Artykuły w czasopismach na temat „Commonwealth Education Fund”

This article explores a unique Networking the Nation Remote Telecommunications Infrastructure Fund $8 million funding application made by the Torres Strait Islanders Media Association Inc (TISMA). The purpose is to install and operate state-of-the-art telecommunication infrastructure on each inhabited Torres Strait Island to enhance the services and operations of the 27 Commonwealth and state government agencies operating in this region and to better meet the education, employment, training, socio-economic, cultural and linguistic needs of the region's inhabitants and to increase production, promotion and revenue-generation of their local cultural industries.

The World Health Organisation (WHO) and others have identified, as a priority, the need to improve antimicrobial stewardship (AMS) interventions as part of the effort to tackle antimicrobial resistance (AMR). An international health partnership model, the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme, was established between selected countries in Africa (Ghana, Tanzania, Zambia and Uganda) and the UK to support AMS. This was funded by UK aid under the Fleming Fund and managed by the Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET). The primary aims were to develop local AMS teams and generate antimicrobial consumption surveillance data, quality improvement initiatives, infection prevention and control (IPC) and education/training to reduce AMR. Education and training were key components in achieving this, with pharmacists taking a lead role in developing and leading AMS interventions. Pharmacist-led interventions in Ghana improved access to national antimicrobial prescribing guidelines via the CwPAMS mobile app and improved compliance with policy from 18% to 70% initially for patients with pneumonia in one outpatient clinic. Capacity development on AMS and IPC were achieved in both Tanzania and Zambia, and a train-the-trainer model on the local production of alcohol hand rub in Uganda and Zambia. The model of pharmacy health partnerships has been identified as a model with great potential to be used in other low and middle income countries (LMICs) to support tackling AMR.

Education and development–whether personal, social, economic or technological–are inextricably bound. In recognition of this, governments, societies and private organizations commit huge financial resources to the funding of education. However, funding for students’ higher education through scholarships suffers a huge disadvantage against funding for higher education institutions. This is more so in developing countries that are even in need of high quality education obtainable in the developed economies through overseas scholarship schemes for deserving candidates. Governments and Sponsoring organizations such as Nigeria’s Tertiary Education Trust Fund (TETFUND), World Bank’s Overseas Scholarships for Developing Countries, America’s USAID, United Nations’ UNESCO or the Commonwealth Scholarship Programs therefore need to deploy performance assessment mechanisms to effectively and regularly monitor the performances of the beneficiaries of the overseas scholarship schemes throughout the course duration of their studies with a view to recalling back home any under-performing candidate(s) to avoid wasted resources.The deliverables of this Research Paper, therefore, include:1) The Nsiegbe Performance Assessment Model for Overseas Scholarship Schemes.2) A Performance Measurement Formula, known as, The Nsiegbe Formula for Scholarship Schemes Performance Measurement. 3) A Student Performance Assessment Plan.

A brief institutional history of the Department of Chemistry at the University of Western Ontario in London, Ontario, from the founding of the university in 1878 until modern times is presented. After its beginnings as a subject taught to medical students, chemistry began to achieve independent status with the construction of a dedicated sciences building in 1924. Growth remained slow until government began to fund university education, and science studies, more generously in the 1950s. Emphasis on research and knowledge creation followed and major funding for infrastructure and senior faculty followed in the 1960s, when Western mined commonwealth sources for researchers of exceptional potential. The arrival of the baby boom generation in the late 1960s forced another expansion of chemistry faculty and staff. Later in the 20th century, a number of specialized and interdisciplinary chemical subspecialties, such as the Centre for Chemical Physics, the Canadian Synchrotron Radiation Facility in Madison, Wisconsin, Surface Science Western, and Interface Science Western, were created under the direction of several visionary chemists. An evolution of investigative interests continues in the 21st century, together with a departmental commitment to outstanding teaching and postuniversity career preparation for its students. After producing its first publication in 1915, the department published its 6000th in 2012, signaling a strong century of growth.

The study, based on archival sources and scientific publications, identifies a number of issues related to the history of the formation of women's educational institutions in Galicia in the early twentieth century. Coverage of the peculiarities of the formation and development of women's seminaries for teacher training in Ukraine as a part of the Austro-Hungarian Empire and the Second Polish-Lithuanian Commonwealth is considered on the example of the State Women's Teachers' Seminary in Berezhany. It has been found that the introduction of new educational institutions – men's and women's teachers' seminaries had been based on the Austrian state school law of 1869, which introduced significant changes in the process of teacher training. From the results of the article it has been identified that women's educational institutions had been created in the Austro-Hungarian Empire to provide public (primary) schools with teachers and aimed at professional self-realization of women. The research focuses on the women's teacher's seminary in Berezhany which was opened in 1910/1911. The article analyzes archival documents from the collection of the Central State Historical Archive of Ukraine in L’viv, in particular the materials of the fund № 179 "Curator of the L’viv School District", case 1111 "Case of transfer of premises in Senyavsky Castle in Berezhany by the local city community for a women's seminary". Based on the documents of the case on the transfer of the Senyavsky Castle in Berezhany by the local city community for the women's seminary, the content of the official correspondence of state and local authorities regarding the location and financing of the women's teacher's seminary in Berezhany during 1913-1926 has been revealed. It has been found that before the war, the magistrate of Berezhany had handed over a house and 1 ½ of morgue - land in the center to the needs of the seminary, but the construction of the seminary building had not been started due to the war. On March 5, 1915, the Ministry of Religion and Education in Vienna granted the Berezhany community an annual subvention of 6,000 kroons as donations to a house on a needs of a teachers' seminary. The war made it impossible to further pay that subvention in the school years from 1914/1915 to 1918/1919. Therefore, the school regional council, expressing a request to the magistrate of Berezhany, appealed to the Ministry of the Second Polish-Lithuanian Commonwealth to support the commitment of the Ministry of Finance regarding the annual subvention payment for 1919 and 1920. The Polish government refused any legal obligations to the Berezhany community to pay debts. subventions for the years 1914-1919 instead of the Austrian government. In the case of the seminary in Berezhany, the curator of the Lviv school district, in a letter dated January 4, 1923, proposed to accept the gift of the castle in Berezhany proposed by Mr. Yakub Potocki for the use of the teacher's seminary, which was rejected by the Ministry of Education of the Second Polish-Lithuanian Commonwealth, based on a careful analysis of the condition of the monument. As a result of an agreement with the Ministry of Finance, the Ministry of Religion and Education decided to distribute the community of Berezhany the amount of 20,000 Polish marks for the needs of the teachers' seminary. The article reveals that the historical experience of the formation and development of women’s education in Galicia on the example of the Berezhany Teachers’ Seminary as an important asset of Ukrainian science and education.

In the article, the scientist focuses on the goal of education – the formation of a leading strata of the Ukrainian people – intellectuals, the national elite. The article states that the national character is formed only by the national school. The purpose of education is defined - formation of the leading layer of the Ukrainian people - intellectuals, national elites. It is noted that a conscious volyn political elite was formed. In a systematic analysis of archival sources, the author notes that in the State Archives of Ternopil region (fund 351) you can learn about the teachers of the gymnasium: the director and teacher of Latin Sergey Ulianovich Milyashkevich, professor of general history, geography and Latin Andrei Kutsa, professor of Ukrainian language and literature Victor Gnazhevsky , teachers of religion (Yuriy Ivanitsky), natural sciences and arithmetic (Luka Skibinetsky), manual labor, calligraphy and drawing (Vasyl Doroshenko), French and German; (Katerina Milyashkevich), teacher of mathematics. Physics and Chemistry (Vasyl Kavun). Describing the preconditions for the emergence of Ukrainian gymnasiums in Volyn, the author notes that at that time in the late 1920's Volyn voivodship operated 1144 schools, of which 390 were late saturdays, 750 Polish and only 4 schools with Ukrainian language education. The state program of assimilation of national minorities (the Ukrainian minority in the Second Common Polish Commonwealth was the second largest national group after the Poles, accounting for about 15% of the total population) in Volhynia was through compulsory school education in the spirit of the Propolis ideology. At the same time, Ukrainians sought to uphold the right to open schools with their native language of instruction even in those areas where they were quantitatively prevailing. This was guaranteed to the Ukrainians by the Polish Constitution of 1921. (Articles 110-111), but in reality it was extremely difficult to achieve this. Even the opening of a Ukrainian private school required a lot of effort - only with the permission of the minister of religion and public education. Kremenets Gymnasium, as well as Lutsk, as well as Rivne (arose thanks to the "Enlightenment" of 1923), nourished the native language, professed Orthodox traditions, revered outstanding national figures, leaders of the nation. It is from this angle that the role of the Ukrainian Gymnasium in Kremenets is shown, along with similar gymnasia in Lutsk and Vinnitsa in the formation of the secular and spiritual national consciousness of the Ukrainian intelligentsia, who later worked on asserting the statehood, including in the UPA ranks, for the development of the Ukrainian national culture.

Abstract Introduction Antimicrobial resistance (AMR) is a global public health issue, which can be addressed through improved antimicrobial stewardship (AMS) knowledge and practice. The CwPAMS programme, launched in 2019, is funded by the UK aid Fleming Fund and managed by Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET).1,2,3 It expanded in 2021 to support 14 health partnerships to enhance AMS capacity by leveraging UK expertise between the UK and 8 Commonwealth countries: Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, Zambia. CwPAMS was supported by UK and LMIC volunteers. Aim The aim of this study was to explore views and experiences of volunteers who took part in the CwPAMS Extension Programme. Methods A cross-sectional survey was developed using Survey Monkey by CPA internal AMS experts and programme managers. The questions explored the key benefits to health organisations and professionals, including the development of AMS skills and competencies, barriers to AMS, and personal/professional development opportunities. Open-ended questions were included to gather further insights into volunteers' views and experiences of volunteering and participating in CwPAMS. The survey was emailed to the 14 health partnerships who took part in the CwPAMS programme between October 2021-May 2022 to be disseminated to all volunteers. Data were collected between 14 April-1 June 2022, transferred to Microsoft Excel and analysed thematically, with frequency counting where appropriate. As it was an internal CPA programme evaluation, no ethical approval was required. Results A total of 83 survey responses were received. The majority respondents were female (60%) and were pharmacists (54%). Volunteers recognised the programme’s positive impact on a personal/professional and organisational level, by fostering knowledge exchange and enhancing AMS practices. Amongst volunteers, 87% noted that their organisation had benefited through their participation in CwPAMS, with 72% stating they had increased AMS capacity in their team. Volunteers highlighted several areas where they applied their newly acquired skills and experiences from their participation in CwPAMS. The most frequently mentioned impactful areas were: 1) Leadership and project management: Volunteers reported improved competencies in establishing local expertise in AMS and infection management, strengthening stakeholder and partnership engagement and improved confidence in project leadership, monitoring, and evaluation. 2) Use of new tools (digital/virtual) for training and AMS use 3) Mentoring, teaching and sharing their knowledge and experiences to support others in their professional development. In addition, volunteers reported they had the opportunity to network and form international partnerships, fostering multidisciplinary collaborations. They also experienced personal development by acquiring leadership, communication, problem-solving, grant application writing, and project management skills. Discussion/Conclusion CwPAMS offers volunteers within health partnerships a distinct opportunity for personal and professional growth, while simultaneously improving AMS related healthcare practices in their organisations. We will continue to expand upon the achievements of the programme by enhancing volunteer experiences, such as the Africa Leadership Fellowship-AMS offering as part of CwPAMS 2, to upskill and enable pharmacists in LMICs to develop leadership roles. Additionally, we aim to strengthen the evaluation of CwPAMS to showcase its impact to the UK and LMICs, respectively. References 1. Commonwealth Pharmacists Association – CwPAMS: Commonwealth Partnerships for Antimicrobial Stewardship. Available at: https://commonwealthpharmacy.org/cwpams (accessed 3 June 2023). 2. Ashiru-Oredope D, Langford BJ, Bonaconsa C, et al. Global collaborations in antimicrobial stewardship: All hands on deck. Antimicrob Steward Healthc Epidemiol, 2023; 3(1): e66. DOI: 10.1017/ash.2023.122. 3. Brandish C, Garraghan F, Ng BY, et al. Assessing the Impact of a Global Health Fellowship on Pharmacists' Leadership Skills and Consideration of Benefits to the National Health Service (NHS) in the United Kingdom. Healthcare (Basel) 2021; 9(7):890. DOI: 10.3390/healthcare9070890.

The article is devoted to a comprehensive study of the Russian ‘soft power’ policy. The author gives her view on the ‘soft power’ phenomenon and practices and draws the line between related concepts of ‘soft power’ and ‘public diplomacy’, all while explaining the reasons for the special interest of the Russian central authorities in the concept for the last two decades, which is embodied in doctrinal documents on foreign affairs. Distinctive features of the country’s understanding of ‘soft power’ and its politics are highlighted.The institutional approach and organizational theory are widely used in the article. With their help, the activities of the main ‘soft power’ institutions functioning in Russian Federation, such as Rossotrudnichestvo (The Federal Agency for the Commonwealth of Independent States Affairs, Compatriots Living Abroad, and International Humanitarian Cooperation), Russkiy Mir Foundation and the Gorchakov Fund are analyzed.The author comes to the conclusion that the lack of a clear formal distribution of responsibilities between departments leads to interdepartmental inconsistency and even competition and significantly reduces the undoubted positive effect of their work.Besides, the article pays special attention to the tools and resources of the Russian ‘soft power’ policy. Apart from traditional tools like language, education, cultural and historical heritage, such new ones that have intensified or appeared due to COVID-19 pandemic are as follows: humanitarian aid and ‘vaccine diplomacy’. And finally, the author gives a forecast on Russian ‘soft power’ in connection with the events on the territory of Ukraine and comes to the conclusion that in the coming years it will be difficult to create an image of an attractive country abroad.

Objective One aim of Australia’s Equally Well National Consensus Statement is to improve monitoring of the physical health of people with mental health conditions, which includes measures of accessibility and people’s experiences of physical health care services. The present analysis contributes to this aim by using population survey data to evaluate whether, and in what domains, Australians with a mental health condition experience barriers in accessing care when compared with Australians without a mental health condition. Methods The 2016 Commonwealth Fund International Health Policy Survey includes a sample of 5248 Australian adults. Access to care was measured using 39 survey questions from before to after reaching services. Multivariable logistic regression models were used to identify disparities in barriers to access, comparing experiences of people with and without a self-reported mental health condition, adjusting for age, sex, immigrant status, income and self-rated health. Results Australians with mental health conditions were more likely to experience barriers for 29 of 39 access measures (odds ratio (OR) >1.55; P<0.05). On average, the prevalence of barriers was 10 percentage points higher for those with a condition. When measured as ratios, the largest barriers for people with mental health conditions were for affordability. When measured as percentage point differences, the largest disparities were observed for experiences of not being treated with respect in hospital. Disparities remained after adjusting for income, rurality, education, immigrant status and self-rated health for 25 of 39 measures. Conclusion Compared with the rest of the community, Australians with mental health conditions have additional challenges negotiating the health system, and are more likely to experience barriers to access to care across a wide range of measures. Understanding the extent to which people with mental health conditions experience barriers throughout the pathway to accessing care is crucial to inform care planning and delivery for this vulnerable group. Results may inform improvements in regular performance monitoring of disparities in access for people with mental health conditions. What is known about this topic? A stated national aim of the Equally Well National Consensus Statement is to improve monitoring of the physical health and well-being of people with mental health conditions through measures of service accessibility and people’s experiences of physical healthcare services. What does this paper add? This paper highlights areas in which health services are not providing equal access to overall care for people with mental health conditions. The analysis offers quantitative evidence of ‘red flag areas’ where people with mental health conditions are significantly more likely to experience barriers to access to care. What are the implications for practitioners? Systematic attention across the health system to making care more approachable and accessible for people with mental health conditions is needed. Practitioners may be engaged to discuss possible interventions to improve access disparities for people with mental health conditions.

This article presents the findings of a study into the effectiveness of trained volunteers working with families where substance abuse was identified as an issue. The study was initiated by Mater Family Support (now known as Mater Parent Aide Unit), Mater Health Services, Brisbane, and funded by the Commonwealth Department of Family and Community Services (now known as the Department of Families, Community Services and Indigenous Affairs). The goals of the study were to begin to understand the effectiveness of volunteer Parent Aide services that have been provided to myriad client groups over many years. The findings demonstrate that the services are valued by this particular target group. This is summed up in the words of one participant who said, ‘Government has to fund this for more people because there are so many people I know who could use it, but haven’t been offered the chance’. Replication of the study with other client groups will further enhance understanding of volunteer service provider effectiveness.

