings is significant for elevated lactate 3.4, hypokalemia 2.2, and an elevated ammonia 53. Other laboratory findings were within normal limits. CXR and Head CT showed no significant findings and EKG was within normal limits.Hospital course complicated with aspiration pneumonia. Patient received a full course of antibiotic therapy. Blood and urine culture showed no growth through admission. Social worker and case manager were involved and patient was offered referral to chemical dependency programs which he refused. Patient was discharged in stable condition and asked to follow up with primary care physician.DiscussionThe recreational use of synthetic cannabinoids such as K2 has been on the rise especially in younger male individuals and in lower socioeconomic status neighborhoods. In turn, the number of admissions secondary to acute intoxication has been increasing in hospitals all over the nation. More recently, since the advent of synthetic cannabinoids, there has been two reported confirmed deaths in New York City associated with K2 abuse. This can be attributed the drugs widespread accessibility. Synthetic marijuana has been legally available in the internet, local smoke shops, and even convenience stores. K2 has been advertised as the new, legal, and more cost effective way to get “high”. The popularity of this new class of drug “fad” is increasing in popularity as an alternative to marijuana and will continue to be a growing health concern.The use of K2 and other synthetic forms of recreational substances has become an escalating problem in many institutions nationwide. Increasing awareness will allow for improved preparedness as well as provide further data on this situation. .

AbstractIntroductionWhen the SARS-Cov2 virus hit the New York and New Jersey metropolitan area in Spring 2020, hospitals and hospital workers were hit hard with a new unknown pathogen that either killed people or made them very ill. There were large numbers of severely ill patients that strained resources. Hospital workers had extraordinary stress with multiple additional patients, the need to use personal protective equipment (PPE) in short supply, and faced with a pathogen that had no treatments beyond care and support initially.MethodsWe surveyed our hospital workers in late Spring 2020 to identify the main stressors and find out what measures were helpful. An online anonymous survey included questionnaires about sleep, mood, outside stressors, helpful measures, and how they coped generally. All levels of hospital workers were surveyed. Resources were provided to all respondents.ResultsOver 240 individuals responded to the survey; most respondents were women (76%). ‘Workplace stressors’ topped the chart for 98 of our respondents. The worst workplace stressor that was cited was ‘irritable workforce,’ but ‘lack of ‘protocols’ and ‘shortage of PPE’ were also cited as stressors. ‘Other’ (not described) and ‘taking care of an ill relative’ were rated highly. Those who had ‘symptoms everyday:’ Anhedonia (loss of pleasure or interest), 13%; feeling down and hopeless, 12%; sleep disturbance, 41%; low energy, feeling tired, 29%; appetite disturbance, 26%; poor concentration and attention, 15%. Respondents told us what resources they used and what was most helpful; exercise was most frequently cited as helpful.Lessons Learned and DiscussionVarious resources for formal and informal mental health support were provided to all respondents at the time of survey. Our hospital mounted its own response with support services, as did our medical school and university. A "warm line" was available through the Department of Psychiatry from late March 2020; tip sheets and online groups were widely circulated; State Department of Health provided resources. There were formal peer support sessions and workers helped each other. Medical students provided child care, shopping, and transport. We learned that extra support for workers and more frequent rest and recharge time are important. A weekly "town hall" was instituted and a weekly update about the hospital and support in healthy activities are widely circulated to employees. Those with active PTSD (some were very disturbed by the number of deceased patients) were referred to professional providers. Hospitals need to be ready to deal with epidemics and pandemics more effectively in order to mitigate stress and support workers. Being prepared, not just with equipment, but with protocols in how to proceed should another pandemic come. We learned that listening to workers is important. Workers also need to know how valued they are.FundingDepartment of Psychiatry, New Jersey Medical School

AbstractIntroduction:Surge capacity is defined as a healthcare system's ability to rapidly expand beyond normal services to meet the increased demand for appropriate space, qualified personnel, medical care, and public health in the event of bioterrorism, disaster, or other large-scale, public health emergencies. There are many individuals and agencies, including policy makers, planners, administrators, and staff at the federal, state, and local level, involved in the process of planning for and executing policy in respect to a surge in the medical requirements of a population. They are responsible to ensure there is sufficient surge capacity within their own jurisdiction.Problem:The [US] federal government has required New York State to create a system of hospital bed surge capacity that provides for 500 adult and pediatric patients per 1 million population, which has been estimated to be an increase of 15–20% in bed availability. In response, the New York City Department of Health and Mental Hygiene (NYC DOH) has requested that area hospitals take an inventory of available beds and set a goal to provide for a 20% surge capacity to be available during a mass-casualty event or other conditions calling for increased inpatient bed availability.Methods:In 2003, under the auspices of the NYC DOH, the New York Institute of All Hazard Preparedness (NYIHP) was formed from four unaffiliated, healthcare facilities in Central Brooklyn to address this and other goals.Results:The NYIHP hospitals have developed a surge capacity plan to provide necessary space and utilities. As these plans have been applied, a bed surge capacity of approximately 25% was identified and created for Central Brooklyn to provide for the increased demand on the medical care system that may accompany a disaster. Through the process of developing an integrated plan that would engage a public health incident, the facilities of NYIHP demonstrate that a model of cooperation may be applied to an inherently fractioned medical system.

IntroductionMild cognitive impairment (MCI) is common in older adults and represents a high-risk group for progression to Alzheimer’s disease (AD). Medication trials in MCI have generally failed, but new discoveries with brain plasticity in ageing have led to the study of cognitive training as a potential treatment to improve cognitive abilities. Computerised cognitive training (CCT) involves computerised cognitive exercises that target specific cognitive abilities and neural networks to potentially improve cognitive functioning through neuroplasticity.Methods and analysisIn a two-site study (New York State Psychiatric Institute/Columbia University Medical Center and Duke University Medical Center), we will randomise 100 patients with MCI (Wechsler Memory Scale-III Logical Memory II score 0–11; Folstein Mini Mental State Examination ≥23) to home-based CCT (suite of exercises: memory, matching, spatial recognition, processing speed) or a home-based active control condition (computerised crossword puzzle training (CPT)) with 12 weeks of intensive training followed by regular booster sessions up to 78 weeks. All patients will receive standard neuropsychological and functional assessments in clinic as well as structural/functional brain MRI scans at study entry and endpoint. We will test if CCT, versus CPT, leads to improved cognitive functioning, transfers to functional ability and tasks of everyday life and impacts hippocampal volume changes and changes in the default mode network of the brain measured by resting-state functional MRI.Ethics and disseminationThe study will be conducted following ethics approval and written informed consent will be obtained from all subjects. Study results will be disseminated via publication, clinicaltrials.gov, media and conference presentations. This will be the first controlled long-term trial to evaluate the effects of home-based CCT versus computerised CPT on cognitive abilities and functional measures and neural outcomes as determined by MRI indices in patients with MCI. Positive results from trial may support further development of home-based CCT.Trial registration numberClinicalTrials.gov identifier (NCT03205709).

Mounting interest in Europe over the incorporation of the human biological model in the laboratory has been fuelled by scientific advances and the much improved accessibility to human tissue. The collection of tissue is complicated by a host of ethical considerations and lack of public awareness of the benefits of donation to research and education. In the United States, the International Institute for the Advancement of Medicine (IIAM) has been successful in networking the cooperation of organ banks, tissue banks and hospitals, to collect otherwise discarded anatomical gifts with consent from the donor or donor's next of kin for medical research applications. IIAM is a non-profit, non-transplant anatomic bank that is provisionally licensed in the state of New York- one of the first states to implement comprehensive licensing procedures. Over the last year, IIAM has been serving a growing number of investigators in Europe with both fresh and frozen preparations. However, the various logistical problems in transAtlantic transportation and economic considerations warrant the exploration of establishing a satellite bank in Europe that would entail a more efficient and cost effective service to this region. This permanent facility would have access to IIAM's frozen inventory of tissue and tissue-derived protein samples, and would serve to facilitate the provision of fresh tissue, cells and slices to European researchers requiring such materials for their studies.

IntroductionAfter infection, herpes simplex virus-1 (HSV1) becomes latent in the trigeminal ganglion and can enter the brain via retrograde axonal transport. Recurrent reactivation of HSV1 may lead to neurodegeneration and Alzheimer’s disease (AD) pathology. HSV1 (oral herpes) and HSV2 (genital herpes) can trigger amyloid beta-protein (Aβ) aggregation and HSV1 DNA is common in amyloid plaques. Anti-HSV drugs reduce Aβ and phosphorylated tau accumulation in cell-culture models. Cognitive impairment is greater in patients with HSV seropositive, and antiviral drugs show robust efficacy against peripheral HSV infection. Recent studies of electronic health records databases demonstrate that HSV infections increase dementia risk, and that antiviral medication treatment reduces this risk. The generic antiviral drug valacyclovir was superior to placebo in improving memory in a schizophrenia pilot trial but has not been tested in AD.Methods and analysisIn patients with mild AD who test positive for HSV1 or HSV2 serum antibodies, valacyclovir, repurposed as an anti-AD drug, will be compared with placebo (lactose pills) in 130 patients (65 valacyclovir and 65 placebo) in a randomised, double-blind, 78-week phase II proof-of-concept trial. Patients on valacyclovir, dose-titrated from 2 g to a targeted oral dose of 4 g daily, compared with placebo, are hypothesised to show smaller cognitive and functional decline, and, using18F-Florbetapir positron emission tomography (PET) and18F-MK-6240 PET imaging, to show less amyloid and tau accumulation, respectively. In the lumbar puncture subsample, cerebrospinal fluid acyclovir will be assayed to assess central nervous system valacyclovir penetration.Ethics and disseminationThe trial is being overseen by the New York State Psychiatric Institute Institutional Review Board (protocol 7537), the National Institute on Ageing, and the Data Safety Monitoring Board. Written informed consent is obtained for all subjects. Results will be disseminated via publication, clinicaltrials.gov, media and conferences.Trial registration numberClinicalTrials.gov identifier (NCT03282916) Pre-results.

In 1918 into a peasant family, was born A. A. Shalimov, who, after finishing school and technical school he enrolled in the Kuban medical Institute (1936-1941), he worked as a doctor in hospitals near Krasnodar, in Chita oblast (1941), in the cities of Bryansk and the eagle; chief surgeon of the Orel region (1949). In 1951, A. A. Shalimov returned to Bryansk, he defended his dissertation and received the title of Honored doctor of the RSFSR. Later A. A. Shalimov moved to Kharkov, he defended his doctoral dissertation (1957) and was appointed head of the Department of thoracic surgery and anesthesiology of the Ukrainian Institute of advanced training of physicians (1959), Director of the Kharkiv Institute of General and urgent surgery (1965), head of the Department of thoracoabdominal surgery of the Kiev Institute of improvement of doctors, as head of the surgical Department, the Director of Kiev research Institute of Hematology and blood transfusion (1970) and Kyiv Sri of clinical and experimental surgery (1971), chief surgeon of the Ministry of health of Ukraine (1980). A. Shalimov was elected a corresponding member of the Academy of Sciences of Ukraine (1969), academician of the National Academy of Sciences of Ukraine (1978). A. A. Shalimova awarded the title Hero of Socialist Labor of the USSR (1982), Hero of Ukraine with the order of Powers (2005). Alexander Shalimov 870 author of scientific papers, including 35 monographs, 112 inventions, he has trained 50 doctors and nearly 100 candidates of medical Sciences. A. A. Shalimov was awarded two orders of Lenin and red banner of Labor, order of the October Revolution, the order of the Ukrainian State (2005) and "For merits" of three degrees, medals and orders and medals of foreign States. Oleksandr Shalimov was a member of the Board of the Association of surgeons im. N. And. Pirogov, the International Association of surgeons, the all-Union scientific society of surgeons, gastroenterologists and cardiologists, Chairman of the Ukrainian Republican scientific society of surgeons, full member of the new York Academy of Sciences, editor-in-chief of the journal "Clinical surgery", Deputy of the Supreme Soviet of the Ukrainian SSR 8-10 convocations. The international chamber of the American biographical Institute, he was elected "Man of the year – 1997", awarded diploma of the International biographical centre of Cambridge University for achievements in medicine of the twentieth century. Died Alexander Shalimov February 28, 2006.

AbstractBackgroundThe authors developed a practical and clinically useful model to predict the risk of psychosis that utilizes clinical characteristics empirically demonstrated to be strong predictors of conversion to psychosis in clinical high-risk (CHR) individuals. The model is based upon the Structured Interview for Psychosis Risk Syndromes (SIPS) and accompanying clinical interview, and yields scores indicating one's risk of conversion.MethodsBaseline data, including demographic and clinical characteristics measured by the SIPS, were obtained on 199 CHR individuals seeking evaluation in the early detection and intervention for mental disorders program at the New York State Psychiatric Institute at Columbia University Medical Center. Each patient was followed for up to 2 years or until they developed a syndromal DSM-4 disorder. A LASSO logistic fitting procedure was used to construct a model for conversion specifically to a psychotic disorder.ResultsAt 2 years, 64 patients (32.2%) converted to a psychotic disorder. The top five variables with relatively large standardized effect sizes included SIPS subscales of visual perceptual abnormalities, dysphoric mood, unusual thought content, disorganized communication, and violent ideation. The concordance index (c-index) was 0.73, indicating a moderately strong ability to discriminate between converters and non-converters.ConclusionsThe prediction model performed well in classifying converters and non-converters and revealed SIPS measures that are relatively strong predictors of conversion, comparable with the risk calculator published by NAPLS (c-index = 0.71), but requiring only a structured clinical interview. Future work will seek to externally validate the model and enhance its performance with the incorporation of relevant biomarkers.

Abstract PURPOSE Multi-parametric MRI and artificial intelligence (AI) methods were previously used to predict peritumoral neoplastic cell infiltration and risk of future recurrence in glioblastoma, in single-institution studies. We hypothesize that important characteristics of peritumoral tissue heterogeneity captured, engineered/selected, and quantified by these methods relate to predictions generalizable in the multi-institutional ReSPOND (Radiomics Signatures for PrecisiON Diagnostics) consortium. METHODS To support further development, generalization, and clinical translation of our proposed method, we trained the AI model on a retrospective cohort of 29 de novo glioblastoma patients from the Hospital of the University of Pennsylvania (UPenn) (Male/Female:20/9, age:22-78 years) followed by evaluation on a prospective multi-institutional cohort of 84 glioblastoma patients (Male/Female:51/33, age:34-89 years) from Case Western Reserve University/University Hospitals (CWRU/UH, 25), New York University (NYU, 13), Ohio State University (OSU, 13), University Hospital Río Hortega (RH, 2), and UPenn (31). Features extracted from pre-resection MRI (T1, T1-Gd, T2, T2-FLAIR, ADC) were used to build our model predicting the spatial pattern of subsequent tumor recurrence. These predictions were evaluated against regions of pathology-confirmed post-resection recurrence. RESULTS Our model predicted the locations that later harbored tumor recurrence with sensitivity 83%, AUC 0.83 (99% CI, 0.73-0.93), and odds ratio 7.23 (99% CI, 7.09-7.37) in the prospective cohort. Odds ratio (99% CI)/AUC(99% CI) per institute were: CWRU/UH, 7.8(7.6-8.1)/0.82(0.75-0.89); NYU, 3.5(3.3-3.6)/0.84(074-0.93); OSU, 7.9(7.6-8.3)/0.8(0.67-0.94); RH, 22.7(20-25.1)/0.94(0.27-1); UPenn, 7.1(6.8-7.3)/0.83(0.76-0.91). CONCLUSION This is the first study that provides relatively extensive multi-institutional validated evidence that AI can provide good predictions of peritumoral neoplastic cell infiltration and future recurrence, by dissecting the MRI signal heterogeneity in peritumoral tissue. Our analyses leveraged the unique dataset of the ReSPOND consortium, which aims to develop and evaluate AI-based biomarkers for individualized prediction and prognostication, by moving from single-institution studies to generalizable, well-validated multi-institutional predictive biomarkers.

Abstract PURPOSE Glioblastoma is extremely infiltrative with malignant cells extending beyond the enhancing rim where recurrence inevitably occurs, despite aggressive multimodal therapy. We hypothesize that important characteristics of peritumoral tissue heterogeneity captured and analyzed by multi-parametric MRI and artificial intelligence (AI) methods are generalizable in the updated multi-institutional ReSPOND (Radiomics Signatures for PrecisiON Diagnostics) consortium and predictive of neoplastic infiltration and future recurrence. METHODS We used the most recent update of the ReSPOND consortium to evaluate and further refine generalizability of our methods with different scanners and acquisition settings. 179 de novo glioblastoma patients with available T1, T1Gd, T2, T2-FLAIR, and ADC sequences at pre-resection baseline and after complete resection with subsequent pathology-confirmed recurrence were included. To establish generalizability of the predictive models, training and testing of the refined AI model was performed through Leave-One-Institution-Out-Cross-Validation schema. The multi-institutional cohort consisted of the Hospital of the University of Pennsylvania (UPenn, 124), Case Western Reserve University/University Hospitals (CWRU/UH, 27), New York University (NYU, 13), Ohio State University (OSU, 13), and University Hospital Río Hortega (RH, 2). Features extracted from pre-resection MRI were used to build the model predicting the spatial pattern of subsequent tumor recurrence. These predictions were evaluated against regions of pathology-confirmed post-resection recurrence. RESULTS Our model predicted the locations that later harbored tumor recurrence with overall odds ratio (99% CI)/AUC (99% CI), 12.0(11.8-12.2)/0.80(0.76-0.85), and per institute, CWRU/UH, 11.0(10.7-11.3)/0.80 (0.64-0.97); NYU, 7.0(6.7-7.3)/0.78(0.56-1.00); OSU, 18.3(17.5-19.1)/0.83(0.54-1.00); RH, 40.0(35.3-45.5)/0.93(0.00-1.00); UPenn, 8.00(7.7-8.3)/0.80(0.75-0.84). CONCLUSION This study provides extensive multi-institutional validated evidence that machine learning tools can identify peritumoral neoplastic infiltration and predict location of future recurrence, by decrypting the MRI signal heterogeneity in peritumoral tissue. Our analyses leveraged the unique dataset of the ReSPOND consortium, which aims to develop and validate AI-based biomarkers for individualized prediction and prognostication and establish generalizability in a multi-institutional setting.

Abstract PURPOSE T2-FLAIR mismatch (T2FM) is a highly specific imaging biomarker for isocitrate dehydrogenase (IDH) mutation in low-grade gliomas. Previous T2FM studies are inconsistent for glioblastoma (GBM)/grade-4 glioma, partly due to low IDH-mutation prevalence in high-grade gliomas. We leveraged a large multi-institutional GBM/grade-4 glioma cohort to analyze the association of partial T2FM and IDH-mutation (T2-hyperintense, FLAIR-hypointense, nonenhancing, nonedema). METHODS We analyzed preoperative MRI of 1500 pathologically confirmed GBM/grade-4 gliomas with known IDH-mutation status from the ReSPOND consortium, consisting of the following institutions (sample size): Ivy GBM Atlas Project (33), Catalan Institute of Oncology (132), Case Western Reserve University/University Hospitals (132), New York University (55), Ohio State University (25), University of Pennsylvania (641), University Hospital Río Hortega (16), Yonsei University Health System (118), The Cancer Imaging Archive (93), Thomas Jefferson University (48), Tata Memorial Hospital (22), University of Pittsburgh Medical Center (156), and Washington University School of Medicine in St. Louis (57). Sequences were co-registered to a common anatomic atlas. Continuous variables were compared by t-test and categorical variables by Χ 2-test. RESULTS 71 (4.7%) were IDH-mutants, significantly younger (43±1 v. 62±12 years, p=5x10-37), and more likely to exhibit partial T2FM (20% v. 0.4%, p=1x10-43), frontal lobe predominance (68% v. 29%, p=7x10-12), nonenhancing components (T2/FLAIR-intermediate signal, nonedema; 45% v. 9%, p=1x10-22), and cystic components (smooth margins, no/minimal enhancement, homogeneous FLAIR suppression; 17% v. 3%, p=7x10-11) than IDH-wildtypes. 20 cases had partial T2FM (14 IDH-mutant, 6 IDH-wildtype). Sensitivity of partial T2FM for IDH-mutation was 19.7%, specificity 99.6%, positive predictive value 70%, and negative predictive value 96.1%. Subset analysis of 983 IDH-wildtypes with known MGMT methylation status (406 MGMT-hypermethylated) showed frontal lobe predominance was more common in MGMT-hypermethylated than MGMT-unmethylated (39.4% v. 24.3%, p=.02); other imaging characteristics did not significantly differ. CONCLUSIONS Partial T2FM is a highly specific imaging biomarker for IDH-mutation in GBM/grade-4 glioma.

Samizdat materials are a huge collection of documents of different genres that can be viewed in the context of the dissident phenomenon in the USSR. Only the latest decade saw the intensive growth of scientific interest to this phenomenon, and, therefore, these historical records require further interpretation and analysis; the latter became the main purposes of the monograph reviewed. The study combines both theoretical and historical aspects of studying Soviet samizdat. The term “samizdat” is understood in its wider sense, not only as fiction prohibited for publication, but also as a product of social, political, journalistic, human rights and other activities. At the same time, emphasis is placed on historical sources that allow documenting the human rights process. Samizdat is considered in three aspects: as a phenomenon of the 20th century supplementing official culture; as a kind of self-organization, self-reflection of society, a sign of intellectual reaction and an information channel; and as a historical source that makes it possible to study Soviet society and its reaction to state policy. This enables the author to present a representative and fairly complete picture of Russian samizdat. The notion “samizdat” is thoroughly analyzed, as well as the problem of the scientific classification of samizdat documents. The new classification system is demanded to be more detailed, presenting a complex structure, which takes into account various types and content of these historical sources. Working out a well-developed classification should ensure the use of available sources and their information potential. The book describes the sources of some varieties of samizdat documents: open letters, appeals and statements of protest, court proceedings, collections of documents. In a separate chapter, self-published magazines are analyzed as one of the most convincing manifestations of the various opposition movements organizational design. Particular attention is paid to the bulletin A Chronicle of Current Events, which has played an important role in reporting on human rights violations, disseminating the ideas of human rights defenders and maintaining links between human rights groups and organizations as a consolidating information center. The first issue of the Chronicle of 1968 is presented in the book as a holistic text, from the list of headings to the definition of the semantic strategy of the periodical, its tactics of layout and design, which allows us to correlate it with the legendary Herzen’s Kolokol [Bell] both in design and in its impact on public consciousness. The bulletin structure and its main sections were formed from the first issues: “Courts”, “Arrests”, “Extra-Judicial Prosecutions”, “Searches and Interrogations”, “In Prisons and Camps”, “In Psychiatric Hospitals”, “Persecution of Believers”, “Right to Leave”, “Jewish Movement”, “Through the Pages of the Soviet press”, “In Exile”, “Official Documents”, “Samizdat News”, etc. The analysis of other quite numerous samizdat magazines (Politicheskiy Dnevnik [Political Diary], Obshchestvennye Problemy [Social Problems], Veche, Vestnik Spaseniya [Herald of Salvation], Iskhod [Exodus], Vestnik Iskhoda [Herald of Exodus], Belaya Kniga Iskhoda [White Book of Exodus], etc.), including the “second culture” ones (37, Chasy [Clock], Obvodnoy Kanal [Bypass Channel], Metrodor, Summa [Sum], Nadezhda [Hope], etc.), allows the author to document the well-known statement of Igor Shafarevich that with all the various shades of independent thought in our country, the unifying principle was the feeling of lack of freedom. The author pays attention to historical discourse aimed at analyzing social and political processes via studying samizdat authors’ and developers’ biographies, as well as to the history of the texts. Biographies are given briefly, most often in the form of page footnotes, but their presence adds “humanity” to historical and documentary research (for example, biographies of V. Krasin, V. Chelidze, Yu. Shikhanovich, V. Rutminsky, Gr. Fedoseev, etc.). The book discusses the main varieties of social and political samizdat – “classic” and little-studied samizdat texts. Considerable attention is paid to “provincial” students’ literary and journalistic amateur periodicals of Sverdlovsk. The almanac Nashe Tvorchestvo [Our Creativity] (Ural State University, 1946–1949), Vskhody [Shoots], V Poiskakh [In Search] (Ural State University, 1956), the Ural Pedagogical Institute wall newspaper BOKS (Boevoy Organ Komsomol’skoy Satiry [Komsomol Satire Combat Organ], 1943–1960) are analyzed for the first time in the all-Union context. Student manuscript and typewritten magazines, a typical phenomenon for Soviet universities of that time, on the one hand, became the harbingers of political samizdat, on the other hand, a consequence of the creative and spiritual upsurge that caused the exposure of the personality cult. The book concludes with a brief bibliography on the Soviet samizdat history and an appendix including well-known examples of samizdat texts (“I Can’t Be Silent!” by P. Grigorenko, “The Final Word of the Accused Bukovsky”, “The White Book of Exodus” (1972)), as well as unique graphic jokes of BOKS.

