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KHN freelancer Sara Reardon discussed allegations by a rail company that a clinic in Libby, Montana, is defrauding Medicare by overdiagnosing asbestos-related diseases on levitra target pharmacy Montana Public Radio on May 13. California Healthline correspondent Angela Hart discussed how the levitra has shaped California Gov. Gavin Newsom’s political outlook on KCBS’ “The State of California” on May 12.

KHN freelancer Joshua Eaton discussed how CVS and levitra target pharmacy Walgreens account for the majority of wasted erectile dysfunction treatments on NPR’s “All Things Considered” on May 9. KHN correspondent Rachana Pradhan discussed how CVS and Walgreens account for the majority of wasted erectile dysfunction treatments on NBC’s “NBC News Now” and Newsy on May 4. Related Topics Contact Us Submit a Story TipColorado health officials so abhor the high costs associated with free-standing emergency rooms they’re offering to pay hospitals to shut the facilities down.

The state wants hospitals to convert them to other purposes, such as providing primary levitra target pharmacy care or mental health services. At least 500 free-standing ERs have set up in more than 20 states in the past decade. Colorado has 44, 34 owned by hospitals.

The trend began a decade ago with hopes these stand-alone facilities would fill a need for ER care when no hospital was nearby and levitra target pharmacy reduce congestion at hospital ERs. But that rarely happened. Instead, these emergency rooms — not physically connected to hospitals — generally set up in affluent suburban communities, often near hospitals that compete with the free-standing ERs’ owners.

And they largely treated patients levitra target pharmacy who did not need emergency care, but still billed them and their insurers at expensive ER rates, several studies have found. €œWe don’t want hospitals to have stand-alone ERs, so we are willing to pay to shut them down,” said Kim Bimestefer, executive director of Colorado’s Department of Health Care Policy &. Financing, which oversees the state’s Medicaid program.

She said using these facilities to treat common injuries and illnesses levitra target pharmacy leads to higher costs for Medicaid, which the state partly finances, and other insurers. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. Colorado’s move is part of a new initiative that requires hospitals to improve their quality of care to qualify for millions of dollars in Medicaid payments. Hospitals can choose among goals provided by the state such as lowering readmission rates or screening patients for social needs such as housing.

Converting free-standing ERs to meet other needs is levitra target pharmacy one of those goals. €œMoney talks,” Bimestefer said in explaining why the state is offering the financial incentives. Money has been a major driver of the boom in free-standing emergency centers.

Hospitals used them to attract patients who could be referred to the main hospital for inpatient care levitra target pharmacy. They are also seen as a way to compete with rivals. For instance, in Palm Beach County, Florida, for-profit hospital chain HCA Healthcare has opened free-standing ERs near competing hospitals in Palm Beach Gardens and Boynton Beach.

In addition, the levitra target pharmacy massive amounts of private equity funds flowing into health care have further fueled the growth of independently owned stand-alone ERs. The Denver-based Center for Improving Value in Health Care found that most conditions treated in these facilities are more appropriate for lower-acuity, lower-cost urgent care centers. Patients can pay 10 times more in a free-standing ER than in an urgent care center for treatment of the same condition, the organization’s studies show.

Adam Fox, deputy director of the Colorado Consumer Health levitra target pharmacy Initiative, said free-standing ERs have not been placed where health care services are scarce. Instead, they’ve opened in middle- and upper-income neighborhoods where most people have health insurance and access to care. €œThis push from the state will help” as hospitals rethink whether these facilities still make sense financially, he said.

A free-standing levitra target pharmacy emergency room in Arvada, Colorado, owned by UCHealth, part of the University of Colorado. (Markian Hawryluk / KHN) In the past few years, Colorado has moved to make owning these facilities less attractive with laws preventing them from sticking patients with surprise bills for high fees because the ER was out of their insurer networks. It also has required that patients without true emergencies be told they can get treatment for a lower price at an urgent care facility.

The law requires a free-standing levitra target pharmacy ER to post a sign informing patients it is an emergency room that treats emergency conditions. It must also specify the prices of the 25 most common services it provides. Even before the new policy begins to roll out later this year, some Colorado hospitals started converting these facilities.

UCHealth has turned nine in the past two years into levitra target pharmacy primary or urgent care centers and one into a specialty center. It still has nine others in operation across the state. The conversions were not prompted by state actions, according to Dan Weaver, a spokesperson for UCHealth, part of the University of Colorado.

€œNeither surprise billing legislation nor price transparency played a role in these decisions levitra target pharmacy — we converted them because we felt patients in these communities needed urgent care, primary care and/or specialty care services close to home,” Weaver said. He added that the hospital system always stressed that people should use lower-cost services, including urgent care, primary care or virtual urgent care, in nonemergencies. Ryan Westrom, senior director of finance at the Colorado Hospital Association, said hospitals have converted some of these centers to services such as urgent care in response to changes in insurance reimbursement and other factors.

He said he wasn’t sure whether many hospitals will accept the state payments to close levitra target pharmacy their free-standing ERs. HealthONE, which has eight free-standing ERs in the Denver area, said it has no plans to close any despite the state incentive payment. Vivian Ho, a health economist at Rice University in Houston who has tracked the growth of these stand-alone emergency rooms, applauded Colorado’s effort.

But she worries hospitals may decide it’s not worth closing a free-standing emergency department levitra target pharmacy and forfeiting the profits. €œYou have to attack free-standing EDs from multiple angles to get people to stop going to them and to get hospitals from using them as a way to generate extra revenues for care that can be delivered at lower-cost sites.” Ho said the erectile dysfunction treatment levitra, which dampened demand for emergency care, and recent federal surprise billing legislation may hurt the growth of free-standing ERs. They are already facing headwinds.

Adeptus Health, the Texas company that’s been leading the trend there and started dozens of the free-standing emergency rooms, often levitra target pharmacy in conjunction with hospitals, filed for bankruptcy this year. And numerous stand-alone facilities closed at least temporarily during the levitra as demand for care fell dramatically. Advisers to Medicare are also pushing back on the growth.

A recent proposal from the Medicare Payment Advisory Commission, which reports to Congress, would cut Medicare payment rates 30% on some services at stand-alone facilities levitra target pharmacy within 6 miles of an emergency room in a hospital. According to a MedPAC analysis of five markets — Charlotte, North Carolina. Cincinnati.

Dallas. Denver. And Jacksonville, Florida — 75% of free-standing facilities were within 6 miles of a hospital with an emergency department.

The average drive time to the nearest such hospital was 10 minutes. Markian Hawryluk, KHN’s senior Colorado correspondent, contributed to this article. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation).

Buy generic levitra

IntroductionLa Peste (Camus visit the site 1947) has served as a basis for several critical works, including some in the field of medical humanities buy generic levitra (Bozzaro 2018. Deudon 1988. Tuffuor and Payne buy generic levitra 2017).

