Effective collaboration within health professional teams is important to provide the patients with holistic care in order to best support them to achieve their goals.

Good relationships go beyond those within the organisation itself but within a complex system such as healthcare, relationships need also be nurtured in how health services interact with their external environment and vice versa.

This includes applying principles of ‘emphatic understanding’ to interactions with colleagues to create a psychologically safe space which can allow health teams to flourish and in turn to be able to deliver high quality of care to patients.

By Dr Maria Kordowicz *

Chartered Psychologist & Senior Lecturer in Business Psychology

University of Lincoln, Lincolnshire, UK 

The Case for Relational Quality Improvement in Health 

 

Quality improvement in health can be described as a systematic approach to enhancing patient care. It is concerned with bringing about beneficial change in quality performance in health services, systems, organisation and delivery. Due to its systematic, often process-driven nature, healthcare quality improvement can be an arena filled with benchmarking, toolkits, financial appraisals and the language of managerialism.  The resulting proliferation of ‘quality’ metrics and standardised processes can at times detract from recognising the importance of the role effectiveness human relationships play in not only implementing but also sustaining change in healthcare. I reflect here about the role of the relational in improving healthcare quality and draw on my own research and experience to illustrate key arguments. Given the challenging global pandemic context, we are called on now more than ever to offer relational support to one another and to creatively use online technologies to facilitate connection in lieu of physical presence.

It is therefore salient to revisit understandings of human relationships at work and the extent to which they can enable effective healthcare systems.  There is a wealth of research within the business and human resource management arena which centres around how one can improve working relationships in the context of the corporation.  Evidence from the healthcare field concerns itself with the well-being of healthcare staff with enquiry often centred around clinician burnout. My own interest as an executive coach and trainee psychotherapist in person-centred and experiential therapy lies in the role of relational in enabling what Carl Rogers defined as ‘self-actualisation’ – our innate capacity to fulfil our full potential. In other words, my work consists of studying and teaching others how relationships can help us to thrive at work in the healthcare sector and beyond.

We also know from the perspective of the English National Health Service (NHS) that there is a growing disquiet among healthcare staff as to how enabling their working environment is and extent to which it contributes towards undermining their mental health. The annual NHS staff survey has for several years now indicated issues with a dissatisfied demotivated workforce as well as capturing feedback around instances of bullying.  We learned from the Francis Report looking into the atrocities that took place in Mid-Staffordshire NHS Foundation Trust in England that an unfavourable and suppressive organisational culture can play a key role in the extent to which quality of care is enacted or destabilised.  Indeed, recommendations from the Mid-Staffordshire enquiry centred around improving organisational cultures to enable individuals can speak up freely when quality of care is subpar, upholding principles of dignified care.

I have had a wide-ranging career including over a decade’s worth of senior healthcare management experience and I am now a Chartered Psychologist and university academic, researching health and social care organisations. Previously, I worked as an interim healthcare manager, which meant that I was posted to a service or a project to temporarily fill a vacancy gap. Often, the roles I undertook were within challenging services and I was tasked with improving their quality in a short period of time. I quickly learned that struggling services contained struggling teams, with poor and strained working relationships. In order to improve the relational within healthcare teams, we must first seek to understand what good relationships look like.

What constitutes good relationships in healthcare teams?

Our work evaluating Clinical Effectiveness Southwark – a quality improvement scheme in primary care in a deprived borough of South East London providing guides and online templates for chronic disease management – found that it was the sense of ‘teamness’ amongst the improvement team and the collaborative inclusive relationships they formed with a range of stakeholders, which enabled the programme of work to embed and gain ‘buy in’ locally. In this vein, Gittel and colleagues (2013) underline the importance of effective collaboration in healthcare to provide the patient with holistic care in order to best support them to achieve their goals. They explore some of the communication and cultural barriers to good relationships and propose that these deeply embedded behaviours and interaction patterns which may be specific to professional groups need to be transformed in order to improve the quality of patient care. This can be achieved over time through creating and working towards shared goals, generating co-produced knowledge and mutual respect across professional boundaries. The authors also see the potential here for enhanced relational working to improve the access to and quality of care at a scale beyond individual teams.

Further, in an earlier paper, Gittel and others (2009) argued that relationships within healthcare teams can be meaningfully coordinated by creating relational pathways of interdependent work which in turn foster high-performance healthcare systems. Indeed, Cramm and Nieboer (2012) discovered that formal relational coordination of disease-management clinicians from different disciplines improved the delivery of chronic illness care. However, whilst relational coordination is a systematic method of integrating tasks around relational touch points, it does not necessarily account for what constitutes personally rewarding and meaningful relationships within healthcare teams. For instance, rewarding social relationships can be viewed as an important component of wellbeing (Kansky & Diner, 2017) and poor wellbeing at work can in turn lead to healthcare professional burnout (Hall et al., 2016). In terms of quality improvement, the detrimental impact of clinician burnout on patient safety is well-documented (see Hall et al., 2016 for a review).

We know that relational competencies, such as good communication, are essential core skills that are associated with enhanced health outcomes and improved satisfaction with care (e.g. Meyer et al., 2009). In order for staff to deliver quality care, they no doubt require the necessary ‘bandwidth’ to withstand the demands and challenges of their working lives. There is a body of evidence from the business and management literature which indicates that employee wellbeing is upheld in workplaces where staff feel valued and work as part of cohesive teams with a shared vision and values (see Mickan & Roger, 2000 for a review). For instance, my colleague and I are currently completing some research conducted within a large multinational corporation which demonstrates how a simple and authentic ‘thank you’ holds much power in nurturing our working relationships. Indeed, a quote from one of our study’s participants is rather apt here: ‘saying “thank you” is so powerful because it lifts up the individual and it makes him strive harder in his work and given tasks. Being appreciated makes an individual motivated and will create a working environment free of resentments and frustrations’. We must however be mindful not to individualise the relational nor view poor relationships at work as the sole responsibility of staff. It is the ‘health’ of the wider organisation which has much impact on ‘teamness’ and cohesion – the influence factors such as a realistic workload, a well-resourced working environment and the appropriate skill mix and so forth cannot be underestimated.