In this article, the author discusses the reasons for creating the National Education Commission, its links with the Enlightenment, the school program, PE and, above all, the centralized system of management and financing of the reform. In the first place, reference was made to the characteristic trends of the Enlightenment, the way the Republic of Poland functioned until the partitions, and in the second part to KEN reform. The reform was not the effect of the long-term state education policy. It was created thanks to the coincidence of the unexpected liquidation of the Jesuit Order in Europe. The financial security of the reform was money gained from the sale of wealth of the Order, used thanks to the pioneering system in Europe of centralized management and financing of the reform. As it turned out, this system – in the absence of control – made it possible to squander and even misappropriate a large part of the funds. The effect of this was the collapse of many schools and a small number of secular teachers (eg. PE was often conducted by older students). In the KEN reform, it is difficult to find the characteristic features of the Enlightenment, because of world-view and mental-cultural issues. Moreover, the reform did not have long term prospects on the one hand due to the limited size of post-Jesussian wealth, on the other – due to the lack of alternative finacial security – regularly incoming taxes to the state, which was not the case in the Commonwealth of Poland.

Purpose – The purpose of this paper is to validate the Endogenous Growth Model by examining the impacts of Human Capital (HK) and Foreign Direct Investment (FDI) on economic growth in ten countries from Commonwealth of Independent States (CIS). Design/methodology/approach – For empirical investigation, a linear regression model based on growth theory and panel data set covering the time-period from 1993 to 2011 are used. Fixed and random effects models are applied. On the basis of the Hausman test, the fixed effects model has been preferred over the random effects model. Findings – The results support the hypothesis of the study by confirming that HK development is critical for economic growth. Similarly, FDI has been found to have a facilitating role in promoting growth in the former Soviet Republics now comprising Central Asian independent economies. This is despite of the fact that there are country-specific differences across CIS. Practical implications – The findings suggest that investment climate in the host countries must be enriched through suitable policies. Improved domestic conditions not only enhance the performance of multinational corporations but also allow host economies to reap greater benefits of FDI inflows. Moreover, the findings demonstrate that investment in both education and health are indispensable. Therefore, improved levels of education and health should be the primary objective running concurrently with other factors in order to stimulate economic growth. Originality/value – The choice of CIS has been made because very little research has been found for the region particularly in the area of economic growth despite strong evidence of commonality in terms of landlocked geographical layout and economic and political structures of these economies. The region has gained importance gradually after independence of these states; and it has started to attract foreign funds in the shape of FDI only recently. Thus, there is a need to evaluate the future prospects pertaining to the importance of FDI and HK on growth performance of these economies and will insistently contribute to the literature.

ARCHITECT IN THE SOCIETY OF THE 18TH CENTURY GRAND DUCHY OF LITHUANIA The article deals with the problem of professional field of activity of an architect, the place of his profession in the system of crafts, sciences and arts, architects’ position in the society of the eighteenth century. Before the education reform undertaken by the Education Commission, architecture had not been developed into a separate subject that provided professional training in the schools of the Grand Duchy of Lithuania. The course in architecture was only a part of general education in Vilnius Jesuit Academy, in nobility schools of a military type, and Jesuit and Piarist Collegium Nobilium. There was not enough focus on architectural studies in these most important educational institutions of the Grand Duchy of Lithuania: a short course of up to two years provided only general and technical basis of the theory of architecture based on classical orders, and it was not capable of training high ranked professionals-practitioners. Until the eighties of the 18th century, to become an independent professional architect one had to continue his studies abroad. It is argued that the Enlightenment concept of a creator serving to the state and society as well as representing them has provided an important impetus to the growth of the value of the architect’s profession and its social status. While many eighteenth-century artists were still very close to craftsmen in terms of social status (it was considered, that they used to do specific tasks and earn a living by employing manual / physical, not intellectual / mental powers), architects, due to the specifics of their education – studies at the university and military careers (they were mostly employed as engineers) were granted titles of nobility. In the eighteenth century, the social and material position of the architect-creator, who had been liberated from the crafts guild system, had evolved considerably and created conditions for privileges and for the establishment in the rank of nobility. The nobilitation of architects, who usually also had the rank of an officer and executed significant orders in large estates, intensified especially during the period of the partitions of the Polish–Lithuanian Commonwealth. Experienced architects were desired and welcome guests in the manors of the nobles. Successful architects used to invest accumulated funds in real estate and manors with land. The architect was no longer just a hired employee but became a patron himself – the one who was initiating and partly financing construction. Keywords: architect, engineer, social status of an architect, Enlightenment, nobilitation.

International Journal of Statistics and Probability wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal is greatly appreciated. Many authors, regardless of whether International Journal of Statistics and Probability publishes their work, appreciate the helpful feedback provided by the reviewers. Reviewers for Volume 8, Number 3 Abdullah A. Smadi, Yarmouk University, Jordan Carla J. Thompson, University of West Florida, USA Carolyn Huston, Commonwealth Scientific and Industrial Research Organization (CSIRO), Australia Faisal Khamis, Al Ain University of Science and Technology, Canada Felix Almendra-Arao, UPIITA del Instituto Politécnico Nacional , México Gane Samb Lo, University Gaston Berger, SENEGAL Gennaro Punzo, University of Naples Parthenope, Italy Gerardo Febres, Universidad Simón Bolívar, Venezuela Jacek Białek, University of Lodz, Poland Kassim S. Mwitondi, Sheffield Hallam University, UK Krishna K. Saha, Central Connecticut State University, USA Man Fung LO, Hong Kong Polytechnic University, Hong Kong Marcelo Bourguignon, Universidade Federal de Pernambuco, Brazil Mingao Yuan, North Dakota State University, USA Mohieddine Rahmouni, University of Tunis, Tunisia Nahid Sanjari Farsipour, Alzahra University, Iran Noha Youssef, American University in Cairo, Egypt Pablo José Moya Fernández, Universidad de Granada, Spain Philip Westgate, University of Kentucky, USA Shatrunjai Pratap Singh, John Hancock Financial Services, USA Sohair F. Higazi, University of Tanta, Egypt Vilda Purutcuoglu, Middle East Technical University (METU), Turkey Vyacheslav Abramov, Swinburne University of Technology, Australia Wei Zhang, The George Washington University, USA Zaixing Li, China University of Mining and Technology (Beijing), China   Wendy Smith On behalf of, The Editorial Board of International Journal of Statistics and Probability Canadian Center of Science and Education

Objective● Describe the diverse determinants of national health and how they are compositely graded in health care system rankings.● Articulate intrinsic reasons why equity should not be subsumed within other evaluative categories.● Design an equity-limited ratings framework for limiting maximum ratings of inequitible healthcare systems.IntroductionHealthcare systems are often evaluated using comparative health care rankings. Simulations have shown that maximally inequitable health care systems can perform well in published, influential health care system rankings by excelling in non-equity categories1, resulting in highly ranked yet grossly inequitable healthcare systems. Recently, despite below average equity rankings, the healthcare systems of Australia and New Zealand ranked among the top four in The Commonwealth Fund’s international comparative study Mirror, Mirror 20172. Equity rankings should logically limit non-equity rankings given the insignificance of healthcare system improvements to those lacking adequate healthcare coverage. We analyzed whether an equity-limited ranking methodology would limit overall rankings for significantly inequitable healthcare systems while maintaining the general findings of the Commonwealth Fund study.MethodsWe reanalyzed The Commonwealth Fund’s 2017 international health care system comparison using a modified, equity-limited methodology. For each country, maximum non-equity domain summary scores were limited to the equity domain summary score. Countries were ranked using the mean of the five domain-specific performance scores. Overall rankings were compared to the original rankings.ResultsSeven of eleven countries had an overall rank change in the equity-limited model. Countries with above average overall ratings but poor equity ratings had the greatest changes in overall rank. Australia’s overall ranking decreased from second to seventh, thereby matching its equity ranking of seventh. New Zealand changed from fourth to eighth overall, matching its equity ranking as well. Other changes were less significant, with changes of only one overall rank position. Notably, the bottom three countries and the top country were unchanged.ConclusionsEquity-limited ranking methodologies can prevent inequitable health care systems from attaining high overall ratings. Such equity-limited rankings are logical considering the diminished significance of health care system improvements to those lacking adequate health coverage. Methodologies that incorporate equity limits should be used to produce fairer rankings that respect the dignity and rights of all individuals.References1. Reisman S, Blumenkranz Z. Comparative health care system rankings can obscure maximal inequities: A simulation study.Society for Public Health Education (SOPHE) 69th Annual Conference. 2018, June.2. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. The Commonwealth Fund. 2017, July.

Mitochondria play a critical role in the life of the cell as they regulate energy production. Translating the significance of Bioenergetics‐ the flow of energy within our living systems for improving mitochondrial health and vitality is critical. Recent reports have highlighted increasing proportion of energy deficiency disorders like childhood obesity, mitochondrial diseases, type II diabetes, to name a few. An important fact is that mitochondrial dysfunction is at the core of these diseases that affect energy production. Therefore our objective was to explore cross‐disciplinary educational methods to teach and engage a wide audience for explaining the complex science and provide a fundamental understanding of how the variety of disorders is related to energy failure. Faculty and students from diverse disciplines in the Arts, Sciences, Engineering and Medicine, along with community partners from the Science Museum of Virginia and patient advocates affiliated with the United Mitochondrial Disease Foundation‐Virginia Chapter, researched and created unique outcomes on bioenergetics and energy deficiency disorders which were displayed over a 3‐month long exhibition to engage the public. Active learning exercises in creative expression, engineering design, digital story telling constituted collaborative, cross‐disciplinary and pedagogical methodologies that resulted in sculptures, documentaries, infographics, public service announcements, computer simulations and teacher training kits. The exhibits at the Science Museum of Virginia support our conclusion that (a) engineering, arts and medicine uniquely contribute to understanding the human condition; (b) integrative problem‐solving methods lead to innovative educational modules and exhibit experiences; and (c) creative communication practices arise from exchange of ideas across diverse disciplines. Our findings are significant, because for the first time, these cell‐to‐society interactive modules have being created to provide students with non‐linear educational experiences while explaining bioenergetics and mitochondrial health to children and adults in our communities.Support or Funding InformationVirginia Commonwealth University Quest for Innovation Fund; Alice T. and William H. Goodwin Jr., Endowment for Engineering Education; Summer at daVinci Works Program; Dean's Office, School of Engineering; Dean's Office, School of the Arts; Pollack Society Student Scholarship; Patients and Families of the United Mitochondrial Disease Foundation, Central VA Chapter; and National Institute of Health (1R15NS080157‐01A1).

Alzheimer's and Parkinson's diseases (AD/PD) are two major neurodegenerative diseases. AD is characterized by the accumulation in brain of two types of abnormal structures, extracellular amyloid plaques and intraneuronal neurofibrillary tangles. Prevalent evidence now indicates that the respective building blocks of plaques and tangles – oligomers of Aβ peptide and the neuron‐specific, axon‐enriched microtubule‐associated protein, tau, represent the most toxic molecular species contributing to AD pathogenesis. Similarly, alpha‐synuclein protein amyloid is a major constitute of Lewy body, protein aggregates that are the pathological hallmark of Parkinson's disease.Currently there are no effective drugs to prevent or cure AD and PD. Because of protein aggregates, including oligomers, mediate neuronal toxicity in AD/PD, small molecule aggregation inhibitors are attractive drug candidates. Many drug trials aimed at preventing or clearing Aβ pathology have failed in recent years. Investigations on tau yielded innovative targets backed by recent findings about the central role of tau in AD pathogenesis (1,2). Preliminary data from a phase 2 trial with the small molecule, methylene blue chloride, have shown some promise and thereby validate the potential of tau aggregation inhibitors (TAIs), but superior TAIs are needed.In this poster we will present our work on expression and purification of human tau and α‐synuclein proteins and their amyloid formation and inhibitor discovery. Tau and α‐synuclein are expressed as recombinant proteins in E. coli and were purified to homogeneity using multiple chromatographic steps. They are further validated by western blot analysis and mass spectrometry. We have developed multiple biochemical, biophysical, and cell‐based assays to monitor oligomer/amyloid formation and amyloid‐induced cytotoxicity assays in characterizing amyloidogenic proteins (3). We use ThT fluorescence‐based assay for semi‐high throughput library screens. Upon identification of “hit” compounds, we validate them with multiple secondary assays including transmission electron microscopy (TEM), photo‐induced crosslinking of unmodified proteins (PICUP), IC50 measurements, and cell‐based cytotoxicity assays. We will further perform mechanistic studies for these validated inhibitors.Support or Funding InformationThis work is in part supported by Virginia Tech new faculty start‐up funds, Commonwealth Health Research Board (CHRB), Alzheimer's and Related Diseases Research Award Fund (ARDRAF) from Virginia Center on Aging, and Diabetes Action Research and Education Foundation (DAREF) to B.X.

Epidemiological and clinical studies showed significant association between type 2 diabetes (T2D) and the risk for Alzheimer's disease. Pancreatic hormone amylin is a highly amyloidogenic protein and amylin amyloid deposition in the pancreas are hallmark features of T2D. Recent clinical studies showed that amylin plaques were deposited in the brain of diabetic patients, but not in healthy controls. We performed cell‐based studies, demonstrating that amylin amyloid is highly toxic to pancreatic β‐cells INS1 and neuronal cells SH‐SY5Y and Neuro2A. From a collection of natural compounds used in alternative medicine, we identified multiple potent inhibitors, including rosmarinic acid (RA) and baicalein (200 nM and 1 μM respectively in apparent IC50). These lead compounds disaggregate amylin fibrils from transmission electron microscopic observations and significantly reduce amylin‐induced cytotoxicity. Dissecting the functional groups of these compounds, we demonstrated, for the first time to our knowledge, that the vicinal hydroxyl groups of the catechol groups played key functional roles in amyloid inhibition in more than a dozen catechol‐containing compounds, including physiological neurotransmitters epinephrine, norepinephrine, and dopamine. Compounds with multiple catechol groups, such as rosmarinic acid, exhibited additive/synergistic effects. We provided further mass spectrometric evidence that incubating several of these catechol‐containing inhibitors with amylin leads to covalent adducts consistent with Schiff base conjugation as a mechanism for blocking toxic amyloid formation. The inhibition effects by these compounds were also demonstrated in molecular simulation analyses, providing additional non‐covalent inhibition mechanisms. To expand protein aggregation inhibitor discovery, we applied the concept of drug repurposing. We developed a 384‐well plate based screening platform and screened a NIH Clinical Collection small molecule library that are currently in phased trials. We were able to rapidly identify 10–30 each of “hits” against four different amyloidogenic proteins: amylin, Aβ, tau, and α‐synuclein. Excitingly, we were able to identify compounds that can inhibit all four amyloids but also “protein‐specific” inhibitors. Mechanisms for “general” protein aggregation inhibitors and for “protein‐specific” aggregation inhibitors will be elucidated.Support or Funding InformationThis work is in part supported by Virginia Tech new faculty start‐up funds, Commonwealth Health Research Board (CHRB), Alzheimer's and Related Diseases Research Award Fund (ARDRAF) from Virginia Center on Aging, Diabetes Action Research and Education Foundation (DAREF), and Virginia Tech Center for Drug Discovery (VTCDD).

