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One person has died after a vehicle plunged into a canal in Westchester while another person managed to escape.The incident took place around 8:30 a.m., Friday, June 4, after the vehicle pulled out of the parking lot of BJ's Gas at 5 Sector Lane in Pelham Manor and went straight into the canal where it became submerged, according to ABC 7 New York.The person who died was reportedly pulled from the water by first responders in cardiac arrest and transported by Pelham Manor EMS who can buy ventolin to an area hospital.A second person was able to escape the vehicle on their own.Firefighters from several departments are still searching the scene for possible victims, ABC 7 said.Mount Vernon Police said on Twitter that due to the investigation, the Fulton Avenue Drawbridge would be closed for several hours.Police said motorists are advised to use the Hutchinson River Parkway or the 5th Avenue/Dyre Avenue/Boston Road routes to avoid the area.This is a developing story. Check back who can buy ventolin to Daily Voice for updates. Click here to sign up for Daily Voice's free daily who can buy ventolin emails and news alerts..

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Latest Neurology News who makes ventolin hfa http://leiderphotographyblog.com/buy-generic-renova-online FRIDAY, Dec. 4, 2020 (HealthDay News)Depression, anxiety and who makes ventolin hfa suicidal thoughts are more common in children and teens with epilepsy than previously known, and they should be screened for such problems, researchers report.They assessed 119 children and teens, aged 9 to18, with epilepsy. None had been diagnosed with depression, anxiety or suicidal thoughts (suicidality).The screenings showed that about 30% of the youngsters had anxiety, nearly 40% had depression, and nearly 11% tested positive for suicidality, according to the study to be presented Friday at the virtual American Epilepsy Society annual meeting. Such research is considered preliminary until published in a peer-reviewed journal.A previous study found that 19% of youngsters with epilepsy have anxiety and 13% have depression."Compared to other studies, the percentage of children, adolescents and teens that screened positive for these mental health issues was quite a bit higher than expected," said study author who makes ventolin hfa Dr.

Anjali Dagar, a clinical research fellow at Cleveland Clinic.In the general population, about 7% of 2- to 17-year-olds have anxiety and 3% have depression, according to the U.S. Centers for Disease who makes ventolin hfa Control and Prevention. There are no clear statistics on suicidality among children and youth in that age range who haven't been diagnosed with depression.Most studies of suicidality in youths with epilepsy have been in children with preexisting psychiatric diagnoses, the researchers noted.They said this study is the first to who makes ventolin hfa assess screening for suicidality in youngsters with epilepsy with no known mental health history. The findings suggest that all children and teens with epilepsy would benefit from screening, even if they have no signs of problems, according to the researchers."Although this is a screening -- meaning the diagnosis must be confirmed by a psychiatrist -- our findings suggest it is important to screen all youths with epilepsy for underlying psychiatric issues even when there are no signs of concern," Dagar said in a meeting news release."The suicide [screening] tool revealed unrecognized suicidality in more than 1 of 10 youths with epilepsy, which is significant," said study co-author Dr.

Tatiana Falcone, a who makes ventolin hfa child and adolescent psychiatrist at the Cleveland Clinic Epilepsy Center. "Suicidality is a life-threatening condition that can exist even in the absence of a preexisting diagnosis of depression or anxiety, so it's important all children, adolescents and teens with epilepsy get screened for all three mental health issues."More informationThe Epilepsy Foundation has more on epilepsy and mental health.SOURCE. American Epilepsy who makes ventolin hfa Society, news release, Dec. 4, 2020Robert who makes ventolin hfa PreidtCopyright © 2020 HealthDay.

All rights reserved. SLIDESHOW What Is who makes ventolin hfa Epilepsy?. Symptoms, Causes, and who makes ventolin hfa Treatments See SlideshowLatest Prevention &. Wellness News By Ernie Mundell and Robin Foster HealthDay ReportersFRIDAY, Dec.

4, 2020 (HealthDay who makes ventolin hfa News) – President-elect Joseph Biden said Thursday that on his first day in office he would ask Americans to wear masks for 100 days, and that Dr. Anthony Fauci will play a pivotal role in his administration's fight to curb the spread of asthma."On the first day I'm inaugurated, I'm going to ask the public for 100 days to mask. Just 100 days to mask — not forever, just 100 days who makes ventolin hfa. And I think we'll see a significant reduction" in the ventolin, Biden told CNN.As for Fauci, Biden made it clear that the nation's top infectious diseases expert would be a central player in the U.S.

asthma response, The New York Times reported."I asked him to stay on in the exact same role he's had for the past several presidents, and I asked him to be a chief medical adviser for me as well, and be part of the asthma treatment team," Biden said.That response is facing its toughest challenge so far, as daily case counts, hospitalizations and deaths continue to set records on a daily basis.California, the first state to impose far-reaching lockdowns after the ventolin struck, announced strict new measures on Thursday, to who makes ventolin hfa try to keep a surge in cases from overwhelming hospitals, the Times reported.Millions of people across Southern and Central California are likely to see outdoor dining shuttered, playgrounds roped off and hair salons closed within days if the available intensive-care capacity in their areas dips below a 15 percent threshold, the Times reported.The new restrictions will last for at least three weeks, strictly limit store capacity and allow restaurants to serve only takeout or delivery."If we don't act now our hospital system will be overwhelmed," Gov. Gavin Newsom who makes ventolin hfa said. "If we don't act now, we'll continue to see our death rate climb."Other states have also taken stronger actions to slow the spread of asthma.In anticipation of a deadly holiday season, Gov. John Carney of who makes ventolin hfa Delaware on Thursday issued a stay-at-home advisory asking people not to gather indoors with anyone outside their household, the Times reported.

In Michigan, Gov. Gretchen Whitmer recently ordered a three-week shutdown that closed casinos and movie theaters and suspended in-person high school and who makes ventolin hfa college classes. Oregon, Washington State, Minnesota and cities from Los Angeles to Philadelphia have also re-imposed restrictions.Britain First to Approve Emergency Use of Pfizer's asthma treatmentBritain became the first Western country to allow emergency use of a asthma treatment on Wednesday, approving Pfizer's candidate in the race who makes ventolin hfa to inoculate millions of people around the globe.Having beat the United States to emergency authorization may pressure American regulators, who are already taking heat for not moving faster to get doses to people, the Times reported. And it has stirred up a global debate about how to balance the dire need for a treatment against the importance of looking for clear signs that a treatment is safe."Help is on its way with this treatment -- and we can now say that with certainty, rather than with all the caveats," British health secretary Matt Hancock said Wednesday.Though Britain has an early jump on distribution of the Pfizer treatment, it will have no effect on the distribution of the hundreds of millions of doses that other wealthy countries like the United States have bought in prepaid contracts, the Times said.But there are daunting obstacles to the treatment's delivery to the masses.The Pfizer treatment, developed with BioNTech, a smaller German firm, must be kept at the unspeakably cold temperature of minus 94 degrees Fahrenheit until shortly before shots are given.

However, Pfizer said who makes ventolin hfa in a statement released Wednesday that it has developed shipping containers that use dry ice to keep the treatment cold. GPS sensors will allow the company to track each shipment and ensure they stay cold, the company added."Pfizer has vast experience and expertise in cold-chain shipping and has an established infrastructure to supply the treatment worldwide, including distribution hubs that can store treatment doses for up to six months," the company said.Still, the temperature requirement could dictate who will be vaccinated first in Britain. While nursing home residents were who makes ventolin hfa supposed to be the top priority under an advisory committee's plans, efforts to limit transportation of the treatment to ensure it remains cold may mean that National Health Service staff will receive the shots first, the Times reported. The British government said Wednesday that 800,000 doses would be available by next week for health workers to begin administering.In the United States, an advisory panel on Tuesday who makes ventolin hfa approved a treatment distribution plan that recommends health care workers and nursing home residents and staff be the first to receive any approved asthma treatment.

The recommendation from the Advisory Committee on Immunization Practice (ACIP), if heeded, will steer the initial short supply of treatments to about 21 million health care personnel and 3 million Americans working or living in long-term care facilities. An FDA advisory panel is who makes ventolin hfa set to meet on Dec. 10 to decide whether the agency should grant emergency authorization to the Pfizer treatment, the Times reported.The global race to develop a treatment is poised to shatter records for time to market. Around the who makes ventolin hfa world, researchers are testing 57 treatments in clinical trials, and nearly 100 others are being tested in animals or cell, the Times reported.

China and Russia have both approved treatments without waiting for the who makes ventolin hfa results of late-stage trials, which experts say raises safety concerns.A global scourgeBy Friday, the U.S. asthma case count passed 14.2 million while the death toll passed 276,000, according to a Times tally. According to the same tally, who makes ventolin hfa the top five states in asthma cases as of Friday were. Texas and California with roughly 1.3 million cases each.

Florida with who makes ventolin hfa just over 1 million cases. Illinois with who makes ventolin hfa more than 761,000. And New York with nearly 679,000.Curbing the spread of the asthma in the rest of the world remains challenging.Many European countries are tightening restrictions, the Associated Press reported. France has entered a nationwide lockdown, and Germany and Austria have started partial lockdowns as government officials across the continent scramble to slow a sharp rise in s that threatens to overwhelm their health care systems.England has who makes ventolin hfa followed suit, while Italy, Greece and Kosovo also announced new measures, the AP reported.Things are no better in India, where the asthma case count passed 9.5 million on Friday, a Johns Hopkins University tally showed.

More than 139,000 asthma patients have died in India, according to the who makes ventolin hfa Hopkins tally, but when measured as a proportion of the population, the country has had far fewer deaths than many others. Doctors say this reflects India's younger and leaner population. Still, the country's public health system is severely strained, and some sick patients cannot find hospital beds, the Times said who makes ventolin hfa. Only the United States has more asthma cases.Meanwhile, Brazil neared 6.5 million cases and had over 175,000 deaths as of Friday, the Hopkins tally showed.Worldwide, the number of reported s passed 65 million on Friday, over 1.5 million deaths recorded, according to the Hopkins tally.More informationThe U.S.

Centers for Disease Control and who makes ventolin hfa Prevention has more on the new asthma.SOURCES. The New who makes ventolin hfa York Times. Associated PressCopyright © 2020 HealthDay. All rights reserved.Latest Pregnancy News who makes ventolin hfa FRIDAY, Dec.

4, 2020 (HealthDay News) -- A baby girl born in Tennessee from a 27-year frozen embryo broke the record for the longest-frozen embryo to result in a live birth, which was held by her older sister, Emma.Molly Gibson was 6 pounds, 13 ounces when she was born in October to Tina Gibson and her husband, Ben, The New York Times reported.Molly's birth was the result of an embryo being frozen in October 1992 and thawed in February 2020. Both she and Emma, who was born in 2017, came from embryos donated by the who makes ventolin hfa same couple in 1992.The Gibsons decided to use donated embryos because Ben has cystic fibrosis and Tina is a carrier, and they feared passing the disease on to their children, the Times reported.Biden to Ask Americans to Wear Masks for 100 DaysOne of Joe Biden's first acts as U.S. President will be to ask Americans to wear masks who makes ventolin hfa for 100 days.He told CNN' that he would make the request on Inauguration Day, the Associated Press reported."On the first day I'm inaugurated, I'm going to ask the public for 100 days to mask. Just 100 days to mask — not forever, just 100 days.

And I think we'll see a significant reduction" in the ventolin, Biden said.Biden has often said that mask-wearing is a "patriotic duty" who makes ventolin hfa and had floated the idea of a nationwide mandate, but decided that would be too difficult to enforce, the AP reported.No Full Sports Stadiums Before Summer. FauciDon't expect to see full sports stadiums in the United States before next summer, Dr. Anthony Fauci said who makes ventolin hfa Thursday."We're gonna be vaccinating the highest priority people [from] the end of December through January, February, March," said Fauci, director of the National Institute of Allergy and Infectious Diseases. "By the time you get to the general public, the people who'll be going to the basketball games, who don't have any underlying conditions, that's gonna be starting the end of April, May, June," he told Yahoo Sports, who makes ventolin hfa CNN reported."So, it probably will be well into the end of the summer before you can really feel comfortable [with full sports stadiums] -- if a lot of people get vaccinated.

I don't think we're going to be that normal in July. I think it probably would be by the end of the summer," Fauci said.He said the chances of having full NBA arenas in July during the league's finals will be "cutting it close," but it's "possible" there will be full NFL stadiums who makes ventolin hfa in September, CNN reported.Copyright © 2020 HealthDay. All rights reserved. QUESTION Men who makes ventolin hfa and women are equally likely to have fertility problems.

Latest Neurology News FRIDAY, Dec who can buy ventolin. 4, 2020 (HealthDay News)Depression, anxiety and suicidal thoughts are more common in who can buy ventolin children and teens with epilepsy than previously known, and they should be screened for such problems, researchers report.They assessed 119 children and teens, aged 9 to18, with epilepsy. None had been diagnosed with depression, anxiety or suicidal thoughts (suicidality).The screenings showed that about 30% of the youngsters had anxiety, nearly 40% had depression, and nearly 11% tested positive for suicidality, according to the study to be presented Friday at the virtual American Epilepsy Society annual meeting. Such research is considered preliminary until published in a peer-reviewed journal.A previous study found that 19% of youngsters with epilepsy have anxiety and 13% have depression."Compared to who can buy ventolin other studies, the percentage of children, adolescents and teens that screened positive for these mental health issues was quite a bit higher than expected," said study author Dr. Anjali Dagar, a clinical research fellow at Cleveland Clinic.In the general population, about 7% of 2- to 17-year-olds have anxiety and 3% have depression, according to the U.S.

Centers for Disease Control and Prevention who can buy ventolin. There are no clear statistics on suicidality among children and youth in that age range who haven't been diagnosed with depression.Most studies of suicidality in youths with epilepsy have been in children with preexisting psychiatric diagnoses, the researchers noted.They said this study is who can buy ventolin the first to assess screening for suicidality in youngsters with epilepsy with no known mental health history. The findings suggest that all children and teens with epilepsy would benefit from screening, even if they have no signs of problems, according to the researchers."Although this is a screening -- meaning the diagnosis must be confirmed by a psychiatrist -- our findings suggest it is important to screen all youths with epilepsy for underlying psychiatric issues even when there are no signs of concern," Dagar said in a meeting news release."The suicide [screening] tool revealed unrecognized suicidality in more than 1 of 10 youths with epilepsy, which is significant," said study co-author Dr. Tatiana Falcone, who can buy ventolin a child and adolescent psychiatrist at the Cleveland Clinic Epilepsy Center. "Suicidality is a life-threatening condition that can exist even in the absence of a preexisting diagnosis of depression or anxiety, so it's important all children, adolescents and teens with epilepsy get screened for all three mental health issues."More informationThe Epilepsy Foundation has more on epilepsy and mental health.SOURCE.

American Epilepsy Society, news release, Dec who can buy ventolin. 4, 2020Robert PreidtCopyright who can buy ventolin © 2020 HealthDay. All rights reserved. SLIDESHOW who can buy ventolin What Is Epilepsy?. Symptoms, Causes, and who can buy ventolin Treatments See SlideshowLatest Prevention &.

Wellness News By Ernie Mundell and Robin Foster HealthDay ReportersFRIDAY, Dec. 4, 2020 (HealthDay News) – President-elect Joseph Biden said Thursday that on his first day in office he would ask Americans to wear who can buy ventolin masks for 100 days, and that Dr. Anthony Fauci will play a pivotal role in his administration's fight to curb the spread of asthma."On the first day I'm inaugurated, I'm going to ask the public for 100 days to mask. Just 100 who can buy ventolin days to mask — not forever, just 100 days. And I think we'll see a significant reduction" in the ventolin, Biden told CNN.As for Fauci, Biden made it clear that the nation's top infectious diseases expert would be a central player in the U.S.

asthma response, The New York Times reported."I asked him to stay on in the exact same role he's had for the past several presidents, and I asked him to be a chief medical adviser for me as well, and be part of the asthma treatment team," Biden said.That response is facing its toughest challenge so far, as daily case counts, hospitalizations and deaths continue to set records on a daily basis.California, the first state to impose far-reaching lockdowns after the ventolin struck, announced strict new measures on Thursday, to try to keep a surge in cases from overwhelming hospitals, the Times reported.Millions of people across Southern and Central California are likely to see outdoor dining shuttered, playgrounds roped off and hair salons closed within days if the available who can buy ventolin intensive-care capacity in their areas dips below a 15 percent threshold, the Times reported.The new restrictions will last for at least three weeks, strictly limit store capacity and allow restaurants to serve only takeout or delivery."If we don't act now our hospital system will be overwhelmed," Gov. Gavin Newsom who can buy ventolin said. "If we don't act now, we'll continue to see our death rate climb."Other states have also taken stronger actions to slow the spread of asthma.In anticipation of a deadly holiday season, Gov. John Carney of Delaware on Thursday issued a stay-at-home who can buy ventolin advisory asking people not to gather indoors with anyone outside their household, the Times reported. In Michigan, Gov.

