In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses.This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients’ terminal status.Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies  and finally by the leadership of individual hospitals. In Israeli hospitals, the Ministry of Health (MOH) policy of inadequate reimbursement for Intensive Care Unit (ICU) admissions has led to a paucity of ICU beds, and the rate of these per 1000 hospital beds is among the lowest in OECD countries  On the oIn the article by Zisk-Rony et al. , which rThe Israel Medical Association should definitely submit to the MOH a demand for an increased percentage of ICU beds out of all hospital beds. However, in this country almost all medical departments are obliged to house multiple patients in hallways on a daily basis because of underfunding for these departments. An increase in the country’s medical budget will probably first lead to an increase in general medical bed availability. Therefore, this paper assumes that no change in ICU reimbursement will occur in the near future. We will discuss several practical as well as controversial solutions to this serious clinical, financial and ethical challenge facing the Israeli medical system and society at large Table .Table 1Thttps://www.ima.org.il/mainsite/ScientificCouncil.aspx)”. Several studies have demonstrated which critically ill patients would benefit from care in these augmented care units [First, most Israeli hospitals have responded to the rise of critically ill patients, included ventilated patients, for whom an ICU bed is unavailable, by setting up an augmented care room in medical departments . Howeverre units –12. As hre units , the absSecond, Zisk-Rony et al.  briefly https://theconversationproject.org/)”, [Community-based physicians in Israel do not initiate talks as a matter of routine with all their elderly and/or ill patients about end-of-life issues. We could draw inspiration from the American “conversation project” as well as from Atul Gawande’s book Being Mortal “(.org/)”,  about thAll of the above is possibly not sufficient or attainable in the near future. Therefore, it seems that Zisk-Rony et al.  have setPhysicians are acutely familiar with the principle “primum non nocere” , but we occasionally fail to recall that the oath ascribed to Hippocrates includes a commitment not to over-treat patients who are “overmastered by their disease”. Terminal extubation indicates the withdrawal of mechanical ventilation from patients who are not expected to regain independent respiration. In these patients, mechanical ventilation is prolonging the patient’s dying process and removing it at the patient’s or their surrogate’s request, allows nature to follow its course.Schloendorff v. Society of New York Hospital, 105 N.E. 92 (N.Y. 1914), the principle of “respondeat superior” was established in US law. In this case, Mary Schloendorff from San Francisco was admitted to New York Hospital to evaluate a stomach disorder. A fibroid tumor was diagnosed and surgical removal recommended, which Schloendorff adamantly refused. She consented to an examination under anesthesia, during which the doctors removed the tumor. Afterwards, Schloendorff developed gangrene of the left arm. Schloendorff sued, and won. Justice Benjamin Cardozo wrote in the Court’s opinion: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained” [Only in 1914 after the famous case of btained” –19.Karen Ann Quinlan. This young woman lost consciousness and stopped breathing after a party. Medical intervention saved her life, but a lack of oxygen left her in a persistent, vegetative state. After several months without change in her condition, Karen’s parents requested the removal of their daughter’s ventilator. The hospital, together with the Quinlans, commenced a legal battle against the Morris County, New Jersey, prosecutor over whether the withdrawal of life support constituted homicide. On March 31, 1976, in a landmark decision, the New Jersey State Supreme Court ruled (7–0) and acknowledged the right of a patient to refuse even life-sustaining treatment and that right still stands even if the patient loses capacity. The ruling also emphasized the importance of the local ethics’ committees in these conflicts [The notion that this principle also applies to life-sustaining treatment emerged only in 1976, in the case of onflicts , 21.Barber v. Superior Court a patient called Herbert suffered cardiac arrest and went into coma. Two physicians determined that Herbert had sustained significant brain damage and the chance of recovering was deemed extremely small. This information was conveyed to Herbert’s family and upon their request, the respirator was removed. The two involved physicians were charged with murder but were eventually acquitted [Another important case, relevant to the issue of mechanical ventilation in medical departments raised by Zisk-Rony et al. , was brocquitted . This caThese cases and others, combined with the ability of medical treatment to prolong life but not necessary to improve the quality of life, has led to an increased interest  about futile medicine. The Annals of Internal Medicine has published a set of criteria for “medical futility” . AccordiOne of us has witnessed terminal extubation during a fellowship in the US in the early 1990s and vividly remembers the associated emotional and moral shock, also expressed by others  that docThe policy changes suggested in this paper could lead to a change from a “necessary evil” situation to one that could be considered a “blessing in disguise”. Rather than refraining from intubation if there is no ICU bed available – as practiced in many western countries – or from being overly compliant with family demands “to do everything” – as currently happens in Israeli hospitals - we would enter a new era in which mechanical ventilation in elderly, chronically ill patients is limited to patients with a reasonable chance for recovery, who can expect to receive better care than is currently available in medical departments.


Much discussion about mental health has revolved around treatment models. As interdisciplinary scholarship has shown, mental health knowledge, far from being a neutral product detached from the society that generated it, was shaped by politics, economics and culture. By drawing on case studies of yoga, religion and fitness, this article will examine the ways in which mental health practices—sometimes scientific, sometimes spiritual—have been conceived, debated and applied by researchers and the public. More specifically, it will interrogate the relationship between yoga, psychedelics, South Asian and Eastern religion (as understood and practiced in the USA) and mental health. San Franciso Oracle put it in 1965: ‘Yoga and psychedelics. Different means, same end’ .During the 1960s countercultural movement, many Americans saw yoga and psychedelic drugs as equally valid routes to spiritual fulfilment and mental health. As the Americans were receptive to novel thinking and practices in the 1960s. Ecologism, conservationism, vegetarianism, veganism and yoga all came to the fore .et al have pondered, then this article should be regarded as a contribution to alternative health.Contemporarily, positive accounts of mental health services gave way to increasingly critical approaches. ‘American psychiatry seems to be in a state of confusion’, was what many people felt, and psychiatrists themselves had become ever more ‘sceptical’.Raja Yoga.Yoga captivated certain Americans as far back as the middle of the 19th century. Henry David Thoreau famously called himself a yogi in 1849. Others were intrigued by the supernatural possibilities of ‘human hibernation’, levitation or simply the opportunity of enhanced sexual powers. Yoga was a niche pursuit at this time, to put it mildly. In 1893, Swami Vivekananda, a monk from Calcutta, advertised India and Hinduism at the Parliament of the World’s Religions in Chicago. At the same time, he introduced yoga to a greater number of Americans. He subsequently toured the USA delivering lectures promoting his book Asanas, a book that showcased yoga postures for a wider audience. However, it was Swami Sivananda, an Indian yogi, who truly commercialised yoga in the West through his English-language publications and Divine Life Society in the 1930s.By the early 1920s, Pierre Bernard, known as ‘The Omnipotent Oom’, and Blanche DeVries opened the Clarkstown Country Club in Nyack, New York, for the upper crust of the Northeast. Yoga constituted part of a programme that focused on ‘health and well-being rather than…religious practice’.and its dangers.Scientists and medical practitioners took an interest in the exotic practice too. Sivananda drew the attention of academics like Dr Kovoor T Behanan of Yale University, who spent a year in India at Gune’s ashram studying the practice before returning to New Haven to assess his findings.Hatha Yoga: The Report of a Personal Experience was published in 1947, which served as a ‘major sourcebook’ for yogis in the 1950s.In the late 1940s and early 1950s, yoga studios opened shop across the USA, from Hollywood to New York. The marketplace began to offer multiple varieties to cater to American consumers, offering up choices that addressed both mind and body. Theos Bernard’s Interest in the spiritual aspects of yoga, and Eastern religion in general, should not be understated. It tacked closely to the 1950s–1960s psychedelic revolution .The Wretched of the Earth in 1968, while Thomas Szasz, another critic, published Law, Liberty, and Psychiatry that same year. Socially conscious psychiatrists in the APA coalesced during the annual convention in Boston and underlined issues of war, race, class and gender. They voiced concern about how breakthroughs in military hardware, advancements in human rights activism and the rising automation of Western civilisation affected Americans’ mental health.Yoga and psychedelics flourished against the backdrop of fluctuating mental health practices and 1968 was certainly an important year. It ‘rocked the world’, ‘changed everything’ and ‘made us who we are’.American Journal of Psychiatry and Psychiatric News disapproved of its use. The era of psychedelic medicine was drawing to a close. Authorities in the UK moved against LSD and in 1966 it was made illegal. Medical use also stopped and was prohibited by the Misuse of Drugs Act when it came into force in 1973. LSD was banned in the USA in 1968. The British Journal of Psychiatry (BJP), for its part, was engaging with the major debates of the time. The October 1968 issue evaluated LSD. BJP’s focus on this mind-expanding drug, among others, represented evolution in sociomedicine and a free marketplace of ideas in which yoga and psychedelics might flourish as an alternative.Drugs were a vital part of the era. In 1968, a series of articles in mainstream psychiatry debated the dangers of cannabis, linking it to psychosis.Psychedelics, between the 1940s and 1970s, seemed like the next frontier in psychiatry and self-awareness. Research and experimentation