Therefore, it is worth noting that good relationships go beyond those within the organisation itself but within a complex system such as healthcare, relationships need also be nurtured in how health services interact with their external environment and vice versa.  In particular, in a public taxpayer-funded healthcare system, the influence of top-down government policy on how healthcare teams operate is wide-ranging.  It is naïve not to consider how continuous change mandates driven by a change in government officials can undermine employee stability and in turn their morale and their wellbeing.  Therefore, there is a strong rationale for change programmes that are negotiated and co-produced locally in order to gain adequate ‘buy in’ from the stakeholders who matter – namely staff and patients.

Applying person-centred values to our work

As part of my present training as a person-centred and experiential psychotherapist, I am beginning to immerse myself in how the relational is understood through the lens of the discipline’s founding father – Carl Rogers. It is within groups, through our relationships with others, that our identities are negotiated and formed. In large part, we make sense of our context, and as part of this we negotiate what constitutes quality improvement, through our collective realities. Rogers identified some prerequisites to an effective therapeutic alliance – one that supports the client in their journey to self-actualisation – and I highlight two of these prerequisites as pointers towards improving our relationships at work. These are ‘empathic understanding’ – taking the time to listen and to seek to understand our colleagues, and ‘unconditional positive regard’ – the acceptance of a person within a non-judgmental space, so our colleagues can share their thoughts and feelings freely and without fear. Arguably, this is how healthcare professionals relate to their patients day in, day out. It is crucial to apply these principles towards our interactions with colleagues to create a psychologically safe space which can allow our team to flourish and in turn be able to deliver high quality of care to patients. We have seen some wonderful examples of person-centred interaction taking place with the aid of digital media, through remote team coffee breaks, writing drop ins, special interest online communities and the like. It goes without saying that exploiting the ‘new normal’ as a means of managerial digital surveillance of the ‘performance’ and outputs of health staff who can work from home will only undermine trust and relational safety.

Crucially, one cannot underestimate the time it takes to achieve engagement with quality improvement initiatives, as well as to forge effective working bonds and collaborations. Often, the quality improvement initiatives, which appear to have most positive outcomes, are those that are shaped within pre-existing teams with established effective working processes. Through our own work exploring how newly Primary Care Network leaders in England navigated these novel organisational forms, we learned of the importance of pre-existing relationships in order to achieve a clear mandate for realising an organisational purpose. Similarly, in their study of primary care reform, Scott and Hofmeyer (2007) called for the need to recognise pre-existing networks within a change context, including understanding their roles and relational impact in order to ‘establish a foundation for the diffusion of innovative practice patterns that will foster collaborative relationships and improve primary healthcare systems’.

As a final point, relational quality improvement should not only be concerned with how relationships can improve quality, but also about recognising how the quality of relationships itself may too need to be improved. Through a Rogerian lens, our interconnectedness with others contributes to the greater whole. Healthcare organisations sit at the interface of the individual and the society and human existence is not possible without co-existence – something that the pandemic has made us even more acutely aware of, not least in highly individualist societies. Here evidence-based government public health interventions such as mask-wearing have been received by some as an infringement of individual liberty, rather than as a small sacrifice for the benefit of many. These unprecedented times however call for unity and I therefore urge you not to forget how important your relationships with your colleagues are and the significant role they play in not only upholding quality of patient care, but also your own sense of wellbeing when it likely needs to be nurtured more than ever before.

 

————————————————–

*Dr Maria Kordowicz is a Chartered Psychologist and Trainee Psychotherapist, an executive coach working with NHS staff, Director of www.respeo.com and Senior Lecturer in Business Psychology at the University of Lincoln. Find out more about Maria here: https://q.health.org.uk/community/directory/maria-kordowicz/ Twitter: @mariakordowicz

The path toward universal health coverage cannot neglect the access to essential medicines for pain management. Unfortunately, there is a dramatic gap in access to opioid narcotics for legitimate medical use, and the needs for palliative care and pain relief remains largely ignored in low- and middle-income countries, even for the most vulnerable groups such as children with terminal illnesses and those living through humanitarian crisis. What can the global health community do, to join efforts to fulfill the human right to adequate medical care also when it comes to pain management?

By Raffaella Ravinetto

Institute of Tropical Medicine

Antwerp, Belgium

Access to Opioid Analgesics for Medical Purposes: a Global Unbalance

 

The Universal Declaration of Human Rights includes the right to medical care (1). Within medical care, opioid analgesics are indispensable for provision of pain relief, including but not limited to palliative care. Therefore, the World Health Organization (WHO) has included opioids in its Model List of Essential Medicines since the publication of the first list in 1977 (2). The presence in the WHO Model List clearly indicates that these medicines should be made timely available to all those in need.