Gretchen Whitmer who can buy ventolin recently ordered a three-week shutdown that closed casinos and movie theaters and suspended in-person high school and college classes. Oregon, Washington State, Minnesota and cities from Los Angeles to Philadelphia have also re-imposed restrictions.Britain First to Approve Emergency Use of Pfizer's asthma treatmentBritain became the first Western country to allow emergency use of a asthma treatment on Wednesday, approving Pfizer's candidate in the race to inoculate millions of people around the globe.Having beat the United States to emergency authorization may pressure American regulators, who are already taking heat for not moving faster to get doses to people, who can buy ventolin the Times reported. And it has stirred up a global debate about how to balance the dire need for a treatment against the importance of looking for clear signs that a treatment is safe."Help is on its way with this treatment -- and we can now say that with certainty, rather than with all the caveats," British health secretary Matt Hancock said Wednesday.Though Britain has an early jump on distribution of the Pfizer treatment, it will have no effect on the distribution of the hundreds of millions of doses that other wealthy countries like the United States have bought in prepaid contracts, the Times said.But there are daunting obstacles to the treatment's delivery to the masses.The Pfizer treatment, developed with BioNTech, a smaller German firm, must be kept at the unspeakably cold temperature of minus 94 degrees Fahrenheit until shortly before shots are given. However, Pfizer said in a statement released Wednesday that it has developed shipping containers that use dry ice to keep who can buy ventolin the treatment cold. GPS sensors will allow the company to track each shipment and ensure they stay cold, the company added."Pfizer has vast experience and expertise in cold-chain shipping and has an established infrastructure to supply the treatment worldwide, including distribution hubs that can store treatment doses for up to six months," the company said.Still, the temperature requirement could dictate who will be vaccinated first in Britain.

While nursing home residents were supposed to be the top priority under an advisory committee's plans, who can buy ventolin efforts to limit transportation of the treatment to ensure it remains cold may mean that National Health Service staff will receive the shots first, the Times reported. The British government said Wednesday that 800,000 doses would be available by next week for health workers to begin administering.In the United States, an who can buy ventolin advisory panel on Tuesday approved a treatment distribution plan that recommends health care workers and nursing home residents and staff be the first to receive any approved asthma treatment. The recommendation from the Advisory Committee on Immunization Practice (ACIP), if heeded, will steer the initial short supply of treatments to about 21 million health care personnel and 3 million Americans working or living in long-term care facilities. An FDA advisory panel is set to meet who can buy ventolin on Dec. 10 to decide whether the agency should grant emergency authorization to the Pfizer treatment, the Times reported.The global race to develop a treatment is poised to shatter records for time to market.

Around the who can buy ventolin world, researchers are testing 57 treatments in clinical trials, and nearly 100 others are being tested in animals or cell, the Times reported. China and Russia have both approved treatments without waiting for the results of late-stage trials, which experts say raises safety concerns.A global scourgeBy who can buy ventolin Friday, the U.S. asthma case count passed 14.2 million while the death toll passed 276,000, according to a Times tally. According to the same who can buy ventolin tally, the top five states in asthma cases as of Friday were. Texas and California with roughly 1.3 million cases each.

Florida with who can buy ventolin just over 1 million cases. Illinois with more than 761,000 who can buy ventolin. And New York with nearly 679,000.Curbing the spread of the asthma in the rest of the world remains challenging.Many European countries are tightening restrictions, the Associated Press reported. France has entered a nationwide lockdown, and Germany and Austria have started partial lockdowns as government officials across the continent scramble to slow a sharp rise in s that threatens to overwhelm their health care systems.England has followed suit, while Italy, Greece and Kosovo also announced new measures, the AP reported.Things are no better in India, where the asthma who can buy ventolin case count passed 9.5 million on Friday, a Johns Hopkins University tally showed. More than 139,000 asthma patients have died in India, according to the Hopkins tally, but when measured as who can buy ventolin a proportion of the population, the country has had far fewer deaths than many others.

Doctors say this reflects India's younger and leaner population. Still, the country's public health system who can buy ventolin is severely strained, and some sick patients cannot find hospital beds, the Times said. Only the United States has more asthma cases.Meanwhile, Brazil neared 6.5 million cases and had over 175,000 deaths as of Friday, the Hopkins tally showed.Worldwide, the number of reported s passed 65 million on Friday, over 1.5 million deaths recorded, according to the Hopkins tally.More informationThe U.S. Centers for Disease Control and Prevention has who can buy ventolin more on the new asthma.SOURCES. The New who can buy ventolin York Times.

Associated PressCopyright © 2020 HealthDay. All rights reserved.Latest Pregnancy News who can buy ventolin FRIDAY, Dec. 4, 2020 (HealthDay News) -- A baby girl born in Tennessee from a 27-year frozen embryo broke the record for the longest-frozen embryo to result in a live birth, which was held by her older sister, Emma.Molly Gibson was 6 pounds, 13 ounces when she was born in October to Tina Gibson and her husband, Ben, The New York Times reported.Molly's birth was the result of an embryo being frozen in October 1992 and thawed in February 2020. Both she and Emma, who was born in 2017, came from embryos donated by the same couple in 1992.The Gibsons decided to use donated embryos because Ben has cystic fibrosis and Tina is a carrier, and they feared passing who can buy ventolin the disease on to their children, the Times reported.Biden to Ask Americans to Wear Masks for 100 DaysOne of Joe Biden's first acts as U.S. President will be to ask Americans to wear masks for 100 days.He told CNN' that he would make the request on Inauguration Day, the Associated Press reported."On the first day I'm inaugurated, I'm going to ask the public for who can buy ventolin 100 days to mask.

Just 100 days to mask — not forever, just 100 days. And I think we'll see a significant reduction" in the ventolin, Biden said.Biden has often said that mask-wearing is a "patriotic duty" and had floated the idea who can buy ventolin of a nationwide mandate, but decided that would be too difficult to enforce, the AP reported.No Full Sports Stadiums Before Summer. FauciDon't expect to see full sports stadiums in the United States before next summer, Dr. Anthony Fauci said Thursday."We're gonna who can buy ventolin be vaccinating the highest priority people [from] the end of December through January, February, March," said Fauci, director of the National Institute of Allergy and Infectious Diseases. "By the time you get to the general public, the people who'll be going to the basketball games, who don't have any underlying conditions, that's gonna be starting the end of April, May, June," he told Yahoo Sports, CNN reported."So, it probably will be well into the end of the summer before you can really feel comfortable who can buy ventolin [with full sports stadiums] -- if a lot of people get vaccinated.

I don't think we're going to be that normal in July. I think it probably would be by the end of the summer," Fauci said.He said the chances of having full NBA arenas in July during the league's finals will be "cutting it close," but it's "possible" there will be full NFL stadiums in September, CNN reported.Copyright © 2020 HealthDay. All rights reserved. QUESTION Men and women are equally likely to have fertility problems. See Answer.

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Take Ventolin by mouth. If Ventolin upsets your stomach, take it with food or milk. Do not take more often than directed. Talk to your pediatrician regarding the use of Ventolin in children. Special care may be needed. Overdosage: If you think you have taken too much of Ventolin contact a poison control center or emergency room at once. Note: Ventolin is only for you. Do not share Ventolin with others.

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Location. The Francis Crick Institute, Midland Road, LondonContract. Fixed Term (3 years), Full timeShort summary The position of Bioinformatics Officer within the Bioinformatics Core Facility will provide primarily computational and bioinformatics expertise to support high throughput post-genomic technologies (next generation sequencers), within an informed biological context, not only for research scientists within the Francis Crick Institute but also for other members of the Core group. In addition this role will provide support in bioinformatics where needed.This position will be part of an already existing Core team of 14 providing bioinformatics expertise to the Crick scientists.PROJECT SUMMARYUsing a variety of programming, statistical and data analysis techniques you will analyse data produced by the latest high throughput genomic technologies.

Typical analysis steps will cycle through quality assessment, results generation, biological interpretation and ultimately named publication. During this process you will be expected to work closely with other members of the bioinformatics team, the Downward lab and the advanced sequencing team.The Downward lab study the effect of oncogenic RAS signalling on the tumour microenvironment in lung cancer. With the recent clinical approval of sotorasib, the first drug targeting KRASG12C, we reached an important milestone in the treatment of this cancer. The Downward lab developed two orthotopic mouse models --immune cold and immune hot-- to test the effect KRASG12C inhibitors on the cancer cells and on the tumour immune microenvironment (TIME) in vivo.

In collaboration with the pharmaceutical company BMS, they generated CITE-Seq and imaging mass cytometry (IMC) data of treated and untreated tumours. Your main project will consist of analysing the CITE-Seq data and interact with other members of the team to correlate the finding with the observations made using IMC.About usThe Francis Crick Institute is a biomedical discovery institute dedicated to understanding the fundamental biology underlying health and disease. Its work is helping to understand why disease develops and to translate discoveries into new ways to prevent, diagnose and treat illnesses such as cancer, heart disease, stroke, s, and neurodegenerative diseases.An independent organisation, its founding partners are the Medical Research Council (MRC), Cancer Research UK, Wellcome, UCL (University College London), Imperial College London and King’s College London.The Crick was formed in 2015, and in 2016 it moved into a new state-of-the-art building in central London which brings together 1500 scientists and support staff working collaboratively across disciplines, making it the biggest biomedical research facility under in one building in Europe.The Francis Crick Institute will be world-class with a strong national role. Its distinctive vision for excellence includes commitments to collaboration.

Developing emerging talent and exporting it the rest of the UK. Public engagement. And helping turn discoveries into treatments as quickly as possible to improve lives and strengthen the economy.If you are interested in applying for this role, please apply via our website.The closing date for applications is 11 December 2021.All offers of employment are subject to successful security screening and continuous eligibility to work in the United Kingdom..

Location. The Francis Crick Institute, Midland Road, LondonContract. Fixed Term (3 years), Full timeShort summary The position of Bioinformatics Officer within the Bioinformatics Core Facility will provide primarily computational and bioinformatics expertise to support high throughput post-genomic technologies (next generation sequencers), within an informed biological context, not only for research scientists within the Francis Crick Institute but also for other members of the Core group. In addition this role will provide support in bioinformatics where needed.This position will be part of an already existing Core team of 14 providing bioinformatics expertise to the Crick scientists.PROJECT SUMMARYUsing a variety of programming, statistical and data analysis techniques you will analyse data produced by the latest high throughput genomic technologies.

Typical analysis steps will cycle through quality assessment, results generation, biological interpretation and ultimately named publication. During this process you will be expected to work closely with other members of the bioinformatics team, the Downward lab and the advanced sequencing team.The Downward lab study the effect of oncogenic RAS signalling on the tumour microenvironment in lung cancer. With the recent clinical approval of sotorasib, the first drug targeting KRASG12C, we reached an important milestone in the treatment of this cancer. The Downward lab developed two orthotopic mouse models --immune cold and immune hot-- to test the effect KRASG12C inhibitors on the cancer cells and on the tumour immune microenvironment (TIME) in vivo.

In collaboration with the pharmaceutical company BMS, they generated CITE-Seq and imaging mass cytometry (IMC) data of treated and untreated tumours. Your main project will consist of analysing the CITE-Seq data and interact with other members of the team to correlate the finding with the observations made using IMC.About usThe Francis Crick Institute is a biomedical discovery institute dedicated to understanding the fundamental biology underlying health and disease. Its work is helping to understand why disease develops and to translate discoveries into new ways to prevent, diagnose and treat illnesses such as cancer, heart disease, stroke, s, and neurodegenerative diseases.An independent organisation, its founding partners are the Medical Research Council (MRC), Cancer Research UK, Wellcome, UCL (University College London), Imperial College London and King’s College London.The Crick was formed in 2015, and in 2016 it moved into a new state-of-the-art building in central London which brings together 1500 scientists and support staff working collaboratively across disciplines, making it the biggest biomedical research facility under in one building in Europe.The Francis Crick Institute will be world-class with a strong national role. Its distinctive vision for excellence includes commitments to collaboration.

Developing emerging talent and exporting it the rest of the UK. Public engagement. And helping turn discoveries into treatments as quickly as possible to improve lives and strengthen the economy.If you are interested in applying for this role, please apply via our website.The closing date for applications is 11 December 2021.All offers of employment are subject to successful security screening and continuous eligibility to work in the United Kingdom..

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EAST LOS ANGELES http://treorisoft.com/?weblizar_portfolio=winsock-net — For the order ventolin online uk past year, 13-year-old twins Ariel Jr. And Abraham Osorio have logged on to their online classes from their parents’ flower shop. Ariel nestles in order ventolin online uk a corner among flowers, bows and stuffed animals. Abraham sets up on a small table in the back, where his dad used to work trimming flowers and keeping the books. It’s not ideal for learning.

It’s loud order ventolin online uk. It’s cramped. It’s bustling with people. Still, when the twins’ mother, Graciela order ventolin online uk Osorio, recently had the chance to send her kids back to Brightwood Elementary in Monterey Park, California, she decided against it. €œAfter what we went through with their father, I’d rather keep them at home where I know they are safe,” said Graciela, 51.

€œThere’s only a month left. It doesn’t make sense that they return for such a short time.” order ventolin online uk The boys’ father, Ariel Osorio Sr., 51, died of asthma treatment in January, four weeks after a trip to Mexico to visit his mother. He fell ill quickly and wasn’t able to say goodbye to his children. Graciela Osorio is mourning the loss of her husband, Ariel Osorio, who died of asthma treatment in January. (Heidi de order ventolin online uk Marco/KHN) “I miss his presence,” Abraham said.

€œI’m used to seeing him sit in his chair working, but not anymore.” Latinos have been hit disproportionately hard by asthma treatment, and many families are opting out of in-person learning. In California, Latinos make up 39% of the order ventolin online uk state’s population but account for 47% of asthma treatment deaths, according to the state Department of Public Health. Nationally, their risk of death from asthma treatment is 2.3 times higher than that of whites. Latinos are vulnerable to the highly transmissible asthma because they are more likely than non-Hispanic whites to work essential jobs that expose them to the public, said David Hayes-Bautista, a professor of public health and medicine at UCLA and co-author of a January study on this topic. They are more likely to lack health insurance, which may make them less likely to seek medical order ventolin online uk care, he said.

And they are more likely to live in multigenerational households, which means the ventolin can spread quickly and easily within families. €œMany of them are essential workers and the breadwinners for their families and don’t have the luxury of telework, of physical distancing and self-isolation,” said Alberto González, a senior health strategist at UnidosUS, a Latino advocacy group in Washington, D.C. The Osorio family has lived in a multigenerational household since Ariel died, and Graciela had to order ventolin online uk keep other family members in mind when deciding whether to send her boys back into the classroom. In February, Graciela and the twins moved in with her 74-year-old mother, Cleotilde Servin, in East Los Angeles. Ten people now share the roughly 1,000-square-foot home, squeezing by one another in the kitchen every morning.

Cleotilde Servin makes lunch for the family order ventolin online uk members who live with her, including two daughters, a son and several grandchildren. (Heidi de Marco/KHN) Graciela’s mother and the other adults in the home have been vaccinated, but the children haven’t. Even though she instructs her sons to wear their masks and doesn’t allow them to visit friends, she’s terrified of what could happen if her kids caught the ventolin at school and brought it home. €œMy mother is active and takes vitamins, but it still worries me,” Graciela order ventolin online uk said. She got asthma treatment from her husband and gave it to her sister and niece.

€œI don’t want anyone order ventolin online uk else to get sick,” she said. State and local education officials don’t have recent data on in-person attendance by race, but an EdSource analysis of California Public Health Department data from February shows that white students were more likely to attend school in person than other students. The analysis showed that 12% of Latinos were attending in-person classes at least some of the time, compared with 32% of whites and 18% of all students. The Los order ventolin online uk Angeles Unified School District, the second-largest in the country, serves more than 600,000 students and reopened for in-person learning in mid-April. Only some campuses are open, mostly elementary schools, and are running on hybrid schedules, combining on-campus classes with distance learning.

€œWe’ve upgraded the air fiation systems in every classroom, reconfigured school facilities to keep all at a school appropriately distanced, doubled the custodial staff, and we’ll provide weekly asthma treatment testing at school for every student and staff member,” district superintendent Austin Beutner said in his weekly recorded video update on March 22. In a statement released May 4, Beutner said 40% to 50% of elementary school students are now back in schools in “more affluent” communities compared with roughly order ventolin online uk 20% in low-income communities. €œWe see the greatest reluctance for children to be back in schools from families who live in some of the highest-needs communities we serve,” he said. Brightwood Elementary is a K-8 school with 870 students, about half of whom are Asian American and 40% Latino, said principal Robby Jung. Just 15% of students are back on campus, order ventolin online uk he said, and, of those, about one-third are Latino.