flourished. LSD, in particular, ‘spawned a global interest in the cross-cultural dimensions of hallucinogens’ during the 1950s .Mysticism constituted a central part of the psychedelic credo .everything is miraculous’. He encouraged his patients to work towards ‘plateau experiences’, or extended periods of serenity, as opposed to transitory peak experiences. One had to expend energy for these states ‘through conscious, diligent effort’Another significant thinker behind the psychedelic credo was Abraham Maslow. A proponent of self-realisation, he agreed that psychedelics had potential, but worried they might cause harm to users’ mental health.Psychotherapeutic models advocated by Maslow (and others) negotiated with countercultural alternatives. From the 1960s, ‘travellers on the hippie trail ended up in Indian ashrams’ and generated enthusiasm for Indian religion and yoga.The heady mixture of psychedelics and yoga was also driven at the institutional and individual level. The famous Esalen Institute, near Big Sur, California, was founded in 1962 by Stanford graduates Michael Murphy and Richard Price. It encouraged the development of ‘human potential’ by offering clients Eastern-influenced spiritual lessons in yoga and other disciplines like gestalt, transactional analysis and reflexology .Be Here Now, reflected this view, which pooled all manner of religious traditions with yoga and psychedelics .Murphy was inspired to found Esalen by Sri Aurobindo, an Indian philosopher and yogi. He had spent several months at the guru’s retreat in Pondicherry, where he absorbed Aurobindo’s cocktail of Eastern and Western thought that combined yoga and psychology. It was a perfect fit for what Murphy and Price wanted in California. These were ideas that would allow individuals to explore their human potential and spirituality. Yoga in particular, claimed Aurobindo, could ‘bring down a divine nature and a divine life into the mental, vital and physical nature and life of humanity’ .For instance, Jack Kornfield, a clinical psychologist and Buddhist teacher, recalled his initial encounter with psychedelics after studying Eastern religion at Dartmouth College. ‘The majority of Western Buddhist teachers’, he noted, ‘used psychedelics at the start of their practice’ in the 1960s. This was because drugs served as a shortcut on the path to the Buddhist heights only attainable through yoga, prayer and meditation .What did spiritual-seekers experience? Who were they? And what was it they were looking for? Researchers highlighted several shared aspects of the ‘psychedelic experience’, as reported by drug-takers. These included unity with the subject’s self; insight into objectivity and reality; transcendence of space and time; a sense of sacredness; a deeply felt positive mood; an awareness of paradoxicality; the ineffability of describing mystical consciousness; the transience of subjectivity and experience and positive changes to attitude and behaviour. Yogis, interestingly, had also reported such phenomena .on the drugs…they were meditating for hours on end…And they weren’t plebeians. Intellectually they were aristocrats…’ .As for the identities of the spiritual-seekers, many came from privileged backgrounds and took full advantage of their college years to transform themselves from the inside out. Students in Cambridge, Massachusetts took seriously New-Age beliefs and practices. They began ‘with Asian philosophy’, and tried meditation, then yoga. ‘And underlying everything’, according to one witness, was psychedelic drugs. ‘They were To their proponents, however, psychedelics were as essential in their ‘spiritual seeking’ as yoga. Even Eastern-trained individuals noticed the symmetry of experience in religious practices and psychedelic experimentation and suggested the latter might be spiritually beneficial.Psychedelic Review article, for example, clearly illustrated the dangers of the drug-taking pathway. John Blofeld, a yogi living in Bangkok, had read Aldous Huxley’s claim ‘that mescaline can induce yogic experiences of a high order’. While sceptical, Blofeld took the drug under supervision at his home and recorded his experiences in a phenomenological fashion. After a short period of pleasantness, he had ‘the sensation of a rapidly fragmenting personality’ and his ‘mental stress grew agonising’. Blofeld felt as though he was a ‘disembodied sufferer’ and that ‘Hell itself could hardly be more terrifying’ than his experience. Then the direction shifted. ‘From hellish torment’, he recounted, “I was plunged into ecstasy”. He felt the ‘undifferentiated unity’ of the world, ‘unutterable bliss’ and an awareness of ‘the Buddhist doctrine of dharmas’. He was confounded about how ‘a dose of mescaline can make such an experience possible to someone who has not yet attained it by the profound and prolonged practice of yogic meditation…’ As a yogi, he noted that a drug might produce a ‘mystical and perhaps quasi-religious’ altered state of consciousness.Pushback against syncretism emanated from multiple directions. A 1966 dharma. Worse still, they might be dangerous .While risk/reward tensions were present from the start, in the later 1960s several thinkers began to disavow the syncretic use of psychedelics entirely. The pushback to yoga and drugs centred on arguments about the cultural appropriation of Eastern spiritual language and metaphors. Yoga gurus with ‘large American followings’, writes Stefanie Syman, regularly ‘dismissed psychedelics…and frowned on any mingling of drugs and discipline’ .Cannabis sativa is the preferred sacrament of this church; although psychedelics (and even wine) may sometimes be used’.A notable example was the Psychedelic Venus Church in California, which built drugs , into all of its religious activities. Promotional materials called it a ‘pantheistic nature religion of hedonism’ and in an ironic message deemed ‘Official Dogmatic Bombast’, declared that ‘Nelly Heathen, the major but short-lived periodical of the church, readers were exposed to erotic imagery, lessons about getting high and the value of yoga. Indeed, a section was devoted entirely to yoga. Versions of Ravi Kumar’s Tantra Asanas were printed, highlighting that ‘energy centres containing latent psychic powers’ could be unlocked with sex and yoga. Here, breathing techniques were emphasised. Other articles asked ‘Are the Hindu Gods destructive?’ and ‘Are we being Easternized?’ In a third article, ‘True Hedonism’, the author suggested that yoga was a panacea for mind and body, as well as a mode of pleasure. ‘Yoga provides two paths to True Enlightenment. The easier way involves discipline and denial. The other way, through pleasure, is considered much more difficult because it is so easy to get lost’. When combined with other Venus Psychedelic Church practices, with its leaders acting as guides, the article ended with a question: ‘what could be more pleasant than true hedonism’.In harmful’ for the spirit, according to Baba, and he believed such substances should only be used ‘when prescribed by a professional medical practitioner in the case of serious mental disorder under his direct supervision’. LSD, for example, had many practical applications, but to reach the divine there was no synthetic shortcut. Mental health treatments were not, in Baba’s view, to be used for spiritual ends. Only through love of, and unity with, God can one attain spiritual progress, he espoused.substitute gratification for psychedelic trips’ and was extremely attractive to former drug users versed in Eastern religion. Baba’s poses, that is, acted as surrogate pills; both were designed to enhance ‘self-insight’ and ‘consciousness expansion’.Meher Baba, a Sufi spiritual teacher in India, who was highly critical of Leary, Blofeld, and groups like the Venus Church, served as a critic of the undermining of traditional practices. In 1966, he penned the antipsychedelic tract ‘God in a Pill?’, where he described LSD, mescaline and psilocybin-fuelled ‘spiritual’ experiences as ‘superficial’. He also described notions of consciousness expansion as illusory. Psychedelics were ‘positively After all, getting ‘highs’ from God, meditation and yoga was easier to integrate into daily life than ‘incapacitating…chemical highs’.Wilson Van Dusen, the Chief Clinical Psychologist at Mendocino State Hospital in Talmage, California—later home to the Buddhist community and monastery The City of Ten Thousand Buddhas—agreed that ‘satori (enlightenment) is better attained by years of meditation’ than by an LSD trip. While Van Dusen ‘would prefer years in a quiet monastery’ to the immediate encounter with the divine afforded by drugs, he admitted that this was not an option for everyone, especially in the USA:But, in the Western world at least, we don’t have the time. It is curious that a fast approach should come out of Western chemical laboratories! Yet, if LSD is rejected in favor of meditation because the latter is natural and the former not, I can’t agree. In the view of Zen this is a foolish distinction. The Lord designed LSD and LSD experimenters and LSD experience just as much as He designed monasteries and sitting meditation. It does look as though the slower way of Zen meditation lays a more solid foundation, though this needs to be tested too…Personally, if enlightenment could be obtained by sitting in cow dung with ashes on my head, I would do it.Although critical of some aspects of psychedelic users claiming spiritual growth, Van Dusen could not deny the need for enlightenment in America. Even ‘sitting in cow dung’ was better than nothing.For right-leaning commentators, and in the run-up to the formal declaration of a War on Drugs, in 1971, the preceding decade had inaugurated an ‘epidemic of drug abuse in the search for means to alter consciousness’. Critics of the counterculture noted that this desire went back millennia and that even ‘yoga, with its transcendental meditation techniques, was an attempt to achieve the psychedelic state’.Special attention must be given to Stanislav Grof. An emigre Czechoslovak psychiatrist, psychedelic researcher and one-time scholar at the Esalen Institute, Grof famously experimented with LSD in 1950s Prague and later in the USA. With an interest in Eastern religion, Grof related how his own psychedelic sessions ‘seemed comparable to the light of supernatural brilliance said in Oriental scriptures’. He went on: ‘The Divine manifested itself and took me over in a modern laboratory in the middle of a scientific experiment conducted in a Communist country with a substance produced in the test tube of a 20th century chemist’. His patients and test subjects regularly reported feelings of transcendence, while he advocated that the brain’s ‘pre-existing matrices’ were activated by psychedelics. But Grof had a hunch that there were other ways of switching this part of the grey matter on.When LSD was banned in the late 1960s, Grof developed Holotropic Breathwork with his wife Christina at the Esalen Institute .Yoga Journal in 1985, Grof recalled how he had mined Eastern thinking to supplement orthodox medical therapies. His goal was