I was born and raised in the old mining town of Barrio DAS (Don Andres Soriano), Lutopan, Toledo City where Atlas Consolidated Mining and Development Corp. (ACMDC) is situated. Dad started his practice in the company’s hospital as an EENT specialist in the early 60’s and was the ‘go to’ EENT Doc not only of nearby towns or cities (including Cebu City) but also the surrounding provinces in the early 70’s. In my elementary years, he was Assistant Director of ACMDC Hospital (we lived just behind in company housing, only a 3-minute walk). I grew interested in what my dad did, sometimes staying in his clinic an hour or so after school, amazed at how efficiently he handled his patients who always felt so satisfied seeing him. At the end of the day, there was always ‘buyot’ (basket) of vegetables, live chickens, freshwater crabs, crayfish, catfish or tilapia. I wondered if he went marketing earlier, but knew he was too busy for that (and mom did that) until I noticed endless lines of patients outside and remembered when he would say: “Being a doctor here - you’ll never go hungry!” I later realized they were PFs (professional fees) of his patients. As a company doctor, Dad received a fixed salary, free housing, utilities, gasoline, schooling for kids and a company car. It was the perfect life! The company even sponsored his further training in Johns-Hopkins, Baltimore, USA. A family man, he loved us so much and was a bit of a joker too, especially at mealtimes. Dad’s daily routine was from 8 am – 5 pm and changed into his tennis, pelota, or badminton outfit. He was the athlete, winning trophies and medals in local sports matches. Dad wanted me to go to the University of the Philippines (UP) High School in the city. I thought a change of environment would be interesting, but I would miss my friends. Anyway, I complied and there I started to understand that my dad was not just an EENT practicing in the Mines but was teaching in Cebu Institute of Medicine and Cebu Doctors College of Medicine (CDCM) and was a consultant in most of the hospitals in Cebu City. And still he went back up to the mountains, back to Lutopan, our mining town where our home was. The old ACMDC hospital was replaced with a new state-of-the-art hospital now named ACMDC Medical Center, complete with Burn Unit, Trauma center and an observation deck in the OR for teaching interns from CDCM. Dad enjoyed teaching them. Most of them are consultants today who are so fond of my dad that they always send their regards when they see me. My dad loved making model airplanes, vehicles, etc. and I realized I had that skill when I was 8 years old and I made my first airplane model. He used to build them out of Balsa wood which is so skillful. I can’t be half the man he was but I realized this hobby enhanced his surgical skills. My dad was so diplomatic and just said to get an engineering course before you become a pilot (most of dads brothers are engineers). I actually gave engineering a go, but after 1 ½ years I realized I was not cut out for it. I actually loved Biology and anything dealing with life and with all the exposure to my dad’s clinic and hospital activities … med school it was! At this point, my dad was already President of the ORL Central Visayas Chapter and was head of ENT Products and Hearing Center. As a graduate of the UP College of Medicine who finished Otorhinolaryngology residency with an additional year in Ophthalmology as one of the last EENTs to finish in UP PGH in the late 50’s, he hinted that if I finished my medical schooling in CDCM that I consider Otorhinolaryngology as a residency program and that UP-PGH would be a good training center. I ended up inheriting the ORL practice of my dad mostly, who taught me some of Ophthalmology outpatient procedures. Dad showed me clinical and surgical techniques in ENT management especially how to deal with patients beyond being a doctor! You don’t learn this in books but from experience. I learned a lot from my dad. Just so lucky I guess! He actually designed and made his own ENT Treatment Unit, which I’m still using to this day (with some modifications of my own). And he created a certain electrically powered ‘eye magnet’ with the help of my cousin (who’s an engineer now in Chicago) which can attract metallic foreign bodies from within the eyeball to the surface so they can easily be picked out – it really works! Dad loved to travel in his younger years especially abroad for conventions or just simply leisure or vacations, most of the time with my mom. But as he was getting older, travels became uncomfortable. His last travel with me was in 2012 for the AAO-HNS Convention in Washington DC. It was a great time as we then proceeded to a US Navy Airshow in nearby Virginia after the convention, meeting up with my brother who is retired from the USN. Then we took the train to New York and stayed with my sister who is a PICU nurse in NY Presbyterian. Then off to Missouri and Ohio visiting the National Museum of the US Air Force, the largest military aircraft museum in the world. For years, Dad had been battling with heredofamilial-hypercholesterolemia problem which took its toll on his liver and made him weak and tired but still he practiced and continued teaching and sharing his knowledge until he retired at the age of 80. By then, my wife and I would take him and my mom out on weekends, he loved to be driven around and eat in different places. I really witnessed and have seen how he suffered from his illness in his final years. But he never showed it or complained, never even wanted to use a cane! He didn’t want to be a burden to anyone. What most affected me was that my dad passed and I wasn’t even there. I had helped call for a physician to rush to the house and had oxygen cylinders to be brought for him as his end stage liver cirrhosis was causing cardio-pulmonary complications (non-COVID). Amidst all this I was the one admitted for 14 days because of COVID-19 pneumonia. My dad passed away peacefully at home as I was being discharged from the hospital. He was 88. I never reached him just to say good bye and cried when I reached home still dyspneic recovering from the viral pneumonia. I realized from my loved ones who told me that dad didn’t want me to stress out taking care of him, as I’ve been doing ever since, but instead to rest and recuperate myself. I cried again with that thought. In my view, he was not only a great Physician and Surgeon but also the greatest Dad. He lived a full life and touched so many lives with his treatments, charity services and teaching new physicians. It’s seeing, remembering and carrying on what he showed and taught us that really makes us miss him. I really love and miss my dad and with a smile on my face, I see he’s also happy to be with his brothers and sisters who passed on ahead. And that he’s rested. He is a man content, I remember he always said this, ‘ As long as I have a roof over my head and a bed to rest my back, I’m okay!”

Objective. To examine the bibliometric characteristics of high-cited publications (HCPs) on Obsessive-Compulsive Disorder (OCD). Design/Methodology/Approach. The Scopus database was searched to identify HCPs on OCD published from 2002 to 2021. Three-hundred and ninety-five (n=395) articles having at least 100 citations were included in the analysis. Quantitative and qualitative indicators were applied to measure and evaluate the research productivity and citation impact of authors from the most productive countries, organizations, and authors. The VOSviewer was used to visualize the collaborative interaction among the most productive countries, organizations, authors, and keywords. Results/Discussion. The 395 HCPs published on OCD during 2012-2021 were cited 75197 times. The authors from the United States (n = 216), United Kingdom (n = 59), Netherlands (n =37), and Canada (n=30) were the most productive. Clinical studies accounted for the largest publications share among publication types, followed by studies focusing on treatment, epidemiology, genetics, risk factors, pathophysiology, and complications. Among important keywords besides OCD, other most common keywords were anxiety (n=89), Cognitive Behavioural Therapy (n=87), Clomipramine (n=68), Fluoxetine (n=65), and Behavioural Therapy (n=53). The topmost productive organizations were the Harvard Medical School, USA (n=37), Massachusetts General Hospital, USA (n=36), Columbus University, USA (n-28), and New York State Psychiatric Institute, USA (n=27). The most productive authors were D. Mataix-Cols (Sweden)(n=21), followed by B.D. Greenberg (USA)(n=18), S.L. Rauch (USA)(n=17) and D.J. Stein (South Africa)(n=17). These 395 HCPs were published in 135 journals, with The American Journal of Psychiatry publishing many papers. Papers published in Neuroscience and Bio-Behavioral Reviews had the highest number of citations per paper (n=509.0). Conclusion. The present study suggests that most HCPs have emerged from the United States, are based on funded research, and have involved authors from more than one country. Originality/Value. This study presents significant results, in a more comprehensive manner, related to the high-cited publications (HCPs) on Obsessive-Compulsive Disorder (OCD).

Individuals with serious mental illness are particularly vulnerable to COVID-19. The New York State (NYS) Office of Mental Health implemented patient and staff rapid testing, quarantining, and vaccination to limit COVID-19 spread in 23 state-operated psychiatric hospitals between November 2020 and February 2021. COVID-19 infection rates in inpatients and staff decreased by 96% and 71%, respectively, and the NYS population case rate decreased by 6%. Repeated COVID-19 testing and vaccination should be priority interventions for state-operated psychiatric hospitals. (Am J Public Health. Published online ahead of print September 16, 2021:e1–e4. https://doi.org/10.2105/AJPH.2021.306444 )

In den USA ist derzeit der wachsende Missbrauch von medizinisch verordneten Opioiden ein viel diskutiertes Thema. Mark Olfson vom New York State Psychiatric Institute und Kollegen untersuchten über einen Zeitraum von 3 Jahren hinweg, ob der medizinische Cannabiseinsatz das Risiko für den nicht bestimmungsgemäßen Gebrauch von verordneten Opioiden verringert hat.

In den USA ist derzeit der wachsende Missbrauch von medizinisch verordneten Opioiden ein viel diskutiertes Thema. Mark Olfson vom New York State Psychiatric Institute und Kollegen untersuchten über einen Zeitraum von 3 Jahren hinweg, ob der medizinische Cannabiseinsatz das Risiko für den nicht bestimmungsgemäßen Gebrauch von verordneten Opioiden verringert hat.

AbstractObjectiveTo explore differences in costs and lengths of stay for cancer patients admitted to National Cancer Institute‐designated Comprehensive Cancer Centers, nondesignated academic medical centers, and community hospitals in New York State.Data SourcesWe use patient‐level data from the New York State Statewide Planning and Research Cooperative System Hospital Inpatient Discharges dataset for the years 2017–2019.Study DesignWe employ ordinary least squares and Poisson regressions to compare hospital costs and length of stay for cancer patients, controlling for hospital type, patient demographics, and patient health. Our key outcomes are differences in costs and lengths of stay.Data CollectionWe use data on patient demographics, total treatment costs, and lengths of stay for patients discharged from New York hospitals with cancer‐related diagnoses between 2017 and 2019.Principal FindingsWe determine that inpatient costs were 27% higher (95% CI 0.252, 0.285), but length of stay was 12% shorter (95% CI −0.131, −0.100), in Comprehensive Cancer Centers relative to community hospitals.ConclusionsThe results imply that, in New York State, Comprehensive Cancer Centers are a magnet for more complex oncology cases and administer more expensive treatments. That expertise, however, seems to be responsible for more efficient care delivery and thorough discharge planning, allowing for shorter average lengths of stay.

Amish Shah, M.D., M.P.H., an emergency medicine physician and former member of the Arizona House of Representatives, was awarded the 2024 APA Jacob K. Javits Public Service Award for his dedication to improving access to quality care, and his advocacy for mental health reform. The Javits Award is the American Psychiatric Association's (APA) highest honor for contributions to the field of mental health by a federal or state public official. “Not only in hospitals, but also in the Arizona House of Representatives, Dr. Shah has left his mark as a distinctly skilled and dedicated voice for mental health,” said APA President Petros Levounis, M.D., M.A., in a statement. “His tireless efforts include working across the aisle to pass legislation like ‘Jake's Law,’ promoting important mental health interventions such as the Collaborative Care Model and advocating for youth to more easily access mental health care services.” APA established the award in 1986 in honor of Sen. Jacob K. Javits, who represented New York state in the U.S. Senate from 1957 to 1981.

Background: Stimulants are highly effective in controlling symptoms of Attention-deficit/hyperactivity disorder (ADHD), but 30% of individuals with ADHD do not respond to them or cannot tolerate their side effects; thus, alternative treatment approaches need to be considered. Objectives: To evaluate the effect and safety of piracetam as an adjuvant therapy plus methylphenidate (MPH) in children with ADHD. Methods: Thirty-six children with ADHD (6-16 years old), admitted to three academic outpatient child psychiatric clinics in the second half of 2015, were randomly assigned to the “methylphenidate plus piracetam group” and the “methylphenidate plus placebo” group, in a double-blind, placebo-controlled study, for 6 weeks. The “Conner’s Parents’ Rating Scale-Revised (CPRS-R), Children Symptom Inventory-4 (CSI-4), Clinical Global Impression-Improvement scale (CGI-I), and Children’ Global Assessment Scale (CGAS) were completed at baseline and at the ends of the third and the sixth week, and the New York State Psychiatric Institute side effect forms were completed weekly, as outcome measures. Results: The level of improvement in CPRS-R, CSI-4, and CGI-I scales were significantly higher in the “methylphenidate plus piracetam” group compared with the “methylphenidate plus placebo” group. Side effects were not remarkable in any group. Conclusions: Piracetam as a short-term adjuvant treatment to methylphenidate can have considerable therapeutic effect and safety profile in children with ADHD and deserves further exploration to assess its potentialities in ADHD treatment.

AbstractObjectiveTo quantify the degree to which health care service area (HCSA) definitions captured hospitalizations and heterogeneity in social determinants of health (SDOH).Data Sources and Study SettingGeospatial data from the Centers for Medicare and Medicaid Services, the Census Bureau, and the Dartmouth Institute. Drive‐time isochrones from MapBox. Area Deprivation Index (ADI) data. 2017 inpatient discharge data from Arizona, Florida, Iowa, Maryland, Nebraska, New Jersey, New York, and Wisconsin, State Emergency Department Databases and State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; and Fee‐For‐Service Medicare data in 48 states.Study DesignCross‐sectional, descriptive analysis.Data Collection/Extraction MethodsThe capture rate was the percentage of inpatient discharges occurring in the same HCSA as the hospital. We compared capture rates for each HCSA definition for different populations and by hospital type. We measured SDOH heterogeneity using the coefficient of variation of the ADI among ZIP codes within each HCSA.Principal FindingsHCSA definitions captured a wide range of inpatient discharges, ranging from 20% to 50% for Public Use Microdata Areas (PUMAs) to 93%–97% for Metropolitan Statistical Areas (MSAs). Three‐quarters of inpatient discharges were from facilities within the same county as the patient's residential ZIP code, while nearly two‐thirds were within the same Hospital Service Area. From the hospital perspective, 74.7% of inpatient discharges originated from within a 30‐min drive and 90.1% within a 60‐min drive. Capture rates were the lowest for teaching hospitals. PUMAs and drive‐time‐based HCSAs encompassed more homogenous populations while MSAs, Commuting Zones, and Hospital Referral Regions captured the most variation.ConclusionsThe proportion of hospital discharges captured by each HCSA varied, with MSAs capturing the highest proportion of discharges and PUMAs capturing the lowest. Additionally, researchers face a trade‐off between capture rate and population homogeneity when deciding which HCSA to use.

