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High-risk foods have been handled by the infected worker order 40 mg propranolol amex blood pressure chart conversion, but staff (including management) has received food safety training and use an approved hazard control system order propranolol 80mg fast delivery arterial duplex. Public notification is usually not indicated if the following conditions are met: a purchase 40 mg propranolol amex heart attack 6 fragger. High-risk foods have been handled by the worker who is ill and staff (including management) has not received food safety training and do not have an approved hazard control system cheap propranolol 40 mg free shipping blood pressure medication beginning with d. Notification of potentially exposed persons via the media should be considered if: a. This may not need to be anything other than a courtesy call, but ensures that the national implications of the outbreak investigation have been considered. This will be important for communication at a national level, and to facilitate the incorporation of the statutory authority of the Director-General of Health, if necessary. Ministry of Health representatives may also be best placed to manage communication with other government agencies, such as the Ministry for Primary Industries, the Ministry of Foreign Affairs and Trade and the Ministry of Education. Health workers The communication plan should include contingencies for communicating with local general practitioners, hospitals and other health services. Communicate with health workers either selectively, through predetermined contact points (i. Industry groups Communication with industry groups will depend on the nature of the outbreak and the stage of confirmation about the outbreak source. In general, make contact with industry groups only when there is a reasonable degree of certainty about the outbreak source, but try to make contact and provide a briefing before the general media become involved. As discussed in Chapter 9 on environmental investigation, state your suspicions and concerns precisely, without embellishment, and describe the plan for further investigation. If the industry group has national responsibility, it may be appropriate to involve the Ministry of Health, either to be party to discussions or to lead communications. Local authorities If local authorities (territorial authority or regional council) have jurisdiction over the type of setting for the outbreak, make sure that a representative has been contacted at an early stage. It may be appropriate to have a local authority representative as a member of the outbreak team. Debrief following outbreak investigation and response The completion of the outbreak investigation and response should be followed by a meeting to review the process. The focus of the meeting should be on critically examining aspects of the investigation that did and did not go well, with the aim of developing some constructive recommendations to improve future outbreak investigations. This debriefing meeting should involve all of the core outbreak team, and sometimes members of the outer team, for example, representatives from laboratories. The issues addressed and recommendations emerging from the debriefing meeting should be documented in an outbreak report, as described in Chapter 13. These matters could either be communicated directly, included in an outbreak report, or be published in a locally or internationally peer-reviewed journal. The aim of organisational debriefing is for staff to communicate their work related experience of an outbreak to their own team and to any others who may subsequently be involved in outbreak investigation (and control). This is necessary so that the strengths and weaknesses of the response can be captured and incorporated into planning and training in the pursuance of best practice, to enhance the organisation’s ability to respond optimally to future outbreaks. Three types of debrief are relevant, the ‘hot’ debrief, internal organisational ‘cold’ debrief, and multi-agency ‘cold’ debrief. Hot Debriefs The overall responsibility for ensuring the debrief takes place belongs to the Incident Controller for the outbreak. The key features include: Holding immediately after the outbreak response or shift (if a large outbreak) is completed Allows a rapid ‘off-load’ of issues and concerns Should address key health and safety issues Provides an opportunity to thank staff and provide positive feedback May be facilitated by a number of people in the organisation A number of hot debriefs may be held within the organisation simultaneously in each work area to identify key issues by area 12. Cold Debriefs The cold debrief should be organised within two to four weeks of the end of the outbreak by the Incident Controller for the outbreak. However, if the outbreak continues to be managed over the medium to long-term it may be necessary to hold regular internal organisational debriefs at key milestones. The key features of the cold debrief should: Involve the same key players who were involved in the response and other people the recommendations may impact Address organisational issues not personal or psychological issues Look for both strengths and weaknesses as well as ideas for future learning Provide an opportunity to thank staff and provide positive feedback (may like to put on a morning tea) Be facilitated by a range of people within the organisation Appoint an administration person to take minutes to allow all participants to participate fully 12. Multi-Agency Debriefs In the event of a multidistrict outbreak or where the outbreak response involved significant contribution from more than one organisation a multi-agency debrief will need to occur. The key features of the cold debrief should: Be held within six weeks of the outbreak. Public health units/agencies, followed by representatives contributing to a debrief of government agencies at a national level 12. Pre-Debrief