to create ‘a bridge between the relatively limited Western point of view and the maps of consciousness provided by the major mystical traditions’. This included Buddhism and yoga. His wife, Christina, discovered the combination when she began practising Hatha Yoga to stay fit during her first marriage. During childbirth, she used the breathing techniques she had honed in class and later argued that ‘this enormous spiritual force was released in me’. The same feeling arose during her second child’s birth. Thereafter, she had ‘spontaneous experiences, all happening within the context of daily life’.In a feature piece for Christina’s experiences, however, were not wholly positive. At times, she thought she was ‘going crazy’. After she met Grof and he explained psychedelic experiences, Christina realised altered states could help her with her mental health issues. In 1980, the couple founded the Spiritual Emergency Network in California to offer workshops in transpersonal therapy and Holotropic Breathwork to those in crisis. Christina characterised the technique as ‘wiser than we are. But it requires a great deal of trust and surrender’.Yoga Journal published a series of retrospective articles on the 1960s’ preoccupation with altered states of consciousness. An emphasis on psychedelics was palpable, which reflected the impact such substances had on American yoga culture. Consumers of psychedelics, Eastern religion and yoga in the 1960s were, of course, mostly middle-class to upper-class, white, college-educated liberals; probably, the same people who subscribed to Yoga Journal in their later years. As historian David Herzberg has pointed out vis-à-vis tranquillisers and antidepressants, the media played an important role in creating ‘meaning[s] for white middle class culture’.Yoga Journal, similarly, reinforced ideas about psychedelics and yoga to its target demographic.In the early 1990s, the Yoga Journal piece contended, “…Buddhist, yogic, Vedantic, Taoist and Sufic philosophies are clearly created from, and designed to induce, multiple states of consciousness. Without experience of those states, we may not be able to appreciate the messages of those other philosophies”.One article suggested that the trippers and yogis of the era had simply rediscovered ‘ancient knowledge about the potentials of the human mind’. Americans’ journey deep into Eastern religion was regarded as an attempt to break the ‘consensus trance’ that dominated ‘normal’ life. The meeting of psychedelics and yoga was, according to this view, a natural reaction. ‘We’ve developed in the West a state-limited philosophy and psychology’, the Tricycle: The Buddhist Review admitted to taking psychedelics. Respondents likewise believed they ‘are not a path, but they can provide a glimpse of the reality to which Buddhist practice points’ .Modern yoga practitioners also viewed psychedelics as a shortcut to an altered state of consciousness and superior mental health. Psychedelics offered a sort of inauthentic consciousness of the divine, as articulated by Meher Baba .The Psychedelic Renaissance, Dr Ben Sessa, a neuroscientist and lifelong student of psychedelic medicine, science and culture, noted that ‘God—if there is such a thing—can, I believe, be known through the psychedelically-induced peak experience’ .This article has traced the contours of psychedelics, yoga and mental health, yet it is clear that there is more work to be done using new sources, approaches and narrower geographical areas. It may have appeared the purists had defeated the proponents of psychedelics, but many yogis and American Buddhists continued to take drugs long after Meher Baba and others had denounced them in the 1960s .Yoga was ‘one of the first and most successful products of globalisation, and it has augured a truly post-Christian, spiritually polyglot country’ .It was, by some accounts, the era ‘of the spiritual wisdom of the unlettered holy man over the intellectual accomplishments of the scholar’.


In the original article, there was a mistake in Table Additionally, heading 3.1 was incorrectly titled as “Recognition of Sights under Debris”. The correct heading is “Recognition of Digits under Debris”.Also, there was an error in the text. When McNemar's test was used to test for a significant difference in multiple digit recognition tasks, we treated each digit as an independent sample. However, the probabilities for correctly identifying multiple digits in the same image are not independent. Therefore, we fail to meet the assumption of independence between samples required for McNemar's test. Instead, a test that corrects for dependence between samples should have been used, such as the variation on McNemar's test proposed by Durkalski et al. . Using tResults, Recognition of Multiple Digits, Paragraphs 1 and 2:A correction has been made to To examine the ability of the networks to handle occlusion when the occluder is not a distractor, the networks were trained and tested on their ability to recognize multiple overlapping digits. In this case, when testing for significance, we used a variant of McNemar's test that corrects for dependence between predictions  = 3.82, p = 0.05]. All other differences were found to be significant (FDR = 0.05). The error rates for all models are shown in Table 4. A similar pattern is found when recognizing both four and five digits simultaneously. However, in both four and five digit tasks, all pairwise differences were found to be significant, with B-K outperforming BT . This suggests that, whilst recurrent networks generally perform better at this task, they do not exclusively outperform feedforward models.When recognizing three digits simultaneously, recurrent networks generally outperformed feedforward networks , with the exception of BT and B-K where no significant difference was found [χThe authors apologize for these errors and state that this does not change the scientific conclusions of the article in any way.The original article has been updated.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Children’s beneficial relationships with animals are well known. Companion animals, particularly dogs, have become an integral part of family life and children’s material culture. Aside from the proven physiological benefits, there is little research about what children say about their relationships with animals and how they describe them. In this paper, we bring together both horse-human and dog-human interactions, finding common ground for understanding the complexity of human development, well-being and flourishing. Dogs in schools are fast becoming a trend in helping to support and enhance children’s learning as well as their social and emotional well-being. Studies have shown that the very presence of a dog can increase children’s concentration, executive function and behaviour. In addition, equine therapy is gaining momentum and empirical studies are showing noteworthy benefits to children and young people. However, the lack of children’s voices means that the mechanisms for these benefits are comparatively unknown and unclear. In seeking to explore this, the authors utilized a visual, sensory ethnographic approach to illuminate, illustrate, experiment and reenact how the children and adolescents related, shared spaces and multiple subjectivities with their companion horse, Henry, and classroom canine, Ted. The former, Henry, champions a programme in which young people discover what can be learned from horses about communication as they learn to ride and care for them.In this paper, we bring together two separate studies and offer a double similitude as it were, in finding “common ground” and “common worlds” between dog–human and horse–human interactions. Appreciation of the process and mechanism of affect (and affect theory) can enable a greater understanding of child–animal interactions in how they benefit and co-constitute one another in enhancing well-being and flourishing. Studies have thus far fallen short of tapping into this significant aspect of human–animal relationships and the features of human flourishing. There has been a tendency to focus more on related biological and cognitive enhancement  such as a dog’s mere “presence” in the classroom improving tests of executive function and performance. Study A details an affective methodology to explore the finer nuances of child–dog encounters. By undertaking a sensory and walking ethnography in a North East England Primary School with Year 6 (aged 10 and 11 years) and Year 4 (aged 7 and 8 years) children , participant observation enabled rich data to emerge. Study B involves two separate groups of young people aged between 16 and 19 years who were excluded from mainstream education and identified as “vulnerable” due to perceived behavioural, social or emotional difficulties. It used mixed methods to gather and examine data from focus groups, interviews and statistics using the Rosenberg Self-Esteem Scale. Photo elicitation was an additional source of information. This equine intervention facilitated vital spaces for social and emotional well-being. The important significance of touch to children’s and young people’s well-being suggests a need for “spaces” in classrooms, and wider society, which open up this possibility further and challenge a “hands-off” pedagogy and professional practice. We vibrate, our hearts are pumping blood. We are a rhythm machine, that’s what we are”.The inimitable question posed by philosopher and dog trainer, Donna Haraway—“whom or what do I touch when I touch this dog” —has beenThis process and synthesis emerged in surprising and illuminating ways in Study A (child-canine interactions) and Study B (adolescent-equine interactions). Indeed, the “common ground” of both studies provides not only a double similitude of HAI narratives through children’s and young people’s voices, but it also aligns with the call for community cohesion between humans and animals as purported by Taylor and Giugni’s concept of “common worlds” . FundameThe idea of “flourishing” is used to expand thinking beyond happiness and highlight the need to consider it as well-being theory . We concThe research design for Study A  and Year 6 (aged 10 and 11 years) children  and their classroom canine, Ted. The children have grown up alongside Ted, a springer spaniel, and he has been in the school setting since being a puppy. He is now 3 years old. Ted joined the school following a landslide victory in a mock election that took place when the children were learning about democracy and voted to get a school dog. The Head Teacher honoured this vote and the school carefully planned Ted’s introduction into the setting, adhering to health and safety protocols and ethical consideration for Ted’s welfare and well-being. He has become an integral part of the children’s learning community, joining in school life as he wishes, such as lessons, reading time, play activities and sharing time with staff in their offices. Ted is cared for by his class teacher, and returns home with them at the end of every school day. Ted is free to move around the classroom