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The COVID-19 pandemic has had a dramatic impact on the health and social care landscape, both in terms of service provision and citizen need. Responsive, evidence-based research is essential to develop and implement appropriate policies and practices that manage both the pandemic itself, and the impact COVID-19 has on other health and social care issues.
To address this, the Wales COVID-19 Evidence Centre (WCEC) was launched in 2021 with the aim of providing the best available, up-to-date, and relevant evidence to inform health and care decision making across Wales.
Funded by the Welsh Government, the WCEC comprises of a core team and several collaborating partner organizations, including Health Technology Wales, Wales Centre for Evidence-Based Care, Specialist Unit for Review Evidence Centre, SAIL Databank, Public Health Wales, Bangor Institute for Health & Medical Research in conjunction with Health and Care Economics Cymru, and the Public Health Wales Observatory. Over the last year, WCEC has developed its rapid review processes and methodology informed by best international practice and aims to provide around 50 reviews each year. WCEC works alongside various stakeholder groups from health and social care across Wales, and they form an integral part of the review process, from scoping to knowledge mobilization.
To date, the WCEC has produced reviews on a diverse range of COVID-19 topics, including transmission, vaccination uptake (barriers, facilitators and interventions), mental health and wellbeing, as well as face coverings and other preventative interventions. The topics have also covered a wide range of populations, from general public, to healthcare workers, to children. These reviews have been used to inform policy and decision-making, including the Welsh Government’s Chief Medical Officer 21-day COVID-19 reviews.
The WCEC has brought together multiple specialist centers with a diverse range of skills to produce timely reviews of the most up-to-date research to support decision makers across health and social care. These reviews have informed policy and decision-making across Wales.
Prisons are susceptible to outbreaks. Control measures focusing on isolation and cohorting negatively affect wellbeing. We present an outbreak of coronavirus disease 2019 (COVID-19) in a large male prison in Wales, UK, October 2020 to April 2021, and discuss control measures.
We gathered case-information, including demographics, staff-residence postcode, resident cell number, work areas/dates, test results, staff interview dates/notes and resident prison-transfer dates. Epidemiological curves were mapped by prison location. Control measures included isolation (exclusion from work or cell-isolation), cohorting (new admissions and work-area groups), asymptomatic testing (case-finding), removal of communal dining and movement restrictions. Facemask use and enhanced hygiene were already in place. Whole-genome sequencing (WGS) and interviews determined the genetic relationship between cases plausibility of transmission.
Of 453 cases, 53% (n = 242) were staff, most aged 25–34 years (11.5% females, 27.15% males) and symptomatic (64%). Crude attack-rate was higher in staff (29%, 95% CI 26–64%) than in residents (12%, 95% CI 9–15%).
Whole-genome sequencing can help differentiate multiple introductions from person-to-person transmission in prisons. It should be introduced alongside asymptomatic testing as soon as possible to control prison outbreaks. Timely epidemiological investigation, including data visualisation, allowed dynamic risk assessment and proportionate control measures, minimising the reduction in resident welfare.
Both early social psychologists and the modern, interdisciplinary scientific community have advocated for diverse team science. We echo this call and describe three common pitfalls of solo science illustrated by the target article. We discuss how a collaborative and inclusive approach to science can both help researchers avoid these pitfalls and pave the way for more rigorous and relevant research.
New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.
We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.
We included outcomes for 230,099 registered patients, assigned to ranked risk groups.
Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.
Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.
Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.
The communist secret police services of Central and Eastern Europe kept detailed records not only of their victims but also of the vast networks of informants and collaborators upon whom their totalitarian systems depended. These records, now open to the public in many former Eastern Bloc countries, reflect a textually mediated reality that has defined and shaped the lives of former victims and informers, creating a tension between official records and personal memories. Exploring this tension between a textually and technically mediated past and the subject/victim's reclaiming and retrospective interpretation of that past in biography is the goal of this volume. While victims' secret police files have often been examined as a type of unauthorized archival life writing, the contributors tothis volume are among the first to analyze the fragmentary and sometimes remedial nature of these biographies and to examine the subject/victims' rewriting and remediation of them in various creativeforms. Essays focus, variously, on the files of the East German Stasi, the Romanian Securitate (in relation to Transylvanian Germans in Romania), and the Hungarian State Security Agency.
Contributors: Carol Anne Costabile-Heming, Ulrike Garde, Valentina Glajar, Yuliya Komska, Alison Lewis, Corina L. Petrescu, Annie Ring, Aniko Szucs.
