Journal articles: 'Street children - Medical care - Angola' – Grafiati (2024)

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AbstractBackgroundEpidemiological patterns of cardiac disease differ between developed countries and African nations. Despite the collaborative efforts of developed countries, several obstacles hinder the implementation of successful programmes for the management of children with heart disease in Africa.Materials and methodsThis study is a retrospective analysis of a bi-national two-institution partnership programme for the treatment of children with congenital and acquired heart disease. In April, 2011, a continuous medical-surgical programme was inaugurated at Clínica Girassol in Luanda. The main goals were to initiate permanent and local delivery of services while training local teams, allowing autonomous medical and surgical management of children with heart disease.ResultsBetween April, 2011 and August, 2015, a total of 1766 procedures were performed on 1682 children. Of them, 1539 had CHD and 143 had acquired heart disease; 94 children underwent interventional treatment. A total of 1672 paediatric surgeries were performed on 1588 children: 1087 (65%) were performed with extracorporeal circulation and 585 (35%) were off-pump. The age distribution of the children was 4.5% (n=76) neonatal, 40.4% (n=675) between 30 days and 1 year, and 55.1% (n=921) over 1 year. There were 76 re-operations (4.5%) due to complications. The 30-day mortality rate was 4.2% (71 patients). Education-wise, several Angolan medical and surgical specialists were trained, allowing near-autonomous cardiac care delivery in children with heart disease.ConclusionAn innovative cooperation model between a European and an African centre based on permanent delivery of care and education allowed for effective training of local teams and treatment of children with heart disease in their own environment.

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Abstract:Despite gains in national income, Ethiopia’s cities have seen a steady increase of homeless women and children. This study focuses on the lives of twenty-five adult women and twenty-seven children living on the streets of Hawassa, Ethiopia. Nearly all were driven to the streets by poverty compounded by abuse and violence and/or loss of supporting family members, illness, and lack of social supports. The Ethiopian government offers a food-for-work program, but this is an inadequate social safety net. Recommendations include government provision of long-term shelter, food assistance, school supplies for children, legal and economic assistance, and access to medical care.

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Abstract Background Sickle cell anemia (SCA) is a significant, under recognized contributor to global childhood mortality, especially in sub-Saharan Africa. Early diagnosis is critical to enable timely access to care and education, before severe and life-threatening complications develop in the first year of life. Unfortunately, such early and comprehensive care remains largely unavailable for many infants across Africa. In an attempt to reduce the high early mortality associated with SCA, an infant SCA clinic was developed and implemented in the capital city of Luanda, Angola. We describe the early experiences and successful outcomes for infants enrolled in this clinic. Methods Infants were enrolled in the clinic if the diagnosis of SCA was made in the first year of life. The clinic was established in the major public pediatric hospital in Angola, Hospital Pediátrico David Bernardino (HPDB). The vast majority of enrolled infants were diagnosed by newborn screening at local maternity hospitals, while some were diagnosed due to clinical suspicion or known family history. Initial clinic visit included intake of demographics such as contact information, family history, and details of basic housing conditions. A dried bloodspot was collected and the diagnosis of SCA was confirmed by isoelectric focusing. All families received sickle cell education and confirmed infants received penicillin prophylaxis (125 mg by mouth twice per day), pneumococcal vaccination series (Prevnar-13), and an insecticide-treated mosquito net for malaria prophylaxis. Results In the first twenty months of the HPDP Infant SCA clinic, 301 infants were enrolled. Eighty-one percent (244/301) were identified through the associated newborn screening program, while the remaining fifty-seven infants presented due to clinical symptoms or known family history. Families live in the urban and poverty-stricken Luanda. The average household has 6.4 people with 2.8 people per bedroom. Only 34.2% of families reported access to water within their household. Despite poverty and difficult housing situations, continued follow-up was extraordinarily high at 97.3%. After the initial visit, only eight families (2.7%) chose not to follow-up – four preferred faith or traditional healing techniques, and four chose follow-up care at a private clinic. With a concentrated effort to track and enable timely follow-up care, there were zero babies truly “lost to follow-up.” For the 167 babies who are now at least one year of age, the calculated infant mortality rate (under 1 year of age) is 6.6%, which compares favorably to the nationally reported infant mortality rate for all children (9.8%). Upon reviewing the 11 deaths, in nearly all cases the families sought appropriate medical care as instructed, and most deaths were likely preventable if appropriate and timely emergency care were available in the community. Conclusions Early mortality associated with SCA can be significantly reduced through early diagnosis and access to care and education, even in countries with few health resources such as Angola. These experiences with a newborn clinic in the urban city of Luanda demonstrate that simple, lifesaving care is feasible and that follow-up and survival is excellent. Although the survival in this Angolan cohort was even better than the national infant mortality rate, the few deaths illustrate gaps in the understanding of emergency SCA care among the healthcare community. It is critical to include education and training of healthcare professionals at all levels of care in any national strategy, so that children with SCA can be promptly triaged and adequately treated for emergent and life-threatening complications. Disclosures: No relevant conflicts of interest to declare.

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Introduction. In the mid-twentieth century, the health care of women and children was inadequate in the post-war Yugoslavia, including the city of Novi Sad, due to the severe post-war reality: poverty in the devastated country, shortage of all commodities and services and especially of medical supplies, equipment and educated staff. Out-of-Hospital Maternity Unit. One of the serious problems was parturition at home and morbidity and mortality of the newborns and women. Soon after the World War II the action programme of improving the women?s health was realized on the state level by establishing out-of-hospital maternity units but under the expert supervision. The Maternity unit at 30 Ljudevita Gaja Street in Novi Sad played a great role in providing skilled birth attendance at mainly normal deliveries. With a minimal number of medical staff and modest medical equipment, about 2000 healthy babies were born in this house. Motherhood Home. After 5 years of functioning in that way, this unit was transformed into the Motherhood Home and became a social and medical institution for pregnant women and new mothers. Regardless of the redefined organization concept the curative and preventive health care as well as women and children social protection programmes were provided successfully for the next 12 years. Although the Motherhood Home was moved into the Women Health Centre of Novi Sad and later into the former Maternity Hospital in Sremski Karlovci, its great importance for women and children?s health care remained unchanged. In 1979 the overall social situation and mostly economic issues led to its closing. Epilogue. The house in Gajeva Street is now used as the municipality office. However, this house with its story recommends itself to become a house for a special social function, such as a museum of medical history of Novi Sad. A small investment could make it possible to collect, preserve and display the valuable records of our past, which is something we do owe to the generations to come.

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Introduction. In recent years, legislation has changed to include the rights of children injured because of physical violence. Trauma departments of St. Petersburg outpatient clinics admit children with injuries of varying severity after physical violence. The actions of medical institutions are always aimed at protecting the child.Aims. The aim of the present study was to analyze the cases of children in connection with injuries sustained as a result of physical violence in 2014–2015, and to compare the results with those of previous studies (2007–2008).Material and methods. In 2014–2015, the trauma department of City Children's Outpatient clinic No 62 treated 268 children, who had suffered from physical violence at home, on the street, or in educational institutions, which accounted for 1.6 per 1000 children living in the district, and 1.2% of all children admitted during 2 years.Results. Compared to 2007–2008, the number of children who suffered from physical violence decreased by almost two times in 2014–2015; in addition, the severity of injuries slightly decreased but the frequency of hospital admission of victims remained high (38%) in 2007–2008. With regard to the circ*mstances in which the injury occurred, violence from strangers was lower, but violence among peers was higher.Conclusions. Positive results have been achieved by a complex of measures, including the implementation of the Federal Law “On Basic Guarantees of the Rights of the Child” to improve the care and safety of children, and an investigation of each case of violence is conducted by local authorities for internal affairs.

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Injuries remain a most important problem in Russia. This article describes child injuries, especially child injuries of the musculoskeletal system in modern conditions. Injuries of the musculoskeletal system in children account for 85-87 % of all injuries. Studied the frequency and pattern of injuries of the musculoskeletal system in children. The frequency of injuries of the musculoskeletal system in children ranged from 156,8 before 170,7 per 1,000 population 0-17 years. Among the injuries was dominated by street and household (total of 68-71 %), school injury was 11-11,7 %, sports - 6,7-7,6 %. Analyzed injuries among patients of different sex. Among all types of injuries boys dominated, accounting for 53.8 to 66.7 % of the affected children. A special attention is paid to road injuries. This article describes some indicators of hospitalized injuries in children. The average hospitalization needed 16 % of injured, the hospitalization rates were 26.3 per 1,000 children. Using the method of least squares, managed to get trends in the development of injuries and to calculate the level of injuries for the next 3 years. Installed a slight downward trend in the rate of injuries - 0.2 cases per 1000 children per year. The analysis of statistical data provides the basis for in-depth study of the causes and circ*mstances of injuries, that allows the development of recommendations for their prevention and organization of medical care. This work can be useful for prospective development of pediatric trauma care in a big city.

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ABSTRACT Background Traffic injuries are among the main causes of death worldwide. Even with the advances in technology, there are still 50% of deaths that cannot be reduced by medical care improvement. These important injuries can though be reduced by prevention of trauma. One of the best ways to address this issue is through incorporating preventive measures to the daily routine of schools. It is the aim of this study to assess children's perception on traumatic events and to introduce a cost-effective peer-education preventive action. Study design A prospective interventional comparative study with children from a basic school in South Brazil. A questionnaire with 9 decision-making questions about traffic scenarios was applied by volunteer medical students from May to June 2012, before and after a peer-educational lecture on prevention of traffic injuries. There were 20 epidemiological questions as well. Data collected was compared between the pre and the posttests of the same students. Statistical analysis was performed using the Chi-square for discrete, and the students’ t-test for continuous variables. Results Among 246 students answered the questionnaires. The mean age was 10.19 years old. 21% reported that always crosses the street alone, while 47% only cross with an adult. Most of the students said they always cross-streets in the zebra-crossing and look to both sides before crossing (60.71 and 84.9% respectively). Impressively, 12.55% said they often/ sometimes drive a car or a motorcycle. Also, 30.76% ride a bike in between the cars. Furthermore, 77.48% of the students use the front seat of the car. Regarding safety issues, only one-third have a horn in their bikes, and less than half use helmet when playing. When comparing their assessments, there was a higher number of correct answers in the decision-making section in the post-test (5.21 vs 3.93, p = 0.000001161). The estimated overall cost was 45 dollars. Conclusion Preventive measures urge to be incorporated to schools curricula. Peer-educational actions are a cost-effective for spreading medical knowledge among children and youth. How to cite this article Abreu-Reis P, Tomasich F, Pinto BES, Manfrinato MFM, Oliveira LB, Nasr A, Slongo H, Cruz JB, Collaço I. Preventive Peer-educational Activities: What can Medical Students do to Potentially Save Lives? Panam J Trauma Critical Care Emerg Surg 2012;1(3):182-185.

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BACKGROUND: Due to the spread of the novel coronavirus infection (COVID-19) and the introduction of restrictive measures to prevent its spread, there has been a change in the organization and work of medical institutions. New rules for admitting patients with injuries, limiting hospitalization of planned patients, examining patients for coronavirus infection, examining parents of children with injuries, conducting remote consultations, and identifying areas without COVID-19 for repeated outpatient care have been introduced in trauma centers and hospitals. New conditions for the organization and functioning of outpatient and inpatient departments have had an impact on the picture of child trauma. AIM: This study aims to conduct a comparative analysis of the level and nature of musculoskeletal injuries in children who sought medical care during the COVID-19 pandemic and injuries that occurred during the same period of the previous year. MATERIALS AND METHODS: The analysis of the medical history data of 3820 patients aged 0 to 17 years, who were admitted to the City Center for Outpatient Surgery and Trauma of St. Petersburg St. Mary Magdalene Childrens City Hospital No. 2 during the period from March 16, 2020, to May 31, 2020, and for the same period in 2019. RESULTS: The number of initial visits with trauma in 2019 was 2851 patients, whereas during the same period in 2020, 969 patients came with trauma. In general, during the study period in 2020, the trauma rate decreased by 66% compared with the same period in 2019. Despite the general decrease in the level of injuries in the study period in 2020, in the injured structures of the musculoskeletal system, the proportion of limb fractures was 35% and exceeded the same indicator in 2019 (p = 0.004, 2 criterion). In 2020, the level of street injuries (p 0.0001) decreased by 83%, while there was a 61% increase in domestic injuries (p 0.0001) and a 47% increase in traffic injuries (p 0.0001). CONCLUSION: The relationship between the outbreak of a pandemic and a decrease in the number of visits to the trauma center of Childrens Hospital No. 2 was revealed and a change in the structure of injuries depending on their cause. This change may be associated with restrictive measures, the transfer to distance learning, the ban on organized sports events, and the reduced usage of playgrounds. This information can be useful for planning the work of health authorities and distributing resources during future pandemic situations.

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AbstractDr Rodney Franklin is the focus of our third in a planned series of interviews in Cardiology in the Young entitled, “Global Leadership in Paediatric and Congenital Cardiac Care.” Dr Franklin was born in London, England, spending the early part of his childhood in the United States of America before coming back to England. He then attended University College London Medical School and University College Hospital in London, England, graduating in 1979. Dr Franklin would then go on to complete his general and neonatal paediatrics training in 1983 at Northwick Park Hospital and University College Hospital in London, England, followed by completing his paediatric cardiology training in 1989 at Great Ormond Street Hospital for Children in London, England. During this training, he additionally would hold the position of British Heart Foundation Junior Research Fellow from 1987 to 1989. Dr Franklin would then complete his training in 1990 as a Senior Registrar and subsequent Consultant in Paediatric and Fetal Cardiology at Wilhelmina Sick Children’s Hospital in Utrecht, the Netherlands. He subsequently obtained his research doctorate at University of London in 1997, consisting of a retrospective audit of 428 infants with functionally univentricular hearts.Dr Franklin has spent his entire career as a Consultant Paediatric Cardiologist at the Royal Brompton & Harefield Hospital NHS Foundation Trust, being appointed in 1991. He additionally holds honorary Consultant Paediatric Cardiology positions at Hillingdon Hospital, Northwick Park Hospital, and Lister Hospital in the United Kingdom, and Honorary Senior Lecturer at Imperial College, London. He has been the Clinical Lead of the National Congenital Heart Disease Audit (2013–2020), which promotes data collection within specialist paediatric centres. Dr Franklin has been a leading figure in the efforts towards creating international, pan European, and national coding systems within the multidisciplinary field of congenital cardiac care. These initiatives include but are not limited to the development and maintenance of The International Paediatric & Congenital Cardiac Code and the related International Classification of Diseases 11th Revision for CHD and related acquired terms and definitions. This article presents our interview with Dr Franklin, an interview that covers his experience in developing these important coding systems and consensus nomenclature to both improve communication and the outcomes of patients. We additionally discuss his experience in the development and implementation of strategies to assess the quality of paediatric and congenital cardiac care and publicly report outcomes.