and the children are assigned caring duties such as replenishing his water bowl and taking him for walks. He has a designated sleeping and resting area, although often chooses alternative spaces alongside the children. The children have been encouraged to learn Ted’s body language so they can ensure his well-being, for example, if he lowers his tail and seeks a separate space, they know to leave him alone and not to disturb him. They have also become attuned to his “springer sprawl” in which he will lie on his back, indicating a wish for tummy and chest rubs See .The study was conducted over a full academic year. In order to apprehend the children’s experiences of their encounters and interactions with Ted, a non-representational, visual and sensory ethnography was employed. As affect often goes unnoticed and uncognitised , a way oHowever, in this instance, primacy is not given to language or words alone. We extrapolate an embodied and corporeal significance to the nature and essence of human–animal interactions (HAIs). We attune to movements and sounds, as Stern suggests, in synchronous and harmonious, mirrored responses from our own bodies. The inside becoming the outside, in affective states of relational attunement and emotion. These concepts help us socially navigate and map our space and place in the world. It creates a score (or lines) like a map on which the sounds and movements encountered and experienced in a territory (or space) are emergent and unfolding as patterns of interaction and interconnection . We see This is further revealed in the “etudes” (drawing exercises) below .We argue, in this paper, that we need to make the body an important aspect of discourse, and by exploring bodily patterns and movements we can reconfigure childhood “attachings” in both the human and non-human world we inhabit. Cartographic-style inquiry has been utilised by the somewhat obscure and little known work of Fernand Deligny , a greatAs shown in Study A’s protocol , workshoA hermeneutic phenomenological approach was adopted in Study B. Although this initially seems at odds with and in contrast to a post-structuralist methodology used in Study A, what is significant and noteworthy is that we highlight our “common ground” stance that truth cannot sit comfortably within any one epistemology. An example of such is given by the post-structuralists Foucault and Heidegger and their “shift” from hermeneutics and language which could be said to be an important exploration into the very constitutive processes (of research) which produce all kinds and types of knowledge. It is on this basis that we “combine” our studies  in order to dynamically and epistemologically reveal new insights and understanding about HAIs. In challenging a traditional and purely positivist paradigm, we offer a double similitude, as it were, to our response to a call for studies which are methodologically qualitative and robust in design.What we observed in our separate research studies was a striking “common ground” in not only the tactile-kinaesthetic movements and rhythms between dog–child and horse–adolescent but also the synergy and synchronicity in movement and “becoming-with” one another. This is dramatically seen in intra-actions when both human and animal bodies appear to merge, couple or double together in an intimate entanglement of closeness almost reminiscent of a symbiotic and, thus, inter/intra-corporeal encounter . These eIn horse-human encounters, horses instinctively recognise authenticity . Horses Just as Winnicott  used theFine (2015) suggests that because the horse is a large animal, in order to interact with the horse, the participant is required to find non-verbal ways to communicate in order to establish any sort of relationship . In effeThe benefits of association with and positive interactions between young people and horses are multi-layered and include “care translation, socialisation and conversation, self-esteem promotion, companionship and affection stimulation” . It is cIn addition, communication between horse–human is gestural and rhythmic, with dressage being perhaps the most significant example of how this process itself, similar to dog walking, is a corporeal inculcation of harmony, synchrony and rhythm. Its dynamic “rhythmic entrainment”  becomes By reproducing embodied ways of knowing, new knowledge has emerged. Lupton  discusseThe revival of thinking in a vitalistic and corporeal way enables the opening up and expansion of spaces for multi-species well-being. Employing visual-material methods, Studies A and B demonstrated, respectively, how qualitative inquiry can allow the essence of experience to be seen and materialized dynamically. Through the interplay of image and text, a fresh and creative element to understanding human-animal interactions is provided. By both researchers being “drawn to see”  and gaziAs Bessell van der Kolk aptly argues , “[t]he Through mapping and drawing out the lines of the event ,56 . Our methods cross over and embrace differing disciplines in order to expose how opening up discussion around the politics and ethics of touch and the body can redefine our understanding of HAIs. This could offer fresh insights into the significant tactile and sensory potential to mutual well-being (of HAIs) for human and non-human flourishing. By mapping, drawing, diagramming and animating human–animal bodies and viewing them as rhythmic events and encounters, we can highlight the mutual co-constitution of benefits such as corporeal modulation  and deterritorialisation–reterritorialisation (creation of space). These vital spaces, in which human–animal bodies move and intra-act in harmony and kinetic melody with one another, become vital spaces for well-being. In true Deleuzian terms, they become bodies without organs (BwO) in deterritorialised spaces, meaning they are not regulated or organized, and are static of fixed entities. They are human–animal bodies which are entangled in intimacy and empathy. This inter-species relationship is one of sociality, doubling and inter-corporeal communication on an egalitarian plane. It disposes of power (puissance), thus opening up the potential for hybrid, common world, relationships .Both Studies A and B exemplify why children’s bodies matter. In conceptualizing the body as “unfinished”, “unbounded” and “becoming”, we concur with Horschelmann and Colls, that traditional constructions of child development need challenging. The need for studies to bring the body back into discourse is highlighted . The aut


The dark proteome, as we define it, is the part of the proteome where 3D structure has not been observed either by homology modeling or by experimental characterization in the protein universe. From the 550.116 proteins available in Swiss-Prot (as of July 2016), 43.2% of the eukarya universe and 49.2% of the virus universe are part of the dark proteome. In bacteria and archaea, the percentage of the dark proteome presence is significantly less, at 12.6% and 13.3% respectively. In this work, we present a necessary step to complete the dark proteome picture by introducing the map of the dark proteome in the human and in other model organisms of special importance to mankind. The most significant result is that around 40% to 50% of the proteome of these organisms are still in the dark, where the higher percentages belong to higher eukaryotes (mouse and human organisms). Due to the amount of darkness present in the human organism being more than 50%, deeper studies were made, including the identification of ‘dark’ genes that are responsible for the production of so-called dark proteins, as well as the identification of the ‘dark’ tissues where dark proteins are over represented, namely, the heart, cervical mucosa, and natural killer cells. This is a step forward in the direction of gaining a deeper knowledge of the human dark proteome. Many key insights and discoveries in the life sciences have been derived from atomic-scale 3D structures of proteins. Thanks to steady improvements in experimental structure determination methods, the PDB, or Protein Data Bank , which sThe present study serves as an introduction for two new features that were added to the Dark Proteome Database: (i) The availability of the ‘Features’ (FT) field of Swiss-Prot to deepen the knowledge of dark and non-dark proteins that allow the characterization of life domains and model organisms to get more thorough analysis; and (ii) the availability of an autonomy value per protein, allowing the analysis of the level of autonomy of dark and non-dark proteomes of those organisms as a whole. Therefore, the main goals of this work are: (i) To detail even more the dark proteins present in the four domains of life, model organisms, and Homo Sapiens and (ii) to map how much of darkness is still present in these model organisms, since they are so important for mankind, i.e., to how much we do and do not know about a certain organism just by looking at the amount of darkness that it holds? Due to the number of existing organisms, we had to select the most important ‘model’ organisms (for us humans) while the ones remaining are work in progress. This choice is not innocent, since sequences originated from non-model organisms are known by the lack of sequence annotation, without being true orphan sequences. In the DPD  we startKeeping our reality in mind, we have to remember that some of the most valuable methods in biological research are invasive or require an organism’s death. For all the previous reasons and more, much of this work is impossible or unethical to perform on humans and in certain organisms. As a solution, biologists have selected some model organisms to be used as testers. The following list contains a simple plant, a worm, a bacterium or prokaryotic, a simple eukaryotic, and a complex eukaryotic or mammal. Finally, we will analyze the human organism (Homo Sapiens) in much more detail, including the genes from where dark proteins came from (‘dark’ genes) and tissues where dark proteins are expressed (‘dark’ tissues).Arabidopsis thaliana (Plant)Arabidopsis thaliana is considered a weed, also known as mouse-ear cress and is the most widely used plant as a model organism. One reason Arabidopsis makes a good model is because it undergoes the same exact processes of growth, flowering, and reproduction as most complex plants, taking only about one month and a half to grow completely producing a huge quantity of seeds in the process. Another reason is due to the fact that Arabidopsis has one of the smallest genomes in the plant kingdom with only 135 mega base pairs and five diploid chromosomes. It is the first plant with a completely sequenced genome.Caenorhabditis Elegans (Worm)Caenorhabditis Elegans is a soil worm or nematode and is considered a model for multicellular organisms. The reason why it is such a good model is related to the fact that it shares a common ancestor (“urbilaterian ancestor”) with humans that lived 500 million years ago, therefore sharing most of the genes that govern most modern organismal development and disease, such as the human