On May 18, 2003, the Australian Minister for Education, Brendon Nelson, appeared on the Channel Nine Sunday programme. The Yoda of political journalism, Laurie Oakes, attacked him personally and professionally. He disclosed to viewers that the Minister for Education, Science and Training had suffered a false start in his education, enrolling in one semester of an economics degree that was never completed. The following year, he commenced a medical qualification and went on to become a practicing doctor. He did not pay fees for any of his University courses. When reminded of these events, Dr Nelson became agitated, and revealed information not included in the public presentation of the budget of that year, including a ‘cap’ on HECS-funded places of five years for each student. He justified such a decision with the cliché that Australia’s taxpayers do not want “professional students completing degree after degree.” The Minister confirmed that the primary – and perhaps the only – task for university academics was to ‘train’ young people for the workforce. The fact that nearly 50% of students in some Australian Universities are over the age of twenty five has not entered his vision. He wanted young people to complete a rapid degree and enter the workforce, to commence paying taxes and the debt or loan required to fund a full fee-paying place. Now – nearly two years after this interview and with the Howard government blessed with a new mandate – it is time to ask how this administration will order education and value teaching and learning. The curbing of the time available to complete undergraduate courses during their last term in office makes plain the Australian Liberal Government’s stance on formal, publicly-funded lifelong learning. The notion that a student/worker can attain all required competencies, skills, attributes, motivations and ambitions from a single degree is an assumption of the new funding model. It is also significant to note that while attention is placed on the changing sources of income for universities, there have also been major shifts in the pattern of expenditure within universities, focusing on branding, marketing, recruitment, ‘regional’ campuses and off-shore courses. Similarly, the short-term funding goals of university research agendas encourage projects required by industry, rather than socially inflected concerns. There is little inevitable about teaching, research and education in Australia, except that the Federal Government will not create a fully-funded model for lifelong learning. The task for those of us involved in – and committed to – education in this environment is to probe the form and rationale for a (post) publicly funded University. This short paper for the ‘order’ issue of M/C explores learning and teaching within our current political and economic order. Particularly, I place attention on the synergies to such an order via phrases like the knowledge economy and the creative industries. To move beyond the empty promises of just-in-time learning, on-the-job training, graduate attributes and generic skills, we must reorder our assumptions and ask difficult questions of those who frame the context in which education takes place. For the term of your natural life Learning is a big business. Whether discussing the University of the Third Age, personal development courses, self help bestsellers or hard-edged vocational qualifications, definitions of learning – let alone education – are expanding. Concurrent with this growth, governments are reducing centralized funding and promoting alternative revenue streams. The diversity of student interests – or to use the language of the time, client’s learning goals – is transforming higher education into more than the provision of undergraduate and postgraduate degrees. The expansion of the student body beyond the 18-25 age group and the desire to ‘service industry’ has reordered the form and purpose of formal education. The number of potential students has expanded extraordinarily. As Lee Bash realized Today, some estimates suggest that as many as 47 percent of all students enrolled in higher education are over 25 years old. In the future, as lifelong learning becomes more integrated into the fabric of our culture, the proportion of adult students is expected to increase. And while we may not yet realize it, the academy is already being transformed as a result. (35) Lifelong learning is the major phrase and trope that initiates and justifies these changes. Such expansive economic opportunities trigger the entrepreneurial directives within universities. If lifelong learning is taken seriously, then the goals, entry standards, curriculum, information management policies and assessments need to be challenged and changed. Attention must be placed on words and phrases like ‘access’ and ‘alternative entry.’ Even more consideration must be placed on ‘outcomes’ and ‘accountability.’ Lifelong learning is a catchphrase for a change in purpose and agenda. Courses are developed from a wide range of education providers so that citizens can function in, or at least survive, the agitation of the post-work world. Both neo-liberal and third way models of capitalism require the labeling and development of an aspirational class, a group who desires to move ‘above’ their current context. Such an ambiguous economic and social goal always involves more than the vocational education and training sector or universities, with the aim being to seamlessly slot education into a ‘lifestyle.’ The difficulties with this discourse are two-fold. Firstly, how effectively can these aspirational notions be applied and translated into a real family and a real workplace? Secondly, does this scheme increase the information divide between rich and poor? There are many characteristics of an effective lifelong learner including great personal motivation, self esteem, confidence and intellectual curiosity. In a double shifting, change-fatigued population, the enthusiasm for perpetual learning may be difficult to summon. With the casualization of the post-Fordist workplace, it is no surprise that policy makers and employers are placing the economic and personal responsibility for retraining on individual workers. Instead of funding a training scheme in the workplace, there has been a devolving of skill acquisition and personal development. Through the twentieth century, and particularly after 1945, education was the track to social mobility. The difficulty now – with degree inflation and the loss of stable, secure, long-term employment – is that new modes of exclusion and disempowerment are being perpetuated through the education system. Field recognized that “the new adult education has been embraced most enthusiastically by those who are already relatively well qualified.” (105) This is a significant realization. Motivation, meta-learning skills and curiosity are increasingly being rewarded when found in the already credentialed, empowered workforce. Those already in work undertake lifelong learning. Adult education operates well for members of the middle class who are doing well and wish to do better. If success is individualized, then failure is also cast on the self, not the social system or policy. The disempowered are blamed for their own conditions and ‘failures.’ The concern, through the internationalization of the workforce, technological change and privatization of national assets, is that failure in formal education results in social exclusion and immobility. Besides being forced into classrooms, there are few options for those who do not wish to learn, in a learning society. Those who ‘choose’ not be a part of the national project of individual improvement, increased market share, company competitiveness and international standards are not relevant to the economy. But there is a personal benefit – that may have long term political consequences – from being ‘outside’ society. Perhaps the best theorist of the excluded is not sourced from a University, but from the realm of fictional writing. Irvine Welsh, author of the landmark Trainspotting, has stated that What we really need is freedom from choice … People who are in work have no time for anything else but work. They have no mental space to accommodate anything else but work. Whereas people who are outside the system will always find ways of amusing themselves. Even if they are materially disadvantaged they’ll still find ways of coping, getting by and making their own entertainment. (145-6) A blurring of work and learning, and work and leisure, may seem to create a borderless education, a learning framework uninhibited by curriculum, assessment or power structures. But lifelong learning aims to place as many (national) citizens as possible in ‘the system,’ striving for success or at least a pay increase which will facilitate the purchase of more consumer goods. Through any discussion of work-place training and vocationalism, it is important to remember those who choose not to choose life, who choose something else, who will not follow orders. Everybody wants to work The great imponderable for complex economic systems is how to manage fluctuations in labour and the market. The unstable relationship between need and supply necessitates flexibility in staffing solutions, and short-term supplementary labour options. When productivity and profit are the primary variables through which to judge successful management, then the alignments of education and employment are viewed and skewed through specific ideological imperatives. The library profession is an obvious occupation that has confronted these contradictions. It is ironic that the occupation that orders knowledge is experiencing a volatile and disordered workplace. In the past, it had been assumed that librarians hold a degree while technicians do not, and that technicians would not be asked to perform – unsupervised – the same duties as librarians. Obviously, such distinctions are increasingly redundant. Training packages, structured through competency-based training principles, have ensured technicians and librarians share knowledge systems which are taught through incremental stages. Mary Carroll recognized the primary questions raised through this change. If it is now the case that these distinctions have disappeared do we need to continue to draw them between professional and para-professional education? Does this mean that all sectors of the education community are in fact learning/teaching the same skills but at different levels so that no unique set of skills exist? (122) With education reduced to skills, thereby discrediting generalist degrees, the needs of industry have corroded the professional standards and stature of librarians. Certainly, the abilities of library technicians are finally being valued, but it is too convenient that one of the few professions dominated by women has suffered a demeaning of knowledge into competency. Lifelong learning, in this context, has collapsed high level abilities in information management into bite sized chunks of ‘skills.’ The ideology of lifelong learning – which is rarely discussed – is that it serves to devalue prior abilities and knowledges into an ever-expanding imperative for ‘new’ skills and software competencies. For example, ponder the consequences of Hitendra Pillay and Robert Elliott’s words: The expectations inherent in new roles, confounded by uncertainty of the environment and the explosion of information technology, now challenge us to reconceptualise human cognition and develop education and training in a way that resonates with current knowledge and skills. (95) Neophilliacal urges jut from their prose. The stress on ‘new roles,’ and ‘uncertain environments,’ the ‘explosion of information technology,’ ‘challenges,’ ‘reconceptualisations,’ and ‘current knowledge’ all affirms the present, the contemporary, and the now. Knowledge and expertise that have taken years to develop, nurture and apply are not validated through this educational brief. The demands of family, work, leisure, lifestyle, class and sexuality stretch the skin taut over economic and social contradictions. To ease these paradoxes, lifelong learning should stress pedagogy rather than applications, and context rather than content. Put another way, instead of stressing the link between (gee wizz) technological change and (inevitable) workplace restructuring and redundancies, emphasis needs to be placed on the relationship between professional development and verifiable technological outcomes, rather than spruiks and promises. Short term vocationalism in educational policy speaks to the ordering of our public culture, requiring immediate profits and a tight dialogue between education and work. Furthering this logic, if education ‘creates’ employment, then it also ‘creates’ unemployment. Ironically, in an environment that focuses on the multiple identities and roles of citizens, students are reduced to one label – ‘future workers.’ Obviously education has always been marinated in the political directives of the day. The industrial revolution introduced a range of technical complexities to the workforce. Fordism necessitated that a worker complete a task with precision and speed, requiring a high tolerance of stress and boredom. Now, more skills are ‘assumed’ by employers at the time that workplaces are off-loading their training expectations to the post-compulsory education sector. Therefore ‘lifelong learning’ is a political mask to empower the already empowered and create a low-level skill base for low paid workers, with the promise of competency-based training. Such ideologies never need to be stated overtly. A celebration of ‘the new’ masks this task. Not surprisingly therefore, lifelong learning has a rich new life in ordering creative industries strategies and frameworks. Codifying the creative The last twenty years have witnessed an expanding jurisdiction and justification of the market. As part of Tony Blair’s third way, the creative industries and the knowledge economy became catchwords to demonstrate that cultural concerns are not only economically viable but a necessity in the digital, post-Fordist, information age. Concerns with intellectual property rights, copyright, patents, and ownership of creative productions predominate in such a discourse. Described by Charles Leadbeater as Living on Thin Air, this new economy is “driven by new actors of production and sources of competitive advantage – innovation, design, branding, know-how – which are at work on all industries.” (10) Such market imperatives offer both challenges and opportunity for educationalists and students. Lifelong learning is a necessary accoutrement to the creative industries project. Learning cities and communities are the foundations for design, music, architecture and journalism. In British policy, and increasingly in Queensland, attention is placed on industry-based research funding to address this changing environment. In 2000, Stuart Cunningham and others listed the eight trends that order education, teaching and learning in this new environment. The Changes to the Provision of Education Globalization The arrival of new information and communication technologies The development of a knowledge economy, shortening the time between the development of new ideas and their application. The formation of learning organizations User-pays education The distribution of knowledge through interactive communication technologies (ICT) Increasing demand for education and training Scarcity of an experienced and trained workforce Source: S. Cunningham, Y. Ryan, L. Stedman, S. Tapsall, K. Bagdon, T. Flew and P. Coaldrake. The Business of Borderless Education. Canberra: DETYA Evaluation and Investigations Program [EIP], 2000. This table reverberates with the current challenges confronting education. Mobilizing such changes requires the lubrication of lifelong learning tropes in university mission statements and the promotion of a learning culture, while also acknowledging the limited financial conditions in which the educational sector is placed. For university scholars facilitating the creative industries approach, education is “supplying high value-added inputs to other enterprises,” (Hartley and Cunningham 5) rather than having value or purpose beyond the immediately and applicably economic. The assumption behind this table is that the areas of expansion in the workforce are the creative and service industries. In fact, the creative industries are the new service sector. This new economy makes specific demands of education. Education in the ‘old economy’ and the ‘new economy’ Old Economy New Economy Four-year degree Forty-year degree Training as a cost Training as a source of competitive advantage Learner mobility Content mobility Distance education Distributed learning Correspondence materials with video Multimedia centre Fordist training – one size fits all Tailored programmes Geographically fixed institutions Brand named universities and celebrity professors Just-in-case Just-in-time Isolated learners Virtual learning communities Source: T. Flew. “Educational Media in Transition: Broadcasting, Digital Media and Lifelong Learning in the Knowledge Economy.” International Journal of Instructional Media 29.1 (2002): 20. There are myriad assumptions lurking in Flew’s fascinating table. The imperative is short courses on the web, servicing the needs of industry. He described the product of this system as a “learner-earner.” (50) This ‘forty year degree’ is based on lifelong learning ideologies. However Flew’s ideas are undermined by the current government higher education agenda, through the capping – through time – of courses. The effect on the ‘learner-earner’ in having to earn more to privately fund a continuance of learning – to ensure that they keep on earning – needs to be addressed. There will be consequences to the housing market, family structures and leisure time. The costs of education will impact on other sectors of the economy and private lives. Also, there is little attention to the groups who are outside this taken-for-granted commitment to learning. Flew noted that barriers to greater participation in education and training at all levels, which is a fundamental requirement of lifelong learning in the knowledge economy, arise in part out of the lack of provision of quality technology-mediated learning, and also from inequalities of access to ICTs, or the ‘digital divide.’ (51) In such a statement, there is a misreading of teaching and learning. Such confusion is fuelled by the untheorised gap between ‘student’ and ‘consumer.’ The notion that technology (which in this context too often means computer-mediated platforms) is a barrier to education does not explain why conventional distance education courses, utilizing paper, ink and postage, were also unable to welcome or encourage groups disengaged from formal learning. Flew and others do not confront the issue of motivation, or the reason why citizens choose to add or remove the label of ‘student’ from their bag of identity labels. The stress on technology as both a panacea and problem for lifelong learning may justify theories of convergence and the integration of financial, retail, community, health and education provision into a services sector, but does not explain why students desire to learn, beyond economic necessity and employer expectations. Based on these assumptions of expanding creative industries and lifelong learning, the shape of education is warping. An ageing population requires educational expenditure to be reallocated from primary and secondary schooling and towards post-compulsory learning and training. This cost will also be privatized. When coupled with immigration flows, technological changes and alterations to market and labour structures, lifelong learning presents a profound and personal cost. An instrument for economic and social progress has been individualized, customized and privatized. The consequence of the ageing population in many nations including Australia is that there will be fewer young people in schools or employment. Such a shift will have consequences for the workplace and the taxation system. Similarly, those young workers who remain will be far more entrepreneurial and less loyal to their employers. Public education is now publically-assisted education. Jane Jenson and Denis Saint-Martin realized the impact of this change. The 1980s ideological shift in economic and social policy thinking towards policies and programmes inspired by neo-liberalism provoked serious social strains, especially income polarization and persistent poverty. An increasing reliance on market forces and the family for generating life-chances, a discourse of ‘responsibility,’ an enthusiasm for off-loading to the voluntary sector and other altered visions of the welfare architecture inspired by neo-liberalism have prompted a reaction. There has been a wide-ranging conversation in the 1990s and the first years of the new century in policy communities in Europe as in Canada, among policy makers who fear the high political, social and economic costs of failing to tend to social cohesion. (78) There are dense social reorderings initiated by neo-liberalism and changing the notions of learning, teaching and education. There are yet to be tracked costs to citizenship. The legacy of the 1980s and 1990s is that all organizations must behave like businesses. In such an environment, there are problems establishing social cohesion, let alone social justice. To stress the product – and not the process – of education contradicts the point of lifelong learning. Compliance and complicity replace critique. (Post) learning The Cold War has ended. The great ideological battle between communism and Western liberal democracy is over. Most countries believe both in markets and in a necessary role for Government. There will be thunderous debates inside nations about the balance, but the struggle for world hegemony by political ideology is gone. What preoccupies decision-makers now is a different danger. It is extremism driven by fanaticism, personified either in terrorist groups or rogue states. Tony Blair (http://www.number-10.gov.uk/output/Page6535.asp) Tony Blair, summoning his best Francis Fukuyama impersonation, signaled the triumph of liberal democracy over other political and economic systems. His third way is unrecognizable from the Labour party ideals of Clement Attlee. Probably his policies need to be. Yet in his second term, he is not focused on probing the specificities of the market-orientation of education, health and social welfare. Instead, decision makers are preoccupied with a war on terror. Such a conflict seemingly justifies large defense budgets which must be at the expense of social programmes. There is no recognition by Prime Ministers Blair or Howard that ‘high-tech’ armory and warfare is generally impotent to the terrorist’s weaponry of cars, bodies and bombs. This obvious lesson is present for them to see. After the rapid and successful ‘shock and awe’ tactics of Iraq War II, terrorism was neither annihilated nor slowed by the Coalition’s victory. Instead, suicide bombers in Saudi Arabia, Morocco, Indonesia and Israel snuck have through defenses, requiring little more than a car and explosives. More Americans have been killed since the war ended than during the conflict. Wars are useful when establishing a political order. They sort out good and evil, the just and the unjust. Education policy will never provide the ‘big win’ or the visible success of toppling Saddam Hussein’s statue. The victories of retraining, literacy, competency and knowledge can never succeed on this scale. As Blair offered, “these are new times. New threats need new measures.” (ht tp://www.number-10.gov.uk/output/Page6535.asp) These new measures include – by default – a user pays education system. In such an environment, lifelong learning cannot succeed. It requires a dense financial commitment in the long term. A learning society requires a new sort of war, using ideas not bullets. References Bash, Lee. “What Serving Adult Learners Can Teach Us: The Entrepreneurial Response.” Change January/February 2003: 32-7. Blair, Tony. “Full Text of the Prime Minister’s Speech at the Lord Mayor’s Banquet.” November 12, 2002. http://www.number-10.gov.uk/output/Page6535.asp. Carroll, Mary. “The Well-Worn Path.” The Australian Library Journal May 2002: 117-22. Field, J. Lifelong Learning and the New Educational Order. Stoke on Trent: Trentham Books, 2000. Flew, Terry. “Educational Media in Transition: Broadcasting, Digital Media and Lifelong Learning in the Knowledge Economy.” International Journal of Instructional Media 29.1 (2002): 47-60. Hartley, John, and Cunningham, Stuart. “Creative Industries – from Blue Poles to Fat Pipes.” Department of Education, Science and Training, Commonwealth of Australia (2002). Jenson, Jane, and Saint-Martin, Denis. “New Routes to Social Cohesion? Citizenship and the Social Investment State.” Canadian Journal of Sociology 28.1 (2003): 77-99. Leadbeater, Charles. Living on Thin Air. London: Viking, 1999. Pillay, Hitendra, and Elliott, Robert. “Distributed Learning: Understanding the Emerging Workplace Knowledge.” Journal of Interactive Learning Research 13.1-2 (2002): 93-107. Welsh, Irvine, from Redhead, Steve. “Post-Punk Junk.” Repetitive Beat Generation. Glasgow: Rebel Inc, 2000: 138-50. Citation reference for this article MLA Style Brabazon, Tara. "Freedom from Choice: Who Pays for Customer Service in the Knowledge Economy?." M/C Journal 7.6 (2005). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0501/02-brabazon.php>. APA Style Brabazon, T. (Jan. 2005) "Freedom from Choice: Who Pays for Customer Service in the Knowledge Economy?," M/C Journal, 7(6). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0501/02-brabazon.php>.