Since the mid-eighties, personality and mood have undergone vigorous surveillance and repair across new populations in the United States. While government and the psy-complexes 1 have always had a stake in promoting citizen health, it is unique that, today, State, industry, and non-governmental organisations recruit consumers to act upon their own mental health. And while citizen behaviours in public spaces have long been fodder for diagnosis, the scope of behaviours and the breadth of the surveyed population has expanded significantly over the past twenty years. How has the notion of behavioural illness been successfully spun to recruit new populations to behavioural diagnosis and repair? Why is it a reasonable proposition that our personalities might be sick, our moods ill? This essay investigates the cultural promotion of a 'script' that assumes sick moods are possible, encourages the self-assessment of risk and self-management of dysfunctional mood, and has thus helped to create a new, adjustable subject. Michel Foucault (1976, 1988) contended that in order for subjects to act upon their selves -- for example, assess themselves via the behavioural health script -- we must view the Self as a construction, a work in progress that is alterable and in need of alteration in order for psychiatric action to seem appropriate. This conception of the self constitutes an extreme theoretical shift from the early modern belief (of Rousseau or Kant) that a core soul inhabited and shaped being, or the moral self.2 Foucault (1976) insisted that subjects are 'not born but made' through formal and informal social discourses that construct knowledge of the 'normal' self. Throughout the 19th century and the modern era, as medical, juridical, and psychiatric institutions gained increasing cultural capital, the normal self became allegedly 'knowable' through science. In turn, the citizen became 'professionalised' (Funicello 1993) -- answerable to these constructed standards, or subject to what Foucault termed biopower. In order to avoid punishments wrested upon the 'deviant' such as being placed in asylum or criminalised, citizens capitulated to social norms, and thus helped the State to achieve social order. 3 While 'technologies of power' or domination determined the conduct of individuals in the premodern era, 'technologies of the self' became prominent in the modern era.4 (Foucault, 'Technologies of the Self') These, explained Foucault, permit individuals to act upon their 'bodies, souls, thoughts, conduct and ways of being' to transform them, to attain happiness, or perfection, among other things (18). Contemporary psychiatric discourses, for example, call upon citizens to transform via self-regulation, and thus lessened the State's disciplinary burden. Since the mid-twentieth century, biopsychiatry has been embraced nationally, and played a key role in propagating self-disciplining citizens. Biopsychiatric logic is viewed culturally as common sense due to a number of occurrences. The dominant media have enthusiastically celebrated so-called biotechnical successes, such as sheep cloning and the development of better drugs to treat Schizophrenia. Hype has also surrounded newer drugs to treat depression (i.e. Prozac) and anxiety (i.e. Paxil), as well as the 'cosmetic' use of antidepressants to allegedly improve personality.5 Citizens, then, are enlisted to trust in psychiatric science to repair mood dysfunction, but also to reveal the 'true' self, occluded by biologically impaired mood. Suggesting that biopsychiatry's 'knowledge' of the human brain has revealed the human condition and can repair sick selves, these discourses have helped to launch the behavioural health script into the national psyche. The successful marketing of the script was also achieved by the diagnostic philosophy encouraged by revisions of Diagnostic and Statistical Manual or Mental Disorders(the DSM; these renovations increased the number of affective (mood) and personality diagnoses and broadened diagnostic criteria. The new DSMs 6 institutionalised the pathologisation of common personality and mood distresses as biological or genetic disorders. The texts constitute 'knowledge' of normal personality and behaviour, and press consumers toward biotechnical tools to repair the defunct self. Ian Hacking (1995) suggests that new moral concepts emerge when old ones acquire new connotations, thereby affecting our sense of who we are. The once moral self, known through introspection, is thus transformed via biopsychiatry into a self that is constructed in accordance with scientific 'knowledge'. The State and various private industries have a stake in promoting this Sick Self script. Promoting Diagnosis of the Sick Self Employing the DSM's broad criteria, research by the National Institute of Mental Health (NIMH), contends that a significant percentage of the population is behaviourally ill. The most recent Surgeon General report on Mental Health (from 1999) which also employed broad criteria, argues that a striking 50 million Americans are afflicted with a mental illness each year, most of which were non-major disorders affecting behaviour, personality and mood.7 Additionally, studies suggest that behavioural illness results in lost work days and increases demand for health services, thus constituting a severe financial burden to the State. Such studies consequently provide the State with ample reason to promote behavioural illness. In predicting an epidemic in behavioural illness and a huge increase in mental health service needs, the State has constructed health policy in accordance with the behavioural sickness script. Health policy embraces DSM diagnostic tools that sweep in a wide population by diagnosing risk as illness and links diagnosis with biotechnical recovery methods. Because criteria for these disorders have expanded and diagnoses have become more vague, however, over-diagnosis of the population has become common . 8 Depression, for example, is broadly defined to include moods ranging from the blues to suicidal ideation. Yet, the Sick Self script is ubiquitously embraced by NGO, industry, and State discourses, calling for consumer self-scrutiny and strongly promoting psychopharmaceuticals. These activities has been most successful; to wit: personality disorders were among the most common diagnoses of the 80's, and depression, which was a rare disorder thirty-five years ago, became the most common mental illness in the late 90's (Healy). Consumer Health Groups & Industry Promotions Health institutions and drug industries promote mood illness and market drug remedies as a means of profit maximisation. Broad spectrum diagnoses are, by definition, easy to sell to a wide population and create a vast market for recovery products. Pharmaceutical and insurance companies (each multibillion dollar industries), an expanding variety of self-help industries, consumer health web sites, and an array of psy-complex workers all have a stake in promoting the broad diagnosis of mood and behavioural disorders. 9 In so doing, consumer groups and the health and pharmaceutical industries not only encourage self-discipline (aligning themselves with State productivity goals), but create a vast, ongoing market for recovery products. Promoting Illness and Recovery So strong is the linkage between illness and recovery that pharmaceutical company Eli Lilly sells Prozac by promoting the broad notion of depression, rather than the drug itself. It does so through depression brochures (advertised on TV) and a web page that discusses depression symptoms and offers a depression quiz, instead of product information. Likewise, Psych Central, a typical informational health site, provides consumers standard DSM depression definitions and information (from the biopsychiatric-driven American Psychiatric Association (APA) or the NIMH, and liberal behavioural illness quizzes that typically over-diagnose consumers. 10The Psych Central site also lists a broad range of depression symptoms, while its FAQ link promotes the self-management of mood ailments. For example, the site directs those who believe that they are depressed and want help to contact a physician, obtain a diagnosis, and initiate antidepressant treatment. Such web sites, viewed as a whole, appear to deliver certified knowledge that a 'normal' mood exists, that mood disorders are common, and that abiding citizens should diagnosis and treat their mood ailment. Another essential component of the behavioural script is the suggestion that the modern self's mood is interminably sick. Because common mood distresses are fodder for diagnosis, the self is always at risk of illness, and requires vigilant self-scrutiny. The self is never a finished product. Moreover, mood sickness is insidious and quickly spirals from risk to full-blown disorder. 11 As such, behavioural illness requires on-going self-assessment. Finally, because mood sickness threatens social productivity and State financial solvency, a moral overtone is added to the mix -- good citizens are encouraged to treat their mood dysfunctions promptly, for the common good. The script thus constructs citizenship as a motive for behavioural self-scrutiny; as such, it can naturally recommend that individuals, rather than experts, take charge of the surveillance process. The recommendation of self-determined illness is also a sales feature of the script, appealing to the American ethic of individualism -- even, paradoxically, as the script proposes that science best directs us to our selves. Self-Managed Recovery Health institutions and industries that deploy this script recommend not only self-diagnosis, but also self-managed treatment as the ideal treatment. Health information web sites, for example, tend to displace the expert by encouraging consumers to pre-diagnose their selves (often via on-line quizzes) and to then consult an expert for formal diagnosis and to organise a treatment program. Like governmental heath organisation's web sites, these commonly link consumer-driven, broad-spectrum diagnosis to psycho-pharmaceutical treatment, primarily by listing drugs as the first line of treatment, and linking consumers to drug information. Unsurprisingly, pharmaceutical companies support or own many 'informational' sites. Depression-net.com, for example, is owned by Organon, maker of Remeron, an SSRI in competition with Prozac.12 Still, even sites that receive little or no funding tend to display drugs prominently; for example, Internet Mental Health, which accepts no drug funding lists drugs immediately after diagnosis on the sidebar. This trend illustrates the extent to which drugs are viewed by consumers as a first step in addressing all types of mood sicknesses. Consumer health sites, geared toward Internet users seeking health care information (estimated to be 43% of the 120 million users) promote the illness-recovery link more aggressively. Dr.koop.com, one of the most visited sites on the Internet, describes itself as 'consumer-focused' and 'interactive'. Yet, the homepage of this site tends to include 'news' stories that relay the success of drugs or report on new biopsychiatric studies in depression or mental health. Some consumer sites such as Consumer health sites, geared toward Internet users seeking health care information (estimated to be 43% of the 120 million users) promote the illness-recovery link more aggressively. Dr.koop.com, one of the most visited sites on the Internet, describes itself as 'consumer-focused' and 'interactive'. Yet, the homepage of this site tends to include 'news' stories that relay the success of drugs or report on new biopsychiatric studies in depression or mental health. Some consumer sites such as WebMD prominently display links to drugstores, (such as Drugstore.com), many of which are owned in part or entirely by pharmaceutical companies.13 Similar to the common practices of direct-to-consumer advertising, both informational and consumer sites by-pass the expert, promote recovery via drugs, and direct the consumer to a doctor in search of a prescription, rather than health care advice. State, informational and consumer web sites all help to construct certain populations as at-risk for behavioural sickness. The NIMH information page on depression -- uncanny in its likeness to consumer health and pharmaceutical sites -- utilises the DSM definition of depression and recommends the standard regime of diagnosis and biotechnical treatments (highlighting antidepressants) most appropriate for a diagnosis of major, rather than minor, depression. The site also elaborates the broad approach to mood illness, and recommends that women, children and seniors -- groups deemed at-risk by the broad criteria -- be especially scrutinised for depression. By articulating the broad DSM definition of depression, a generalisable 'self' -- anyone suffering common ailments including sadness, lethargy or weight change -- is deemed at risk of depression or other behavioural illness. At the same time, at-risk groups are constructed as populations in need of more urgent scrutiny, namely society's less powerful individuals, rather than middle-aged males. That is, society's decision-makers--psychiatric researchers, State policy-makers, pharmaceutical CEO's, (etc) are considered least at risk for having defunct selves and productivity functioning. Selling Mood Sickness These brief examples illustrate the standard presentation of behavioural illness information on the Web and from traditional resources such as mailings, brochures, and consumer manuals. Presenting the ideal self as knowable and achievable with the help of bio-psychiatric science, these discourses encourage citizens to self-scrutinise, self-define, and even self-manage the possibility of mood or behavioural dysfunction. Because the individual gathers information, determines her pre-diagnosis, and seeks out a recovery technology, the many choices involved in behavioural scrutiny make it appear to be a free and 'democratic' activity. Additionally, as individuals take on the role of the expert, self-diagnosing via questionnaires, the highly disciplinary nature of the behavioural diagnosis appears unthreatening to individual sovereignty. Thus, this technology of the self solves an age-old problem of capitalist democracy -- how to simultaneously instill citizen's faith in absolute individual liberty (as a source of good government), and, at the same time, the need to achieve the absolute governance of the individual (Miller). Foucault contended that citizens are brought into the social contract of citizenship not simply through social and governmental contracts but by processes of policing that become embedded in our notions of citizenship. The process of self-management recommended by the ubiquitous behavioural script functions smoothly as a technology of surveillance in this era, where the ideal self is known and repaired through biopsychiatric science, the democratic responsibility of a good citizen. The liberal contract has always entailed an exchange of rights for freedoms -- in Rousseau's terms 'making men free by making them subjects.' (Miller xviii) When we make ourselves subjects to ongoing behavioural scrutiny, the resulting Self is not freed, rather it is constrained by a perpetual sickness. Notes 1 This term is used in a Foucaultian sense, to refer to all those who work under and benefit or profit from the dominant biological model of psychiatry dominant since the 1950's in the U.S. 2 For more discussion, see Ian Hacking, Rewriting the Soul; Multiple Personality and the Sciences of Memory. (1995) 3 In his essay 'Technologies of the Self' (1988) Foucault outlines the four major types of technologies that function as practical reason and entice citizens to behave according to constructed social standards. Among these are technologies of production (that permit us to produce things), technologies of sign systems (permitting us to use symbols), and the technologies of power and self mentioned in the above text. Through these technologies, operations of individuals become highly regulated, some visible and some difficult to perceive. The less visible technologies of the self became essential to the smooth functioning of society in the modern era. 4 'Technologies' is used to refer to mechanisms and actions of institutions or simply social norms and habits, that work, ultimately, to govern the individual, or create behaviour that serves desires of the State and dominant social bodies. 5 Peter Kramer, author of the best-selling book Listening to Prozac (1995) contends that his patients using Prozac often credited the drug with helping their true personalities to surface. 6 The two revisions occurred in 1987 and 1994. 7 Of that group, only five percent of that group suffers a 'severe' form of mental illness (such as schizophrenia, or extreme form of bipolar or obsessive compulsive disorder), while the rest suffer less severe behavioural and mood disorders. Similar research (also based on broad criteria) was published throughout the 90's suggesting an American epidemic of behavioural illness; it was claimed that 17% of the population is neurotic, while 10-15% of the population (and 30-50% of those seeking care) was said to possess a personality disorder. (Hales and Hales, 1995) 8 The most widely assigned diagnoses in this category today are: depression, multiple personality, adjustment disorder, eating disorders and Attention Deficit Hyperactivity Disorder (ADHD), which have extremely broad criteria, and are easily assigned to a wide segment of the population. 9The quizzes offered at these sites are standard in psychiatry; the difference here is that these are consumer-conducted. Lilly uses the Zung Self-Assessment Tool, which asks 20 broad questions regarding mood, and overdiagnoses individuals with potential depression. By responding to vague questions such as 'Morning is when I feel the best', 'I notice that I am losing weight', and 'I feel downhearted, blue and sad' with the choice of 'sometimes', individuals are thereby pre-diagnosed with potential depression. (https://secure.prozac.com/Main/zung.jsp) Psych central uses the Goldberg Inventory that is similarly broad, consumer-operated, and also tends to overdiagnose. 10 The DSM and other psychiatric texts and consumer manuals commonly suggest that undiagnosed depression will lead, eventually, to full-blown major depression. While a minority of individuals who suffer ongoing episodes of major depression will eventually suffer chronic major depression, it has not been found that minor depression will snowball into major depression or chronic major depression. This in fact, is one of the many suspicions among researchers that is referred to as fact in psychiatric literature and consumer manuals. A similar case in point is the suggestion that depression is a brain disorder, when in fact, research has not determined biochemistry or genetics to be the 'cause' of major depression. 11 Increasingly, Pharmaceutical sites are indistinguishable from consumer sites, as in the case of Bristol-Meyers Squibb's depression page, (http://www.livinglifebetter.com/src/htdo...) offering a layperson's depression definition and, immediately thereafter, information on its antidepressant Serzone. 12 Like the informational and State sites, these also link consumers to depression information (generally NIMH, FDA or APA research), as well as questionnaires. References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C: American Psychiatric Press, Inc., 1994. Cruikshank, Barbara. The Will to Empower: Democratic Citizens and Other Subjects. Ithaca, NY: Cornell University Press, 1999. Foucault, Michel. Madness and Civilization; A History of Insanity in the Age of Reason. New York: Vintage, 1961. - - - . The Order of Things; An Archaeology of the Human Science., New York: Vintage, 1966. - - - . The History of Sexuality; An Introduction, Volume I. New York: Vintage, 1976. - - - . 'Technologies of the Self', Technologies of the Self; A Seminar with Michel Foucault. Ed. Luther Martin, Huck Gutman, and Patrick H. Hutton. Amherst: University of Amherst Press, 1988. 16-49. Funicello, Theresa. The Tyranny of Kindness; Dismantling the Welfare System to End Poverty in America. New York: Atlantic Monthly Press, 1993. Hales, Dianne R. and Robert E. Hales. Caring For the Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books, 1995. Healy, David. The Anti-Depressant Era. Cambridge, Mass: Harvard University Press, 1997. Kramer, Peter D. Listening to Prozac; A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. New York: Viking, 1993. Miller, Toby. The Well-Tempered Self; Citizenship, Culture and the Postmodern Subject. Baltimore: The John Hopkins University Press, 1993. - - - . Technologies of Truth: Cultural Citizenship and the Popular Media. Minneapolis: University of Minnesota Press, 1998. Office of the Surgeon General. Mental Health: A Report of the Surgeon General. 1999. <http://www.surgeongeneral.gov/library/me...> Rose, Nickolas. Governing the Soul; The Shaping of the Private Self. London: Routledge, 1990. Links http://www.drugstore.com http://psychcentral.com/library/depression_faq.htm http://www.wikipedia.com/wiki/DSM-IV http://www.nimh.nih.gov/publicat/depression.cfm http://www.livinglifebetter.com/src/htdocs/index.asp?keyword=depression_index http://my.webmd.com http://www.mentalhealth.com http://www.surgeongeneral.gov/library/mentalhealth/home.html http://www.prozac.com http://my.webmd.com/ http://www.a-silver-lining.org/BPNDepth/criteria_d.html#MDD http://psychcentral.com/depquiz.htm Citation reference for this article Substitute your date of access for Dn Month Year etc... MLA Style Gardner, Paula. "The Perpetually Sick Self" M/C: A Journal of Media and Culture 5.5 (2002). [your date of access] < http://www.media-culture.org.au/mc/0210/Gardner.html &gt. Chicago Style Gardner, Paula, "The Perpetually Sick Self" M/C: A Journal of Media and Culture 5, no. 5 (2002), < http://www.media-culture.org.au/mc/0210/Gardner.html &gt ([your date of access]). APA Style Gardner, Paula. (2002) The Perpetually Sick Self. M/C: A Journal of Media and Culture 5(5). < http://www.media-culture.org.au/mc/0210/Gardner.html &gt ([your date of access]).

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

Photo by Adhy Savala on Unsplash ABSTRACT During a crisis, when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, crisis standards of care are invoked to distribute scarce hospital space, staff, and supplies. When transitioning between conventional standards of care and crisis standards, hospitals may have to manage resources under scarcity constraints in an intermediate phase defined as the contingency phase. While much attention has been paid to the ethics of crisis standard of care protocols, contingency measures were more widely implemented, though little exists within the literature on the ethics of contingency measures or a clearly explicated contingency standard of care. This paper addresses three ethical issues with the current contingency response to COVID-19: the lack of formalization, the risks of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. INTRODUCTION When transitioning between conventional standards of care and crisis standards, or in situations where shortages do not immediately threaten care delivery, hospitals may have to manage scarce resources in an intermediate phase, known as the “contingency” phase.[1] While much attention has been paid to the ethics of crisis standards, less literature covers the ethics of contingency measures or a clearly explicated contingency standard of care. Many states and hospital systems do not have contingency standards of care to dictate allocation absent an event triggering crisis standards. Crisis standards of care, used when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, reflect ethical priorities relevant in times of shortage or other emergencies. These priorities include saving the most lives, the stewardship of scarce resources, and justice relating to equitable resource distribution.[2] Crisis standards of care delineate specialized allocation protocols and triage decision-making bodies at the institutional or state levels. Crisis standards of care require formal activation at the state level, and in the absence of clear triggers or governmental willingness to use them, hospitals may adopt informal strategies to manage allocation in the form of contingency measures. The contingency phase is defined by two simultaneous goals: prevent or stall crisis-level scarcity by managing limited resources and providing patient care that is functionally equivalent to usual care.[3] In other words, allocate scarce resources with no significant health consequences to patients. However, this is an unrealistic expectation: meeting a patient’s medical needs and allocating resources on the basis of scarcity instead of medical indications can be at odds, creating ethical tension. This paper addresses three ethical issues with the current contingency response stemming from this tension: the lack of formalization, the risk of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. l. Lack of Formalization One shortcoming of current contingency measures is that they fail to meet the same level of procedural detail and clarity as crisis standards. The early COVID-19 surges in Italy and France demonstrated the pitfalls of bedside allocation in the absence of procedural guidance. The acute scarcity of critical care resources forced doctors in these countries to make allocation decisions at the bedside, which often resulted in de facto age-based allocation as well as experiences of moral distress and shame among providers.[4] In France, medical allocation guidelines and statistics were never released to the public, raising concerns over the role of transparency in implementing crisis standards and triage guidelines and causing the public to question the trustworthiness of provider triage.[5] Though many states in the US have crisis standards of care that can be implemented in the case of a large-scale triage event, these measures vary widely. A 2020 review of 31 crisis standards of care in the US found that only 18 contained strong “ethical grounding,” 28 used “evidence-based clinical processes and operations,” 21 included “ongoing community and provider engagement, education, and communication,” and 16 had “clear indicators, triggers, and lines of responsibility.”[6] The need for standardization, public transparency, and guidelines for crisis standards of care to prevent bedside allocation has been widely recognized. However, these issues remain unresolved by public policy or legislative efforts during the contingency period before (or after) crisis standards apply. A recent public health study that observed triage team members in a high-fidelity triage simulation highlighted the challenges of making equitable frontline allocation decisions.[7] In the simulation, participants nudged patient priority status up or down depending on what they subjectively identified as morally relevant factors. Through the simulation, participants reported difficulty separating implicit biases about patient characteristics from their clinical judgment. In the absence of formal institutional or regional guidelines for allocation during contingency-level shortages, there are few to no procedural safeguards against biased, ad hoc, and non-transparent rationing. Without formalized or standardized contingency allocation guidance, providers are left to make bedside allocation decisions that are susceptible to individual biases and patterns of unintended discrimination. An example of this susceptibility is seen when hospitals allow patients who no longer benefit from ICU resources to continue occupying ICU beds. This is based on a first-come-first-served (FCFS) approach to bed allocation. FCFS is often a default for patient intake, which led to disparities in care access during the early COVID-19 pandemic. Media reports of hospitals with “plenty of space” being unwilling to accept patients from overwhelmed, lower-income hospitals illustrate that the FCFS default advantages those who could show up first to a particular hospital: often privileged, well-funded healthcare systems that were inaccessible to low-income communities.[8] FCFS is blind to several morally relevant factors, including the likelihood of survival to discharge, reciprocity (i.e. prioritizing healthcare workers), and varying degrees of access to healthcare. Therefore, it inappropriately privileges those in proximity to healthcare systems or with social connections enabling greater initial access to care.[9] During crisis standards of care, excessive mortality that would result from FCFS is mitigated through formalized system-wide triage protocols based on current patient health status and potential benefit from resources. Crisis and contingency standards may provide liability coverage for providers who reallocate critical care beds away from those who no longer benefit during periods of scarcity. This liability coverage shifts bed allocation away from an FCFS model, but only if the policy is well-defined, clearly established, and known to providers. Without a formal system to guide the process or transition from the usual method of allocation to the contingency period, contingency decisions about who gets a scarce resource may continue to operate on an implicit FCFS basis, even when approaching crisis levels of scarcity. Additionally, these decisions will fall unsustainably on individual providers or transfer center workers, leading to moral distress on the frontlines when hospitals are already strained. Lessons from the crisis and contingency responses during COVID-19 can improve future contingency responses. There are multiple ways of achieving equity during contingency allocation, ranging from hospital-level to state-level policy changes. State-wide policies and interventions to facilitate resource-sharing can relieve some of the scarcity burdens that hospitals may face during the contingency period. For example, moving ICU patients to lower levels of care once they have sufficiently recovered is a challenge for doctors, who often call other hospitals to find open beds. In these situations, providers who do not move patients who no longer benefit from ICU beds unknowingly reinforce the FCFS system in which those who arrive first keep the scarce beds, while those who arrive later or wait for one are disadvantaged by having limited access to them. State-wide patient transfer centers, often facilitated by state public health departments, present an alternative by balancing patient needs and bed distribution more equitably and efficiently than individual physicians do, as demonstrated following COVID-19 surges in hospitalization.[10] These centers aid not only in allocating open tertiary care beds, but also in identifying open beds at lower levels of care and assisting physicians with transferring out patients who can be safely downgraded and no longer benefit from tertiary care resources. However, the simplest solution is to encourage the creation of ethics guidance or protocols for contingency allocation at the hospital level. In hospitals, institutional ethics guidance can help providers navigate difficult decisions and conversations with patients. When providers face time-sensitive allocation decisions, like the allocation of open ICU beds, the guidance would be a useful tool for making transparent, principled, and ethically justified allocation decisions in real-time to mitigate the risk of ad hoc or implicit rationing. ll. Unsuited for Prolonged Resource Shortages Secondly, neither contingency nor crisis standards are currently designed to respond to prolonged strains on the healthcare system. Since the start of the pandemic, a prolonged period of staffing shortages began and is projected to persist.[11] However, both crisis and contingency standards assume that the system will eventually return to conventional standards of care. For example, as a contingency or crisis standard, many hospitals deferred elective surgeries to preserve limited resources for emergency and life-saving procedures. Massachusetts, for instance, issued a public health emergency order that required hospitals to defer 50 percent of all non-essential and non-urgent (elective) surgeries. This order demonstrates the use of this contingency measure in response to prolonged staffing and bed shortages.[12] However, the deferral of elective procedures can result in adverse long-term community health consequences. Medical conditions typically addressed through elective surgery, such as joint replacement surgeries for osteoarthritis patients, may worsen if delayed. This can result in greater numbers of acute emergencies, the need for more complex surgical procedures later, increased reliance on pain medications, and longer recovery times.[13] Without a greater understanding of long-term complications in community health, existing contingency strategies, such as the deferral of elective surgeries, may be unsuitable for prolonged shortages. This becomes a greater threat to patient safety when contingency measures inappropriately take the place of crisis standards, risking the long-term implementation of emergency measures designed for temporary use. Although some state emergency planning documents identify indicators and triggers for activating contingency and crisis operations,[14] this transition is not always clear in action. For example, New York did not implement crisis standards of care during the early COVID-19 pandemic despite being one of the hardest-hit cities in the US.[15] Other states, including California, Texas, and Florida, did not activate crisis standards of care, leaving hospitals to implement informal contingency measures that ultimately required allocation strategies very similar or identical to many crisis standards of care protocols.[16] Due to the hesitance to activate crisis standards, ad hoc contingency measures and bedside decision-making prevailed over formal triage protocols. If contingency measures are not set forth in objective documents and are inappropriately used in the place of crisis standards, these short-term measures may result in an unfair or non-transparent distribution of scarce resources. When shortages in space, staff, or supplies jeopardize the ability to provide necessary care for critically ill patients under a conventional standard of care, failures to activate crisis standards risk the inappropriate use of ad hoc contingency measures in their place. With clear contingency standards of care, the duration of an ad hoc approach could be limited. Crisis standards are defined and activated at the regional or state-wide level, but outside of hospital-specific resource limitations, there are generally no standardized indications or triggers for transitioning into and out of contingency measures. Leaving contingency needs to individual hospitals may seem beneficial but defining the contingency period at the hospital level and the crisis period at the state or regional level blurs the line about when it is appropriate for decision makers to activate crisis standards, risking delayed activation or failure to activate them at all. Therefore, it is important that state policies implement automatic triggers for activation that clearly delineate between contingency and crisis responses.[17] Automatic triggers based on validated metrics like remaining available resources can inform the appropriate decision makers about when they must activate crisis standards. These triggers should be transparent to the public, validated, and updated over time with evolving data. These automatic triggers would prevent confusion, inconsistent guidelines, and inequitable contingency allocation at the hands of distressed providers when crisis standards are needed. Defining when to begin crisis standards could help limit the length of the contingency period. This would protect against the inappropriate application of contingency measures to crisis-level scarcity and prolonged shortages that they could not sustainably ameliorate. lll. Potential to Exacerbate Health Disparities Inconsistencies in contingency allocation open the door to disparities in care and unequal distribution of scarcity burdens among different communities based on their location or health needs. This is a concern because it is unclear whether contingency measures can meet their goal of achieving functionally equivalent patient outcomes when resource allocation must be balanced with patient-centered care.[18] The care under contingency standards is meant to be functionally equivalent to regular care. The definition assumes (or may wrongly suggest) that any contingency strategy in place to avoid critical scarcity has no significant impact on patient outcomes. While functional equivalence is attainable, there is currently little research into which contingency measures achieve functionally equivalent outcomes and which patient groups may be disproportionately affected by harmful resource allocation strategies. Although the transition from contingency standards to crisis standards is defined by the inability to provide functionally equivalent care, the difference in practice may merely be a distinction between visible, immediate sacrifices to patient well-being during crises and less-obvious, long-term decrements in community health due to protracted contingency care alterations. Two common contingency measures are cause for concern over disparate patient outcomes and the attainability of functional equivalence. First, restricting emergency room visits by the patient’s degree of need has worrying consequences. In late 2021 and early 2022, hospitals in Massachusetts faced widespread staffing shortages, leading to an emergency order that restricted emergency visits to emergency needs.[19] While this order is a reasonable method of allocating limited staff in the emergency department during severe shortages, it is doubtful that the outcomes of this restriction were equivalent to usual care. Health issues that are soon-to-be emergencies are filtered out until they worsen, resulting in patients overflowing to urgent care clinics or presenting to ERs with more severe forms of sicknesses later on. Given the empirical evidence demonstrating ER treatment and admission disparities that disadvantage Black and Hispanic patients, such a measure would only exacerbate these disparities by further limiting access to needed care.[20] Second, altered staffing ratios, which stretch a limited number of providers to meet patient needs during a staffing shortage, are another concerning yet common contingency measure. Staffing allocation is often viewed similarly to the allocation of space and medical equipment, such that contingency alterations to staffing operations may not seem like they significantly jeopardize patient care quality and outwardly appear functionally equivalent.[21] However, lower ratios of qualified nurses are associated with poor outcomes such as higher inpatient mortality[22] and lower survival rates of in-hospital cardiac arrest for Black patients.[23] These examples highlight the strong potential for contingency measures to amplify social health disparities, particularly when adopted over a prolonged time frame. Lowered standards of care in crisis allocation disproportionately impact racial and ethnic minorities.[24] For example, crisis standards of care used clinical scoring systems that were not developed or validated for crisis triage to prioritize access to life-saving treatments during the COVID-19 pandemic. This practice actively gives rise to racial health disparities and discrimination against disabled patients.[25] Not only were the standards inequitable in practice, but they varied widely from state to state and sometimes even from hospital to hospital, creating disparities across and within geographic regions.[26] If contingency measures are similarly implemented across hospitals or hospital departments without standardization or advance planning to ensure equitable outcomes, it is likely that the burden of a lower standard of care will fall primarily on disadvantaged patient groups and racial minorities. However, standardization alone may be insufficient. Other factors like varying levels of details on patients’ charts between hospitals could produce unfair outcomes if used to determine patient admission or transfer priority, even if the criteria for admissions and transfers are consistent. Thus, ongoing monitoring for unintended patterns of disparity must accompany standardization to ensure that blind spots in the allocation process are identified and corrected. Bioethics has long been preoccupied with the micro-allocation of limited resources within hospitals instead of confronting the structural inequities that underlie broader scarcity and patient needs. The traditional dilemma of allocating limited hospital resources among a certain number of patients overlooks questions about how other resources have already been allocated, which patients were present at the hospital in the first place, where hospitals have (and have not) been built, and whether previous allocation strategies created bias in the broader distribution of resources. Therefore, to achieve fairness, bioethicists must pay attention to aspects of the broader distribution of resources, such as social determinants of health and the allocation of preventative resources at the public health level. One strategy for measuring and addressing these disparities is the Area Deprivation Index (ADI). The ADI quantifies the effects of race, class, and socioeconomic background by geographic region for use in public health research and the prioritization of resources.[27] It has shown promise in identifying geographic regions in need of targeted community health efforts for diabetes management based on electronic patient health records.[28] The ADI and similar tools would be useful in proactively deciding how to allocate public health resources when hospitals are strained. Moreover, through using population health and resource data, public health organizations may forecast contingency shortages allowing for the adoption of early measures to mitigate health disparities that might otherwise be amplified from hospital-level contingency allocation decisions. CONCLUSION Meeting community health needs during periods of contingency scarcity, both before and after crisis standards of care apply, will require contingency standards of care rather than a bedside ad hoc distribution of scarce resources. While it is not inherently ethically unjustifiable for hospitals to adopt measures that may lower the standard of care during contingency standards, the necessity of these measures requires that bioethicists consider how equity, transparency, and the overall aim of functional equivalence can best be achieved under conditions of scarcity. The long-term health consequences of existing contingency measures, the potential for ad hoc and inconsistent allocation of scarce resources, and the need for consensus about when it becomes appropriate to make the formal transition to crisis standards of care demand further consideration. Because contingency measures will likely amplify existing disparities as crisis standards have, hospital-level management of scarcity is inadequate. Public health measures should be adopted in parallel to anticipate and manage health needs at the community or state level when resources are strained. - [1] Altevogt, B. M., Stroud, C., Hanson, S. L., Hanfling, D., & Gostin, L. O. (2009). Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. The National Academies Press. https://doi.org/10.17226/12749 [2] Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine, 382(21), 2049–2055. https://doi.org/10.1056/NEJMsb2005114 [3] Alfandre, D., Sharpe, V. A., Geppert, C., Foglia, M. B., Berkowitz, K., Chanko, B., & Schonfeld, T. (2021). Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures. The American Journal of Bioethics, 21(8), 4–16. https://doi.org/10.1080/15265161.2021.1925778 [4] Rosenbaum, L. (2020). Facing Covid-19 in Italy—Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. New England Journal of Medicine, 382(20), 1873–1875. https://doi.org/10.1056/NEJMp2005492 [5] Orfali, K. (2020). What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France. Journal of Bioethical Inquiry, 17(4), 675–679. https://doi.org/10.1007/s11673-020-10059-y [6] Romney, D., Fox, H., Carlson, S., Bachmann, D., O’Mathuna, D., & Kman, N. (2020). Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents. Disaster Medicine and Public Health Preparedness, 14(5), 677–683. https://doi.org/10.1017/dmp.2020.101 [7] Butler, C. R., Webster, L. B., Diekema, D. S., Gray, M. M., Sakata, V. L., Tonelli, M. R., & Vranas, K. C. (2022). Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Network Open, 5(4), e227639. https://doi.org/10.1001/jamanetworkopen.2022.7639 [8] Dwyer, J. (2020, May 14). One Hospital Was Besieged by the Virus. Nearby Was ‘Plenty of Space.’—The New York Times. The New York Times. https://www.nytimes.com/2020/05/14/nyregion/coronavirus-ny-hospitals.html [9] Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. Lancet (London, England), 373(9661), 423–431. https://doi.org/10.1016/S0140-6736(09)60137-9 [10] Mitchell, S. H., Rigler, J., & Baum, K. (2022). Regional Transfer Coordination and Hospital Load Balancing During COVID-19 Surges. JAMA Health Forum, 3(2), e215048. https://doi.org/10.1001/jamahealthforum.2021.5048 [11] ASPE. (2022, May 3). Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce: Challenges and Policy Responses. ASPE. https://aspe.hhs.gov/reports/covid-19-health-care-workforce [12] Executive Office of Health and Human Services. (2021). Baker-Polito Administration Provides COVID-19 Update on Mask Advisory, Hospital Support | Mass.gov. https://www.mass.gov/news/baker-polito-administration-provides-covid-19-update-on-mask-advisory-hospital-support [13] The Lancet Rheumatology. (2021). Too long to wait: The impact of COVID-19 on elective surgery. The Lancet Rheumatology, 3(2), e83. https://doi.org/10.1016/S2665-9913(21)00001-1 [14] For an example of transition planning between crisis and contingency standards, see Minnesota Department of Health. (2021). Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions in Pervasive or Catastrophic Public Health Events with Medical Surge Implications (Minnesota Crisis Standards of Care). https://www.health.state.mn.us/communities/ep/surge/crisis/framework_transitions.pdf [15] Powell, T., & Chuang, E. (2020). COVID in NYC: What We Could Do Better. The American Journal of Bioethics, 20(7), 62–66. https://doi.org/10.1080/15265161.2020.1764146 [16] Persoff, J., & Wynia, M. K. (2021). Ethically Navigating the Murky Waters of “Contingency Standards of Care.” The American Journal of Bioethics, 21(8), 20–21. https://doi.org/10.1080/15265161.2021.1939810 [17] Board on Health Sciences Policy & Institute of Medicine. (2013). Indicators and Triggers. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK202381/ [18] Frith, L., Draper, H., Fovargue, S., Baines, P., Redhead, C., & Chiumento, A. (2021). Neither ‘Crisis Light’ nor ‘Business as Usual’: Considering the Distinctive Ethical Issues Raised by the Contingency and Reset Phases of a Pandemic. The American Journal of Bioethics, 21(8), 34–37. https://doi.org/10.1080/15265161.2021.1940363 [19] Rosseau, M. (2022, January 14). New emergency orders issued to help understaffed Mass. Hospitals. Boston.Com. https://www.boston.com/news/coronavirus/2022/01/14/new-emergency-orders-issued-to-help-understaffed-mass-hospitals/ [20] Zhang, X., Carabello, M., Hill, T., Bell, S. A., Stephenson, R., & Mahajan, P. (2020). Trends of Racial/Ethnic Differences in Emergency Department Care Outcomes Among Adults in the United States From 2005 to 2016. Frontiers in Medicine, 7. https://www.frontiersin.org/articles/10.3389/fmed.2020.00300 [21] Hick, J. L., Hanfling, D., & Wynia, M. (2022). Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. The Joint Commission Journal on Quality and Patient Safety. https://doi.org/10.1016/j.jcjq.2022.02.003 [22] Musy, S. N., Endrich, O., Leichtle, A. B., Griffiths, P., Nakas, C. T., & Simon, M. (2021). The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study. International Journal of Nursing Studies, 120, 103950. https://doi.org/10.1016/j.ijnurstu.2021.103950 [23] Brooks Carthon, M., Brom, H., McHugh, M., Sloane, D. M., Berg, R., Merchant, R., Girotra, S., & Aiken, L. H. (2021). Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests. Medical Care, 59(2), 169–176. https://doi.org/10.1097/MLR.0000000000001464 [24] Annas, G. J., & Crosby, S. S. (2021). Standard Racism: Trying to Use “Crisis Standards of Care” in the COVID-19 Pandemic. The American Journal of Bioethics, 21(8), 1–3. https://doi.org/10.1080/15265161.2021.1941424 [25] Wynia, M. K., & Sottile, P. D. (2020). Ethical Triage Demands a Better Triage Survivability Score. The American Journal of Bioethics, 20(7), 75–77. https://doi.org/10.1080/15265161.2020.1779412 [26] Fink, S. (2020). Ethical Dilemmas in Covid-19 Medical Care: Is a Problematic Triage Protocol Better or Worse than No Protocol at All? The American Journal of Bioethics, 20(7), 1–5. https://doi.org/10.1080/15265161.2020.1788663 [27] Knighton, A. J., Savitz, L., Belnap, T., Stephenson, B., & VanDerslice, J. (2016). Introduction of an Area Deprivation Index Measuring Patient Socioeconomic Status in an Integrated Health System: Implications for Population Health. EGEMS (Washington, DC), 4(3), 1238. https://doi.org/10.13063/2327-9214.1238 [28] Kurani, S. S., Lampman, M. A., Funni, S. A., Giblon, R. E., Inselman, J. W., Shah, N. D., Allen, S., Rushlow, D., & McCoy, R. G. (2021). Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. JAMA Network Open, 4(12), e2138438. https://doi.org/10.1001/jamanetworkopen.2021.38438