and nematode. This is extremely important because many genetic and developmental experiments are impossible in humans . Some evasive procedures associated with experiments are extremely time-consuming or cost-intensive. C. Elegans presents itself as a reliable alternative because of its short generation time (four days), and due to its complete anatomy also being known. The adult hermaphrodite has exactly 959 cells, while the adult male has exactly 1031 cells and both are transparent. This allows researchers to relate behaviors to particular cells, to trace the effects of genetic mutations and gain relevant insights into the mechanisms of development and ageing. Therefore, due to the evolutionary conservation of gene function, C. Elegans is the ideal model organism to trace basic genetic mechanisms of human development and disease, such as cancer and neurodegenerative diseases. C. Elegans was the first multicellular eukaryotic organism to have its whole genome sequenced. Escherichia Coli (Bacteria)The Escherichia Coli (E. Coli) can be found in the intestine of warm blood organisms. The reasons why this bacterium is such a good model are firstly, because it is a simple organism, and secondly that it can be cultured and grown easily and inexpensively in a laboratory. However, the main reason why it is heavily tested and trialed even though a bacterium, is related to the fact that its basic biochemical mechanisms are common to the human organism. Another important aspect is that E. Coli was the reason for first understanding the transcription factors that activate and deactivate genes in the presence of a virus. From that point on, E. Coli was used as a host in genetic engineering and especially in health, producing several types of proteins, encoding them with the majority of human genes that are applied as medicinal drugs. There are several variants of E. Coli, most of them harmless. However, some of them can be lethal and are responsible for product recall due to food contamination or food poisoning. This bacterium was the first prokaryotic model organism to have its genome sequenced (K12 strain) and has a single circular chromosome with 4.6 million base pairs.Saccharomyces cerevisiae (Yeast)Saccharomyces cerevisiae is recognized as the key factor in brewing for centuries. The main reasons for it being considered a model organism are related to its easy culture, fast growing process, and inexpensive production in a laboratory. Being a eukaryote, it share the same complex internal cell structure of plants or animals without the high percentage of junk DNA present in more complex eukaryotes facilitating research. Since S. cerevisiae is biochemically very similar to the human organism, many studies about the molecular processes involved in cell cycle, meiosis, recombination, DNA reparation, ageing, and other fundamental areas of biology were possible. S. cerevisiae was the first eukaryotic genome to be completely sequenced. It is composed of 12 chromosomes containing approximately 12.2 million base pairs.Mus musculus (Mouse)The Mus Musculus (Mouse) is the most famous model organism because is the mostly used mammal in medicine and biology scientific communities. The main reason why is such a good model is that it is a mammal and, therefore, has organs and development processes that are very similar to the human organism; next, they are easily reproductible, grow fast, and very easy to maintain and manipulate in a laboratory; finally, mice suffer from most of the diseases and calamities that affect mankind. Therefore, mice have an extremely important role in the development of new pharmaceuticals for humans. The mouse genome consists of 40 chromosomes with 2.63 billion amino acids. In our previous work , we analDataset: The set of protein sequences selected for this work were prevenient from Swiss-Prot release of July 2016 Dataset: uly 2016  are versuly 2016 , also frMapping Darkness: For each Swiss-Prot protein, each residue was categorized as “non-dark” if it met either one of the following criteria: If the residue was aligned onto the “ATOM” record of any PDB entry [D) as defined in Reference [D = 0 this means it is PDB or a white protein, otherwise, if D = 1, this means it is a dark protein. If 0 < D < 1 means it is a grey protein with grey regions containing dark regions [DB entry  in the ceference . If D =  regions .Dark and non-Dark Percentages: The percentages displayed for “dark” proteins, “dark” regions, grey regions, and PDB regions present in the above sets (domains of life and model organisms) consist first in obtaining both “dark” and PDB proteins in the sets mentioned above. Next, “dark” as well as, “non-dark” regions are mapped, subtracting the “dark” proteins from the former, and subtracting the PDB proteins from the later, obtaining the cardinality of “dark” regions and “non-dark” regions. If we divide the above cardinalities by the total amount of dark and non-dark regions, we obtain the percentages presented in Annotation Enrichment: The functional analysis compares annotations between dark and non-dark proteins in a reliable manner, by the application of annotation enrichment to the ‘Description’ (DE) field, which were now extended with the ‘Features’ (FT) field of the Swiss-Prot proteins through Fisher exact tests [p value of ≤ 1%, calculated via:p is from Fisher’s test, n is the total of number of annotations in the set, and k is the rank of the largest p value that satisfies the false discovery criteria as in Reference [ct tests ,12 folloct tests  with α, eference . This apTree Maps. From the ‘Description’ enrichment analysis results, we selected 21 (of 25) subcategories judged to be most significative and visualized them using a tree map [p values—as well as subcategories such as “Similarity,” which only give information about groups of very similar proteins and the specific functions they perform; although interesting, these specific annotations do not reveal more general properties of dark proteins. In tree map . For theMapping Autonomy per protein. For every human protein we evaluated its autonomy, i.e., using STRING [m(N) indicates the number of matches that occur for a link score of N. This means, if a protein has m(0) equals to zero matches, then the protein is fully autonomous because at the lowest quality cut-off score no interactions occur between it and other proteins. On the other hand, if at the highest cut-off score there still exist interactions with other proteins  is not zero) then it can be concluded that the protein is completely non-autonomous. g STRING  we countg STRING : Low   and ‘FeaObserving Swiss-Prot proteins through the TreeMap  of the ‘Descriptions’ field (DE) by life domain show the following: Archaea dark proteins A in “SubBacteria dark proteins B like arEukaryota dark proteins C are oveFinally, viruses dark proteins D are oveWe wanted to detail even more the Dark Proteome therefore, we used the ‘Features’ field (FT) which is a subsection of the ‘Description’ field (DE) by life domain through TreeMap . Observing Archaea dark proteins A are oveBacteria dark proteins B like arEukaryota dark proteins C are oveFinally, in viruses, dark proteins D are oveArabidopsis has 41.2% of its proteome in the dark . The conThe C. Elegans organism contains 45.8% of dark proteome . AnalyziE. Coli contains 32.5% of dark matter in its proteome. Attending TreeMap A of ‘DesS. Cerevisiae has 40.1% of its proteome on the dark side, and there are not sufficient proteins to infer conclusions about it using Fisher-tests for ‘Descriptions’ and ‘Features’. The Mus Musculus have 50.2% of dark proteome. Concerning ‘Descriptions’ A, the daThe last organism studied in this work was the Homo Sapiens (Human) proteome. It was found that over half of it 51.7%) was dark . The res1.7% was Concerning autonomy in Arabidopsis A it can It was also determined which dark proteins came from sequential genes, finding seven ‘dark’ gene clusters. Basically, you can take each protein and mapped down to the gene where the protein comes from and mapping down to chromosomes (See Methods), and if we do that proteins from these clusters had many features described above as typical for dark proteins .Length indicates the number of amino acids; ‘Binds’ indicates the number of known binding partners in the same cluster from STRING ; ‘Bias’ Finally, using ProteomicsDB  we lookeOur previous work  didn’t pConcerning functions, the results confirmed that dark proteins perform a wide spectrum of functions depending on the organism in question, being more focused in simpler organisms and wider in higher organisms . Again, Concerning autonomy, up to now there is no comprehensive map of all relevant functionally for PPI’s in simple or complex organisms. The existence of this map is of crucial importance to understand cellular behavior. Several databases started to flourish helping in the construction of this global protein interactions map. Some databases are dedicated to register interaction experiments such as physical binding detection among proteins ,25,26,27A point that we want to bring to discussion is the difference between intrinsically disordered proteins (IDP’s) and their relationship with the Dark Proteome (DP) as we coined it in 2015 . The neeIntrinsic disorder in proteins is a complex and poorly understood phenomenon, in addition to IUPred, many other prediction methods have been developed focusing on a range of different aspects of disorder . It woulFive hundred years ago, very little of the Earth was known. People suspect that it was a sphere, with land and water and they had roughly mapped out Europe, but that was it. Knowing what they didn’t know gave Portuguese explorers like Pedro Álvares Cabral, Vasco da Gama, and Fernão de Magalhães a direction in which to head—the same principle applies to science and discovery today. We have been able to identify regions within each protein that are different to any region where the structure has been determined experimentally. This unknown area is called the ‘dark proteome’ and actually accounts for nearly half the proteins in viruses and in eukaryotes, which includes humans. It will provide insight into protein-based illnesses like cancer, type 2 Diabetes, and many neurodegenerative diseases, such as Parkinson’s and Alzheimer’s. Just like the early Portuguese explorers that discovered Africa, America, and Asia, knowing what we don’t know has provided us with a roadmap upon which to focus our future research and agendas. Knowing that the Dark Proteome is mostly not disordered, mostly not compositionally biased, mostly not transmembrane and that dark proteins are mostly Unknown Unknowns, the purpose of this study was a detailed characterization of the dark proteins belonging to the human and model organisms under the pharmacological umbrella. Because we already saw too many unexpected surprises, the next step of DPD are the IDP’s because who knows what secrets are still hidden in the dark proteome. As far as we are concerned, we are only interested in the truth, regardless of how unexpected, difficult or amazing it will be.