Frequently interpreted as an allegory of Nazism (with the plague as a symbol of the German occupation of France) (Finel-Honigman 1978. Haroutunian 1964), it has also received philosophical readings beyond the sociopolitical context in which it was written (Lengers 1994). Other scholars, on the other hand, have centred their analyses on its literary aspects (Steel 2016).The erectile dysfunction treatment levitra has increased buy generic levitra general interest about historical and fictional epidemics.

La Peste, as one of the most famous literary works about this topic, has been revisited by many readers during recent months, leading to an unexpected growth in sales in certain countries (Wilsher 2020. Zaretsky 2020). Apart from that, commentaries about the novel, especially among health sciences scholars, buy generic levitra have emerged with a renewed interest (Banerjee et al.

2020. Bate 2020. Vandekerckhove 2020 buy generic levitra.

Wigand, Becker, and Steger 2020). This sudden curiosity is easy to understand if we consider both La Peste’s literary value, and people’s desire to discover real or fictional situations similar to theirs. Indeed, Oran inhabitants’ experiences are not quite far from our own, even if geographical, chronological and, specially, scientific factors (two different diseases occurring at two different stages in the history of buy generic levitra medical development) prevent us from establishing too close resemblances between both situations.Furthermore, it will not be strange if erectile dysfunction treatment serves as a frame for fictional works in the near future.

Other narrative plays were based on historical epidemics, such as Daniel Defoe’s A Journal of the Plague Year or Giovanni Boccaccio’s Decameron (Wigand, Becker, and Steger 2020. Withington 2020). The biggest levitra in buy generic levitra the last century, the so-called ‘Spanish Influenza’, has been described as not very fruitful in this sense, even if it produced famous novels such as Katherine A Porter’s Pale Horse, Pale Rider or John O’Hara’s The Doctor Son (Honigsbaum 2018.

Hovanec 2011). The overlapping with another disaster like World War I has been argued as one of the reasons explaining this scarce production of fictional works (Honigsbaum 2018). By contrast, we may think that erectile dysfunction treatment is having a global impact hardly overshadowed by other events, and that it will leave a significant mark on the collective memory.Drawing on the reading of La Peste, we buy generic levitra point out in this essay different aspects of living under an epidemic that can be identified both in Camus’s work and in our current situation.

We propose a trip throughout the novel, from its early beginning in Part I, when the Oranians are not aware of the threat to come, to its end in Part V, when they are relieved of the epidemic after several months of ravaging disasters.We think this journey along La Peste may be interesting both to health professionals and to the lay person, since all of them will be able to see themselves reflected in the characters from the novel. We do not skip critique of some aspects related to the authorities’ management of erectile dysfunction treatment, as Camus does concerning Oran’s rulers. However, what we want to foreground is La Peste’s intrinsic value, its suitability to be read now and after erectile dysfunction treatment has passed, when Camus’s novel endures as a solid art work and erectile dysfunction treatment remains only as a defeated plight.MethodsWe confronted our own experiences about buy generic levitra erectile dysfunction treatment with a conventional reading of La Peste.

A first reading of the novel was used to establish associations between those aspects which more saliently reminded us of erectile dysfunction treatment. In a second reading, we searched for some examples to illustrate those aspects and tried to detect new associations. Subsequent readings buy generic levitra of certain parts were done to integrate the information collected.

Neither specific methods of literary analysis, nor systematic searches in the novel were applied. Selected paragraphs and ideas from Part I to Part V were prepared in a draft copy, and this manuscript was written afterwards.Part ISome phrases in the novel could be transposed word by word to our situation. This one pertaining to its start, for instance, may make us remember the first months of 2020:By buy generic levitra now, it will be easy to accept that nothing could lead the people of our town to expect the events that took place in the spring of that year and which, as we later understood, were like the forerunners of the series of grave happenings that this history intends to describe.

(Camus 2002, Part I)By referring from the beginning to ‘the people of our town’, Camus is already suggesting an idea which is repeated all along the novel, and which may be well understood by us as erectile dysfunction treatment’s witnesses. Epidemics affect the community as a whole, they are present in everybody’s mind and their joys and sorrows are not individual, but collective. For example (and we are anticipating Part II), the narrator says:But, once the gates were closed, they all noticed that they were in the same boat, including the narrator himself, and that they had buy generic levitra to adjust to the fact.

(Camus 2002, Part II)Later, he will insist in this opposition between the concepts of ‘individual’, which used to prevail before the epidemic, and ‘collective’:One might say that the first effect of this sudden and brutal attack of the disease was to force the citizens of our town to act as though they had no individual feelings. (Camus 2002, Part II)There were no longer any individual destinies, but a collective history that was the plague, and feelings shared by all. (Camus 2002, Part III)This distinction is not trivial, since the story will display a strong confrontation between those who get involved and help their neighbours buy generic levitra and those who remain behaving selfishly.

Related to this, Claudia Bozzaro has pointed out that the main topic in La Peste is solidarity and auistic love (Bozzaro 2018). We may add that the disease is so attached to people’s lives that the epidemic becomes the new everyday life:In the morning, they would return to the pestilence, that is to say, to routine. (Camus 2002, Part III)Being collective issues does not mean that epidemics always enhance buy generic levitra auism and solidarity.

As said by Wigand et al, they frequently produce ambivalent reactions, and one of them is the opposition between auism and maximised profit (Wigand, Becker, and Steger 2020). Therefore, the dichotomy between individualism and collectivism, a central point in the characterisation of national cultures (Hofstede 2015), could play a role in epidemics. In fact, concerning erectile dysfunction treatment, some authors have described a greater impact of the levitra in those countries with higher levels of individualism (Maaravi buy generic levitra et al.

However, this finding should be complemented with other national cultures’ aspects before concluding that collectivism itself exerts a protective role against epidemics. Concerning this, it has been shown how ‘power distance’ frequently intersects with collectivism, being only a few countries in which the last one coexists with a small distance to power, namely with a capacity to disobey the power authority (Gupta, Shoja, and Mikalef 2021). Moreover, those countries classically classified as ‘collectivist’ (China, Japan, South Korea, India, Vietnam, etc.) are also characterised by high levels of power distance, and their citizens have been quite often forced to adhere to erectile dysfunction treatment restrictions and punished if not (Gupta, Shoja, and Mikalef 2021).

Thus, it is important to consider that individualism is not always opposed to ‘look after each other’ (Ozkan et al. 2021, 9). For instance, the European region, seen as a whole as highly ‘individualistic’, holds some of the most advanced welfare protection systems worldwide.

It is worth considering too that collectivism may hide sometimes a hard institutional authority or a lack in civil freedoms.Coming back to La Peste, we may think that Camus’s Oranians are not particularly ‘collectivist’. Their initial description highlights that they are mainly interested in their own businesses and affairs:Our fellow-citizens work a good deal, but always in order to make money. They are especially interested in trade and first of all, as they say, they are engaged in doing business.