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A cross-sectional survey of the prevalence of eye injuries among primary school children in two noncontiguous local government areas of Enugu State of Nigeria was undertaken. One of the local government areas was urban, while the other one was rural. Children who were <15 years in two randomly selected primary schools in the urban area and three randomly selected schools in the rural area were interviewed and examined with Snellen chart, pen torch, head loupe, and direct ophthalmoscope. The findings were recorded using a semi-structured questionnaire and the World Health Organization Programme for Prevention of Blindness (WHO/PBL) eye examination form. Training on visual acuity measurement was done for each of the class teachers. A total of 1,236 children <15 years of age were studied and analyzed. Slightly more females, 652 (52.8%), than males, 584 (47.2%), constituted the sample population giving a female/male ratio of 1.1:1. A total of 98 (7.93%) children had evidence of injury to the eye or its adnexa. Eyelid scar was the commonest (5.34%) followed by eyebrow scar (2.10%). Canthal scar was the next (0.32%). Two girls had monocular blindness from eye trauma (0.16%). One had leucoma, while the other had a dislocated lens. All the monocular blind children of this study were from the urban area. The home was the commonest environment for an eye injury (69.39%) followed by the school (20.41%). The farm was next in frequency (7.14%), especially among boys in the rural area. The church and the road/street constituted the remainder. Regarding persons causing the injury, the child's playmate was the commonest (55.10%) followed by self (27.55%). Parents and guardians were the next (9.18%). These were injuries associated with corporal punishment. Corporal punishment-related eye injury, according to this study, appears to be common in the rural area and affects boys predominantly. Other human intermediary agents that cause an eye injury include passersby (2.04%), RTA (2.04%), siblings (2.04%), and others (1.02%). The primary agents that caused an eye injury were sticks/wood, 29 (29.60%); stone, 21 (21.43%); pieces of metal, 19 (19.39%); fall, 10 (10.20%); fight/fist blow, 9 (9.918%); plastic, 2 (2.04%); fingernails, 2 (2.04%); farm tools/fruits, 2 (2.04%); and RTA, glass, and headbutt, each 1.02%. Farm implements/fruits as well as fingernails appear to be fairly common primary agents that cause an eye injury in the rural Enugu, Nigeria. In terms of prevalence, there was no significant difference between the urban and rural areas. The findings from this study showed a high prevalence of eye injury among primary school children. In terms of treatment, 58.16% of the children with an eye injury had no form of treatment for it. The children from this study with monocular blindness did not receive adequate medical treatment. Treatment of an eye injury, according to this study, was sought from chemists (19.39%), at hospital/health centers (16.33%), at home (3.06%), and from traditional healers (3.06%). The persons who treated an eye injury, as observed from this study, were doctors (14.29%), nurses (4.08%), chemists (17.35%), and traditional healers and fathers (3.06% each). The frequency of noninjury-related diagnosis made in this study was refractive error, 4.85%; allergic conjunctivitis, 1.94%; oculocutaneous albinism, 0.24%; prepapillary vascular loops, 0.40%; and then ptosis, exotropia, stye, corneal opacity, and retinitis pigmentosa, 0.08% each. The annual incidence of an eye injury according to this study was 3.48%. The majority of the causes of an eye injury, as per this study, were preventable. Appropriate promotion of preventive eye care among children may go a long way in reducing the burden of blindness from eye injuries.

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Aims/Objectives/BackgroundGlobally, injuries cause more than 5 million deaths annually. Children and young people are a particularly vulnerable group and injuries are the leading cause of death in people aged 5–24 years globally and a leading cause of disability.In most low and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited. There is a continuing need for better data on childhood injuries and for injury surveillance.The aim of our study was to introduce a hospital-based injury surveillance tool – the first of its kind in Nepal and explore its feasibility. We undertook prospective collection of data on all injuries/trauma presenting to 2 hospital emergency departments to describe the epidemiology of paediatric hospital injury presentations and associated risk factors.Methods/DesignA new injury surveillance system for use in emergency departments in Nepal was designed and used to collect data on patients presenting with injuries. Data were collected prospectively in two hospitals 24 h a day over 12 months (April 2019 - March 2020) by trained data collectors using tablet computers.Abstract 432 Table 1Socio-demographic profile and characteristics of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020 (N=2696)CharacteristicsFrequencyGender Male 1778 Female 918 Age groups 0–4 years 653 5–9 years 866 10–14 years 680 15–17 years 497 Median year (IRQ) 8 (5 – 13) Ethnicity/caste Janajati 1384 Brahmin/Chhetri 892 Dalit 148 Madhesi 146 Muslim 74 Others 50 Unknown 2 Place where injury occurred Home/Compound 1576 Highway/road/street 636 School 233 Recreational area 138 Workplace 76 Other 37 Activities at the time injury occurred Leisure/Play 1889 Travelling (other than to/from school/work) 296 Work 202 Travelling (to/from school/work) 184 Education 42 Organised sports 11 Other 52 Unknown 20 Intent of injury Unintentional 2560 Intentional (self-harm) 61 Intentional (assault) 75 Unintentional (n=2560) Fall 912 Animal or insect related 728 Road traffic injury 356 Injured by a blunt force 201 Stabbed, cut or pierced 176 Fire, burn or scald 65 Poisoning 52 Suffocation/choking 36 Electrocution 12 Drowning and submersion 7 Other 13 Unknown 2 Self-harm (n=61) Poisoning 38 Hanging, strangulation, suffocation 12 Stabbed, cut or pierced 6 Injured by blunt object 4 Other 1 Assault (n=75) Bodily force (physical violence) 43 Injured by blunt object 18 Stabbed, cut or pierced 8 Pushing from a high place 2 Poisoning 2 Sexual assault 1 Other 1 Nature of injury (one most severe) Cuts, bites or open wound 1378 Bruise or superficial injury 383 Fracture 299 Sprain, strain or dislocation 243 Internal injury 124 Head Injury/Concussion 83 Burns 67 Other 115 Unknown 2 Not recorded 2 Severity of injury No apparent injury 125 Minor 1645 Moderate 813 Severe 111 Not recorded 2 Disposition Discharged 2317 Admitted to hospital 164 Transferred to another hospital 179 Died 21 Leave Against Medical Advice (LAMA) 11 Unknown 2 Not recorded 2 Note:Not recorded = missing cases95% CI calculated using one proportion test and normal approximation method in Minitab.Abstract 432 Table 2Distribution of injuries by age-group, sex and mechanism of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020Age groups & Sex0 - 4 years5 - 9 years10–14 years15–17 yearsMaleFemaleTotalIntent & mechanismsn (%)n (%)n (%)n (%)n (%)n (%)n (%)Unintentional Fall 239 (26.2) 328 (36.0) 249 (27.3) 96 (10.5) 636 (69.7) 276 (30.3) 912 (100) Animal or insect related 175 (24.0) 260 (35.7) 190 (26.1) 103 (14.1) 470 (64.6) 258 (35.4) 728 (100) Road traffic injury 49 (13.8) 108 (30.3) 86 (24.2) 113 (31.7) 223 (62.6) 133 (37.4) 356 (100) Injured by a blunt force 54 (26.9) 74 (36.8) 49 (24.4) 24 (11.9) 150 (74.6) 51 (25.4) 201 (100) Stabbed, cut or pierced 20 (11.4) 56 (31.8) 49 (27.8) 51 (29.0) 127 (72.2) 49 (27.8) 176 (100) Fire, burn or scald 42 (64.6) 10 (15.4) 9 (13.8) 4 (6.2) 27 (41.5) 38 (58.5) 65 (100) Poisoning 33 (63.5) 6 (11.5) 5 (9.6) 8 (15.4) 26 (50.0) 26 (50.0) 52 (100) Suffocation/choking 24 (66.7) 5 (13.9) 2 (5.6) 5 (13.9) 20 (55.6) 16 (44.4) 36 (100) Electrocution 2 (15.7) 0 (0.0) 3 (25.0) 7 (58.3) 10 (83.3) 2 (16.7) 12 (100) Drowning and submersion 1 (14.3) 1 (14.3) 3 (42.9) 2 (28.6) 3 (42.9) 4 (57.1) 7 (100) Other 6 (46.2) 4 (30.8) 3 (23.1) 0 (0.0) 10 (76.9) 3 (23.1) 13 (100) Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) 2 (100) Total 647 (25.3) 852 (33.3) 648 (25.3) 413 (16.1) 1702 (66.5) 858 (33.5) 2560 (100) Self-harm Poisoning 0 (0.0) 0 (0.0) 6 (15.8) 32 (84.2) 7 (18.4) 31 (81.6) 38 (100) Hanging 0 (0.0) 0 (0.0) 3 (25.0) 9 (75.0) 4 (33.3) 8 (66.7) 12 (100) Stabbed, cut or pierced 0 (0.0) 0 (0.0) 2 (33.3) 4 (66.7) 1 (16.7) 5 (83.3) 6 (100) Injured by blunt object 0 (0.0) 2 (50.0) 2 (50.0) 0 (0.0) 4 (100) 0 (0.0) 4 (100) Other 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 1 (100) 0 (0.0) 1 (100) Total 0 (0.0) 2 (3.3) 13 (21.3) 46 (75.4) 17 (27.9) 44 (72.1) 61 (100) Assault Bodily force (physical violence) 3 (7.0) 1 (2.3) 11 (25.6) 28 (65.1) 37 (86.0) 6 (14.0) 43 (100) Injured by blunt object 2 (11.1) 8 (44.4) 4 (22.2) 4 (22.2) 13 (72.2) 5 (27.8) 18 (100) Stabbed, cut or pierced 1 (12.5) 0 (0.0) 2 (25.0) 5 (62.5) 7 (87.5) 1 (12.5) 8 (100) Pushing from a high place 0 (0.0) 1 (50.0) 1 (50.0) 0 (0.0) 1 (50.0) 1 (50.0) 2 (100) Poisoning 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 1 (50.0) 1 (50.0) 2 (100) Sexual assault 0 (0.0) 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 1 (100) 1 (100) Other 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 1 (100) Total 6 (8.0) 12 (16.0) 19 (25.3) 38 (50.7) 59 (78.7) 16 (21.3) 75 (100) Abstract 432 Table 3Association of injury location, nature and severity with age among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020Age groups0 – 4 years5 – 9 years10–14 years15–17 yearsTotalChi-SquareInjury characteristicsn (%)n (%)n (%)n (%)n (%)P valueLocation of injury sustained Home/Compound 537 (34.1) 504 (32.0) 319 (20.2) 216 (13.7) 1576 (100) <0.001 Highway/road/street 85 (13.4) 196 (30.8) 190 (29.9) 165 (25.9) 636 (100) School 15 (6.4) 107 (45.9) 85 (36.5) 26 (11.2) 233 (100) Recreational area 9 (6.5) 44 (31.9) 55 (39.9) 30 (21.7) 138 (100) Workplace 1 (1.3) 4 (5.3) 19 (25.0) 52 (68.4) 76 (100) Other 6 (16.2) 11 (29.7) 12 (32.4) 8 (21.6) 37 (100) Total 653 (24.2) 866 (32.1) 680 (25.2) 497 (18.4) 2696 (100) Nature of injury Cuts, bites or open wound 328 (23.8) 506 (36.7) 314 (22.8) 230 (16.7) 1378 (100) <0.001 Bruise or superficial injury 81 (21.1) 99 (25.8) 118 (30.8) 85 (22.2) 383 (100) Fracture 48 (16.1) 101 (33.8) 112 (37.5) 38 (12.7) 299 (100) Sprain, strain or dislocation 48 (19.8) 78 (32.1) 72 (29.6) 45 (18.5) 243 (100) Internal injury 44 (35.5) 8 (6.5) 18 (14.5) 54 (43.5) 124 (100) Head Injury/Concussion 18 (21.7) 26 (31.3) 18 (21.7) 21 (25.3) 83 (100) Burns 42 (62.7) 9 (13.4) 10 (14.9) 6 (9.0) 67 (100) Other 41 (35.7) 38 (33.0) 18 (15.7) 18 (15.7) 115 (100) Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) Total 652 (24.2) 865 (32.1) 680 (25.2) 497 (18.4) 2694 (100) Severity of injury No apparent injury 39 (31.2) 45 (36.0) 26 (20.8) 15 (12.0) 125 (100) <0.001 Minor 419 (25.5) 535 (32.5) 406 (24.7) 285 (17.3) 1645 (100) Moderate 171 (21.0) 262 (32.2) 225 (27.7) 155 (19.1) 813 (100) Severe 23 (20.7) 23 (20.7) 23 (20.7) 42 (37.8) 111 (100) Total 652 (24.2) 865 (32.1) 680 (25.2) 497 (18.4) 2694 (100) Abstract 432 Table 4Association of injury location, nature and severity with sex among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020SexMaleFemaleTotalChi-SquareInjury characteristicsn (%)n (%)n (%)P valueLocation of injury sustained Home/Compound 979 (62.1) 597 (37.9) 1576 (100) <0.001 Highway/road/street 421 (66.2) 215 (33.8) 636 (100) School 176 (75.5) 57 (24.5) 233 (100) Recreational area 111 (80.4) 27 (19.6) 138 (100) Workplace 62 (81.6) 14 (18.4) 76 (100) Other 29 (78.4) 8 (21.6) 37 (100) Total 1778 (65.9) 918 (34.1) 2696 (100) Nature of injury Cuts, bites or open wound 959 (69.6) 419 (30.4) 1378 (100) <0.001 Bruise or superficial injury 246 (64.2) 137 (35.8) 383 (100) Fracture 200 (66.9) 99 (33.1) 299 (100) Sprain, strain or dislocation 154 (63.4) 89 (36.6) 243 (100) Internal injury 50 (40.3) 74 (59.7) 124 (100) Head Injury/Concussion 59 (71.1) 24 (28.9) 83 (100) Burns 27 (40.3) 40 (59.7) 67 (100) Other 79 (68.7) 36 (31.3) 115 (100) Unknown 2 (100) 0 (0.0) 2 (100) Total 1776 (65.9) 918 (34.1) 2694 (100) Severity of injury No apparent injury 81 (64.8) 44 (35.2) 125 (100) 0.048 Minor 1102 (67.0) 543 (33.0) 1645 (100) Moderate 533 (65.6) 280 (34.4) 813 (100) Severe 60 (54.1) 51 (45.9) 111 (100) Total 1776 (65.9) 918 (34.1) 2694 (100) Abstract 432 Table 5Distribution of injuries by outcome and mechanism of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020Outcome of injuryDischargedAdmittedTransferredDiedLAMAUnknownTotalIntent & mechanismsn (%)n (%)n (%)n (%)n (%)n (%)n (%)Unintentional Fall 787 (86.5) 65 (7.1) 53 (5.8) 0 (0.0) 4 (0.4) 1 (0.1) 910 (100) Animal/insect bite/sting 704 (96.7) 3 (0.4) 19 (2.6) 0 (0.0) 1 (0.1) 1 (0.1) 728 (100) Road traffic injury 260 (73.0) 47 (13.2) 44 (12.4) 5 (1.4) 0 (0.0) 0 (0.0) 356 (100) Injured by a blunt force 190 (94.5) 4 (2.0) 6 (3.0) 0 (0.0) 1 (0.5) 0 (0.0) 201 (100) Stabbed, cut or pierced 165 (93.8) 8 (4.5) 3 (1.7) 0 (0.0) 0 (0.0) 0 (0.0) 176 (100) Fire, burn or scald 52 (80.0) 12 (18.5) 1 (1.5) 0 (0.0) 0 (0.0) 0 (0.0) 65 (100) Poisoning 30 (57.7) 4 (7.7) 16 (30.8) 1 (1.9) 1 (1.9) 0 (0.0) 52 (100) Suffocation/choking/asphyxia 24 (66.7) 4 (11.1) 6 (16.7) 1 (2.8) 1 (2.8) 0 (0.0) 36 (100) Electrocution 7 (58.3) 2 (16.7) 2 (16.7) 1 (8.3) 0 (0.0) 0 (0.0) 12 (100) Drowning and submersion 4 (57.1) 0 (0.0) 0 (0.0) 3 (42.9) 0 (0.0) 0 (0.0) 7 (100) Other 12 (92.3) 1 (7.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 13 (100) Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) Total 2237 (87.5) 150 (5.9) 150 (5.9) 11 (0.4) 8 (0.3) 2 (0.1) 2558 (100) Self-harm Poisoning 5 (13.2) 8 (21.1) 23 (60.5) 0 (0.0) 2 (5.3) 0 (0.0) 38 (100) Hanging 1 (8.3) 0 (0.0) 1 (8.3) 10 (83.3) 0 (0.0) 0 (0.0) 12 (100) Stabbed, cut or pierced 6 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 (100) Injured by blunt object 4 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100) Other 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) Total 17 (27.9) 8 (13.1) 24 (39.3) 10 (16.4) 2 (3.3) 0 (0.0) 61 (100) Assault Bodily force (physical violence) 34 (79.1) 5 (11.6) 3 (7.0) 0 (0.0) 1 (2.3) 0 (0.0) 43 (100) Injured by blunt object 18 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 18 (100) Stabbed, cut or pierced 6 (75.0) 1 (12.5) 1 (12.5) 0 (0.0) 0 (0.0) 0 (0.0) 8 (100) Pushing from a high place 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) Poisoning 1 (50) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) Sexual assault 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) Other 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) Total 63 (84.0) 6 (8.0) 5 (6.7) 0 (0.0) 1 (1.3) 0 (0.0) 75 (100) Abstract 432 Figure 1Seasonal variation of injuries identified by the injury surveillance system over a year among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020Results/ConclusionsThe total number of ED patients with injury in the study was 10,154.2,696 were patients aged <18 years. Most injuries in children were unintentional and over half of children presenting with injuries were <10 years of age. Falls, animal bites/stings and road traffic injuries accounted for nearly 75% of all injuries with some (drowning, poisonings and burns) under-represented. Over half of injuries were cuts, bites and open wounds. The next most common injury types were superficial injuries (14.2%); fractures (11.1%); sprains/dislocations (9.0%). Child mortality was 1%.This is the biggest prospective injury surveillance study in a low or middle country in recent years and supports the use of injury surveillance in Nepal for reducing child morbidity and mortality through improved data.CHILD PAPER: RESULTS SECTIONTotal number of ED patients: 33046Total number of ED patient with injury: 10154 (adult=7458 & children=2696)8.2% (n=2696) patients with injury were children aged <18 yearsHetauda hospital: 2274 (84.3%)Chure hill hospital: 422 (15.7%)