The increase in problematic substance use is a major problem in Canada and elsewhere, placing a heavy burden on health and justice system resources given a spike in drug-related offences. Thus, achievement of Sustainable Development Goal (SDG) Target 3.5 to ‘Strengthen the prevention and treatment of substance abuse’ is important for Canada’s overall realization of the SDGs, including SDG 3 . Since 2008, Vancouver’s Downtown Community Court (DCC) has pioneered an innovative partnership among the justice, health and social service systems to address individuals’ needs and circumstances leading to criminal behaviour. While researchers have examined the DCC’s impact on reducing recidivism, with Canada’s SDG health commitments in mind, we set out to examine the ways health and the social determinants of health (SDH) are engaged and framed externally with regard to DCC functioning, as well as internally by DCC actors. We employed a multi-pronged approach analyzing (1) publicly available DCC documents, (2) print media coverage, and (3) health-related discourse and references in DCC hearings.The documentary analysis showed that health and the SDH are framed by the DCC as instrumental for reducing drug-related offences and improving public safety. The observation data indicate that judges use health and SDH in providing context, understanding triggers for offences and offering rationale for sentencing and management plans that connect individuals to healthcare, social and cultural services.Our study contributes new insights on the effectiveness of the DCC as a means to integrate justice, health and social services for improved health and community safety. The development of such community court interventions, and their impact on health and the SDH, should be reported on by Canada and other countries as a key contribution to SDG 3 achievement, as well as the fulfillment of other targets under the SDG framework that contain the SDH. Consideration should be given by Canada as to how to capture and integrate the important data generated by the DCC and other problem-solving courts into SDG reporting metrics. Certainly, the DCC advances the SDGs’ underlying Leave No One Behind principle in a high-income country context. This paper examines how the Downtown Community Court (DCC) in Vancouver addresses the health needs and realizes the full human potential of individuals, as proscribed under the Sustainable Development Goals (SDGs) agenda, of a local and marginalized segment of the Canadian population . As in oUsing the DCC as a case study, the objective of our analysis is to examine the ways in which health and the SDH are addressed by a purpose-built court that implicitly aims to tackle the underlying SDH that lead to or are consequences of criminal offences fueled by addiction, poverty, mental illness, poor health, insecure housing, discrimination and rights abuses, as well as fractured social and familial networks. We therefore designed a study that consists of three inter-related research components: 1) documentary analysis of all publicly-available DCC reports and newsletters; 2) observational analysis of the court and how health and the SDH are addressed in practice; and a 3) print media analysis with a focus on how media addresses the DCC’s impact on client health and the SDH. Together, these methods allow us to gain deeper insight into how the DCC’s design and daily operation intersect with and could inform Canada’s SDG agenda and, specifically, SDG 3 achievement.The Background section sets out our understanding of the context in which the DCC has emerged and operates in Canada, and within the context of problem-solving courts more broadly. Problem-solving courts form part of the cluster of “specialized courts”, which can include community courts, such as the DCC, mental health courts, domestic violence courts and drug courts, as discussed later in this paper.There is also risk that by employing a recidivism lens, the metrics and language of recidivism may skew research to appear to align with the recovery agenda. The recovery agenda, according to Paylor, “can be seen as reinforcing negative stigma around drug use” as it suggests that “only those willing to ‘get clean’ deserve the benefits offered by society” . AlternaIn September 2008, Canada’s first community court, the DCC, was launched in Vancouver’s Downtown Eastside.In 2004, the British Columbia Justice Review Task Force established a Street Crime Working Group to scope and propose strategies to address street crime and disorderly behavior in downtown Vancouver. The Working Group held public hearings and consultations with diverse stakeholders, including all levels of the justice system, social service agencies, community organizations, and affected communities. It also undertook data analysis and a review of approaches from other jurisdictions, particularly the United States . This reIn 2006, the federal and provincial governments together with the Office of the Chief Judge endorsed the report and created a planning committee to design the DCC. The planning committee engaged with other jurisdictions with successful community courts, held public forums and discussions with affected communities, Indigenous organizations, justice system staff and service providers in the DCC catchment area . This caIn 2007, the committee received funding to implement a pilot project to develop the physical space for the courthouse, and the DCC opened in 2008 . The DCCDrug courts, one of the first types of specialized courts, originated in Miami in the United States in the late 1980s to respond to the increasing number of felony drug charges in the Miami-Dade County area –31. The Problem-solving courts are an important tool to break the revolving door pattern of drug-fueled offending and to reduce prison costs and inmate numbers. Such courts may impose mandatory drug treatment combined with drug testing to ensure participants continue to adhere to the court program; but this is not the case of the DCC, where treatment is arranged on a voluntary basis. Problem-solving court models use “legal leverage”, broadly defined as the use of legal authority to promote treatment adherence and good health and well-being  and to bOverall, the literature on problem-solving courts is multi-disciplinary, principally spanning the legal, medical and public health disciplines. As the literature on problem-solving courts has expanded in the past two decades, there has been a shift in focus from a ‘war on drugs’ approach to drug addiction and drug-related crime, to a comprehensive public health and well-being response to court participants and their families , 42. TheSince 2000, the body of literature on the operation of drug courts in high-income nations has grown, although it continues to focus mainly on the United States. Much literature on these courts investigates their efficacy through a cost-effectiveness lens , 43, 44,However, calls remain for more rigorous cost-effectiveness evidence, research on the impact on reduced recidivism over the longer term, and family and child welfare outcomes –52. TherThe public health literature examining problem-solving courts’ impact on health and well-being focuses on four main areas (1) the role of healthcare professionals and how they can optimally support court participants –60; (2) The public health literature also shows that the complex health, well-being and recidivism issues faced by court participants are often inherently structural, and therefore interconnect with the SDH such as employment, education, training and housing , 78. ResReturning to the Canadian context, the literature examining problem-solving courts is largely from other provinces and not British Columbia , 54. TheIn the tradition of ‘law and society’ scholarship , this stThe document analysis aimed to determine how the DCC framework engaged with health and the SDH. Two complete sets of publicly available records were located and analyzed: evaluation reports and DCC newsletters. Using content analysis , we begaOur Court observation aimed to understand how, when and why the Court raises and addresses health and the SDH in practice . Court oEven though the DCC hearings are open to the public and decisions are public record, we undertook a number of precautionary measures to gain entry to the DCC and maintain client confidentiality. For example, we closely corresponded with DCC staff and judges to engage in court observation and answered their questions with respect to research aims, data collection, and data dissemination plan. Research team members made no contact with clients. Although names are available through the online record, we chose neither to identify judges, prosecutors, lawyers or clients nor to list specific hearing dates in order to offer a degree of confidentiality to Court actors and vulnerable populations.In terms of data collection, detailed notes were taken of all mentions of health and SDH with direct quotations where possible. Notes were entered into two structured grids, titled ‘sentencing hearings’ and ‘adjournment hearings’, and hearings were numbered in chronological order according to Court appearance to facilitate comparative analysis and quotations. In total, team members RG and DG observed 86 sentencing hearings and 375 adjournment hearings. Because adjournment hearings were brief and lacked information in our area of focus, we decided to limit our analysis to sentencing hearings only, with KHK thematically coding the observation data from the sentencing hearing grids . There wGlobeandmail.com)) for January 1, 2008 to February 1, 2019. Our media survey slightly pre-dates the Court’s launch, as we wanted to capture media coverage in the lead up. We started by a general Google search, followed by a university library portal search to locate any other media sources reporting on the DCC. A total of 60 articles were located using these methods, of which 21 contained a detailed rather than passing reference to the DCC and were included in the content analysis.Finally, the research team (led by JC) conducted a media review to examine how the Court is depicted in Canada’s mainstream print media. We identified key local, provincial and national publications using the search term “Downtown Community Court” in each publication, as well as the Google search shortcut  ; and theWe found that in the Interim and Final Reports health intersected with the DCC’s goals in two contexts. First, it intersected in relation to the health of the DCC’s target population: “chronic offenders whose offences are associated with problematic substance use, mental illness and poverty” . Second,We further found that the Interim and Final Reports on the DCC often referenced the SDH. Housing was the most referenced SDH with 31 references in the Interim Report, and seven references in the Final Report. Housing, as well as other SDH, were discussed in relation to the DCC’s goals in two ways: to provide context for the criminal behavior , and to indicate the types of services integrated into the DCC’s multidisciplinary Case Management Team.We located and analyzed six DCC newsletters. The purpose of the newsletters was to inform the public about program updates, community services, client profiles and achievements and provide judge’s perspectives. The newsletters contained occasional references to how the DCC’s programs intersect with health and the SDH. For example, in the judge’s perspective section of the Fall 2012 newsletter, Judge Gove is quoted on how the DCC’s Mental Health Program “has allowed offenders with mental health disorders to connect with