(Camus 2002, Part I)And later, we see some of them trying selfishly to leave the city by illegal methods. By contrast, we observe in the novel some examples of more ‘collectivistic’ attitudes, such as the discipline of those quarantined at the football pitch, and, over all, the main characters’ behaviour, which is generally driven by auism and common goals.Turning to another topic, the plague in Oran and erectile dysfunction treatment are similar regarding their animal origin. This is not rare since many infectious diseases pass to humans through contact with animal vectors, being rodents, especially rats (through rat fleas), the most common carriers of plague bacteria (CDC.

N.d.a, ECDC. N.d, Pollitzer 1954). Concerning erectile dysfunction, even if further research about its origin is needed, the most recent investigations conducted in China by the WHO establish a zoonotic transmission as the most probable pathway (Joint WHO-China Study Team 2021).

In Camus’s novel, the animal’s link to the epidemic seemed very clear since the beginning:Things got to the point where Infodoc (the agency for information and documentation, ‘ all you need to know on any subject’) announced in its free radio news programme that 6,231 rats had been collected and burned in a single day, the 25th. This figure, which gave a clear meaning to the daily spectacle that everyone in town had in front of their eyes, disconcerted them even more. (Camus 2002, Part I)This accuracy in figures is familiar to us.

People nowadays have become very used to the statistical aspects of the levitra, due to the continuous updates in epidemiological parameters launched by the media and the authorities. Camus was aware about the relevance of figures in epidemics, which always entail:…required registration and statistical tasks. (Camus 2002, Part II)Because of this, the novel is scattered with numbers, most of them concerning the daily death toll, but others mentioning the number of rats picked up, as we have seen, or combining the number of deaths with the time passed since the start of the epidemic:“ Will there be an autumn of plague?.

Professor B answers. €˜ No’ ”, “ One hundred and twenty-four dead. The total for the ninety-fourth day of the plague.” (Camus 2002, Part II)We permit ourselves to introduce here a list of recurring topics in La Peste, since the salience of statistical information is one of them.

These topics, some of which will be treated later, appear several times in the novel, in various contexts and stages in the evolution of the epidemic. We synthesise them in Table 1, coupled with a erectile dysfunction treatment parallel example extracted from online press. This ease to find a current example for each topic suggests that they are not exclusive of plague or of Camus’s mindset, but shared by most epidemics.View this table:Table 1 Recurring topics in La Peste.

Each topic is accompanied by two examples from the novel and one concerning erectile dysfunction treatment, extracted from online press.Talking about journalism and the media (one of the topics above), we might say that erectile dysfunction treatment’s coverage is frequently too optimistic when managing good news and too alarming when approaching the bad. Media’s ‘exaggerated’ approach to health issues is not new. It was already a concern for medical journals’ editors a century ago (Reiling 2013) and it continues to be it for these professionals in recent times (Barbour et al.

2008). It is well known that media tries to attract spectators’ attention by making the news more appealing. However, they deal with the risk of expanding unreliable information, which may be pernicious for the public opinion.

Related to the intention of ‘garnishing’ the news, Aslam et al. (2020) have described that 82% of more than 100 000 pieces of information about erectile dysfunction treatment appearing in media from different countries carried an emotional, either negative (52%) or positive (30%) component, with only 18% of them considered as ‘neutral’ (Aslam et al. 2020).

Some evidence about this tendency to make news more emotional was described in former epidemics. For instance, a study conducted in Singapore in 2009 during the H1N1 crisis showed how press releases by the Ministry of Health were substantially transformed when passed to the media, by increasing their emotional appeal and by changing their dominant frame or their tone (Lee and Basnyat 2013). In La Peste, this superficial way of managing information by the media is also observed:The newspapers followed the order that they had been given, to be optimistic at any cost.

(Camus 2002, Part IV)At the first stages of the epidemic in Oran, journalists proclaim the end of the dead rats’ invasion as something to be celebrated. Dr Rieux, the character through which Camus symbolises caution (and comparable nowadays to trustful scientists, well-informed journalists or sensible authorities), exposes then his own angle, quite far from suggesting optimism:The vendors of the evening papers were shouting that the invasion of rats had ended. But Rieux found his patient lying half out of bed, one hand on his belly and the other around his neck, convulsively vomiting reddish bile into a rubbish bin.

(Camus 2002, Part I)Camus, who worked as a journalist for many years, insists afterwards on this cursory interest that some media devote to the epidemic, more eager to grab the noise than the relevant issues beneath it:The press, which had had so much to say about the business of the rats, fell silent. This is because rats die in the street and people in their bedrooms. And newspapers are only concerned with the street.

(Camus 2002, Part I)By then, Oranians continue rejecting the epidemic as an actual threat, completely immersed in that phase that dominates the beginning of all epidemics and is characterised by ‘denial and disbelief’ (Wigand, Becker, and Steger 2020, 443):A pestilence does not have human dimensions, so people tell themselves that it is unreal, that it is a bad dream which will end. […] The people of our town were no more guilty than anyone else, they merely forgot to be modest and thought that everything was still possible for them, which implied that pestilence was impossible. They continued with business, with making arrangements for travel and holding opinions.

Why should they have thought about the plague, which negates the future, negates journeys and debate?. They considered themselves free and no one will ever be free as long as there is plague, pestilence and famine. (Camus 2002, Part I)Probably to avoid citizens' disapproval, among other reasons, the Oranian Prefecture (health authority in Camus' novel) does not want to go too far when judging the relevance of the epidemic.

While not directly exposed, we can guess in this fragment the tone of the Prefect’s message, his intention to convey confidence despite his own doubts:These cases were not specific enough to be really disturbing and there was no doubt that the population would remain calm. None the less, for reasons of caution which everyone could understand, the Prefect was taking some preventive measures. If they were interpreted and applied in the proper way, these measures were such that they would put a definite stop to any threat of epidemic.

As a result, the Prefect did not for a moment doubt that the citizens under his charge would co-operate in the most zealous manner with what he was doing. (Camus 2002, Part I)The relevant role acquired by health authorities during epidemics is another topic listed in our table. Language use, on the other hand, is an issue linkable both with the media topic and with this one.

As in La Peste, during erectile dysfunction treatment we have seen some public figures using words not always truthfully, carrying out a careful selection of words that serves to the goal of conveying certain interests in each moment. Dr Rieux refers in Part I to this language manipulation by the authorities:The measures that had been taken were insufficient, that was quite clear. As for the ‘ specially equipped wards’, he knew what they were.

Two outbuildings hastily cleared of other patients, their windows sealed up and the whole surrounded by a cordon sanitaire. (Camus 2002, Part I)He illustrates the need of frankness, the preference for clarity in language, which is often the clarity in thinking:No. I phoned Richard to say we needed comprehensive measures, not fine words, and that either we must set up a real barrier to the epidemic, or nothing at all.

(Camus 2002, Part I)At the end of this part, his fears about the inadequacy of not taking strict measures are confirmed. Oranian hospitals become overwhelmed, as they are now in many places worldwide due to erectile dysfunction treatment.Part IILeft behind the phases of ‘denial and disbelief’ and of ‘fear and panic’, it appears among the Oranians the ‘acceptance paired with resignation’ (Wigand, Becker, and Steger 2020, 443):Then we knew that our separation was going to last, and that we ought to try to come to terms with time. […] In particular, all of the people in our town very soon gave up, even in public, whatever habit they may have acquired of estimating the length of their separation.