Ariel Osorio Jr. Works on his school homework at the back of the flower shop. (Heidi de Marco/KHN) Graciela Osorio owns order ventolin online uk Gracy’s Flower Shop in East Los Angeles, California, which she used to run with her husband. (Heidi de Marco/KHN) For the Osorio family, the overriding reason the eighth grade twins are not back at Brightwood is fear. Like so many other Latino families — roughly 28,000 Latinos have died of asthma treatment in California — they are reeling from the grief and trauma that the disease has already wrought, and the fear of what it could do if it struck again.

€œThe boys are seeing a therapist order ventolin online uk to deal with their dad’s death,” Graciela said. €œI know I should probably talk to someone, too.” With the memory of her husband’s death still so fresh that she can’t speak of him without crying, Graciela is still adjusting to the emotional toll, and to the day-to-day realities of running a flower shop by herself. Originally from Guerrero, Mexico, she started order ventolin online uk Gracy’s Flower Shop with her husband in 1997. Ariel took care of the finances at home and at the shop and was the better English speaker of the two. €œNow being alone with the boys, it’s more difficult to keep up,” she said.

After losing her husband to asthma treatment, Graciela Osorio decided not to let her sons return to in-person learning out of fear they might order ventolin online uk contract the ventolin at school. €œI tell them they have to stay focused now that their dad isn’t around to push them,” she says. (Heidi de Marco/KHN) During the asthma treatment lockdowns, the boys joined the couple at the shop. Her husband sat next to their children while they attended school order ventolin online uk online, helping with their homework and acting as the main contact for the school. €œThey were always with us,” Graciela said.

€œThey grew up in the flower shop, so they didn’t have a problem setting up their school stations there.” Brightwood reopened its doors April 12, offering in-person learning two days a week for a few hours a day, with the rest of the sessions online. Graciela said the limited order ventolin online uk schedule doesn’t work with her role as the family breadwinner. €œI would have to take them to school, pick them up for lunch and then bring them back,” she said. €œI can’t do that. I have to work.” But mostly she’s keeping them off campus because she doesn’t want to order ventolin online uk lose another family member.

She said she knows online classes aren’t the same as in-person instruction “but they have been keeping their grades up,” she said. €œI thank God order ventolin online uk I have good boys. They listen. They understand why I kept them home.” Abraham Osorio and Ariel Osorio Jr. Outside their order ventolin online uk mother’s flower shop.

(Heidi de Marco/KHN) The last day of school is May 28. Ariel and Abraham said they’re looking forward to high school in the fall. Still dealing order ventolin online uk with their father’s death, the boys, who are shy and reserved by nature, are torn between returning to school in person or continuing their classes online. €œWe might go back,” Abraham said. €œFor now, we keep each other company.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Heidi de order ventolin online uk Marco. heidid@kff.org, @Heidi_deMarco Related Topics Contact Us Submit a Story TipAn exclusive Montana resort wants to turn sewage into snow so that its rich and famous members can ski its slopes in a winter season that’s shrinking because of climate change. The Yellowstone Club — a ski and golf resort just north of Yellowstone National Park that counts Bill Gates, Justin Timberlake and Jessica Biel among its members — has asked the Montana Department of Environmental Quality for a permit to allow it to use wastewater for snowmaking operations on its ski slopes. About a dozen other order ventolin online uk ski areas across the U.S. Have used wastewater to make artificial snow before, but the Yellowstone Club would be the first in Montana.

The technique has also been used in Europe and Australia. Officials at the club say the program would not only ensure the slopes can open on time, usually in late November and early December, but also replenish the area’s watershed and keep streams running longer into the order ventolin online uk season. And it would allow the growing Big Sky resort area to handle its increasing wastewater volumes. €œIt’s an order ventolin online uk outside-the-box-idea,” said Rich Chandler, environmental manager for the club. €œBut it also checks a lot of boxes.” Is it a safe plan for the rich and famous who will occasionally ingest it when they wipe out on the slopes?.

The short answer from state officials is yes. The method is safe for order ventolin online uk people and the environment as long as there is close monitoring to ensure contamination levels stay within standards, according to an environmental analysis. But, the state officials said, that analysis did not study potential pollutants for which there are no environmental standards in wastewater, such as traces of prescription drugs. A similar effort to turn wastewater into snow was controversial at the Arizona Snowbowl ski resort near Flagstaff. To combat snowless winters there, the resort in the early 2000s purchased wastewater from Flagstaff and pumped it from the treatment plant to the ski area, where it would be turned into snow and sprayed onto order ventolin online uk the San Francisco Peaks.

That drew protests from the Hopi Tribe, which said the artificial snow posed risks to public health and the environment and would desecrate a mountain it considers sacred. The tribe lost a legal challenge to prevent the Arizona ski area from moving ahead with the plan. In December 2012, order ventolin online uk the ski area fired up its snow guns and started making powder. During the legal fight, environmental groups, including the Center for Biological Diversity, raised specific concerns about how wastewater can reduce local aquatic populations and cause some male fish to take on female appearances and reproductive traits. Wastewater’s effect on human health also raises concerns.

Although modern water treatment can eliminate many pollutants — and, in order ventolin online uk some instances, prepare that water for human consumption — some elements still escape the process, specifically pharmaceuticals. The research is in its infancy, but a 2017 study by the United Nations Educational, Scientific and Cultural Organization found that only half of the pharmaceutical compounds were removed in the water treatment process. It noted order ventolin online uk that evidence suggests some of the chemicals could affect human reproductive systems, too, just as studies have shown on aquatic life. “Modern wastewater treatment plants mostly reduce solids and bacteria by oxidizing the water. They were not designed to deal with complex chemical compounds,” said Birguy Lamizana-Diallo, program management officer at the United Nations Environment Program and an expert on wastewater treatment.

Officials in order ventolin online uk Montana are quick to point out differences between their plan and what happened in Arizona. For one, the ski area near Flagstaff often makes all its snow from treated wastewater, whereas the Yellowstone Club will use it, at least initially, on only about 10% of the 2,700 acres of skiable terrain and usually only in October and November to create a base layer for its ski runs. Come December, most of the snow people would be skiing and riding on would be natural. But perhaps the biggest difference between the two projects is the level of support the Yellowstone Club has for its plan, which is backed by environmental and conservation groups including the Gallatin River Task Force, the Association order ventolin online uk of Gallatin Agricultural Irrigators and Trout Unlimited. The idea to turn Big Sky’s wastewater into snow has been brewing for more than a decade and emerged from a collaboration between the Yellowstone Club and other local groups concerned about depleted snowpack due to climate change, which could starve area creeks and streams of water later in the season.

Yellowstone already http://www.ec-sud-illkirch-graffenstaden.ac-strasbourg.fr/?p=4108 uses treated wastewater to hydrate its golf courses, and in 2011 it teamed up with the Montana DEQ and the Gallatin River Task Force to see if they could safely turn the same water into snow. Chandler, the club’s environmental manager, said they successfully turned a half-million gallons of wastewater into 2 acres of snow about 18 order ventolin online uk inches deep. Kristin Gardner, executive director of the Gallatin River Task Force, said the snowmaking process effectively re-treats the wastewater by blasting it out of a filtered snowmaking gun that atomizes the water. €œIt’s an added layer of security for the human health side of things,” Chandler said. Chandler said the information gathered from the pilot study forms the core of the ski club’s application with the Montana order ventolin online uk DEQ.

A draft permit tentatively approving the project has been issued by the state agency, and a final decision is expected later this year. Officials at DEQ said that the wastewater used to make snow will be treated to the highest standards possible and that they can issue permits only to projects that will not pollute state waters. But the order ventolin online uk effect of pharmaceuticals remains uncharted territory. Amy Steinmetz, public water supply bureau chief, said that neither the DEQ nor the U.S. Environmental Protection Agency has standards to specifically treat wastewater for pharmaceuticals order ventolin online uk.

€œThe science is still emerging on that,” she said. If the DEQ does issue its final permit this year, the Yellowstone Club will most likely begin turning wastewater into snow in late 2022. It would then be required to post signage advising skiers not to consume the snow order ventolin online uk. Similar signage can be found at Arizona Snowbowl. Chandler said that the Yellowstone Club is proud of the collaborative work and that, ultimately, the process will benefit the community and watershed.

Making more snow and increasing the snowpack during the winter, Chandler estimates, will increase the summer runoff in area creeks by order ventolin online uk about 19 days, a big win in the increasingly arid West. It’s also better than the alternative, he said. Treating the wastewater and then just pushing it directly into the Gallatin River. €œIt’s not like the Earth is producing more order ventolin online uk water, so we have to use what we have effectively,” he said. Related Topics Contact Us Submit a Story Tip[Editor’s note.

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you order ventolin online uk can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] KIOWA, Colo. €” The yellow-and-green facade of Patty Ann’s Cafe stands out on the main street of this ranching community just 25 miles from the Denver suburbs. Before the ventolin, the cafe was a place for ranchers to order ventolin online uk gather for meals and to swap stories. “Some people would call it almost like a conference room,” said Lance Wheeler, a local rancher and regular at the cafe.

€œThere are some guys that, if you drive by Patty Ann’s at a certain time of day, their car or truck will always be there on certain days.” When asthma treatment restrictions closed in-person dining across Colorado last year, Patty Ann’s opened a takeout window. Customers spread their food on order ventolin online uk the hoods of their trucks and ate there while sharing news and commiserating over the stresses of ranching during the ventolin. Keeping that community hub operating has been vital for the ranchers around Kiowa as the ventolin takes its toll on mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent. Wheeler heads into Patty Ann’s Cafe for lunch. Ranchers often come to the Kiowa, Colorado, cafe for breakfast or lunch, which Wheeler order ventolin online uk said is a way to connect with others experiencing similar stresses.

€œThat’s your support group, because you have commonality, a common experience, common difficulty.” (Eli Imadali for KHN) Roberta Kusma (left) laughs with her old friend Betty Hood at Patty Ann’s Cafe. The two worked in the same building when it was a grocery store years ago. (Eli Imadali for KHN) The ventolin over the past year has been a order ventolin online uk surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business. But coupled with everyday worries about weather and commodity prices, the ventolin also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation found that about 3 in 5 rural adults reported that the ventolin has affected mental health in their communities, while two-thirds of farmers and farmworkers said the ventolin has impacted their mental health.

Treatment for mental health problems caused or worsened by the stress and order ventolin online uk isolation of the ventolin has obstacles particular to ranching and farming country. The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support. €œI guess my cows are my therapists,” joked order ventolin online uk Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the ventolin.

But he feels lucky to have a family that supports him order ventolin online uk. Because drought has impeded hay production in Colorado, Wheeler has had to have bales shipped in from South Dakota. Wheeler says the lack of rain has been his biggest stressor. (Eli Imadali for KHN) Similar to other Rocky Mountain states, Colorado has one of the highest order ventolin online uk suicide rates in the country. The rates are often worse in the state’s rural communities, a factor consistent with rural Americans’ risks nationwide.

A Centers for Disease Control and Prevention report examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties. Kiowa is in Elbert County, whose 1,850 square miles of mostly dusty, flat plains order ventolin online uk start where the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its suburban neighbors, just four clinics to serve a population of 27,000. A health care center in Elizabeth, Colorado, offers counseling, among other services. The few physical and mental health resources order ventolin online uk available in Elbert County are concentrated in the west, closer to Denver.

(Eli Imadali for KHN) Dwayne Smith, Elbert County’s public health director, said that to help solve the problem residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease. €œIn a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said. €œEven saying order ventolin online uk the words ‘anxiety,’ ‘depression,’ ‘mental health’ — all those things that in prior generations were very much a taboo subject.” Elbert County Public Health Director Dwayne Smith poses outside the Department of Health and Human Services, surrounded by prairie. (Eli Imadali for KHN) The public health crisis is just an added burden to the already high stress on people in the agricultural industry. €œFarmers and ranchers are absorbing a lot of the shocks order ventolin online uk to the system for us.

Hailstorms, pest outbreaks, drought, markets — they’re adjusting for all that to keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg. Unpredictable weather, a volatile commodity market and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her order ventolin online uk husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. But she was devastated after those losses, followed by her youngest child’s departure for college. €œThat’s kind of when the wheels fell off for me.

And then I kind order ventolin online uk of spiraled down,” Negley said. The ventolin exacerbated Laura Negley’s anxiety, isolating her from extended family and causing worry about her elderly parents.(Eli Imadali for KHN) Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six winter weeks getting counseling 200 miles north. Those visits eventually transitioned to phone counseling order ventolin online uk and an anti-anxiety medication. €œI do think you have to have a support group,” said Negley, who said her faith has helped her, too.

Over the years, slashed budgets to local health departments have cut to the bone. In Elbert County, Smith order ventolin online uk is one of just three full-time employees in his department. About 15 years ago, it had at least six nurses. It now has none. It is trying to order ventolin online uk hire one.

€œWe have a lack of health providers” in rural America, Negley said. €œThe ones we do have are doing their best — but they’re trying to wear multiple hats.” Negley talks with son Jayce as he repairs a sweep plow on their family land in Eads, Colorado order ventolin online uk. (Eli Imadali for KHN) Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. (Eli Imadali for KHN) Stressors like severe drought and exhaustion from unrelenting hard work can lead to mental health struggles for farmers and ranchers. Negley will likely not have cattle this year because drought impeded grass growth.(Eli Imadali for order ventolin online uk KHN) Agencies in Colorado recognize the need to improve mental health services offered to rural residents.

Colorado Crisis Services has a hotline and text-messaging number to refer people to free, confidential support. And the state is working on tailored messaging campaigns to help farmers and ranchers understand those numbers are free and confidential to contact. These services order ventolin online uk can help. According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide. A bill introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services.

€œWe have to be flexible order ventolin online uk. What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health. But in tightknit small towns, ranchers say, even if the resources are there the stigma remains. €œThese are normal order ventolin online uk people with normal problems. We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said.

€œTimecards and schedules have had no meaning for the order ventolin online uk past year,” says Smith, one of three full-time employees in his department. €œIt’s just been never-ending.” (Eli Imadali for KHN) Stigmas are something 26-year-old Jacob Walter and his family want to help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide. Before Walter order ventolin online uk left the family’s ranch in southeastern Colorado to start his sophomore year in college, he lost his own father, Rusty, to suicide in 2016. Walter said there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away.

Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression. €œThe day before he committed suicide, we had been order ventolin online uk talking at the kitchen table, and he was just talking about [his depression], and he said. €˜You know, you can always get help and stuff.’” That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should be conveyed most. It’s OK to acknowledge when you need help. €œIf your tractor needed maintenance … you would stop what you’re doing and you’d get it working right before you go try and go out in the field,” Atkinson said.

€œYou are the most important piece of equipment on your farm.” Cattle eat hay on Rafter W Ranch near Simla, Colorado. Drought hasn’t allowed grazing on grassy pastures. (Eli Imadali for KHN) [Editor’s note. If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] Related Topics Contact Us Submit a Story Tip.

EAST LOS ANGELES — For helpful hints the past year, 13-year-old twins Ariel Jr who can buy ventolin. And Abraham Osorio have logged on to their online classes from their parents’ flower shop. Ariel nestles who can buy ventolin in a corner among flowers, bows and stuffed animals. Abraham sets up on a small table in the back, where his dad used to work trimming flowers and keeping the books. It’s not ideal for learning.

It’s loud who can buy ventolin. It’s cramped. It’s bustling with people. Still, when the twins’ mother, Graciela Osorio, recently had the chance to send who can buy ventolin her kids back to Brightwood Elementary in Monterey Park, California, she decided against it. €œAfter what we went through with their father, I’d rather keep them at home where I know they are safe,” said Graciela, 51.

€œThere’s only a month left. It doesn’t make sense that they return for such a short time.” who can buy ventolin The boys’ father, Ariel Osorio Sr., 51, died of asthma treatment in January, four weeks after a trip to Mexico to visit his mother. He fell ill quickly and wasn’t able to say goodbye to his children. Graciela Osorio is mourning the loss of her husband, Ariel Osorio, who died of asthma treatment in January. (Heidi de Marco/KHN) “I who can buy ventolin miss his presence,” Abraham said.