Planning The following actions should take place to prepare for debriefing: Send invitations to all those involved Confirm attendees and set the length of the debrief depending on the number attending Confirm venue and set-up (around a table (preferable if numbers permit), seats in rows (if large group)) Create an agenda Create a feedback template Email debrief feedback template to all participants prior to the debrief meeting for completion and to formulate their thoughts and to handover for collation. Debrief Ground Rules It is important to set ground rules when undertaking a debriefing session to ensure the process and environment are safe for all participants and encourage active participation from all. Key features include: Conducting the debriefing openly and honestly Don’t interrupt other people as each person is entitled to their own opinion If the issue has already been identified there is no need to return to it No one person should monopolise the debriefing Be about organisational understanding and learning Be consistent with professional responsibilities Respect the rights of individuals Value equally all those concerned Be about learning not assigning blame. Debrief Agenda A successful debrief needs to be structured to make the most of the participants’ time and experiences. It is best to start with the positives, move on to what might have been done better and conclude with positive take home messages. Recommendations and Action Points Dealing with the output from a debrief should include the following: The minute taker should compete the minutes within 24-48 hours of the debrief and forward to the Incident Controller. Further Information Further information on Organisational Debriefing is contained in the Ministry of Civil Defence and Emergency Management ‘Organisational Debriefing’ document which can be accessed at the following link: http://www. Documentation of outbreaks and investigations High quality, comprehensive documentation of all recognised outbreaks is essential for any disease surveillance system because: national collection of outbreak data facilitates the recognition of relationships between events occurring in different areas of the country, such as the identification of widely dispersed outbreaks the reports can be used to convince health professionals and the public of the need for preventive measures documentation of outbreaks may be used to evaluate and improve prevention strategies it is rarely, if ever, possible to identify risk factors for disease from single, sporadic cases. Almost all risk factors are identified from investigations of outbreaks or groups of cases understanding of emerging diseases may be improved, especially modes of transmission and risk factors reports can be used as teaching aids for diseases and outbreak investigation, including identifying how future outbreak investigations may be improved outbreak investigations are generally improved through the discipline of systematic and comprehensive documentation local and national statistics on outbreak occurrence can more readily be compiled when a uniform approach to their recording is used it may be necessary for the fulfilment of international reporting requirements, especially if the disease is one where eradication is expected. Whether both levels occur in a particular investigation will depend on the extent of the outbreak and its investigation. Routine outbreak documentation Document preliminary and final outbreak data onto the Outbreak Report Form included in EpiSurv, the national notifiable disease database. Use the outbreak number assigned by EpiSurv for all food, water and other environmental samples submitted to the laboratory for analysis. The Outbreak Report Form in EpiSurv should be updated periodically as the investigation progresses. Completed Outbreak Report Forms are also used in the production of local and national statistics on outbreak occurrence, including causal agents, modes of transmission and risk factors. Level two documentation: the Outbreak Investigation Report A higher level of detail about the investigation can be documented in a formal Outbreak Investigation Report. These reports record the full details of the methods, results, discussion and recommendations from the outbreak investigation in a form suitable for wider distribution and possible publication. Preparation and dissemination of an Outbreak Investigation Report ensures that the investigation process is open for peer review, and that the findings can have an impact beyond the local circumstances. Outbreak Investigation Reports can be circulated directly among other agencies, or disseminated using pre-existing communication networks such as FoodNet, OzFoodNet and the New Zealand equivalent, http://www. Please attach a copy of all Outbreak Investigation Reports to the EpiSurv record so that details can be included in the monthly surveillance report and considered for inclusion in the New Zealand Public Health Surveillance Report. Coordinated outbreak control plans with detailed check lists whilst ideal have not been considered as being essential in the local situation. Conclusion This guidelines document presents a unified framework for outbreak management in New Zealand. The document builds substantially on previous sets of guidelines by adding sections on environmental and laboratory aspects of outbreak investigation to the section on epidemiology, and by describing outbreak management (control, communication and documentation). As such, the document encompasses the entire range of outbreak response activities. The title of the document has been changed to reflect more closely its particular focus on food- and water- borne outbreaks. The guidelines document also shows that the interrelationships between the different components of outbreak management do not necessarily occur in a linear and progressive sequence. Outbreak management must be adapted to the circumstances of each outbreak as it emerges.