Unfortunately, the availability of opioid analgesics remains dramatically inadequate in many countries. In 2006, the WHO estimated that each year pain treatment was not provided to tens of millions of patients in need, including those with end-stage HIV/AIDS, terminal cancer, accidents- or violence-induced injuries, chronic illnesses, post-surgery pain, as well as to women in labour and children with acute or chronic pain (3). The Lancet Commission on Palliative Care and Pain Relief estimated that in 2015, more than 80% of people with serious health-related suffering were living in low- and middle-income countries (LMICs), where access to palliative care and pharmaceutical pain relief is (very) limited or lacking (4).  The findings of a multi-country study of the International Narcotics Control Board (INCB), based on the concept of defined daily doses for statistical purposes (S-DDD) per million inhabitants, revealed that the use of opioid analgesics more than doubled worldwide between 2001–03 and 2011–13, but that substantial increases were limited to North America, western and central Europe and Oceania (5). Countries in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe showed no substantial increase in use, due to a number of factors such as absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulations (5).

The multiplicity of barriers and challenges makes the “access problem” particularly complex for opioid analgesics; and in many LMICs, the underreporting complicates the accurate assessment of needs, with an important gap between actual needs, reported requirements and actual consumptions. Furthermore, problems of access are magnified during public health emergencies, in presence of unplanned and sudden additional needs.

International treaties such as the Single Convention on Narcotic Drugs (1961) and the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988) have been rightly established to prevent the harm and human suffering that derive from abuse of these substances. However, equal emphasis should be put on ensuring that opioid analgesics are made timely and universally available for legitimate medical use. In 2016, the UN General Assembly Special Session (UNGASS) Joint commitment to effectively addressing and countering the world drug problem explicitly addressed the need of ensuring the availability of and access to controlled substances, including opioid analgesics,  for medical and scientific purposes, while preventing their diversion (6). Nonetheless, the needs for palliative care and pain relief remains largely ignored in LMICs, “even for the most vulnerable populations, including children with terminal illnesses and those living through humanitarian crisis, and even in the SDGs” (4).

What is the role for the global health community here? King and Fraser argued that global inequalities in untreated pain also result from lacunae in the “prevailing ideologies of global health”, which prioritize the treatment and eradication of diseases, while the need for pain management may be perceived as a mark of failure within the biomedical model (7). Therefore, it seems important that the needs of patients with pain are put high on the agenda of global health, including researchers and advocates. Collaborative research efforts could investigate, for instance, the effectiveness of the strategies adopted to strengthen awareness, education and training in this field; the impact of the COVID19 pandemic on access to opioid analgesics; and the access to opioid analgesics in specific groups and contexts (e.g. chronic pain in children, palliative care in humanitarian contexts, etc.). This could help to generate evidence to guide policy makers; to reorient the attention of the international community on the needs of under-researched contexts and communities; and eventually to strengthen the global efforts to fulfill the human right to adequate medical care including  the management of pain.

 

References

1) UN General Assembly. Universal declaration of human rights. New York: United Nations, 1948. Available at http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf

2) Richards GC et al. Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists. BMJ Global Health 2020;5:e003563. doi:10.1136/bmjgh-2020-003563

3) World Health Organization. Briefing note, Access to Controlled Medications Programme, Improving access to medications controlled under international drug conventions. Geneva. Available at https://www.who.int/medicines/areas/quality_safety/AccessControlledMedicinesProgr.Framework.pdf

4) Knaul F, et al. 2018. Alleviating the access abyss in palliative care and pain relief-an imperative of uni­versal health coverage: The Lancet Commission report. The Lancet, 391: 1391–1454. DOI: https://doi. org/10.1016/S0140-6736(17)32513-8

5) Berterame S et al. Use of and barriers to access to opioid analgesics
Lancet 2016; 387: 1644–56

6) https://www.unodc.org/ungass2016/en/about.html

7) King NB, Fraser V (2013) Untreated Pain, Narcotics Regulation, and Global Health Ideologies. PLoS Med 10(4): e1001411. https://doi.org/10.1371/journal.pmed.1001411

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Economic Growth, Accessibility, and COVID-19: a Policy Analysis Examining a Decade of Greater Alcohol Liberalization in Ontario by Yipeng Ge, Elspeth McTavish, Rohit Vijh, Lawrence Loh 

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Between 2010-2020, alcohol policy liberalization in Ontario has seen the loosening of regulations and restrictions on alcohol access and pricing.

Alcohol is a controlled psychoactive substance that is largely normalized in our society, often served and consumed in a variety of settings and environments, with notable health and social consequences.

Health policy evidence demonstrates that policies and regulations that limit access to alcohol (e.g. through age, timing, and pricing restrictions) is successful in limiting the harmful effects of alcohol on individuals and communities.

In Ontario, initial alcohol policy and regulation liberalization was driven by economic and values-based arguments by the government to provide opportunity and fairness for small businesses and to increase choice for location for alcohol to be served/sold and ease of accessibility for customers.

The COVID-19 pandemic has driven even more significant liberalization with regulations permitting home-based alcohol delivery by both producers and licensed establishments.