Abstract Study Question What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference? Summary Answer International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS. What is Known Already The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist. Study Design, Size, Duration The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout. Participants/Materials, Setting, Methods This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC). Main Results and the Role of Chance The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management. Limitations, Reasons for Caution Overall, recommendations are strengthened and evidence is improved, but remain generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided. Wider Implications of the Findings The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation programme supports the Guideline with an integrated evaluation program. Study Funding/Competing Interest(s) This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and the European Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the sponsoring organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.

IntroductionThe National School Chaplaincy and Student Welfare Program (NSCSWP) has been one of the most controversial Australian news topics in the past eight years. Newspaper representations of the NSCSWP have been prolific since the Program began in 2006/07. In my previous research into the NSCSWP, I found that initially the Program was well received. Following the High Court Challenge campaign, however, which began in late 2010, newspaper reports portrayed the NSCSWP in a predominantly negative light. These negative portrayals of the NSCSWP persisted in the lead up to the second High Court Challenge from 2013 until June 2014. During this time, newspaper representations portrayed the Program as an illegitimate form of counseling for state school students. However, I would argue that it was the newspaper representations of the NSCSWP that were in fact illegitimate. In this article, I contend that illegitimate representations of the NSCSWP became hegemonic because of a lack of evidence-based research conducted into the Program’s operation within state schools. Evidence-based research would have appropriately evaluated the Program’s progress and contributed to a legitimate and fair representation of chaplains in online newspapers. My analysis acknowledges the overwhelming prejudice against the NSCSWP. Whether chaplains were indeed a legitimate or illegitimate form of counseling is not my argument. My argument is that newspaper representations of the NSCSWP were illegitimate because news articles were presenting biased and incomplete information to the Australian community. Defining IllegitimacyIllegitimacy as a term has a long history dating back to early modern England, when it was commonly used to refer to children born out of wedlock (Pritchard 19). However, the definition of illegitimacy extends beyond this social phenomenon. Katie Pritchard states:The understanding of illegitimacy encompasses a kind of theoretical illegitimacy that is nothing to do with birth, referring to a kind of falseness or unsuitability that can be applied in many circumstances. (21)For this article, I will be using the term ‘illegitimate’ to describe how the newspaper representations of the NSCSWP were unsuitable because they were biased and lacked valuable information. Newspaper reports, which can be accessed online via the newspaper company’s website, include important authoritative voices. However, these voices expressed a certain opinion or concern, rather than delivering information that contributed to society’s understanding of the NSCSWP. Therefore, newspapers did not present legitimate facts, but instead a range of subjective opinions.The Illegitimacy of Newspaper ReportingThe ideological bias of newspapers has been recently examined regarding News Corp, the owner of national title The Australian, and many of the major Australian state newspapers: The Daily Telegraph; The Courier Mail, Herald Sun; The Advertiser; and Sunday Times. This organisation has recently been accused of showing bias in its newspaper articles (Meade). Meade quotes Mark Scott, the ABC Managing Director, who states:Given the aggressive editorial positioning of some of their mastheads and their willingness to adopt and pursue an editorial position, an ideological position and a market segmentation, you could argue that News Corporation newspapers have never been more assertive in exercising media power. (1)The market domination enjoyed by large organisations such as News Corp, and even Fairfax Media, leads to consistency in journalists’ writing on political, social, religious, and economic issues, which may predominate over the articles published by smaller newspapers. There is the concern that over time a particular point of view will be favoured. According to Mark Scott “a range of influential voices [is] essential to ensure a fair and open media” (Meade 1). Scott cites Rupert Murdoch who stated, back in 1967, that “freedom of the press mustn’t be one-sided just for a publisher to speak as he pleases, to try and bully the community” (Meade 1). Therefore, it has been acknowledged that a biased news article is illegitimate, and national news articles are to present facts, not the opinions of the newspaper.A Methodological Framework For this article I will utilise Norman Fairclough’s theory of Critical Discourse Analysis. Fairclough states:By ‘critical’ discourse analysis I mean discourse analysis which aims to systematically explore often opaque relationships of causality and determination between (a) discursive practices, events and texts and (b) wider social and cultural structures, relations and processes. (132-133)This method of analysis examines three assumptions: Existential, Propositional and Value. Existential assumptions make claims about what exists with regards to the problem, and refers to social phenomena such as globalisation or social cohesion (56). Propositional assumptions make predictions about what is or will be (55). Value assumptions simply evaluate things as good or bad, needed or not needed (57). These assumptions can be identified through analysis of the various direct quotes included within online newspaper articles.Direct quotations in newspaper articles available online often represent polarised views demonstrating whether people agree or disagree with the topic being discussed. The selection, or framing, of dominant voices within an article can be used to construct or re-present certain ideologies (Entman, 165). Entman explains that “we can define framing as the process of culling a few elements of perceived reality and assembling a narrative that highlights connections among them to promote a particular interpretation” (164). The framing of direct quotes within an article, therefore, assists the reader in identifying the article’s bias. The National School Chaplaincy and Student Welfare ProgramThe National School Chaplaincy Program was first established in 2006 by the Howard Government, and in 2011 Julia Gillard included secular youth workers, expanding it from 2012 to become the National School Chaplaincy and Student Welfare Program. According to the National School Chaplaincy and Student Welfare Guidelines, the Program aimed to “assist school communities to provide pastoral care and general spiritual, social and emotional comfort to all students, irrespective of their faith or beliefs” (6). Chaplaincy in Australia has been a predominantly Christian counseling service with Christianity being the most commonly practiced religion in Australia (Australian Bureau of Statistics). However, there have been chaplains representing other faiths such as Islam, Judaism and Buddhism (Australian Government 8). Chaplains were chosen by their respective schools and were partly funded by the Government to provide support to students and staff.State Newspaper Articles Online: Representations 2013-2014My sample of articles came from nine state newspapers with an online presence: The Sydney Morning Herald, Brisbane Courier Mail, Adelaide Advertiser, Melbourne Age, Northern Times, The Australian, The West Australian, The Daily Telegraph, and The Mercury. A total of 36 articles were collected, from the newspaper’s Website, for 2013 and 2014, and were divided into two categories.The two categories are Supportive (of the Program) and Unsupportive (of the Program). In 2013, two articles were supportive of the Program, whereas in 2014 there were four. In 2013 three articles were unsupportive of the Program, whereas in 2014 there were 27 unsupportive articles, representing the growing interest in the scheme in the final lead up to the High Court Challenge in 2014. An online newspaper article from 2013, which portrays the NSCSWP and in particular chaplains as illegitimate, is Call for Naked School Chaplain to Be Defrocked (Domjen). This article explains how an off-duty school chaplain was preaching naked in the main street of a country town in NSW. The NSW Teachers Federation President Maurie Mulheron, and Parents and Citizens Association publicity officer Rachael Sowden were quoted in this article. It is through their direct quotes that the illegitimacy of chaplaincy is framed. President Mulheron states:We believe the chaplaincy program is wrong and that money should be used for an increase in school-based counsellors. Obviously the right checks and balances are not in place. (1)When President Mulheron states “We” it is unclear to the reader as to whether he is referring to all NSW Teachers or the organisation’s administrators. The reader is left to make their own assumptions about whom he is referring to. The President also makes a value assumption that the money would be better spent on school-based counselors, thus expressing his own opinion that they are a better option. A propositional assumption is made when he claims that the “right checks and balances are not in place”, but is he basing his claim on this one incident or is there other research to support this assumption?Perhaps this naked chaplain appeared fine when the school hired him, perhaps he does not have a previous record of inappropriate behaviour, perhaps it was an isolated incident. The reader is not given any background information on this chaplain and is therefore meant to take the President’s assumptions as legitimate fact. Ms Sowden, representing the Parents’ and Citizens’ Association, also expresses the same assumptions and concerns. Ms Sowden states:We have great concerns about the chaplain scheme - many parents do. We are concerned about whether they go through the same processes as teachers in terms of working with children checks and their suitability to the position, and this case highlights that.Ms Sowden makes a propositional assumption that many parents and citizens are concerned about the Program. It would be interesting to know what the Parents and Citizens Association was doing about this, considering the choice to have a chaplain is a decision made by the school community? Ms Sowden also asks whether chaplains “go through the same processes as teachers in terms of working with children checks and their suitability to the position”. Chaplains do not go through the same process as teachers in their training as they have a different role in the school. However, chaplains do require a Certificate IV in Pastoral Care as well as a Working with Children Check because they are in close proximity to children, and are being paid for their school counseling service (Working with Children Check). Ms Sowden’s value assumption that chaplains are unsuitable for the position is based on her own limited understanding of their qualifications, which she admits to not knowing. In fact, to be appointed to represent parents and citizens and to even voice their concerns, but not know the qualifications of chaplains in her community, is an interesting area of ignorance.This article has been framed to evaluate the actions of all chaplains through the example of a publicly-naked chaplain, discussed without context in this article. The Program is portrayed as hiring unsuitable and thus illegitimate chaplains. However, the quotes are based on concerns and assumptions that are unfounded, and are fears presented as facts. Therefore the representation is illegitimate because it does not report any information that the public can use to better understand the NSCSWP, or even to understand the circumstances surrounding the chaplain who preached naked in the street. Another article from 2014, which represents chaplains as illegitimate, is Push to Divert Chaplain Cash to School Councillors (Paine). This article focuses on the comments of the Tasmanian Association of State School Organisations President Jenny Eddington, and the Australian Education Union President Angelo Gavrielatos. These dominant voices within the Tasmanian and Australian communities are chosen to express their opinion that the money once used for chaplains should now be used to fund psychologists in schools. AEU President Angelo Gavrielatos states: Apart from undermining our secular traditions, this additional funding should have been allocated to schools to better meet the educational needs of students with trained, specialist staff.Mr Gavrielatos makes a propositional assumption that chaplains are untrained staff and are thus illegitimate staff. However, chaplains are trained and specialise in providing counseling services. Thus, through his call for “trained, specialist staff” he aims to delegitimize the training of chaplains. Mr Gavrielatos also makes a value assumption when he claims that the funding put towards the NSCSWP undermines “our secular traditions”. “Secular traditions” is an existential assumption in positioning that Australians have secular traditions, and that these do not involve chaplaincy because the Australian Government is not supposed to support religion. The Australian Bureau of Statistics states:Enlightenment principles promoted a secular government, detached from the church, that encouraged tolerance and supported religious pluralism, including the right to practice no religion. By Federation, this diversity was enshrined in the Australian Constitution, which says that the Commonwealth shall not make any law for establishing any religion, or for imposing any religious observance, or for prohibiting the free exercise of any religion. (1)The funding of the Program was a contentious issue from the time of its inception; although it could be argued that it was the prerogative of the Government to support the practice of diverse cultural and religious beliefs by allowing schools to hire religious counselors of their choice. Given that not every student is Christian some would perhaps benefit from chaplains or counselors representing other faiths.These news articles have selected dominant voices to construct and promote an ideology of chaplains as an illegitimate resource for school communities. In these newspaper reports existential, propositional and value assumptions were expressed by dominant voices who expressed concern about the role and behaviour of chaplains in schools. However, research into the Program and its operation within each state may have avoided the representation of unfounded and illegitimate assumptions.Evidence-Based Research: Avoiding Illegitimacy Over the course of the Chaplaincy Program various resources, such as reports and journal articles attempted to provide evidence of how the NSCSWP was funded and operated within state schools.The Department of Education received frequent progress reports by state schools who hired chaplains, although this information was not made available to the public. However, in 2011 then Education Minister Peter Garrett released a discussion paper informing Australians about the current set up of the Program and how the community could have their say on the Program’s fulfillment from 2012-2014. The discussion paper was reported on by The Australian, which portrayed the Program as not catering to the needs of Australian youth because chaplains are predominantly Christian (Ferrari). The newspaper report focuses on the concerns of Australian communities regarding the funding, and qualifications of chaplains, and the cost of the Program. Thus, the Program appeared illegitimate and as though it could not cater to the Australian community’s expectations.Reports conducted by organisations external to the Education Department tried to examine schools communities’ expectations and experiences of the Program. One such report was written in 2009 by Dr Philip Hughes and Professor Margaret Sims from Edith Cowan University who aimed to examine how Australian schools evaluated the Program, and the role of chaplains, but their report excluded the state of NSW.Hughes and Sims state that chaplains’ “contribution was widely appreciated” by schools (6). This report attempted to provide a legitimate and independent account of the Program, however, the report was deemed biased by NSW Greens MLC, Dr John Kaye who remarked that the study was “deeply flawed” and lacked independence (Thielking & MacKenzie 1). According to critics, the study focussed on the positive benefits of chaplains, but the only benefit that was unique to them was that they were religious (The Greens). The study also neglected to report that Hughes was an employee of the Christian Research Association and that his background could impede his objectivity. In the same year, 2009, ACCESS ministries published a report titled: The value of chaplains in Victorian schools. The independent research conducted by Social Compass covers: “the value of chaplains; their social, spiritual and academic impacts; the difference made to the health, well being and quality of life of students; and the contributions made to strengthen communities” (2).This study promoted a positive view of chaplaincy within schools and tried to report on a portion of the community’s experiences with chaplains. However, it was limited in that it pertains only to Victorian schools and received very little media attention online. Even if this information were available online it would have only related to Victoria. Further research conducted into chaplaincy has been published in the Journal of Christian Education. This journal contains many articles on chaplaincy, but these are not easily available online as they require a subscription. The findings from these articles have not been published in newspaper articles online and have therefore not been made available to the general public. The Christian bias of the journal may have also contributed to its contents being neglected by news articles made available online, although they might have assisted in providing a more balanced representation of the NSCSWP.The extent of the research conducted into The National School Chaplaincy and Student Welfare Program has not been entirely delineated here, but these are some of the prominent resources. Nonetheless, the rigorous evaluation of the contribution of the NSCSWP was minimal, and the quality of its evaluation predominantly biased.Robert Slavin states that school program evaluations must “produce reliable, unbiased, and meaningful information on the strength of evidence behind each program” (1). Unfortunately, the research conducted into the Chaplaincy Program was not free from bias, consistent or properly designed in a way that legitimately evaluated the NSCSWP. According to Monica Thielking and David MacKenzie:The fact is that the provision of support services for students in Australian schools has never been subjected to serious research and evaluation, and any analysis is made more difficult by the fact that the various states and territories deploy somewhat different models. (1)Thus, the information on the Chaplaincy Program’s progress and the responsibilities of chaplains in schools was not comprehensive or accurate enough to be appropriately reported in newspapers available online. Therefore, newspaper articles used quotes and information based on a limited understanding of the Program, which in turn produced illegitimate representations of the NSCSWP.ConclusionNewspaper reports available online drew conclusions about the Program’s effectiveness, which had not been appropriately tested. If research had been made available to the public, or published within state-based media online, Australians would have had a more legitimate understanding of the Program’s operation within state education, even if that understanding could not have changed the High Court ruling.The Chaplaincy Program demonstrates how a lack of evidence-based research allows the media to construct illegitimate representations based on promoting the assumptions of dominant, and I would argue the loudest, voices, in society. The bias represented in a consistent approach adopted by newspapers owned by dominant media companies, is a factor in the re-presentation and promotion of certain ideologies. This was made evident by the fact that, in 2014, across nine state newspapers available online, 27 articles were unsupportive of the Program as opposed to only four articles that were supportive. Audiences need to be presented with facts rather than opinions, which are based on very little research. Hopefully newspaper reporting will change in the future to offer audiences a more legitimate representation of news events. ReferencesACCESS Ministries. The Value of Chaplains in Victorian Schools. NSW, 2009. Australian Bureau of Statistics. "Reflecting a Nation: Stories from the 2011 Census, 2012–2013." 2012. Australian Government. National School Chaplaincy Program: A Discussion Paper. Australia: Commonwealth of Australian, 2011. Chaplaincy Australia. "Training." n.d. Commonwealth of Australia. National School Chaplaincy and Student Welfare Program Guidelines. Australia: Australian Government, 2012. Domjen, Briana. “Call for Naked School Chaplain to Be Defrocked.” The Australian 3 Feb. 2013: 1.Entman, Robert. "Framing Bias: Media in the Distribution of Power." Journal of Communications 1 (2007): 163-73.Fairclough, Norman. Analysing Discourse: Textual Analysis for Social Research. London: Longman, 2003.Ferrari, Justine. "School Chaplains Not Representative." The Australian 12 Feb. 2011: 1.Hughes, Philip, and Margaret Sims. The Effectivess of Chaplaincy: As Provided by the National School Chaplaincy Association to Government Schools in Australia. Perth: Edith Cowan University, 2009.Meade, Amanda. "Mark Scott: News Corp Papers Never More Aggressive than Now." The Guardian 3 Oct. 2014: 1.Paine, Michelle. “Push to Divert Chaplain Cash to School Councillors.” The Mercury 21 Jun. 2014: 1.Pritchard, Katie. "Legitimacy, Illegitimacy and Sovereignty in Shakespeare’s British Plays." U of Manchester, 2011.Slavin, Robert. "Perspectives on Evidence-Based Research in Education: What Works? Issues in Synthesizing Educational Program Evaluations." Educational Researcher 37.1 (2008): 5-14. The Greens. "Chaplaincy Program Study 'Flawed and Biased': Conclusions Not Justified." n.d. Thielking, Monica, and David MacKenzie. “School Chaplains: Time to Look at the Evidence.” 2011. Working with Children Check. "Categories of Work." 2008.