€œI’m used to seeing him sit in his chair working, but not anymore.” Latinos have been hit disproportionately hard by asthma treatment, and many families are opting out of in-person learning. In California, Latinos make up 39% of the state’s population but account for 47% of asthma treatment deaths, according to the state who can buy ventolin Department of Public Health. Nationally, their risk of death from asthma treatment is 2.3 times higher than that of whites. Latinos are vulnerable to the highly transmissible asthma because they are more likely than non-Hispanic whites to work essential jobs that expose them to the public, said David Hayes-Bautista, a professor of public health and medicine at UCLA and co-author of a January study on this topic. They are who can buy ventolin more likely to lack health insurance, which may make them less likely to seek medical care, he said.

And they are more likely to live in multigenerational households, which means the ventolin can spread quickly and easily within families. €œMany of them are essential workers and the breadwinners for their families and don’t have the luxury of telework, of physical distancing and self-isolation,” said Alberto González, a senior health strategist at UnidosUS, a Latino advocacy group in Washington, D.C. The Osorio family has lived in a multigenerational household since who can buy ventolin Ariel died, and Graciela had to keep other family members in mind when deciding whether to send her boys back into the classroom. In February, Graciela and the twins moved in with her 74-year-old mother, Cleotilde Servin, in East Los Angeles. Ten people now share the roughly 1,000-square-foot home, squeezing by one another in the kitchen every morning.

Cleotilde Servin makes lunch for the family members who who can buy ventolin live with her, including two daughters, a son and several grandchildren. (Heidi de Marco/KHN) Graciela’s mother and the other adults in the home have been vaccinated, but the children haven’t. Even though she instructs her sons to wear their masks and doesn’t allow them to visit friends, she’s terrified of what could happen if her kids caught the ventolin at school and brought it home. €œMy mother is who can buy ventolin active and takes vitamins, but it still worries me,” Graciela said. She got asthma treatment from her husband and gave it to her sister and niece.

€œI don’t want who can buy ventolin anyone else to get sick,” she said. State and local education officials don’t have recent data on in-person attendance by race, but an EdSource analysis of California Public Health Department data from February shows that white students were more likely to attend school in person than other students. The analysis showed that 12% of Latinos were attending in-person classes at least some of the time, compared with 32% of whites and 18% of all students. The Los Angeles Unified School District, the second-largest in the country, who can buy ventolin serves more than 600,000 students and reopened for in-person learning in mid-April. Only some campuses are open, mostly elementary schools, and are running on hybrid schedules, combining on-campus classes with distance learning.

€œWe’ve upgraded the air fiation systems in every classroom, reconfigured school facilities to keep all at a school appropriately distanced, doubled the custodial staff, and we’ll provide weekly asthma treatment testing at school for every student and staff member,” district superintendent Austin Beutner said in his weekly recorded video update on March 22. In a statement released May 4, Beutner said 40% to 50% of elementary school students are now back in who can buy ventolin schools in “more affluent” communities compared with roughly 20% in low-income communities. €œWe see the greatest reluctance for children to be back in schools from families who live in some of the highest-needs communities we serve,” he said. Brightwood Elementary is a K-8 school with 870 students, about half of whom are Asian American and 40% Latino, said principal Robby Jung. Just 15% of students are back on campus, he who can buy ventolin said, and, of those, about one-third are Latino.

Ariel Osorio Jr. Works on his school homework at the back of the flower shop. (Heidi de who can buy ventolin Marco/KHN) Graciela Osorio owns Gracy’s Flower Shop in East Los Angeles, California, which she used to run with her husband. (Heidi de Marco/KHN) For the Osorio family, the overriding reason the eighth grade twins are not back at Brightwood is fear. Like so many other Latino families — roughly 28,000 Latinos have died of asthma treatment in California — they are reeling from the grief and trauma that the disease has already wrought, and the fear of what it could do if it struck again.

€œThe boys who can buy ventolin are seeing a therapist to deal with their dad’s death,” Graciela said. €œI know I should probably talk to someone, too.” With the memory of her husband’s death still so fresh that she can’t speak of him without crying, Graciela is still adjusting to the emotional toll, and to the day-to-day realities of running a flower shop by herself. Originally from Guerrero, Mexico, she started Gracy’s Flower Shop who can buy ventolin with her husband in 1997. Ariel took care of the finances at home and at the shop and was the better English speaker of the two. €œNow being alone with the boys, it’s more difficult to keep up,” she said.

After losing her husband to asthma treatment, Graciela Osorio decided not to let her sons return to in-person learning out of who can buy ventolin fear they might contract the ventolin at school. €œI tell them they have to stay focused now that their dad isn’t around to push them,” she says. (Heidi de Marco/KHN) During the asthma treatment lockdowns, the boys joined the couple at the shop. Her husband sat next to their children while they attended school online, helping with who can buy ventolin their homework and acting as the main contact for the school. €œThey were always with us,” Graciela said.

€œThey grew up in the flower shop, so they didn’t have a problem setting up their school stations there.” Brightwood reopened its doors April 12, offering in-person learning two days a week for a few hours a day, with the rest of the sessions online. Graciela said the limited schedule doesn’t who can buy ventolin work with her role as the family breadwinner. €œI would have to take them to school, pick them up for lunch and then bring them back,” she said. €œI can’t do that. I have to work.” But mostly she’s keeping them off campus because she doesn’t who can buy ventolin want to lose another family member.

She said she knows online classes aren’t the same as in-person instruction “but they have been keeping their grades up,” she said. €œI thank God I have good boys who can buy ventolin. They listen. They understand why I kept them home.” Abraham Osorio and Ariel Osorio Jr. Outside their who can buy ventolin mother’s flower shop.

(Heidi de Marco/KHN) The last day of school is May 28. Ariel and Abraham said they’re looking forward to high school in the fall. Still dealing with their father’s death, the boys, who who can buy ventolin are shy and reserved by nature, are torn between returning to school in person or continuing their classes online. €œWe might go back,” Abraham said. €œFor now, we keep each other company.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Heidi de who can buy ventolin Marco. heidid@kff.org, @Heidi_deMarco Related Topics Contact Us Submit a Story TipAn exclusive Montana resort wants to turn sewage into snow so that its rich and famous members can ski its slopes in a winter season that’s shrinking because of climate change. The Yellowstone Club — a ski and golf resort just north of Yellowstone National Park that counts Bill Gates, Justin Timberlake and Jessica Biel among its members — has asked the Montana Department of Environmental Quality for a permit to allow it to use wastewater for snowmaking operations on its ski slopes. About a dozen other ski who can buy ventolin areas across the U.S. Have used wastewater to make artificial snow before, but the Yellowstone Club would be the first in Montana.

The technique has also been used in Europe and Australia. Officials at the club say the program would not only ensure the slopes can open on time, usually in late November and early December, but also replenish the who can buy ventolin area’s watershed and keep streams running longer into the season. And it would allow the growing Big Sky resort area to handle its increasing wastewater volumes. €œIt’s an outside-the-box-idea,” said Rich Chandler, who can buy ventolin environmental manager for the club. €œBut it also checks a lot of boxes.” Is it a safe plan for the rich and famous who will occasionally ingest it when they wipe out on the slopes?.

The short answer from state officials is yes. The method is safe for people and the environment as long as there is close monitoring to ensure contamination levels stay within standards, according to an environmental analysis who can buy ventolin. But, the state officials said, that analysis did not study potential pollutants for which there are no environmental standards in wastewater, such as traces of prescription drugs. A similar effort to turn wastewater into snow was controversial at the Arizona Snowbowl ski resort near Flagstaff. To combat snowless winters there, the resort in the early 2000s purchased wastewater from Flagstaff and pumped it from the treatment plant to the ski area, where it would be turned into who can buy ventolin snow and sprayed onto the San Francisco Peaks.

That drew protests from the Hopi Tribe, which said the artificial snow posed risks to public health and the environment and would desecrate a mountain it considers sacred. The tribe lost a legal challenge to prevent the Arizona ski area from moving ahead with the plan. In December 2012, the ski who can buy ventolin area fired up its snow guns and started making powder. During the legal fight, environmental groups, including the Center for Biological Diversity, raised specific concerns about how wastewater can reduce local aquatic populations and cause some male fish to take on female appearances and reproductive traits. Wastewater’s effect on human health also raises concerns.

Although modern water treatment can eliminate many pollutants — and, in some instances, prepare that water for human consumption — who can buy ventolin some elements still escape the process, specifically pharmaceuticals. The research is in its infancy, but a 2017 study by the United Nations Educational, Scientific and Cultural Organization found that only half of the pharmaceutical compounds were removed in the water treatment process. It noted that evidence suggests some of the chemicals could affect human reproductive systems, too, just as studies have shown who can buy ventolin on aquatic life. “Modern wastewater treatment plants mostly reduce solids and bacteria by oxidizing the water. They were not designed to deal with complex chemical compounds,” said Birguy Lamizana-Diallo, program management officer at the United Nations Environment Program and an expert on wastewater treatment.

Officials in Montana are quick to point out differences between their plan and what happened in Arizona who can buy ventolin. For one, the ski area near Flagstaff often makes all its snow from treated wastewater, whereas the Yellowstone Club will use it, at least initially, on only about 10% of the 2,700 acres of skiable terrain and usually only in October and November to create a base layer for its ski runs. Come December, most of the snow people would be skiing and riding on would be natural. But perhaps the biggest difference between the two projects is the level of support the Yellowstone Club has for its plan, which is backed by environmental and conservation groups including the Gallatin River Task Force, the Association of who can buy ventolin Gallatin Agricultural Irrigators and Trout Unlimited. The idea to turn Big Sky’s wastewater into snow has been brewing for more than a decade and emerged from a collaboration between the Yellowstone Club and other local groups concerned about depleted snowpack due to climate change, which could starve area creeks and streams of water later in the season.

Yellowstone already uses treated wastewater to hydrate its golf courses, and in 2011 it teamed up with the Montana DEQ and the Gallatin River Task Force to see if order ventolin online they could safely turn the same water into snow. Chandler, the club’s environmental manager, said they successfully turned a half-million gallons who can buy ventolin of wastewater into 2 acres of snow about 18 inches deep. Kristin Gardner, executive director of the Gallatin River Task Force, said the snowmaking process effectively re-treats the wastewater by blasting it out of a filtered snowmaking gun that atomizes the water. €œIt’s an added layer of security for the human health side of things,” Chandler said. Chandler said the information gathered from the pilot study forms the core of the ski club’s application with who can buy ventolin the Montana DEQ.

A draft permit tentatively approving the project has been issued by the state agency, and a final decision is expected later this year. Officials at DEQ said that the wastewater used to make snow will be treated to the highest standards possible and that they can issue permits only to projects that will not pollute state waters. But the effect who can buy ventolin of pharmaceuticals remains uncharted territory. Amy Steinmetz, public water supply bureau chief, said that neither the DEQ nor the U.S. Environmental Protection Agency who can buy ventolin has standards to specifically treat wastewater for pharmaceuticals.

€œThe science is still emerging on that,” she said. If the DEQ does issue its final permit this year, the Yellowstone Club will most likely begin turning wastewater into snow in late 2022. It would then be required to post signage advising skiers not to consume the snow who can buy ventolin. Similar signage can be found at Arizona Snowbowl. Chandler said that the Yellowstone Club is proud of the collaborative work and that, ultimately, the process will benefit the community and watershed.

Making more snow and increasing the snowpack during who can buy ventolin the winter, Chandler estimates, will increase the summer runoff in area creeks by about 19 days, a big win in the increasingly arid West. It’s also better than the alternative, he said. Treating the wastewater and then just pushing it directly into the Gallatin River. €œIt’s not like the Earth is producing more water, so we have to use what who can buy ventolin we have effectively,” he said. Related Topics Contact Us Submit a Story Tip[Editor’s note.

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado who can buy ventolin Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] KIOWA, Colo. €” The yellow-and-green facade of Patty Ann’s Cafe stands out on the main street of this ranching community just 25 miles from the Denver suburbs. Before the ventolin, the cafe was a who can buy ventolin place for ranchers to gather for meals and to swap stories. “Some people would call it almost like a conference room,” said Lance Wheeler, a local rancher and regular at the cafe.

€œThere are some guys that, if you drive by Patty Ann’s at a certain time of day, their car or truck will always be there on certain days.” When asthma treatment restrictions closed in-person dining across Colorado last year, Patty Ann’s opened a takeout window. Customers spread their food on the hoods of who can buy ventolin their trucks and ate there while sharing news and commiserating over the stresses of ranching during the ventolin. Keeping that community hub operating has been vital for the ranchers around Kiowa as the ventolin takes its toll on mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent. Wheeler heads into Patty Ann’s Cafe for lunch. Ranchers often who can buy ventolin come to the Kiowa, Colorado, cafe for breakfast or lunch, which Wheeler said is a way to connect with others experiencing similar stresses.

€œThat’s your support group, because you have commonality, a common experience, common difficulty.” (Eli Imadali for KHN) Roberta Kusma (left) laughs with her old friend Betty Hood at Patty Ann’s Cafe. The two worked in the same building when it was a grocery store years ago. (Eli Imadali for KHN) The ventolin over the who can buy ventolin past year has been a surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business. But coupled with everyday worries about weather and commodity prices, the ventolin also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation found that about 3 in 5 rural adults reported that the ventolin has affected mental health in their communities, while two-thirds of farmers and farmworkers said the ventolin has impacted their mental health.

Treatment for mental health who can buy ventolin problems caused or worsened by the stress and isolation of the ventolin has obstacles particular to ranching and farming country. The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support. €œI guess who can buy ventolin my cows are my therapists,” joked Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the ventolin.

But he feels lucky to who can buy ventolin have a family that supports him. Because drought has impeded hay production in Colorado, Wheeler has had to have bales shipped in from South Dakota. Wheeler says the lack of rain has been his biggest stressor. (Eli Imadali for KHN) Similar to other Rocky Mountain states, Colorado has one of the who can buy ventolin highest suicide rates in the country. The rates are often worse in the state’s rural communities, a factor consistent with rural Americans’ risks nationwide.

A Centers for Disease Control and Prevention report examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties. Kiowa is in Elbert County, whose 1,850 square miles of who can buy ventolin mostly dusty, flat plains start where the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its suburban neighbors, just four clinics to serve a population of 27,000. A health care center in Elizabeth, Colorado, offers counseling, among other services. The few physical and mental health resources available in Elbert County are concentrated in who can buy ventolin the west, closer to Denver.

(Eli Imadali for KHN) Dwayne Smith, Elbert County’s public health director, said that to help solve the problem residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease. €œIn a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said. €œEven saying the words ‘anxiety,’ ‘depression,’ ‘mental health’ — all those things that in prior generations were very much a taboo subject.” Elbert County who can buy ventolin Public Health Director Dwayne Smith poses outside the Department of Health and Human Services, surrounded by prairie. (Eli Imadali for KHN) The public health crisis is just an added burden to the already high stress on people in the agricultural industry. €œFarmers and who can buy ventolin ranchers are absorbing a lot of the shocks to the system for us.

Hailstorms, pest outbreaks, drought, markets — they’re adjusting for all that to keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg. Unpredictable weather, a volatile commodity market and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her husband’s families have been in agriculture since the late 1600s and who can buy ventolin early 1700s, and they are now the third generation on the same Colorado land. But she was devastated after those losses, followed by her youngest child’s departure for college. €œThat’s kind of when the wheels fell off for me.

And then who can buy ventolin I kind of spiraled down,” Negley said. The ventolin exacerbated Laura Negley’s anxiety, isolating her from extended family and causing worry about her elderly parents.(Eli Imadali for KHN) Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six winter weeks getting counseling 200 miles north. Those visits eventually transitioned to phone counseling and an who can buy ventolin anti-anxiety medication. €œI do think you have to have a support group,” said Negley, who said her faith has helped her, too.

Over the years, slashed budgets to local health departments have cut to the bone. In Elbert County, Smith is one of just three full-time employees in his department who can buy ventolin. About 15 years ago, it had at least six nurses. It now has none. It is who can buy ventolin trying to hire one.

€œWe have a lack of health providers” in rural America, Negley said. €œThe ones we do have are doing their best — but they’re who can buy ventolin trying to wear multiple hats.” Negley talks with son Jayce as he repairs a sweep plow on their family land in Eads, Colorado. (Eli Imadali for KHN) Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. (Eli Imadali for KHN) Stressors like severe drought and exhaustion from unrelenting hard work can lead to mental health struggles for farmers and ranchers. Negley will likely not have cattle this year because drought impeded grass growth.(Eli Imadali for KHN) Agencies in Colorado recognize the need to who can buy ventolin improve mental health services offered to rural residents.

Colorado Crisis Services has a hotline and text-messaging number to refer people to free, confidential support. And the state is working on tailored messaging campaigns to help farmers and ranchers understand those numbers are free and confidential to contact. These services who can buy ventolin can help. According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide. A bill introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services.