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Chronic venous insufficiency is most com- monly encountered in the lower limbs as a result of thrombosis of the deep veins of the lower limbs buy propranolol 80mg cheap blood pressure 5332. The mildest form of venous insufficiency is mini- mal edema after prolonged standing discount propranolol 40 mg fast delivery arrhythmia medication. More clinically relevant is chronic venous insufficiency order propranolol 40mg otc hypertension occurs when, which presents as progressive leg edema buy 80mg propranolol mastercard blood pressure chart video, pruritic atrophic skin, a cyanotic limb, and chronic recurrent ulceration. Excess pressure on a normal or weakened 437 438 Part Two / Disease Management vessel wall predisposes the vessel to tortuosity. The likelihood of venous tortuosity is increased by pressure such as that which occurs with venous valvular incompetence or straining on defecation as in constipation. Impaired blood flow may result from partial or complete occlusion of the vessel lumen, most often caused by thrombosis. Preventing deep vein thrombosis reduces the risk of both varicose veins and venous insufficiency. The risk of thrombosis is increased by stasis, damage to the intima of the vessel wall, or increased blood coagulability. The aims of intervention are to prevent external occlusive pressure on the vessel wall, to improve venous tone, and to prevent blood coagulation. Good bowel habits are fundamental to decreasing the risk of hemorrhoids, constipation, and straining on defecation. Strategies include not suppressing the urge to defecate, a high fluid intake, and a fiber-rich diet. Good sources of dietary fiber include nuts, whole-grain products, fruits, and vegetables. Particularly good sources of insoluble fiber are figs, raspberries, dried fruit, and whole-grain cereals. Stone fruits, pineapple, and citrus fruits have good fiber content, as do cabbage, peas, beans, cauliflower, and brus- sels sprouts. An adequate total dietary fiber intake appears to be one that yields a stool of 200 to 250 g in one or two passes a day. Prunes and kiwi fruit, in addition to their fiber content, have other chemicals conducive to the regular passage of a soft stool. Omega-3 fatty acids are believed to be responsible for the prolonged bleeding tendency observed among Eskimos. A diet rich in fish oil, which favors decreased production of throm- boxane A2 and increased production of thromboxane A3 and prostaglandin I , inhibits platelet aggregation. Animal stud- ies have shown that flavonoids reduce neutrophil activation, mediate inflammation, and decrease soluble endothelial adhesion molecules. Symptoms of venous insufficiency have been reduced in patients receiving 300 mg of oligomeric proanthocyanidin complexes from grapeseed daily, and venous tone and low capillary resistance improved in patients receiving 150 mg. Pittler and Ernst13 concluded, from a sys- tematic review, that horse chestnut seed extract decreased the lower-leg vol- ume, reduced leg circumference at the calf and ankle, and lessened symptoms such as leg pain, pruritus, and feelings of fatigue and tenseness. The active constituents appear to be saponins (escin) and flavonoids, lipids, and sterols. Escin reduces the edema of inflammation by reducing capillary permeability and increasing capillary strength as determined by the petechiae test. Horse chestnut should only be applied to intact skin, and enteric-coated preparations are recommended to avoid gastric irritation. Its flavonoid content strengthens blood vessels, reduces capillary fragility, and helps maintain healthy circula- tion. Clinical trials support the topical use of arnica flowers (Arnica montana L) in chronic venous insufficiency to relieve muscle aches12 and bruising. Arnica flowers contain, among other substances, sesquiterpene lactones, flavonoids, and phenolic acids. Other herbal options are sweet clover (meliotus), which improves venous return and reduces edema, and ginkgo, which is also useful for circulatory problems. Ron Y, Wainstein J, Leibovitz A, et al: The effect of acarbose on the colonic transit time of elderly long-term care patients with type 2 diabetes mellitus, J Gerontol A Biol Sci Med Sci 57:M111-M114, 2002. MacKay D: Hemorrhoids and varicose veins: a review of treatment options, Altern Med Rev 6:126-40, 2001. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Despite having been used to increase vitality and as an immunostimulant for many years, conclusive data from clinical trials are lacking. Nonetheless, astragalus has demon- strated a wide range of immunopotentiating effects and has proven effica- cious as an adjunct cancer therapy. The root of the plant contains some unique flavones, including kumatakenin and 3′,7 -dihydroxy-4′ methoxyisoflavone, and their glucosides. Astragalus’ immunostimulatory properties lie, in part, in the saponins and polysaccharides present in the root. Astragalus enhances the cytotoxic- ity of natural and lymphokine-activated killer cells. Studies have shown that injected Astragalus membranaceus extracts enhance the antibody response to a T-cell–dependent antigen in normal, immunosuppressed, and elderly mice. This may explain its beneficial effects in angina and early heart failure and its energiz- ing effects in mice. Doses of 20 mg every 6 hours may be taken for bronchitis, and 445 446 Part Three / Dietary Supplements 200 mg twice a day for 3 weeks may be taken to boost the immune system. It may also benefit persons with ischemic heart disease, myocardial infarction, heart failure, or anginal pain by enhancing perfusion and reduc- ing free radical damage to the myocardium. The Chinese herb used for medicinal purposes should not be confused with locoweed, an American variant that is toxic to cattle. Sinclair S: Chinese herbs: a clinical review of Astragalus, Ligusticum, and Schizandrae, Altern Med Rev 3:338-44, 1998. Kurashige S, Akuzawa Y, Endo F: Effects of astragali radix extract on carcinogenesis, cytokine production, and cytotoxicity in mice treated with a carcinogen, N-butyl-N′-butanolnitrosoamine, Cancer Invest 17:30-5, 1999. Toda S, Yase Y, Shirataki Y: Inhibitory effects of astragali radix, crude drug in Oriental medicines on lipid peroxidation and protein oxidative modification of mouse brain homogenate by copper, Phytother Res 14:294-6, 2000. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Could this account for discrepancies detected between anecdotal and scientific reports of the efficacy of bilberry? A rich source of various flavonoids, bilberry is a particularly good source of antho- cyanins. These flavonoids are believed to improve perfusion, reduce capil- lary permeability, and enhance ocular health. Anthocyanins normal- ize capillary permeability and are more effective than bioflavonoids in decreasing edema after microvascular trauma. Although antho- cyanins have great biologic importance, it has been suggested that they have little pharmacologic significance. Cooking bilberries in water and sugar results in a 40% loss of quercetin, as does storing bilberries at 20˚ C for 9 months. Myricetin and kaempferol are even more susceptible than quercetin to depletion during storage. Bilberry has been used to enhance microcirculation, counteract venous insufficiency, and hasten vas- cular repair.

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There are buy generic propranolol 40 mg online iglesias heart attack, however quality 80 mg propranolol blood pressure 40 year old woman, several valid enormous generic propranolol 40 mg with visa arterial blood pressure, particularly in high income countries with concerns generic propranolol 40mg on-line arrhythmia research technology. Disability weights will be affected by choice Perhaps the most important limitation arises from the of respondents used to determine them. The information provided about the health states, exercise have pointed out, the weights were developed and the precise wording of the vignettes used to using a robust methodology that was approved in describe each of the health states is likely to have advance by the expert groups, who themselves drafted an important impact upon respondent perceptions. For example, they may forget been highly infuential in setting national, regional and that their daughter had visited the previous intergovernmental priorities for policy development and day, or when or whether they had taken their investment in health care. They are likely to feel bewildered, selected explicitly on the basis of their contribution to anxious and sad. Only early memories are past for failing to align its budgetary allocation to retained. They may not know the day, the identifcation of cardiovascular disease, diabetes, date or time of day. They cannot communicate high-level meeting on non-communicable disease clearly, having problems fnding the right word prevention and control, and the acknowledgment that; and using the wrong words. They may hear “Mental and neurological disorders, including voices or see things that are not there, and can Alzheimer’s disease, are an important cause develop false beliefs, for example that children of morbidity and contribute to the global non- are entering their house and stealing things. They communicable disease burden, for which there are likely to be anxious, sad, bewildered, and can is a need to provide equitable access to effective become agitated or aggressive. They may no longer recognise Global Burden of Disease estimates have also been their close family. They have severe speech used to hold governments and other bodies to account diffculties or are unable to communicate. They for the rationality of allocation of research grant funding(23-25), and the generation of research evidence may be apathetic and totally inactive, but at through clinical trials(26) and Cochrane systematic times can be agitated and verbally and physically reviews(27). They cannot coordinate their physical movements; may have lost the ability to walk and feed themselves and have diffculty swallowing. Perhaps the most signifcant issue is the way in upon disability, needs for care, and attendant societal which the questions were framed. This limitation is most evident for older were asked to compare two health states, and decide which person was ‘the healthier’, not ‘the people, among whom most of these needs arise, and least disabled’, nor ‘the best able to function for conditions such as dementia, vision and hearing independently’. The ‘evidence test’ is much more important One approach would be simply to stop using currently than the ‘common sense’ test referred to earlier. Dementia and cognitive impairment are by far the An alternative approach would be to incorporate leading chronic disease contributors to disability, direct survey assessments of activity limitation, and and, particularly, needs for care (dependence) participation restriction derived from information among older people worldwide. The need for support from a caregiver often directly measured disability, dependence, and cost starts early in the dementia journey, intensifes as Table 5. Moving into a care home is generally a marker of population-based surveys carried out by the 10/66 particularly high needs for care, although other Dementia Research Group have shown clearly that factors can be involved. Other attest to the leading contribution of dementia and/ chronic conditions including arthritis, lung disease or or cognitive impairment to prevalent or incident cardiovascular disease did not show any signifcant disability, controlling for comorbidity with other association. Therefore, the current and future costs of long-term caregivers of people with