(Camus 2002, Part II)In erectile dysfunction treatment as well, even if border closure has not been so immovable as in Oran, many people have seen themselves separated from their loved ones and some of them have not yet had the possibility of reunion. This is why, in the actual levitra, the idea of temporal horizons has emerged like it appeared in Camus’s epidemic. In Spain, the general lockdown in March and April 2020 made people establish the summer as their temporal horizon, a time in which they could resume their former habits and see their relatives again.

This became partially true, and people were allowed in summer to travel inside the country and to some other countries nearby. However, there existed some reluctance to visit ill or aged relatives, due to the fear of infecting them, and some families living in distant countries were not able to get together. Moreover, autumn brought an increase in the number of cases (‘the second wave’) and countries returned to limit their internal and external movements.Bringing all this together, many people nowadays have opted to discard temporal horizons.

As Oranians, they have noted that the epidemic follows its own rhythm and it is useless to fight against it. Nonetheless, it is in human nature not to resign, so abandoning temporal horizons does not mean to give up longing for the recovery of normal life. This vision, neither maintaining vain hopes nor resigning, is in line with Camus’s philosophy, an author who wrote that ‘hope, contrary to what it is usually thought, is the same to resignation.’ (Camus 1939, 83.

Cited by Haroutunian 1964, 312 (translation is ours)), and that ‘there is not love to human life but with despair about human life.’ (Camus 1958, 112–5. Cited by Haroutunian 1964, 312–3 (translation is ours)).People nowadays deal with resignation relying on daily life pleasures (being not allowed to make further plans or trips) and in company from the nearest ones (as they cannot gather with relatives living far away). Second, they observe the beginning of vaccination campaigns as a first step of the final stage, and summer 2021, reflecting what happened with summer 2020, has been fixed as a temporal horizon.

This preference for summers has an unavoidable metaphorical nuance, and their linking to joy, long trips and life in the streets may be the reason for which we choose them to be opposed to the lockdown and restrictions of the levitra.We alluded previously to the manipulation of language, and figures, as relevant as they are, they are not free from manipulation either. Tarrou, a close friend to Dr Rieux, points out in this part of the novel how this occurred:Once more, Tarrou was the person who gave the most accurate picture of our life as it was then. Naturally he was following the course of the plague in general, accurately observing that a turning point in the epidemic was marked by the radio no longer announcing some hundreds of deaths per week, but 92, 107 and 120 deaths a day.

€˜The newspapers and the authorities are engaged in a battle of wits with the plague. They think that they are scoring points against it, because 130 is a lower figure than 910.’ (Camus 2002, Part II)Tarrou collaborates with the health teams formed to tackle the plague. Regarding these volunteers and workers, Camus refuses to consider them as heroes, as many essential workers during erectile dysfunction treatment have rejected to be named as that.

The writer thinks their actions are the natural behaviour of good people, not heroism but ‘a logical consequence’:The whole question was to prevent the largest possible number of people from dying and suffering a definitive separation. There was only one way to do this, which was to fight the plague. There was nothing admirable about this truth, it simply followed as a logical consequence.

(Camus 2002, Part II)We consider suitable to talk here about two issues which represent, nowadays, a great part of erectile dysfunction treatment fears and hopes, respectively. New genetic variants and treatments. Medical achievements are another recurrent issue included in table 1, and we write about them here because it is in Part II where Camus writes for the first time about treatments, and where it insists on an idea aforementioned in Part I.

That the plague bacillus affecting Oran is different from previous variants:…the microbe differed very slightly from the bacillus of plague as traditionally defined. (Camus 2002, Part II)Related to erectile dysfunction treatment new variants, they represent a challenge because of two main reasons. Their higher transmissibility and/or severity and their higher propensity to skip the effect of natural or treatment-induced immunity.

Public health professionals are determining which is the actual threat of all the new variants discovered, such as those first characterised in the UK (Public Health England 2020), South Africa (Tegally et al. 2021) or Brazil (Fujino et al. 2021).

In La Peste, Dr Rieux is always suspecting that the current bacteria they are dealing with is different from the one in previous epidemics of plague. Since several genetic variations for the bacillus Yersinia pestis have been characterised (Cui et al. 2012), it could be possible that the epidemic in Oran originated from a new one.

However, we should not forget that we are analysing a literary work, and that scientific accuracy is not a necessary goal in it. In fact, Rieux’s reluctances have to do more with clinical aspects than with microbiological ones. He doubts since the beginning, relying exclusively on the symptoms observed, and continues doing it after the laboratory analysis:I was able to have an analysis made in which the laboratory thinks it can detect the plague bacillus.

However, to be precise, we must say that certain specific modifications of the microbe do not coincide with the classic description of plague. (Camus 2002, Part II)Camus is consistent with this idea and many times he mentions the bacillus to highlight its oddity. Insisting on the literary condition of the work, and among other possible explanations, he is maybe declaring that that in the novel is not a common (biological, natural) bacteria, but the Nazism bacteria.Turning to treatments, they constitute the principal resource that the global community has to defeat the erectile dysfunction treatment levitra.

Vaccination campaigns have started all over the world, and three types of erectile dysfunction treatments are being applied in the European Union, after their respective statements of efficacy and security (Baden et al. 2021. Polack et al.

2020. Voysey et al. 2021), while a fourth treatment has just recently been approved (EMA 2021a).

Although some concerns regarding the safety of two of these treatments have been raised recently (EMA 2021b. EMA 2021c), vaccination plans are going ahead, being adapted according to the state of knowledge at each moment. Some of these treatments are mRNA-based (Baden et al.

2021. Polack et al. 2020), while others use a viral vector (Bos et al.

They are mainly two-shot treatments, with one exception (Bos et al. 2020), and complete immunity is thought to be acquired 2 weeks after the last shot (CDC. N.d.b, Voysey et al.

2021). Other countries such as China or Russia, on the other hand, were extremely early in starting their vaccination campaigns, and are distributing among their citizens different treatments than the aforementioned (Logunov et al. 2021.

Zhang et al. 2021).Even if at least three types of plague treatments had been created by the time the novel takes place (Sun 2016), treatments do not play an important role in La Peste, in which therapeutic measures (the serum) are more important than prophylactic ones. Few times in the novel the narrator refers to prophylactic inoculations:There was still no possibility of vaccinating with preventive serum except in families already affected by the disease.

(Camus 2002, Part II)Deudon has pointed out that Camus mixes up therapeutic serum and treatment (Deudon 1988), and in fact there exists a certain amount of confusion. All along the novel, the narrator focuses on the prophylactic goals of the serum, which is applied to people already infected (Othon’s son, Tarrou, Grand…). However, both in the example above (which can be understood as vaccinating household contacts or already affected individuals) and in others, the differences between treating and vaccinating are not clear:After the morning admissions which he was in charge of himself, the patients were vaccinated and the swellings lanced.