Introduction Most developed countries, including Australia, have a strong focus on national, state and local strategies for emergency management and response in the face of disasters and crises. This framework can include coping with catastrophic dislocation, service disruption, injury or loss of life in the face of natural disasters such as major fires, floods, earthquakes or other large-impact natural events, as well as dealing with similar catastrophes resulting from human actions such as bombs, biological agents, cyber-attacks targeting essential services such as communications networks, or other crises affecting large populations. Emergency management frameworks for crisis and disaster response are distinguished by their focus on the domestic context for such events; that is, how to manage and assist the ways in which civilian populations, who are for the most part inexperienced and untrained in dealing with crises and disasters, are able to respond and behave in such situations so as to minimise the impacts of a catastrophic event. Even in countries like Australia that demonstrate a strong public commitment to cultural pluralism and social cohesion, ethno-cultural diversity can be seen as a risk or threat to national security and values at times of political, natural, economic and/or social tensions and crises. Australian government policymakers have recently focused, with increasing intensity, on “community resilience” as a key element in countering extremism and enhancing emergency preparedness and response. In some sense, this is the result of a tacit acknowledgement by government agencies that there are limits to what they can do for domestic communities should such a catastrophic event occur, and accordingly, the focus in recent times has shifted to how governments can best help people to help themselves in such situations, a key element of the contemporary “resilience” approach. Yet despite the robustly multicultural nature of Australian society, explicit engagement with Australia’s cultural diversity flickers only fleetingly on this agenda, which continues to pursue approaches to community resilience in the absence of understandings about how these terms and formations may themselves need to be diversified to maximise engagement by all citizens in a multicultural polity. There have been some recent efforts in Australia to move in this direction, for example the Australian Emergency Management Institute (AEMI)’s recent suite of projects with culturally and linguistically diverse (CALD) communities (2006-2010) and the current Australia-New Zealand Counter-Terrorism Committee-supported project on “Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism” (Grossman and Tahiri), which I discuss in a longer forthcoming version of this essay (Grossman). Yet the understanding of ethno-cultural identity and difference that underlies much policy thinking on resilience remains problematic for the way in which it invests in a view of the cultural dimensions of community resilience as relic rather than resource – valorising the preservation of and respect for cultural norms and traditions, but silent on what different ethno-cultural communities might contribute toward expanded definitions of both “community” and “resilience” by virtue of the transformative potential and existing cultural capital they bring with them into new national and also translocal settings. For example, a primary conclusion of the joint program between AEMI and the Australian Multicultural Commission is that CALD communities are largely “vulnerable” in the context of disasters and emergency management and need to be better integrated into majority-culture models of theorising and embedding community resilience. This focus on stronger national integration and the “vulnerability” of culturally diverse ethno-cultural communities in the Australian context echoes the work of scholars beyond Australia such as McGhee, Mouritsen (Reflections, Citizenship) and Joppke. They argue that the “civic turn” in debates around resurgent contemporary nationalism and multicultural immigration policies privileges civic integration over genuine two-way multiculturalism. This approach sidesteps the transculturational (Ortiz; Welsch; Mignolo; Bennesaieh; Robins; Stein) aspects of contemporary social identities and exchange by paying lip-service to cultural diversity while affirming a neo-liberal construct of civic values and principles as a universalising goal of Western democratic states within a global market economy. It also suggests a superficial tribute to cultural diversity that does not embed diversity comprehensively at the levels of either conceptualising or resourcing different elements of Australian transcultural communities within the generalised framework of “community resilience.” And by emphasising cultural difference as vulnerability rather than as resource or asset, it fails to acknowledge the varieties of resilience capital that many culturally diverse individuals and communities may bring with them when they resettle in new environments, by ignoring the question of what “resilience” actually means to those from culturally diverse communities. In so doing, it also avoids the critical task of incorporating intercultural definitional diversity around the concepts of both “community” and “resilience” used to promote social cohesion and the capacity to recover from disasters and crises. How we might do differently in thinking about the broader challenges for multiculturalism itself as a resilient transnational concept and practice? The Concept of Resilience The meanings of resilience vary by disciplinary perspective. While there is no universally accepted definition of the concept, it is widely acknowledged that resilience refers to the capacity of an individual to do well in spite of exposure to acute trauma or sustained adversity (Liebenberg 219). Originating in the Latin word resilio, meaning ‘to jump back’, there is general consensus that resilience pertains to an individual’s, community’s or system’s ability to adapt to and ‘bounce back’ from a disruptive event (Mohaupt 63, Longstaff et al. 3). Over the past decade there has been a dramatic rise in interest in the clinical, community and family sciences concerning resilience to a broad range of adversities (Weine 62). While debate continues over which discipline can be credited with first employing resilience as a concept, Mohaupt argues that most of the literature on resilience cites social psychology and psychiatry as the origin for the concept beginning in the mid-20th century. The pioneer researchers of what became known as resilience research studied the impact on children living in dysfunctional families. For example, the findings of work by Garmezy, Werner and Smith and Rutter showed that about one third of children in these studies were coping very well despite considerable adversities and traumas. In asking what it was that prevented the children in their research from being negatively influenced by their home environments, such research provided the basis for future research on resilience. Such work was also ground-breaking for identifying the so-called ‘protective factors’ or resources that individuals can operationalise when dealing with adversity. In essence, protective factors are those conditions in the individual that protect them from the risk of dysfunction and enable recovery from trauma. They mitigate the effects of stressors or risk factors, that is, those conditions that predispose one to harm (Hajek 15). Protective factors include the inborn traits or qualities within an individual, those defining an individual’s environment, and also the interaction between the two. Together, these factors give people the strength, skills and motivation to cope in difficult situations and re-establish (a version of) ‘normal’ life (Gunnestad). Identifying protective factors is important in terms of understanding the particular resources a given sociocultural group has at its disposal, but it is also vital to consider the interconnections between various protective mechanisms, how they might influence each other, and to what degree. An individual, for instance, might display resilience or adaptive functioning in a particular domain (e.g. emotional functioning) but experience significant deficits in another (e.g. academic achievement) (Hunter 2). It is also essential to scrutinise how the interaction between protective factors and risk factors creates patterns of resilience. Finally, a comprehensive understanding of the interrelated nature of protective mechanisms and risk factors is imperative for designing effective interventions and tailored preventive strategies (Weine 65). In short, contemporary thinking about resilience suggests it is neither entirely personal nor strictly social, but an interactive and iterative combination of the two. It is a quality of the environment as much as the individual. For Ungar, resilience is the complex entanglements between “individuals and their social ecologies [that] will determine the degree of positive outcomes experienced” (3). Thinking about resilience as context-dependent is important because research that is too trait-based or actor-centred risks ignoring any structural or institutional forces. A more ecological interpretation of resilience, one that takes into a person’s context and environment into account, is vital in order to avoid blaming the victim for any hardships they face, or relieving state and institutional structures from their responsibilities in addressing social adversity, which can “emphasise self-help in line with a neo-conservative agenda instead of stimulating state responsibility” (Mohaupt 67). Nevertheless, Ungar posits that a coherent definition of resilience has yet to be developed that adequately ‘captures the dual focus of the individual and the individual’s social ecology and how the two must both be accounted for when determining the criteria for judging outcomes and discerning processes associated with resilience’ (7). Recent resilience research has consequently prompted a shift away from vulnerability towards protective processes — a shift that highlights the sustained capabilities of individuals and communities under threat or at risk. Locating ‘Culture’ in the Literature on Resilience However, an understanding of the role of culture has remained elusive or marginalised within this trend; there has been comparatively little sustained investigation into the applicability of resilience constructs to non-western cultures, or how the resources available for survival might differ from those accessible to western populations (Ungar 4). As such, a growing body of researchers is calling for more rigorous inquiry into culturally determined outcomes that might be associated with resilience in non-western or multicultural cultures and contexts, for example where Indigenous and minority immigrant communities live side by side with their ‘mainstream’ neighbours in western settings (Ungar 2). ‘Cultural resilience’ considers the role that cultural background plays in determining the ability of individuals and communities to be resilient in the face of adversity. For Clauss-Ehlers, the term describes the degree to which the strengths of one’s culture promote the development of coping (198). Culturally-focused resilience suggests that people can manage and overcome stress and trauma based not on individual characteristics alone, but also from the support of broader sociocultural factors (culture, cultural values, language, customs, norms) (Clauss-Ehlers 324). The innate cultural strengths of a culture may or may not differ from the strengths of other cultures; the emphasis here is not so much comparatively inter-cultural as intensively intra-cultural (VanBreda 215). A culturally focused resilience model thus involves “a dynamic, interactive process in which the individual negotiates stress through a combination of character traits, cultural background, cultural values, and facilitating factors in the sociocultural environment” (Clauss-Ehlers 199). In understanding ways of ‘coping and hoping, surviving and thriving’, it is thus crucial to consider how culturally and linguistically diverse minorities navigate the cultural understandings and assumptions of both their countries of origin and those of their current domicile (Ungar 12). Gunnestad claims that people who master the rules and norms of their new culture without abandoning their own language, values and social support are more resilient than those who tenaciously maintain their own culture at the expense of adjusting to their new environment. They are also more resilient than those who forego their own culture and assimilate with the host society (14). Accordingly, if the combination of both valuing one’s culture as well as learning about the culture of the new system produces greater resilience and adaptive capacities, serious problems can arise when a majority tries to acculturate a minority to the mainstream by taking away or not recognising important parts of the minority culture. In terms of resilience, if cultural factors are denied or diminished in accounting for and strengthening resilience – in other words, if people are stripped of what they possess by way of resilience built through cultural knowledge, disposition and networks – they do in fact become vulnerable, because ‘they do not automatically gain those cultural strengths that the majority has acquired over generations’ (Gunnestad 14). Mobilising ‘Culture’ in Australian Approaches to Community Resilience The realpolitik of how concepts of resilience and culture are mobilised is highly relevant here. As noted above, when ethnocultural difference is positioned as a risk or a threat to national identity, security and values, this is precisely the moment when vigorously, even aggressively, nationalised definitions of ‘community’ and ‘identity’ that minoritise or disavow cultural diversities come to the fore in public discourse. The Australian evocation of nationalism and national identity, particularly in the way it has framed policy discussion on managing national responses to disasters and threats, has arguably been more muted than some of the European hysteria witnessed recently around cultural diversity and national life. Yet we still struggle with the idea that newcomers to Australia might fall on the surplus rather than the deficit side of the ledger when it comes to identifying and harnessing resilience capital. A brief example of this trend is explored here. From 2006 to 2010, the Australian Emergency Management Institute embarked on an ambitious government-funded four-year program devoted to strengthening community resilience in relation to disasters with specific reference to engaging CALD communities across Australia. The program, Inclusive Emergency Management with CALD Communities, was part of a wider Australian National Action Plan to Build Social Cohesion, Harmony and Security in the wake of the London terrorist bombings in July 2005. Involving CALD community organisations as well as various emergency and disaster management agencies, the program ran various workshops and agency-community partnership pilots, developed national school education resources, and commissioned an evaluation of the program’s effectiveness (Farrow et al.). While my critique here is certainly not aimed at emergency management or disaster response agencies and personnel themselves – dedicated professionals who often achieve remarkable results in emergency and disaster response under extraordinarily difficult circumstances – it is nevertheless important to highlight how the assumptions underlying elements of AEMI’s experience and outcomes reflect the persistent ways in which ethnocultural diversity is rendered as a problem to be surmounted or a liability to be redressed, rather than as an asset to be built upon or a resource to be valued and mobilised. AEMI’s explicit effort to engage with CALD communities in building overall community resilience was important in its tacit acknowledgement that emergency and disaster services were (and often remain) under-resourced and under-prepared in dealing with the complexities of cultural diversity in emergency situations. Despite these good intentions, however, while the program produced some positive outcomes and contributed to crucial relationship building between CALD communities and emergency services within various jurisdictions, it also continued to frame the challenge of working with cultural diversity as a problem of increased vulnerability during disasters for recently arrived and refugee background CALD individuals and communities. This highlights a common feature in community resilience-building initiatives, which is to focus on those who are already ‘robust’ versus those who are ‘vulnerable’ in relation to resilience indicators, and whose needs may require different or additional resources in order to be met. At one level, this is a pragmatic resourcing issue: national agencies understandably want to put their people, energy and dollars where they are most needed in pursuit of a steady-state unified national response at times of crisis. Nor should it be argued that at least some CALD groups, particularly those from new arrival and refugee communities, are not vulnerable in at least some of the ways and for some of the reasons suggested in the program evaluation. However, the consistent focus on CALD communities as ‘vulnerable’ and ‘in need’ is problematic, as well as partial. It casts members of these communities as structurally and inherently less able and less resilient in the context of disasters and emergencies: in some sense, as those who, already ‘victims’ of chronic social deficits such as low English proficiency, social isolation and a mysterious unidentified set of ‘cultural factors’, can become doubly victimised in acute crisis and disaster scenarios. In what is by now a familiar trope, the description of CALD communities as ‘vulnerable’ precludes asking questions about what they do have, what they do know, and what they do or can contribute to how we respond to disaster and emergency events in our communities. A more profound problem in this sphere revolves around working out how best to engage CALD communities and individuals within existing approaches to disaster and emergency preparedness and response. This reflects a fundamental but unavoidable limitation of disaster preparedness models: they are innately spatially and geographically bounded, and consequently understand ‘communities’ in these terms, rather than expanding definitions of ‘community’ to include the dimensions of community-as-social-relations. While some good engagement outcomes were achieved locally around cross-cultural knowledge for emergency services workers, the AEMI program fell short of asking some of the harder questions about how emergency and disaster service scaffolding and resilience-building approaches might themselves need to change or transform, using a cross-cutting model of ‘communities’ as both geographic places and multicultural spaces (Bartowiak-Théron and Crehan) in order to be more effective in national scenarios in which cultural diversity should be taken for granted. Toward Acknowledgement of Resilience Capital Most significantly, the AEMI program did not produce any recognition of the ways in which CALD communities already possess resilience capital, or consider how this might be drawn on in formulating stronger community initiatives around disaster and threats preparedness for the future. Of course, not all individuals within such communities, nor all communities across varying circumstances, will demonstrate resilience, and we need to be careful of either overgeneralising or romanticising the kinds and degrees of ‘resilience capital’ that may exist within them. Nevertheless, at least some have developed ways of withstanding crises and adapting to new conditions of living. This is particularly so in connection with individual and group behaviours around resource sharing, care-giving and social responsibility under adverse circumstances (Grossman and Tahiri) – all of which are directly relevant to emergency and disaster response. While some of these resilient behaviours may have been nurtured or enhanced by particular experiences and environments, they can, as the discussion of recent literature above suggests, also be rooted more deeply in cultural norms, habits and beliefs. Whatever their origins, for culturally diverse societies to achieve genuine resilience in the face of both natural and human-made disasters, it is critical to call on the ‘social memory’ (Folke et al.) of communities faced with responding to emergencies and crises. Such wellsprings of social memory ‘come from the diversity of individuals and institutions that draw on reservoirs of practices, knowledge, values, and worldviews and is crucial for preparing the system for change, building resilience, and for coping with surprise’ (Adger et al.). Consequently, if we accept the challenge of mapping an approach to cultural diversity as resource rather than relic into our thinking around strengthening community resilience, there are significant gains to be made. For a whole range of reasons, no diversity-sensitive model or measure of resilience should invest in static understandings of ethnicities and cultures; all around the world, ethnocultural identities and communities are in a constant and sometimes accelerated state of dynamism, reconfiguration and flux. But to ignore the resilience capital and potential protective factors that ethnocultural diversity can offer to the strengthening of community resilience more broadly is to miss important opportunities that can help suture the existing disconnects between proactive approaches to intercultural connectedness and social inclusion on the one hand, and reactive approaches to threats, national security and disaster response on the other, undermining the effort to advance effectively on either front. This means that dominant social institutions and structures must be willing to contemplate their own transformation as the result of transcultural engagement, rather than merely insisting, as is often the case, that ‘other’ cultures and communities conform to existing hegemonic paradigms of being and of living. In many ways, this is the most critical step of all. A resilience model and strategy that questions its own culturally informed yet taken-for-granted assumptions and premises, goes out into communities to test and refine these, and returns to redesign its approach based on the new knowledge it acquires, would reflect genuine progress toward an effective transculturational approach to community resilience in culturally diverse contexts.References Adger, W. Neil, Terry P. Hughes, Carl Folke, Stephen R. Carpenter and Johan Rockström. “Social-Ecological Resilience to Coastal Disasters.” Science 309.5737 (2005): 1036-1039. ‹http://www.sciencemag.org/content/309/5737/1036.full> Bartowiak-Théron, Isabelle, and Anna Corbo Crehan. “The Changing Nature of Communities: Implications for Police and Community Policing.” Community Policing in Australia: Australian Institute of Criminology (AIC) Reports, Research and Policy Series 111 (2010): 8-15. Benessaieh, Afef. “Multiculturalism, Interculturality, Transculturality.” Ed. A. Benessaieh. Transcultural Americas/Ameriques Transculturelles. Ottawa: U of Ottawa Press/Les Presses de l’Unversite d’Ottawa, 2010. 11-38. Clauss-Ehlers, Caroline S. “Sociocultural Factors, Resilience and Coping: Support for a Culturally Sensitive Measure of Resilience.” Journal of Applied Developmental Psychology 29 (2008): 197-212. Clauss-Ehlers, Caroline S. “Cultural Resilience.” Encyclopedia of Cross-Cultural School Psychology. Ed. C. S. Clauss-Ehlers. New York: Springer, 2010. 324-326. Farrow, David, Anthea Rutter and Rosalind Hurworth. Evaluation of the Inclusive Emergency Management with Culturally and Linguistically Diverse (CALD) Communities Program. Parkville, Vic.: Centre for Program Evaluation, U of Melbourne, July 2009. ‹http://www.ag.gov.au/www/emaweb/rwpattach.nsf/VAP/(9A5D88DBA63D32A661E6369859739356)~Final+Evaluation+Report+-+July+2009.pdf/$file/Final+Evaluation+Report+-+July+2009.pdf>.Folke, Carl, Thomas Hahn, Per Olsson, and Jon Norberg. “Adaptive Governance of Social-Ecological Systems.” Annual Review of Environment and Resources 30 (2005): 441-73. ‹http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.energy.30.050504.144511>. Garmezy, Norman. “The Study of Competence in Children at Risk for Severe Psychopathology.” The Child in His Family: Children at Psychiatric Risk. Vol. 3. Eds. E. J. Anthony and C. Koupernick. New York: Wiley, 1974. 77-97. Grossman, Michele. “Resilient Multiculturalism? Diversifying Australian Approaches to Community Resilience and Cultural Difference”. Global Perspectives on Multiculturalism in the 21st Century. Eds. B. E. de B’beri and F. Mansouri. London: Routledge, 2014. Grossman, Michele, and Hussein Tahiri. Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism. Canberra: Australia-New Zealand Counter-Terrorism Committee, forthcoming 2014. Grossman, Michele. “Cultural Resilience and Strengthening Communities”. Safeguarding Australia Summit, Canberra. 23 Sep. 2010. ‹http://www.safeguardingaustraliasummit.org.au/uploader/resources/Michele_Grossman.pdf>. Gunnestad, Arve. “Resilience in a Cross-Cultural Perspective: How Resilience Is Generated in Different Cultures.” Journal of Intercultural Communication 11 (2006). ‹http://www.immi.se/intercultural/nr11/gunnestad.htm>. Hajek, Lisa J. “Belonging and Resilience: A Phenomenological Study.” Unpublished Master of Science thesis, U of Wisconsin-Stout. Menomonie, Wisconsin, 2003. Hunter, Cathryn. “Is Resilience Still a Useful Concept When Working with Children and Young People?” Child Family Community Australia (CFA) Paper 2. Melbourne: Australian Institute of Family Studies, 2012.Joppke, Christian. "Beyond National Models: Civic Integration Policies for Immigrants in Western Europe". West European Politics 30.1 (2007): 1-22. Liebenberg, Linda, Michael Ungar, and Fons van de Vijver. “Validation of the Child and Youth Resilience Measure-28 (CYRM-28) among Canadian Youth.” Research on Social Work Practice 22.2 (2012): 219-226. Longstaff, Patricia H., Nicholas J. Armstrong, Keli Perrin, Whitney May Parker, and Matthew A. Hidek. “Building Resilient Communities: A Preliminary Framework for Assessment.” Homeland Security Affairs 6.3 (2010): 1-23. ‹http://www.hsaj.org/?fullarticle=6.3.6>. McGhee, Derek. The End of Multiculturalism? Terrorism, Integration and Human Rights. Maidenhead: Open U P, 2008.Mignolo, Walter. Local Histories/Global Designs: Coloniality, Subaltern Knowledges, and Border Thinking. Princeton: Princeton U P, 2000. Mohaupt, Sarah. “Review Article: Resilience and Social Exclusion.” Social Policy and Society 8 (2009): 63-71.Mouritsen, Per. "The Culture of Citizenship: A Reflection on Civic Integration in Europe." Ed. R. Zapata-Barrero. Citizenship Policies in the Age of Diversity: Europe at the Crossroad." Barcelona: CIDOB Foundation, 2009: 23-35. Mouritsen, Per. “Political Responses to Cultural Conflict: Reflections on the Ambiguities of the Civic Turn.” Ed. P. Mouritsen and K.E. Jørgensen. Constituting Communities. Political Solutions to Cultural Conflict, London: Palgrave, 2008. 1-30. Ortiz, Fernando. Cuban Counterpoint: Tobacco and Sugar. Trans. Harriet de Onís. Intr. Fernando Coronil and Bronislaw Malinowski. Durham, NC: Duke U P, 1995 [1940]. Robins, Kevin. The Challenge of Transcultural Diversities: Final Report on the Transversal Study on Cultural Policy and Cultural Diversity. Culture and Cultural Heritage Department. Strasbourg: Council of European Publishing, 2006. Rutter, Michael. “Protective Factors in Children’s Responses to Stress and Disadvantage.” Annals of the Academy of Medicine, Singapore 8 (1979): 324-38. Stein, Mark. “The Location of Transculture.” Transcultural English Studies: Fictions, Theories, Realities. Eds. F. Schulze-Engler and S. Helff. Cross/Cultures 102/ANSEL Papers 12. Amsterdam and New York: Rodopi, 2009. 251-266. Ungar, Michael. “Resilience across Cultures.” British Journal of Social Work 38.2 (2008): 218-235. First published online 2006: 1-18. In-text references refer to the online Advance Access edition ‹http://bjsw.oxfordjournals.org/content/early/2006/10/18/bjsw.bcl343.full.pdf>. VanBreda, Adrian DuPlessis. Resilience Theory: A Literature Review. Erasmuskloof: South African Military Health Service, Military Psychological Institute, Social Work Research & Development, 2001. Weine, Stevan. “Building Resilience to Violent Extremism in Muslim Diaspora Communities in the United States.” Dynamics of Asymmetric Conflict 5.1 (2012): 60-73. Welsch, Wolfgang. “Transculturality: The Puzzling Form of Cultures Today.” Spaces of Culture: City, Nation World. Eds. M. Featherstone and S. Lash. London: Sage, 1999. 194-213. Werner, Emmy E., and Ruth S. Smith. Vulnerable But Invincible: A Longitudinal Study of\ Resilience and Youth. New York: McGraw Hill, 1982. NotesThe concept of ‘resilience capital’ I offer here is in line with one strand of contemporary theorising around resilience – that of resilience as social or socio-ecological capital – but moves beyond the idea of enhancing general social connectedness and community cohesion by emphasising the ways in which culturally diverse communities may already be robustly networked and resourceful within micro-communal settings, with new resources and knowledge both to draw on and to offer other communities or the ‘national community’ at large. In effect, ‘resilience capital’ speaks to the importance of finding ‘the communities within the community’ (Bartowiak-Théron and Crehan 11) and recognising their capacity to contribute to broad-scale resilience and recovery.I am indebted for the discussion of the literature on resilience here to Dr Peta Stephenson, Centre for Cultural Diversity and Wellbeing, Victoria University, who is working on a related project (M. Grossman and H. Tahiri, Harnessing Resilience Capital in Culturally Diverse Communities to Counter Violent Extremism, forthcoming 2014).