€œWe have who can buy ventolin to be flexible. What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health. But in tightknit small towns, ranchers say, even if the resources are there the stigma remains. €œThese are normal people who can buy ventolin with normal problems. We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said.

€œTimecards and schedules have had no meaning for the past year,” says Smith, one of three full-time employees in who can buy ventolin his department. €œIt’s just been never-ending.” (Eli Imadali for KHN) Stigmas are something 26-year-old Jacob Walter and his family want to help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide. Before Walter left who can buy ventolin the family’s ranch in southeastern Colorado to start his sophomore year in college, he lost his own father, Rusty, to suicide in 2016. Walter said there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away.

Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression. €œThe day before he committed suicide, we had been talking at the kitchen table, and he was just talking about [his depression], and who can buy ventolin he said. €˜You know, you can always get help and stuff.’” That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should be conveyed most. It’s OK to acknowledge when you need help. €œIf your tractor who can buy ventolin needed maintenance … you would stop what you’re doing and you’d get it working right before you go try and go out in the field,” Atkinson said.

€œYou are the most important piece of equipment on your farm.” Cattle eat hay on Rafter W Ranch near Simla, Colorado. Drought hasn’t allowed grazing on grassy pastures. (Eli Imadali for KHN) [Editor’s note. If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] Related Topics Contact Us Submit a Story Tip.

Is ventolin and salbutamol the same thing

Justice, one of the four Beauchamp and Childress prima facie basic principles of is ventolin and salbutamol the same thing biomedical ethics, is explored in two excellent papers http://www.ec-cath-boersch.ac-strasbourg.fr/ in the current issue of the journal. The papers stem from a British Medical Association (BMA) essay competition on justice and fairness in medical practice and policy. Although the competition was open to (almost) is ventolin and salbutamol the same thing all comers, of the 235 entries both the winning paper by Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by practising doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself.

Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read.The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’.In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires.First, some background. As president I was offered the wonderful opportunity to pursue, with the organisation’s formidable assistance, a ‘project’ is ventolin and salbutamol the same thing consistent with the BMA’s interests and values.

As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp and Childress four principles approach to medical ethics,3 I chose to try to raise the ethical profile of justice and fairness within medical ethics.My first objective was to ask the BMA to ask the World Medical Association (WMA) to add an explicit commitment ‘to strive to practise fairly and justly throughout my professional life’ to its contemporary version of the Hippocratic Oath—the Declaration of Geneva4—and to the companion document the International Code of Medical Ethics.5 The stimulus for this proposal was the WMA’s addition in 2017 of the principle of respect for patients’ autonomy. Important as that addition is, it is widely perceived (though in my own view mistakenly) as being too much focused on individual patients and not enough on communities, groups and is ventolin and salbutamol the same thing populations. The simple addition of a commitment to fairness and justice would provide a ‘balancing’ moral commitment.Adding the fourth principleIt would also explicitly add the fourth of those four prima facie moral commitments, increasingly widely accepted by doctors internationally.

Two of them—benefiting our patients (beneficence) and doing so with as little harm as possible (non-maleficence)—have been an integral part of medical ethics since Hippocratic times. Respect for is ventolin and salbutamol the same thing autonomy and justice are very much more recent additions to medical ethics. The WMA, having added respect for autonomy to the Declaration of Geneva, should, I proposed, complete the quartet by adding the ‘balancing’ principle of fairness and justice.Since the Declaration is unlikely to be revised for several years, it seems likely that the proposal to add to it an explicit commitment to practise fairly and justly will have to wait.

However, an explicit commitment to justice and fairness has, at the BMA’s request, been added to the draft of the International Code of Medical Ethics and it seems reasonable to hope and expect that it will remain in the final document.Adding is ventolin and salbutamol the same thing a commitment to fairness and justice is the easy part!. Few doctors would on reflection deny that they ought to try to practise fairly and justly. It is far more difficult to say what is actually meant by this.

Two additional components of my Presidential project—the essay competition and a conference (which with luck will have been held, virtually, shortly before publication of this is ventolin and salbutamol the same thing editorial)—sought to help elucidate just what is meant by practising fairly and justly.One of the most striking features of the essay competition was the readiness of many writers to point to injustices in the context of medical practice and policy and describe ways of remedying them, but without giving a specific account of justice and fairness on the basis of which the diagnosis of injustice was made and the remedy offered.Wardrope’s winning essay comes close to such an approach by challenging the implied premise that an account of justice and fairness must provide some such formal theory. In preference, he points to the evident injustice and unsustainability of humans’ degradation of ‘the Land’ and its atmosphere and its inhabitants and then challenges some assumptions of contemporary philosophy and ethics, especially what he sees as their anthropocentric and individualistic focus. Instead, he invokes Leopold Aldo’s ‘Land Ethic’ (as well as drawing in aid Isabelle Stenger’s focus on ‘the intrusion of is ventolin and salbutamol the same thing Gaia’).

In his thoughtful and challenging paper, he seeks to refocus our ethics—including our medical ethics and our sense of justice and fairness—on mankind’s exploitative threat, during this contemporary ‘anthropocene’ stage of evolution, to the continuing existence of humans and of all forms of life in our ‘biotic community’. As remedy, the author, allying his approach to those of contemporary virtue ethics, recommends the beneficial outcomes that would be brought about by a sense of fairness and justice—a developed and sensitive ‘ecological conscience’ as he calls it—that embraces the interests of the entire biotic community of which we humans are but a part.Fritz and Cox pursue a very different and philosophically more conventional approach to the essay competition’s question and offer a combination and development of two established philosophical theories, those of John Rawls and Thomas Scanlon, to provide a philosophically robust and practically beneficial methodology for justice and fairness in medical practice and policy. Briefly summarised, they recommend is ventolin and salbutamol the same thing a two-stage approach for healthcare justice.

First, those faced with a problem of fairness or justice in healthcare or policy should use Thomas Scanlon’s proposed contractualist approach whereby reasonable people seek solutions that they and others could not ‘reasonably reject’. This stage would involve committees of decision-makers and representatives of relevant stakeholders looking at the immediate and longer term impact on existing stakeholders of proposed solutions. They would then check those solutions against substantive criteria of justice derived from is ventolin and salbutamol the same thing Rawls’ theory (which, via his theoretical device of the ‘veil of ignorance’, Rawls and the authors argue that all reasonable people can be expected to accept!.

). The Rawlsian criteria relied on is ventolin and salbutamol the same thing by Fritz and Cox are equity of access to healthcare. The ‘difference principle’ whereby avoidable inequalities of primary goods can only be justified if they benefit the most disadvantaged.

The just savings principle, of particular importance for ensuring intergenerational justice and sustainability. And a criterion of increased openness, transparency and accountability.It would of course be naïve to expect a single universalisable solution to the question ‘what do is ventolin and salbutamol the same thing we mean by fairness and justice in health care?. €™ As the papers by Wardrope1 and Fritz and Cox2 demonstrate, there can be very wide differences of approach in well-defended accounts.

My own hope for my project is to emphasise is ventolin and salbutamol the same thing the importance first of committing ourselves within medicine to practising fairly and justly in whatever branch we practise. And then to think carefully about what we do mean by that and act accordingly.Following AristotleFor my own part, over 40 years of looking, I have not yet found a single substantive theory of justice that is plausibly universalisable and have had to content myself with Aristotle’s formal, almost content-free but probably universalisable theory, according to which equals should be treated equally and unequals unequally in proportion to the relevant inequalities—what some health economists refer to as horizontal and vertical justice or equity.6Beauchamp and Childress in their recent eighth and ‘perhaps final’ edition of their foundational ‘Principles of biomedical ethics’1 acknowledge that ‘[t]he construction of a unified theory of justice that captures our diverse conceptions and principles of justice in biomedical ethics continues to be controversial and difficult to pin down’.They still cite Aristotle’s formal principle (though with less explanation than in their first edition back in 1979) and they still believe that this formal principle requires substantive or ‘material’ content if it is to be useful in practice. They then describe six different theories of justice—four ‘traditional’ (utilitarian, libertarian, communitarian and egalitarian) and two newer theories, which they suggest may be more helpful in the context of health justice, one based on capabilities and the other on actual well-being.They again end their discussion of justice with their reminder that ‘Policies of just access to health care, strategies of efficiencies in health care institutions, and global needs for the reduction of health-impairing conditions dwarf in social importance every other issue considered in this book’ …….

€˜every society must ration its resources but many societies can close gaps in fair rationing more conscientiously than they have to date’ [emphasis is ventolin and salbutamol the same thing added]. And they go on to stress their own support for ‘recognition of global rights to health and enforceable rights to health care in nation-states’.For my own part I recommend, perhaps less ambitiously, that across the globe we extract from Aristotle’s formal theory of justice a starting point that ethically requires us to focus on equality and always to treat others as equals and treat them equally unless there are moral justifications for not doing so. Where such justifications exist we should say what they are, explain the moral assumptions that justify them and, to the extent possible, seek the agreement of those affected.IntroductionIt did not occur to the Governor that there might be more than one definition of what is good … It did not occur to him that while the courts were writing one definition of goodness in the law books, fires were writing quite another one on the face of the is ventolin and salbutamol the same thing land.

(Leopold, ‘Good Oak’1, pp 10–11)As I wrote the abstract that would become this essay, wildfires were spreading across Australia’s east coast. By the time I was invited to write the essay, back-to-back winter storms were flooding communities all around my home. The essay has been written is ventolin and salbutamol the same thing in moments of respite between shifts during the asthma treatment ventolin.

Every one of these events was described as ‘unprecedented’. Yet each is becoming increasingly likely, and that due to our interactions with our environment.Public discourse surrounding these events is dominated by questions of justice and fairness. How to balance competing imperatives of protecting is ventolin and salbutamol the same thing individual lives against risk of spreading contagion.

How best to allocate scarce resources like intensive care beds or mechanical ventilators. The conceptual tools of clinical ethics is ventolin and salbutamol the same thing are well tailored to these sorts of questions. The rights of the individual versus the community, issues of distributive justice—these are familiar to anyone with even a passing acquaintance with its canonical debates.What biomedical ethics has remained largely silent on is how we have been left to confront these decisions.

How human activity has eroded Earth’s life support systems to make the ‘unprecedented’ the new normal. A medical ethic fit for the Anthropocene—our (still tentative) geological epoch defined by human influence on natural systems—must be able not just to react to the consequences of our exploitation of the is ventolin and salbutamol the same thing natural world, but reimagine our relationship with it.Those reimaginations already exist, if we know where to look for them. The ‘Land Ethic’ of the US conservationist Aldo Leopold offers one such vision.i Developed over decades of experience working in and teaching land management, the Land Ethic is most famously formulated in an essay of the same name published shortly before Leopold’s death fighting a wildfire on a neighbour’s farm.

It begins with a reinterpretation of the ethical relationship between humanity and the ‘land is ventolin and salbutamol the same thing community’, the ecosystems we live within and depend upon. Moving us from ‘conqueror’ to ‘plain member and citizen’ of that community1 (p 204). Land ceases to be a resource to be exploited for human need once we view ourselves as part of, and only existing within, the land community.

Our moral evaluations is ventolin and salbutamol the same thing shift consonantly:A thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.1 (pp 224–225)The justice of the Land Ethic questions many presuppositions of biomedical ethics. By valuing the community in itself—in a way irreducible to the welfare of its members—it steps away from the individualism axiomatic in contemporary bioethics.2 Viewing ourselves as citizens of the land community also extends the moral horizons of healthcare from a solely human is ventolin and salbutamol the same thing focus, taking seriously the interests of the non-human members of that community.

Taking into account the ‘stability’ of the community requires intergenerational justice—that we consider those affected by our actions now, and their implications for future generations.3 The resulting vision of justice in healthcare—one that takes climate and environmental justice seriously—could offer health workers an ethic fit for the future, demonstrating ways in which practice must change to do justice to patients, public and planet—now and in years to come.Healthcare in the AnthropoceneSeemeth it a small thing unto you to have fed upon good pasture, but ye must tread down with your feet the residue of your pasture?. And to have drunk of the clear waters, but ye must foul the residue with your feet?. (Ezekiel 34:18, quoted in Leopold, ‘Conservation in the Southwest’4, p 94)The majority of the development of human societies is ventolin and salbutamol the same thing worldwide—including all of recorded human history—has taken place within a single geological epoch, a roughly 11 600 yearlong period of relative warmth and climatic stability known as the Holocene.

That stability, however, can no longer be taken for granted. The epoch that has sustained most of human development is giving way to one shaped by the planetary consequences of that development—the Anthropocene.The Anthropocene is marked by accelerating degradation of the ecosystems that have sustained human societies. Human activity is already estimated to have raised is ventolin and salbutamol the same thing global temperatures 1°C above preindustrial levels, and if emissions continue at current levels we are likely to reach 1.5°C between 2030 and 2052.5 The global rate of species extinction is orders of magnitude higher than the average over the past 10 million years.6 Ocean acidification, deforestation and disruption of nitrogen and phosphorus flows are likely at or beyond sustainable planetary boundaries.7Yet this period has also seen rapid (if uneven) improvements in human health, with improved life expectancy, falling child mortality and falling numbers of people living in extreme poverty.

The 2015 report of the Rockefeller Foundation-Lancet Commission on planetary health explained this dissonance in stark terms. €˜we have is ventolin and salbutamol the same thing been mortgaging the health of future generations to realise economic and development gains in the present.’7In the instrumental rationality of modernity, nature has featured only as inexhaustible resource and infinite sink to fuel social and economic ends. But this disenchanted worldview can no longer hide from the implausibility of these assumptions.

It cannot resist what the philosopher Isabelle Stengers has called ‘the intrusion of Gaia’.8 The present ventolin—made more likely by deforestation, land use change and biodiversity loss9—is just the most immediately salient of these intrusions. Anthropogenic environmental changes are increasing undernutrition, increasing range and transmissibility of many vectorborne and waterborne diseases like dengue fever and cholera, increasing frequency and severity of extreme weather events like heatwaves and wildfires, is ventolin and salbutamol the same thing and driving population exposure to air pollution—which already accounts for over 7 million deaths annually.10These intrusions will shape healthcare in the Anthropocene. This is because health workers will have to deal with their consequences, and because modern industrialised healthcare as practised in most high-income countries—and considered aspirational elsewhere—was borne of the same worldview that has mortgaged the health of future generations.

The health sector in the USA is estimated to account for 8% of the country’s greenhouse gas footprint.11 Pharmaceutical production and waste causes more local environmental degradation, accumulating in water supplies with is ventolin and salbutamol the same thing damaging effects for local flora and fauna.12 Public health has similarly embraced short-term gains with neglect of long-term consequences. Health messaging was instrumental to the development and popularisation of many disposable and single-use products, while a 1947 report funded by the Rockefeller Foundation (who would later fund the landmark 2015 Lancet report on planetary health) popularised the high-meat, high-dairy ‘American’ diet—dependent on fossil fuel-driven intensive agricultural practices—as the healthy ideal.13Healthcare fit for the Anthropocene requires a shift in perspectives that allows us to see and work with the intrusion of Gaia. But can dominant approaches in bioethics incorporate that shift?.

A perfect moral stormWe have built a beautiful piece of social machinery … which is coughing along on two cylinders because we have been too timid, and too anxious for quick success, to tell the farmer the true magnitude of his is ventolin and salbutamol the same thing obligations. (Leopold, ‘The Ecological Conscience’4, p 341)At local, national and international scales, the lifestyles of the wealthiest pose an existential threat to the poorest and most marginalised in society. Our actions now are depriving future generations of the environmental is ventolin and salbutamol the same thing prerequisites of good health and social flourishing.

If justice means, as Ranaan Gillon parses it, ‘the moral obligation to act on the basis of fair adjudication between competing claims’,14 then this state of affairs certainly seems unjust. However, the tools available for grappling with questions of justice in bioethics seem ill equipped to deal with these sorts of injustice.To illustrate this problem, consider how Gillon further fleshes out his description of justice. In terms of fair distribution of scarce is ventolin and salbutamol the same thing resources, respect for people’s rights, and respect for morally acceptable laws.

The first of these—labelled distributive justice—concerns how fairly to allot finite resources among potential beneficiaries. Classic problems of distributive justice in healthcare concern a group of people at a particular time (usually patients), who could each benefit from a particular resource (historically, discussions have often focused on transplant organs. More recently, intensive is ventolin and salbutamol the same thing care beds and ventilators have come to the fore).

But there are fewer of these resources than there are people with a need for them. Such discussions are not easy, but they are at least familiar—we know where to begin with is ventolin and salbutamol the same thing them. We can consider each party’s need, their potential to benefit from the resource, any special rights or other claims they may have to it, and so forth.