Public health and other stakeholder input play an important role in policy decisions around alcohol that impact communities; previous engagements in Ontario’s liberalization have been limited and will become even more critical in the post-pandemic recovery phase

credit: Worldatlas

Economic Growth, Accessibility, and COVID-19: a Policy Analysis Examining a Decade of Greater Alcohol Liberalization in Ontario

 

By Yipeng Ge¹, Elspeth McTavish², Rohit Vijh³, Lawrence Loh⁴

 

¹University of Ottawa Faculty of Medicine School of Epidemiology and Public Health, Public Health and Preventive Medicine Residency Program; 600 Peter Morand Crescent, Room 101, Ottawa, Ontario K1G 5Z3; Yipeng.ge@uottawa.ca 

²University of Toronto, Dalla Lana School of Public Health, 155 College Street, Toronto, ON, M5T 3M7; e.mctavish@mail.utoronto.ca 

³University of British Columbia, School of Population and Public Health, Public Health and Preventive Medicine Residency Program, 2206 East Mall, Vancouver, BC, V6T 1Z3; rohit.vijh@alumni.ubc.ca 

⁴University of Toronto, Dalla Lana School of Public Health, 155 College Street, Toronto, ON, M5T 3M7; lawrence.loh@peelregion.ca

Corresponding author: Yipeng Ge  Yipeng.ge@uottawa.ca

 

 

Introduction

Over the past ten years, the Canadian province of Ontario has seen significant alcohol policy liberalization, including the expansion of alcohol sales into grocery stores, fewer restrictions on alcohol marketing and advertising, and lowering the minimum price of alcohol. The COVID-19 pandemic led to even more significant opening of the sector with home deliveries from producers and licenced establishments.

This policy analysis examines peer-reviewed and grey literature identified through a literature search and analyzed using the 3-I framework (ideas, interests, and institutions). The paper summarizes timelines for Ontario’s alcohol liberalization, analyzing context and the role of health in policy decision-making.

Pre-pandemic policy changes did not comprehensively explore potential public health impacts in moving towards liberalization. The means for public health experts to provide input appeared largely absent despite recommendations for consultation in considering the expansion of alcohol access and privatization. Decisions seen in the COVID-19 pandemic confirm the predominant driver has appeared to be economic value and sustaining government and small business revenues, as well as increased autonomy and choice for consumers.

Public health evidence is clear that regulating alcohol access, availability, and discouraging normalization of alcohol use is critical to reducing alcohol-related harms in the community. To date, policy decisions in Ontario towards greater liberalization arguably puts Ontario citizens at increased risk of harms. Going forward post-pandemic, public health must play a vital role in revisiting policy decisions around alcohol in aiming to strike a balance between business interests and the long-term health and wellbeing of our communities.

Background

Alcohol consumption is a leading risk factor for death and disability in Canada and worldwide with associations to cancer, stroke, liver disease, spousal and domestic violence, assaults, and motor vehicle collisions from impaired driving (1–3). The 2018 Chief Public Health Officer of Canada report highlighted alcohol as being responsible for the greatest economic and social burden in Canada, driven by its social acceptability and a widespread underappreciation for its associated harms (4). Despite these concerns, per capita sales of alcohol in Canada have steadily continued to rise, with $22.5 billion worth of alcoholic beverages sold in 2017, up 2.3% from the previous year (5).

In Ontario, Canada’s most populous province, the past decade has seen significant liberalization in government alcohol policy, leading to increased availability and access and significant concerns of population health risks associated with alcohol consumption. (6–10)

This policy analysis reviews Ontario’s path to greater alcohol liberalization, examining drivers of change, the involvement of health agencies, and potential policy impacts before proposing future strategies to focus on health in alcohol policy.

Methodology

A literature search of peer-reviewed (using CINAHL, Embase, Medline (Ovid), PubMed databases) and grey literature (using Google search engine, Ontario e-Laws database, Canadian digital media outlets) including news articles was conducted. Of relevant articles identified, the 3-I framework (ideas, interests, and institutions) for public policy analyses was applied to identify themes relevant to each section of the framework.

Ontario’s Changing Alcohol Landscape

In Ontario, alcohol sales are provincially regulated by the Liquor Control Act (1990) and Liquor License Act (1990), and operate within a mixed private and public retail system. The Liquor Control Act (1990) specifies where alcohol can be sold, sets a minimum price, and created the Liquor Control Board of Ontario (LCBO). LCBO is a Crown corporation that sells liquor through LCBO stores. Other venues include The Beer Store (TBS), operated by Brewers Retail Inc., a company owned by three foreign-owner brewers (Molson, Labatt, Sleeman), and winery retail stores that are owned and operated by six Ontario wineries. The Alcohol and Gaming Commission of Ontario (AGCO) is responsible for regulating the Liquor License Act (1990) and specific sections of the Liquor Control Act (1990) pertaining to the sale and service of alcohol in liquor sales license settings such as, craft brewery locations, bars and restaurants (15).

In April 2014, the Minister of Finance announced the Premier’s Advisory Council on Government Assets to advise the Premier on how best to maximize the economic value and performance of government business enterprises and Provincial assets. This led to two reports in 2015 and 2016, published by the Council, which presented recommendations for 450 grocery stores to sell beer, wine and spirits, and for the LCBO to begin selling a wider variety of products through more accessible means (18,19). This paved the way for revised alcohol sales regulations that allowed grocery stores to start selling beer, wine, and cider—an increase in 25% of stores where alcohol could be purchased (20,21) and the launch of an LCBO e-commerce platform (22).

Further liberalization occurred following a change of government in 2018, with commitments to allow alcohol sales in corner stores, a decrease in the minimum price of beer (‘buck-a-beer’), cancelled automatic increases in beer prices and lengthening of weekly hours of sale at the LCBO and TBS. (23,24) This continued in 2019 with changes to the Liquor License Act (1990) to permit extended hours for the sale and service of alcohol, loosening previous marketing restrictions for ‘happy hour’, opening up municipal choice for designating public areas for alcohol consumption, and allowing tailgate events (7).