Abstract:

Corrigendum: On 25/10/2013 the author “Dr. Mahmudul Hasan Siddiqui” was replaced by “Dr. Mahmudul Hasan Siddiqi”.This cross-sectional descriptive study evaluated the general health knowledge and practices of hygiene among semi-urban school children in Bangladesh and assessed the extent to which proper knowledge of hygiene was associated with personal hygiene characteristics. The study population was limited within mature students of class VIII and class X, which were randomly selected. The objectives of the study was first to assess the health knowledge acquired and health care practice undertaken by the students and finally to assess needs for improvement so that they could enjoy a better living and quality life. A well written pre-tested questionnaire was supplied to each student under study. Data were collected and analyzed using Computer Excel Program. The result of the study revealed that approximately 59% of students were classified as having little or no idea or knowledge of health. The majority of the respondents (44.95%) considered early going to bed. Only 11.01% respondents mentioned that they liked to go to bed at late hours after 11 pm. Regarding awakening time, 94.92% respondents in favor of get up early in the morning before sunrise, but actually 36(15%) habituated to get up early in the morning before the sun rise and a great number 200(84.74%) were habituated to late rise. A great number of students (78.81%) were in favor of taking home-made foods and majority respondents considered these foods as safe and wholesome. More than 98% respondents admitted that street vender foods were unhygienic and might cause intestinal disturbances, nausea, vomiting and worm infestation. 100% respondents had access to drink tube well water and it was safe and portable according to 84.75% respondents. To mention about access to proper and adequate defecation facilities it was reported that 90.68% students had the habit to use sanitary latrines. A very low percent of respondents (4.24%) used soap for washing of hands after defecation. About 95.76% of students reported that they washed their hands with water only and soaps were seldom used. The findings with respect to oral hygiene practice, 55.08% respondents preferred to brush teeth. A good number of respondents 50.85%, 20.34%, 15.25%, 8.47% and 5.08% used ash, followed by neem stick, tooth paste, Kalo Majon and magic tooth powder respectively. Although 87.29% of respondents never smoked, but it is very undesirable that more than 10% of students developed smoking habit. The present study revealed that 83.00% of respondents were in favor of keeping nails short. Regarding personal cleanliness 14.83% of the students reported not taking bathing regularly. About 83% realized the importance of wearing underwear. Lastly, the students under interview although clearly stressed upon the need of regular exercise which is good for health, but quite a big number of respondents (91.53%) were not inclined to take exercise regularly. DOI: http://dx.doi.org/10.3329/cbmj.v2i1.14186 Community Based Medical Journal Vol.2(1) 2013 55-62

Abstract:

Background: Trauma among street children is an emerging but neglected public health problem in most low and middle income countries. This study was conducted to determine the incidence, etiological spectrum, injury characteristics and treatment outcome among street children and to identify the predictors of the outcome of these patients at Bugando Medical Centre in Mwanza, Tanzania.Methods: The study included street children aged <18 years. Routine investigations including haematological, biochemical and imaging were performed on admission. The severity of injury was determined using the Kampala Trauma Score II. Data on patient’s characteristics, circ*mstances of injury, injury characteristics, treatment offered, outcome variables, length of hospital stay and mortality were collected using a questionnaire.Results: A total of 342 street children (M: F = 6.8: 1) representing 11.5% of all paediatric injury patients were studied. The modal age group was 11-15 years (median = 12 years) accounting for 53.2% (n=182) of the patients. Assault was the most frequent (73.7%) cause of injury. More than three quarter of injuries occurred along the street. Most of patients (59.1%) presented late (>24 hours) after injury. Blunt injuries were the most common (76.0%) mechanism of injuries. Musculoskeletal (30.8%) and head (25.3%) were the most frequent body regions affected. Soft tissue injuries were the most common type of injuries affecting 322 (94.2%) cases. Majority of patients (96.5%) underwent surgical treatment of which wound debridement (97.6%) was the most common surgical procedure performed. Complication rate was 39.5%. The median hospital stay was 6 days. Mortality rate was 13.5% and it was significantly associated with injury-arrival time (OR =2.4, 95%CI (1.3-5.6), p = 0.002), severe injury (Kampala Trauma Score <6) (OR = 3.6, 95%CI (2.5-7.9), p = 0.001), severe head injuries (OR= 5.1, 95%CI (4.6 – 8.2), p =0.012) and surgical site infection.Conclusion: Trauma among street children is an emerging but neglected epidemic in Tanzania and contributes significantly to high morbidity and mortality. Assault was the most frequent cause of injury. Urgent preventive measures targeting at reducing the occurrence of assault is necessary to reduce the incidence of trauma among street children in this region.

Abstract:

Abstract Purpose of the study. To study and analyze the trend of injuries among children aged 0-14 years and organizational aspects of providing them with medical care at the regional level. Material and methods. The research was conducted on the basis of the municipal nonprofit enterprise «Zaporizhzhya Regional Clinical Children's Hospital» of Zaporizhzhya Regional Council, and was performed as part of a comprehensive research work «Medical and social substantiation of the model of prevention of morbidity and mortality of children and adolescents behavior»(№ state registration: 0118U003679), performed in the State Institution «ZaporozhyeMedical Academy of Postgraduate Education of the Ministry of Health of Ukraine» since 2017. According to the objectives of the study, an analysis of medical histories of patients who were treated in the institution for injuries from 2014–2018. Research results and their discussion. During the period from 2014 to 2018, 4457 children aged 0 to 14 were treated for injuries and other injuries at the Zaporizhia Regional Clinical Children's Hospital. The number of injured children during this period tends to increase. It was found that the number of injured among boys is almost twice as high as among girls. The growth trend during the study period, injuries among boys is + 27,1%, among girls it tends to decrease and is -26,1%. The study found significantly more cases of injuries among children in urban areas. Thus, in 2018 they amounted to 82,5%, compared to 17,5% of cases among rural children. It was found that the number of hospitalized children with traffic injuries during the study period increased 5 times. The trend for the study period is +333,3%. The number of children hospitalized due to street injuries has doubled. The study found that the number of appeals during the first hour after the injury in rural areas is 2 times less than in urban areas. Conclusions. The results of the obtained research became a roadmap for the organization of preventive work at the inter-sectoral level, aimed at preventing the causes of injuries, the organization of timely medical care at the pre-hospital stage. Keywords: injuries of children, types of injuries, interval of appeals, medical care.

Abstract:

Abstract Objectives To compare the treatment approaches and disease outcomes of children with JDM followed in two European tertiary care pediatric rheumatology centers. Methods The medical notes of patients with JDM seen at Istituto Giannina Gaslini (IGG) of Genoa, Italy or Great Ormond Street Hospital (GOSH) of London, UK between January 2000 and December 2015 within 6 months after disease onset and followed for at least 6 months were reviewed. Demographic, clinical and therapeutic data were collected. At each visit, the caring physician was asked to rate the disease state subjectively. Results A total of 127 patients were included, 88 at GOSH and 39 at IGG. At 24 months, the median values of muscle strength and disease activity were at the normal end of the scale and around three quarters of patients were said to have inactive disease. Also, at 2 years, 38.6% and 36% of British and Italian patients, respectively, had damage. Cyclophosphamide, azathioprine, infliximab, rituximab and mycophenolate mofetil were used more frequently by UK physicians, whereas ciclosporin, intravenous immunoglobulin and hydroxychloroquine were prescribed by Italian physicians. Conclusion This study shows a significant difference in the choice of medications between pediatric rheumatologists practising in the two centres. Despite this, a high proportion of patients had inactive disease at 2 years and there was a low frequency of damage: modern treatments have improved outcomes.

Abstract:

Injuries, poisoning and other effects of external causes in the structure of morbidity and mortality of children consistently occupy a leading position, the indicators in the Khabarovsk territory exceed the average, while the possibility of effective prevention is limited. Aims: to study the structure, causes and circ*mstances of injuries in children of Khabarovsk to create the possibility of effective primary prevention. Materials and methods: the analysis 21 081 case cases children in 2018 in hospital Khabarovsk, providing emergency medical care for children with injuries, poisoning, burns. Results: of the study allowed to establish that among children older than 3 years boys prevailed, there are two age peaks of trauma in 1-2 years and 11-14 years, but the largest number of injuries is characteristic of adolescents. According to the circ*mstances of injury, the children were divided into five groups: street injury – the most frequent type of injury (5 004 children, 40,34 % of cases), increased from 4-5 years of age, reaching a maximum of 10-11 years. Home accident (30,53 %, 3 231 case) had the maximum cases in 1-2 years. Injuries in General education institutions (school, kindergarten) amounted to 14,48 % of cases (1 786 children), there was a peak in 11-14 years, followed by a decrease. Sports injury was 10,90 % (1 497 cases). 143 children (1,65 % of all injuries) were victims of violence and/or hooliganism. Auto-injury was the most rare and amounted to 2,11 % of cases.