housing and community mental health services resulting in many cases no longer proceeding by way of criminal charges”. Another example is reported in the Spring/Summer 2012 edition, with an article reporting on a DCC program that supports food security tilted “Community Based Experiential Learning”, a program in which the DCC hosts fourth year students from the University of British Columbia’s Faculty of Land and Food Systems. In this particular newsletter, it was reported that the students developed a cookbook for the “Healthy Eating” program, which is “a low-barrier program teaching clients how to cook healthy, nutritious meals in a SRO [Single Room Occupancy rentals in hotels in the Downtown Eastside], on a single burner for under $5”.Our observed sample consists of substantial judicial decisions, primarily a sentence or a judicial interim release, in the cases of 86 different defendants – referred to as “clients” in the DCC system.n = 75) of all clients. Twenty-six clients were held in custody, attending Court either in person or through videoconference; twelve of these were overnight arrests. Three clients did not speak English and were assisted by interpreters.We found that males were over-represented in the sample, accounting for 87.2% (n = 43) appeared or had previously appeared before the court for charges of theft under $5000. Thirty-seven per cent of clients (n = 32) were in Court due to breaches of bail, probation order, recognizance or undertaking. Offences involving violence or uttering threats came next, with 17.4% of clients (n = 15) charged with assault (including with weapons or causing bodily harm), while 12.8% of clients (n = 11) were charged for uttering threats. Just over 9% of clients (n = 8) were charged with matters involving domestic violence. There were 18.6% of clients (n = 16) charged with mischief; 5.8% of clients (n = 5) charged with possession of stolen property; four charged with unlawful possession of identification documents; four with unlawful possession of weapon; three with break and enter; two with driving while impaired; and one with possession of controlled substance. We found it is not uncommon for clients to appear before the Court with multiple charges, particularly in combination with a breach of Court order.In our observational sample, the most common criminal offences brought before the Court were theft and breach of court orders, and virtually all clients had a previous breach. Fifty per cent of clients  and in justifying sentencing. In 67 of the 86 hearings observed, judges explicitly recognized health  and the SDH  as the underlying causes of criminal offences and aimed to address these issues through therapeutic sentencing and engagement with health and social service agencies.Challenges relating to client housing were referenced in 32 hearings, with 19 clients indicated by the Court as homeless and an additional three referred to as having previously been homeless. Other mentions of housing included impending eviction and precarious arrangements such as living in hotels, squats or with friends and family. Homelessness and housing were referenced to provide context, indicate the ability to access services and to explain motivations. In one hearing, lack of housing was noted as a barrier to needed care, with counsel stating that “counselling is difficult” as the client was moving between shelters [client 5]. In several cases, the lack of secure housing was linked to a ‘disorganized life’ with several references across our data to clients consequently struggling with adherence to medication regularly or relapsing into addiction. For example, a defence lawyer explained, “[my client] is at a shelter at Cordova Street. His lack of participation [in the DCC’s Mental Health Program] is due to his disorganized life.” [client 62]. In another case, a judge noted, “I am familiar with [the client’s] long history of mental health and of not taking his medication while on the streets in addition to street drug use.” [client 4].“[The client] has 116 convictions and 75 breaches. [The client] goes back to these [no-go] areas because this is where he lived before. His situation is a revolving door. A referral [to the DCC’s Case Management Team] would offer a more supervised unit, assistance with homelessness, basic income, and counselling condition”. [client 9].The Crown counsel, in this case, indicated that police had suggested “trying something new” [client 9] with more structure and support with housing and access to healthcare. The client indicated he was willing to accept help, noting: “I am homeless. I want to be far from drugs, far from trouble. I am willing to work with everybody here. I am ready”. [client 9]. In sentencing this case, the judge acknowledged the “revolving door pattern”, noting: “you showed a lack of respect for Court orders. But I see a pattern of homeless and addiction here.” [client 9]. In this illustrative case, to assist with the client’s multiple needs, the judge ordered the client’s judicial interim release from overnight custody [clients waiting for a bail hearing] combined with one-year probation and Case Management Team supervision.In many instances, judges also recognized homelessness as a trigger for Court order breaches; breaches represented the vast majority of observed hearings. Homelessness was linked to failure to appear in Court or maintain contact with probation officers leading to a reinforcing cycle of homelessness and criminal behaviour. In one such hearing, Crown counsel explained:Poverty and access to income surfaced frequently as an additional SDH affecting the Court’s clients. There were nine references to unemployment or loss of employment, with six clients described as being on social assistance of some form, and four references to clients in need of access to social assistance. In several instances, judges explicitly linked poverty and offences (often in relation to theft under $1000). One judge explained: “your offence was motivated by poverty rather than addiction”, deciding: “I will not have you reporting, because you have a job and I don’t want you to lose your job”. [client 78].In 72 of the 86 hearings, the presiding judge referred to problematic substance use as critical contextual factors. The range of drugs to which clients were addicted included pain medication, crack, heroin, cocaine, fentanyl, crystal meth and alcohol. In some cases, clients reported losing employment, relationships and connections to their children through addiction, while in others such losses precipitated addiction. For example, in one hearing the client’s lawyer explained: “[He] lost his job in the oil industry. He is now homeless and has serious addiction issues.” [client 79]. In other cases, physical injuries impeded physical forms of employment, and resulted in a prescription for painkillers that led to opioid addictions.Mental health issues beyond addiction were also frequently referenced in the DCC. Mental health issues recorded in our data included depression, post-traumatic stress disorder, anxiety, bipolar disorder, drug-induced psychosis, attention deficit and hyperactivity disorder, schizophrenia, self-harm, and general references to mental illness, or to being detained under British Columbia’s Mental Health Act. Mental illness issues were contextualized as resulting from life disruptions and traumas, including childhood abuse, sexual assault, inter-generational trauma of Indian Residential Schools, relationship breakdowns and the death of close family and friends. Mental health issues were also referenced as contributing causes to family estrangement, job loss or difficulty maintaining employment, and conflict with the law.In many hearings featuring addiction and mental health, the judge, in consultation with defence and Crown counsels, developed a plan to access treatment as part of a suspended sentence. Counselling was often recommended, as was engagement with affiliated services, including the DCC’s Case Management Team and Mental Health Program, residential treatment programs, detox programs and hospital-based programs. The DCC’s Case Management Team alone was referenced 72 times in the cases observed. As the diversity of programs suggests, recommended treatment did not follow a prescribed modality, but was context-specific and included recovery-oriented detoxification programs and harm-reduction programs of drug substitution involving drugs such as methadone and Suboxone , 16.In sentencing, DCC judges often considered the reason for the crime, the health of the client, their comfort with existing service providers and their mental and physical capacity to perform community service. For example, in one case the judge noted that the client had been working with the DCC’s Case Management Team, and did not add counselling in the sentence, as the client was comfortable continuing with the DCC’s team. In considering a client’s ability to adhere to drug treatment, a judge ordered the client change the location of his methadone prescription by imposing an area restriction condition; to stay away from the Downtown Eastside neighborhood, an area with “too many temptations” for this particular client. In another example, the judge acknowledged a client’s progress on the methadone program while in custody, but doubted his ability to abide by probation conditions, and thus decided to keep the client in custody to better manage his addiction. In considering community service, a judge noted physical capacity stating, “I saw you hurt your back. I will not sentence community work”. [client 57].In 27 of the 86 cases observed (31%), clients expressed a desire for drug treatment, while in eight cases (9%) clients expressed an unwillingness to receive treatment. One client living with bipolar disorder and addiction was described as “determined to get help” and willing to engage with the DCC’s Case Management Team, explaining her offence  stating: “I did things in desperation. I need help. I need to get well.” [client 13]. In some instances clients were “not keen on counselling” [client 34] and on two occasions, clients were not interested in drug treatment at all, which generally resulted in mandatory counselling and treatment provisions not being included in sentencing.Other health issues that arose in sentencing included chronic illness , physical injury, mental injury and cognitive impairment. On two occasions, the presiding judge did not include mandatory counselling in sentencing where clients faced challenges in benefitting from treatment due to health conditions such as brain injury and depression.Social and familial disruption and the role these connections played in healing were prominent themes throughout the hearings. Many of those before the Court experienced disruption of family and social networks and intergenerational trauma. For example, Indian Residential Schools were referenced as a contributing factor in four hearings - in one case the client had attended residential school, while three clients had parents who attended such schools. In presenting the client’s background in each instance, the defence linked these schools, which removed Indigenous children from their families and communities, punished cultural expression and the speaking of Indigenous languages, to intergenerational trauma. In one of these cases, the client was described as having “no family connections”, “restricted access” to his children and was now “seeking assistance to deal with childhood trauma.” [client 57]. In several other cases, social and familial connections and disruptions were reported in relation to international or domestic migration. Several clients had come to Vancouver from other countries including the Philippines, El Salvador, Egypt and Fiji, either alone or with limited family. One defence counsel noted in reference to his client’s isolation: “He is from Fiji. He is alone, no family and is isolated.” [client 78]. Isolation and distance from family were also reported with respect to migration from within the province and country, with DCC clients from Ontario, Manitoba, Alberta, Nova Scotia and other parts of British Columbia.While family breakdowns and estrangement were often mentioned, the Court also referenced familial connections as sources of support, strength and motivation. In one case where addiction followed divorce, it was noted that the client’s mother and daughter were seated in the gallery, with defence counsel stating, “[the client] is motivated to undergo counselling because he wants to become clean from addiction and be the good father he once was.” [client 41]. In another case, the defence counsel similarly stated: “[the client] has a 9-year-old son and is motivated to be good for his son’s birthday next week.”