dementia were more likely care will be driven to a very large extent by the than caregivers of people with other conditions coming epidemic of dementia(29). Our success in to be required to provide help with getting in and designing and implementing successful strategies out of bed (54% vs. These fndings were confrmed social care costs, currently rising inexorably in the in reports from the 10/66 Dementia Research context of population ageing. The enormous global societal costs of dementia among those needing care, those with dementia were estimated in the World Alzheimer Report stood out as being more disabled, as needing more 2010, and these estimates have been updated to care (particularly support with core activities of 2015 in the next chapter. There have been relatively daily living), and as being more likely to have paid few attempts to compare dementia costs with caregivers - dementia caregivers also experienced those of other chronic diseases. Another proxy indicator of the relevance of dementia combined costs of cancer (£12bn), heart disease to dependence is the extent to which older people (£8bn) and stroke (£5bn)(43). Dr Zhaorui Liu carried out such were more than twice as likely as others to receive an analysis using data from the 10/66 Dementia paid home care, and used the services twice as Research Group baseline surveys in Latin America, intensively as did cognitively normal users of paid India and China (Table 5. Medical care costs for dementia were negligible, refecting limited access to services, but 1 The Global Burden of Disease. A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in dementia costs dominated for social care, informal 1990 and projected to 2020. Global Burden of Disease 2004 Update: Disability Weights for Diseases and Conditions. Geneva: to provide information about the contribution of World Health Organization; 2004. Common values in assessing health outcomes from estimates fail to refect the societal impact of dementia, disease and injury: disability weights measurement study for the relative to other chronic diseases and, as such, cannot Global Burden of Disease Study 2010. As Dr Margaret Chan, Director- disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet 2012 December General of the World Health Organization, expressed 15;380(9859):2129-43. Cross- national agreement on disability weights: the European Disability “I can think of no other disease that has such Weights Project. The burden of disease in older people and burden on families, communities, and societies. Lancet 2015 February I can think of no other disease where innovation, 7;385(9967):549-62. Prevalence of cognitive Burden to “Best Buys”: Reducing the Economic Impact of Non- impairment and associated factors among elderly Hong Kong Communicable Diseases in Low- and Middle-Income Countries. Disability weights for vision in the Dominican Republic; a cross-sectional survey. Institutionalization in the elderly: the role of chronic High-level Meeting of the General Assembly on the Prevention diseases and dementia. Cambridge: Alzheimer’s Research by the National Institutes of Health and the burden of disease. N Engl J Med between the burden of disease and research funding by the 2013 April 4;368(14):1326-34. Australian samhällskostnader och antalet dementa i Sverige 2005 (The clinical trial activity and burden of disease: an analysis of societal costs of dementia and the number of people with registered trials in National Health Priority Areas. Alignment of systematic reviews published in the Cochrane Database of Systematic Reviews and the Database of Abstracts and Reviews of Effectiveness with global burden-of-disease data: a bibliographic analysis. The contribution of chronic diseases to the prevalence of dependence among older people in Latin America, China and India: a 10/66 Dementia Research Group population-based survey. The impact of somatic and cognitive disorders on the functional status of the elderly. Dementia is the major cause of functional dependence in the elderly: 3-year follow-up data from a population-based study. Costs are estimated at the country level and (3) then aggregated in various combinations to summarise published as a scientifc paper , have been widely worldwide cost, cost by Global Burden of Disease cited, generally accepted, and infuential in raising world region, cost by World Bank country income awareness of the scale and impact of the current level (high income, upper middle income, lower middle global epidemic*. For each country there is a prevalence of dementia have changed for some cost per person (per capita) estimate which is then regions, and the numbers affected have increased multiplied by the number of people estimated to be for all regions in line with the increase in the older living with dementia in that country. For the 2010 report, there was only one published cost of illness study from Latin America(12), which was These new estimates should be considered to be a used for imputation of estimates across the region. They do beneft from a fully information from Latin America considerably, making systematic review of the prevalence of dementia, and numbers affected (see Chapter 2). For further a fully systematic review of service utilisation and cost details and discussions of the principles for imputation, please see the 2010 report. The assumption between 2010 and 2012 were applied between 2010 to for the imputation is that there is a relationship 2015). These proportions were used estimates as a basis for imputation in many Asian and African Besides the updated estimates of prevalence and countries. The 2010 estimates impact on costs of the changes in numbers of people based on the original prevalence estimates from the affected. We present the estimated costs in 2030 as well as an estimate of the date when global our 2010 estimate of 1.