Photo by Owen Beard on Unsplash Introduction Through its professional associations and healthcare organizations, the medical community has made numerous anti-racism statements in the past year, including the American Medical Association’s (“AMA’s) Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.[1] Converting these statements into practical change will take time and money. In addition to implementing anti-bias training and education on racism in clinical practice, the medical community should also advocate to enhance and enforce Title VI anti-discrimination laws. The current limitations on enforcement conflict with the medical community’s ethical duty to improve health equity and treat all patients with a high standard of care. Advocating for legislation that meets the standards of other civil rights laws to hold the healthcare industry legally responsible for discrimination should be part of medical professionals’ anti-racism work. Development of Civil Rights in Health Care Despite the lack of a federal constitutional right to health care, the United States does acknowledge the importance of health and health care through its laws and spending decisions. In 2010, the Affordable Care Act (“ACA”) created health insurance options for 20 million additional Americans and reduced the gap in healthcare access among populations.[2] Although it did not ensure a right to health care and it does not guarantee a right to health, healthcare access is an important element of a healthy life and broadening the reach of health insurance is a worthy goal. Outside of the ACA’s offer of affordable health insurance, only a few stakeholders have gained “weak” statutory rights to publicly funded health care such as incarcerated people, the elderly, disabled, and the very poor.[3] Yet, the adoption of the public insurance programs Medicaid and Medicare in 1965, along with Title VI of the 1964 Civil Rights Act (“Title VI”), did create some rights to sue for discrimination in health care, even for people who are not recipients of Medicaid and Medicare benefits. Under Title VI, private institutions that receive federal financial assistance are prohibited from discriminating on the basis of race, color, and national origin.[4] Initially, this civil rights legislation had a major effect on health care because more than 1000 segregated hospitals immediately integrated their facilities in order to comply with the legislation and participate in Medicaid and Medicare.[5] Medical professionals interested in anti-racist work would do well to learn the history of Title VI; grassroots support of civil rights laws in the 1960s encouraged huge steps forward in eliminating de jure segregation in health care.[6] Title VI Lacks Mechanisms to Combat Structural Racism Title VI has been less effective when addressing more subtle forms of discrimination. Despite being one of the broadest anti-discrimination statutes, Title VI has been referred to as a “sleeping giant” because its full power has not been used to great effect.[7] The ACA included some attempts to improve Title VI’s effectiveness (see below), but much more could be done. Like most civil rights laws, Title VI discrimination may be alleged as disparate treatment (intentional) or disparate impact. Disparate impact claims are challenging to prove and may involve arguments such as how moving a hospital from an inner-city area to a wealthier suburban location will have a disparate impact on the local Black population. Besides the evidentiary challenges involved in demonstrating disparate impact, such a claim fails unless the plaintiffs can prove that a reasonable explanation for the action, such as cost savings, is a pretext for discrimination.[8] Title VI claims are also challenging because of the limitation on plaintiffs, the limitation on the scope of defendants, and enforcement issues. In 2001, the US Supreme Court held that individual plaintiffs cannot sue under Title VI for disparate impact claims, requiring a federal agency to do so.[9] While hospitals and other entities are potential defendants under Title VI, individual medical professionals are not, even though approximately 40 percent of Medicaid and Medicare reimbursements now go to physician and outpatient care.[10] The primary enforcement mechanism for Title VI healthcare claims is forcing compliance with the law through the threat of withdrawal of federal reimbursement.[11] The threat of financial punishments may harm communities, however, when low-resourced hospitals lose funding or are forced to fund rehabilitation programs.[12] Inequities between hospitals in different locations currently cannot be addressed under Title VI. Recent attempts to improve Title VI have failed. In the ACA, legislators included several updates to Title VI that appeared to improve its potential as a tool for reducing healthcare inequities. Section 1557 of the ACA changed the definition of “federal financial assistance” programs to include Medicaid and Medicare Advantage, thus expanding the pool of possible defendants to include individual providers.[13] However, the Department of Health and Human Services issued an implementing rule that specifically did not include Medicare Part B, so as of now patients cannot bring suit against sue their doctors for Title VI discrimination.[14] Some authors argue that the ACA also repealed the Supreme Court decision that prevented individuals from bringing disparate impact claims under Title VI.[15] So far, however, courts still interpret Title VI as supporting private claims only for intentional discrimination.[16] Individuals can still bring disparate impact claims to the Office of Civil Rights (“OCR”) and the Federal government may take action on their behalf. Because of the lack of available private action, however, there is no robust group of Title VI attorneys developing these civil rights cases.[17] If the legislature wants to encourage private enforcement of Title VI discrimination cases, it could also add punitive and compensatory damages to the available remedies, as it did with Title VII employment discrimination cases,[18] thus empowering plaintiffs and their lawyers to seek private remedies for discrimination in health care. Private litigation could be used as an additional lever in strategic approaches to eliminating discriminatory practices and improving health equity.[19] In 2003, the Institute of Medicine’s Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care recommended that the federal government increase funding for the OCR to encourage investigations into violations of Title VI based on systemic discrimination in health care.[20] The committee saw such enforcement as a “last line” of defense against systemic racism in health care, and a way to find such suspected racism through proactive investigations. Unfortunately, the OCR continues to be “notoriously” underfunded, but future administrations may be encouraged to rectify that problem.[21] Permitting more individual lawsuits may improve Title VI by providing better enforcement mechanisms and broadening the scope of possible defendants. These litigation tools will never bring about a right to health but can reduce inequities in access to and treatment in the healthcare system. Health professionals can support such proposals as individuals and through their professional associations. Of course, not all stakeholders agree that the federal government should enforce greater access to health care; after several states brought suit, the US Supreme Court struck down the ACA provision that would have effectively required states to expand Medicaid eligibility.[22] In addition, many health professionals will object to individual Title VI lawsuits. Distinguishing between malpractice litigation and discrimination litigation will be important so that healthcare practitioners do not feel their livelihoods are threatened by Title VI. If improving health equity and combating racism is seen part of one’s ethical duty, then medical professionals should embrace a willingness to be held accountable personally, and even more importantly, as part of a healthcare organization. The AMA has a well-documented history of racism, and the organization has apologized and sought atonement. Part of that history includes a failure to support civil rights legislation in the 1960s and active opposition to Medicare, Medicaid, and the desegregation of hospital staff.[23] Notably, the National Medical Association, an African American medical association, worked hard to support civil rights laws and integration in the 1960s, but could not convince the “White” AMA to follow suit. As part of its anti-racism efforts, the AMA could work with legislators to craft appropriate changes to Title VI and take on the task of educating its membership. Health professionals should understand that the shortcomings of Title VI in eradicating racism in health care were due to decisions about and interpretations of the law which were influenced by the medical profession itself. Educating all the stakeholders about the connections between health, healthcare access, and strong enforcement of our civil rights statutes and regulations is one way that health professionals can actively engage in anti-racism work in the healthcare profession. [1] “The AMA’s Strategic Plan to Embed Racial Justice and Advance Health Equity,” American Medical Association, accessed June 25, 2021, https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. [2] “How ACA Narrowed Racial Ethnic Disparities Access to Health Care | Commonwealth Fund,” accessed March 10, 2021, https://www.commonwealthfund.org/publications/2020/jan/how-ACA-narrowed-racial-ethnic-disparities-access. [3] Aeyal Gross and Colleen Flood, The Right to Health at the Public/Private Divide : A Global Comparative Study, New York (Cambridge University Press, 2014), , 348, https://web-a-ebscohost-com.ezproxy.cul.columbia.edu/ehost/ebookviewer/ebook/ZTAyNXhuYV9fNzcwMjExX19BTg2?sid=5201c555-548f-4599-ae3d-857f6911322f@sessionmgr4007&vid=0&format=EB&lpid=lp_261&rid=0. [4] Title VI of the 1964 Civil Rights Act, § 2000d (“No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”) [5] Amitabh Chandra, Michael Frakes, and Anup Malani, “Challenges to Reducing Discrimination and Health Inequity Through Existing Civil Rights Laws,” Health Affairs (Project Hope) 36, no. 6 (June 1, 2017): 1041–47, 1042, https://doi.org/10.1377/hlthaff.2016.1091. [6] David Barton Smith, “The ‘Golden Rules’ for Eliminating Disparities: Title VI, Medicare, and the Implementation of the Affordable Care Act,” Health Matrix, 2015, Gale OneFile: LegalTrac. [7] Olatunde C. A. Johnson, “Lawyering That Has No Name: Title VI and the Meaning of Private Enforcement,” Stanford Law Review 66, 6 (June 2014): 1293-1331, at 1294. [8] Chandra, Frakes, and Malani, at 1043. [9] Alexander v. Sandoval, 532 U.S. 275 (2001). [10] Chandra, Frakes, and Malani, at 1043. [11] See 42 U.S.C. §2000d-1. [12] Chandra, Frakes, and Malani, at 1045. [13] 42 U.S.C. §18116. [14] Chandra, Frakes, and Malani, at 1045. [15] Sarah G. Steege, “Finding a Cure in the Courts: A Private Right of Action for Disparate Impact in Health Care,” Michigan Journal of Race & Law 16, 439 (April 2011): 439- 468. [16] See, e.g., Lemon v. Aurora Health Care North Inc., 19-CV-1384 (E.D. WI Feb. 22, 2021). [17] Johnson, “Lawyering That Has No Name,” at 1295. [18] Pub. L. No. 102-166, § 102, 105 Stat. 1071, 1072-72 (codified as amended at 42 U.S.C. § 1981a). [19] Sara Rosenbaum and Sara Schmucker, “Viewing Health Equity through a Legal Lens: Title VI of the 1964 Civil Rights Act,” Journal of Health Politics, Policy and Law 42, no. 5 (October 1, 2017): 771–88, 777, https://doi.org/10.1215/03616878-3940423. [20] Institute of Medicine (US) Committee On Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, ed. Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson (Washington (DC): National Academies Press (US), 2003), http://www.ncbi.nlm.nih.gov/books/NBK220358/. [21] Chandra, Frakes, and Malani, at 1045. [22] National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012). [23] Harriet A. Washington et al., “Segregation, Civil Rights, and Health Disparities: The Legacy of African American Physicians and Organized Medicine, 1910-1968,” Journal of the National Medical Association 101, no. 6 (June 2009): 513–27, https://doi.org/10.1016/S0027-9684(15)30936-6.