The distribution of benefits and harms in the Anthropocene, however, does not comfortably fit this formalism. It is one thing to say that there is but one intensive care bed, from which Smith has a good chance of gaining another year is ventolin and salbutamol the same thing of life, Jones a poor chance, and so offer it to Smith. Another entirely to say that production of the materials consumed in Smith’s care has contributed to the degradation of scarce water supplies on the other side of the globe, or that the unsustainable pattern of energy use will affect innumerable other future persons in poorly quantifiable ways through fuelling climate change.

The calculations of distributive justice are well suited to problems where there are a set pool of potential beneficiaries, and the is ventolin and salbutamol the same thing use of the scarce resources available affects only those within that pool. But global environmental problems do not fit this pattern—the effects of our actions are spatially and temporally dispersed, so that large numbers of present and future people are affected in different ways.Nor can this problem be readily addressed by turning to Gillon’s second category of obligations of justice, those grounded in human rights. For while it might be plausible (if not entirely uncontroversial) to say that those communities whose water supplies are degraded by pharmaceutical production have a right to clean water, it is another thing entirely to say that Smith’s healthcare is directly violating that right.

It would not be true to say that, were is ventolin and salbutamol the same thing it not for the resources used in caring for Smith, that the communities in question would face no threat to water security—indeed, they would likely make no appreciable difference. Similarly for the effects of Smith’s care on future generations facing accelerating environmental change.iiThe issue here is of fragmentation of agency. While it is not the case that Smith’s care is directly responsible for these environmental harms, the cumulative consequences of many such acts—and the ways in which these acts are embedded in particular systems of energy generation, waste management, international trade, and so on—are reliably is ventolin and salbutamol the same thing producing these harms.

The injustice is structural, in Iris Marion Young’s terminology—arising from the ways in which social structures constrain individuals from pursuing certain courses of action, and enable them to follow others, with side effects that cumulatively produce devastating impacts.15Gillon describes the third component of justice as respect for morally acceptable laws. But there is little reason to believe that existing legal frameworks provide sufficient guidance to address these structural injustices. While the intricacies of global governance are well beyond what I can hope to address here, the stark fact remains that, despite the http://go-fore-the-green.com/?p=814 international commitment of the 2015 Paris Agreement to attempt to keep global temperature rise to 1.5°C above preindustrial levels, the Intergovernmental Panel on Climate Change estimates that present national commitments—even if these are substantially increased in coming years—will take us well beyond that target.5 Confronted by such institutional inadequacy, respect for the rule of law is inadequate to remedy injustice.The confluence of these particular features—dispersion of causes and effects, fragmentation of agency and institutional inadequacy—makes it difficult for us to reason ethically about is ventolin and salbutamol the same thing the choices we have to make.

Stephen Gardiner calls this a ‘perfect moral storm’.16 Each of these factors individually would be difficult to address using the resources of contemporary biomedical ethics. Their convergence makes it seem insurmountable.This perfect storm was not, however, unpredictable. Van Rensselaer Potter, a professor of Oncology responsible for introducing the term ‘bioethics’ into Anglophone discourse, is ventolin and salbutamol the same thing observed that since he coined the phrase, the study of bioethics had diverged from his original usage (governing all issues at the intersection of ethics and the biological sciences) to a narrow focus on the moral dilemmas arising in interactions between individuals in biomedical contexts.

Potter predicted that the short-term, individualistic and medicalised focus of this approach would result in a neglect of population-level and ecological-level issues affecting human and planetary health, with catastrophic consequences.17 His proposed solution was a new ‘global bioethics’, grounded in a new understanding of humanity’s position within planetary systems—one articulated by the Land Ethic.The Land EthicA land ethic changes the role of Homo sapiens from conqueror of the land-community to plain member and citizen of it. It implies respect for his fellow-members, and also respect for the community as such.iii (Leopold, ‘The Land Ethic’1, p 204)Developed throughout a career in forestry, conservation and wildlife management, the Land Ethic is less an is ventolin and salbutamol the same thing attempt to provide a set of maxims for moral action, than to shift our perspectives of the moral landscape. In his working life, Aldo Leopold witnessed how actions intended to optimise short-term economic outcomes eroded the environments on which we depend—whether soil degradation arising from intensive farming and deforestation, or disruption of freshwater ecosystems by industrial dairy farming.

He also saw that contemporary morality remained silent on such actions, even when their consequences were to the collective detriment of all.Leopold argued that a series of ‘historical accidents’ left our morality particularly ill suited to handle these intrusions of Gaia—with a worldview that considered them ‘intrusions’, rather than the predictable response of our biotic community. These ‘accidents’ is ventolin and salbutamol the same thing were. The unusual resilience of European ecological communities to anthropogenic interference (England survived an almost wholesale deforestation without consequent loss of ecosystem resilience, while similar changes elsewhere resulted in permanent environmental degradation).

And the legacy of European settler colonialism, is ventolin and salbutamol the same thing meaning that an ethic arising in these particular conditions came to dominate global social arrangements4 (p 311). The first of these supported a worldview in which ‘Land … is … something to be tamed rather than something to be understood, loved, and lived with. Resources are still regarded as separate entities, indeed, as commodities, rather than as our cohabitants in the land community’4 (p 311).

The second enabled the is ventolin and salbutamol the same thing marginalisation of other views. In this genealogy, Leopold anticipated the perfect moral storm discussed above. His intent with the Land Ethic was is ventolin and salbutamol the same thing to navigate it.There are three key components of the Land Ethic that comprise the first three sections of Leopold’s final essay on the subject.

(1) the ‘community concept’ that allows communities as wholes to have intrinsic value. (2) the ‘ethical sequence’ that situates the value of such communities as extending, not replacing, values assigned to individuals. And (3) the ‘ecological conscience’ that views ethical action not in terms of following a particular code, is ventolin and salbutamol the same thing but in developing appropriate moral perception.The community conceptThe most widely quoted passage of Leopold’s opus—already cited above, and frequently (mis)taken as a summary maxim of the ethic—states that:A thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community.

It is wrong when it tends otherwise.1 (pp 224–225)This passage makes the primary object of our moral responsibilities ‘the biotic community’, a term Leopold uses interchangeably with the ‘land community’. Leopold’s community concept is notable in at least three respects. Its holism—an embrace of the moral significance of communities in a way that is not simply reducible to the significance of its individual members is ventolin and salbutamol the same thing.

Its understanding of communities as temporally extended, placing importance on their ‘integrity’ and ‘stability’. And its rejection of anthropocentrism, affording humanity a place as ‘plain member and citizen’ of a broader land community.Individualism is so prevalent in biomedical ethics that it is scarcely argued for, instead forming part of is ventolin and salbutamol the same thing the ‘background constellation of values’2 tacitly assumed within the field. We are used to evaluating the well-being of a community as a function of the well-being of its individual members—this is the rationale underlying quality-adjusted life year calculations endemic within health economics, and most discussions of distributive justice adopt some variation of this approach.

Holism instead proposes that this makes no more sense than evaluating a person’s well-being as an aggregate of the well-being of their individual organs. While we can sensibly talk about people’s hearts, livers or kidneys, their health is defined in terms is ventolin and salbutamol the same thing of and constitutively dependent on the health of the person as a whole. Similarly, holism proposes, while individuals can be identified separately, it only makes sense to talk about them and their well-being in the context of the larger biotic community which supports and defines us.Holism helps us to negotiate the issues that confront individualistic accounts of collective well-being in Anthropocene health injustices.

In the previous section, we found in the environmental consequences of industrialised healthcare that it is is ventolin and salbutamol the same thing difficult to identify which parties in particular are harmed, and how much each individual action contributes to those harms. But our intuition that the overall result is unfair or unjust is itself a holistic assessment of the overall outcome, not dependent on our calculation of the welfare of every party involved. Holism respects the intuition that says—no matter the individuals involved—a world where people now exploit ecological resources in a fashion that deprives people in the future of the prerequisites of survival, is worse than one where communities now and in the future live in a sustainable relationship with their environment.The second aspect of Leopold’s community concept is that the community is something that does not exist at a single time and place—it is defined in terms of its development through time.

Promoting the ‘integrity’ and ‘stability’ is ventolin and salbutamol the same thing of the community requires that we not just consider its immediate interests, but how that will affect its long-term sustainability or resilience. We saw earlier the difficulties in trying to say just who is harmed and how when we approach harm to future generations individualistically. But from the perspective of the Land is ventolin and salbutamol the same thing Ethic, when we exploit environmental resources in ways that will have predictable damaging results for future generations, the object of our harm is not just some purely notional future person.

It is a presently existing, temporally extended entity—the community of which they will be part.Lastly, Leopold’s community is quite consciously a biotic—not merely human—community. Leopold defines the land community as the open network of energy and mineral exchange that sustains all aspects of that network:Land… is not merely soil. It is is ventolin and salbutamol the same thing a fountain of energy flowing through a circuit of soils, plants, and animals.

Food chains are the living channels which conduct energy upward. Death and decay return it to the soil. The circuit is ventolin and salbutamol the same thing is not closed.

Some energy is dissipated in decay, some is added by absorption, some is stored in soils, peats, and forests, but it is a sustained circuit, like a slowly augmented revolving fund of life.4 (pp 268–269)While the components within this network may change, the land community as a whole remains stable when the overall complexity of the network is not disrupted—other components are able to adjust to these changes, or new ones arise to take their place.ivThe normative inference Leopold makes from his understanding of the land community is this. It makes no sense to single out individual entities within the community as being especially valuable or useful, without taking into account the whole community upon which they mutually is ventolin and salbutamol the same thing depend. To do so is self-defeating.

By privileging the interests of a few members of the community, we ultimately undermine the prerequisites of their existence.The ethical sequenceThe Land Ethic’s holism is in fact its most frequently critiqued feature. Its emphasis on the value of the biotic community leads some is ventolin and salbutamol the same thing to allege a subjugation of individual interests to the needs of the environment. This critique neglects how Leopold positions the Land Ethic in what he calls the ‘ethical sequence’.

This is the gradual extension of scope of ethical considerations, both in terms of the complexity of social interactions they cover (from interactions between two people, to the structure of progressively larger social groups), and in is ventolin and salbutamol the same thing the kinds of person they acknowledge as worthy of moral consideration (as we resist, for example, classist, sexist or racist exclusions from personhood).This sequence serves less as a description of the history of morality, than a prescription for how we should understand the Land Ethic as adding to, rather than supplanting, our responsibilities to others. We do not argue that taking seriously health workers’ responsibilities for public health and health promotion supplants their duties to the patients they work with on a daily basis. Similarly, the Land Ethic implies ‘respect for [our] fellow members, and also respect for the community as such’1 (p 204).

At times, our responsibilities towards these different parties may come into tension is ventolin and salbutamol the same thing. But balancing these responsibilities has always been part of the work of clinical ethics.The ecological conscienceIf the community concept gives a definition of the good, and the ethical sequence situates this definition within the existing moral landscape, neither offers an explicit decision procedure to guide right action. In arguing is ventolin and salbutamol the same thing for the ‘ecological conscience’, Leopold explains his rationale for not attempting to articulate such a procedure.

In his career as conservationist, Leopold witnessed time and again laws nominally introduced in the name of environmental protection that did little to achieve their long-term goals, while exacerbating other environmental threats.v This is not surprising, given the ‘perfect moral storm’ of Anthropocene global health and environmental threats discussed above. The cumulative results of apparently innocent actions can be widespread and damaging.Leopold’s response to this problem is to advocate the cultivation of an ‘ecological conscience’. What is needed to promote a healthy human relationship with the land community is not for us to be told exactly how and how not to act in the face of environmental health threats, but rather to shift our view of the land from ‘a commodity belonging to us’ towards ‘a community to which we belong’1 (p viii) is ventolin and salbutamol the same thing.

To understand what the Land Ethic requires of us, therefore, we should learn more about the land community and our relationship with it, to develop our moral perception and extend its scope to embrace the non-human members of our community.Seen in this light, the Land Ethic shares much in common with virtue ethics, where right action is defined in terms of what the moral agent would do, rather than vice versa. But rather than the Eudaimonia of individual human flourishing proposed by Aristotle, the phronimos of the Land Ethic sees their telos coming from their position within the land community. While clinical virtue ethicists have traditionally taken the virtues of medical practice to be grounded in the interaction with individual patients, the realities of healthcare in the Anthropocene mean that limiting our moral perceptions in this way would ultimately be self-defeating—hurting those very patients we mean to serve (and many more besides).18 The virtuous clinician must adopt a view of the moral world that can focus on a person both as an individual, and simultaneously as is ventolin and salbutamol the same thing member of the land community.

I will close by exploring how adopting that perspective might change our practice.Justice in the AnthropoceneFailing this, it seems to me we fail in the ultimate test of our vaunted superiority—the self-control of environment. We fall back into the biological category of the potato bug is ventolin and salbutamol the same thing which exterminated the potato, and thereby exterminated itself. (Leopold, ‘The River of the Mother of God’4, p 127)I have articulated some of the challenges healthcare faces in the Anthropocene.

I have suggested that the tools presently available to clinical ethics may be inadequate to meet them. The Land Ethic invites us to is ventolin and salbutamol the same thing reimagine our position in and relationship with the land community. I want to close by suggesting how the development of an ecological conscience might support a transition to more just healthcare.

I will not is ventolin and salbutamol the same thing endeavour to give detailed prescriptions for action, given Leopold’s warnings about the limitations of such codifications. Rather, I will attempt to show how the cultivation of an ecological conscience might change our perception of what justice demands. Following the tradition of virtue ethics with which the Land Ethic holds much in common, this is best achieved by looking at models of virtuous action, and exploring what makes it virtuous.19Industrialised healthcare developed within a paradigm that saw the environment as inert resource and held that the scope of clinical ethics ranged only over the clinician’s interaction with their patients.

When we begin to see clinician and patient not as standing apart from the environment, but as is ventolin and salbutamol the same thing ‘member and citizen of the land community’, their relationship with one another and with the world around them changes consonantly. The present ventolin has only begun to make commonplace the idea that health workers do not simply treat infectious diseases, but interact with them in a range of ways, including as vector—and as a result our moral obligations in confronting them may extend beyond the immediate clinical encounter, to cover all the other ways we may contract or spread disease. But we is ventolin and salbutamol the same thing may be responsible for disease outbreaks with conditions other than asthma treatment, and in ways beyond simply becoming infected.

The development of an ecological conscience would show how our practices of consumption may fuel deforestation that accelerates the emergence of novel pathogens, or support intensive animal rearing that drives antibiotic resistance.18The Land Ethic also challenges us not to abstract our work away from the places in which it takes place. General practitioner surgeries and hospitals are situated within social and land communities alike, shaping and shaped by them. These spaces can be used in ways that support or is ventolin and salbutamol the same thing undermine those communities.

Surgeries can work to empower their communities to pursue more sustainable and healthy diets by doubling as food cooperatives, or providing resources and ‘social prescriptions’ for increased walking and cycling. Hospitals can use their extensive real estate to provide publicly accessible green and wild spaces within urban environments, and use their role as major nodes in transport infrastructure to change that infrastructure to support active travel alternatives.ivThe Land Ethic reminds us that a community (human or land) is not healthy if its flourishing cannot be sustainably maintained. An essential component of Anthropocene health justice is ventolin and salbutamol the same thing is intergenerational justice.

Contemporary industrialised healthcare has an unsustainable ecological footprint. Continuing with such a model of care would serve only to mortgage the health of future generations for the sake of those living is ventolin and salbutamol the same thing now. Ecologically conscious practice must take seriously the sorts of downstream, distributed consequences of activity that produce anthropogenic global health threats, and evaluate to what extent our most intensive healthcare practices truly serve to promote public and planetary health.

It is not enough for the clinician to assume that our resource usage is a necessary evil in the pursuit of best clinical outcomes, for it is already apparent that much of our environmental exploitation is of minimal or even negative long-term value. The work of the National Health Service (NHS) Sustainable Development Unit has seen a 10% reduction in greenhouse gas emissions in the NHS from 2007 to 2015 despite an 18% increase in clinical activity,20 while different models of care used in less is ventolin and salbutamol the same thing industrialised nations manage to provide high-quality health outcomes in less resource-intensive fashion.21ConclusionOur present problem is one of attitudes and implements. We are remodelling the Alhambra with a steam-shovel.

We shall hardly relinquish the steam-shovel, which after all has many good points, but we are in need of gentler and more objective criteria for its is ventolin and salbutamol the same thing successful use. (Leopold, ‘The Land Ethic’1, p 226)The moral challenges of the Anthropocene do not solely confront health workers. But the potentially catastrophic health effects of anthropogenic global environmental change, and the contribution of healthcare activity to driving these changes provide a specific and unique imperative for action from health workers.Yet it is hard to articulate this imperative in the language of contemporary clinical ethics, ill equipped for this intrusion of Gaia.