(Camus 2002, Part II)In any case, this is another situation in which Camus stands aside from scientific matters, which are to him less relevant in his novel than philosophical or literary ones. The distance existing between the relevance of treatments in erectile dysfunction treatment and the superficial manner with which Camus treats the topic in La Peste exemplifies this.Part IIIIn part III, the plague’s ravages become tougher. The narrator turns his focus to burials and their disturbance, a frequent topic in epidemics’ narrative (table 1).

Camus knew how acutely increasing demands and hygienic requirements affect funeral habits during epidemics:Everything really happened with the greatest speed and the minimum of risk. (Camus 2002, Part III)Like many other processes during epidemics, the burial process becomes a protocol. When protocolised, everything seems to work well and rapidly.

But this perfect mechanism is the Prefecture’s goal, not Rieux’s. He reveals in this moment an aspect in his character barely shown before. Irony.The whole thing was well organized and the Prefect expressed his satisfaction.

He even told Rieux that, when all was said and done, this was preferable to hearses driven by black slaves which one read about in the chronicles of earlier plagues. €˜ Yes,’ Rieux said. €˜ The burial is the same, but we keep a card index.

No one can deny that we have made progress.’ (Camus 2002, Part III)Even if this characteristic may seem new in Dr Rieux, we must bear in mind that he is the story narrator, and the narration is ironic from time to time. For instance, speaking precisely about the burials:The relatives were invited to sign a register –which just showed the difference that there may be between men and, for example, dogs. You can keep check of human beings-.

(Camus 2002, Part III)In Camus’s philosophy, the absurd is a core issue. According to Lengers, Rieux is ironic because he is a kind of Sisyphus who has understood the absurdity of plague (Lengers 1994). The response to the absurd is to rebel (Camus 2013), and Rieux does it by helping his fellow humans without questioning anything.

He does not pursue any other goal than doing his duty, thus humour (as a response to dire situations) stands out from him when he observes others celebrating irrelevant achievements, such as the Prefect with his burial protocol. In the field of medical ethics, Lengers has highlighted the importance of Camus’s perspective when considering ‘the immediacy of life rather than abstract values’ (Lengers 1994, 250). Rieux himself is quite sure that his solid commitment is not ‘abstract’, and, even if he falls into abstraction, the importance relies on protecting human lives and not in the name given to that task:Was it truly an abstraction, spending his days in the hospital where the plague was working overtime, bringing the number of victims up to five hundred on average per week?.

Yes, there was an element of abstraction and unreality in misfortune. But when an abstraction starts to kill you, you have to get to work on it. (Camus 2002, Part II)Farewells during erectile dysfunction treatment may have not been particularly pleasant for some families.

Neither those dying at nursing homes nor in hospitals could be accompanied by their families as previously, due to corpses management protocols, restrictions of external visitors and hygienic measures in general. However, as weeks passed by, certain efforts were made to ease this issue, allowing people to visit their dying beloved sticking to strict preventive measures. On the other hand, the number of people attending funeral masses and cemeteries was also limited, which affected the conventional development of ceremonies as well.

Hospitals had to deal with daily tolls of deaths never seen before, and the overcrowding of mortuaries made us see rows of coffins placed in unusual spaces, such as ice rinks (transformation of facilities is another topic in table 1).We turn now to two other points which erectile dysfunction treatment has not evaded. s among essential workers and epidemics’ economic consequences. The author links burials with s among essential workers because gravediggers constitute one of the most affected professions, and connects this fact with the economic recession because unemployment is behind the large availability of workers to replace the dead gravediggers:Many of the male nurses and the gravediggers, who were at first official, then casual, died of the plague.

[…] The most surprising thing was that there was never a shortage of men to do the job, for as long as the epidemic lasted. […] When the plague really took hold of the town, its very immoderation had one quite convenient outcome, because it disrupted the whole of economic life and so created quite a large number of unemployed. […] Poverty always triumphed over fear, to the extent that work was always paid according to the risk involved.

(Camus 2002, Part III)The effects of the plague over the economic system are one of our recurrent topics (table 1). The plague in Oran, as it forces to close the city, impacts all trading exchanges. In addition, it forbids travellers from arriving to the city, with the economic influence that that entails:This plague was the ruination of tourism.

(Camus 2002, Part II)Oranians, who, as we saw, were very worried about making money, are especially affected by an event which jeopardises it. In erectile dysfunction treatment, for one reason or for another, most of the countries are suffering economic consequences, since the impact on normal life from the epidemic (another recurrent topic) means also an impact on the normal development of trading activities.Part IVIn Part IV we witness the first signals of a stabilisation of the epidemic:It seemed that the plague had settled comfortably into its peak and was carrying out its daily murders with the precision and regularity of a good civil servant. In theory, in the opinion of experts, this was a good sign.

The graph of the progress of the plague, starting with its constant rise, followed by this long plateau, seemed quite reassuring. (Camus 2002, Part IV)At this time, we consider interesting to expand the topic about the transformation of facilities. We mentioned the case of ice rinks during erectile dysfunction treatment, and we bring up now the use of a football pitch as a quarantine camp in Camus’s novel, a scene which has reminded some scholars of the metaphor of Nazism and concentration camps (Finel-Honigman 1978).

In Spain, among other measures, a fairground was enabled as a field hospital during the first wave, and it is plausible that many devices created with other purposes were used in tasks attached to healthcare provision during those weeks, as occurred in Oran’s pitch with the loudspeakers:Then the loudspeakers, which in better times had served to introduce the teams or to declare the results of games, announced in a tinny voice that the internees should go back to their tents so that the evening meal could be distributed. (Camus 2002, Part IV)Related to this episode, we can also highlight the opposition between science and humanism that Camus does. The author alerts us about the dangers of a dehumanised science, of choosing procedures perfectly efficient regardless of their lack in human dignity:The men held out their hands, two ladles were plunged into two of the pots and emerged to unload their contents onto two tin plates.

The car drove on and the process was repeated at the next tent.‘ It’s scientific,’ Tarrou told the administrator.‘ Yes,’ he replied with satisfaction, as they shook hands. €˜ It’s scientific.’ (Camus 2002, Part IV)Several cases with favourable outcomes mark Part IV final moments and prepare the reader for the end of the epidemic. To describe these signs of recovering, the narrator turns back to two elements with a main role in the novel.

Rats and figures. In this moment, the first ones reappear and the second ones seem to be declining:He had seen two live rats come into his house through the street door. Neighbours had informed him that the creatures were also reappearing in their houses.

Behind the walls of other houses there was a hustle and bustle that had not been heard for months. Rieux waited for the general statistics to be published, as they were at the start of each week. They showed a decline in the disease.