Introduction This paper explores some specific conjunctions that tie together two nations, Japan and the Philippines. Over the past 30 years both have become entwined as a transfer of people, cultures and societies have connected and formed some interesting developments. Relations between both countries have been highly influenced through the deployment of State intervention (historically colonial and post-colonial), as well as through actors’ initiatives, leading to the development of a complex network that links both countries. It is in these relations that I would like to locate a transition between two stages in Japan-Philippine relations. I argue, this is a transition, where marriages of one kind (international marriages), the bonding of social actors from two distinct cultural spheres, gives way to another form of marriage. This transition locates the term marriage as part of an ongoing process and a discursive realm in a larger ‘affective complex’ that has developed. In this paper, I focus on this term ‘affective complex’ as it offers some interesting avenues in order to understand the continuing development of relations between Japan and the Philippines. By ‘affective complex’ I refer to the ‘cultural responses’ that people use in reaction to situations in which they find themselves which are not mediated by language. I suggest that this complex is a product of a specific encounter that exists between two nations as understood and mediated by Japanese actors’ positionings vis-à-vis foreign resident Filipinos. In tracing a moment between Japan and the Philippines, I delineate emerging properties that currently allude to a transition in relations between both countries. I would like to show that the properties of this transition are creating an emergent phenomena, a complex? This is developing through interactions between human actors whose trajectories as transnational migrants and permanent foreign residents are coming under the scrutiny of Japanese State forces in a heavily contested discursive field. This paper focuses upon the nature of the complex that entwines both countries and examines Japan’s particular restructuring of parts of its workforce in an attempt to include foreign migrants. To do this I first offer an outline of my fieldwork and then delineate the complex that ties both countries within present theoretical boundaries. This paper is based on fieldwork which deals with the theme of International Marriages between Japanese and Filipino couples. In the field I have observed the different ways in which Filipinos or Japanese with a connection to the Philippines orientate themselves within Japanese society vis-à-vis the Philippines. For the purpose of this paper, I will focus exclusively on a particular moment in my field: a care-giver course run privately with approval and recognition from local government. This course was offered exclusively for Filipino nationals with permanent residency and a high level of Japanese. As part of a larger field, a number of overlapping themes and patterns were present within the attitudes of those participating in the course. These were cultural responses that social actors carry with them which constitute part of an ‘affective complex’, its gradual emergence and unfolding. To further locate this fieldwork and its theoretical boundaries, I also position this research within current understandings of complexity. Chesters and Welsh have referred to a complex system as being a non-linear, non-deterministic system. However, from my perspective, these parameters are insufficient if institutions, organisations and human actors exhibit linear and deterministic properties (properties that discursively capture, locate and define elements in a system). In my research, I am dealing with actors, in this case Filipinos who are seen first as recipients and then as providers of welfare services. Japanese actors act as suppliers of a service both to long-term residents and to the State. In this case the following question arises: whose ‘complexes’ may be defined by a mixture of both these parameters and how can it be possible to take into account relationships whose existence cuts across them? Could a complex not be any number of these terrains which have emerged through encounters between two countries? Marriage could be a starting point for complexes that can come under scrutiny at a higher level, that of the State forces. In addition, a study of complexity in the Social Sciences focuses on how structures form rather than by focusing on any prior structured existence. Any focus on a complex system is to analyze holistic multiple elements in order to descriptively locate structures, what they penetrate, and what they are penetrated by. Human actors’ actions, strategies and expectations merge under the influence of these structures, while simultaneously influencing them. As elements interact, emergent phenomena (properties that emerge at a higher level) show a system that is process dependent, organic, and always evolving (Arthur 109). Locating Affect Deleuze and Guattari refined the discursive realm to emphasise how spaces of creation, dialogue and the casting of influence are affective, institutional and State-influenced. Within these spaces I locate the existence of ‘affective complexes’ which are discursively constructed and deployed by local actors. I will to argue that international marriages have laid a groundwork in which ‘affect’ itself has become a catalyst, re-orientating perceptions of and toward Filipinos. Following Deleuze, we can understand ‘affect’ as an intensity which, to repeat, is an expression of human relationships not mediated directly through language (Rodriguez). However, I want to suggest ‘affect’ also comes under the scrutiny of, and is discursively appealed to by, State forces as ‘affective capital’. When I refer to ‘affective capital’ I mean the potential labour discursively constructed. This construction is then “projected and tapped” in response to the changing nature of Japan’s labour market – in particular, the shortage of care-givers. This construction itself exists as an ongoing management strategy that deals with certain foreign nationals in Japan. Here, in response to the transformations of service work, ‘affective capital’ is the commoditised value of care inherent the discourse. It is the kernel of ‘affective labour’. This was very clear in my fieldwork, wherein Filipinos were targeted exclusively as the recipients of training in the health-care sector based on an understanding of the form of ‘affect’ that they possess. In this context, ‘affect’ adds intensity to meaning and is used in a wide range of cultural contexts, yet its very essence eludes description, especially when that essence as used by ‘active agents’ may be misconstrued in its deployment or discursively captured. Returning to the Deleuzian interpretation of ‘affect’, it could be interpreted as the outcome of encounters between actors and as such, a ‘mode’ in which becoming can initiate possibilities. I refer to ‘affect’, the deployment of shared, performed, communicated non-verbal ‘content’, as a powerful tool and an essential component in everyday habituated practice. In other areas of my field (not included in this discussion), ‘affect’ deployed by both actors, husband and wife, within and beyond the family, manifests itself as a mode of being. This at times adds to the location of actors’ intentions, be they spoken or performative. In this sense, locating the ‘affect’ in my research has meant observing the way in which Filipinos negotiate the availability of life strategies and opportunities available to them. At the same time, ‘affect’ is also produced by Japanese actors realigning themselves vis-à-vis both foreign actors and social change, as well as by effectuating strategies to emergent situations in Japan such as care management. ‘Affective capital’ is an inherent long-term strategy which has its roots in the cultural resources at the disposal of non-Japanese partners who, over the years, in the short and long term put to use discursively produced ‘affect’. ‘Affect’, produced in reactions to situations, encounters and events, can work in favour of long-term residents who do not have access to the same conditions Japanese may find in the labour sector. From encounters in my fieldwork, the location of ‘affect’ is an asset not just within immediate relationships, but as a possible expression of strategies that have arisen in response to the recognition of reactionary elements in Japanese society. By reactionary elements I refer to the way in which a complex may realign itself when ‘interfered’ with at another level, that of the State. The Japanese State is facing labour shortages in certain sectors due to social change, therefore they must secure other potential sources of labour. Appropriation of human resources locally available has become one Japanese State solution for this labour shortage. As such, ‘affect’ is brought into the capitalist fold in response to labor shortages in the Health Sector. Background The Philippines is a prime example of a nomad nation, where an estimated eight million of the population currently work or live overseas while remitting home (Phillippines Overseas Employment Agency). Post-colonial global conditions in the Asia Pacific region have seen the Philippines cater to external national situations in order to participate in the global labour market. These have been in the form of flows of labour and capital outsourced to those economies which are entangled with the Philippines. In this context, marriage between both countries has come to be made up almost exclusively of Japanese men with Filipina women (Suzuki). These marriages have created nascent partnerships that have formed links within homes in both countries and supported the creation of a complex system tying together both nations. Yet, in the entanglement of what seems to be two economies of desire, some interesting observations can be drawn from what I consider to be the by-products of these marriages. Yet what does this have to do with a marriage? First, I would like to put forward that certain international marriages may have developed within the above discursive framework and, in the case of the Philippines and Japan, defined certain characteristics that I will explain in more detail. Over the past 20 years, Filipinos who came to Japan on entertainment visas or through encounters with Japanese partners in the Philippines have deployed discursively constructed ‘affective capital’ in strategies to secure relationships and a position in both societies. These strategies may be interpreted as being knowledgeable, creative and possessive of the language necessary for negotiating long-term dialogues, not only with partners and surrounding family, but also with Japanese society. These deployments also function as an attempt to secure additional long term benefits which include strengthening ties to the Philippines through increasing a Japanese spouse’s involvement and interest in the Philippines. It is here that Filipinos’ ‘affect’ may be traced back to a previous deployment of categories that influences local Japanese actors’ decisions in offering a course exclusively for Filipino residents. This offers the first hint as to why only Filipinos were targeted. In Japan, secure permanent work for resident Filipinos can be, at times, difficult even when married to a partner with a stable income. The reality of remitting home to support family members and raising a family in Japan is a double burden which cannot be met solely by the spouse’s salary. This is an issue which means actors (in this case, partners) recourse to their ‘affective capital’ in order to secure means towards a livelihood. In this context, marriages have acted as a primary medium entangling both countries. Yet changes in Japan are re-locating ‘possible’ resources that are rationalised as a surplus from these primary encounters. Shifts in Japan’s social landscape have over the past 10 years led to an increasing awareness of the high stakes involved in care for the ageing and invalid in Japanese society. With over 21% of the population now over 65, the care industry has seen a surge in demand for labour, of which there is currently a shortfall (Statistics Bureau Japan). With the Philippines having strategically relocated its economy to accommodate demands for the outsourcing of health care workers and nurses overseas, Japan, realigning its economy to domestic change, has shown a new type of interest (albeit reluctant) in the Philippines. In 2005, changes and reforms to Japan’s Immigration Control and Refugee Recognition Act successfully curtailed the flow of Filipinos applying to Japan to work as entertainers. This was in part due to pressure from the interventionary power of the U.S: in 2006 the U.S. State department published the Trafficking in Persons Report, which stipulated that Japan had yet to comply in improving the situation of persons trafficked to Japan (U.S. State Department). This watershed reform has become a precursor to the Philippines Economic Partnership Agreement ratified by Japan and the Philippines to promote the ‘trans-border flow of goods, person, services and capital between Japan and the Philippines (Ministry of Foreign Affairs) and has now temporarily realigned both economies into a new relationship. Under the terms ‘movement of natural persons’, Filipino candidates for qualified nurses and certified care workers would be allowed a stay of up to three years as nurses, or four for certified care workers (Ministry of Foreign Affairs). Nonetheless, this lip service in showing openness to admit a new category of Filipino is the continuation of a mode of ‘servicing’ within the Japanese nation, albeit under the guise of ‘care work’, and rests upon the capitalist rationalisation of hired workers for Japan’s tertiary sectors. The Philippines, a nation which is positively export-orientated in terms of its human resources in response to care inequalities that exist between nations at a global level (Parreñas 12-30), is now responding to the problematic issue of care that has become a serious concern in Japan. Fieldwork To place these issues in context I want to locate the above issues within a part of my present fieldwork. In 2006, I participated in a privately funded non-profit venture set up for Filipino residents with the aim of training them to be care-givers. The course was validated and acknowledged by the local prefectural government and primarily limited to a group of 20 participants who paid approximately sixty thousand yen ($485) for the three month course including training and text books. One Filipina acquaintance enthusiastically introduced me to the retired bank manager who had set up a fund for the three month care-giver course for Filipina residents. Through interviews with the course providers, one underlying theme in the planning of the course was clear: the core idea that Filipinos have a predisposition to care for the elderly, reflecting Filipino social values no longer existent in Japan. In particular, two Japanese words employed to reflect these views – ‘omoiyari’ (思いやり), meaning “compassion” or “considerateness” and ‘yasashisa’ (優しさ) meaning “kindness toward others” – were reiterated throughout the course as a requisite for dealing with the elderly or those in need of care. One core presupposition underlining the course was that the Philippines still cherishes values which are on the decline in Japan, offering a care ethos based on Christian values ready for deployment in such work. I believe this marks a transition point in how both countries’ relations are moving away from ‘entertainment-based’ care to ‘care within an institutional setting’, such as private nursing homes or hospitals. In both cases, ‘care’ (as it is ironically known in both industries, the deployment of hospitality and attendance), operates as a dynamic of desire within a social field which orientates how residents (i.e. foreign female residents with permanent residency) are used. Yet, why would the Philippines be such an attractor? It is not difficult to see how ‘affect’ is discursively rationalised and deployed and projected onto Philippine society. This ‘affect’ acts as an attractor and belongs to an ‘imagined’ cultural repertoire that Japan has created in response to its turbulent marriage to the Philippines. In this sense, the care course promoted this ‘caring affective side’ of Filipinas here in Japan, and provided a dynamic engagement for potential negotiation, persuasion and tension between ‘local actors’ (course providers and participants) who come under the direct remit of the Japanese State (care institutions, hospitals and nursing homes). I say “tension”, as to date only a handful (three women out of a total of sixty) of those who participated in the course have taken up employment in the care industry. As one participant, a divorcee, commented, the reluctance to seek work as a qualified care worker resided in an economic framework, she says: this is a useful investment, but I don’t know if I can do this work full time to live off and support my families…but it is another arrow in my bow if the situation changes. Yet, for another woman, care work was an extension of something that they were familiar with. She jokingly added with a sigh of resignation: Oh well, this is something we are used to, after all we did nothing but care for our papa-san (husband)! When I discussed these comments with an N.G.O. worker connected to the course she pessimistically summed up what she thought by saying: The problem of care in Japan was until very recently an issue of unpaid work that women have had to bear. In a sense, looking after the aged living at home has been a traditional way to treat people with respect. Yet, here in Japan we have experienced an excessively long period whereby it was de facto that when a woman married into someone’s family, she would care for the husband and his family. Now, this isn’t an individual problem anymore, it’s a societal one. Care is now becoming an institutional practice which is increasing paid work, yet the State works on the assumption that this is low paid work for people who have finished raising their children; hard labour for low wages. All the women have graduated and are licensed to work, yet at 1000 yen (U.S. $8) an hour for psychologically demanding hard labour they will not work, or start and finish realising the demands. Travelling between locations also is also unpaid, so at the most in one day they will work 2-3 hours. It is the worst situation possible for those who choose to work. The above opinion highlights the ambiguities that exist in the constant re-alignment of offering work to foreign residents in the effort to help integrate people into Japan’s tertiary ‘care sector’ in response to the crisis of a lack of manpower. To date most women who trained on this course have not pursued positions within the health sector. This indicates a resistance to the social beliefs that continue to categorise female foreign residents for gendered care work. Through three successive batches of students (sixty women in total) the president, staff and companies who participated in this pilot scheme have been introduced to Filipino residents in Japanese society. In one respect, this has been an opportunity for the course providers to face those who have worked, or continue to work at night. Yet, even this exposure does not reduce the hyper-feminisation of care; rather, it emphasises positions. One male coordinator brazenly mentioned the phrase ashi wo aratte hoshii, meaning ‘we want to give them a clean break’. This expression is pregnant with the connotation that these women have been involved in night work have done or still participate in. These categorisations still do not shake themselves free from previous classifications of female others located in Japanese society; the ongoing legacy that locates Filipinos in a feminised discursive space. As Butler has elucidated, ‘cultural inscriptions’ and ‘political forces with strategic interests’ work to keep the ‘body bounded and constituted’ (Butler 175). It is possible to see that this care course resides within a continuously produced genealogy that tries to constitute bodies. This resides under the rubric of a dominant fantasy that locates the Philippines in Japan as a source of caring and hospitality. Now, those here are relocated under a restructuring industry outsourcing work to those located in the lower tiers of the labour sector. Why other nationals have not been allowed to participate in the course is, I stress, a testimony to this powerful discourse. Major national and international media coverage of both the course and company and those women who found employment has also raised interest in the curious complex that has arisen from this dynamic, including a series of specials aired on Japanese television by NHK (NHK Kaigo no Jinzai ga Nigete iku). This is very reminiscent of a ‘citationary’ network where writings, news items and articles enter into a perpetuating relationship that foments and bolsters the building up of a body of work (Said) to portray Japan’s changing circumstances. As seen from a traced genealogy, initial entanglements between two nations, in conjunction with societal change in Japan, have created a specific moment in both countries’ trajectories. Here, we can see an emergent phenomena and the relocation of a discursive structure. An affective complex can be located that marks a shift in how foreign residents are perceived and on what terms they can participate or contribute to Japanese society. Within this structure, ‘care’ is relocated – or, rather, trapped – and extracted as labour surplus that resides in an antagonistic relationship of domination highlighting how a specific moment existing between two countries can be ‘structured’ by needs in the ‘engaging’ country, in this case Japan. Non-linear elements in a complex system that contest how discursive practices in Japanese society locate foreign residents, within the rubric of an ‘imagined’ ethos of compassion and kindness that emanates from outside of Japan, seem to display ‘affective’ qualities. Yet, are these not projected categories deployed to continue to locate migrant labour (be they permanent or temporary residents) within an ongoing matrix that defines what resources can be discursively produced? However, these categories do not take into account the diverse structures of experience that both Japanese nationals and Filipino nationals experience in Japan (Suzuki). Conclusion In this paper I have briefly delineated a moment which rests between specific trajectories that tie two nations. A complex of marriages brought about within a specific historic post-colonial encounter has contributed to feminising the Philippines: firstly, for women in marriages, and now secondly for ‘potential resources’ available to tackle societal problems in Japan. As I have argued a discursively produced ‘affective complex’ is an authorising source of otherness and could be part of a precursor complex which is now discursively relocating human resources within one country (Japan) as a ‘reluctant source’ of labour, while entering into a new discursive mode of production that shapes attitudes toward others. I also suggest that there is a very specific complex at work here which follows an as of yet faint trajectory that points to the re-organisation of a relationship between Japan and the Philippines. Yet, there are linear elements (macro-level forces rooted in the Japanese State’s approach to care vis-à-vis the Philippines) operating at the fundamental core of this care-giver course that are being constantly challenged and cut across by non-linear elements, that is, human actors and their ambivalence as the beneficiaries/practitioners of such practices. This is the continued feminisation of a highly gendered dynamic that locates labour as and when it sees fit, but through the willing coercion of local agents, with an interest in mediating services through and for the State, for the welfare of the Nation. The desiring-machine that brings together Japan and the Philippines is also one that continues to locate the potential in foreign actors located within Japan’s institutional interpellation for its care market. Within these newly emergent relationships, available political and social capital is being reshaped and imagined in reaction to social change in Japan. By exploring two entangled nations situated within global capitalist production in the twenty-first century, my research points towards new ways of looking at emerged complexes (international marriages) that precludes the reconfigurations of ongoing emerging complexes that discursively locate residents as caregivers, who fall under the jurisdiction and glare of political powers, government subjects and State forces. References Artur, W. Brian. “Complexity and the Economy.” Science 284.2 (1999): 107-109. Butler, Judith. Gender Trouble: Feminism and the Subversion of Identity. New York: Routledge, 2006. Chester, Graeme, and Ian Welsh. “Complexity and Social Movement(s): Process and Emergence in Planetary Action Systems.” Theory, Culture & Society 22.5 (2005): 187-211. Deleuze, Giles, and Felix Guattari. A Thousand Plateaus: Capitalism and Schizophrenia. Minnesota: U of Minnesota P, 1987. Ministry of Foreign Affairs (Japan). Japan-Philippines Economic Partnership Agreement Press Statement. 29 Nov. 2004. 29 Mar. 2007 http://www.mofa.go.jp/region/asia-paci/philippine/joint0411.html>. NHK Kaigo no Jinzai ga Nigete iku. 介護の人材が逃げて行く (“Care Workers Are Fleeing.”) Televised 11 Mar. 2007. 29 Mar. 2007 http://www.nhk.or.jp/special/onair/070311.html>. Parreñas, Rachel Salazar. Children of Global Migration: Transnational Families and Gendered Woes. Stanford: Stanford UP, 2005. Philippines Overseas Employment Agency. “Stock Estimates of Filipinos Overseas.” 2 May 2007 http://www.poea.gov.ph/html/statistics.html>. Rodriguez, Encarnación Gutiérrez. “Reading Affect – On the Heterotopian Spaces of Care and Domestic Work in Private Households.” Forum: Qualitative Social Research 8 (2007). 2 May 2007 http://www.qualitative-research.net/fqs-texte/2-07/07-2-11-e.pdf>. Said, Edward. Orientalism. London: Penguin, 1995. Statistics Bureau and Statistical Research and Training Institute. Ministry of Internal Affairs and Communications (Philippines). 2005. 2 May 2007 http://www.poea.gov.ph/docs/STOCK%20ESTIMATE%202004.xls>. Suzuki, Nobue. “Inside the Home: Power and Negotiation in Filipina-Japanese Marriages.” Women’s Studies: An Interdisciplinary Journal 33.4 (2004): 481-506. “Trafficking in Persons Report.” U.S. State Department. 2006. 29 Apr. 2007. http://www.state.gov/documents/organization/66086.pdf>. Citation reference for this article MLA Style Lopez, Mario. "From Bride to Care Worker?: On Complexes, Japan and the Philippines." M/C Journal 10.3 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0706/04-lopez.php>. APA Style Lopez, M. (Jun. 2007) "From Bride to Care Worker?: On Complexes, Japan and the Philippines," M/C Journal, 10(3). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0706/04-lopez.php>.