At one point in Victor Hugo’s novel, The Hunchback of Notre Dame, the archdeacon, Claude Frollo, looked up from a book on his table to the edifice of the gothic cathedral, visible from his canon’s cell in the cloister of Notre Dame: “Alas!” he said, “this will kill that” (146). Frollo’s lament, that the book would destroy the edifice, captures the medieval cleric’s anxiety about the way in which Gutenberg’s print technology would become the new universal means for recording and communicating humanity’s ideas and artistic expression, replacing the grand monuments of architecture, human engineering, and craftsmanship. For Hugo, architecture was “the great handwriting of humankind” (149). The cathedral as the material outcome of human technology was being replaced by the first great machine—the printing press. At this point in the third millennium, some people undoubtedly have similar anxieties to Frollo: is it now the book’s turn to be destroyed by yet another great machine? The inclusion of “post print” in our title is not intended to sound the death knell of the book. Rather, we contend that despite the enduring value of print, digital publishing is “present and active” and is changing the way in which research, particularly in the humanities, is being undertaken. Our approach has three related parts. First, we consider how digital technologies are changing the way in which content is constructed, customised, modified, disseminated, and accessed within a global, distributed network. This section argues that the transition from print to electronic or digital publishing means both losses and gains, particularly with respect to shifts in our approaches to textuality, information, and innovative publishing. Second, we discuss the Children’s Literature Digital Resources (CLDR) project, with which we are involved. This case study of a digitising initiative opens out the transformative possibilities and challenges of digital publishing and e-scholarship for research communities. Third, we reflect on technology’s capacity to bring about major changes in the light of the theoretical and practical issues that have arisen from our discussion. I. Digitising in a “post-print age” We are living in an era that is commonly referred to as “the late age of print” (see Kho) or the “post-print age” (see Gunkel). According to Aarseth, we have reached a point whereby nearly all of our public and personal media have become more or less digital (37). As Kho notes, web newspapers are not only becoming increasingly more popular, but they are also making rather than losing money, and paper-based newspapers are finding it difficult to recruit new readers from the younger generations (37). Not only can such online-only publications update format, content, and structure more economically than print-based publications, but their wide distribution network, speed, and flexibility attract advertising revenue. Hype and hyperbole aside, publishers are not so much discarding their legacy of print, but recognising the folly of not embracing innovative technologies that can add value by presenting information in ways that satisfy users’ needs for content to-go or for edutainment. As Kho notes: “no longer able to satisfy customer demand by producing print-only products, or even by enabling online access to semi-static content, established publishers are embracing new models for publishing, web-style” (42). Advocates of online publishing contend that the major benefits of online publishing over print technology are that it is faster, more economical, and more interactive. However, as Hovav and Gray caution, “e-publishing also involves risks, hidden costs, and trade-offs” (79). The specific focus for these authors is e-journal publishing and they contend that while cost reduction is in editing, production and distribution, if the journal is not open access, then costs relating to storage and bandwith will be transferred to the user. If we put economics aside for the moment, the transition from print to electronic text (e-text), especially with electronic literary works, brings additional considerations, particularly in their ability to make available different reading strategies to print, such as “animation, rollovers, screen design, navigation strategies, and so on” (Hayles 38). Transition from print to e-text In his book, Writing Space, David Bolter follows Victor Hugo’s lead, but does not ask if print technology will be destroyed. Rather, he argues that “the idea and ideal of the book will change: print will no longer define the organization and presentation of knowledge, as it has for the past five centuries” (2). As Hayles noted above, one significant indicator of this change, which is a consequence of the shift from analogue to digital, is the addition of graphical, audio, visual, sonic, and kinetic elements to the written word. A significant consequence of this transition is the reinvention of the book in a networked environment. Unlike the printed book, the networked book is not bound by space and time. Rather, it is an evolving entity within an ecology of readers, authors, and texts. The Web 2.0 platform has enabled more experimentation with blending of digital technology and traditional writing, particularly in the use of blogs, which have spawned blogwriting and the wikinovel. Siva Vaidhyanathan’s The Googlization of Everything: How One Company is Disrupting Culture, Commerce and Community … and Why We Should Worry is a wikinovel or blog book that was produced over a series of weeks with contributions from other bloggers (see: http://www.sivacracy.net/). Penguin Books, in collaboration with a media company, “Six Stories to Start,” have developed six stories—“We Tell Stories,” which involve different forms of interactivity from users through blog entries, Twitter text messages, an interactive google map, and other features. For example, the story titled “Fairy Tales” allows users to customise the story using their own choice of names for characters and descriptions of character traits. Each story is loosely based on a classic story and links take users to synopses of these original stories and their authors and to online purchase of the texts through the Penguin Books sales website. These examples of digital stories are a small part of the digital environment, which exploits computer and online technologies’ capacity to be interactive and immersive. As Janet Murray notes, the interactive qualities of digital environments are characterised by their procedural and participatory abilities, while their immersive qualities are characterised by their spatial and encyclopedic dimensions (71–89). These immersive and interactive qualities highlight different ways of reading texts, which entail different embodied and cognitive functions from those that reading print texts requires. As Hayles argues: the advent of electronic textuality presents us with an unparalleled opportunity to reformulate fundamental ideas about texts and, in the process, to see print as well as electronic texts with fresh eyes (89–90). The transition to e-text also highlights how digitality is changing all aspects of everyday life both inside and outside the academy. Online teaching and e-research Another aspect of the commercial arm of publishing that is impacting on academe and other organisations is the digitising and indexing of print content for niche distribution. Kho offers the example of the Mark Logic Corporation, which uses its XML content platform to repurpose content, create new content, and distribute this content through multiple portals. As the promotional website video for Mark Logic explains, academics can use this service to customise their own textbooks for students by including only articles and book chapters that are relevant to their subject. These are then organised, bound, and distributed by Mark Logic for sale to students at a cost that is generally cheaper than most textbooks. A further example of how print and digital materials can form an integrated, customised source for teachers and students is eFictions (Trimmer, Jennings, & Patterson). eFictions was one of the first print and online short story anthologies that teachers of literature could customise to their own needs. Produced as both a print text collection and a website, eFictions offers popular short stories in English by well-known traditional and contemporary writers from the US, Australia, New Zealand, UK, and Europe, with summaries, notes on literary features, author biographies, and, in one instance, a YouTube movie of the story. In using the eFictions website, teachers can build a customised anthology of traditional and innovative stories to suit their teaching preferences. These examples provide useful indicators of how content is constructed, customised, modified, disseminated, and accessed within a distributed network. However, the question remains as to how to measure their impact and outcomes within teaching and learning communities. As Harley suggests in her study on the use and users of digital resources in the humanities and social sciences, several factors warrant attention, such as personal teaching style, philosophy, and specific disciplinary requirements. However, in terms of understanding the benefits of digital resources for teaching and learning, Harley notes that few providers in her sample had developed any plans to evaluate use and users in a systematic way. In addition to the problems raised in Harley’s study, another relates to how researchers can be supported to take full advantage of digital technologies for e-research. The transformation brought about by information and communication technologies extends and broadens the impact of research, by making its outputs more discoverable and usable by other researchers, and its benefits more available to industry, governments, and the wider community. Traditional repositories of knowledge and information, such as libraries, are juggling the space demands of books and computer hardware alongside increasing reader demand for anywhere, anytime, anyplace access to information. Researchers’ expectations about online access to journals, eprints, bibliographic data, and the views of others through wikis, blogs, and associated social and information networking sites such as YouTube compete with the traditional expectations of the institutions that fund libraries for paper-based archives and book repositories. While university libraries are finding it increasingly difficult to purchase all hardcover books relevant to numerous and varied disciplines, a significant proportion of their budgets goes towards digital repositories (e.g., STORS), indexes, and other resources, such as full-text electronic specialised and multidisciplinary journal databases (e.g., Project Muse and Proquest); electronic serials; e-books; and specialised information sources through fast (online) document delivery services. An area that is becoming increasingly significant for those working in the humanities is the digitising of historical and cultural texts. II. Bringing back the dead: The CLDR project The CLDR project is led by researchers and librarians at the Queensland University of Technology, in collaboration with Deakin University, University of Sydney, and members of the AustLit team at The University of Queensland. The CLDR project is a “Research Community” of the electronic bibliographic database AustLit: The Australian Literature Resource, which is working towards the goal of providing a complete bibliographic record of the nation’s literature. AustLit offers users with a single entry point to enhanced scholarly resources on Australian writers, their works, and other aspects of Australian literary culture and activities. AustLit and its Research Communities are supported by grants from the Australian Research Council and financial and in-kind contributions from a consortium of Australian universities, and by other external funding sources such as the National Collaborative Research Infrastructure Strategy. Like other more extensive digitisation projects, such as Project Gutenberg and the Rosetta Project, the CLDR project aims to provide a centralised access point for digital surrogates of early published works of Australian children’s literature, with access pathways to existing resources. The first stage of the CLDR project is to provide access to digitised, full-text, out-of-copyright Australian children’s literature from European settlement to 1945, with selected digitised critical works relevant to the field. Texts comprise a range of genres, including poetry, drama, and narrative for young readers and picture books, songs, and rhymes for infants. Currently, a selection of 75 e-texts and digital scans of original texts from Project Gutenberg and Internet Archive have been linked to the Children’s Literature Research Community. By the end of 2009, the CLDR will have digitised approximately 1000 literary texts and a significant number of critical works. Stage II and subsequent development will involve digitisation of selected texts from 1945 onwards. A precursor to the CLDR project has been undertaken by Deakin University in collaboration with the State Library of Victoria, whereby a digital bibliographic index comprising Victorian School Readers has been completed with plans for full-text digital surrogates of a selection of these texts. These texts provide valuable insights into citizenship, identity, and values formation from the 1930s onwards. At the time of writing, the CLDR is at an early stage of development. An extensive survey of out-of-copyright texts has been completed and the digitisation of these resources is about to commence. The project plans to make rich content searchable, allowing scholars from children’s literature studies and education to benefit from the many advantages of online scholarship. What digital publishing and associated digital archives, electronic texts, hypermedia, and so forth foreground is the fact that writers, readers, publishers, programmers, designers, critics, booksellers, teachers, and copyright laws operate within a context that is highly mediated by technology. In his article on large-scale digitisation projects carried out by Cornell and University of Michigan with the Making of America collection of 19th-century American serials and monographs, Hirtle notes that when special collections’ materials are available via the Web, with appropriate metadata and software, then they can “increase use of the material, contribute to new forms of research, and attract new users to the material” (44). Furthermore, Hirtle contends that despite the poor ergonomics associated with most electronic displays and e-book readers, “people will, when given the opportunity, consult an electronic text over the print original” (46). If this preference is universally accurate, especially for researchers and students, then it follows that not only will the preference for electronic surrogates of original material increase, but preference for other kinds of electronic texts will also increase. It is with this preference for electronic resources in mind that we approached the field of children’s literature in Australia and asked questions about how future generations of researchers would prefer to work. If electronic texts become the reference of choice for primary as well as secondary sources, then it seems sensible to assume that researchers would prefer to sit at the end of the keyboard than to travel considerable distances at considerable cost to access paper-based print texts in distant libraries and archives. We considered the best means for providing access to digitised primary and secondary, full text material, and digital pathways to existing online resources, particularly an extensive indexing and bibliographic database. Prior to the commencement of the CLDR project, AustLit had already indexed an extensive number of children’s literature. Challenges and dilemmas The CLDR project, even in its early stages of development, has encountered a number of challenges and dilemmas that centre on access, copyright, economic capital, and practical aspects of digitisation, and sustainability. These issues have relevance for digital publishing and e-research. A decision is yet to be made as to whether the digital texts in CLDR will be available on open or closed/tolled access. The preference is for open access. As Hayles argues, copyright is more than a legal basis for intellectual property, as it also entails ideas about authorship, creativity, and the work as an “immaterial mental construct” that goes “beyond the paper, binding, or ink” (144). Seeking copyright permission is therefore only part of the issue. Determining how the item will be accessed is a further matter, particularly as future technologies may impact upon how a digital item is used. In the case of e-journals, the issue of copyright payment structures are evolving towards a collective licensing system, pay-per-view, and other combinations of print and electronic subscription (see Hovav and Gray). For research purposes, digitisation of items for CLDR is not simply a scan and deliver process. Rather it is one that needs to ensure that the best quality is provided and that the item is both accessible and usable by researchers, and sustainable for future researchers. Sustainability is an important consideration and provides a challenge for institutions that host projects such as CLDR. Therefore, items need to be scanned to a high quality and this requires an expensive scanner and personnel costs. Files need to be in a variety of formats for preservation purposes and so that they may be manipulated to be useable in different technologies (for example, Archival Tiff, Tiff, Jpeg, PDF, HTML). Hovav and Gray warn that when technology becomes obsolete, then content becomes unreadable unless backward integration is maintained. The CLDR items will be annotatable given AustLit’s NeAt funded project: Aus-e-Lit. The Aus-e-Lit project will extend and enhance the existing AustLit web portal with data integration and search services, empirical reporting services, collaborative annotation services, and compound object authoring, editing, and publishing services. For users to be able to get the most out of a digital item, it needs to be searchable, either through double keying or OCR (optimal character recognition). The value of CLDR’s contribution The value of the CLDR project lies in its goal to provide a comprehensive, searchable body of texts (fictional and critical) to researchers across the humanities and social sciences. Other projects seem to be intent on putting up as many items as possible to be considered as a first resort for online texts. CLDR is more specific and is not interested in simply generating a presence on the Web. Rather, it is research driven both in its design and implementation, and in its focussed outcomes of assisting academics and students primarily in their e-research endeavours. To this end, we have concentrated on the following: an extensive survey of appropriate texts; best models for file location, distribution, and use; and high standards of digitising protocols. These issues that relate to data storage, digitisation, collections, management, and end-users of data are aligned with the “Development of an Australian Research Data Strategy” outlined in An Australian e-Research Strategy and Implementation Framework (2006). CLDR is not designed to simply replicate resources, as it has a distinct focus, audience, and research potential. In addition, it looks at resources that may be forgotten or are no longer available in reproduction by current publishing companies. Thus, the aim of CLDR is to preserve both the time and a period of Australian history and literary culture. It will also provide users with an accessible repository of rare and early texts written for children. III. Future directions It is now commonplace to recognize that the Web’s role as information provider has changed over the past decade. New forms of “collective intelligence” or “distributed cognition” (Oblinger and Lombardi) are emerging within and outside formal research communities. Technology’s capacity to initiate major cultural, social, educational, economic, political and commercial shifts has conditioned us to expect the “next big thing.” We have learnt to adapt swiftly to the many challenges that online technologies have presented, and we have reaped the benefits. As the examples in this discussion have highlighted, the changes in online publishing and digitisation have provided many material, network, pedagogical, and research possibilities: we teach online units providing students with access to e-journals, e-books, and customized archives of digitised materials; we communicate via various online technologies; we attend virtual conferences; and we participate in e-research through a global, digital network. In other words, technology is deeply engrained in our everyday lives. In returning to Frollo’s concern that the book would destroy architecture, Umberto Eco offers a placatory note: “in the history of culture it has never happened that something has simply killed something else. Something has profoundly changed something else” (n. pag.). Eco’s point has relevance to our discussion of digital publishing. The transition from print to digital necessitates a profound change that impacts on the ways we read, write, and research. As we have illustrated with our case study of the CLDR project, the move to creating digitised texts of print literature needs to be considered within a dynamic network of multiple causalities, emergent technological processes, and complex negotiations through which digital texts are created, stored, disseminated, and used. Technological changes in just the past five years have, in many ways, created an expectation in the minds of people that the future is no longer some distant time from the present. Rather, as our title suggests, the future is both present and active. References Aarseth, Espen. “How we became Postdigital: From Cyberstudies to Game Studies.” Critical Cyber-culture Studies. Ed. David Silver and Adrienne Massanari. New York: New York UP, 2006. 37–46. An Australian e-Research Strategy and Implementation Framework: Final Report of the e-Research Coordinating Committee. Commonwealth of Australia, 2006. Bolter, Jay David. Writing Space: The Computer, Hypertext, and the History of Writing. Hillsdale, NJ: Erlbaum, 1991. Eco, Umberto. “The Future of the Book.” 1994. 3 June 2008 ‹http://www.themodernword.com/eco/eco_future_of_book.html>. Gunkel, David. J. “What's the Matter with Books?” Configurations 11.3 (2003): 277–303. Harley, Diane. “Use and Users of Digital Resources: A Focus on Undergraduate Education in the Humanities and Social Sciences.” Research and Occasional Papers Series. Berkeley: University of California. Centre for Studies in Higher Education. 12 June 2008 ‹http://www.themodernword.com/eco/eco_future_of_book.html>. Hayles, N. Katherine. My Mother was a Computer: Digital Subjects and Literary Texts. Chicago: U of Chicago P, 2005. Hirtle, Peter B. “The Impact of Digitization on Special Collections in Libraries.” Libraries & Culture 37.1 (2002): 42–52. Hovav, Anat and Paul Gray. “Managing Academic E-journals.” Communications of the ACM 47.4 (2004): 79–82. Hugo, Victor. The Hunchback of Notre Dame (Notre-Dame de Paris). Ware, Hertfordshire: Wordsworth editions, 1993. Kho, Nancy D. “The Medium Gets the Message: Post-Print Publishing Models.” EContent 30.6 (2007): 42–48. Oblinger, Diana and Marilyn Lombardi. “Common Knowledge: Openness in Higher Education.” Opening up Education: The Collective Advancement of Education Through Open Technology, Open Content and Open Knowledge. Ed. Toru Liyoshi and M. S. Vijay Kumar. Cambridge, MA: MIT Press, 2007. 389–400. Murray, Janet H. Hamlet on the Holodeck: The Future of Narrative in Cyberspace. Cambridge, MA: MIT Press, 2001. Trimmer, Joseph F., Wade Jennings, and Annette Patterson. eFictions. New York: Harcourt, 2001.