(Camus 2002, Part IV)Part VGiven that we continue facing erectile dysfunction treatment, and that forecasts about its end are not easy, we cannot compare ourselves with the Oranians once they have reached the end of the epidemic, what occurs in this part. However, we can analyse our current situation, characterised by a widespread, though cautious, confidence motivated by the beginning of vaccination campaigns, referring it to the events narrated in Part V.Even more than the Oranians, since we feel further than them from the end of the problem, we are cautious about not to anticipate celebrations. From time to time, however, we lend ourselves to dream relying on what the narrator calls ‘a great, unadmitted hope’.

erectile dysfunction treatment took us by surprise and everyone wants to ‘reorganise’ their life, as Oranians do, but patience is an indispensable component to succeed, as fictional and historical epidemics show us.Although this sudden decline in the disease was unexpected, the towns-people were in no hurry to celebrate. The preceding months, though they had increased the desire for liberation, had also taught them prudence and accustomed them to count less and less on a rapid end to the epidemic. However, this new development was the subject of every conversation and, in the depths of people’s hearts, there was a great, unadmitted hope.

[…] One of the signs that a return to a time of good health was secretly expected (though no one admitted the fact) was that from this moment on people readily spoke, with apparent indifference, about how life would be reorganized after the plague. (Camus 2002, Part V)We put our hope on vaccination. Social distancing and other hygienic measures have proved to be effective, but treatments would bring us a more durable solution without compromising so hardly many economic activities and social habits.

As we said, a more important role of scientific aspects is observed in erectile dysfunction treatment if compared with La Peste (an expected fact if considered that Camus’s story is an artistic work, that he skips sometimes the most complex scientific issues of the plague and that health sciences have evolved substantially during last decades). Oranians, in fact, achieve the end of the epidemic not through clearly identified scientific responses but with certain randomness:All one could do was to observe that the sickness seemed to be going as it had arrived. The strategy being used against it had not changed.

It had been ineffective yesterday, and now it was apparently successful. One merely had the feeling that the disease had exhausted itself, or perhaps that it was retiring after achieving all its objectives. In a sense, its role was completed.

(Camus 2002, Part V)They receive the announcement made by the Prefecture of reopening the town’s gates in 2 weeks time with enthusiasm. Dealing with concrete dates gives them certainty, helps them fix the temporal horizons we wrote about. This is also the case when they are told that preventive measures would be lifted in 1 month.

Camus shows us then how the main characters are touched as well by this positive atmosphere:That evening Tarrou and Rieux, Rambert and the rest, walked in the midst of the crowd, and they too felt they were treading on air. Long after leaving the boulevards Tarrou and Rieux could still hear the sounds of happiness following them… (Camus 2002, Part V)Then, Tarrou points out a sign of recovery coming from the animal world. In a direct zoological chain, infected fleas have vanished from rats, which have been able again to multiply across the city, making the cats abandon their hiding places and to go hunting after them again.

At the final step of this chain, Tarrou sees the human being. He remembers the old man who used to spit to the cats beneath his window:At a time when the noise grew louder and more joyful, Tarrou stopped. A shape was running lightly across the dark street.

It was a cat, the first that had been seen since the spring. It stopped for a moment in the middle of the road, hesitated, licked its paw, quickly passed it across its right ear, then carried on its silent way and vanished into the night. Tarrou smiled.

The little old man, too, would be happy. (Camus 2002, Part V)Unpleasant things as a town with rats running across its streets, or a man spending his time spitting on a group of cats, constitute normality as much as the reopening of gates or the reboot of commerce. However, when Camus speaks directly about normality, he highlights more appealing habits.

He proposes common leisure activities (restaurants, theatres) as symbols of human life, since he opposes them to Cottard’s life, which has become that of a ‘wild animal’:At least in appearance he [ Cottard ] retired from the world and from one day to the next started to live like a wild animal. He no longer appeared in restaurants, at the theatre or in his favourite cafés. (Camus 2002, Part V)We do not disclose why Cottard’s reaction to the end of the epidemic is different from most of the Oranians’.

In any case, the narrator insists later on the assimilation between common pleasures and normality:‘ Perhaps,’ Cottard said, ‘ Perhaps so. But what do you call a return to normal life?. €™ ‘ New films in the cinema,’ said Tarrou with a smile.

(Camus 2002, Part V)Cinema, as well as theatre, live music and many other cultural events have been cancelled or obliged to modify their activities due to erectile dysfunction treatment. Several bars and restaurants have closed, and spending time in those who remain open has become an activity which many people tend to avoid, fearing contagion. Thus, normality in our understanding is linked as well to these simple and pleasant habits, and the complete achievement of them will probably signify for us the desired defeat of the levitra.In La Peste, love is also seen as a simple good to be fully recovered after the plague.

While Rieux goes through the ‘reborn’ Oran, it is lovers’ gatherings what he highlights. Unlike them, everyone who, during the epidemic, sought for goals different from love (such as faith or money, for instance) remain lost when the epidemic has ended:For all the people who, on the contrary, had looked beyond man to something that they could not even imagine, there had been no reply. (Camus 2002, Part V)And this is because lovers, as the narrator says:If they had found that they wanted, it was because they had asked for the only thing that depended on them.

(Camus 2002, Part V)We have spoken before about language manipulation, hypocrisy and public figures’ roles during epidemics. Camus, during Dr Rieux’s last visit to the old asthmatic man, makes this frank and humble character criticise, with a point of irony, the authorities’ attitude concerning tributes to the dead:‘ Tell me, doctor, is it true that they’re going to put up a monument to the victims of the plague?. €™â€˜ So the papers say.

A pillar or a plaque.’‘ I knew it!. And there’ll be speeches.’The old man gave a strangled laugh.‘ I can hear them already. €œ Our dead…” Then they’ll go and have dinner.’ (Camus 2002, Part V)The old man illustrates wisely the authorities’ propensity for making speeches.

He knows that most of them usually prefer grandiloquence rather than common words, and seizes perfectly their tone when he imitates them (‘Our dead…’). We have also got used, during erectile dysfunction treatment, to these types of messages. We have also heard about ‘our old people’, ‘our youth’, ‘our essential workers’ and even ‘our dead’.

Behind this tone, however, there could be an intention to hide errors, or to falsely convey carefulness. Honest rulers do not usually need nice words. They just want them to be accurate.We have seen as well some tributes to the victims during erectile dysfunction treatment, some of which we can doubt whether they serve to victims’ relief or to authorities’ promotion.

We want rulers to be less aware of their own image and to stress truthfulness as a goal, even if this is a hard requirement not only for them, but for every single person. Language is essential in this issue, we think, since it is prone to be twisted and to become untrue. The old asthmatic man illustrates it with his ‘There’ll be speeches’ and his ‘Our dead…’, but this is not the only time in the novel in which Camus brings out the topic.

For instance, he does so when he equates silence (nothing can be thought as further from wordiness) with truth:It is at the moment of misfortune that one becomes accustomed to truth, that is to say to silence. (Camus 2002, Part II)or when he makes a solid statement against false words:…I understood that all the misfortunes of mankind came from not stating things in clear terms. (Camus 2002, Part IV)The old asthmatic, in fact, while praising the deceased Tarrou, remarks that he used to admire him because ‘he didn’t talk just for the sake of it.’ (Camus 2002, Part V).Related to this topic, what the old asthmatic says about political authorities may be transposed in our case to other public figures, such as scholars and researchers, media leaders, businessmen and women, health professionals… and, if we extend the scope, to every single citizen.