Justice in the Anthropocene requires us to be able to adopt a perspective from which these changes no longer appear as is ventolin and salbutamol the same thing unexpected intrusions, but that acknowledges the land community as part of our moral community. The Land Ethic articulates an understanding of justice that is holistic, structural, intergenerational, and rejects anthropocentrism. This understanding seeks not to supplant, but to augment, our existing one is ventolin and salbutamol the same thing.

It aims to do so by helping us to develop an ‘ecological conscience’, seeing ourselves as ‘plain member and citizen’ of the land community. The Land Ethic does not provide a step-by-step guide to just action. Nor does it definitively adjudicate is ventolin and salbutamol the same thing on how to balance the interests of our patients, other populations now and in the future, and the planet.

It could, however, help us on the first step towards that change—showing how to cultivate the ‘internal change in our intellectual emphasis, loyalties, affections, and convictions’1 (pp 209–210) necessary to realise the virtues of just healthcare in the Anthropocene.AcknowledgmentsThis essay was written as a submission for the BMA Presidential Essay Prize. I am grateful to the organisers and judging panel for the opportunity..

Justice, one of the who can buy ventolin four Beauchamp and Childress prima facie basic principles of biomedical ethics, is explored in two excellent papers in the current issue buy ventolin usa of the journal. The papers stem from a British Medical Association (BMA) essay competition on justice and fairness in medical practice and policy. Although the competition was open to (almost) all comers, of the 235 entries both the winning paper by who can buy ventolin Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by practising doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself.

Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read.The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’.In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires.First, some background. As president I was offered the wonderful opportunity who can buy ventolin to pursue, with the organisation’s formidable assistance, a ‘project’ consistent with the BMA’s interests and values.

As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp and Childress four principles approach to medical ethics,3 I chose to try to raise the ethical profile of justice and fairness within medical ethics.My first objective was to ask the BMA to ask the World Medical Association (WMA) to add an explicit commitment ‘to strive to practise fairly and justly throughout my professional life’ to its contemporary version of the Hippocratic Oath—the Declaration of Geneva4—and to the companion document the International Code of Medical Ethics.5 The stimulus for this proposal was the WMA’s addition in 2017 of the principle of respect for patients’ autonomy. Important as that addition is, it is widely perceived (though in my own who can buy ventolin view mistakenly) as being too much focused on individual patients and not enough on communities, groups and populations. The simple addition of a commitment to fairness and justice would provide a ‘balancing’ moral commitment.Adding the fourth principleIt would also explicitly add the fourth of those four prima facie moral commitments, increasingly widely accepted by doctors internationally.

Two of them—benefiting our patients (beneficence) and doing so with as little harm as possible (non-maleficence)—have been an integral part of medical ethics since Hippocratic times. Respect for autonomy and justice are very much more recent who can buy ventolin additions to medical ethics. The WMA, having added respect for autonomy to the Declaration of Geneva, should, I proposed, complete the quartet by adding the ‘balancing’ principle of fairness and justice.Since the Declaration is unlikely to be revised for several years, it seems likely that the proposal to add to it an explicit commitment to practise fairly and justly will have to wait.

However, an explicit commitment to justice and fairness has, at the BMA’s request, been added to the draft of the International Code of Medical Ethics and it seems reasonable to hope and expect that it will remain in the final document.Adding a who can buy ventolin commitment to fairness and justice is the easy part!. Few doctors would on reflection deny that they ought to try to practise fairly and justly. It is far more difficult to say what is actually meant by this.

Two additional components of my Presidential project—the essay competition and a conference (which with luck will have been held, virtually, shortly before publication of this editorial)—sought to help elucidate just what is who can buy ventolin meant by practising fairly and justly.One of the most striking features of the essay competition was the readiness of many writers to point to injustices in the context of medical practice and policy and describe ways of remedying them, but without giving a specific account of justice and fairness on the basis of which the diagnosis of injustice was made and the remedy offered.Wardrope’s winning essay comes close to such an approach by challenging the implied premise that an account of justice and fairness must provide some such formal theory. In preference, he points to the evident injustice and unsustainability of humans’ degradation of ‘the Land’ and its atmosphere and its inhabitants and then challenges some assumptions of contemporary philosophy and ethics, especially what he sees as their anthropocentric and individualistic focus. Instead, he invokes Leopold Aldo’s ‘Land Ethic’ (as well as drawing in who can buy ventolin aid Isabelle Stenger’s focus on ‘the intrusion of Gaia’).

In his thoughtful and challenging paper, he seeks to refocus our ethics—including our medical ethics and our sense of justice and fairness—on mankind’s exploitative threat, during this contemporary ‘anthropocene’ stage of evolution, to the continuing existence of humans and of all forms of life in our ‘biotic community’. As remedy, the author, allying his approach to those of contemporary virtue ethics, recommends the beneficial outcomes that would be brought about by a sense of fairness and justice—a developed and sensitive ‘ecological conscience’ as he calls it—that embraces the interests of the entire biotic community of which we humans are but a part.Fritz and Cox pursue a very different and philosophically more conventional approach to the essay competition’s question and offer a combination and development of two established philosophical theories, those of John Rawls and Thomas Scanlon, to provide a philosophically robust and practically beneficial methodology for justice and fairness in medical practice and policy. Briefly summarised, they recommend who can buy ventolin a two-stage approach for healthcare justice.

First, those faced with a problem of fairness or justice in healthcare or policy should use Thomas Scanlon’s proposed contractualist approach whereby reasonable people seek solutions that they and others could not ‘reasonably reject’. This stage would involve committees of decision-makers and representatives of relevant stakeholders looking at the immediate and longer term impact on existing stakeholders of proposed solutions. They would then check those solutions against substantive criteria of justice derived from Rawls’ theory (which, via his theoretical device of the ‘veil of ignorance’, Rawls and the authors argue that all reasonable people who can buy ventolin can be expected to accept!.

). The Rawlsian criteria relied on by Fritz and who can buy ventolin Cox are equity of access to healthcare. The ‘difference principle’ whereby avoidable inequalities of primary goods can only be justified if they benefit the most disadvantaged.

The just savings principle, of particular importance for ensuring intergenerational justice and sustainability. And a criterion of increased openness, transparency and who can buy ventolin accountability.It would of course be naïve to expect a single universalisable solution to the question ‘what do we mean by fairness and justice in health care?. €™ As the papers by Wardrope1 and Fritz and Cox2 demonstrate, there can be very wide differences of approach in well-defended accounts.

My own hope for my project is to emphasise the importance first of committing ourselves within medicine to who can buy ventolin practising fairly and justly in whatever branch we practise. And then to think carefully about what we do mean by that and act accordingly.Following AristotleFor my own part, over 40 years of looking, I have not yet found a single substantive theory of justice that is plausibly universalisable and have had to content myself with Aristotle’s formal, almost content-free but probably universalisable theory, according to which equals should be treated equally and unequals unequally in proportion to the relevant inequalities—what some health economists refer to as horizontal and vertical justice or equity.6Beauchamp and Childress in their recent eighth and ‘perhaps final’ edition of their foundational ‘Principles of biomedical ethics’1 acknowledge that ‘[t]he construction of a unified theory of justice that captures our diverse conceptions and principles of justice in biomedical ethics continues to be controversial and difficult to pin down’.They still cite Aristotle’s formal principle (though with less explanation than in their first edition back in 1979) and they still believe that this formal principle requires substantive or ‘material’ content if it is to be useful in practice. They then describe six different theories of justice—four ‘traditional’ (utilitarian, libertarian, communitarian and egalitarian) and two newer theories, which they suggest may be more helpful in the context of health justice, one based on capabilities and the other on actual well-being.They again end their discussion of justice with their reminder that ‘Policies of just access to health care, strategies of efficiencies in health care institutions, and global needs for the reduction of health-impairing conditions dwarf in social importance every other issue considered in this book’ …….

€˜every society who can buy ventolin must ration its resources but many societies can close gaps in fair rationing more conscientiously than they have to date’ [emphasis added]. And they go on to stress their own support for ‘recognition of global rights to health and enforceable rights to health care in nation-states’.For my own part I recommend, perhaps less ambitiously, that across the globe we extract from Aristotle’s formal theory of justice a starting point that ethically requires us to focus on equality and always to treat others as equals and treat them equally unless there are moral justifications for not doing so. Where such justifications exist we should say what they are, explain the moral assumptions that justify them and, to the extent possible, seek the agreement of those affected.IntroductionIt who can buy ventolin did not occur to the Governor that there might be more than one definition of what is good … It did not occur to him that while the courts were writing one definition of goodness in the law books, fires were writing quite another one on the face of the land.

(Leopold, ‘Good Oak’1, pp 10–11)As I wrote the abstract that would become this essay, wildfires were spreading across Australia’s east coast. By the time I was invited to write the essay, back-to-back winter storms were flooding communities all around my home. The essay has who can buy ventolin been written in moments of respite between shifts during the asthma treatment ventolin.

Every one of these events was described as ‘unprecedented’. Yet each is becoming increasingly likely, and that due to our interactions with our environment.Public discourse surrounding these events is dominated by questions of justice and fairness. How to balance competing imperatives of protecting individual lives against who can buy ventolin risk of spreading contagion.

How best to allocate scarce resources like intensive care beds or mechanical ventilators. The conceptual tools of clinical who can buy ventolin ethics are well tailored to these sorts of questions. The rights of the individual versus the community, issues of distributive justice—these are familiar to anyone with even a passing acquaintance with its canonical debates.What biomedical ethics has remained largely silent on is how we have been left to confront these decisions.

How human activity has eroded Earth’s life support systems to make the ‘unprecedented’ the new normal. A medical ethic fit for the Anthropocene—our who can buy ventolin (still tentative) geological epoch defined by human influence on natural systems—must be able not just to react to the consequences of our exploitation of the natural world, but reimagine our relationship with it.Those reimaginations already exist, if we know where to look for them. The ‘Land Ethic’ of the US conservationist Aldo Leopold offers one such vision.i Developed over decades of experience working in and teaching land management, the Land Ethic is most famously formulated in an essay of the same name published shortly before Leopold’s death fighting a wildfire on a neighbour’s farm.

It begins with a reinterpretation of the ethical relationship between humanity and the ‘land community’, the ecosystems we live within and who can buy ventolin depend upon. Moving us from ‘conqueror’ to ‘plain member and citizen’ of that community1 (p 204). Land ceases to be a resource to be exploited for human need once we view ourselves as part of, and only existing within, the land community.

Our moral evaluations shift consonantly:A thing is right when it tends to preserve the integrity, stability, and beauty who can buy ventolin of the biotic community. It is wrong when it tends otherwise.1 (pp 224–225)The justice of the Land Ethic questions many presuppositions of biomedical ethics. By valuing the community in itself—in a way irreducible to the welfare who can buy ventolin of its members—it steps away from the individualism axiomatic in contemporary bioethics.2 Viewing ourselves as citizens of the land community also extends the moral horizons of healthcare from a solely human focus, taking seriously the interests of the non-human members of that community.

Taking into account the ‘stability’ of the community requires intergenerational justice—that we consider those affected by our actions now, and their implications for future generations.3 The resulting vision of justice in healthcare—one that takes climate and environmental justice seriously—could offer health workers an ethic fit for the future, demonstrating ways in which practice must change to do justice to patients, public and planet—now and in years to come.Healthcare in the AnthropoceneSeemeth it a small thing unto you to have fed upon good pasture, but ye must tread down with your feet the residue of your pasture?. And to have drunk of the clear waters, but ye must foul the residue with your feet?. (Ezekiel 34:18, quoted in Leopold, ‘Conservation in the Southwest’4, p 94)The who can buy ventolin majority of the development of human societies worldwide—including all of recorded human history—has taken place within a single geological epoch, a roughly 11 600 yearlong period of relative warmth and climatic stability known as the Holocene.

That stability, however, can no longer be taken for granted. The epoch that has sustained most of human development is giving way to one shaped by the planetary consequences of that development—the Anthropocene.The Anthropocene is marked by accelerating degradation of the ecosystems that have sustained human societies. Human activity is already estimated to have raised global temperatures 1°C above preindustrial levels, and if emissions continue at current levels we are likely to reach 1.5°C between 2030 and 2052.5 The global rate of species extinction is orders of magnitude higher than the average over the past 10 million years.6 Ocean acidification, deforestation and disruption of nitrogen and phosphorus flows are likely at or beyond sustainable planetary boundaries.7Yet this period has also who can buy ventolin seen rapid (if uneven) improvements in human health, with improved life expectancy, falling child mortality and falling numbers of people living in extreme poverty.

The 2015 report of the Rockefeller Foundation-Lancet Commission on planetary health explained this dissonance in stark terms. €˜we have been mortgaging the health of future generations to realise economic and development gains in the present.’7In the instrumental rationality of modernity, nature has featured only as inexhaustible resource and infinite sink to fuel social and economic who can buy ventolin ends. But this disenchanted worldview can no longer hide from the implausibility of these assumptions.

It cannot resist what the philosopher Isabelle Stengers has called ‘the intrusion of Gaia’.8 The present ventolin—made more likely by deforestation, land use change and biodiversity loss9—is just the most immediately salient of these intrusions. Anthropogenic environmental changes are increasing undernutrition, increasing range and transmissibility of many vectorborne and waterborne diseases like dengue fever and cholera, increasing frequency and severity of extreme weather events like heatwaves and wildfires, and driving who can buy ventolin population exposure to air pollution—which already accounts for over 7 million deaths annually.10These intrusions will shape healthcare in the Anthropocene. This is because health workers will have to deal with their consequences, and because modern industrialised healthcare as practised in most high-income countries—and considered aspirational elsewhere—was borne of the same worldview that has mortgaged the health of future generations.

The health sector in the USA is estimated to account for 8% of the country’s greenhouse gas footprint.11 who can buy ventolin Pharmaceutical production and waste causes more local environmental degradation, accumulating in water supplies with damaging effects for local flora and fauna.12 Public health has similarly embraced short-term gains with neglect of long-term consequences. Health messaging was instrumental to the development and popularisation of many disposable and single-use products, while a 1947 report funded by the Rockefeller Foundation (who would later fund the landmark 2015 Lancet report on planetary health) popularised the high-meat, high-dairy ‘American’ diet—dependent on fossil fuel-driven intensive agricultural practices—as the healthy ideal.13Healthcare fit for the Anthropocene requires a shift in perspectives that allows us to see and work with the intrusion of Gaia. But can dominant approaches in bioethics incorporate that shift?.

A perfect moral stormWe have built a beautiful piece of social machinery … which is coughing along on two cylinders because we have been too timid, and who can buy ventolin too anxious for quick success, to tell the farmer the true magnitude of his obligations. (Leopold, ‘The Ecological Conscience’4, p 341)At local, national and international scales, the lifestyles of the wealthiest pose an existential threat to the poorest and most marginalised in society. Our actions now are depriving future generations of the environmental prerequisites of who can buy ventolin good health and social flourishing.

If justice means, as Ranaan Gillon parses it, ‘the moral obligation to act on the basis of fair adjudication between competing claims’,14 then this state of affairs certainly seems unjust. However, the tools available for grappling with questions of justice in bioethics seem ill equipped to deal with these sorts of injustice.To illustrate this problem, consider how Gillon further fleshes out his description of justice. In terms of fair distribution of who can buy ventolin scarce resources, respect for people’s rights, and respect for morally acceptable laws.

The first of these—labelled distributive justice—concerns how fairly to allot finite resources among potential beneficiaries. Classic problems of distributive justice in healthcare concern a group of people at a particular time (usually patients), who could each benefit from a particular resource (historically, discussions have often focused on transplant organs. More recently, intensive care beds and ventilators have come who can buy ventolin to the fore).

But there are fewer of these resources than there are people with a need for them. Such discussions who can buy ventolin are not easy, but they are at least familiar—we know where to begin with them. We can consider each party’s need, their potential to benefit from the resource, any special rights or other claims they may have to it, and so forth.

The distribution of benefits and harms in the Anthropocene, however, does not comfortably fit this formalism. It is one thing to say that there is but one intensive care bed, from which Smith has a good chance of who can buy ventolin gaining another year of life, Jones a poor chance, and so offer it to Smith. Another entirely to say that production of the materials consumed in Smith’s care has contributed to the degradation of scarce water supplies on the other side of the globe, or that the unsustainable pattern of energy use will affect innumerable other future persons in poorly quantifiable ways through fuelling climate change.