Abstract:

The Slemenda Scholarship: The Slemenda Scholarship is a program that was developed in 1998 for rising second year medical students in order for them to gain experience in the field of global health through the context of the AMPATH Consortium in Eldoret, Kenya. As a medical professional aspiring to work internationally, it is an invaluable experience to observe practices in a well-established partnership such as the one between Moi Teaching and Referral Hospital, Moi University, and Indiana University. Community Experiences: The first half of the summer was spent visiting and participating in various AMPATH initiatives. This included rounding on the medical, surgical, gynecological, and pediatric wards, volunteering with the child life team, visiting community health and microfinance projects, observing rural HIV clinics, and working at a school developed for street children in Eldoret. Primary Project: The second half of the summer was spent working with the Maternal Newborn and Child Health team, specifically in the Reproductive Health department. I worked as a research assistant for a new project seeking to develop an antenatal care clinic for young girls aged 10-19 in Uasin Gishu County at the Rafiki Centre for Adolescents at Moi Teaching and Referral Hospital. I developed recruitment materials and a database for qualitative and quantitative data collection for the project. Moving Forward: On returning to Indiana, it is my goal to champion the work of the AMPATH Consortium and attempt to ensure its longevity through the next generation of globally-minded physician-scientists. I will take the lessons I learned and observations I made in this setting and work to apply them to improving healthcare in underserved areas in our own community as well.

Abstract:

Story spreads out through time the behaviors or bodies – the shapes – a self has been or will be, each replacing the one before. Hence a story has before and after, gain and loss. It goes somewhere…Moreover, shape or body is crucial, not incidental, to story. It carries story; it makes story visible; in a sense it is story. Shape (or visible body) is in space what story is in time. (Bynum, quoted in Garland Thomson, 113-114) Drawing on Goffman’s classic work on stigma, research documenting the existence of discrimination and bias against individuals classified as obese goes back five decades. Since Cahnman published “The Stigma of Obesity” in 1968, other researchers have well documented systematic and growing discrimination against fat people (cf. Puhl and Brownell; Puhl and Heuer; Puhl and Heuer; Fikkan and Rothblum). While weight-based stereotyping has a long history (Chang and Christakis; McPhail; Schwartz), contemporary forms of anti-fat stigma and discrimination must be understood within a social and economic context of neoliberal healthism. By neoliberal healthism (see Crawford; Crawford; Metzel and Kirkland), I refer to the set of discourses that suggest that humans are rational, self-determining actors who independently make their own best choices and are thus responsible for their life chances and health outcomes. In such a context, good health becomes associated with proper selfhood, and there are material and social consequences for those who either unwell or perceived to be unwell. While the greatest impacts of size-based discrimination are structural in nature, the interpersonal impacts are also significant. Because obesity is commonly represented (at least partially) as a matter of behavioral choices in public health, medicine, and media, to “remain fat” is to invite commentary from others that one is lacking in personal responsibility. Guthman suggests that this lack of empathy “also stems from the growing perception that obesity presents a social cost, made all the more tenable when the perception of health responsibility has been reversed from a welfare model” (1126). Because weight loss is commonly held to be a reasonable and feasible goal and yet is nearly impossible to maintain in practice (Kassierer and Angell; Mann et al.; Puhl and Heuer), fat people are “in effect, asked to do the impossible and then socially punished for failing” (Greenhalgh, 474). In this article, I explore how weight-based stigma shaped the decisions of bariatric patients to undergo weight loss surgery. In doing so, I underline the work that emotion does in circulating anti-fat stigma and in creating categories of subjects along lines of health and responsibility. As well, I highlight how fat bodies are lived and negotiated in space and place. I then explore ways in which participants take up notions of time, specifically in regard to risk, in discussing what brought them to the decision to have bariatric surgery. I conclude by arguing that it is a dynamic interaction between the material, social, emotional, discursive, and the temporal that produces not only fat embodiment, but fat subjectivity “failed”, and serves as an impetus for seeking bariatric surgery. Methods This article is based on 30 semi-structured interviews with American bariatric patients. At the time of the interview, individuals were between six months and 12 years out from surgery. After obtaining Intuitional Review Board approval, recruitment occurred through a snowball sample. All interviews were audio-taped with permission and verbatim interview transcripts were analyzed by means of a thematic analysis using Dedoose (www.dedoose.com). All names given in this article are pseudonyms. This work is part of a larger project that includes two additional interviews with bariatric surgeons as well as participant-observation research. Findings Navigating Anti-Fat Stigma In discussing what it was like to be fat, all but one of the individuals I interviewed discussed experiencing substantive size-based stigma and discrimination. Whether through overt comments, indirect remarks, dirty looks, open gawking, or being ignored and unrecognized, participants felt hurt, angry, and shamed by friends, family, coworkers, medical providers, and strangers on the street because of the size of their bodies. Several recalled being bullied and even physically assaulted by peers as children. Many described the experience of being fat or very fat as one of simultaneous hypervisibility and invisibility. One young woman, Kaia, said: “I absolutely was not treated like a person … . I was just like this object to people. Just this big, you know, thing. That’s how people treated me.” Nearly all of my participants described being told repeatedly by others, including medical professionals, that their inability to lose weight was effectively a failure of the will. They found these comments to be particularly hurtful because, in fact, they had spent years, even decades, trying to lose weight only to gain the weight back plus more. Some providers and family members seemed to take up the idea that shame could be a motivating force in weight loss. However, as research by Lewis et al.; Puhl and Huerer; and Schafer and Ferraro has demonstrated, the effect this had was the opposite of what was intended. Specifically, a number of the individuals I spoke with delayed care and avoided health-facilitating behaviors, like exercising, because of the discrimination they had experienced. Instead, they turned to health-harming practices, like crash dieting. Moreover, the internalization of shame and blame served to lower a sense of self-worth for many participants. And despite having a strong sense that something outside of personal behavior explained their escalating body weights, they deeply internalized messages about responsibility and self-control. Danielle, for instance, remarked: “Why could the one thing I want the most be so impossible for me to maintain?” It is important to highlight the work that emotion does in circulating such experiences of anti-fat stigma and discrimination. As Fraser et al have argued in their discussion on fat and emotion, the social, the emotional, and the corporeal cannot be separated. Drawing on Ahmed, they argue that strong emotions are neither interior psychological states that work between individuals nor societal states that impact individuals. Rather, emotions are constitutive of subjects and collectivities, (Ahmed; Fraser et al.). Negative emotions in particular, such as hate and fear, produce categories of people, by defining them as a common threat and, in the process, they also create categories of people who are deemed legitimate and those who are not. Thus following Fraser et al, it is possible to see that anti-fat hatred did more than just negatively impact the individuals I spoke with. Rather, it worked to produce, differentiate, and drive home categories of people along lines of health, weight, risk, responsibility, and worth. In this next section, I examine the ways in which anti-fat discrimination works at the interface of not only the discursive and the emotive, but the material as well. Big Bodies, Small Spaces When they discussed their previous lives as very fat people, all of the participants made reference to a social and built environment mismatch, or in Garland Thomson’s terms, a “misfit”. A misfit occurs “when the environment does not sustain the shape and function of the body that enters it” (594). Whereas the built environment offers a fit for the majority of bodies, Garland Thomson continues, it also creates misfits for minority forms of embodiment. While Garland Thomson’s analysis is particular to disability, I argue that it extends to fat embodiment as well. In discussing what it was like to navigate the world as fat, participants described both the physical and emotional pain entailed in living in bodies that did not fit and frequently discussed the ways in which leaving the house was always a potential, anxiety-filled problem. Whereas all of the participants I interviewed discussed such misfitting, it was notable that participants in the Greater New York City area (70% of the sample) spoke about this topic at length. Specifically, they made frequent and explicit mentions of the particular interface between their fat bodies and the Metropolitan Transit Authority (MTA), and the tightly packed spaces of the city itself. Greater New York City area participants frequently spoke of the shame and physical discomfort in having to stand on public transportation for fear that they would be openly disparaged for “taking up too much room.” Some mentioned that transit seats were made of molded plastic, indicating by design the amount of space a body should occupy. Because they knew they would require more space than what was allotted, these participants only took seats after calculating how crowded the subway or train car was and how crowded it would likely become. Notably, the decision to not take a seat was one that was made at a cost for some of the larger individuals who experienced joint pain. Many participants stated that the densely populated nature of New York City made navigating daily life very challenging. In Talia’s words, “More people, more obstacles, less space.” Participants described always having to be on guard, looking for the next obstacle. As Candice put it: “I would walk in some place and say, ‘Will I be able to fit? Will I be able to manoeuvre around these people and not bump into them?’ I was always self-conscious.” Although participants often found creative solutions to navigating the hostile environment of both the MTA and the city at large, they also identified an increasing sense of isolation that resulted from the physical discomfort and embarrassment of not fitting in. For instance, Talia rarely joined her partner and their friends on outings to movies or the theater because the seats were too tight. Similarly, Decenia would make excuses to her husband in order to avoid social situations outside of the home: “I’d say to my husband, ‘I don’t feel well, you go.’ But you know what? It was because I was afraid not to fit, you know?” The anticipatory scrutinizing described by these participants, and the anxieties it produced, echoes Kirkland’s contention that fat individuals use the technique of ‘scanning’ in order to navigate and manage hostile social and built environments. Scanning, she states, involves both literally rapidly looking over situations and places to determine accessibility, as well as a learned assessment and observation technique that allows fat people to anticipate how they will be received in new situations and new places. For my participants, worries about not fitting were more than just internal calculation. Rather, others made all too clear that fat bodies are not welcome. Nina recalled nasty looks she received from other subway riders when she attempted to sit down. Decenia described an experience on a crowded commuter train in which the woman next to her openly expressed annoyance and disgust that their thighs were touching. Talia recalled being aggressively handed a weight loss brochure by a fellow passenger. When asked to contrast their experiences living in New York City with having travelled or lived elsewhere, participants almost universally described the New York as a more difficult place to live for fat people. However, the experiences of three of the Latinas that I interviewed troubled this narrative. Katrina felt that the harassment she received in her country of origin, the Dominican Republic, was far worse than what she now experienced in the New York Metropolitan Area. Although Decenia detailed painful experiences of anti-fat stigma in New York City, she nevertheless described her life as relatively “easy” compared to what it was like in her home country of Brazil. And Denisa contrasted her neighbourhood of East Harlem with other parts of Manhattan: “In Harlem it's different. Everybody is really fat or plump – so you feel a bit more comfortable. Not everybody, but there's a mix. Downtown – there's no mix.” Collectively, their stories serve as a reminder (see Franko et al.; Grabe and Hyde) to be suspicious of over determined accounts that “Latino culture” is (or people of colour communities in general are), more accepting of larger bodies and more resistant to weight-based stigma and discrimination. Their comments also reflect arguments made by Colls, Grosz, and Garland Thomson, who have all pointed to the contingent nature between space and bodies. Colls argue that sizing is both a material and an emotional process – what size we take ourselves to be shifts in different physical and emotional contexts. Grosz suggests that there is a “mutually constitutive relationship between bodies and cities” – one that, I would add, is raced, classed, and gendered. Garland Thomson has described the relationship between bodies and space/place as “a dynamic encounter between world and flesh.” These encounters, she states, are always contingent and situated: “When the spatial and temporal context shifts, so does the fit, and with it meanings and consequences” (592). In this sense, fat is materialized differently in different contexts and in different scales – nation, state, city, neighbourhood – and the materialization of fatness is always entangled with raced, classed, and gendered social and political-economic relations. Nevertheless, it is possible to draw some structural commonalities between divergent parts of the Greater New York City Metropolitan Area. Specifically, a dense population, cramped physical spaces, inaccessible transportation and transportation funding cuts, social norms of fast paced life, and elite, raced, classed, and gendered norms of status and beauty work to materialize fatness in such a way that a ‘misfit’ is often the result for fat people who live and/or work in this area. And importantly, misfitting, as Garland Thomson argues, has consequences: it literally “casts out” when the “shape and function of … bodies comes into conflict with the shape and stuff of the built world” (594). This casting out produces some bodies as irrelevant to social and economic life, resulting in segregation and isolation. To misfit, she argues, is to be denied full citizenship. Responsibilising the Present Garland Thomson, discussing Bynum’s statement that “shape carries story”, argues the following: “the idea that shape carries story suggests … that material bodies are not only in the spaces of the world but that they are entwined with temporality as well” (596). In this section, I discuss how participants described their decisions to get weight loss surgery by making references to the need take responsibility for health now, in the present, in order to avoid further and future morbidity and mortality. Following Adams et al., I look at how the fat body is lived in a state of constant anticipation – “thinking and living toward the future” (246). All of the participants I spoke with described long histories of weight cycling. While many managed to lose weight, none were able to maintain this weight loss in the long term – a reality consistent with the medical fact that dieting does not produce durable results (Kassirer and Angell; Mann et al.; Puhl and Heuer). They experienced this inability as not only distressing, but terrifying, as they repeatedly regained the lost weight plus more. When participants discussed their decisions to have surgery, they highlighted concerns about weight related comorbidities and mobility limitations in their explanations. Consistent then with Boero, Lopez, and Wadden et al., the participants I spoke with did not seek out surgery in hopes of finding a permanent way to become thin, but rather a permanent way to become healthy and normal. Concerns about what is considered to be normative health, more than simply concerns about what is held to be an appropriate appearance, motivated their decisions. Significantly, for these participants the decision to have bariatric surgery was based on concerns about future morbidity (and mortality) at least as much, if not more so, than on concerns about a current state of ill health and impairment. Some individuals I spoke with were unquestionably suffering from multiple chronic and even life threatening illnesses and feared they would prematurely die from these conditions. Other participants, however, made the decision to have bariatric surgery despite the fact that they had no comorbidities whatsoever. Motivating their decisions was the fear that they would eventually develop them. Importantly, medial providers explicitly and repeatedly told all of these participants that lest they take drastic and immediate action, they would die. For example: Faith’s reproductive endocrinologist said: “you’re going to have diabetes by the time you’re 30; you’re going to have a stroke by the time you’re 40. And I can only hope that you can recover enough from your stroke that you’ll be able to take care of your family.” Several female participants were warned that without losing weight, they would either never become pregnant or they would die in childbirth. By contrast, participants stated that their bariatric surgeons were the first providers they had encountered to both assert that obesity was a medical condition outside of their control and to offer them a solution. Within an atmosphere in which obesity is held to be largely or entirely the result of behavioural choices, the bariatric profession thus positions itself as unique by offering both understanding and what it claims to be a durable treatment. Importantly, it would be a mistake to conclude that some bariatric patients needed surgery while others choose it for the wrong reasons. Regardless of their states of health at the time they made the decision to have surgery, the concerns that drove these patients to seek out these procedures were experienced as very real. Whether or not these concerns would have materialized as actual health conditions is unknown. Furthermore, bariatric patients should not be seen as having been duped or suffering from ‘false consciousness.’ Rather, they operate within a particular set of social, cultural, and political-economic conditions that suggest that good citizenship requires risk avoidance and personal health management. As these individuals experienced, there are material and social consequences for ‘failing’ to obtain normative conceptualizations of health. This set of conditions helps to produce a bariatric patient population that includes both those who were contending with serious health concerns and those who feared they would develop them. All bariatric patients operate within this set of conditions (as do medical providers) and make decisions regarding health (current, future, or both) by using the resources available to them. In her work on the temporalities of dieting, Coleman argues that rather than seeing dieting as a linear and progressive event, we might think of it instead a process that brings the future into the present as potential. Adams et al suggest concerns about potential futures, particularly in regard to health, are a defining characteristic of our time. They state: “The present is governed, at almost every scale, as if the future is what matters most. Anticipatory modes enable the production of possible futures that are lived and felt as inevitable in the present, rendering hope and fear as important political vectors” (249). The ability to act in the present based on potential future risks, they argue, has become a moral imperative and a marker of proper of citizenship. Importantly, however, our work to secure the ‘best possible future’ is never fully assured, as risks are constantly changing. The future is thus always uncertain. Acting responsibly in the present therefore requires “alertness and vigilance as normative affective states” (254). Importantly, these anticipations are not diagnostic, but productive. As Adams et al state, “the future arrives already formed in the present, as if the emergency has already happened…a ‘sense’ of the simultaneous uncertainty and inevitability of the future, usually manifest in entanglements of fear and hope” (250). It is in this light, then, that we might see the decision to have bariatric surgery. For these participants, their future weight-related morbidity and mortality had already arrived in the present and thus they felt they needed to act responsibly now, by undergoing what they had been told was the only durable medical intervention for obesity. The emotions of hope, fear, anxiety and I would suggest, hatred, were key in making these decisions. Conclusion Medical, public health, and media discourses frame obesity as an epidemic that threatens to bring untold financial disaster and escalating rates of morbidity and mortality upon the nation state and the world at large. As Fraser et al argue, strong emotions (such hatred, fear, anxiety, and hope), are at the centre of these discourses; they construct, circulate, and proliferate them. Moreover, they create categories of people who are deemed legitimate and categories of others who are not. In this context, the participants I spoke with were caught between a desire to have fatness understood as a medical condition needing intervention; the anti-fat attitudes of others, including providers, which held that obesity was a failure of the will and nothing more; their own internalization of these messages of personal responsibility for proper behavioural choices, and, the biologically intractable nature of fatness wherein dieting not only fails to reduce weight in the vast majority of cases but results, in the long term, in increased weight gain (Kassirer and Angell; Mann et al.; Puhl and Heuer). Widespread anxiety and embarrassment over and fear and hatred of fatness was something that the individuals I interviewed experienced directly and which signalled to them that they were less than human. Their desire for weight loss, therefore was partially a desire to become ‘normal.’ In Butler’s term, it was the desire for a ‘liveable life. ’A liveable life, for these participants, included a desire for a seamless fit with the built environment. The individuals I spoke with were never more ashamed of their fatness than when they experienced a ‘misfit’, in Garland Thomson’s terms, between their bodies and the material world. Moreover, feelings of shame over this disjuncture worked in tandem with a deeply felt, pressing sense that something must be done in the present to secure a better health future. The belief that bariatric surgery might finally provide a durable answer to obesity served as a strong motivating factor in their decisions to undergo bariatric surgery. By taking drastic action to lose weight, participants hoped to contest stigmatizing beliefs that their fat bodies reflected pathological interiors. Moreover, they sought to demonstrate responsibility and thus secure proper subjectivities and citizenship. In this sense, concerns, anxieties, and fears about health cannot be disentangled from the experience of anti-fat stigma and discrimination. Again, anti-fat bias, for these participants, was more than discursive: it operated through the circulation of emotion and was experienced in a very material sense. The decision to have weight loss surgery can thus be seen as occurring at the interface of emotion, flesh, space, place, and time, and in ways that are fundamentally shaped by the broader social context of neoliberal healthism. AcknowledgmentI am grateful to the anonymous reviewers of this article for their helpful feedback on earlier version. References Adams, Vincanne, Michelle Murphy, and Adele E. Clarke. “Anticipation: Technoscience, Life, Affect, Temporality.” Subjectivity 28.1 (2009): 246-265. Ahmed, Sara. “Affective Economies.” Social Text 22.2 (2004): 117-139 Boero, Natalie. Killer Fat: Media, Medicine, and Morals in the American "Obesity Epidemic". New Brunswick: Rutgers University Press, 2012. Butler, Judith. Undoing Gender. New York: Routledge, 2004. Bynum, Caroline Walker. 1999. Jefferson Lecture in the Humanities. National Endowment for the Humanities. Washington, DC, 1999. Cahnman, Werner J. “The Stigma of Obesity.” The Sociological Quarterly 9.3 (1968): 283-299. Chang, Virginia W., and Nicholas A. Christakis. “Medical Modeling of Obesity: A Transition from Action to Experience in a 20th Century American Medical Textbook.” Sociology of Health & Illness 24.2 (2002): 151-177. Coleman, Rebecca. “Dieting Temporalities: Interaction, Agency and the Measure of Online Weight Watching.” Time & Society 19.2 (2010): 265-285. Colls, Rachel. “‘Looking Alright, Feeling Alright:’ Emotions, Sizing, and the Geographies of Women’s Experience of Clothing Consumption.” Social & Cultural Geography 5.4 (2004): 583-596. Crawford, Robert. “You Are Dangerous to Your Health: The Ideology and Politics of Victim Blaming.” International Journal of Health Services 7.4 (1977): 663-680. ———. “Health as a Meaningful Social Practice.: Health 10.4 (2006): 401-20. Dedoose. Computer Software. n.d. Franko, Debra L., Emilie J. Coen, James P. Roehrig, Rachel Rodgers, Amy Jenkins, Meghan E. Lovering, Stephanie Dela Cruz. “Considering J. Lo and Ugly Betty: A Qualitative Examination of Risk Factors and Prevention Targets for Body Dissatisfaction, Eating Disorders, and Obesity in Young Latina Women.” Body Image 9.3 (2012), 381-387. Fikken, Janna J., and Esther D. Rothblum. “Is Fat a Feminist Issue? Exploring the Gendered Nature of Weight Bias.” Sex Roles 66.9-10 (2012): 575-592. Fraser, Suzanne, JaneMaree Maher, and Jan Wright. “Between Bodies and Collectivities: Articulating the Action of Emotion in Obesity Epidemic Discourse.” Social Theory & Health 8.2 (2010): 192-209. Garland Thomson, Rosemarie. “Misfits: A Feminist Materialist Disability Concept.” Hypatia 26.3 (2011): 591-609. Goffman, Erving. Stigma: Notes on the Management of Spoiled Identity. New York: Simon & Schuster, 1963. Grabe, Shelly, and Janet S. Hyde. “Ethnicity and Body Dissatisfaction among Women in the United States: A Meta-Analysis.” Psychological Bulletin 132.2 (2006): 622. Greenhalgh, Susan. “Weighty Subjects: The Biopolitics of the U.S. War on Fat.” American Ethnologist 39.3 (2012): 471-487. Grosz, Elizabeth A. “Bodies-Cities.” Feminist Theory and the Body: A Reader, eds. Janet Price and Margrit Shildrick. New York: Routledge, 1999. 381-387. Guthman, Julie. “Teaching the Politics of Obesity: Insights into Neoliberal Embodiment and Contemporary Biopolitics.” Antipode 41.5 (2009): 1110-1133. Kassirer, Jerome P., and M. Marcia Angell. “Losing Weight: An Ill-Fated New Year's Resolution.” The New England Journal of Medicine 338.1 (1998): 52. Kirkland, Anna. “Think of the Hippopotamus: Rights Consciousness in the Fat Acceptance Movement.” Law & Society Review 42.2 (2008): 397-432. Lewis, Sophie, Samantha L. Thomas, R. Warwick Blood, David Castle, Jim Hyde, and Paul A. Komesaroff. “How Do Obese Individuals Perceive and Respond to the Different Types of Obesity Stigma That They Encounter in Their Daily Lives? A Qualitative Study.” Social Science & Medicine 73.9 (2011): 1349-56. López, Julia Navas. “Socio-Anthropological Analysis of Bariatric Surgery Patients: A Preliminary Study.” Social Medicine 4.4 (2009): 209-217. McPhail, Deborah. “What to Do with the ‘Tubby Hubby?: ‘Obesity,’ the Crisis of Masculinity, and the Nuclear Family in Early Cold War Canada. Antipode 41.5 (2009): 1021-1050. Mann, Traci, A. Janet Tomiyama, Erika Westling, Ann-Marie Lew, Barbara Samuels, and Jason Chatman. “Medicare’s Search for Effective Obesity Treatments.” American Psychologist 62.3 (2007): 220-233. Metzl, Jonathan. “Introduction: Why ‘Against Health?’” Against Health: How Health Became the New Morality, eds. Jonathan Metzl and Anna Kirkland. New York: NYU Press, 2010. 1-14. Puhl, Rebecca M. “Obesity Stigma: Important Considerations for Public Health.” American Journal of Public Health 100.6 (2010): 1019-1028.———, and Kelly D. Brownell. “Psychosocial Origins of Obesity Stigma: Toward Changing a Powerful and Pervasive Bias.” Obesity Reviews 4.4 (2003): 213-227. ——— and Chelsea A. Heuer. “The Stigma of Obesity: A Review and Update.” Obesity 17.5 (2009): 941-964. Schafer, Markus H., and Kenneth F. Ferraro. “The Stigma of Obesity: Does Perceived Weight Discrimination Affect Identity and Physical Health?” Social Psychology Quarterly 74.1 (2011): 76-97. Schwartz, H. Never Satisfied: A Cultural History of Diets, Fantasies, and Fat. New York: Anchor Books, 1986. Wadden, Thomas A., David B. Sarwer, Anthony N. Fabricatore, LaShanda R. Jones, Rebecca Stack, and Noel Williams. “Psychosocial and Behavioral Status of Patients Undergoing Bariatric Surgery: What to Expect before and after Surgery.” The Medical Clinics of North America 91.3 (2007): 451-69. Wilson, Bianca. “Fat, the First Lady, and Fighting the Politics of Health Science.” Lecture. The Graduate Center of the City University of New York. 14 Feb. 2011.