Because hypocrisy, language manipulation and the fact of putting individual interests ahead of collective welfare fit badly with collective issues such as epidemics. Hopefully, also examples to the contrary have been observed during erectile dysfunction treatment.The story ends with the fireworks in Oran and the depiction of Dr Rieux’s last feelings. While he is satisfied because of his medical performance and his activity as a witness of the plague, he is concerned about future disasters to come.

When erectile dysfunction treatment will have passed, it will be time for us as well to review our life during these months. For now, we are just looking forward to achieving our particular ‘part V’..

IntroductionLa Peste (Camus 1947) has served as a basis for several critical works, including some in the field of levitra target pharmacy medical humanities Lowest price propecia (Bozzaro 2018. Deudon 1988. Tuffuor and levitra target pharmacy Payne 2017).

Frequently interpreted as an allegory of Nazism (with the plague as a symbol of the German occupation of France) (Finel-Honigman 1978. Haroutunian 1964), it has also received philosophical readings beyond the sociopolitical context in which it was written (Lengers 1994). Other scholars, on levitra target pharmacy the other hand, have centred their analyses on its literary aspects (Steel 2016).The erectile dysfunction treatment levitra has increased general interest about historical and fictional epidemics.

La Peste, as one of the most famous literary works about this topic, has been revisited by many readers during recent months, leading to an unexpected growth in sales in certain countries (Wilsher 2020. Zaretsky 2020). Apart from that, commentaries about levitra target pharmacy the novel, especially among health sciences scholars, have emerged with a renewed interest (Banerjee et al.

2020. Bate 2020. Vandekerckhove 2020 levitra target pharmacy.

Wigand, Becker, and Steger 2020). This sudden curiosity is easy to understand if we consider both La Peste’s literary value, and people’s desire to discover real or fictional situations similar to theirs. Indeed, Oran inhabitants’ experiences are not quite far from our own, even if geographical, chronological and, specially, scientific factors (two different diseases occurring at two different stages in the history of medical development) prevent us from establishing too close resemblances between both situations.Furthermore, it will not be strange if erectile dysfunction treatment serves as a levitra target pharmacy frame for fictional works in the near future.

Other narrative plays were based on historical epidemics, such as Daniel Defoe’s A Journal of the Plague Year or Giovanni Boccaccio’s Decameron (Wigand, Becker, and Steger 2020. Withington 2020). The biggest levitra in the last century, levitra target pharmacy the so-called ‘Spanish Influenza’, has been described as not very fruitful in this sense, even if it produced famous novels such as Katherine A Porter’s Pale Horse, Pale Rider or John O’Hara’s The Doctor Son (Honigsbaum 2018.

Hovanec 2011). The overlapping with another disaster like World War I has been argued as one of the reasons explaining this scarce production of fictional works (Honigsbaum 2018). By contrast, we may think that erectile dysfunction treatment is having a global impact hardly overshadowed by other events, and that it will leave a significant mark on the collective memory.Drawing on the reading of La Peste, we point out in this essay different aspects of living under an epidemic that can levitra target pharmacy be identified both in Camus’s work and in our current situation.

We propose a trip throughout the novel, from its early beginning in Part I, when the Oranians are not aware of the threat to come, to its end in Part V, when they are relieved of the epidemic after several months of ravaging disasters.We think this journey along La Peste may be interesting both to health professionals and to the lay person, since all of them will be able to see themselves reflected in the characters from the novel. We do not skip critique of some aspects related to the authorities’ management of erectile dysfunction treatment, as Camus does concerning Oran’s rulers. However, what we want to foreground is La Peste’s intrinsic value, its suitability to be read now and after erectile dysfunction treatment has passed, when Camus’s novel endures as a solid art work and erectile dysfunction treatment remains only as levitra target pharmacy a defeated plight.MethodsWe confronted our own experiences about erectile dysfunction treatment with a conventional reading of La Peste.

A first reading of the novel was used to establish associations between those aspects which more saliently reminded us of erectile dysfunction treatment. In a second reading, we searched for some examples to illustrate those aspects and tried to detect new associations. Subsequent readings of certain parts were levitra target pharmacy done to integrate the information collected.

Neither specific methods of literary analysis, nor systematic searches in the novel were applied. Selected paragraphs and ideas from Part I to Part V were prepared in a draft copy, and this manuscript was written afterwards.Part ISome phrases in the novel could be transposed word by word to our situation. This one pertaining to its start, for instance, may make us remember the first months of 2020:By now, it will be easy to accept that nothing could levitra target pharmacy lead the people of our town to expect the events that took place in the spring of that year and which, as we later understood, were like the forerunners of the series of grave happenings that this history intends to describe.

(Camus 2002, Part I)By referring from the beginning to ‘the people of our town’, Camus is already suggesting an idea which is repeated all along the novel, and which may be well understood by us as erectile dysfunction treatment’s witnesses. Epidemics affect the community as a whole, they are present in everybody’s mind and their joys and sorrows are not individual, but collective. For example (and we are anticipating Part II), the narrator says:But, once the gates levitra target pharmacy were closed, they all noticed that they were in the same boat, including the narrator himself, and that they had to adjust to the fact.

(Camus 2002, Part II)Later, he will insist in this opposition between the concepts of ‘individual’, which used to prevail before the epidemic, and ‘collective’:One might say that the first effect of this sudden and brutal attack of the disease was to force the citizens of our town to act as though they had no individual feelings. (Camus 2002, Part II)There were no longer any individual destinies, but a collective history that was the plague, and feelings shared by all. (Camus 2002, Part III)This distinction is not trivial, since the story levitra target pharmacy will display a strong confrontation between those who get involved and help their neighbours and those who remain behaving selfishly.

Related to this, Claudia Bozzaro has pointed out that the main topic in La Peste is solidarity and auistic love (Bozzaro 2018). We may add that the disease is so attached to people’s lives that the epidemic becomes the new everyday life:In the morning, they would return to the pestilence, that is to say, to routine. (Camus 2002, levitra target pharmacy Part III)Being collective issues does not mean that epidemics always enhance auism and solidarity.

As said by Wigand et al, they frequently produce ambivalent reactions, and one of them is the opposition between auism and maximised profit (Wigand, Becker, and Steger 2020). Therefore, the dichotomy between individualism and collectivism, a central point in the characterisation of national cultures (Hofstede 2015), could play a role in epidemics. In fact, concerning erectile dysfunction treatment, some authors levitra target pharmacy have described a greater impact of the levitra in those countries with higher levels of individualism (Maaravi et al.

However, this finding should be complemented with other national cultures’ aspects before concluding that collectivism itself exerts a protective role against epidemics. Concerning this, it has been shown how ‘power distance’ frequently intersects with collectivism, being only a few countries in which the last one coexists with a small distance to power, namely with a capacity to disobey the power authority (Gupta, Shoja, and Mikalef 2021). Moreover, those countries classically classified as ‘collectivist’ (China, Japan, South Korea, India, Vietnam, etc.) are also characterised by high levels of power distance, and their citizens have been quite often forced to adhere to erectile dysfunction treatment restrictions and punished if not (Gupta, Shoja, and Mikalef 2021).