Photo by Mika Baumeister on Unsplash INTRODUCTION When the COVID-19 pandemic swept the globe, governments and healthcare systems scrambled to control it. While most of the global public health community agreed that actions against the COVID-19 pandemic needed to be prompt and efficient, there were disagreements on what those actions should be. Some governments opted to adopt a containment strategy while others implemented mitigation measures; each had reasons to support their course of action, whether rooted in governmental structures, scientific findings, beliefs, or ethical and moral values. However, the dramatically different response strategies may have led to disparate results. This divide is furthered when ethical and moral values and cultural norms are added to this equation. In this paper, I will examine China and Korea, two countries that implemented a preventative containment strategy, and the United States of America and the United Kingdom, which adopted mitigation strategies. I will examine the differences in their outcomes and whether there is a “correct” response to pandemics like COVID-19. l. Response in China and Korea After its initial discovery in December 2019, COVID-19 rapidly spread beyond China to surrounding countries, including South Korea, Japan, and Singapore. China implemented swift measures drawing on its experience with the SARS outbreak. Measures included lockdowns, contact tracing, testing all individuals exposed to the virus, and consequently enforcing isolation and quarantine provisions.[1] During the early stages, the public health systems and the national government moved to a “health care to all” system to avoid nationwide spread. The government and all sectors of society were mobilized to track, contain, and adapt to the overall state of the epidemic.[2] COVID-19 continued and spread in China during Lunar New Year celebrations when population movement within the country was at its peak. Thus, Wuhan entered lockdown to control the number of infected people leaving the city to contain the virus;[3] even in areas where there were few to no cases, the general population of China voluntarily abided by measures like those implemented in Wuhan. The measures included wearing masks, social distancing, and following stay-at-home orders. Furthermore, healthcare workers from all over the country volunteered to travel to Hubei, where Wuhan is, and assembled several Fangcang shelter hospitals.[4] Fangcang hospitals were designed based on emergency medical care cabins that were used after two devastating earthquakes in China and served as temporary quarantine housing and hospital facilities.[5] They are mobile, have fast deployment, and can adapt quickly to different environments. At the start of the pandemic, Wuhan converted gymnasiums, convention centers, sports arenas and training centers, factories, and other venues into Fangcang hospitals. Although temporary, these quarantine hospital facilities were equipped with full medical equipment and personnel, allowing for complete medical functions for “treatment, disease monitoring, diagnosis and other clinical tasks.”[6] Teams of psychologists were also assigned to each hospital to provide counseling for patients.[7] Beyond separating those who were infected from the rest of the population and thus having more control over the community spread of the virus, Fangcang hospitals played a vital role in reducing patient density in traditional hospitals and medical centers by expanding treatment capacities.[8] South Korea reported its first COVID-19 case in January 2020, and, within days, the government activated the Central Disaster and Safety Countermeasures Headquarters.[9] Similar to China, South Korea used existing epidemic protocols and implemented the 3Ts strategy, prioritizing testing, tracing, and treatment.[10] High-capacity screening facilities and working with the private sector to ensure an adequate supply of tests made South Korea’s efforts successful.[11] The South Korean government strictly regulated self-isolation and quarantine. Contact tracing efforts used various data sources, “including credit card transactions and closed-circuit television footage.”[12] The government also placed stringent restrictions on travel, beginning with designated entry lines and questionnaires, but expanding to include temperature checks, testing for all travelers at the border, and a mandatory fourteen-day monitored quarantine for anyone entering the country.[13] The majority of the population responded immediately with compliance, with national weekly movement decreasing by 38 percent between February 24, 2020, and March 1, 2020, compared to the corresponding week the previous month. Schools swiftly closed across the nation, and the entire country transitioned to remote learning until the gradual reopening in May and June 2020.[14] There was some discontentment within the population, especially with the South Korean government’s practice of publicly announcing the names of individuals who tested positive.[15] Critics of this practice say it is an infringement of patient privacy and can even be viewed as an invitation to public bullying.[16] However, even with some dissatisfaction with government regulations, a survey of 1,200 South Koreans in September 2020 asking people to agree if they were satisfied with the government’s response showed that the overwhelming majority either agreed or strongly agreed (44.08 percent and 19.75 percent, respectively), and less than 20 percent of the respondents either disagreed or strongly disagreed (11.50 percent and 5.08 percent, respectively).[17] Regulations surrounding isolation and quarantine were strict and applied to those with confirmed cases of COVID-19, anyone who traveled internationally, or individuals suspected to be infected. Individuals were required to use the Self-Quarantine Safety Protection app that tracked location for fourteen days to ensure that quarantine protocols were followed.[18] Case officers monitored the app, and violators not only faced a substantial fine but were also required to wear electronic wristbands that would alert the officers if the individual left the location of their mobile device.[19] ll. The Western Response: The UK and US COVID-19 was reported in many Western nations around January 2020. However, unlike South Korea, many countries did not immediately respond to the outbreak with surveillance and containment strategies but had a wait-and-see approach. As the pandemic worsened, they gradually adopted mitigation strategies to combat the disease as it progressed. While the US adopted a combination of containment and mitigation strategies, a concrete response from state and federal governments did not occur until March 2020.[20] Even then, many states did little to address the pandemic. Although equipped with a robust healthcare system, a shortage of ventilators and hospital beds became evident in some localities early on. The US healthcare system failed to acknowledge the pandemic and prepare a coordinated response in time to stop the momentum of the disease.[21] The goal became “flattening the curve” (keeping the number of cases that needed hospital care low enough to avoid overwhelming the hospital system) as it was clear containment would be impossible. Once tests were developed, poor coordination of testing efforts and insufficient resources to test at the necessary scale to provide comprehensive national surveillance of the disease further hindered efforts to contain infected individuals and decelerate its spread.[22] Eventually, regulations and mitigation measures were implemented, including mask mandates, school closures, caps or bans on in-person gatherings, and the closure of non-essential businesses.[23] However, enforcement of these measures proved difficult, and people instigated protests against many of the recommended policies and requirements. The UK and the US both encountered a shortage of personal protective equipment for healthcare workers.[24] However, a more prominent problem arose from the UK’s initial response to the pandemic. The UK first said COVID-19 was like influenza and therefore did not call for emergency measures to deter its spread.[25] Furthermore, in the first few weeks of the pandemic, the UK government believed herd immunity was the best course of action, stating that most people would have mild symptoms,[26] and the population would become mostly immune to the virus once enough people were infected.[27] In theory, herd immunity was a potentially effective strategy. The public health authorities thought that if the threshold for herd immunity was reached, enough people would have developed protective antibodies against any future infection.[28] However, the risks of COVID-19 were high and the cases “would lead to high rates of hospitalization and need for critical care, straining health service capacity past the breaking point.”[29] Furthermore, while getting COVID-19 would offer some natural immunity against reinfection, reinfection remained a possibility, especially during the early stages of the pandemic when vaccines were unavailable.[30] Later, when vaccines were available, a study showed that an unvaccinated person who contracted the virus was more than twice as likely to become reinfected than a fully vaccinated person.[31] The UK government also expressed concern for “behavioral fatigue.”[32] It claimed that if restrictions were enforced pre-emptively and prematurely, people might become progressively “uncooperative and less vigilant.”[33] Regarding the concern for “behavioral fatigue,” numerous behavioral scientists stated that they were unconvinced that this reason was enough to hold off implementing restrictions. There was a lack of evidence of this phenomenon, and a group of 681 UK behavioral scientists said in an open letter that “[s]uch evidence is necessary if we are to base a high-risk public health strategy on it.”[34] Fortunately, this strategy only remained under consideration for a short period. After rapid increases in confirmed cases and deaths due to COVID-19, the UK government implemented more strict measures, like city lockdown, school closures, and the closure of non-essential businesses.[35] These restrictions took legal effect on March 26th, 2020 – around two weeks after the first proposal of the “herd immunity” strategy.[36] lll. Comparing the Two Approaches The Eastern and Western countries experienced significant outbreaks of COVID-19. However, looking at the mortality rate and new confirmed cases, the differences between the two categories of response to COVID-19 are significant. As of December 31, 2020, the mortality rate per 100,000 population for China and South Korea were 0.3 and 1.8, respectively, and new confirmed cases per day per 100,000 population were 87 and 1,029, respectively. However, the mortality rates per 100,000 in the US and the UK were 107 and 108, respectively, and they had up to 234,133 and 56,029 new confirmed cases every day, respectively.[37] As of July 2022, total deaths in China were 22, 994[38] (population 1.45 billion)[39] and in South Korea 24,794[40] (population 51.36 million)[41] compared to 1,015,093[42] in the US (population 335.03 million)[43] and 182,727[44] in the UK (population 68.62 million).[45] Further differences can be seen in the varying sectors of society, such as healthcare systems and authority models, political structures, and cultural customs among these countries, which in turn affect the response and control strategies.[46] In the US and the UK, rights-based political structures affected the response, making tracking and surveillance more problematic early on. But Western countries did have strict lockdowns and quarantines. China and South Korea maintained a proactive approach by “identifying and managing cases, tracking and isolating close contacts, and strictly restricting or controlling population movement when feasible and appropriate.”[47] In contrast, the UK implemented nationwide lockdowns early on, and the US restrictions varied among states. Both the UK and the US focused on treating the severe cases and those with underlying conditions rather than proactively preventing new cases from developing in the early pandemic.[48] They did shift gears to mass testing schemes and attempts to slow transmission. By the time they implemented cohesive strategies, COVID-19 was widespread. Due to their slow initial responses, they needed to manage an onslaught of cases while trying to prevent transmission. lV. Ethical Implications The “West vs. Rest” culture divide emerges when comparing the COVID-19 response strategies of East Asian countries to those of Western countries. The differences in their strategies further highlight the differences in the prevailing moral values influencing public policy. The preventative stance adopted by many East Asian countries shows a stronger collective identity among citizens. But it also may show more substantial governmental power and less appetite for protest. In contrast, the mostly non-interfering nature of Western governments’ actions shows a reliance on the “autonomous and unanimous responsibility of individuals.”[49] The moral values in the US also may reflect the prioritized position of personal rights and the suspicion of intrusive government policies. Culturally, the populations of South Korea and China are generally more tolerant of personal data-sharing and monitoring, suggesting there is less concern for autonomy or privacy. However, many people in the US and UK would consider the use of location tracking apps and electronic bracelets to be violations of individual autonomy and privacy.[50] Sectors of the Western world also argue that mandating masking or social distancing imposes on individual autonomy and free will. Mask-wearing was an existing practice in East Asian countries, even without mandates or pandemics. Individuals wear masks for common colds and influenza and do not consider a mask requirement an infringement of their autonomy. Furthermore, whether it is due to the authoritarian nature of the government or not, there is a general tendency toward public compliance and accepting government policies in many East Asian countries,[51] and the lack of public dissent played an important part in making combating COVID-19 easier for countries like China and South Korea. The lack of initiative from Western nations arguably violates the bioethical principles of beneficence and nonmaleficence.[52] For example, the promotion of the “herd immunity” strategy from the UK government and consequently the government’s inaction, risked the well-being of its citizens. The government failed to avoid the harm that COVID-19 brought. Similarly, by delaying its response until nearly two months after the initial case was reported, the US also violated the principle of non-maleficence. The success seen in South Korea and China during the early pandemic better exemplifies beneficence and nonmaleficence. The strategy of contact tracing and strict containment saved lives. The consequences of the restrictions varied across the countries as well. Not everyone can afford to self-isolate or quarantine and being required to do so can significantly impact many individuals’ well-being. Furthermore, not everyone’s occupation allows them to work from home and business closures disadvantaged portions of the population disparately. For those who are essential workers, school closures may also burden parents who do not have access to affordable childcare. The stringent restrictions regarding quarantine and self-isolation in East Asian countries also harmed people disparately, raising problems surrounding the principle of justice. However, the speed at which China had COVID-19 contained allowed people there to return to their normal lives quickly. Compared to some Western countries’ waves of lockdown and reinforcement of restrictions, the “zero-COVID” strategy in countries like China showed success, at least during the early stages of the pandemic. The contact tracing and containment was likely financially beneficial. While the pandemic resulted in substantial economic growth downgrades and global recessions, regions like East Asia were estimated to grow by around 0.5 percent. In comparison, the economy in regions like Europe contracted by around 4.7 percent.[53] CONCLUSION China arguably had an advantage in combating COVID-19 since the outbreak was relatively concentrated in one region. This allowed early detection of symptoms and quick containment of the virus. Other countries, like the US, had new cases on both coasts early in the pandemic; thus, containment was more challenging than it was in China. However, the delayed and reluctant response from countries like the US and the UK did not benefit the well-being of their populations and proved to put more stress on their healthcare systems. While mass tracking of people is politically contentious, the promptness of actions many East Asian countries employed at the beginning of COVID-19 seemed to be the more effective course of action that best protected the well-being of their citizens. - [1] Chen, Haiqian, et al. “Response to the COVID-19 Pandemic: Comparison of Strategies in Six Countries.” Frontiers in Public Health, vol. 9, September 30, 2021, pp. 1-11. doi: 10.3389/fpubh.2021.708496. [2] Chen, et al. [3] Chen, et al. [4] Chen, et al. [5] Wang, Ke-Wei, et al. “Fangcang shelter hospitals are a One Health approach for responding to the COVID-19 outbreak in Wuhan, China.” One Health, vol. 10, August 29th, 2020, pp. 1-6. doi: 10.1016/j.onehlt.2020.100167. https://www.sciencedirect.com/science/article/pii/S2352771420302688. [6] Wang. [7] Wang. [8] Wang. [9] Kim, June-Ho, et al. “Emerging COVID-19 Success Story: South Korea Learned the Lesson of MERS.” Our World Data, University of Oxford, March 5, 2021. https://ourworldindata.org/covid-exemplar-south-korea. [10] Chen, Haiqian, et al. [11] Kim, et al. [12] Kim. [13] Kim. [14] Scott, Dylan and Jun Michael Park. “South Korea’s Covid-19 success story started with failure.” Vox, April 19, 2021. https://www.vox.com/22380161/south-korea-covid-19-coronavirus-pandemic-contact-tracing-testing.. [15] Scott and Park. [16] Rich, Timothy S., et al. “What Do South Koreans Think of Their Government’s COVID-19 Response?” The Diplomat, October 7, 2020. https://thediplomat.com/2020/10/what-do-south-koreans-think-of-their-governments-covid-19-response/. [17] Rich, et al. [18] Kim, et al. [19] Kim, et al. [20] Chen, et al. [21] Chen, et al. [22] Chen, et al. [23] Chen, et al. [24] Chen, et al. [25]Chen, et al. [26] Chen, et al. [27] O’Grady, Cathleen. “The U.K. backed off on herd immunity. To beat COVID-19, we’ll ultimately need it.” National Geographics, March 20, 2020. https://www.nationalgeographic.com/science/article/uk-backed-off-on-herd-immunity-to-beat-coronavirus-we-need-it. [28] “Herd immunity and COVID-19: What you need to know.” Mayo Clinic, April 20, 2022. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808?p=1. [29] O’Grady. [30] O’Grady. [31] Mayo Clinic, April 20, 2022. [32] Yong, Ed. “The UK’s Coronavirus ‘Herd Immunity’ Debacle.” The Atlantic, March 16, 2020. https://www.theatlantic.com/health/archive/2020/03/coronavirus-pandemic-herd-immunity-uk-boris-johnson/608065/. [33] Yong. [34] Harvey, Nigel. “Behavioral Fatigue: Real Phenomenon, Naïve Construct or Policy Contrivance?” Frontiers in Psychology, vol. 11, November 6, 2020. doi: 10.3389/fpsyg.2020.589892, quoting a March 16, 2020 open letter to the UK government. [35] Chen, et al. [36]“Timeline of UK coronavirus lockdowns, March 2020 to March 2021.” Institute for Government Analysis. https://www.instituteforgovernment.org.uk/sites/default/files/timeline-lockdown-web.pdf. [37] Chen, et al. [38] “China: WHO Coronavirus Disease (COVID-19) Dashboard.” World Health Organization, 2022, https://covid19.who.int/region/wpro/country/cn. [39] “China Population.” Worldometer, 2022, https://www.worldometers.info/world-population/china-population/. [40] “The Republic of South Korea: WHO Coronavirus Disease (COVID-19) Dashboard.” World Health Organization, 2022, https://covid19.who.int/region/wpro/country/kr. [41] “South Korea Population,” Worldometer, 2022, https://www.worldometers.info/world-population/south-korea-population/. [42] “The United States of America: WHO Coronavirus Disease (COVID-19) Dashboard.” World Health Organization, 2022, https://covid19.who.int/region/amro/country/us. [43] “United States Population,” Worldometer, 2022, https://www.worldometers.info/world-population/us-population/. [44] “The United Kingdom: WHO Coronavirus Disease (COVID-19) Dashboard.” World Health Organization, 2022, https://covid19.who.int/region/euro/country/gb. [45] “U.K. Population,” Worldometer, 2022, https://www.worldometers.info/world-population/uk-population/. [46] Chen, et al. [47] Chen, et al., p 6. [48] Chen, et al. [49] Festing, Marion, Tobias Schumacher and Yong-Yueh Lee. “How Cultural Norms and Values Shape National Responses to the COVID-19 Pandemic.” The London School of Economics and Political Science, April 15, 2021. https://blogs.lse.ac.uk/businessreview/2021/04/15/how-cultural-norms-and-values-shaped-national-responses-to-the-covid-19-pandemic/. [50] Festing, et al. [51] Festing, et al. [52] Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. (New York: Oxford University Press, 2009). [53] “The Global Economic Outlook During the COVID-19 Pandemic: A Changed World.” The World Bank, June 8, 2020. https://www.worldbank.org/en/news/feature/2020/06/08/the-global-economic-outlook-during-the-covid-19-pandemic-a-changed-world.