Valentina Glajar is Professor of German at Texas State University, San Marcos. Alison Lewis is Professor of German in the School of Languages and Linguistics, The University of Melbourne, Australia. Corina L. Petrescu is Associate Professorof German at the University of Mississippi.
Alison Lewis, Professor of German in the School of Languages and Linguistics, The University of Melbourne, Australia,
Valentina Glajar, Professor of German at Texas State University, San Marcos,
Corina L. Petrescu, Associate Professor of German at the University of Mississippi
In a system of ubiquitous spying, where everybody may be a police agent and each individual feels himself under constant surveillance […] every word becomes equivocal and subject to retrospective “interpretation.”
—Hannah Arendt, The Origins of Totalitarianism
The Secret Police Files of the Eastern Bloc
WHEN THE SECRET POLICE SERVICES OF THE FORMER EASTERN BLOC were dismantled at the end of the Cold War, they left an ambivalent legacy for successor governments. The extensive historical archives that were salvaged during the transition—the copious quantities of paper documents either left behind in the confusion of shifting relations of power or rescued by farsighted reformers—are damning evidence of the activities of the disproportionately large political police forces that mushroomed in Central and Eastern European countries under communist rule. Unlike many physical remains of these regimes that have been consigned to the dustbin of history, the files have miraculously survived. As material remnants of the Cold War from a predigital era of surveillance, they have proved to be an invaluable source of knowledge about the pervasive systems of personalized secret policing of domestic populations that involved alarming numbers of collaborators. However, for each of the three countries at the center of this book—Germany, Romania, and Hungary— the secret police files have posed considerable challenges. The archives contain many personal and state secrets, and exposing these has been a fraught and controversial process. The files are for the most part textbased artifacts and must be read with particular care. Often encrypted in impenetrable textual formats and encoded in arcane language—the now historical lingo of Cold War espionage—the archives’ secrets must first be deciphered before they can be meaningfully used.
The secret police files reflect a textually mediated reality about Cold War surveillance practices that sheds light on the deeply suspicious mindsets of Eastern bloc regimes. When the activities of secret police services in Eastern Europe were first revealed in the early 1990s, it was not their foreign intelligence branches that came under most scrutiny but the surveillance of their own populations. While the communist regimes expected unconditional loyalty from their own citizens, all too often they refused to reciprocate this trust, turning individuals into “enemies of the people” and “traitors of the nation,” sometimes at the slightest hint of nonconformist behavior.
Secret Police Files and the Life Stories of Stasi Informers
BEFORE THEY WERE DECLASSIFIED UNDER LUSTRATION LEGISLATION in the early nineties, the secret police files of Stasi informers (or Inoffizielle Mitarbeiter) employed by the domestic branch of the East German secret police in the Ministry for State Security (Ministerium für Staatssicherheit) represented top-secret narratives that were never intended to become public documents. Once unmoored from these original contexts, the files have become a public good, used to tell stories about the communist past and individuals’ entanglement with authority. Security files are a rich archive about power and the secret life of power. And because Cold War surveillance needed humans, rather than technology, to execute it, the Stasi archive is a powerful source of information about human lives— the secret lives of “enemies of the state” under surveillance as well as of those who performed the surveillance. To turn this information into stories, secret police files must first be made intelligible, and this involves acknowledging their narrative character.
According to Paul Ricoeur, life stories, whether historical or fictional, “become more intelligible when what one applies to them are the narrative models or plots borrowed from history or fiction.” With careful interpretation, therefore, the secret police dossiers of Stasi informants can be repurposed to offer up valuable insights into the secret lives of the regime's collaborators. This chapter argues for the usefulness of reading the Stasi files and their emplotment of lives in terms of life writing. As will be demonstrated in three case studies, the files of informers offer detailed and complex backstories of individuals’ entanglements with the secret police—stories that sometimes accompanied their public and private lives like an insistent shadow and sometimes ran at odds with them. Each of these file stories has its own beginning, middle, and ending, some resulting in a relatively stable, enduring relationship between the informant and the Ministry for State Security and some ending in tears, with a falling-out or a gradual parting of ways, usually prompted by the emergence of irreconcilable ideological differences between informer and the Stasi. These stories of secret entanglements can help shed light on the role the Stasi played in structuring ordinary East German lives as well as on informers’ motivations.