Abstract:

Abstract Case report - Introduction It has been reported by the European Centre for Disease Prevention and Control that by May 2020 there were 230 suspected cases of PIMS-TR COVID-19. At Great Ormond Street Hospital NHS Foundation Trust (GOSH) there were 50 suspected cases. This report summarises the physiotherapy input to these patients outside of PICU. The rheumatology team were allocated the COVID-19positive ward and therefore were able to be involved in the evolving understanding of the clinical presentation and management of this new disease. Case report - Case description 50 children were admitted to GOSH with suspected PIMS-TR COVID-19, of these, 36 were admitted to PICU. The mean length of stay in PICU was 4.6 days and the median 3.5 days (Range 1–16 days). The mean total length of stay in hospital was 11 days (range 2–94 days). 42% were male and 57% female and the age ranged from 5 weeks -17 years, but the mean age was 9 yrs. Most were previously well, but 3 had asthma, 2 diabetes, 1 obese, 1 with liver disease and 2 with sickle cell disease. The physiotherapy provided included assessment and relatively quickly it was recognised that these patients had a specific pattern of muscle weakness (proximal&gt;distal) and so the Manual Muscle Test of 8 muscle groups (MMT8) and the Childhood Myositis Assessment Score (CMAS) were adopted as outcomes. The initial mean MMT8 score was 56/80 (42–79) and mean CMAS score 20/52 (4–51) Assessment of respiratory function, mobility and safety of postural changes including sitting to standing, gait and managing the stairs was also included. The treatment provided included breathing exercises and specific muscle strengthening that was progressed as able. Advice to the nursing and medical staff was provided to ensure that patients were safe while they were regaining strength and stability. Gait re-education and stairs assessment was completed before discharge. The patients have now been placed into a multidisciplinary assessment programme to follow up the long-term outcomes including physiotherapy outcomes. At the 2 months follow up the mean MMT8 was 72/80 and the mean CMAS is 46/52 indicating that there may be a long-term impact upon musculoskeletal function in young people. Case report - Discussion At GOSH the rheumatology physiotherapy team were redeployed to the temporary general paediatrics service. This service was responsible for the patients who were diagnosed with this new and evolving disease and who were transferred from the PICU. The physiotherapy team started to recognise the extent of their illness including postural instability, muscle weakness, severe fatigue, and joint involvement. The children also had impairment in respiratory function and cardiac function. It was recognised that mobility was limited for many reasons and care was required in the intensity and frequency of exercise and level of activity. Initially moving around the bed was exhausting and had to be effective and safe before progressing to weight-bearing and walking. Because the physiotherapy team were musculoskeletal specialists, they were able to consider different outcome measures and quickly decided upon using the MMT8 and the CMAS as well as assessing joint range of movement and muscle length. Respiratory assessments were also completed. It was also recognised that as the hospital had rapidly developed the COVID-19ward (Hedgehog ward) and as the staff were from many different areas of the hospital effective communication between this new team had to be established and within weeks a daily MDT meeting was started that ensured all aspects of each patients care were discussed to enable complete co-ordinated treatment of the patient. This meeting allowed staff to contribute to decisions about treatment as well as ensuring the nursing staff were informed about safety for each child regarding mobility. The meeting also allowed for discharge planning to ensure that every child was safe to be discharged and was able to physically manage at home. A weekly psychosocial meeting was also developed and so the psychological and social factors for each child and their family could also be considered and supported. Case report - Key learning points The hospital planned and prepared for the Pandemic and staff were placed together to work in different ways. Because of the diversity of the skills of the staff it was possible to recognise the many systems that were affected by the disease and to pull together the expertise of the staff to be able to provide a high level and holistic clinical management for each and every child. It has also been possible to explore outcome measures and to be able to work with each other and to learn and discuss treatments moving forwards. The speed in which a completely new service was established was impressive especially as there had been a misunderstanding initially that children would probably not be severely affected by COVID-19. The importance of physiotherapy treatment in order to enable these young people to regain strength, mobility and function was apparent and with the longer term follow up it is demonstrating that several of these patients need longer term care and treatment after discharge. The outcome measures that are being used for the longer term follow up; CMAS, MMT8, 6 min walking test as well as neurological examinations and questionnaires to assess function and psychological well-being and fatigue are able to be used if other patients develop this disease and these measures can be used nationwide in order to enable a cohesive approach to managing PIMS-TR COVID-19.