In this paper, I will be looking at how the news media may be both helpful (‘good’) and a hindrance (‘bad’) to lesbian and gay parents. While I acknowledge the incommensurable differences between the experiences of lesbian parents and gay parents, I do believe that representations of both lesbian and gay parents in the media tend to focus on any similarities that exist between (and within) the two groups, rather than looking at the important differences. I would suggest that this is the result of the hetero-normative assumptions that inform the news media, which take heterosexual parents to be the norm from which all other parents differ. Such normative assumptions thus suggest that it is important to look at how particular moral frameworks are employed in both pro- and anti-gay news media reports of lesbian and gay parents, the implication being that the former may not necessarily be better than the latter. As lesbian and gay parents, we may thus do ourselves a disservice by uncritically accepting that ‘positive’ media accounts are useful in our fight for rights. ‘Good Parents’ and the ‘Rhetoric of Pseudoscience’ One of the most central aspects of representations of lesbian and gay parents in the news media is the use of ‘scientific proof’ to legitimate lesbian and gay parenting. Some examples include: Significant, reliable social scientific evidence indicates that lesbian and gay parents are as fit, effective and successful as heterosexual parents (Judith Stacey reported in http://www.lethimstay.com/wrong_socscience_expert.html). Because many beliefs about lesbian and gay parents and their children are open to empirical test, psychological research can evaluate their accuracy (American Psychological Association [APA], 1995, http://www.apa.org/pi/parent.html). Scientific findings debunk the myth that gay men cannot be nurturing parents (http://www.familypride.org/issues/myths.htm). A comprehensive international review of 25 years of research into lesbian and gay parenting… shows convincingly that the children of lesbian and gay parents do not demonstrate any important differences from those of heterosexual parents (Gay & Lesbian Rights Lobby, 2002, http://www.glrl.org.au/issues/parenting.htm). One particular strategy of legitimation evident in these extracts demonstrates what Kitzinger has termed the ‘rhetoric of pseudoscience’ – disproving your opponents claims to truth by demonstrating their ‘bad science’ (see also Riggs, “Politics”). Thus, in the examples above, ‘significant, reliable social scientific evidence’ is contrasted with ‘debunk[ed]… myth[s]’. Another example of this is provided in Stacey’s claim that: Paul Cameron is the primary disreputable and discredited figure in this [anti-lesbian and gay parenting] literature. He was expelled from the APA… for unethical scholarly practices, such as selective, misleading representations of research and making claims that could not be substantiated (http://www.lethimstay.com/wrong_socscience_expert.html). Here, Stacey uses the authority of ‘good’ social scientific research in order to disprove the claims of ‘bad’ ‘disreputable and discredited figure[s]’. In so doing, while she seeks to support lesbian and gay parents in our fight for rights, she also perpetuates the notion that scientific knowledge is the appropriate arbiter of what counts as ‘good parenting’. This is reinforced in the statement of the APA, which suggests that ‘many beliefs about lesbian and gay parents and their children are open to empirical test’. While this is intended to demonstrate the importance of using psychological research to ‘evaluate [the] accuracy’ of such beliefs, it also demonstrates the risks that we run when using science to determine what will count as ‘truth’ (Clarke; Riggs, “Politics”, “On Whose Terms”). Thus, while psychological knowledge in the extracts above is deployed in support of lesbian and gay parents, we only need to look back 30-odd years to see a vastly different story. It is as recently as that that same-sex attraction was classified as a pathology in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-II). Thus, as Joshua Gamson (76) suggests, that which is considered ‘“normal” is often a synonym for “power”’. In this regard, the power that is evoked through the use of scientific discourse in news media may also be used against lesbian and gay parents. For example, Bill Maier, a clinical psychologist and vice president of the (right-wing and, anti-gay) Focus on the Family Institute is reported as saying that: Every responsible psychologist in the APA should be ashamed; the organization is obviously more concerned with appeasing its powerful gay lobby than it is with retaining any semblance of moral and ethical duty (Baptist Press News, http://www.bpnews.net/bpnews.asp?ID=18784). Here morality and ethics are constructed as being a priori oriented towards the values of the heterosexual majority. Even if lesbian and gay rights activists are to counter this with ‘proof’ of the normality of lesbians and gay men, this does little to destabilise the hegemony of scientific knowledge and its ability to define what counts as moral and ethical. Indeed, Maier draws attention to a very important point – while organisations such as the APA may seek to use psychological knowledge to refute anti-gay claims, they do so without challenging the ideological assumptions that underpin it. As a result, the APA (and those who use psychological knowledge in pro-accounts more generally) are left open to accusations of bias and wilful ignorance of a system of law that is based upon the values of white, heterosexual, middle-class men (Bernstein). ‘Taking Sides’: Is There Any Difference? This leads me to ask the following question: Do we as lesbians and gay men actually want to be ‘good parents’? How might our location within this position only serve to erase the unique experiences of parenting and families that we share? Eldridge suggests that what appear as debates over social issues may more accurately be described as ‘one-sided debates’, wherein the ‘opposing parties’ are actually arguing very similar points. This is particularly evident in debates over lesbian and gay parenting, as both those for and those against lesbian and gay parents often uncritically accept the notions of ‘science’ that inhere to the debates. For example, in the previous section we saw Stacey claim that anti-gay researchers have questionable ethics, just as Maier suggested that the support for lesbian and gay issues given by the APA represents a crisis in its ‘ethical and moral duty’. While pro-accounts of lesbian and gay parents may be useful in the short term to generate ‘positive’ representations of lesbian and gay parents in the media (which in some cases may be an important aspect of legal challenges in regards to lesbian and gay adoption rights), they do little to challenge the networks of power within which they are located, focused as they are upon stereotypical representations of ‘good’ lesbian and gay parents who are typically white, able-bodied, and financially secure. As a result, these representations further marginalise those lesbians and gay men who do not fit within this category (for example, due to economic or cultural difference from the white, middle-class majority), in addition to those lesbians and gay men who choose not to parent. These points demonstrate how the fight for ‘positive representation’ within the media can lead to the further marginalisation of groups of lesbian and gay men who already have little access to such representation (Gamson). Within this paper, I have demonstrated some of the ways in which ‘good’ representations of lesbian and gay parents may also be ‘bad’—they may render us complicit with discourses of science that have often been used against us, and they also encourage us to conform to a heterosexual model of relationality. In this way, lesbian and gay parents are expected to be ‘as fit, effective and successful as heterosexual parents’ (Stacey). As a result, lesbian and gay parents are encouraged to accept a form of subjectivity that recognises scientific arguments as legitimate, and which thus encourages lesbians and gay men to open their lives to scientific scrutiny, measurement, and objectification. Moreover, it encourages lesbian and gay parents ‘not [to] demonstrate any important differences from… heterosexual parents’ (Gay & Lesbian Rights Lobby) under threat of being declared, by default, unfit parents. The converse effect of news media reports of lesbian and gay parents can also be true: ‘bad’ representations may inadvertently draw attention to the problems that inhere to using science to ‘prove the case’. Thus, as the extract from Maier suggests, naively believing that science is the answer ignores the moral assumptions that shape news media and which further marginalise the often critical moral frameworks of lesbian and gay parents. Obviously, I am not advocating here for more statements like those of Maier. Rather, I am suggesting that as lesbian and gay parents we need to be wary of accepting normative framework when mounting our resistances. In other words, if ‘bad’ is often ‘good’, and ‘good’ is often ‘bad’ in scientific media accounts of lesbian and gay parents, then it would seem important that we develop alternate ways of accounting for our experiences, at the same time as we critique such accounts in order to demonstrate their moral assumptions. Acknowledgements I would first like to acknowledge the sovereignty of the Kaurna people, upon whose land I live in Adelaide, South Australia. Thanks as always go to Greg for support and proof reading, and to our foster child, Gary, for helping this all make sense. References Bernstein, Mary. “Gender, Queer Family Policies, and the Limits of the Law.” Queer Families, Queer Politics: Challenging Culture and the State. Ed. Mary Bernstein and Renate Reimann. New York: Columbia UP, 2001. Clarke, Victoria. “‘Stereotype, Attack and Stigmatize Those Who Disagree’: Employing Scientific Rhetoric in Debates about Lesbian and Gay Parenting.” Feminism & Psychology 10 (2000): 152-9. Eldridge, John. “News, Truth and Power.” Getting the Message: News, Truth and Power. Ed. John Eldridge. London: Routledge, 1993. Gamson, Joshua. “Talking Freaks: Lesbian, Gay, Bisexual and Transgender Families on Daytime Talk TV.” Queer Families, Queer Politics: Challenging Culture and the State. Ed. Mary Bernstein and Renate Reimann. New York: Columbia UP, 2001. Kitzinger, Celia. “The Rhetoric of Pseudoscience.” Deconstructing Social Psychology. Eds. Ian Parker and John Shotter. London: Routledge, 1990. Riggs, Damien W. “The Politics of Scientific Knowledge: Constructions of Sexuality and Ethics in the Conversion Therapy Literature.” Lesbian & Gay Psychology Review 5 (2004): 6-14. Riggs, Damien W. “On Whose Terms?: Psychology and the Legitimisation of Lesbian and Gay Parents.” GLIP News 3 (2004): 3-6. http://www.psychology.org.au/units/interest_groups/gay_lesbian/publications.asp>. Riggs, Damien W. “The Psychologisation of Foster Care: Implications for Lesbian and Gay Parents.” PsyPag Quarterly 51 (2004): 34-43. Citation reference for this article MLA Style Riggs, Damien. "Who Wants to Be a 'Good Parent'?: Scientific Representations of Lesbian and Gay Parents in the News Media." M/C Journal 8.1 (2005). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0502/05-riggs.php>. APA Style Riggs, D. (Feb. 2005) "Who Wants to Be a 'Good Parent'?: Scientific Representations of Lesbian and Gay Parents in the News Media," M/C Journal, 8(1). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0502/05-riggs.php>.

Photo by National Cancer Institute on Unsplash INTRODUCTION Gift-giving by patients or their families to physicians has happened since there were patients and physicians, and in many places, it’s still quite common. It’s also potentially problematic, and the why and how of it offer important insight into the physician-patient relationship and human relationships more broadly. Yet ethicists, regulators, and the public have not paid much systematic attention. In the United States, no federal or state legislation directly addresses it. Only in the past two decades did the American Medical Association (AMA) release guidance to physicians about it. That guidance, which permits physicians to accept certain gifts by certain patients under certain circumstances, namely, when it will not influence their medical judgment or cause hardship to the gift-giver, is vague and incomplete – indeed, it’s all of 200 words.[1] Other physician professional organizations have little to add.[2] A few academics and opinion columnists have studied or reflected on the psychology of gift-giving and -receiving and recommended everything from categorical rejection of patient gifts[3] to erring on the side of accepting them, provided they are of modest value, and the motivation behind them can be discerned.[4] However, insufficient attention has been paid to the when and where of those gifts or the significance of clinic-, hospital- or other systems-level ethical safeguards. ANALYSIS When deciding whether they will accept a gift from a patient or their family, physicians must balance the possibility that the gift could cloud medical judgment, lead to favoritism, exploitation, and slippery slopes, or pressure other patients to give, and perhaps even debase the meaning of medical treatment, against the prospect that gift-giving could increase patient trust and satisfaction, as well as empower patients and respect their autonomy and culture.[5] Performing this harm-benefit calculation case by case is challenging and time-consuming. Unsurprisingly, many physicians opt simply to tell would-be gift-giving patients that they appreciate the sentiment, but, as a rule, they accept no gifts. I submit many physicians do this also because they are unaware of how meaningful giving a gift can be for patients or anyone in a disadvantaged position with respect to the gift recipient. They may also not know that there are simple accountability mechanisms they can institute that may prevent many of the possible adverse consequences of gift-giving and -receiving in the context of the physician-patient or physician-patient-family relationship. Unfortunately, many instances in which accepting a gift would have led to net benefit are foregone. It is my belief a consensus could quickly be formed about which types of gifts would clearly be wrong to accept. Few would defend the physician who agrees to use a patient’s villa in the Bahamas or welcomes expensive jewelry or lewd photos. The timing and intent of a gift also matter. Few would forgive the physician who accepted even a modestly valuable voucher to eat at a patient’s restaurant while their eligibility for transplant was being debated or after they had run out of opioid painkillers and were denied a prescription renewal. On the other hand, I doubt even Charles Weijer or the College of Physicians and Surgeons of Prince Edward Island, which views accepting gifts from patients as “boundary crossing,”[6] would demand an orthopedic surgeon turn down the happy picture a pediatric patient drew after recovering from a hip injury and resuming sports. They are also unlikely to criticize an oncology team that graciously receives a fruitcake baked by the sister of an elderly cancer patient after the decision was made and agreed to, around Christmastime, not to initiate another round of chemotherapy. These unlikely refusals may be because rejecting those gifts, all things considered, would seem cruel. But it might also be because there is disagreement about what constitutes a gift: whether it must be a tangible object (are heartfelt thank-yous and hugs not also “gifts”?) or whether it must be something that requires the physician actively do something, e.g., get on a plane. These disagreements about definitions may also partially underlie disagreements about practice. Suppose a patient in a sparsely populated, heavily wooded part of Maine takes it upon himself to offer a sack of apples from his orchard to his internist, who regularly waives fees for those who cannot pay them or will make a house call at any time of the night. In that case, the internist may not consider the apples a gift. He may not think of them as payment or re-payment either. They may exist in some in-between category, much like the knitted slippers brought in by a patient in whose culture “thank you” is seldom said. But clearly, some things are widely perceived as gifts or to have substantial gift-like character. Should they, at least, be rejected? I don’t think so. The act of gift-giving and -receiving can be a sort of ritual and gradually lead to trust and closeness.[7] Perhaps a shy patient whose wife previously sent chocolates to his physician around Christmastime will come to see the physician as a part of his extended family. Perhaps he needs to do so to feel comfortable talking about his erectile dysfunction. Gifts can be expressions of caring.[8] Perhaps an elderly Texan patient imagines her younger physician, whom she has known for thirty years and often sees at the grocery store, as her son and asks to prepare a homecoming mum (traditionally a chrysanthemum flower corsage) for his children’s school dance. Perhaps doing so will give her purpose, make her feel useful, as all her own children have moved away. Giving gifts may also provide patients with a sense of control and help them feel as if less of a power imbalance exists between them and their physician. Perhaps a young judge, who is not used to not being in control, and was previously misdiagnosed with rheumatoid arthritis, is now struggling to come to terms with his Lupus. Perhaps giving the physician who made the correct diagnosis a moderately-priced bottle of scotch restores his confidence or sense of pride to. Gifts are also undoubtedly important to the recipient. When medical providers receive a gift, they may interpret it as a sign that they are valued. While it would be wrong to practice medicine to receive gifts or expect them, there are times, like when ERs and ICUs are overwhelmed because of a viral pandemic,[9] which threatens the will to continue working, and most anything (within reason) that bolsters resolve can be considered good. There is also no obvious distinction between the satisfaction physicians normally receive on seeing their patients recover or being thanked or smiled at and what they feel when they receive a small or “token” gift, like a plate of homemade cookies. The point is that the physician-patient relationship is a human one. Many advocate it should be personal, that physicians should be emotionally invested in their patients, care about and have compassion for them in ways that professional oaths do not fully capture.[10] This dynamic is particularly important in primary care or when the physician-patient relationship continues for long periods. According to one Israeli study, many patients even wish for a relationship with their physician akin to friendship. Those who felt they had such a relationship were more satisfied with their care than those who believed the relationship was business-like.[11] The precedent for this “friendship between unequals” goes back at least to the time of Erasmus, some five hundred years ago.[12] There may be good reasons for physicians to draw the line before friendship, but if accepting certain gifts builds intimacy, and that intimacy does not cross over into an inappropriate relationship, e.g., a sexual or romantic relationship, and if it has the chance to improve healthcare outcomes through improved mood or early disclosure of problems, I think it should be done. Physicians have a prima facie duty to do good for their patients.[13] Most physicians want to do good for their patients and respect their traditions and preferences. I suspect that accepting the gifts from the patients in the examples above would do a lot of good, or at least that rejecting them could do significant harm, including making them or their families feel estranged from the medical community, impeding future care. Physicians might be more comfortable accepting gifts if receiving gifts would not subject them to scrutiny or penalty. They also may feel better if they knew that receiving gifts would not harm their patients and that rejecting gifts might. They should document all gifts they receive.[14] This will enable them to detect if gifts from a particular patient are increasing in frequency or lavishness or changing markedly in character, which could warrant attention. I maintain this “Gift Log” should be maintained in common with everyone at the clinic or in the relevant hospital department and potentially made available to hospital administration for audit. Investigation might be necessary if a gift is given (and accepted) with no explicable context, e.g., not near holiday season or after a treatment milestone is achieved. When possible, gifts should be shared communally, such as placing fruit baskets or chocolates in the staff room. Other gifts, like artwork, can be displayed on the walls. Others should be encouraged to hold physicians accountable if they feel patients who have given gifts receive preferential treatment, including something as seemingly small as priority for appointment bookings. Appearances matter and even the appearance of impropriety can affect the public’s trust in medicine. The culture of medicine has already changed such that nurses now reproach physicians they feel violate the standard of care,[15] and this would be an extension of that trend. Depending on the set-up of the practice, a staff member can be designated for receiving gifts and politely declining those that ought to be declined. Staff members should tell patients, who give gifts in full view of other patients, that they cannot do so in the future. Physicians can politely rebuff patients who wish to give inappropriate gifts, or gifts at inappropriate times and suggest they donate to charity instead. Medical practices and hospitals should develop a gift policy in consultation with staff and patients to avoid needlessly rejecting gifts that benefit both doctor and patient and to avoid pressuring patients into giving gifts. The policy should be flexible to account for the crucial human element in any provider-patient relationship and the cultural nuances of any practice setting. Psychiatrists, who work with particularly vulnerable patients, may need to be more vigilant when accepting gifts.[16] CONCLUSION Though we tend to think health innovation occurs in urban medical centers and spreads outward, there may be something big-city physicians can learn from their rural colleagues about personalized patient-physician relationships. The value of gifts is only one example. Normalizing the acceptance of patient gifts in appropriate restricted circumstances has the added benefit of shining a spotlight on the acceptance of patient gifts in dubious ones. By bringing an already fairly common practice into the open and talking about it, we can create policies that respect patients as persons, prevent abuse, and deconstruct the stereotype of the austere and detached physician. While there is no reason to think that gift-giving would get out of control if appropriate safeguards are put in place, the medical community can always re-evaluate after a period, or an individual medical practice can re-evaluate based on the circumstances of their practice environment. Gift-giving, especially when gifts are of small monetary value, should be recognized as a culturally appropriate gesture with meaning far beyond that monetary value. It is best governed by reasonable gift-giving policies, not banned altogether. - [1] Council on Ethical and Judicial Affairs. “Ethics of Patient-Physician Relationships.” In AMA Code of Medical Ethics, 11. Chicago: American Medical Association, 2021. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-1.pdf. [2] Sulmasy, Lois Snyder, and Thomas A. Bledsoe. “American College of Physicians Ethics Manual.” Annals of Internal Medicine 170, no. 2_Supplement (January 15, 2019): S1–32. https://doi.org/10.7326/M18-2160; Committee on Bioethics. “Pediatrician-Family-Patient Relationships: Managing the Boundaries.” Pediatrics 124, no. 6 (December 1, 2009): 1685–88. https://doi.org/10.1542/peds.2009-2147. [3] Weijer, Charles. “No: Gifts Debase the True Value of Care.” Western Journal of Medicine 175, no. 2 (August 2001): 77. [4] Lyckholm, Laurie J. “Should Physicians Accept Gifts From Patients?” JAMA 280, no. 22 (December 9, 1998): 1944–46. https://doi.org/10.1001/jama.280.22.1944; Spence, Sean A. “Patients Bearing Gifts: Are There Strings Attached?” BMJ 331, no. 7531 (December 22, 2005): 1527–29. https://doi.org/10.1136/bmj.331.7531.1527; Gaufberg, Elizabeth. “Should Physicians Accept Gifts from Patients?” American Family Physician 76, no. 3 (August 1, 2007): 437; Caddell, Andrew, and Lara Hazelton. “Accepting Gifts from Patients.” Canadian Family Physician 59, no. 12 (December 2013): 1259–60. [5] See above commentators and Drew, Jennifer, John D. Stoeckle, and J. Andrew Billings. “Tips, Status and Sacrifice: Gift Giving in the Doctor-Patient Relationship.” Social Science & Medicine 17, no. 7 (January 1, 1983): 399–404. https://doi.org/10.1016/0277-9536(83)90343-X. [6] College of Physicians and Surgeons of Prince Edward Island. “Respecting Boundaries.” Accessed April 4, 2021. https://cpspei.ca/respecting-boundaries/. [7] The Atlantic’s Marketing Team. “What Gifting Rituals from Around the Globe Reveal About Human Nature.” The Atlantic, 2018. https://www.theatlantic.com/sponsored/hennessy-2018/what-gifting-rituals-around-globe-reveal-about-human-nature/2044/. [8] Parker-Pope, Tara. “A Gift That Gives Right Back? The Giving Itself.” The New York Times, December 11, 2007, sec. Health. https://www.nytimes.com/2007/12/11/health/11well.html. [9] Harlan, Chico, and Stefano Pitrelli. “As Coronavirus Cases Grow, Hospitals in Northern Italy Are Running out of Beds.” Washington Post. Accessed April 4, 2021. https://www.washingtonpost.com/world/europe/italy-coronavirus-patients-lombardy-hospitals/2020/03/12/36041dc6-63ce-11ea-8a8e-5c5336b32760_story.html. [10] Frankel, Richard M. “Emotion and the Physician-Patient Relationship.” Motivation and Emotion 19, no. 3 (September 1, 1995): 163–73. https://doi.org/10.1007/BF02250509. [11] Magnezi, Racheli, Lisa Carroll Bergman, and Sara Urowitz. “Would Your Patient Prefer to Be Considered Your Friend? Patient Preferences in Physician Relationships.” Health Education & Behavior 42, no. 2 (April 1, 2015): 210–19. https://doi.org/10.1177/1090198114547814. [12] Albury, W. R., and G. M. Weisz. “The Medical Ethics of Erasmus and the Physician-Patient Relationship.” Medical Humanities 27, no. 1 (June 2001): 35–41. https://doi.org/10.1136/mh.27.1.35. [13] Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th edition. New York: Oxford University Press, 2012. [14] Caddell and Hazelton, 2013. [15] See, e.g. Peplau, Hildegard E. “A Glance Back in Time: Nurse-Doctor Relationships.” Nursing Forum 34, no. 3 (1999): 31–35. https://doi.org/10.1111/j.1744-6198.1999.tb00991.x and Ahmad, Ahmir. “The Doctor-Nurse Relationship: Time for Change?” British Journal of Hospital Medicine (2005), September 27, 2013. https://doi.org/10.12968/hmed.2009.70.Sup4.41642. [16] Hundert, Edward M. “Looking a Gift Horse in the Mouth: The Ethics of Gift-Giving in Psychiatry.” Harvard Review of Psychiatry 6, no. 2 (January 1, 1998): 114–17. https://doi.org/10.3109/10673229809000319.