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Today discount propranolol 80 mg amex blood pressure medication that starts with c, arts and health programs continue to grow both in number and scope as they focus on promoting well-being and enhancing quality of life in the broadest sense for both individuals and communities purchase propranolol 80mg with amex white coat hypertension xanax. Community Partnership for Arts and Culture 10 Creative Minds in Medicine case study cleveland clinic arts and medicine institute At Cleveland Clinic cheap 40 mg propranolol fast delivery blood pressure kiosk machines, board-certifed music therapists treat patients to improve symptoms and conditions associated with illness and injury cheap propranolol 40mg visa blood pressure chart in hindi. Music therapy has been shown to decrease pain and anxiety, and improve quality of life, mood, and speech. Photo by Kulas Foundation & Taxel Image Group, 2008 Community Partnership for Arts and Culture 11 Creative Minds in Medicine lifing the spirit You expect to see and feel certain things when you go to the hospital: white coats; cold stethoscopes; hard, sterile, gleaming surfaces; worry. You don’t generally expect to fnd musicians playing there or spaces flled with colorful art. The surprise you get when you walk into the arts-flled Cleveland Clinic may be part of your treatment. The Arts and Medicine Institute was formed in 2008 to build on Cleveland Clinic’s solid tradition of mixing art with health care, she says. Since its founding in 1921, Cleveland Clinic has been known for displays of fne art on its walls and of artistic talent from its employees. With the Institute in place, arts of all kinds have become an offcial part of Cleveland Clinic’s health mission and programming, explains Maria Jukic, executive director of Arts and Medicine. To the organization’s original ends of featuring art in the medical facility so that patients’ experiences there will be more pleasant, two more aims have been added: The Institute’s purpose is also to engage in, and scientifcally research, the use of arts in medical practice at the Clinic, especially art and music therapy, and to build community around arts, health, and medicine. Those goals have allowed the Clinic’s range of arts therapies and programs to expand and deepen: Jukic and her colleagues are making more art available on Clinic campuses, fnding more ways of using it to heal, and identifying more people who need its good effects. And art improved their few things take you out of yourself or cheer you up faster than an unexpected delight: mood. Jukic calls it “normalizing,” a process art can create that helps people feel more in control, less fearful. True, the sick remain the Clinic’s central concern and patients are measurably benefting from the presence of art and musicians – a 2012 Clinic survey found 91 percent of patients responding reported that visual art improved their mood during hospital stays of two to three days. Community Partnership for Arts and Culture 12 Creative Minds in Medicine But pictures, concerts, and arts therapies also soothe the stressed-out families of the sick, refresh the Clinic’s hardworking staff members, and engage and enlighten the public. That program, which focuses on visual art, manages Cleveland Clinic’s existing art collection, This is something and adds to that collection by commissioning and acquiring new pieces. Many of the programs and works of art have been subsidized by donations from grateful patients and visitors to Cleveland Clinic. Committees of experts including curators select the pieces to be bought and/or displayed. The quality of the art selected must be high, says Cohen, because it needs to stand the test of time. Those who choose the art aim for eclectic media and subject matter, because Cleveland Clinic has a global reach, and staff and patients from all over the world. It wants to refect those many different viewpoints, which is also “far more interesting and engaging to a diverse population” across Cleveland and other geographic areas, she adds. Yet the something-for-everyone approach does contain one other qualifcation: Cleveland Clinic art needs to have something positive to say about the human condition and spirit. Art that’s collaborative and/ or environmentally conscious, art that calms, comforts, amuses or uplifts – these are the kinds of images and objects that contribute to healing. Water, landscapes, sunlight – such subjects tend to mellow people’s moods and brighten their outlooks. Cohen says that one of Cleveland Clinic’s most successful pieces is a video by Jennifer Steinkamp of a tree that went through seasonal changes. Displayed in the cardiovascular Jennifer Steinkamp’s video installation, “Mike Kelley 1,” 2007, evokes many reactions