In 2020, the COVID-19 pandemic resulted in significant business closures to bring the disease under control in Ontario communities. During these closures, alcohol distribution was deemed an essential service and licenced establishments and producers were permitted under emergency regulations to deliver alcohol directly to consumers at their home. The AGCO permitted newly allowed licensed liquor delivery services to contract out work to freelance drivers and boat operators with liquor licences to sell and serve beer, wine, and spirits while docked. These changes offered unprecedented access and were seen favourably by many Ontarians (25).

What Interests Played a Role?

Economic interests have driven many government decisions around alcohol, up to and including emergency decisions taken during the COVID-19 pandemic. Government agenda appears to be responsive to decreasing support for alcohol control policies in Ontario among the general public (16) and lobbying from craft and artisanal brewing companies to dismantle the former TBS/LCBO economic monopoly (17).

A May 2019 report to the Minister of Finance, the Ontario Special Advisor for the Beverage Alcohol Review addressed liberalization largely from an economic perspective for small businesses and breweries/wineries and an autonomy perspective for the individual. This perspective aligned with positions advanced by The Retail Council of Canada and The Convenience Industry Council of Canada in ‘building a system that’s fair for everyday Ontarians” (30). While the report mentions certain health and safety provisions, including calls for socially responsible beverage alcohol retail and a recommendation to work with public health experts to ensure that increasing convenience does not lead to increased societal costs, the broader implications on public health were not clearly stated.

Similarly, primary stakeholders consulted in the production of the Premier’s Advisory Council on Government Assets reports included the business entities involved, relevant ministers and representatives from various sector unions. Input from healthcare and public health stakeholders was notably absent from these reports, despite the efforts of civil society groups and public health agencies to advocate for careful consideration and mitigation of negative health impacts associated with greater liberalization. (28,29) (31,32).

What Ideas Played a Role?

Public ideas reported by the Wynne government cited increasing choice for consumers to purchase alcohol at convenient locations and increasing business opportunity for small business (breweries and wineries), along with a dissatisfaction with the 2015 Master Service Agreement that had been signed by the previous government with Molson, Labatt, and Sleeman. The argument for privatization in favour of competition for driving down prices and increasing options was also shared by the president of the Alberta Liquor Store Association (34).

The value of autonomy and independence of the consumer’s role in alcohol access and self-control was also expressed through a desire to ‘treat adults as adults’. Healthcare services research has shown that liberalization measures in 2015 (increased hours of operation and number of alcohol outlets available) were associated with increased emergency department visits tied to alcohol, particularly among women and younger adults (9,10). Despite this, public support for liberalization has also grown over time (35), and other popular ideas include a willingness to pursue convenience store expansion provided it is conducted in a safe and regimented manner. This perspective draws on lessons from the Registrar’s Standards for Cannabis Retail Stores, recognizing if changes are inevitable, that harms are mitigated as best as possible with available evidence and tools.

What Institutions Played a Role?

When it comes to the institutions, the formal and informal rules, norms, precedents, and organizational factors that structure political behaviour, it is clear that the topic of convenient access to inexpensive alcohol appears to be one of few bipartisan issues left in Ontario (21).

To some extent, the province also experiences a conflict of interest in that expansion of alcohol vendors and ownership of the LCBO/TBS generates significant tax revenues, even though the costs of alcohol consumption may be higher than that of financial benefit to the province. A government-run and regulated alcohol distribution model (LCBO/TBS) provided an avenue for small business owners (e.g. craft breweries) to argue for increased consumer choice in product and consumer convenience in where to purchase alcohol. The LCBO as an institution is a policy legacy from the end of prohibition in 1927, which was a drastically paternalistic policy contrast to current norms. This meant that the continual erosion of public trust in public institutions and perceived paternalistic policies may have set this topic up as both favourable for political behaviour and public buy-in.

Most recently, COVID-19 saw additional alcohol liberalization as an unintended consequence of broader government-led efforts to reduce interactions and control the spread of the deadly virus. This saw the declaration of alcohol sales and distribution an essential service in recognizing the potential burden that a withdrawal of service might present an additional burden to the hospital and healthcare sector. The delivery of alcohol by licenced establishments and producers was also used by government to provide additional revenue streams to those economic sectors and allow consumers to access products while adhering to physical distancing and isolation requirements in the short-term. This has led to the creation of a new societal norm legitimized by government that will importantly require revisiting once the pandemic is brought under control.

Discussion

Taken together, this 3-I analysis suggests that the Ontario context had recently become primed for alcohol policy reform, with a focus on economic value and efficiency for the Ontario government and small businesses and increased autonomy and choice for individuals. Impacts to public health were not at the forefront in the rationale for these policy changes and means for public health experts to provide input appeared largely absent despite recommendations to do so in work that recommended expanding alcohol access and privatization. 

Public health evidence shows that limiting harms from alcohol depends on limiting alcohol access and availability and discouraging normalization of alcohol use (6,8). Centralized government interventions, such as control over manufacturing, retailing and licensing of alcohol, limits on the number and density of alcohol outlets and their hours of operation, and diligently trained staff enforcing legal requirements (i.e. minimum age of purchase) have been shown to have the greatest impact (5). Additional interventions include optimizing taxes and a minimum price of alcohol, strict regulation and enforcement of impaired driving, marketing restrictions, and greater resources, access and linkages to medical interventions for alcohol use disorder (36).

Noted alcohol policy changes in Ontario are likely to lead to broad unintended effects associated with greater alcohol availability and access. There is potential to exacerbate health inequities; evidence shows, for example, that individuals living in lower income neighborhoods are most likely to experience higher rates of hospitalizations due to alcohol compared to those living in higher income neighborhoods (8,37). Without accompanying policies to mitigate and restrict availability and access, increased liberalization may lead to population health harms that will outweigh economic gains. (21,30).