Introduction While individuals from marginalised and vulnerable communities have long been confronted with the task of developing coping strategies, COVID-19 lockdowns intensified the conditions under which resilience and wellbeing were/are negotiated, not only for marginalised communities but for people from all walks of life. In particular, the pandemic has highlighted in simple terms the stark divide between the “haves” and “have nots”, and how pre-existing physical conditions and material resources (or lack thereof), including adequate income, living circumstances, and access to digital and other resources, have created different conditions for people to be able to physically isolate, avoid working in conditions that put them at greater risk of exposure to the virus, and maintain up-to-date information. The COVID-19 pandemic has changed the way we live, and its conditions have tested our capacity for resilience to varying degrees. Poor mental health has become an increasingly urgent concern, with almost one in ten people contemplating suicide during Victoria’s second wave and prolonged lockdown in 2020 (Ali et al.; Czeisler & Rajaratnam; Paul). The question of what enables people to cope and adapt to physical distancing is critical for building a more resilient post-pandemic society. With the understanding that resilience is comprised of an intersection of material and immaterial resources, this project takes as its focus the material dimensions of everyday resilience. Specifically, “Objects for Everyday Resilience” explores the intersection of material objects and everyday resilience, focussing on the things that have supported mental and physical health of different sections of the community in Melbourne, Australia, during the pandemic. People in the Victorian city of Melbourne, Australia – including the research team authors of this article – experienced 262 days of lockdown due to the COVID-19 pandemic, more than any other city in the world. The infection rate was high, as was the death rate. Hospitals were in crisis attempting to deal with the influx (McReadie). During lockdowns in 2020 and 2021, all movement in the city was restricted, with 9 pm to 5 am curfews and a five-kilometre travel limit. Workplaces, schools, businesses, sports and leisure clubs were closed. One person per household could shop. Masks were mandatory at all times. PCR testing was extensive. People stayed in their homes, with no visitors. The city limits were closed by roadblocks. Rare instances of air travel required a hard-to-get exemption. Vaccines were delayed. The state government provided financial support for most workers who lost income from their regular work due to the restrictions. However, the financial assistance criteria rejected many casual workers, including foreign students who normally supported themselves through casual employment (McReadie). The mental health toll of protracted lockdowns on Melbourne residents was high (Klein, Tyler-Parker, and Bastian). Yet people developed measures of resilience that helped them cope with lockdown isolation (Gerrand). While studies of resilience have been undertaken during the pandemic, including increased attention towards the affordances of online platforms in lockdown, relatively little attention has been paid to whether and how material objects support everyday resilience. The significant amount of literature on objects and things (e.g. Whitlock) offers a wide range of potential applications when brought to bear on the material conditions of resilience in the COVID-19 pandemic as it continues to unfold. As ethnographer Paula Zuccotti notes in her study of objects that people used in lockdowns around the world, “Future Archeology of a Global Lockdown”, the everyday items we use tell us stories about how we exist (Zuccotti). Paying attention to the intersection of objects with resilience in everyday contexts can enable us to view resilience as a potential practice that can shape the conditions of social life that produce adversity in the first place (Chalmers). By studying relationships between material objects and people in conditions of adversity, this project aims to enhance and extend emerging understandings of multisystemic resilience (Ungar). Objects have been central to human history, culture, and life. According to Maurizio Ferraris, objects are characterised by four qualities: sensory-ness, manipulability, ordinariness, and relationality. “Unlike the three spheres of biological life – the mineral, the vegetable and the animal – objects and things have been customarily considered dependent on humans’ agency and presence” (Bartoloni). In everyday life, objects can enhance resilience when they are mobilised in strategies of resourcefulness and “making do” (de Certeau). Objects may also support the performance of identity and enable inter-subjective relations that create a sense of agency and of being at home, wherever one is located (Ahmed et al.; Gerrand). From an existential perspective, the experience of being confined in lockdown, “stuck” in one place, challenges cosmopolitan connectedness and sense of belonging. It also bears some similarities to the experiences of migrants and refugees who have endured great uncertainty, distance, and immobility due to detention or vintage of migration (Yi-Neumann et al.). It is possible that certain objects, although facilitating resilience, might also trigger mixed feelings in the individuals who relied on them during the lockdown (Svašek). From domestic accoutrements to digital objects, what kinds of things supported wellbeing in situations of confinement? Multisystemic Resilience in Lockdown It is especially useful to consider the material dimensions of resilience when working with people who have experienced trauma, marginalisation, or mental health challenges during the pandemic, as working with objects enables interaction beyond language barriers and enables alternatives to the re-telling of experiences. Resilience has been theorised as a social process supported (or inhibited) by a range of “everyday” intersecting external and contextual factors at individual, family, social, institutional, and economic resource levels (Ungar; Sherrieb et al.; Southwick et al.). The socio-ecological approach to resilience demonstrates that aspects of individual, family, and community resilience can be learned and reinforced (Bonanno), but they can also be eroded or weakened, depending on the dynamic interplay of various forces and influences in the social ecology of an individual or a group. This means that while factors at the level of the individual, family, community, or institutions may strengthen resistance to harms or the ability to overcome adversity in one context, the same factors can promote vulnerability and erode coping abilities in others (Rutter). Our project asked to what extent this social-ecological understanding of resilience might be further enhanced by attending to nonhuman materialities that can contribute or erode resilience within human relations. We were particularly interested in understanding the potential of the exhibition for creating an inclusive and welcoming space for individuals who had experienced long COVID lockdowns to safely reflect on the material conditions that supported their resilience. The aim of this exercise was not to provide answers to a problem, but to draw attention to complexity, and generate additional questions and uncertainties, as encouraged by Barone and Eisner. The exhibition, through its juxtaposition of (lockdown-induced) loneliness with the conviviality of the public exhibition format, enabled an exploration of the tension between the neoliberal imperative to physically isolate oneself and the public messaging concerning the welfare of the general populace. Our project emerged from insights collected on the issue of mental health during “Living Lab” Roundtables undertaken in 2020 by our Centre For Resilient and Inclusive Societies, convened as part of the Foundation Project (Lam et al.). In particular, we deployed an object-based analysis to investigate the art- and object-based methodology in the aftermath of a potentially traumatising lockdown, particularly for individuals who may not respond as well to traditional research methods. This approach contributes to the emerging body of work exploring the affordances of visual and material methods for capturing feelings and responses generated between people and objects during the pandemic (Watson et al.). “Objects for Everyday Resilience” sought to facilitate greater openness to objects’ vitality (Bennett) in order to produce new encounters that further understandings of multisystemic resilience. Such insights are critically tied to human mental health and physical wellbeing. They also enabled us to develop shared resources (as described below) that support such resilience during the period of recovery from the pandemic and beyond. Arts and Objects as Research The COVID-19 pandemic provoked not only a global health response, but also a reorientation of the ways COVID-related research is conducted and disseminated. Javakhishvili et al. describe the necessity of “a complex, trauma-informed psycho-socio-political response” in the aftermath of “cultural/societal trauma” occurring at a society-wide scale, pointing out the prevalence of mental health issues following previous epidemics (1). As they note, an awareness of such trauma is necessary “to avoid re-traumatization and to facilitate recovery”, with “safety, trustworthiness, transparency, collaboration and peer support, empowerment, choice” among the key principles of trauma-informed policies, strategies, and practices (3). Our project received funding from the Centre for Resilient and Inclusive Societies (CRIS) in July 2021, and ethics approval in November 2021. Centring materiality, in November 2021 we circulated a “call for objects” through CRIS’ and the research team’s social media channels, and collected over 40 objects from participants of all ages for this pilot study. Our participants comprised 33 women and 10 men. Following is a breakdown of the self-described cultural background of some participants: Five Australian (including one ‘6th generation Australian’); four Vietnamese; two Caucasian; one Anglo-Australian; one Asian; one Brazilian; one British; one Caucasian/English Australian; one Filipino; one Filipino-Australian; one German/Portuguese/US; one Greek Australian; one Iranian; one Irish and Welsh; one Israeli; one Half German, Half Middle Eastern; one Middle Eastern; one Singaporean; one White British. Participants’ objects and stories were analysed by the team both in terms of their ‘people, place, and things’ affordances – enhancing participants’ reflections of life in the pandemic – and through the prism of their vibrancy, drawing on object-oriented ontology and materiality as method (Ravn). Our participants were encouraged to consider how their chosen object(s) supported their resilience during the pandemic. For example, some objects enabled linking with memories that assist in elaborating experiences of loss or grief (Trimingham Jack and Devereux). To guide those submitting objects, we asked about: 1) their relationship to the object, 2) the meaning of the object, and 3) which features of resilience are mobilised by the object. From an analysis of our data, we have developed a working typology of objects to understand their particular relationship role to features of resilience (social capital, temporality) and to thematise our data in relation to emerging priorities in research in multisystemic resilience, materiality, and mental health. Things on Display Whilst we were initially unable to gather in person, we built an online Instagram gallery (@objectsforeverydayresilience) of submitted objects, with accompanying stories from research participants. Relevant hashtags in several languages were added to each post by the research team to ensure their widest possible visibility. This gallery features objects such as a female participant’s jigsaw puzzle which “helped me to pass the downtime in an enjoyable way”. Unlike much of her life in lockdown that was consumed by chores that “did not necessarily make me feel content or happy”, jigsaw puzzles made this participant “happy for that time I was doing them, transport[ing] me out of the confines of the lockdown with landscapes and images from across the globe”. Another female participant submitted a picture of her worn sneakers, which she used to go on what she called her “sanity walks”. To counteract the overwhelm of “being in the house all the time with 3 (autistic) children who were doing home learning and needed a lot of support”, while attempting to work on her PhD, going for walks every day helped clear my mind, get some fresh air, keep active and have some much needed quiet / me time. I ordered these shoes online because we couldn’t go to the shops and wore them almost daily during the extended lockdowns. Books were also popular. During lockdowns, according to a female participant, reading helped me connect with the outside world and be able to entertain myself without unhealthy coping mechanisms such as scrolling endlessly through TikTok. It also helped me feel less alone during the pandemic. Another female participant found that her son’s reading gave her time to work. Olfactory objects provided comfort for a participant who mourned the loss of smell due to mask wearing: perfumes were my sensory transport during this time – they could evoke memories of places I’d travelled to, seasons, people, feelings and even colours. I could go to far-off places in my mind through scent even though my body was largely stationary within my home. (Female participant) Through scent objects, this participant was “able to bring the world to meet me when I was unable to go out to meet the world”. Other participants sought to retreat from the world through homely objects: throughout lockdown I felt that my bed became an important object to my sanity. When I felt overwhelmed, I would come to bed and take a nap which helped me feel less out of control with everything going on in the world. (Female participant) For an essential worker who injured her leg whilst working in a hospital, an Ikea couch enabled recovery: “the couch saved my throbbing leg for many months. It served as a place to eat, paint and rest.” (Female participant) While pets were not included as objects within this project, several participants submitted their pets’ accoutrements. A female participant who submitted a photograph of her cat’s collar and tree movingly recounts how while I was working online in lockdown, this cat tree kept my cat entertained. She was so enthusiastic while scratching (covered in her fur) she somehow managed to remove her collar. I call Bouny my Emotional support cat … . She really stepped up her treatments of me during the pandemic. My mother had advanced dementia and multiple lockdowns [which] meant I could not see her in the weeks leading up to her death. These objects highlight the ways in which this participant found comfort during lockdown at a time of deep grief. For other participants, blankets and shawls provided sources of comfort “since much of lockdown was either in cool weather or deepest winter”. I found myself taking [my shawl] whenever I went out for any of the permitted activities and I also went to bed with it at night. The soft texture and the warmth against my face, neck and shoulders relaxed my body and I felt comforted and safe. (Female participant) Another used a calming blanket during lockdown “for time-outs on my bed (I was confined to a tiny flat at the time and separated from my family). It gave me a safe space”. (Female participant) In a similar vein, journalling provided several participants with “a safe space to explore thoughts and make them more tangible, acting as a consistent mindful practice I could always turn to”. The journal provided consistency throughout the ever-changing lockdown conditions and a strong sense of stability. Recording thoughts daily allowed me to not only process adversity, but draw attention to the areas in my life which I was grateful for … even from home. (Female participant) In addition to fostering mindfulness, the creative practice of journalling enabled this participant to exercise her imagination: writing from the perspectives of other people, from friends to strangers, also allowed me to reflect on the different experiences others had during lockdown. I found this fostered empathy and motivated me to reach out and check in on others, which in turn also benefited my own mental health. (Female participant) Creative practices were critical to sustaining many participants of this study. The Norman family, for example, submitted an acrylic on canvas artwork, Surviving COVID in Port Melbourne (2021), as their object of resilience: this work represents the sentiments and experiences of our family after a year of successive COVID lockdowns. Each section of the canvas has been completed a member of our family – 2 parents and a 21, 18 and 14 year-old. (Norman family) Likewise, musical instruments and sound objects – whether through analogue or digital means – helped participants to stay sane in long lockdowns: wen I didn’t know what to do with myself I always turned to the guitar. (Male participant) Music was so important to us throughout the lockdowns. It helped us express and diffuse big feelings. We played happy songs to amplify nice moments, funny songs to cheer each other up, angry songs to dance out rage. (Family participants) Curating the Lockdown Lounge To enhance the capacity of our project’s connections to the wider community, and respond to the need we felt to gather in person to reflect on what it meant for each of us to endure long lockdowns, we held an in-person exhibition after COVID-19 restrictions had eased in Melbourne in November 2022. The decision to curate the “Lockdown Lounge” art and research exhibition featuring objects submitted by research participants was consistent with a trauma-informed approach to research as described above. According to Crowther, art exhibits have the potential to redirect viewers’ attention from “aesthetic critique” to emotional connection. They can facilitate what Moon describes as “relational aesthetics”, whereby viewers may connect with the art and artists, and enhance their awareness of the self, artist, and the world. As a form of “guided relational viewing” (Potash), art exhibits are non-coercive in that they invite responses, discussion, and emotional involvement while placing no expectation on viewers to engage with or respond to the exhibition in a particular way. When considering such questions, our immersive in-person exhibition featured a range of object-based installations including audio-visual and sound objects, available for viewing in our Zine, The Lockdown Lounge (Walimunige et al.). The living room design was inspired by French-Algerian artist Zineb Sedira’s immersive living room installation, “Dreams Don’t Have Titles”, at the 59th Venice Art Biennale’s French pavilion (Sedira), attended by project co-lead Vivian Gerrand in June 2022. The project team curated the gallery space together, which was located at Deakin University’s city conference venue, “Deakin Downtown”, in Melbourne, Australia. Fig. 1: The Lockdown Lounge, living room. “What Got You through Lockdown?” research exhibition and experience, Deakin Downtown, Melbourne, 21-25 November 2022. In the centre of the Lockdown Lounge’s living room (see fig. 1), for example, a television screen played a looped collection of popular YouTube videos, many of which had gone viral in the early months of the COVID-19 pandemic. There was Victorian Premier Daniel Andrews, admonishing Victorians to avoid non-essential activities through the example of an illicit dinner party held that resulted in a spike in coronavirus cases in March 2020 (ABC News). This short video excerpt of the Premier’s press conference concluded with his advice not to “get on the beers”. While not on display in this instance, many visitors would have been familiar with the TikTok video remix made later in the pandemic that featured the same press conference, with Premier Andrews’s words spliced to encourage listeners to “get on the beers!” (Kutcher). We recalled the ways in which such videos provided light relief through humour at a time of grave illness and trauma: when army trucks were being summoned to carry the deceased from Northern Italian hospitals to makeshift gravesites, those of us privileged to be at home, at a remove from the ravages of the virus, shared videos of Italian mayors shouting at their constituents to “vai a casa!” (Go home!). Or of Italians walking fake dogs to have an excuse to go outside. We finished the loop with a reproduction of the viral Kitten Zoom Filter Mishap, in which in online American courtroom defendant Rod Ponton mistakenly dons a cat filter while telling the judge, ‘I am not a cat’. The extraordinary nature of living in lockdown initially appeared as an opportunity to slow down, and this pandemic induced immobility appeared to prompt a kind of “degrowth” as industries the world over paused operation and pollution levels plummeted (Gerrand). In reflection of this, we included videos in our YouTube playlist of wild animals returning to big cities, and of the waters of Venice appearing to be clear. These videos recalled how the pandemic has necessitated greater appreciation of the power of things. The spread of the novel coronavirus’s invisible variants has permanently altered the conditions and perceptions of human life on the planet, forcing us to dwell on the vitality intrinsic to materiality, and renewing awareness of human lives as taking place within a broader ecology of life forms (Bennett). Within this posthuman perspective, distinctions between life and matter are blurred, and humans are displaced from a hierarchical ontological centre. In an essay titled “The Go Slow Party”, anthropologist Michael Taussig theorises a “mastery of non-mastery” that yields to the life of the object. This yielding – a necessary response to the conditions of the pandemic – can enable greater attentiveness to the interconnectedness and enmeshment of all things, leading to broader understandings of self and of resilience. To understand how participants responded to the exhibition, we asked them to respond to the following questions in the form of open-ended comments: What if anything affected you most? Did any of the objects resonate with you? Did the exhibition provide a safe environment for you to reflect on your sense of resilience during the pandemic? Fig. 2: Research exhibition participant standing beside artwork by the Norman family: Surviving COVID in Port Melbourne, acrylic on canvas (2021), The Lockdown Lounge. Through curating the art exhibition, we engaged in what Wang et al. describe as “art as research”, whereby the artist-researcher aims to “gain a deeper understanding of what art, art creation, or an artistic installation can do or activate … either in terms of personal experiences or environmental circumstances” (15). As Wang et al. write, “the act of creating is simultaneously the act of researching”, neither of which can be distinguished from one another (15). Accordingly, the process of curating the gallery space triggered memories of living in lockdown for members of our team, including one male youth researcher who remembers: as the space gradually began to be populated with object submissions … the objects began to find their place … . We slowly developed an understanding of the specific configurations of objects and the feelings that these combinations potentially could invoke. As we negotiated where my object might be placed, I felt an odd sense of melancholy seeing my record player and guitar at the exhibition, reminiscing about the music that I used to play and listen to with my family when we were all in lockdown … . As my Bon Iver record spun, and the familiar melodies rung out into the space, I felt as if I was sharing an intimate memory with others … . It also reminded me of the times when I had felt the most uplifted, when I was with family, near and far, knowing that we all were a unit. Another of our youth researcher team members served as an assistant curator and agreed to monitor the gallery space by being there for most of the five days of the exhibition’s opening to the public. She describes her work in the gallery thus: my role involved general exhibition upkeep – setup, answering visitor inquiries and monitoring the space – which meant being in the exhibition space for around 7.5 hours a day. Although it cannot be fully compared to living through Melbourne’s lockdowns, being in a space meant to mimic that time meant that comparisons naturally arose. I can see similarities between the things that supported my resilience during the lockdowns and the things that made my time at the gallery enjoyable. Through engaging with the gallery, this researcher was reminded of how spending time engaging in hands-on tasks made physical distancing more manageable. Spending time in the exhibition space also facilitated her experience of the lockdowns and the material conditions supporting resilience. She reflects that the hands-on, creative tasks of setting up the exhibition space and helping design a brochure reminded me of how I turned to baking so I could create something using my hands … . In the beginning, I approached my time at the gallery as a requirement of my work in this project … . Looking back now, I believe I understand both the person I was those years ago, and resilience itself, a little bit better. Fig. 3: Research exhibition participant wearing an Oculus virtual reality headset, watching the film Melbourne Locked Down (van Leeuwen), The Lockdown Lounge, November 2022. As these examples demonstrate, complex assemblages of people, places, and things during the COVID-19 pandemic were, and are, “suffused with multisensory and affective feelings”; exploring the ways affect is distributed through socio-spatialities of human experience enables researchers to better unpack individuals’ COVID experiences in ways that include their surroundings (Lupton). This was further evident in the feedback received from participants who attended the exhibition. Exhibition Feedback Feedback from participants suggested that the public exhibition format enabled them to explore this tension between isolation and orientation to the greater good in a safe and inclusive way (e.g. fig. 2). For Harry (29/m/Argentinian/New Zealand), interacting with the exhibition “reminded me that I wasn’t the only one that went through it”, while Sam (40/m/Chinese Australian) resonated with “many … people’s testimonials” of how objects helped support their resilience during long periods of confinement. Sam further added that participating in the exhibition was a “pleasant, friendly experience”, and that “everyone found something to do”, speaking to the convivial and inclusive nature of the exhibition. This resonates with Chaplin’s observation that “the production and reception of visual art works are social processes” that cannot be understood with reference to aesthetic factors alone (161-2). In the quotes above, it is evident that participants’ experience of the exhibition was inherently entwined with the sociality of the exhibition, evoking a sense of connection to others who had experienced the pandemic (in Harry’s case), and other exhibition attendees, whom he observed “all found something to do”. Additionally, participants’ responses highlighted the crucial role of the “artist researcher”, whom Wang et al. describe as qualitative researchers who use “artistically inspired methods or approaches” to blend research and art to connect with participants (10). In particular, the curation of the exhibition was something participants highlighted as key to facilitating their recollections of the pandemic in ways that were relatable. Nala (19/f/East-African Australian) commented that “the room’s layout allowed for this the most”: “the room was curated so well, it encaptured [sic] all the various stages of COVID lockdown – it made me feel like I was 16 again”. Returning to Wang et al.’s description of “art as research” as a means through which artist researchers can “gain a deeper understanding of what art, art creation, or an artistic installation can do or activate” (15), participant responses suggest that the curation of Lockdown Lounge as a trauma-informed art exhibition allowed participants to re-experience the pandemic lockdowns in ways that did not re-traumatise, but enabled the past and present to coexist safely and meaningfully for participants. Conclusion: Object-Oriented Wellbeing From different sections of the community, “Objects for Everyday Resilience” collected things that tell stories about how people coped in long lockdowns. Displaying the objects and practices that sustained us through the peak of the COVID-19 health crisis helped our participants to safely reflect on their experiences of living through long lockdowns. The variety of objects submitted and displayed draws our attention to the complex nuances of resilience and its material and immaterial intersections. These contributions composed, as fig. 1 illustrates, an almost accidentally curated diorama of a typical lockdown scene, imitating not only the materiality of living room itself but something also, through the very process of contribution, of the strange collectivity that the city of Melbourne experienced during lockdown periods. Precisely partitioned within domestic zones (with important differences for many “essential workers”, residents of public housing high-rises, and other exceptions), lockdowns enforced a different and necessarily unifying rhythm: attention to daily briefings on COVID numbers, affective responses to the heaves and sighs of infection rates, mourning over a new and untameable cause of loss of life, and routine check-ins on newly isolated friends and family. In hindsight, as the city has regained – perhaps redoubled, a sign of impatience with earlier governmental languages of austerity and moderation? – its economic and hedonistic pulse, there are also signs that any lockdown collectivity – which we also acknowledge was always partial and differentiated – has dispersed into the fragmentation of social interests and differences typical of late capitalism. The fascination with “public” objects – the Northface jacket of the state premier, COVID masks and testing kits, even toilet paper rolls, serving metonymically for a shared panic over scarcity – has receded. To the point, less than two years on, of this media attention being a scarcely remembered dream. The Lockdown Lounge is an example of a regathering of experiences through a process that, through its methods, also serves as a reminder of a common sociality integral to resilience. 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