[client 63].[Y] ou have a period [where] you were doing well. It is encouraging the CMT is willing to take you back. 30-day conditional sentencing is nicer, and then you are not in custody. I hope you are focused. I want you to focus on your recovery.” [client 34].This understanding however, was not without limits. Acknowledging that poor behaviour was “obviously [ …] due to addiction”, while determining probation, one judge noted: “if you breach [conditions] again, you won’t get [probation] from me again, but instead will receive a custodial sentence.” [client 6]. In another case, while considerate to the client’s adverse circumstances, a judge noted that while the current sentence was probation, “from here [the next step is] you go to jail” advising the client, “you need to engage with the [DCC’s] Case Management Team. They have not given up on you. Participate in programs: detox, counselling.” [client 59].Judges often showed a deep understanding and respect for clients’ life circumstances in the hearings. For example, comments included “I acknowledge you struggle with many barriers” [client 15], “I recognize that you had a hard time” [client 1], and “I am very motivated by your recovery” [client 16]. One judge stated to a client:In cases of domestic violence, the measures DCC judges employed to protect the victim included orders of no-contact or permissive contact where the client was mandated to leave the victim immediately upon request. In such cases, discussions among the judge, counsels, clients, etc., typically revolved around the management plan to keep the victim safe and involved reference to the DCC’s Victim Services. In these cases, the violent behavior of clients was considered in terms of the victim’s safety, with the judge deciding in one such case, “I will allow permissive contact incrementally, [and] once you take steps toward the right direction [couples’ counselling], I will determine reporting for the purpose of counselling.” [client 59].The findings from our content analysis of the mainstream print media on the DCC reflected many of the themes and issues that emerged from our Court observation. Of the 21 media articles examined, 20 articles mentioned health in some capacity, primarily referencing addiction and mental health. The SDH were addressed in 18 articles with a particular emphasis on housing and social connectivity.“[Judge] [Name] explained that when defendants first come to the court, they're given a needs assessment by one of 14 on-site service groups, which range from mental and physical health practitioners to probation officers who can help with housing and income assistance.” This example provides a number of insights into the DCC’s operation and approach, including services offered at the courthouse, information sharing to provide context concerning the underlining factors leading to crimes, mentions of received medications, addiction-related concerns, the need for additional services to meet health needs, and the need to understand client’s overall health.Articles included interviews with judges and profiles of clients. A 2016 Canadian Broadcasting Corporation report featured a lengthy explanation from a DCC judge on the Court’s intake procedure, noting:SDH as factors influencing drug-related crime also arose in pieces profiling clients. For example, a Globe and Mail newspaper article of 2019 examined how “poverty, family breakdown and problematic substance use, can impact one’s life” . This arConsistent with our findings of the DCC Evaluation Reports set out in the first part of the Results section, we found that efficiency  was another prominent theme of media coverage. Indeed, the DCC Reports prompted media coverage, with a majority of articles include in our analysis published after the release of the DCC’s Final Evaluation Report in 2013. One such article noted: “the results of the efficiency evaluation indicate that the DCC had a neutral impact on efficiencies.” . The samThis study investigates how health and well-being were addressed and framed in the DCC’s framework and daily operations by Court judges, counsels and clients. We employed a multi-pronged investigative approach examining: (1) publicly available DCC documents, (2) coverage by the print media, and a series of (3) Court observations examining health-related discourse and reference.n = 133) direct references to health were made in the two reports analyzed. The SDH were also discussed, with housing the most frequently raised. The newsletters’ reference to health was more infrequent and nuanced and mainly referenced SDH.In the documentary analysis we found explicit and recurrent references to the health of DCC clients in the reports in comparison with the newsletters. One hundred and thirty-three , low and high-income alike, with the over-arching goal that ‘No One Will Be Left Behind’ [The growing problematic substance use has been detrimentally affecting individuals, families, communities and government resources in Vancouver and other jurisdictions within and beyond Canada’s borders. To achieve the 2030 Agenda for Sustainable Development and its 17 SDGs, and particularly SDG 3, countries must address both the impacts of and the underlying conditions leading to problematic substance use, and drug-related crimes; consistent with a harm reduction and health and human rights approach. Our study contributes new insights on the effectiveness of the DCC as a means to integrate justice, health and social services for improved health and community safety. In so doing, it highlights the DCC’s rich potential to serve as an explicit SDG lever for impactful local change.As challenges to health and social equality advance in Canada and elsewhere, questions of how resources should be allocated are of utmost importance as they lay the necessary groundwork to give effect to the SDGs’ principle of Leave No One Behind. A new focus on service integration and coordination among the justice, health and social systems and sectors is needed to advance the rights of marginalized populations in Canada. Canada’s commitments under the SDG agenda and the DCC intervention should serve as both the inspiration and vehicle to bring about this much needed multi-sectoral, rights-based policy and planning shift.


To the Editor,I am writing in response to Dr Sharon Galper Grossman’s recent fascinating article, “Vape Gods and Judaism—E-cigarettes and Jewish Law.”halachic perspective, several factors may not be as simple as presented.However, as one who has written extensively on the topic of “Smoking and Halacha” and whose article was cited extensively in Galper Grossman’s paper, and although I applaud the author for bringing this important issue to the fore, nonetheless, I believe that such an absolute position is not clear-cut, and, from a Tzitz Eliezer’s responsum that the leniency of Shomer Pesa’im Hashem (G-d protects the simple)Tzitz Eliezer himself did not make such an assessment regarding classic cigarettes until far more medical studies were performed and the absolute link from smoking to death was proved. Compare Shu”t Tzitz Eliezer from 1945,Issurim.Tzitz Eliezer held it was still not truly prohibited by halacha. Yet, subsequently, and as the knowledge of the health risks associated with smoking became more widespread and universally acknowledged, and the number of smokers starting dropping, only then did he change his psak to reflect the emerging reality, using extremely harsh terms to decry smoking, and ultimately outright forbidding it.The author extrapolates from the Poskim whose psak evolved in accordance with medical findings, gradually becoming more stringent in this matter, include Rav Yosef Shalom Elyashiv,teshuvos years earlier.Other However, and consequently, based on the current reality, with a lacuna in compelling scientific data attesting to the dangers of these products, coupled with the Surgeon General’s rather tepid warning regarding e-cigarettes , for better or for worse, it appears far from certain that the extrapolation made was indeed accurate.Poskim “have a unique opportunity to seize this moment to stop e-cigarette use before it becomes widespread,” can one truly expect this? Even the Tzitz Eliezer, who was of the most vociferous in his objections to smoking, wrote regarding smoking combustible cigarettes that, as it is deemed enough of a health risk that in every civilized country cigarettes are exclusively sold with a warning printed on the package that it damages health, smoking loses its classification of Shomer Pesa’im Hashem. However, regarding e-cigarettes, if the Surgeon General did not see fit to issue a stronger warning for the mainstream public, it would seem quite tenuous to suggest that the Poskim—who follow his lead on what is considered hazardous behavior—are obligated to take a more prohibitive stance.Although the author opines that hetter of Shomer Pesa’im Hashem, and since e-cigarettes (at least currently) lack the medical studies to prove that they are just as harmful as classic cigarettes, they may actually still fit this hetter at least according to certain opinions .Moreover, as there are different understandings of the Kashrus Magazine Raavad of the Badatz Eida Hachareidis, who is one of the most vocal prohibitors of combustible cigarettes,hashgacha (kashrus certification), as one is receiving tangible benefit from its flavor. Hence, it would seem that, in his opinion at least, there is a quantifiable difference between the levels of sakana present in classic versus electronic cigarettes. As he outright, and quite strongly, prohibited classic cigarettes, but not e-cigarettes, writing to make sure to only use those with hashgacha, this is implicit proof that he holds they are not in the same halachic category.Proof of this, perhaps, is that in a recent a mazik (damaging) to them.Regarding the second-hand smoke issue, Rav Moshe Feinstein famously prohibited smoking around others as the smoke was considered halachic perspective. Yet, in my opinion, it seems—based on the current proven medical knowledge of its intrinsic and inherent risks—it would be somewhat premature at this time to classify it as downright prohibited.In summation, I commend the author for raising awareness and presenting the dangers and associated health risks of vaping to the public. Obviously, smoking e-cigarettes is an inadvisable and imprudent activity (barring certain specific circumstances detailed in the article), and this certainly holds true from a