Recommendations from “The Case for Change: Increasing Choice and Expanding Opportunity in Ontario’s Alcohol Sector” now include that the government’s proposed retail alcohol expansion workplan includes consulting with public health experts so that social responsibility and health and wellbeing of citizens are taken into account and protected, and harms from alcohol consumption mitigated (30). This is crucial and necessary to forestall and mitigate the harms associated with alcohol consumption in an environment where the product is increasingly available, particularly during the COVID-19 pandemic, and even more socially accepted than before.

Increased access to alcohol from online sales and delivery services, in concert with the impacts of the COVID-19 pandemic (quarantine measures,  individual financial and psychological stress)  will likely increase the negative effects of alcohol and there may be a corresponding spike in both incidence and prevalence of alcohol use disorder and alcohol-associated liver disease (38–40). The COVID-19 pandemic response measures including a post-pandemic recovery plan ought to incorporate supporting, treating, and preventing substance use disorders, including the impact of alcohol consumption.

Conclusion

Since 2014, Ontario has increasingly liberalized provincial alcohol policies; however, the extent to which there was input and involvement from public health experts and healthcare services perspectives was limited. Many of the decisions taken run contrary to commonly accepted evidence including the calls to action the 2018 Chief Public Health Officer of Canada report.

Public health agencies and units must be involved in policymaking and consultations whenever possible and must continue to monitor and analyse the impact of alcohol liberalization. Economic analysis of the costs of health and social impact versus economic gains from these recent policy changes would also assist in alcohol policy reform. An understanding of the impacts of policies on access, availability, and normalization on cannabis access will also inform alcohol policy reform. The reversal of any policies leading to accessibility prior to and during the COVID-19 pandemic will be more challenged by the transformation of many of these changes into the status quo.

 

Contributions

All authors were involved in the manuscript drafting and editing process, with initial iterations of the manuscript and analyses developed by EM and RV, and additional revisions and analyses added by YG. The conception of the research question including guidance and supervision with the manuscript preparation was provided by LL. There was no source of funding for this work.

 

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Even in the best possible post-pandemic world, inequalities that have been further magnified will be remediable only through huge programmes of public investment and direct redistribution, realistically financed by way of long-term borrowing at current low interest rates and progressive income, wealth and land value taxes. Unfortunately, … In a world of increasingly ungovernable private wealth…, it is far from clear that most governments even have the political capacity to undertake them… at a time when… the most disturbing aspect of events over the past few weeks is the demonstration they have provided of just how widespread the evisceration of basic public health capabilities has become.

Truth-telling on this point is long overdue

By Ted Schrecker

Professor of Global Health Policy, Newcastle University

Whistling Past the Graveyard of Dreams:  Hard Truths About the Likely Post-Pandemic World

Note:  All views expressed here are exclusively those of the author.  Others quoted here do not necessarily agree with them.

 

Whistling past the graveyard is a long-ago expression that describes the behaviour of people who are afraid of ghosts, but like to pretend that they are not.  So, they whistle as a show of nonchalance while walking past graveyards late at night.  The expression well describes the current behaviour of academics and apparatchiks alike, in much of the world, as they respond to the coronavirus pandemic.  The malevolent spirits that they try to ignore are long-term economic and health implosion and possible state collapse.  No one really wants to admit how bad things could get, and how long the damage could persist.  On the part of political classes and oligarchs, such behaviour is perhaps understandable; they want to risk neither riots nor collapsing financial markets.  On the part of academics who should stand up for serious scholarship, it is inexcusable.

In June 2020 – how long ago that now seems! – I argued in a webinar that the best available model for understanding the probable long-term consequences of the pandemic is the experience of post-Soviet Russia, where over a period of a few years the economy shrank by about 50 percent; social provision mechanisms and large portions of the health care system crumbled; and life expectancy  plunged by several years.  Subsequent economic recovery was accompanied by drastic increases in inequality and massive capital flight, so that half of all Russians’ financial wealth is now held offshore, and the emergence of a new stratum of politically connected billionaire oligarchs.  They now own, among much else, substantial chunks of London.  The leading authority on the post-Soviet mortality crisis and colleagues have pointed out that a quarter-century later, Russian life expectancy still did not reflect the country’s economic recovery.  In other words, it was several years lower than would be expected given its GDP per capita – years lower than in (for example) slightly poorer Brazil, Chile and China.  Back to this model later.

I am writing this from the United Kingdom (UK), which has been an especially disturbing case thanks to the fecklessness, despotic inclinations and corruption of Prime Minister Johnson’s Conservative government.  These have been ably described by George Monbiot, whose commentaries are essential reading for anyone wanting to understand the situation here.  The most disturbing aspect of events over the past few weeks, in Europe in the first instance but not only there, is the demonstration they have provided of just how widespread the evisceration of basic public health capabilities has become.   It helps to understand this process by way of a political science construct known as the Overton window – an idea emanating from a right-wing think tank that was concerned, in the first instance, with ways to soften public opposition to privatising education.  The window frames the universe of public policies that are considered at least plausible, rather than beyond the pale.  ‘Shifting the window’ means that, over time, policies that once were well outside the mainstream, on either end of the left-right political spectrum, come to be considered plausible and, eventually, just common sense.