Photo by 193001056 © Yee Xin Tan on Dreamstime.com ABSTRACT Suicide and overdose, associated with perinatal mental health conditions, are the leading causes of maternal mortality in the United States. Experts in the field of perinatal mental health are using perinatal mood and anxiety disorders (PMAD) as an umbrella term that includes many mental health conditions and bring to light the lack of screening and treatment for perinatal mental health in the United States. There is a growing need to equip Obstetricians and Gynecologist (OB-GYN) providers with better tools to screen, triage, and refer to mental health services that are equitable and immediately accessible to their patients. Integrating a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change is a novel approach to addressing the maternal mental health crisis by improving outcomes, reducing disparities, and lowering costs. INTRODUCTION Over the past two decades, maternal mortality and other maternal health outcomes have worsened in the United States disproportionately to those in other developed countries.[1] In 2021, 1,205 pregnant women died in the US, representing a 40 percent increase in maternal death from 2020 and the highest rise in rates since the 1960s.[2] Suicide and overdose associated with perinatal mental health conditions are the leading causes of maternal mortality.[3] Mental health-related deaths are most likely to occur after six weeks postpartum.[4] Despite the postpartum period representing a higher risk for mental health conditions, historically, only a single postpartum visit is performed between 4 and 6 weeks after delivery. 40 percent of women do not attend a postpartum visit.[5] Recent data from Maternal Mortality Review Committees reveal that 80 percent of maternal deaths are preventable. The maternal mental health crisis represents a unique ethical dilemma. For perinatal women, the current healthcare system is unjust. There is a growing need to equip obstetricians and gynecologists (OB-GYNs) with the tools to screen, triage, and refer patients to mental health services that are equitable and immediately accessible to their patients. This paper will analyze the current state of perinatal mental healthcare in America. It will introduce the Psychiatric Collaborative Care Model and demonstrate its effectiveness. I highlight research performed using the Psychiatric Collaborative Care Model in obstetrics as well as barriers to real-world implementation. Lastly, this paper will argue that the integration of a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change would improve outcomes, reduce disparities, and lower costs. I. Scope of the Problem Prior to the COVID-19 pandemic, the prevalence of postpartum depression ranged from 13.2 percent, to as high as 23.5 percent, of births in the US.[6] The COVID-19 pandemic has exacerbated this issue, with studies revealing up to 1 in 3 postpartum women experiencing postpartum depression.[7] Although postpartum depression has been the focus of perinatal mental health conditions, it is just the tip of the iceberg. Experts in the field of perinatal mental health are now using perinatal mood and anxiety disorders as an umbrella term that includes perinatal depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar disorder, and psychosis from the prenatal period through the first year postpartum. Socio-economically disadvantaged women are at increased risk of experiencing perinatal mood and anxiety disorders and face greater barriers to high-quality mental health care.[8] The American College of Obstetricians and Gynecologists (ACOG) recommends that physicians perform postpartum depression screenings during pregnancy. The Health Resources and Services Administration provides Healthy Start Initiative Grants to communities with high rates of adverse perinatal outcomes. Yet, the Healthcare Effectiveness Data and Information Set (HEDIS) reveals that screening in both pregnancy and the postpartum period occurs in fewer than 20 percent of patients.[9] Furthermore, in the US, if screening does occur, only 22 percent of women who are deemed positive in their screening receive mental health care.[10] The United States is currently experiencing a shortage of mental health providers that is expected to worsen in the upcoming years.[11] Nearly half of all Americans currently live in a mental health professional desert.[12] Waitlists for therapists and psychiatrists average 48 days, and individuals report not seeking mental health care due to cost or lack of insurance coverage.[13] Given the significant mental health provider shortage, obstetric providers have a unique opportunity to care for the “whole patient” during and after pregnancy by addressing not only their physical health but also their mental health. Approximately one-third of women consider their OB-GYN their primary care provider during and after pregnancy, and over 50 percent of OB-GYNs perceive themselves as primary care providers for women, supporting primary, specialty, and preventive care.[14] Medicaid covers 42 percent of all births in the US, and more than half of all births in some states, thus OB-GYNs provide a disproportionate amount of care for poor and minority women as compared to other specialties.[15] Yet, OB-GYN providers commonly feel hesitant to screen for depression due to the shortage of therapists and psychiatrists to address the mental health needs of their patients, particularly in the Medicaid population.[16] As a result, fewer than 10 percent of pregnant women with mental health conditions receive adequate treatment.[17] A recent study of 288 obstetrics fellows revealed that 84 percent prescribed SSRIs to their patients; obstetricians are filling the mental health provider gap and taking ownership over their patients’ mental health.[18] Despite ACOG’s recommendations that obstetrics providers screen for and treat mental health conditions in the perinatal period, OB-GYNs do not receive formal mental health training during residency or fellowship and do not typically use validated tools such as the Diagnostic and Statistical Manual of Mental Disorders-Forth Edition (DSM-IV) for diagnosis of depression or prior to prescribing antidepressants. Their lack of a standard reference can lead to misdiagnoses.[19] In fact, 22 percent of women screened and found to have postpartum depression are later diagnosed with bipolar disorder.[20] Screening and treatment for perinatal mood and anxiety disorders are further impacted by patients’ lack of trust in healthcare providers. Distrust between patients, particularly those receiving Medicaid, and their OB-GYNs in the US is high and strongly associated with worse self-reported health outcomes.[21] Notably, women with Medicaid coverage reported being treated unfairly and with disrespect by providers because of their race and insurance status. They reported a loss of decision-making autonomy during labor and delivery and less postpartum emotional and practical support at home.[22] Many women do not feel comfortable discussing mental disorders with a healthcare provider.[23] Connecting perinatal women to a person with shared lived experiences, known as peer-to-peer engagement or coaching, may be a simple solution. II. Collaborative Care Model The Psychiatric Collaborative Care Model (collaborative care), developed by the University of Washington in 2002, is an integrated behavioral health approach designed to treat common mental health conditions such as depression and anxiety that require measurement-based follow-up due to their chronic nature.[24] Centers for Medicare and Medicaid Services issued billing codes for the Psychiatric Collaborative Care Model in 2016. Medicare adopted them in 2017, and they were widely operationalized in the primary care field.[25] As of 2022, the collaborative care billing codes have been adopted by 19 state Medicaid plans.[26] The collaborative care model facilitates the integration of a behavioral health care manager, typically a licensed therapist or care worker, in the primary care setting. The behavioral health care manager can provide in-person or virtual care and facilitate mental health screenings, symptom monitoring, psychiatric consultations, and care coordination.[27] A psychiatric consultant, typically a board-certified psychiatrist or psychiatric nurse practitioner, is an integrated behavioral health provider on the collaborative care team. Psychiatric consultants do not see patients one on one. Rather, they review complex or treatment-resistant cases and provide psychiatric management recommendations to the primary provider. Thus, the primary care team is expanded by two members who provide behavioral health expertise to the primary care provider, who is ultimately the prescribing provider if any psychoactive medications are indicated.[28] This model has been tested in over 90 randomized clinical trials evaluating efficacy for the treatment of depression and anxiety across multiple medical specialties.[29] Data from the primary care setting indicate that this integrated behavioral health approach is both successful and more cost-effective than usual care for patients with behavioral health conditions.[30] Studies show that the collaborative care model improves clinical outcomes and lowers costs, returning $6.50 for every dollar spent on treatment of depression. Furthermore, the model is effective across diverse patient populations.[31] III. Evidence for Collaborative Care in Obstetrics The success of the collaborative care model for identifying anxiety and depression in the primary care setting and its potential for cost savings suggest that implementation of perinatal collaborative care for perinatal mood and anxiety disorders is a feasible approach.[32] Randomized clinical trials showed significant improvement in quality care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women.[33] In addition, collaborative care is associated with mitigating racial disparities in antenatal depression care; it may be an equity-promoting intervention for maternal health.[34] The trials faced limitations, including the inability to establish causality, and the researchers recommended further research. Although further research is warranted, the collaborative care model in obstetrics programs has indicated improved depression outcomes. IV. Barriers to Adoption of a Collaborative Care Model in Obstetrics Despite promising results, implementation is limited, and collaborative care is billable under Medicaid in only 19 states.[35] Large health systems have difficulty operationalizing a collaborative care model in obstetrics due to implementation costs, mental health provider shortages, and administrative burdens. More evidence of financial benefits to obstetrics clinics, hospitals, and health systems is needed. Additionally, obstetric practices must adapt to updated care plans, and obstetricians must be motivated to become involved in behavioral health issues and potentially broaden their scope of practice.[36] As this is a major ask from practices and providers, robust evidence is lacking to show that a perinatal collaborative care model can be applied without the resources and infrastructure of a randomized trial. V. Peer-to-Peer Engagement Peer support in healthcare is growing. Peer support is defined as help and support that people with lived experiences can give one another.[37] Effective examples of peer support or engagement are found in addiction, mental health services, and the workforce. Regarding addiction recovery support, a systematic review concluded that peer support interventions have a beneficial effect on participants and positively contribute to substance use outcomes.[38] Peer support is highly used in medicine and other professions when attending physicians or skilled professionals train new colleagues. The nursing profession uses peer support to help deliver quality care and reduce symptoms of burnout.[39] Peer support has been well described in literature, and programs differ in their methodology and delivery. The feasibility and maintenance of peer support programs are possible through collaboration with all healthcare stakeholders.[40] Understanding that shared experiences establish a foundation of trust may help obstetricians see peers as a way to bridge the gap. A peer coach may be valuable in the collaborative care model. VI. Integrating Peer-to-Peer into the Collaborative Care Model for Obstetrics Currently, a start-up based in Boston and Philadelphia, FamilyWell, has piloted tech-enabled peer-to-peer engagement into a collaborative care model for obstetric patients. The company strives to solve the perinatal mental health crisis and close the health equity gap in the US by applying a text messaging platform to connect expecting and newly postpartum mothers with peer coaches. Peer coaches are trained to support perinatal mothers, defined as third-trimester pregnancy through 12 months postpartum, by providing quality support based on the latest research. Coaches have their own unique birth and postpartum stories, making them relatable and equipped to support mothers through the ups and downs of parenthood.[41] Increased education, screening, and treatment for perinatal mood and anxiety disorders co-occur as connections are being made through texting and virtual visits with coaches. On demand texting with coaches ensures no mother feels alone and that mothers have a safe space to ask questions and process emotions. If needed, enrolled moms can request longer virtual coaching sessions of 50 minutes with certified perinatal mental health coaches, who focus on current issues and how to move forward and feel better, accomplished through cognitive behavioral coaching techniques.[42] The platform schedules automated text messages containing educational content. Individual care plans are developed in collaboration with an individual’s OB and include monthly mental health screenings during and post-pregnancy. Notably, at three-week postpartum, participants are sent the Edinburg postnatal depression scale 3 (EPDS-3) questions via text messages.[43] This screening is three weeks prior to the national six-weeks postpartum screening recommendation and focuses on antepartum anxiety, which represents a risk factor for depression.[44] If an individual needs more mental health support compared to coaching, virtual therapy sessions are available through the platform, giving access to licensed therapist, specializing in perinatal mental health without extensive waitlist. Therapists can diagnosis and provide medication management if needed. FamilyWell CEO and founder, Jessica Gaulton, revealed that preliminary data collected during the first two months of the company’s launch, limited to the Philadelphia, PA region and three clinics, indicated that 24 postpartum mothers consented to the program. A total of 3,000 texts were exchanged, and 44.2 percent of those texts came from participants to peer coaches.[45] The platform expediates appropriate referrals, creates individualized maternal wellness treatment plans, and serves as a resource for navigating the medical system. VII. Providing Justice in the Maternal Healthcare System The well-being of mothers is a bellwether for the well-being of society; every injustice in our society shows up in maternal health.[46] Earlier, broader, and more frequent screening combined with direct mental health access is essential to address perinatal mood and anxiety disorders and ultimately the maternal mortality rate. Integrating collaborative care with peer-to-peer coaching provides new mothers with direct support and follow-up care. This simple yet novel integration begins to close the gap by providing equitable care. The tech-based platform’s research and success highlight that a broader focus on screening is critical. Limiting mental illness to depression fails to serve women adequately. Expanding criteria to screen for indicators of future depression, such as anxiety, is a simple, proactive step. A relatable peer may be a critical factor in helping perinatal women feel comfortable openly discussing problems they are facing and beginning conversations not otherwise occurring in a perinatal or postpartum visit. Companies like FamilyWell can contribute to making collaborative care feasible in the OB-GYN setting. Having an outside organization with peer-coaches building a foundation of trust and championing the collaborative care model reduces the burden for overworked obstetricians. Furthermore, the tech-based platform can organize and facilitate interprofessional communications, which rarely take place in the current system.[47] The texting and telehealth approach brings compassion, care, and more frequent contact directly to the patient, which is critical for socioeconomically disadvantaged women as they are the demographic not properly accessing care now. As the coaches and behavior care coordinator make the referrals for mental health services that align with a mother’s insurance coverage, they reduce stress for new mothers who might not know where to begin when navigating the mental health care system. Additionally, obstetricians may feel more comfortable performing mental health screenings knowing their patients can access mental health care. CONCLUSION The perinatal mental health crisis is significant. Women are currently experiencing injustice in the healthcare system due to a lack of trust, screening, and effective, accessible care. The psychiatric collaborative care model has been proven effective in the primary care setting, and randomized clinical trials conclude it is also effective in obstetrics, but barriers exist. Integrating peer-to-peer coaching through a tech-enabled platform into obstetrics collaborative care may eliminate barriers and build trust between patients and the healthcare system. More research is needed to show the efficacy of a tech-enabled model, and more research is critical to demonstrate that this model can be financially sustainable and revenue-generating for hospitals and obstetrics departments. However, this simple novel step may begin to generate equitable care for women and potentially save lives. - [1] Collier, A. R. Y., & Molina, R. L. (2019). Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews, 20(10), e561-e574. [2] Hoyert, D. L. (2023). Maternal Mortality Rates in the United States, 2021.Health E-Stats. National Center for Health Statistics. Centers for Disease Control. https://dx.doi.org/10.15620/cdc:124678 [3] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [4] Trost, S. L., Beauregard, J. L., Smoots, A. N., Ko, J. Y., Haight, S. C., Moore Simas, T. A., ... & Goodman, D. (2021). Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008–17: Study examines maternal mortality and mental health. Health Affairs, 40(10), 1551-1559. [5] Blenning, C. E., & Paladine, H. L. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496; ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics and gynecology, 132(3), 784–785. https://doi.org/10.1097/AOG.0000000000002849 [6]Bauman, B. L., Ko, J. Y., Cox, S., D'Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2 [7] Shuman, C.J., Peahl, A.F., Pareddy, N. (2022) Postpartum depression and associated risk factors during the COVID-19 pandemic. BMC Res Notes 15, 102. https://doi.org/10.1186/s13104-022-05991-8 [8] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and Anxiety, 32(11), 821-834. [9] HESI Annual Report. HESI. (2022, November). Retrieved April 30, 2023, from Special-Report-Nov-2022-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf (ncqa.org) [10] Byatt, N., Levin, L. L., Ziedonis, D., Moore Simas, T. A., & Allison, J. (2015). Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstetrics and Gynecology, 126(5), 1048–1058. https://doi.org/10.1097/AOG.0000000000001067 [11] Satiani, A., Niedermier, J., Satiani, B., & Svendsen, D. P. (2018). Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatric Services (Washington, D.C.), 69(6), 710–713. https://doi.org/10.1176/appi.ps.201700344 [12] Bureau of Health Workforce Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services. (April 27, 2023) Designated Health Professional Shortage Areas Statistics, Second Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary. https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport [13] Coward, K. (2021). New data shows CCBHCs improve behavioral health access, reduce wait times. Behavioral Health Business. https://bhbusiness.com/2021/05/25/new-data-shows-ccbhcs-improve-behavioral-health-access-reduce-wait-times; The United States Government. (2022, June 17). Reducing the economic burden of unmet mental health needs - CEA. The White House. Retrieved April 30, 2023, from https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/ [14] LaRocco-Cockburn, A., Reed, S. D., Melville, J., Croicu, C., Russo, J. E., Inspektor, M., ... & Katon, W. (2013). Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care. Contemporary clinical trials, 36(2), 362-370. [15] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [16] Hansen, M. E. D., Tobón, A. L., Haider, U. K., Simas, T. A. M., Newsome, M., Finelli, J., ... & Byatt, N. (2023). The role of perinatal psychiatry access programs in advancing mental health equity. General Hospital Psychiatry. [17] Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of clinical psychiatry, 77(9), 20901. [18] Taouk, L. H., Matteson, K. A., Stark, L. M., & Schulkin, J. (2018). Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence. Archives of women's mental health, 21(1), 85–91. https://doi.org/10.1007/s00737-017-0760-7 [19] Garbarino, A. H., Kohn, J. R., Coverdale, J. H., & Kilpatrick, C. C. (2019). Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs. Academic psychiatry: the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 43(3), 294–299. https://doi.org/10.1007/s40596-019-01018-w ; [20] Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L.,& Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA psychiatry, 70(5), 490-498 [21] Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust of the health care system and self-reported health in the United States. Journal of general internal medicine, 21(4), 292–297. https://doi.org/10.1111/j.1525-1497.2006.00396.x [22] Declercq, E., & Zephyrin, L. (2020). Maternal mortality in the United States: A Primer. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer [23] Scholle, S. H., & Kelleher, K. (2003). Preferences for depression advice among low-income women. Maternal and child health journal, 7(2), 95–102. https://doi.org/10.1023/a:1023864810207https://doi.org/10.1023/a:1023864810207 [24] AIMS Center. (n.d.). Collaborative care. https://aims.uw.edu/collaborative-care [25] Press, M. J., Howe, R., Schoenbaum, M., Cavanaugh, S., Marshall, A., Baldwin, L., & Conway, P. H. (2017). Medicare payment for behavioral health integration. n Engl j Med, 376(5), 405-407. [26] Chang, D., Morrison, D. J., Bowen, D. J., Harris, H. M., Dusic, E. J., Velasquez, M. B., & Ratzliff, A. D. H. (2023). Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care. Psychiatric services (Washington, D.C.), appips20220596. Advance online publication. https://doi.org/10.1176/appi.ps.20220596 [27] Miller, E. S., Jensen, R., Hoffman, M. C., Osborne, L. M., McEvoy, K., Grote, N., & Moses-Kolko, E. L. (2020). Implementation of perinatal collaborative care: a health services approach to perinatal depression care. Primary health care research & development, 21, e30. [28] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [29] Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr, Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., Langston, C., & IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836 [30] Raney, L. (2020). [31] Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, 1-13. [32] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [33] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and anxiety, 32(11), 821-834 [34] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275; Snowber, K., Ciolino, J. D., Clark, C. T., Grobman, W. A., & Miller, E. S. (2022). Associations Between Implementation of the Collaborative Care Model and Disparities in Perinatal Depression Care. Obstetrics & Gynecology, 140(2), 204-211. [35] Percent of People Covered By Medicaid/CHIP, 2022. (2022). Medicaid State Fact Sheets. KFF. Retrieved May 1, 2023, from https://www.kff.org/interactive/medicaid-state-fact-sheets/ [36] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [37] Shalaby, R. A. H., & Agyapong, V. I. (2020). Peer support in mental health: literature review. JMIR mental health, 7(6), e15572. [38] Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-delivered recovery support services for addictions in the United States: A systematic review. Journal of substance abuse treatment, 63, 1-9. [39] Eastburg, M. C., Williamson, M., Gorsuch, R., & Ridley, C. (1994). Social support, personality, and burnout in nurses. Journal of Applied Social Psychology, 24(14), 1233-1250. [41] FamilyWell. (2023.). https://familywellhealth.com/ [42] Patients, Family Well (2023). https://familywellhealth.com/patients [43] Providers, Family Well (2023). https://familywellhealth.com/providers [44] Patients, Family Well (2023). https://familywellhealth.com/patients [45] Author interview with Jessica Gaulton, FamilyWell. (2023) [46] Maven (2022). “If moms are unwell, society is unwell.” Recapping our Q&A with Dr. Neel Shah. Maven. https://www.mavenclinic.com/post/if-moms-are-unwell-society-is-unwell-recapping-our-q-a-with-dr-neel-shah#! [47] Klatter, C. K., van Ravesteyn, L. M., & Stekelenburg, J. (2022). Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review. Archives of Women's Mental Health, 25(6), 1029-1039.