The calculations of distributive justice are well suited to problems where there are a set pool of potential beneficiaries, and the who can buy ventolin use of the scarce resources available affects only those within that pool. But global environmental problems do not fit this pattern—the effects of our actions are spatially and temporally dispersed, so that large numbers of present and future people are affected in different ways.Nor can this problem be readily addressed by turning to Gillon’s second category of obligations of justice, those grounded in human rights. For while it might be plausible (if not entirely uncontroversial) to say that those communities whose water supplies are degraded by pharmaceutical production have a right to clean water, it is another thing entirely to say that Smith’s healthcare is directly violating that right.

It would not be true to say that, who can buy ventolin were it not for the resources used in caring for Smith, that the communities in question would face no threat to water security—indeed, they would likely make no appreciable difference. Similarly for the effects of Smith’s care on future generations facing accelerating environmental change.iiThe issue here is of fragmentation of agency. While it is not the case that Smith’s care is directly responsible who can buy ventolin for these environmental harms, the cumulative consequences of many such acts—and the ways in which these acts are embedded in particular systems of energy generation, waste management, international trade, and so on—are reliably producing these harms.

The injustice is structural, in Iris Marion Young’s terminology—arising from the ways in which social structures constrain individuals from pursuing certain courses of action, and enable them to follow others, with side effects that cumulatively produce devastating impacts.15Gillon describes the third component of justice as respect for morally acceptable laws. But there is little reason to believe that existing legal frameworks provide sufficient guidance to address these structural injustices. While the intricacies of global governance are well beyond what I can hope to address here, the stark fact remains that, despite the international commitment of the 2015 Paris Agreement to attempt who can buy ventolin to keep global temperature rise to 1.5°C above preindustrial levels, the Intergovernmental Panel on Climate Change estimates that present national commitments—even if these are substantially increased in coming years—will take us well beyond that target.5 Confronted by such institutional inadequacy, respect ventolin purchase for the rule of law is inadequate to remedy injustice.The confluence of these particular features—dispersion of causes and effects, fragmentation of agency and institutional inadequacy—makes it difficult for us to reason ethically about the choices we have to make.

Stephen Gardiner calls this a ‘perfect moral storm’.16 Each of these factors individually would be difficult to address using the resources of contemporary biomedical ethics. Their convergence makes it seem insurmountable.This perfect storm was not, however, unpredictable. Van Rensselaer Potter, a who can buy ventolin professor of Oncology responsible for introducing the term ‘bioethics’ into Anglophone discourse, observed that since he coined the phrase, the study of bioethics had diverged from his original usage (governing all issues at the intersection of ethics and the biological sciences) to a narrow focus on the moral dilemmas arising in interactions between individuals in biomedical contexts.

Potter predicted that the short-term, individualistic and medicalised focus of this approach would result in a neglect of population-level and ecological-level issues affecting human and planetary health, with catastrophic consequences.17 His proposed solution was a new ‘global bioethics’, grounded in a new understanding of humanity’s position within planetary systems—one articulated by the Land Ethic.The Land EthicA land ethic changes the role of Homo sapiens from conqueror of the land-community to plain member and citizen of it. It implies respect for his fellow-members, and also respect for the community as such.iii (Leopold, ‘The Land Ethic’1, p 204)Developed throughout a career in forestry, conservation and wildlife management, the Land who can buy ventolin Ethic is less an attempt to provide a set of maxims for moral action, than to shift our perspectives of the moral landscape. In his working life, Aldo Leopold witnessed how actions intended to optimise short-term economic outcomes eroded the environments on which we depend—whether soil degradation arising from intensive farming and deforestation, or disruption of freshwater ecosystems by industrial dairy farming.

He also saw that contemporary morality remained silent on such actions, even when their consequences were to the collective detriment of all.Leopold argued that a series of ‘historical accidents’ left our morality particularly ill suited to handle these intrusions of Gaia—with a worldview that considered them ‘intrusions’, rather than the predictable response of our biotic community. These ‘accidents’ who can buy ventolin were. The unusual resilience of European ecological communities to anthropogenic interference (England survived an almost wholesale deforestation without consequent loss of ecosystem resilience, while similar changes elsewhere resulted in permanent environmental degradation).

And the legacy of European settler colonialism, meaning that an ethic arising in these particular conditions came who can buy ventolin to dominate global social arrangements4 (p 311). The first of these supported a worldview in which ‘Land … is … something to be tamed rather than something to be understood, loved, and lived with. Resources are still regarded as separate entities, indeed, as commodities, rather than as our cohabitants in the land community’4 (p 311).

The second enabled the marginalisation of who can buy ventolin other views. In this genealogy, Leopold anticipated the perfect moral storm discussed above. His intent with the Land Ethic was to navigate it.There are three key components of the who can buy ventolin Land Ethic that comprise the first three sections of Leopold’s final essay on the subject.

(1) the ‘community concept’ that allows communities as wholes to have intrinsic value. (2) the ‘ethical sequence’ that situates the value of such communities as extending, not replacing, values assigned to individuals. And (3) the ‘ecological conscience’ that views ethical action not in terms of following a particular code, but in developing appropriate moral perception.The community conceptThe most widely quoted passage of Leopold’s opus—already cited above, and frequently (mis)taken as a summary maxim of the ethic—states that:A thing is right when who can buy ventolin it tends to preserve the integrity, stability, and beauty of the biotic community.

It is wrong when it tends otherwise.1 (pp 224–225)This passage makes the primary object of our moral responsibilities ‘the biotic community’, a term Leopold uses interchangeably with the ‘land community’. Leopold’s community concept is notable in at least three respects. Its holism—an embrace of the moral significance of communities in a way that is who can buy ventolin not simply reducible to the significance of its individual members.

Its understanding of communities as temporally extended, placing importance on their ‘integrity’ and ‘stability’. And its rejection of anthropocentrism, affording humanity a place as ‘plain member and citizen’ who can buy ventolin of a broader land community.Individualism is so prevalent in biomedical ethics that it is scarcely argued for, instead forming part of the ‘background constellation of values’2 tacitly assumed within the field. We are used to evaluating the well-being of a community as a function of the well-being of its individual members—this is the rationale underlying quality-adjusted life year calculations endemic within health economics, and most discussions of distributive justice adopt some variation of this approach.

Holism instead proposes that this makes no more sense than evaluating a person’s well-being as an aggregate of the well-being of their individual organs. While we can sensibly talk who can buy ventolin about people’s hearts, livers or kidneys, their health is defined in terms of and constitutively dependent on the health of the person as a whole. Similarly, holism proposes, while individuals can be identified separately, it only makes sense to talk about them and their well-being in the context of the larger biotic community which supports and defines us.Holism helps us to negotiate the issues that confront individualistic accounts of collective well-being in Anthropocene health injustices.

In the previous section, we found in the environmental consequences of industrialised healthcare that it is difficult to identify which parties in particular are harmed, and how much each individual action contributes to those who can buy ventolin harms. But our intuition that the overall result is unfair or unjust is itself a holistic assessment of the overall outcome, not dependent on our calculation of the welfare of every party involved. Holism respects the intuition that says—no matter the individuals involved—a world where people now exploit ecological resources in a fashion that deprives people in the future of the prerequisites of survival, is worse than one where communities now and in the future live in a sustainable relationship with their environment.The second aspect of Leopold’s community concept is that the community is something that does not exist at a single time and place—it is defined in terms of its development through time.

Promoting the ‘integrity’ and ‘stability’ of the community requires that we not just consider who can buy ventolin its immediate interests, but how that will affect its long-term sustainability or resilience. We saw earlier the difficulties in trying to say just who is harmed and how when we approach harm to future generations individualistically. But from the perspective of the Land Ethic, when we exploit environmental resources in ways who can buy ventolin that will have predictable damaging results for future generations, the object of our harm is not just some purely notional future person.

It is a presently existing, temporally extended entity—the community of which they will be part.Lastly, Leopold’s community is quite consciously a biotic—not merely human—community. Leopold defines the land community as the open network of energy and mineral exchange that sustains all aspects of that network:Land… is not merely soil. It is a fountain of energy flowing through a circuit of soils, plants, who can buy ventolin and animals.

Food chains are the living channels which conduct energy upward. Death and decay return it to the soil. The circuit is not closed who can buy ventolin.

Some energy is dissipated in decay, some is added by absorption, some is stored in soils, peats, and forests, but it is a sustained circuit, like a slowly augmented revolving fund of life.4 (pp 268–269)While the components within this network may change, the land community as a whole remains stable when the overall complexity of the network is not disrupted—other components are able to adjust to these changes, or new ones arise to take their place.ivThe normative inference Leopold makes from his understanding of the land community is this. It makes no sense to who can buy ventolin single out individual entities within the community as being especially valuable or useful, without taking into account the whole community upon which they mutually depend. To do so is self-defeating.

By privileging the interests of a few members of the community, we ultimately undermine the prerequisites of their existence.The ethical sequenceThe Land Ethic’s holism is in fact its most frequently critiqued feature. Its emphasis on the value of the biotic community leads some to allege a subjugation who can buy ventolin of individual interests to the needs of the environment. This critique neglects how Leopold positions the Land Ethic in what he calls the ‘ethical sequence’.

This is the gradual extension of scope of ethical considerations, both in terms of the complexity of social interactions they cover (from interactions between two people, to the structure of progressively larger social groups), and in the kinds who can buy ventolin of person they acknowledge as worthy of moral consideration (as we resist, for example, classist, sexist or racist exclusions from personhood).This sequence serves less as a description of the history of morality, than a prescription for how we should understand the Land Ethic as adding to, rather than supplanting, our responsibilities to others. We do not argue that taking seriously health workers’ responsibilities for public health and health promotion supplants their duties to the patients they work with on a daily basis. Similarly, the Land Ethic implies ‘respect for [our] fellow members, and also respect for the community as such’1 (p 204).

At times, who can buy ventolin our responsibilities towards these different parties may come into tension. But balancing these responsibilities has always been part of the work of clinical ethics.The ecological conscienceIf the community concept gives a definition of the good, and the ethical sequence situates this definition within the existing moral landscape, neither offers an explicit decision procedure to guide right action. In arguing for the ‘ecological who can buy ventolin conscience’, Leopold explains his rationale for not attempting to articulate such a procedure.

In his career as conservationist, Leopold witnessed time and again laws nominally introduced in the name of environmental protection that did little to achieve their long-term goals, while exacerbating other environmental threats.v This is not surprising, given the ‘perfect moral storm’ of Anthropocene global health and environmental threats discussed above. The cumulative results of apparently innocent actions can be widespread and damaging.Leopold’s response to this problem is to advocate the cultivation of an ‘ecological conscience’. What is needed to promote a healthy human relationship with the land community is not for us to be told exactly how and how not to act in the face of environmental health threats, but rather to shift our view of the land from who can buy ventolin ‘a commodity belonging to us’ towards ‘a community to which we belong’1 (p viii).

To understand what the Land Ethic requires of us, therefore, we should learn more about the land community and our relationship with it, to develop our moral perception and extend its scope to embrace the non-human members of our community.Seen in this light, the Land Ethic shares much in common with virtue ethics, where right action is defined in terms of what the moral agent would do, rather than vice versa. But rather than the Eudaimonia of individual human flourishing proposed by Aristotle, the phronimos of the Land Ethic sees their telos coming from their position within the land community. While clinical virtue ethicists have traditionally taken the virtues of medical practice to be grounded in the interaction with individual patients, the realities of healthcare in the Anthropocene mean that limiting our moral perceptions in this way would ultimately be self-defeating—hurting those very patients we mean to serve (and many more besides).18 The virtuous clinician must adopt a view of the moral who can buy ventolin world that can focus on a person both as an individual, and simultaneously as member of the land community.

I will close by exploring how adopting that perspective might change our practice.Justice in the AnthropoceneFailing this, it seems to me we fail in the ultimate test of our vaunted superiority—the self-control of environment. We fall back into the biological category of the potato bug which exterminated the potato, and thereby who can buy ventolin exterminated itself. (Leopold, ‘The River of the Mother of God’4, p 127)I have articulated some of the challenges healthcare faces in the Anthropocene.

I have suggested that the tools presently available to clinical ethics may be inadequate to meet them. The Land who can buy ventolin Ethic invites us to reimagine our position in and relationship with the land community. I want to close by suggesting how the development of an ecological conscience might support a transition to more just healthcare.

I will not endeavour to give detailed prescriptions for who can buy ventolin action, given Leopold’s warnings about the limitations of such codifications. Rather, I will attempt to show how the cultivation of an ecological conscience might change our perception of what justice demands. Following the tradition of virtue ethics with which the Land Ethic holds much in common, this is best achieved by looking at models of virtuous action, and exploring what makes it virtuous.19Industrialised healthcare developed within a paradigm that saw the environment as inert resource and held that the scope of clinical ethics ranged only over the clinician’s interaction with their patients.

When we begin to see clinician and patient not as standing apart from the environment, but as ‘member and citizen of the land community’, their relationship with one another and with the world around who can buy ventolin them changes consonantly. The present ventolin has only begun to make commonplace the idea that health workers do not simply treat infectious diseases, but interact with them in a range of ways, including as vector—and as a result our moral obligations in confronting them may extend beyond the immediate clinical encounter, to cover all the other ways we may contract or spread disease. But we may be responsible for disease outbreaks with conditions other than asthma treatment, who can buy ventolin and in ways beyond simply becoming infected.

The development of an ecological conscience would show how our practices of consumption may fuel deforestation that accelerates the emergence of novel pathogens, or support intensive animal rearing that drives antibiotic resistance.18The Land Ethic also challenges us not to abstract our work away from the places in which it takes place. General practitioner surgeries and hospitals are situated within social and land communities alike, shaping and shaped by them. These spaces who can buy ventolin can be used in ways that support or undermine those communities.

Surgeries can work to empower their communities to pursue more sustainable and healthy diets by doubling as food cooperatives, or providing resources and ‘social prescriptions’ for increased walking and cycling. Hospitals can use their extensive real estate to provide publicly accessible green and wild spaces within urban environments, and use their role as major nodes in transport infrastructure to change that infrastructure to support active travel alternatives.ivThe Land Ethic reminds us that a community (human or land) is not healthy if its flourishing cannot be sustainably maintained. An essential who can buy ventolin component of Anthropocene health justice is intergenerational justice.

Contemporary industrialised healthcare has an unsustainable ecological footprint. Continuing with such a model of care would serve only to mortgage the health of future generations for the sake of who can buy ventolin those living now. Ecologically conscious practice must take seriously the sorts of downstream, distributed consequences of activity that produce anthropogenic global health threats, and evaluate to what extent our most intensive healthcare practices truly serve to promote public and planetary health.

It is not enough for the clinician to assume that our resource usage is a necessary evil in the pursuit of best clinical outcomes, for it is already apparent that much of our environmental exploitation is of minimal or even negative long-term value. The work of the National Health Service (NHS) Sustainable Development Unit has seen a 10% reduction in greenhouse gas emissions in the NHS from who can buy ventolin 2007 to 2015 despite an 18% increase in clinical activity,20 while different models of care used in less industrialised nations manage to provide high-quality health outcomes in less resource-intensive fashion.21ConclusionOur present problem is one of attitudes and implements. We are remodelling the Alhambra with a steam-shovel.

We shall hardly relinquish who can buy ventolin the steam-shovel, which after all has many good points, but we are in need of gentler and more objective criteria for its successful use. (Leopold, ‘The Land Ethic’1, p 226)The moral challenges of the Anthropocene do not solely confront health workers. But the potentially catastrophic health effects of anthropogenic global environmental change, and the contribution of healthcare activity to driving these changes provide a specific and unique imperative for action from health workers.Yet it is hard to articulate this imperative in the language of contemporary clinical ethics, ill equipped for this intrusion of Gaia.

Justice in the Anthropocene requires us to be able to adopt a perspective from which these who can buy ventolin changes no longer appear as unexpected intrusions, but that acknowledges the land community as part of our moral community. The Land Ethic articulates an understanding of justice that is holistic, structural, intergenerational, and rejects anthropocentrism. This understanding seeks not to supplant, but to who can buy ventolin augment, our existing one.

It aims to do so by helping us to develop an ‘ecological conscience’, seeing ourselves as ‘plain member and citizen’ of the land community. The Land Ethic does not provide a step-by-step guide to just action. Nor does it definitively adjudicate on how to balance the interests of our patients, other populations now and in the future, who can buy ventolin and the planet.

It could, however, help us on the first step towards that change—showing how to cultivate the ‘internal change in our intellectual emphasis, loyalties, affections, and convictions’1 (pp 209–210) necessary to realise the virtues of just healthcare in the Anthropocene.AcknowledgmentsThis essay was written as a submission for the BMA Presidential Essay Prize. I am grateful to the organisers and judging panel for the opportunity..

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