President Trump’s destruction of a range of political norms is one illustration of shifting the window.  Over the longer term, decades of well-funded neoliberal efforts to shift the Overton window rightward, the trajectory of which is clear for those willing to do the necessary reading, have led to a situation in which maintaining basic public health infrastructure needed for pandemic preparedness came to seem like an extravagance, an unnecessary expenditure on a too-large state, despite authoritative warnings of the economic and public health importance of pandemic preparedness.  In much of the world, Covid-19 must therefore be understood as a neoliberal epidemic – a phrase my colleague Clare Bambra and I coined in 2015.  As another colleague, public health physician Allyson Pollock, has put it, austerity in the UK has led to a situation in which ‘[n]ational and local expertise has been lost and many of [her] colleagues in communicable disease control were made redundant.’

The unwisdom of such abandonment of precaution was articulated in 2015, on a small scale, by 267 economists led by Lawrence Summers – Lawrence Summers, of all people – writing about the benefits of universal health coverage: ‘The debilitating effect of Ebola could have been mitigated by building up public health systems in Guinea, Liberia, and Sierra Leone at one-third of the cost of the Ebola response so far.’  If there really were such a thing as the international community, it might usefully reflect on how much it would have been worth investing in measures that could have mitigated a pandemic now anticipated to result in the loss of more than US $12 trillion in economic output in 2020 and 2021 alone, according to the International Monetary Fund.

According to projections from the Institute for Health Metrics and Evaluation at this writing (30 October, 2020), on current trends the virus will have killed approximately 2.5 million people as of 1 February 2021, with a wide variation in outcomes possible depending on what precautions are taken, and where.  This projection deals only with the short term, and cannot address the longer term health consequences of the pandemic, for at least two reasons.

First, it does not include deaths attributable to reduced access to treatment or prevention for other conditions among people not infected by the virus.  In the UK alone, a former Conservative health secretary is warning of ‘tens of thousands of avoidable deaths within a year.’  Second, it does not and cannot anticipate health impacts of the economic depression and ratcheting-up of inequality that will follow the locking down of major segments of entire economies and societies.  Unfortunately, and despite everything we know about the social determinants of health and health inequalities, in much of the academic world arguing for consideration of these health impacts is immediately equated with callous indifference to human life.  This should not be the case.

This is why I am more convinced than ever of the distinctive relevance of the Russian experience.  As the UK enters another nationwide lockdown, with an economic cataclysm that will be life-threatening for some certain to follow, all that will remain of some local and regional economies, and millions of individual futures, is wreckage.  Much the same can be said for many other jurisdictions.  It is possible, of course, that an effective vaccine will be developed sooner rather than later, avoiding some of the more disastrous scenarios.  But there is no vaccine for the inequalities that were already devastating lives before the pandemic.  As just one illustration, in 2011 – at just the start of the UK’s decade of viciously disequalising Conservative austerity – the ‘Great British Class Survey’ found that one-third of British households, supported by low-wage or precarious employment, had an average of just under £1,000 in savings.

Even in the best possible post-pandemic world, inequalities that have been further magnified will be remediable only through huge programmes of public investment and direct redistribution, realistically financed by way of long-term borrowing at current low interest rates and progressive income, wealth and land value taxes.  Such policies, for the moment, remain well outside the Overton window anywhere I know of, despite important advocacy by agencies like the United Nations Conference on Trade and Development.   In a world of increasingly ungovernable private wealth and the opportunities for capital flight and tax avoidance offered by a borderless financial world, it is far from clear that most governments even have the political capacity to undertake them.  Many dreams of the young and the old alike will be consigned to the graveyard referred to in my title.  Truth-telling on this point is long overdue.

 

A first hand snapshot here of the response of Oregon to COVID-19 outbreak as of October 30, 2020

By Susan M. Severance, MPH

Forward Channel LLC

sseverancepdx@gmail.com

http://www.linkedin.com/in/susanseverance

The State of Oregon’s COVID-19 Response

 

My home is in the Portland metropolitan area of Oregon in The United States. Oregon has a diverse landscape from the coast of the Pacific ocean to the mountains to the high deserts in the East.

          

Like almost everywhere we have been dealing with COVID-19. The Oregon Health Authority is the state agency in charge of the response to the pandemic. The Federal Centers for Disease Control & Prevention (CDC) provide guidance that the state of Oregon has embraced since the beginning of the outbreak. The available information has been evolving as we learn more about the virus and how it presents. New knowledge impacts the responses in the communities.

The status of COVID-19 is at an all record high for cases and deaths in most of the states, and Oregon is no exception. The states have varied in their responses to COVID-19. Oregon is largely Democratic and has followed the CDC guidelines. The approach in Oregon has been conservative with requiring face masks and limiting restaurant activity and gatherings of people in the community. I have family in Atlanta, Georgia, and lived there for eight years. I even had a volunteer internship at the CDC. I worked on campylobacter and studied the different species of this bacteria. The college I went to was close by at Emory University. I also worked at the children’s hospital also close by walking distance for me from my dorm room. I had an interest in public health early on, which eventually led me to study and obtain my masters in public health at Boston University.

Georgia is largely Republican and has consistently been less conservative in the state’s response to COVID-19. Only recently have they required wearing masks indoors and in the workplace. Also, churches there have held scaled down services where my church in Oregon has been online since early on and will continue to be through the end of the year including virtual Christmas services.

On March 8, 2020, Governor Kate Brown declared a state of emergency to address the spread of COVID-19 in Oregon. Here are the cumulative COVID-19 numbers to date for Oregon. There are 43,793 total cases, 41,565 positive test results, and 805,002 negative test results. Total deaths are at 673 for the state of Oregon. We have statewide mask, face covering, and face shield guidance. We also have statewide gatherings, indoor social get-together guidance. There is also guidance on re-opening for employers. Oregon has a three-phase re-opening program. Republicans have repeatedly challenged the mandates – not laws – and have lost in court every time in Oregon. Fines are being issued for violations. In comparison, the state of Washington that borders Oregon to the North has 110,748 confirmed cases and 2,463 deaths. The United States has 9,043,390 confirmed cases total and 232,194 deaths to date. The global numbers are 45,179,529 cases and 1,183,213 deaths.