The Coming of Coffee Before World War II, Australians followed British tradition and largely drank tea. When coffee challenged the tea drinking habit in post-war Australia, the tea industry fought back using the most up-to-date marketing techniques imported from America. The shift to coffee drinking in post-war Australia is, therefore, explored through a focus on both the challenges faced by the tea industry and how that industry tackled the trend towards coffee. By focusing on the Australian Tea Council’s marketing campaign promoting tea as a fashionable drink and preferable to coffee, this article explores Australia’s cultural shift from tea drinking to coffee drinking. This complex and multi-layered transition, often simply explained by post-war migration, provides an opportunity to investigate other causal aspects of this shift. In doing so, it draws on oral histories—including of central figures working in the tea and coffee industries—as well as reports in newspapers and popular magazines, during this period of culinary transition. Australians always drank coffee but it was expensive, difficult and inconsistent to brew, and was regarded as a drink “for the better class of person” (P. Bennett). At the start of World War II, Australia was second only to Britain in terms of its tea consumption and maintaining Australia’s supply of tea was a significant issue for the government (NAA, “Agency Notes”). To guarantee a steady supply, tea was rationed, as were many other staples. Between 1941 and 1955, the tea supply was under government control with the Commonwealth-appointed Tea Control Board responsible for its purchase and distribution nationwide (Adams, “From Instant” 16). The influence of the USA on Australia’s shift from tea-drinking has been underplayed in narratives of the origins of Australia’s coffee culture, but the presence of American servicemen, either stationed in Australia or passing through during the war in the Pacific, had a considerable impact on what Australians ate and drank. In 2007, the late John Button noted that:It is when the countries share a cause that the two peoples have got to know each other best. Between 1942 and 1945, when Australia’s population was seven million, one million US service personnel came to Australia. They were made welcome, and strange things happened. American sporting results and recipes were published in the newspapers; ‘The Star-Spangled Banner’ was played at the start of theatre and concert performances. Australians were introduced to the hot dog; Americans, reluctantly, to the dim sim. 10 or 15 years after the war, there were stories of New York cab drivers who knew Australia well and spoke warmly of their wartime visits. For years, letters between Australia and the US went back and forth between pen friends […] following up friendships developed during the war. Supplying the daily ration of coffee to American servicemen was another concern for the Australian government as Australia had insufficient roasting capacity to supply this coffee—and so three roasting machines were shipped to Australia to help meet this new demand (NAA, MP5/45 a). To ensure a steady supply, coffee too came under the control of the Tea Controller and the Tea Control Board became the Tea and Coffee Control Board. At this time, civilians became more aware of coffee as newspapers raised its profile and Australian families invited American servicemen in their homes. Differences in food preferences between American servicemen and Australians were noticed, with coffee the most notable of these. The Argus reported that: “The main point of issue in these rival culinary fancies is the longstanding question of coffee” (“Yanks Differ” 8). It concluded that Australians and Americans ate the same foods, only prepared in different ways, but the most significant difference between them was the American “preference for coffee” (8). When Australian families invited hosted servicemen in their homes, housewives needed advice on how to make prepare coffee, and were told:One of the golden rules for hostesses entertaining American troops should be not to serve them coffee unless they know how to make it in the American fashion [...] To make coffee in the proper American fashion requires a special kind of percolating. Good results may be obtained by making coffee with strong freshly ground beans and the coffee should be served black with cream to be added if required (“Coffee for Americans” 5). Australian civilians also read reports of coffee, rather than tea, being served to Australian servicemen overseas, and the following report in The Argus in 1942 shows: “At Milne Bay 100 gallons of coffee were served to the men after pictures had been shown each night. Coffee was not the only comfort to be supplied. There were also chocolate, tobacco, toothpaste, and other articles appreciated by the troops” (“Untitled” 5). Due largely to tea rationing and the presence of American servicemen, Australia’s coffee consumption increased to 500 grams per person per annum between 1941 and 1944, but it also continued to rise in the immediate post-war period when the troops had departed (ABS). In May 1947, the Tea (and Coffee) Controller reported an increased consumption of 54 per cent in the two years after the war ended (NAA, MP5/45 b). Tea Loses Its Way Australian tea company and coffee roaster, Bushells, had an excellent roast and ground coffee—Bushells Pure Coffee—according to Bill Bennett who worked for the company from 1948 to 1950 (B. Bennett). It was sold freshly roasted in screw-top jars that could be re-used for storage in the kitchen or pantry. In 1945, in a series of cartoon-style advertisements, Bushells showed consumers how easy it was to make coffee using this ground beans, but the most significant challenge to tea’s dominance came not with this form of coffee, but in 1948 with the introduction of Nestlé instant coffee. Susie Khamis argues that “of all the coffee brands that vied for Australians’ attention, Nestlé was by far the most salient, by virtue of its frequency, timeliness and resonance” (218). With Nestlé instant coffee, “you use just the quantity you need for each cup and there are no grounds or sediment. Nescafé made perfect full-flavoured coffee in a matter of seconds” (Canberra Times). Figure 1. Advertisement for Nestlé Coffee. The Canberra Times 5 Aug. 1949: 2. Figure 2. Advertisement for Bushells Coffee. The Argus 22 Aug. 1945: 11. Instant coffee, as well as being relatively cheap, solved the “problem” of its brewing and was marketed as convenient, economical, and consistent. It also was introduced at a time when the price of tea was increasing and the American lifestyle had great appeal to Australians. Khamis argues that the discovery of instant coffee “spoke to changes in Australia’s lifestyle options”, noting that the “tea habit was tied to Australia’s development as a far-flung colonial outpost, a daily reminder that many still looked to London as the nation’s cultural capital; the growing appeal of instant coffee reflected a widening and more nuanced cultural palate” (218). Instant coffee, modernity, America, and glamour became thus entwined in a period when Australia’s cultural identity “was informed less by the staid conservatism of Britain than the heady flux of the new world glamour” (Khamis 219). In the 1950s, Australians were seduced by espresso coffee presented to them in imaginatively laid out coffee lounges featuring ultra modern décor and streamlined fittings. Customers were reportedly “seduced by the novelty of the impressive-looking espresso machines, all shining chrome and knobs and pressure gauges” (Australasian Confectioner and Restaurant Journal 61). At its best, espresso coffee is a sublime drink with a rich thick body and a strong flavour. It is a pleasure to look at and has about it an air of European sophistication. These early coffee lounges were the precursors of the change from American-style percolated coffee (Adams, “Barista” vi). According to the Australasian Confectioner and Restaurant Journal, in 1956 espresso coffee was changing the way people drank coffee “on the continent, in London and in other parts of the world,” which means that as well as starting a new trend in Australia, this new way of brewing coffee was making coffee even more popular elsewhere (61). The Connoisseurship of Coffee Despite the popularities of cafés, the Australian consumer needed to be educated to become a connoisseur, and this instruction was provided in magazine and newspaper articles. Rene Dalgleish, writing for Australian Home Beautiful in 1964, took “a look around the shops” to report on “a growing range of glamorous and complicated equipment designed for the once-simple job of brewing a cup of tea, or more particularly, coffee” (21). Although she included teapots, her main focus was coffee brewing equipment—what it looked like and how it worked. She also discussed how to best appreciate coffee, and described a range of home grinding and brewing coffee equipment from Turkish to percolation and vacuum coffee makers. As there was only one way of making tea, Dalgleish pays little attention to its method of brewing (21) and concludes the piece by referring only to coffee: “There are two kinds of coffee drinkers—those who drink it because it is a drink and coffee lovers. The sincere coffee lover is one who usually knows about coffee and at the drop of a hat will talk with passionate enthusiasm on the only way to make real coffee” (21). In its first issue in 1966, Australasian Gourmet Magazine reflected on the increased consumption and appreciation of coffee in a five-page feature. “More and more people are serving fine coffee in their homes,” it stated, “while coffee lounges and espresso bars are attracting the public in the city, suburbs and country towns” (Repin and Dressler 36). The article also noted that there was growing interest in the history and production of coffee as well as roasting, blending, grinding, and correct preparation methods. In the same year, The Australian Women’s Weekly acknowledged a growing interest in both brewing, and cooking with, coffee in a lift-out recipe booklet titled “Cooking with Coffee.” This, according to the Weekly, presented “directions that tell you how to make excellent coffee by seven different methods” as well as “a variety of wonderful recipes for cakes, biscuits, desserts, confectionary and drinks, all with the rich flavor of coffee” (AWW). By 1969, the topic was so well established that Keith Dunstan could write an article lampooning coffee snobbery in Australian Gourmet Magazine. He describes his brother’s attention to detail when brewing coffee and his disdain for the general public who were all drinking what he called “muck”. Coffee to the “coffee-olics” like his brother was, Dunstan suggested, like wine to the gourmand (5). In the early 1960s, trouble was brewing in the tea business. Tea imports were not keeping pace with population growth and, in 1963, the Tea Bureau conducted a national survey into the habits of Australian tea drinkers (McMullen). This found that although tea was the most popular beverage at the breakfast table for all socio-economic groups, 30 per cent of Australian housewives did not realise that tea was cheaper than coffee. 52 per cent of coffee consumed was instant and one reason given for coffee drinking between meals was that it was easier to make one cup (Broadcasting and Television “Tea Gains”). Marketing Tea against a Turning Tide Coffee enjoyed an advantage that tea was unlikely to ever have, as the margin between raw bean and landed product was much wider than tea. Tea was also traditionally subject to price-cutting by grocery chains who used it as a loss leader “to bring the housewife into the store” (Broadcasting and Television “Tea Battles”) and, with such a fine profit margin, the individual tea packer had little to allocate for marketing expenses. In response, a group of tea merchants, traders and members of tea growing countries formed The Tea Council of Australia in 1963 to pool their marketing funds to collectively market their product. With more funds, the Council hoped to achieve what individual companies could not (Adams “From Instant” 1-19). The chairman of the Tea Council, Mr. G. McMullan, noted that tea was “competing in the supermarkets with all beverages that are sold […]. All the beverages are backed by expensive marketing campaigns. And this is the market that tea must continue to hold its share” (McMullen 6). The Tea Council employed the services of Jackson Wain and Company for its marketing and public relations campaign. Australian social historian Warren Fahey worked for the company in the 1960s and described it in an interview. He recalled: Jackson Wain was quite a big advertising agency. Like a lot of these big agencies of the time it was Australian owned by Barry Wain and John Jackson. Jackson Wain employed some illustrious creative directors at that time and its clients were indeed big: they had Qantas, Rothmans, the Tea Council, White Wings—which was a massive client—and Sunbeam. And they are just some of the ones they had. Over the following eleven years, the Tea Council sought innovative ways to identify target markets and promote tea drinking. Much of this marketing was directed at women. Since women were responsible for most of the household shopping, and housewives were consuming “incidental” beverages during the day (that is, not with meals), a series of advertisements were placed in women’s magazines. Showing how tea could be enjoyed at work, play, in the home, and while shopping, these kick-started the Tea Council’s advertising campaign in 1964. Fahey remembers that: tea was seen as old-fashioned so they started to talk about different aspects of drinking tea. I remember the images of several campaigns that came through Jackson Wain of the Tea Board. The Women’s Weekly ones were a montage of images where they were trying to convince people that tea was refreshing […] invigorating […] [and] friendly. Figure 3. Tea Council Advertisement. The Australian Women’s Weekly 29 Jan. 1964, 57. Radio was the Tea Council’s “cup of tea”. Transistor and portable radio arrived in Australia in the 1950s and this much listened to medium was especially suited to the Tea Council’s advertising (Tea Council Annual Report 1964). Radio advertising was relatively low-cost and the Council believed that people thought aurally and could picture their cup of tea as soon as they heard the word “tea”. Fahey explains that although radio was losing some ground to the newly introduced television, it was still the premier media, largely because it was personality driven. Many advertisers were still wary of television, as were the agencies. Radio advertisements, read live to air by the presenter, would tell the audience that it was time for a cuppa—“Right now is the right time to taste the lively taste of tea” (Tea Council Annual Report 1964)—and a jingle created for the advertisement completed the sequence. Fahey explained that agencies “were very much tuned into the fact even in those days that women were a dominant fact in the marketing of tea. Women were listening to radio at home while they were doing their work or entertaining their friends and those reminders to have a cup of tea would have been quite useful triggers in terms of the marketing”. The radio jingle, “The taste of tea makes a lively you” (Jackson Wain, “Tea Council”) aired 21,000 times on 85 radio stations throughout Australia in 1964 (Tea Council of Australia Annual Report). In these advertisements, tea was depicted as an interesting, exciting and modern beverage, suitable for consumption at home as outside it, and equally, if not more, refreshing than other beverages. People were also encouraged to use more tea when they brewed a pot by adding “one [spoonful] for the pot” (Jackson Wain, “Tea Council”). These advertisements were designed to appeal to both housewives and working women. For the thrifty housewife, they emphasised value for money in a catchy radio jingle that contained the phrase “and when you drink tea the second cup’s free” (Jackson Wain “Tea Council”). For the fashionable, tea could be consumed with ice and lemon in the American fashion, and glamorous fashion designer Prue Acton and model Liz Holmes both gave their voices to tea in a series of radio advertisements (Tea Council of Australia, “Annual Reports”). This was supported with a number of other initiatives. With the number of coffee lounges increasing in cities, the Tea Council devised a poster “Tea is Served Here” that was issued to all cafes that served tea. This was strategically placed to remind people to order the beverage. Other print tea advertisements targeted young women in the workforce as well as women taking time out for a hot drink while shopping. Figure 4. “Tea Is Served Here.” Tea Council of Australia. Coll. of Andy Mac. Photo: Andy Mac. White Wings Bake-off The cookery competition known as the White Wings Bake-Off was a significant event for many housewives during this period, and the Tea Council capitalised on it. Run by the Australian Dairy Board and White Wings, a popular Australian flour milling company, the Bake-Off became a “national institution […] and tangible proof of the great and growing interest in good food and cooking in Australia” (Wilson). Starting in 1963, this competition sought original recipes from home cooks who used White Wings flour and dairy produce. Winners were feted with a gala event, national publicity and generous prizes presented by international food experts and celebrity chefs such as Graham Kerr. Prizes in 1968 were awarded at a banquet at the Southern Cross Hotel and the grand champion won A$4,750 and a Metters’ cooking range. Section winners received A$750 and the stove. In 1968, the average weekly wage in Australia was A$45 and the average weekly spend on food was $3.60, which makes these significant prizes (Talkfinancenet). In a 1963 television advertisement for White Wings, the camera pans across a table laden with cakes and scones. It is accompanied by the jingle, “White Wings is the Bake Off flour—silk sifted, silk sifted” (Jackson Wain, “Bake-Off”). Prominent on the table is a teapot and cup. Fahey noted the close “simpatico” relationship between White Wings and the Tea Council:especially when it came down to […] the White Wings Bake Off [...]. Tea always featured prominently because of the fact that people were still in those days baking once a week [...] having that home baking along side a cup of tea and a teapot was something that both sides were trying to capitalise on. Conclusion Despite these efforts, throughout the 1960s tea consumption continued to fall and coffee to rise. By 1969, the consumption of coffee was over a kilogram per person per annum and tea had fallen to just over two kilograms per person per year (ABS). In 1973, due to internal disputes and a continued decline in tea sales, the Tea Council disbanded. As Australians increasingly associated coffee with glamour, convenience, and gourmet connoisseurship, these trajectories continued until coffee overtook tea in 1979 (Khamis 230) and, by the 1990s, coffee consumption was double that of tea. Australia’s cultural shift from tea drinking to coffee drinking—easily, but too simplistically, explained by post-war migration—is in itself a complex and multi layered transition, but the response and marketing campaign by the Tea Council provides an opportunity to investigate other factors at play during this time of change. Fahey sums the situation up appropriately and I will conclude with his remarks: “Advertising is never going to change the world. It can certainly persuade a market place or a large percentage of a market place to do something but one has to take into account there were so many other social reasons why people switched over to coffee.” References Adams, Jillian. Barista: A Guide to Espresso Coffee. Frenchs Forest NSW: Pearson Education Australia, 2006. -----. “From Instant Coffee to Italian Espresso: How the Cuppa Lost its Way.” Masters Thesis in Oral History and Historical Memory. Melbourne: Monash University, 2009. Advertisement for Bushells Coffee. The Argus 22 Aug. (1945): 11. Australian Bureau of Statistics [ABS]. “4307.0 Apparent Consumption of Tea and Coffee, Australia 1969-1970.” Canberra: Australian Bureau of Statistics, 2000. Australasian Confectioner and Restaurant Journal. “Espresso Comes to Town.” Australian Confectioner and Restaurant Journal Feb. (1956): 61. Bennett, Bill. Interview. 22 Jun. 2007. Bennett, Peter. Interview. 10 Mar. 2010. Broadcasting and Television. “Tea Gains 98% Market Acceptance.” Broadcasting and Television 6 Jun. (1963): 16. -----. “Tea Battles Big Coffee Budgets.” Broadcasting and Television News 14 Oct. (1965): 16. Button, John. “America’s Australia: Instructions for a Generation.” The Monthly Feb. (2007) 28 Mar. 2012 ‹http://www.themonthly.com.au/monthly-essays-john-button-americas-australia-instructions-generation-456›. Canberra Times, The. Advertisement for Nestle Coffee. The Canberra Times 5 Aug. (1949): 2. “Coffee for Americans.” The Argus 20 Apr. (1942): 5.Dalgleish, Rene. “Better Tea and Coffee.” Australian Home Beautiful Jun. (1964): 21–5. Dunstan, Keith. “The Making of a Coffee-olic.” The Australian Gourmet Magazine Sep./Oct. (1969): 5. Fahey, Warren. Interview. 19 Aug. 2010. Howard, Leila. ‘Cooking with Coffee.” The Australian Women’s Weekly 6 Jul. (1966): 1–15. Jackson Wain. “The Bake-off Flour!” TV Commercial, 30 secs. Australia: Fontana Films for Jackson Wain, 1963. 1 Feb. 2012 ‹www.youtube.com/watch?v=1X50sCwbUnw›. -----. “Tea Council of Australia.” TV commercials, 30 secs. National Film and Sound Archive, 1964–1966. Khamis, Susie. “ It Only Takes a Jiffy to Make.” Food Culture and Society 12.2 (2009): 218–33. McMullen, G. F. The Tea Council of Australia Annual Report. Sydney, 1969. National Archives of Australia [NAA]. Agency Notes CP629/1. “History of the Tea Control and Tea Importation Board, January 1942–December 1956.” -----. Series MP5/45 a. Minutes of the Tea Control Board. 17 Aug. 1942. -----. Series MP5/45 b. Minutes of the Tea Control Board. 29 May 1947. Repin, J. D., and H. Dressler. “The Story of Coffee.” Australian Gourmet Magazine 1.1 (1966): 36–40. Talkfinance.net. “Cost of Living: Today vs. 1960.” 1 May 2012 ‹http://www.talkfinance.net/f32/cost-living-today-vs-1960-a-3941› Tea Council of Australia. Annual Reports Tea Council of Australia 1964–1973. ----- Advertisement. The Australian Women’s Weekly 3 Jul. (1968): 22.“Untitled.” The Argus 20 Apr. (1942): 5. Wilson, Trevor. The Best of the Bake-Off. Sydney: Ure Smith, 1969.“Yanks and Aussies Differ on ‘Eats’.” The Argus 4 Jul. (1942): 8.