Abstract:

ObjectiveTo inform asthmatic, health plan patients of air quality conditions in their specific geographic location and to assess if the communication is successful in reducing the number of emergency department visits for asthmatic/respiratory flare ups.IntroductionSouthwest states are prone to wildfires, dust storms, and high winds especially during the monsoon season (June – September). Wildfire smoke is a complex mixture of carbon monoxide, carbon dioxide, water vapor, hydrocarbons, nitrogen, oxides, metals, and particulate matter (PM). Dust storms are made up of aerosols and dust particles varying in size; particles bigger than 10 µm are not breathable, but can damage external organs such as causing skin and eye irritations. Particles smaller than 10 µm are inhalable and often are trapped in the nose, mouth, and upper respiratory tracts, and can cause respiratory disorders such as asthma and pneumonia. Numerous studies have characterized the epidemiological and toxicological impact of exposure to PM in dust or smoke form on human health.1All of these environmental conditions can have impacts on cardiovascular conditions such as hypertension and cause respiratory flare ups, especially asthma. Previous studies have shown a relationship between PM exposure and increases in respiratory-related hospital admissions.1-4 In an analysis of the health effects of a large wildfire in California in 2008, Reid, et. al, observed a linear increase in risk for asthma hospitalizations (RR=1.07, 95% CI= (1.05, 1.10) per 5 µg/m3 increase) and asthma emergency department visits (RR=1.06, 95% CI=(1.05, 1.07) per 5 µg/m3 increase) with increasing PM2.5 during wildfires.5 In a study specific to New Mexico, Resnick, et. al, found that smoke from the Wallow fire in Arizona in 2011 impacted the health of New Mexicans, observing increases in emergency department visits for asthma flare-ups in Santa Fe, Espanola, and Albuquerque residents.6This current study will evaluate the effectiveness of outreach to asthmatic members during times of poor air quality; informing them of the air quality, instructing them to limit their outdoor activity, and to remind them to carry or access their inhalers or other medical necessities if/when needed.MethodsA recent 12-month eligible member list was generated including member ID, street address, zip code, and a count of the number of emergency department (ED) visits for the specified time period. The member list was then geocoded using the tool Quest. Any records that did not map to a latitude and longitude within the state boundary of New Mexico were excluded. The geocoded list was then joined to a list of members who had an indicator for asthma (a hospital admission or ED visit with a primary diagnosis for asthma). This list of asthmatic, eligible members was then mapped using QGIS 3.2.The New Mexico Environment Department’s (NMED) air quality bureau operates a network of ambient air monitors across the state. Monitors range in size from neighborhood level to regional and pollutants measured include ozone, PM2.5, PM10, Nitrogen Dioxide, and Sulfur Dioxide. Each individual air monitor was mapped to a point location with individual buffer zones (dependent on the monitor’s collection size).Asthmatic members were mapped to air monitor buffers using a spatial overlap program in QGIS. Each air monitor then had a list of asthmatic members who were tied to the air monitor and would be contacted if the air quality index (AQI) value for that air monitor was less than good (>50).ResultsIn a given 12-month period, there were 38,364 asthmatic members mapped to a geographic point within the state boundary of New Mexico. Of the 14 air monitors across the state, 9,965 (26%) asthmatic members mapped to an air monitor. NMED posts air monitor readings on their website daily. During the upcoming 2019 monsoon season, air monitors with a daily AQI reading of >50 will trigger the emailing of a scripted letter to asthmatic members (connected to that specific monitor) informing them of poor air quality in their area and alerting them to limit their outdoor time and to ensure that their medications are up-to-date and easily available. In order to construct this letter in a non-intrusive, succinct manner, collaboration with business partners (who have experience with working with members on a 1:1 basis) within the organization will assist with ensuring a targeted message.After the 2019 monsoon season, this project will be evaluated to determine if the intervention was beneficial in reducing the number of ED visits for the members who were contacted. ED visit rates specific to asthma (inclusion of asthma specific diagnosis code) will be compared for the pre and post intervention monsoon seasons.ConclusionsCombining external, state-level data with internal member-level data can have powerful results. Due to protected health information (PHI), state level data sometimes is unavailable at a person-level basis, and thus pointed, individual interventions are not possible. By combining internal and external data sources on different health related topics, it is possible to create a more cohesive, person-level, health-impactful view of a person and their environment.References1. Fann N, Alman B, Broome RA, et al. The health impacts and economic value of wildland fire episodes in the U.S.: 2008-2012. Sci Total Environ. 2018;610-611:802-809.2. Delfino RJ, Brummel S, Wu J, et al. The relationship of respiratory and cardiovascular hospital admissions to the southern california wildfires of 2003. Occup Environ Med. 2009;66(3):189-197.3. Gan RW, Ford B, Lassman W, et al. Comparison of wildfire smoke estimation methods and associations with cardiopulmonary-related hospital admissions. Geohealth. 2017;1(3):122-136.4. Kanatani KT, Ito I, Al-Delaimy WK, et al. Desert dust exposure is associated with increased risk of asthma hospitalization in children. Am J Respir Crit Care Med. 2010;182(12):1475-1481.5. Reid CE, Jerrett M, Tager IB, Petersen ML, Mann JK, Balmes JR. Differential respiratory health effects from the 2008 northern california wildfires: A spatiotemporal approach. Environ Res. 2016;150:227-235.6. Resnick A, Woods B, Krapfl H, Toth B. Health outcomes associated with smoke exposure in albuquerque, new mexico, during the 2011 wallow fire. J Public Health Manag Pract. 2015;21 Suppl 2:S55-61.

Abstract:

Introduction In The X-Files episode “Humbug”, agents Scully and Mulder travel to Florida to investigate a series of murders taking place in a community of sideshow performers, or freaks. At the episode’s end, one character, a self-made freak and human blockhead, muses on the future of the freak community:twenty-first century genetic engineering will not only eradicate the Siamese twins and the alligator-skinned people, but you’re going to be hard-pressed to find a slight overbite or a not-so-high cheek bone … . Nature abhors normality. It can’t go very long without creating a mutant. (“Humbug”) Freaks, he says, are there to remind people of the necessity of mutations. His observation that genetic engineering will eradicate anomalies of nature accurately illustrates the gradual shift that society was witnessing in the late twentieth century away from the anomalous freak and toward surgical perfection. Yet this desire for perfection, which has manifested itself in often severe surgical deformities, has seen a shift in what constitutes the freak for a contemporary audience, turning what was once an anomaly into a mass-produced creation. While the freaks of the nineteenth and early twentieth century were born with facial or anatomical deformities that warranted their place in the sideshow performance (bearded ladies, midgets, faints, lobster men, alligator-skinned people, etc.), freaks of the twenty-first century can be seen as something created by a plastic surgeon, a shift which undermines the very understanding of freak ontology. As Katherine Dunne put it: “a true freak cannot be made. A true freak must be born” (28). In her discussion of the monstrous body, Linda Williams writes that “the monster’s body is perceived as freakish in its possession of too much or too little” (63). This may have included a missing or additional limb, distorted sizes and heights, and anatomical growths. John Merrick, or the “Elephant Man” (fig. 1), as he was famously known, perfectly embodied this sense of excess that is vital to what people perceive as the monstrous body. In his discussion of freaks and the freakshow, Robert Bogdan notes that promotional posters exaggerated the already-deformed nature of freaks by emphasising certain physical anomalies and turning them into mythological creatures: “male exhibits with poorly formed arms were billed as ‘The Seal Man’; with poorly formed legs, ‘the Frog Man’; with excesses of hair, ‘The Lion Man’ or ‘Dog Boy’” (100). Figure 1: John Merrick (the Elephant Man) <https://www.pinterest.com.au/pin/193584483966192229/>.The freak’s anomalous nature made them valuable, financially but also culturally: “in many ways, the concept of ‘freak,’ is an anomaly in current social scientific thinking about demonstrable human variation. During its prime the freak show was a place where human deviance was valuable, and in that sense valued” (Bogdan 268). Many freaks were presented as “human wonders”, while “their claims to fame were quite commonplace” (Bogdan 200). Indeed, Bogdan argues that “while highly aggrandized exhibits really were full of grandeur, with respectable freaks the mundane was exploited as amazing and ordinary people were made into human wonders” (200). Lucian Gomoll similarly writes that freakshows “directed judgement away from the audience and onto the performers, assuring observers of their own unmarked normalcy” (“Objects of Dis/Order” 205).The anomalous nature of the freak therefore promoted the safety of normality at the same time as it purported to showcase the brilliance of the extraordinary. While the freaks themselves were normal, intelligent people, the freakshow served as a vehicle to gaze at oneself with a sense of relief. As much as many freakshows attempt to dismantle notions of normality, they serve to emphasise empathy, not envy. The anomalous freak is never an envied body; the particular dimensions of the freakshow mean that it is the viewer who is to be envied, and the freak who is to be pitied. From Freakshow to SideshowIn nineteenth-century freakshows, exploitation was rife; as Alison Piepmeier explains, “many of the so-called Aztecs, Pinheads, and What Is Its?”, were, in fact, “mentally disabled people dressed in wild costumes and forced to perform” (53). As a result, “freakishness often implied loss of control over one’s self and one’s destiny” (53). P.T. Barnum profited from his exploitation of freaks, while many freaks themselves also benefited from being exhibited. As Jessica Williams writes, “many freak show performers were well paid, self-sufficient, and enjoyed what they did” (69). Bogdan similarly pointed out that “some [freaks] were exploited, it is true, but in the culture of the amusem*nt world, most human oddities were accepted as showmen. They were congratulated for parlaying into an occupation [that], in another context, might have been a burden” (268). Americans of all classes, Anissa Janine Wardi argues, enjoyed engaging in the spectacle of the freak. She writes that “it is not serendipitous that the golden age of the freak show coincided with the building of America’s colonial empire” (518). Indeed, the “exploration of the non-Western world, coupled with the transatlantic slave trade, provided the backdrop for America’s imperialist gaze, with the native ‘other’ appearing not merely in the arena of popular entertainment, but particularly in scientific and medical communities” (518). Despite the accusations levelled against Barnum, his freakshows were seen as educational and therefore beneficial to both the public and the scientific community, who, thanks to Barnum, directly benefited from the commercialisation of and rising public interest in the freak. Discussing “western conventions of viewing exotic others”, Lucian Gomoll writes that “the freak and the ‘normal’ subject produced each other in a relationship of uneven reciprocity” (“Feminist Pleasures” 129). He writes that Barnum “encouraged onlookers to define their own identities in contrast to those on display, as not disabled, not animalistic, not androgynous, not monstrous and so on”. By the twentieth century, he writes, “shows like Barnum’s were banned from public spaces as repugnant and intolerable, and forced to migrate to the margins” (129).Gomoll commends the Freakatorium, a museum curated by the late sword swallower Johnny Fox, as “demonstrating and commemorating the resourcefulness and talents of those pushed to the social margins” (“Objects of Dis/Order” 207). Gomoll writes that Fox did not merely see freaks as curiosities in the way that Barnum did. Instead, Fox provided a dignified memorial that celebrated the uniqueness of each freak. Fox’s museum displays, he writes, are “respectable spaces devoted to the lives of amazing people, which foster potential empathy from the viewers – a stark contrast to nineteenth-century freakshows” (205). Fox himself described the necessity of the Freakatorium in the wake of the sideshow: New York needs a place where people can come see the history of freakdom. People that were born with deformities that were still amazing and sensitive people and they allowed themselves to be viewed and exhibited. They made a good living off doing that. Those people were to be commended for their courageousness and bravery for standing in front of people. (Hartzman)Fox also described the manner in which the sideshow circuit was banned over time:then sideshows went out because some little girl was offended because she thought the only place she could work was the sideshow. Her mother thought it was disgraceful that people exhibited themselves so she started calling the governor and state’s attorney trying to get sideshows banned. I think it was Florida or South Carolina. It started happening in other states. They said no exhibiting human anomalies. These people who had been working in sideshows for years had their livelihood taken away from them. What now, they’re supposed to go be institutionalized? (Hartzman) Elizabeth Stephens argues that a shift occurred in the early twentieth century, and that by the late ‘30s “people with physical anomalies had been transformed in the cultural imagination from human oddities or monsters to sick people requiring diagnoses and medical intervention” (Stephens). Bogdan noted that by the 1930s, “the meaning of being different changed in American society. Scientific medicine had undermined the mystery of certain forms of human variation, and the exotic and aggrandized modes had lost their flamboyant attractiveness” (274). So-called freaks became seen as diseased bodies who “were now in the province of physicians, not the general public” (274). Indeed, scientific interest transformed the freak into a medical curiosity, contributing to the waning popularity of freakshows. Ironically, although the freaks declined in popularity as they moved into the medical community, medicine would prove to be the domain of a new kind of freak in the ensuing years. The Manufactured Freak As the freakshow declined in popularity, mainstream culture found other subjects whose appearance provoked curiosity, awe, and revulsion. Although plastic surgery is associated with the mid-to-late twentieth century and beyond, it has a long history in the medical practice. In A History of Plastic Surgery, Paolo Santoni-Rugiu and Philip J. Sykes note that “operations for the sole purpose of improving appearances came on the scene in 1906” (322). Charles C. Miller was one of the earliest pioneers of plastic surgery; Santoni-Rugiu and Sykes write that “he never disguised the fact that his ambition was to do Featural Surgery, correcting imperfections that from a medical point of view were not considered to be deformities” (302). This attitude would fundamentally transform notions of the “normal” body. In the context of cosmetic surgery, it is the normal body that becomes manipulated in order to produce something which, despite intentions, proves undoubtedly freakish. Although men certainly engage in plastic surgery (notably Igor and Grichka Bogdanoff) the twenty-first century surgical freak is synonymous with women. Kirsty Fairclough-Isaacs points out the different expectations levelled against men and women with respect to ageing and plastic surgery. While men, she says, “are closely scrutinised for attempting to hide signs of ageing, particularly hair loss”, women, in contrast, “are routinely maligned if they fail to hide the signs of ageing” (363). She observes that while popular culture may accept the ageing man, the ageing woman is less embraced by society. Consequently, women are encouraged—by the media, their fans, and by social norms around beauty—to engage in surgical manipulation, but in such a way as to make their enhancements appear seamless. Women who have successful plastic surgery—in the sense that their ageing is well-hidden—are accepted as having successfully manipulated their faces so as to appear flawless, while those whose surgical exploits are excessive or turn out badly become decidedly freakish. One of the most infamous plastic surgery cases is that of Jocelyn Wildenstein, also known as “catwoman”. Born Jocelynnys Dayannys da Silva Bezerra Périsset in 1940, Wildenstein met billionaire art dealer Alec N. Wildenstein whom she married in the late 1970s. After discovering her husband was being unfaithful, Wildenstein purportedly turned to cosmetic surgery in order to sculpt her face to resemble a cat, her husband’s favourite animal. Ironically but not surprisingly, her husband purportedly screamed in terror when he saw his wife’s revamped face for the first time. And although their relationship ended in divorce, Wildenstein, dubbed “the Bride of Wildenstein”, continued to visit her plastic surgeon, and her face became progressively more distorted over the years (Figure 2). Figure 2: Jocelyn Wildenstein over the years <https://i.redd.it/vhh3yp6tgki31.jpg>. The exaggerated and freakish contours of Wildenstein’s face would undoubtedly remind viewers of the anatomical exaggerations seen in traditional freaks. Yet she does not belong to the world of the nineteenth century freak. Her deformities are self-inflicted in an attempt to fulfil certain mainstream beauty ideals to exaggerated lengths. Like many women, Wildenstein has repeatedly denied ever having received plastic surgery, claiming that her face is natural, while professing admiration for Brigitte Bardot, her beauty idol. Such denial has made her the target of further criticism, since women are not only expected to conceal the signs of ageing successfully but are also ironically expected to be honest and transparent about having had work done to their faces and bodies, particularly when it is obvious. The role that denial plays not just in Wildenstein’s case, but in plastic surgery cases more broadly, constitutes a “desirability of naturalness” (122), according to Debra Gimlin. There is, she argues, an “aesthetic preference for (surgically enhanced) ‘naturalness’” (122), a desire that sits between the natural body and the freak. This kind of appearance promotes more of an uncanny naturalness that removes signs of ageing but without being excessive; as opposed to women whose use of plastic surgery is obvious (and deemed excessive according to Williams’ “monstrous body”) the unnatural look that some plastic surgery promotes is akin to an absence of normal features, such as wrinkles. One surgeon that Gimlin cites argues that he would not remove the wrinkles of a woman in her 60s: “she’s gonna look like a freak without them”, he says. This admission signifies a clear distinction between what we understand as freakish plastic surgery (Wildenstein) and the not-yet-freakish appearance of women whose surgically enhanced appearance is at once uncanny and accepted, perpetuating norms around plastic surgery and beauty. Denial is thus part of the fabric of performing naturalness and the desire to make the unnatural seem natural, adding another quasi-freakish dimension to the increasingly normalised appearance of surgically enhanced women. While Wildenstein is mocked for her grotesque appearance, in addition to her denial of having had plastic surgery, women who have navigated plastic surgery successfully are congratulated and envied. Although contemporary media increasingly advocates the ability to age naturally, with actresses like Helen Mirren and Meryl Streep frequently cited as natural older beauties, natural ageing is only accepted to the extent that this look of naturalness is appeasing. Unflattering, unaltered naturalness, on the other hand, is demonised, with such women encouraged to turn to the knife after all in order to achieve a more acceptable look of natural ageing, one that will inevitably and ironically provoke further criticism. For women considering plastic surgery, they are damned if they do and damned if they don’t. Grant McCracken notes the similarities between Wildenstein and the famous French body artist Orlan: “like Orlan, Wildenstein had engaged in an extravagant, destructive creativity. But where Orlan sought transformational opportunity by moving upward in the Renaissance hierarchy, toward saints and angels, Wildenstein moved downwards, toward animals” (25). McCracken argues that it isn’t entirely clear whether Orlan and Wildenstein are “outliers or precursors” to the contemporary obsession with plastic surgery. But he notes how the transition of plastic surgery from a “shameful secret” to a ubiquitous if not obligatory phenomenon coincides with the surgical work of Orlan and Wildenstein. “The question remains”, he says, “what will we use this surgery to do to ourselves? Orlan and Wildenstein suggest two possibilities” (26).Meredith Jones, in her discussion of Wildenstein, echoes the earlier sentiments of Williams in regards to the monster’s body possessing too much or too little. In Wildenstein’s case, her freakishness is provoked by excess: “when too many body parts become independent they are deemed too disparate: wayward children who no longer lend harmony or respect to their host body. Jocelyn Wildenstein’s features do this: her cheeks, her eyes, her forehead and her lips are all striking enough to be deemed untoward” (125). For Jones, the combination of these features “form a grotesquery that means their host can only be deemed, at best, perversely beautiful” (125). Wildenstein has been referred to as a “modern-day freak”, and to a certain extent she does share something in common with the nineteenth century freak, specifically through the manner in which her distorted features invite viewers to gawk. Like the Elephant Man, her freakish body possesses “too much”, as Williams put it. Yet her appearance evokes none of the empathy afforded traditional freaks, whose facial or anatomical deformities were inherent and thus cause for empathy. They played no role in the formation of their deformities, only reclaiming agency once they exhibited themselves. While Wildenstein is, certainly, an anomaly in the sense that she is the only known woman who has had her features surgically altered to appear cat-like, her appearance more broadly represents an unnerving trajectory that reconstructs the freak as someone manufactured rather than born, upending Katherine Dunne’s assertion that true freaks are born, not made. Indeed, Wildenstein can be seen as a precursor to Nannette Hammond and Valeria Lukyanova, women who surgically enhanced their faces and bodies to resemble a real-life Barbie doll. Hammond, a woman from Cincinnati, has been called the first ‘Human Barbie’, chronicling the surgical process on her Instagram account. She states that her children and husband are “just so proud of me and what I’ve achieved through surgery” (Levine). This surgery has included numerous breast augmentations, botox injections and dental veneers, in addition to eyelash extensions and monthly fake tans. But while Hammond is certainly considered a “scalpel junkie”, Valeria Lukyanova’s desire to transform herself into a living Barbie doll is particularly uncanny. Michael’s Idov’s article in GQ magazine titled: “This is not a Barbie Doll. This is an Actual Human Being” attests to the uncanny appearance of Lukyanova. “Meeting Valeria Lukyanova is the closest you will come to an alien encounter”, Idov writes, describing the “queasy fear” he felt upon meeting her. “A living Barbie is automatically an Uncanny Valley Girl. Her beauty, though I hesitate to use the term, is pitched at the exact precipice where the male gaze curdles in on itself.” Lukyanova, a Ukrainian, admits to having had breast implants, but denies that she has had any more modifications, despite the uncanny symmetry of her face and body that would otherwise allude to further surgeries (Figure 3). Importantly, Lukyanova’s transformation both fulfils and affronts beauty standards. In this sense, she is at once freakish but does not fit the profile of the traditional freak, whose deformities are never confused with ideals of beauty, at least not in theory. While Johnny Fox saw freaks as talented, unique individuals, their appeal was borne of their defiance of the ideal, rather than a reinforcement of it, and the fact that their appearance was anomalous and unique, rather than reproducible at whim. Figure 3: Valeria Lukyanova with a Barbie Doll <http://shorturl.at/mER06>.Conclusion As a modern-day freak, these Barbie girls are a specific kind of abomination that undermines the very notion of the freak due to their emphasis on acceptance, on becoming mainstream, rather than being confined to the margins. As Jones puts it: “if a trajectory […] is drawn between mainstream cosmetic surgery and these individuals who have ‘gone too far’, we see that while they may be ‘freaks’ now, they nevertheless point towards a moment when such modifications could in fact be near mainstream” (188). The emphasis that is placed on mainstream acceptance and reproducibility in these cases affronts traditional notions of the freak as an anomalous individual whose features cannot be replicated. But the shift that society has seen towards genetic and surgical perfection has only accentuated the importance of biological anomalies who affront the status quo. While Wildenstein and the Barbie girls may provoke a similar sense of shock, revulsion and pity as the Elephant Man experienced, they possess none of the exceptionality or cultural importance of real freaks, whose very existence admonishes mainstream standards of beauty, ability, and biology. References Bogdan, Robert. Freak Show: Presenting Human Oddities for Amusem*nt and Profit. Chicago and London: U of Chicago P, 1990. Dunne, Katherine. Geek Love. London: Abacus, 2015. Fairclough-Isaacs, Kirsty. "Celebrity Culture and Ageing." Routledge Handbook of Cultural Gerontology. Eds. Julia Twigg and Wendy Martin. New York: Routledge, 2015. 361-368.Gimlin, Debra. Cosmetic Surgery Narratives: A Cross-Cultural Analysis of Women’s Accounts. New York: Palgrave Macmillan, 2012. Gommol, Lucian. “The Feminist Pleasures of Coco Rico’s Social Interventions.” Art and the Artist in Society. Eds. José Jiménez-Justiniano, Elsa Luciano Feal, and Jane Elizabeth Alberdeston. Newcastle upon Tyne: Cambridge Scholars Publishing, 2013. 119-134. ———. “Objects of Dis/Order: Articulating Curiosities and Engaging People at the Freakatorium.” Defining Memory: Local Museums and the Construction of History in America’s Changing Communities. Eds. Amy K. Levin and Joshua G. Adair. Lanham: Rowman & Littlefield, 2017. 197-212. Hartzman, Marc. “Johnny Fox: A Tribute to the King of Swords.” Weird Historian. 17 Dec. 2017. <https://www.weirdhistorian.com/johnny-fox-a-tribute-to-the-king-of-swords/>.“Humbug.” The X-Files: The Complete Season 3. Writ. Darin Morgan. Dir. Kim Manners. Fox, 2007. Idov, Michael. “This Is Not a Barbie Doll. This Is an Actual Human Being.” GQ. 12 July 2017. <https://www.gq.com/story/valeria-lukyanova-human-barbie-doll>.Jones, Meredith. Skintight: An Anatomy of Cosmetic Surgery. Oxford: Berg, 2008.McCracken, Grant. Transformations: Identity Construction in Contemporary Culture. Bloomington and Indianapolis: Indiana UP, 2008.Levine, Daniel D. “Before and After: What $500,000 of Plastic Surgery Bought Human Barbie.” PopCulture.com. 7 Dec. 2017. <https://popculture.com/trending/news/nannette-hammond-before-human-barbie-cost-photos/>. Piepmeier, Alison. Out in Public: Configurations of Women's Bodies in Nineteenth-Century America. Chapel Hill and London: U of North Carolina P, 2004. Santoni-Rugiu, Paolo, and Philip J. Sykes. A History of Plastic Surgery. Berlin: Springer-Verlag, 2017. Stephens, Elizabeth. “Twenty-First Century Freak Show: Recent Transformations in the Exhibition of Non-Normative Bodies.” Disability Studies Quarterly 25.3 (2005). <https://dsq-sds.org/article/view/580/757>.Wardi, Anissa Janine. “Freak Shows, Spectacles, and Carnivals: Reading Jonathan Demme’s Beloved.” African American Review 39.4 (Winter 2005): 513-526.Williams, Jessica L. Media, Performative Identity, and the New American Freak Show. London and New York: Palgrave MacMillan, 2017. Williams, Linda. “When the Woman Looks.” Horror, The Film Reader. Ed. Mark Jancovich. London and New York: Routledge, 2002. 61-66.

Abstract:

IntroductionFor over five years, Romanians have been using their bodies in public spaces to challenge politicians’ disregard for the average citizen. In a region low in standards of civic engagement, such as voter turnout and petition signing, Romanian people’s “citizenship of the streets” has stopped environmentally destructive mining in 2013, ousted a corrupt cabinet in 2015, and blocked legislation legalising abuse of public office in 2017 (Solnit 214). This article explores the democratic affordances of collective resistive walking, by focusing on Romania’s capital, Bucharest. I illustrate how walking in protest of political corruption cultivates a democratic public and reconfigures city spaces as spaces of democratic engagement, in the context of increased illiberalism in the region. I examine two sites of protest: the Parliament Palace and Victoriei Square. The former is a construction emblematic of communist dictator Nicolae Ceaușescu and symbol of an authoritarian regime, whose surrounding area protestors reclaim as a civic space. The latter—a central part of the city bustling with the life of cafes, museums, bike lanes, and nearby parks—hosts the Government and has become an iconic site for pro-democratic movements. Spaces of Democracy: The Performativity of Public Assemblies Democracies are active achievements, dependent not only on the solidity of institutions —e.g., a free press and a constitution—but on people’s ability and desire to communicate about issues of concern and to occupy public space. Communicative approaches to democratic theory, formulated as inquiries into the public sphere and the plurality and evolution of publics, often return to establish the significance of public spaces and of bodies in the maintenance of our “rhetorical democracies” (Hauser). Speech and assembly, voice and space are sides of the same coin. In John Dewey’s work, communication is the main “loyalty” of democracy: the heart and final guarantee of democracy is in free gatherings of neighbors on the street corner to discuss back and forth what is read in the uncensored news of the day, and in gatherings of friends in the living rooms of houses and apartments to converse freely with one another. (Dewey qtd. in Asen 197, emphasis added) Dewey asserts the centrality of communication in the same breath that he affirms the spatial infrastructure supporting it.Historically, Richard Sennett explains, Athenian democracy has been organised around two “spaces of democracy” where people assembled: the agora or town square and the theatre or Pnyx. While the theatre has endured as the symbol of democratic communication, with its ideal of concentrated attention on the argument of one speaker, Sennett illuminates the square as an equally important space, one without which deliberation in the Pnyx would be impossible. In the agora, citizens cultivate an ability to see, expect, and think through difference. In its open architecture and inclusiveness, Sennett explains, the agora affords the walker and dweller a public space to experience, in a quick, fragmentary, and embodied way, the differences and divergences in fellow citizens. Through visual scrutiny and embodied exposure, the square thus cultivates “an outlook favorable to discussion of differing views and conflicting interests”, useful for deliberation in the Pnyx, and the capacity to recognise strangers as part of the imagined democratic community (19). Also stressing the importance of spaces for assembly, Jürgen Habermas’s historical theorisation of the bourgeois public sphere moves the functions of the agora to the modern “third places” (Oldenburg) of the civic society emerging in late seventeenth and eighteenth-century Europe: coffee houses, salons, and clubs. While Habermas’ conceptualization of a unified bourgeois public has been criticised for its class and gender exclusivism, and for its normative model of deliberation and consensus, such criticism has also opened paths of inquiry into the rhetorical pluralism of publics and into the democratic affordances of embodied performativity. Thus, unlike Habermas’s assumption of a single bourgeois public, work on twentieth and twenty-first century publics has attended to their wide variety in post-modern societies (e.g., Bruce; Butler; Delicath and DeLuca; Fraser; Harold and DeLuca; Hauser; Lewis; Mckinnon et al.; Pezzullo; Rai; Tabako). In contrast to the Habermasian close attention to verbal argumentation, such criticism prioritizes the embodied (performative, aesthetic, and material) ways in which publics manifest their attention to common issues. From suffragists to environmentalists and, most recently, anti-precarity movements across the globe, publics assemble and move through shared space, seeking to break hegemonies of media representation by creating media events of their own. In the process, Judith Butler explains, such embodied assemblies accomplish much more. They disrupt prevalent logics and dominant feelings of disposability, precarity, and anxiety, at the same time that they (re)constitute subjects and increasingly privatised spaces into citizens and public places of democracy, respectively. Butler proposes that to best understand recent protests we need to read collective assembly in the current political moment of “accelerating precarity” and responsibilisation (10). Globally, increasingly larger populations are exposed to economic insecurity and precarity through government withdrawal from labor protections and the diminishment of social services, to the profit of increasingly monopolistic business. A logic of self-investment and personal responsibility accompanies such structural changes, as people understand themselves as individual market actors in competition with other market actors rather than as citizens and community members (Brown). In this context, public assembly would enact an alternative, insisting on interdependency. Bodies, in such assemblies, signify both symbolically (their will to speak against power) and indexically. As Butler describes, “it is this body, and these bodies, that require employment, shelter, health care, and food, as well as a sense of a future that is not the future of unpayable debt” (10). Butler describes the function of these protests more fully:[P]lural enactments […] make manifest the understanding that a situation is shared, contesting the individualizing morality that makes a moral norm of economic self-sufficiency precisely […] when self-sufficiency is becoming increasingly unrealizable. Showing up, standing, breathing, moving, standing still, speech, and silence are all aspects of a sudden assembly, an unforeseen form of political performativity that puts livable life at the forefront of politics […] [T]he bodies assembled ‘say’ we are not disposable, even if they stand silently. (18)Though Romania is not included in her account of contemporary protest movements, Butler’s theoretical account aptly describes both the structural and ideological conditions, and the performativity of Romanian protestors. In Romania, citizens have started to assemble in the streets against austerity measures (2012), environmental destruction (2013), fatal infrastructures (2015) and against the government’s corruption and attempts to undermine the Judiciary (from February 2017 onward). While, as scholars have argued (Olteanu and Beyerle; Gubernat and Rammelt), political corruption has gradually crystallised into the dominant and enduring framework for the assembled publics, post-communist corruption has been part and parcel of the neoliberalisation of Central and Eastern-European societies after the fall of communism. In the region, Leslie Holmes explains, former communist elites or the nomenklatura, have remained the majority political class after 1989. With political power and under the shelter of political immunity, nomenklatura politicians “were able to take ethically questionable advantage in various ways […] of the sell-off of previously state-owned enterprises” (Holmes 12). The process through which the established political class became owners of a previously state-owned economy is known as “nomenklatura privatization”, a common form of political corruption in the region, Holmes explains (12). Such practices were common knowledge among a cynical population through most of the 1990s and the 2000s. They were not broadly challenged in an ideological milieu attached, as Mihaela Miroiu, Isabela Preoteasa, and Jerzy Szacki argued, to extreme forms of liberalism and neoliberalism, ideologies perceived by people just coming out of communism as anti-ideology. Almost three decades since the fall of communism, in the face of unyielding levels of poverty (Zaharia; Marin), the decaying state of healthcare and education (Bilefsky; “Education”), and migration rates second only to war-torn Syria (Deletant), Romanian protestors have come to attribute the diminution of life in post-communism to the political corruption of the established political class (“Romania Corruption Report”; “Corruption Perceptions”). Following systematic attempts by the nomenklatura-heavy governing coalition to undermine the judiciary and institutionalise de facto corruption of public officials (Deletant), protestors have been returning to public spaces on a weekly basis, de-normalising the political cynicism and isolation serving the established political class. Mothers Walking: Resignifying Communist Spaces, Imagining the New DemosOn 11 July 2018, a protest of mothers was streamed live by Corruption Kills (Corupția ucide), a Facebook group started by activist Florin Bădiță after a deadly nightclub fire attributed to the corruption of public servants, in 2015 (Commander). Organized protests at the time pressured the Social-Democratic cabinet into resignation. Corruption Kills has remained a key activist platform, organising assemblies, streaming live from demonstrations, and sharing personal acts of dissent, thus extending the life of embodied assemblies. In the mothers’ protest video, women carrying babies in body-wraps and strollers walk across the intersection leading to the Parliament Palace, while police direct traffic and ensure their safety (“Civil Disobedience”). This was an unusual scene for many reasons. Walkers met at the entrance to the Parliament Palace, an area most emblematic of the former regime. Built by Communist dictator, Nicolae Ceaușescu and inspired by Kim Il-sung’s North Korean architecture, the current Parliament building and its surrounding plaza remain, in the words of Renata Salecl, “one of the most traumatic remnants of the communist regime” (90). The construction is the second largest administrative building in the world, after the Pentagon, a size matching the ambitions of the dictator. It bears witness to the personal and cultural sacrifices the construction and its surrounded plaza required: the displacement of some 40,000 people from old neighbourhood Uranus, the death of reportedly thousands of workers, and the flattening of churches, monasteries, hospitals, schools (Parliament Palace). This arbitrary construction carved out of the old city remains a symbol of an authoritarian relation with the nation. As Salecl puts it, Ceaușescu’s project tried to realise the utopia of a new communist “centre” and created an artificial space as removed from the rest of the city as the leader himself was from the needs of his people. Twenty-nine years after the fall of communism, the plaza of the Parliament Palace remains as suspended from the life of the city as it was during the 1980s. The trees lining the boulevard have grown slightly and bike lanes are painted over decaying stones. Still, only few people walk by the neo-classical apartment buildings now discoloured and stained by weather and time. Salecl remarks on the panoptic experience of the Parliament Palace: “observed from the avenue, [the palace] appears to have no entrance; there are only numerous windows, which give the impression of an omnipresent gaze” (95). The building embodies, for Salecl, the logic of surveillance of the communist regime, which “created the impression of omnipresence” through a secret police that rallied members among regular citizens and inspired fear by striking randomly (95).Against this geography steeped in collective memories of fear and exposure to the gaze of the state, women turn their children’s bodies and their own into performances of resistance that draw on the rhetorical force of communist gender politics. Both motherhood and childhood were heavily regulated roles under Ceaușescu’s nationalist-socialist politics of forced birth, despite the official idealisation of both. Producing children for the nationalist-communist state was women’s mandated expression of citizenship. Declaring the foetus “the socialist property of the whole society”, in 1966 Ceaușescu criminalised abortion for women of reproductive ages who had fewer than four children, and, starting 1985, less than five children (Ceaușescu qtd. in Verdery). What followed was “a national tragedy”: illegal abortions became the leading cause of death for fertile women, children were abandoned into inhumane conditions in the infamous orphanages, and mothers experienced the everyday drama of caring for families in an economy of shortages (Kligman 364). The communist politicisation of natality during communist Romania exemplifies one of the worst manifestations of the political as biopolitical. The current maternal bodies and children’s bodies circulating in the communist-iconic plaza articulate past and present for Romanians, redeploying a traumatic collective memory to challenge increasingly authoritarian ambitions of the governing Social Democratic Party. The images of caring mothers walking in protest with their babies furthers the claims that anti-corruption publics have made in other venues: that the government, in their indifference and corruption, is driving millions of people, usually young, out of the country, in a braindrain of unprecedented proportions (Ursu; Deletant; #vavedemdinSibiu). In their determination to walk during the gruelling temperatures of mid-July, in their youth and their babies’ youth, the mothers’ walk performs the contrast between their generation of engaged, persistent, and caring citizens and the docile abused subject of a past indexed by the Ceaușescu-era architecture. In addition to performing a new caring imagined community (Anderson), women’s silent, resolute walk on the crosswalk turns a lifeless geography, heavy with the architectural traces of authoritarian history, into a public space that holds democratic protest. By inhabiting the cultural role of mothers, protestors disarmed state authorities: instead of the militarised gendarmerie usually policing protestors the Victoriei Square, only traffic police were called for the mothers’ protest. The police choreographed cars and people, as protestors walked across the intersection leading to the Parliament. Drivers, usually aggressive and insouciant, now moved in concert with the protestors. The mothers’ walk, immediately modeled by people in other cities (Cluj-Napoca), reconfigured a car-dominated geography and an unreliable, driver-friendly police, into a civic space that is struggling to facilitate the citizens’ peaceful disobedience. The walkers’ assembly thus begins to constitute the civic character of the plaza, collecting “the space itself […] the pavement and […] the architecture [to produce] the public character of that material environment” (Butler 71). It demonstrates the possibility of a new imagined community of caring and persistent citizens, one significantly different from the cynical, disconnected, and survivalist subjects that the nomenklatura politicians, nested in the Panoptic Parliament nearby, would prefer.Persisting in the Victoriei Square In addition to strenuous physical walking to reclaim city spaces, such as the mothers’ walking, the anti-corruption public also practices walking and gathering in less taxing environments. The Victoriei Square is such a place, a central plaza that connects major boulevards with large sidewalks, functional bike lanes, and old trees. The square is the architectural meeting point of old and new, where communist apartments meet late nineteenth and early twentieth century architecture, in a privileged neighbourhood of villas, museums, and foreign consulates. One of these 1930s constructions is the Government building, hosting the Prime Minister’s cabinet. Demonstrators gathered here during the major protests of 2015 and 2017, and have walked, stood, and wandered in the square almost weekly since (“Past Events”). On 24 June 2018, I arrive in the Victoriei Square to participate in the protest announced on social media by Corruption Kills. There is room to move, to pause, and rest. In some pockets, people assemble to pay attention to impromptu speakers who come onto a small platform to share their ideas. Occasionally someone starts chanting “We See You!” and “Down with Corruption!” and almost everyone joins the chant. A few young people circulate petitions. But there is little exultation in the group as a whole, shared mostly among those taking up the stage or waving flags. Throughout the square, groups of familiars stop to chat. Couples and families walk their bikes, strolling slowly through the crowds, seemingly heading to or coming from the nearby park on a summer evening. Small kids play together, drawing with chalk on the pavement, or greeting dogs while parents greet each other. Older children race one another, picking up on the sense of freedom and de-centred but still purposeful engagement. The openness of the space allows one to meander and observe all these groups, performing the function of the Ancient agora: making visible the strangers who are part of the polis. The overwhelming feeling is one of solidarity. This comes partly from the possibilities of collective agency and the feeling of comfortably taking up space and having your embodiment respected, otherwise hard to come by in other spaces of the city. Everyday walking in the streets of Romanian cities is usually an exercise in hypervigilant physical prowess and self-preserving numbness. You keep your eyes on the ground to not stumble on broken pavement. You watch ahead for unmarked construction work. You live with other people’s sweat on the hot buses. You hop among cars parked on sidewalks and listen keenly for when others may zoom by. In one of the last post-socialist states to join the European Union, living with generalised poverty means walking in cities where your senses must be dulled to manage the heat, the dust, the smells, and the waiting, irresponsive to beauty and to amiable sociality. The euphemistic vocabulary of neoliberalism may describe everyday walking through individualistic terms such as “grit” or “resilience.” And while people are called to effort, creativity, and endurance not needed in more functional states, what one experiences is the gradual diminution of one’s lives under a political regime where illiberalism keeps a citizen-serving democracy at bay. By contrast, the Victoriei Square holds bodies whose comfort in each other’s presence allow us to imagine a political community where survivalism, or what Lauren Berlant calls “lateral agency”, are no longer the norm. In “showing up, standing, breathing, moving, standing still […] an unforeseen form of political performativity that puts livable life at the forefront of politics” is enacted (Butler 18). In arriving to Victoriei Square repeatedly, Romanians demonstrate that there is room to breathe more easily, to engage with civility, and to trust the strangers in their country. They assert that they are not disposable, even if a neoliberal corrupt post-communist regime would have them otherwise.ConclusionBecoming a public, as Michael Warner proposes, is an ongoing process of attention to an issue, through the circulation of discourse and self-organisation with strangers. For the anti-corruption public of Romania’s past years, such ongoing work is accompanied by persistent, civil, embodied collective assembly, in an articulation of claims, bodies, and spaces that promotes a material agency that reconfigures the city and the imagined Romanian community into a more democratic one. The Romanian citizenship of the streets is particularly significant in the current geopolitical and ideological moment. In the region, increasing authoritarianism meets the alienating logics of neoliberalism, both trying to reduce citizens to disposable, self-reliant, and disconnected market actors. Populist autocrats—Recep Tayyip Erdogan in Turkey, the Peace and Justice Party in Poland, and recently E.U.-penalized Victor Orban, in Hungary—are dismantling the system of checks and balances, and posing threats to a European Union already challenged by refugee debates and Donald Trump’s unreliable alliance against authoritarianism. In such a moment, the Romanian anti-corruption public performs within the geographies of their city solidarity and commitment to democracy, demonstrating an alternative to the submissive and disconnected subjects preferred by authoritarianism and neoliberalism.Author's NoteIn addition to the anonymous reviewers, the author would like to thank Mary Tuominen and Jesse Schlotterbeck for their helpful comments on this essay.ReferencesAnderson, Benedict R. Imagined Communities: Reflections on the Origin and Spread of Nationalism. London: Verso, 2016.Asen, Robert. “A Discourse Theory of Citizenship.” Quarterly Journal of Speech 90.2 (2004): 189-211. 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