My volunteer activities in the community have also been affected by COVID-19. My volunteering at a local senior community has been on hold. My volunteering at a local Federal wildlife refuge as a naturalist has been on hold. There have been some Zoom calls for volunteers, and they recently announced some remote volunteer activities for us. These social distancing measures in the community have impacted lots of people in their day-to-day life and in their plans in the community. My position on my homeowners’ board has continued through the pandemic. We meet outside and space apart wearing masks. There are five homeowners on the board, and we all have continued to contribute remotely as well as in person at our outdoor meetings.

Oregon is remaining vigilant against COVID-19 and news here includes expectations that we will remain in the fighting mode through the end of the year into next year. Most schools are operating remotely. I see a lot of restaurants in the neighborhood have added outdoor seating and even closed down some streets to traffic so they could set up outdoor seating. I am still not comfortable eating at a restaurant, but I do get take out. My friends here are all working from home. I have been spending time outdoors with friends on walks and birding in the area. I plan to continue the outdoor activities and dress for the winter weather as we head towards it. We have a highly charged presidential election, and the country is divided by it. We shall see what early November brings. COVID-19 is here now and will remain after the election is over and the next president is sworn in. Overall, I am supportive of the measures taken by Oregon in response to COVID-19.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Climate finance driving poor countries deeper into debt, says Oxfam 

EU leaders to decide tougher climate goal in December  

Renovation Wave: doubling the renovation rate to cut emissions, boost recovery and reduce energy poverty 

Green Deal: Commission adopts new Chemicals Strategy towards a toxic-free environment 

EU to push new standards for ‘greenest’ car batteries on earth 

Dried, pressed plants predict climate future 

 

 

 

 

 

 

 

 

 

 

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 402

 

Public health should better recognise local and contextual research 

IN THE INTEREST OF HEALTH FOR ALL? THE DUTCH ‘AID AND TRADE’ AGENDA AS PURSUED IN THE AFRICAN HEALTHCARE CONTEXT  

Dutch Court Orders AstraZeneca to Pay Damages in Patent Evergreening Case  

On 12 December, the world celebrates the International Universal Health Coverage Day (UHC Day) 

La valutazione della performance in sanità in Paesi a risorse limitate sabato 17 ottobre alle ore 09.00: diretta streaming Youtube . In alternativa: Password: Cuamm_2020

Piano Nazionale per l’Assistenza Socio-sanitaria Territoriale 

Despite A Bumpy Road Ahead, Incremental Progress On Price Transparency 

Webinar: How your country can end medical research waste (22 October 15:00 CEST)  

Series of webinars on 19/26 October and 2 November 2020
Stronger Collaboration, Better Health? Watch the GAP!  

20 October 2020 – Save the Date – Government Funding of COVID-19 Vaccines and Other Medical Technologies 

Coronavirus disease (COVID-19) Weekly Epidemiological Update  

Latest Covid-19 Statistics from African Countries 

China, Republic of Korea Join COVAX Global Vaccine Pool – WHO Urges Countries To Jumpstart Vaccine Campaigns 

Webinar: MSF Korea: COVID-19 Vaccines for the People Oct 21, 2020 

Johnson & Johnson ‘Pauses’ COVID-19 Vaccine Trial Due To Unexplained Illness In Participant; Eli Lilly Reportedly Suspending Trial Of Antibody Treatment 

World Bank board approves $12 billion for COVID-19 vaccines 

Pursuing COVID ‘Herd Immunity’ Without A Vaccine Could Be Dangerous & Unethical, WHO Warns – As World Reaches Record Peaks For New Infections

Genomic evidence for reinfection with SARS-CoV-2: a case study 

Dying in a Leadership Vacuum  

The Pandemic Shows That Philanthropy Needs to Play the Long Game on Global Health 

WAIVER FROM CERTAIN PROVISIONS OF THE TRIPS AGREEMENT FOR THE PREVENTION, CONTAINMENT AND TREATMENT OF COVID-19 COMMUNICATION FROM INDIA AND SOUTH AFRICA (to be discussed at the WTO TRIPS Council meeting on 15-16^th October)  

Recognizing Frailties In How We Measure Health and Health Care—And Charting A Pandemic-Resistant Path Forward  

Assessing the spread of COVID-19 in Brazil: Mobility, morbidity and social vulnerability

Rapid Assessment on the Impact of COVID-19 among Female Sex Workers, Adolescent Girls and Young Women, and Women Living with HIV & AIDS in Uganda by AWAC-Alliance of Women Advocating for Change

WHO: Global TB progress at risk 

World Bank’s Malpass says G20 may agree to only six-month debt relief extension 

Human Rights Reader 548 

‘Money needs to be found’: African leaders call for urgent action on nutrition 

Overcoming Ecological Crises: Reconnecting Food, Nature and Human Rights

Ending world hunger by 2030 would cost $330bn, study finds 

Timmermans calls for greater urgency to tackle biodiversity crisis 

‘Staggering’ rise in climate emergencies in last 20 years, new disaster research shows 

World Bank Still Investing Billions in Fossil Fuels, Study Shows 

The future of cities: sustainable or bust 

Working Animals’ Role in SDGs and Addressing Climate Change, Pandemic Crises