from patients, families and employees. Others danced in front of it, and the wall had to be repainted frequently because so many viewers tried to touch and hug it. They can also help decrease the amount of staff turnover by making the workplace less stressful. So there are economic benefts to having an arts program – but the value of the Arts and Medicine Institute is much greater than that, Fattorini says. Photo by Cleveland Clinic Photography Below: Docents lead tours of the Cleveland Clinic art collection several times per week. Patients suffering from memory loss and their caregivers enjoy a special tour program monthly. Photo by Jim Lang Community Partnership for Arts and Culture 14 Creative Minds in Medicine the intersection of arts and health What is the Arts and Health Intersection? From writing poetry or playing music with friends to taking photos or experiencing theater, arts and culture serve as outlets for individual learning, expression and creativity. Participation in arts and culture has been shown to yield positive cognitive, social and behavioral outcomes for human development and for overall quality of life throughout the human lifespan. For the arts and culture sector, such outcomes have traditionally been discussed from two different, but not mutually exclusive, viewpoints: the more subjective, individual benefts of arts and culture; and the more practical community-wide benefts. Because of its ability to span both personal and public spheres in varying degrees, arts and culture participation can yield far-reaching results. At another level, the paintings can be developed into public murals that call attention to areas or issues in need of improvement. Even further, the paintings can become an exhibition that rallies the broader community, encouraging it to take actions that address neighborhood challenges. In this way, a multifaceted view of impact is critical to develop a full understanding of the ways in which arts and culture infuence the human condition on a personal and global scale. In a similar way, an inquiry into the nature of the arts and culture / health and human services intersection (referred to hereafter as the “arts and health” intersection, for simplicity) requires4 a multifaceted approach. In this general sense, the terms “arts” and “health” can be ambiguous because their defnitions are dependent on the manner through which they intersect. Defnitions are ultimately determined by who is participating in the arts and health intersection, where the intersection takes place and what the intersection’s goals are. Clinical outcomes in physical and mental health, improved health and human services delivery and personal enjoyment of arts and culture all exist on the continuum of this creative intersection. Artistic practice commonly challenges convention, organically develops new methods and accepts subjective outcomes, while protocols for health practice and clinical outcome measurement demand greater rigidity. In these ways, arts and culture have the10 ability to span multiple disciplines and be applied through a wide range of methods. This ability makes arts and culture interventions useful in responding to the unique needs and concerns of individuals that arise in multiple healthcare situations. Arts and Health in Cleveland Cleveland is fortunate to be home to world-class sets of healthcare and cultural institutions. Both of these sectors were formed in response to the industrialization of Cleveland’s economy, which grew rapidly during the 19th and 20th centuries, greatly increasing the area’s urban population and fnancial resources. With those resources, wealthy industrialists funded the development and endowment of numerous cultural organizations, greatly improving quality of life for the growing numbers of Cleveland residents. The resulting growth of the local healthcare industry led to advances in medicine and the establishment of boards of health and other certifcation agencies which, in turn, promoted the creation of more health education resources. These assets, along with Cleveland’s location on key transportation routes, helped the city’s medical community grow into one of the most notable metropolitan healthcare sectors in the world. Meanwhile, Cleveland’s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for both local and international audiences. The Framework of this White Paper While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices illustrating the many ways in which arts and culture contribute to healthcare practice and human services delivery:11 • Arts integration in healthcare environments. The infusion of arts and culture in, or the design of, settings where healthcare and medical treatment are given to individuals.

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