Thus, it is important to consider that individualism is not always opposed to ‘look after each other’ (Ozkan et al. 2021, 9). For instance, the European region, seen as a whole as highly ‘individualistic’, holds some of the most advanced welfare protection systems worldwide.

It is worth considering too that collectivism may hide sometimes a hard institutional authority or a lack in civil freedoms.Coming back to La Peste, we may think that Camus’s Oranians are not particularly ‘collectivist’. Their initial description highlights that they are mainly interested in their own businesses and affairs:Our fellow-citizens work a good deal, but always in order to make money. They are especially interested in trade and first of all, as they say, they are engaged in doing business.

(Camus 2002, Part I)And later, we see some of them trying selfishly to leave the city by illegal methods. By contrast, we observe in the novel some examples of more ‘collectivistic’ attitudes, such as the discipline of those quarantined at the football pitch, and, over all, the main characters’ behaviour, which is generally driven by auism and common goals.Turning to another topic, the plague in Oran and erectile dysfunction treatment are similar regarding their animal origin. This is not rare since many infectious diseases pass to humans through contact with animal vectors, being rodents, especially rats (through rat fleas), the most common carriers of plague bacteria (CDC.

N.d.a, ECDC. N.d, Pollitzer 1954). Concerning erectile dysfunction, even if further research about its origin is needed, the most recent investigations conducted in China by the WHO establish a zoonotic transmission as the most probable pathway (Joint WHO-China Study Team 2021).

In Camus’s novel, the animal’s link to the epidemic seemed very clear since the beginning:Things got to the point where Infodoc (the agency for information and documentation, ‘ all you need to know on any subject’) announced in its free radio news programme that 6,231 rats had been collected and burned in a single day, the 25th. This figure, which gave a clear meaning to the daily spectacle that everyone in town had in front of their eyes, disconcerted them even more. (Camus 2002, Part I)This accuracy in figures is familiar to us.

People nowadays have become very used to the statistical aspects of the levitra, due to the continuous updates in epidemiological parameters launched by the media and the authorities. Camus was aware about the relevance of figures in epidemics, which always entail:…required registration and statistical tasks. (Camus 2002, Part II)Because of this, the novel is scattered with numbers, most of them concerning the daily death toll, but others mentioning the number of rats picked up, as we have seen, or combining the number of deaths with the time passed since the start of the epidemic:“ Will there be an autumn of plague?.

Professor B answers. €˜ No’ ”, “ One hundred and twenty-four dead. The total for the ninety-fourth day of the plague.” (Camus 2002, Part II)We permit ourselves to introduce here a list of recurring topics in La Peste, since the salience of statistical information is one of them.

These topics, some of which will be treated later, appear several times in the novel, in various contexts and stages in the evolution of the epidemic. We synthesise them in Table 1, coupled with a erectile dysfunction treatment parallel example extracted from online press. This ease to find a current example for each topic suggests that they are not exclusive of plague or of Camus’s mindset, but shared by most epidemics.View this table:Table 1 Recurring topics in La Peste.

Each topic is accompanied by two examples from the novel and one concerning erectile dysfunction treatment, extracted from online press.Talking about journalism and the media (one of the topics above), we might say that erectile dysfunction treatment’s coverage is frequently too optimistic when managing good news and too alarming when approaching the bad. Media’s ‘exaggerated’ approach to health issues is not new. It was already a concern for medical journals’ editors a century ago (Reiling 2013) and it continues to be it for these professionals in recent times (Barbour et al.

2008). It is well known that media tries to attract spectators’ attention by making the news more appealing. However, they deal with the risk of expanding unreliable information, which may be pernicious for the public opinion.

Related to the intention of ‘garnishing’ the news, Aslam et al. (2020) have described that 82% of more than 100 000 pieces of information about erectile dysfunction treatment appearing in media from different countries carried an emotional, either negative (52%) or positive (30%) component, with only 18% of them considered as ‘neutral’ (Aslam et al. 2020).

Some evidence about this tendency to make news more emotional was described in former epidemics. For instance, a study conducted in Singapore in 2009 during the H1N1 crisis showed how press releases by the Ministry of Health were substantially transformed when passed to the media, by increasing their emotional appeal and by changing their dominant frame or their tone (Lee and Basnyat 2013). In La Peste, this superficial way of managing information by the media is also observed:The newspapers followed the order that they had been given, to be optimistic at any cost.

(Camus 2002, Part IV)At the first stages of the epidemic in Oran, journalists proclaim the end of the dead rats’ invasion as something to be celebrated. Dr Rieux, the character through which Camus symbolises caution (and comparable nowadays to trustful scientists, well-informed journalists or sensible authorities), exposes then his own angle, quite far from suggesting optimism:The vendors of the evening papers were shouting that the invasion of rats had ended. But Rieux found his patient lying half out of bed, one hand on his belly and the other around his neck, convulsively vomiting reddish bile into a rubbish bin.

(Camus 2002, Part I)Camus, who worked as a journalist for many years, insists afterwards on this cursory interest that some media devote to the epidemic, more eager to grab the noise than the relevant issues beneath it:The press, which had had so much to say about the business of the rats, fell silent. This is because rats die in the street and people in their bedrooms. And newspapers are only concerned with the street.

(Camus 2002, Part I)By then, Oranians continue rejecting the epidemic as an actual threat, completely immersed in that phase that dominates the beginning of all epidemics and is characterised by ‘denial and disbelief’ (Wigand, Becker, and Steger 2020, 443):A pestilence does not have human dimensions, so people tell themselves that it is unreal, that it is a bad dream which will end. […] The people of our town were no more guilty than anyone else, they merely forgot to be modest and thought that everything was still possible for them, which implied that pestilence was impossible. They continued with business, with making arrangements for travel and holding opinions.

Why should they have thought about the plague, which negates the future, negates journeys and debate?. They considered themselves free and no one will ever be free as long as there is plague, pestilence and famine. (Camus 2002, Part I)Probably to avoid citizens' disapproval, among other reasons, the Oranian Prefecture (health authority in Camus' novel) does not want to go too far when judging the relevance of the epidemic.

While not directly exposed, we can guess in this fragment the tone of the Prefect’s message, his intention to convey confidence despite his own doubts:These cases were not specific enough to be really disturbing and there was no doubt that the population would remain calm. None the less, for reasons of caution which everyone could understand, the Prefect was taking some preventive measures. If they were interpreted and applied in the proper way, these measures were such that they would put a definite stop to any threat of epidemic.

As a result, the Prefect did not for a moment doubt that the citizens under his charge would co-operate in the most zealous manner with what he was doing. (Camus 2002, Part I)The relevant role acquired by health authorities during epidemics is another topic listed in our table. Language use, on the other hand, is an issue linkable both with the media topic and with this one.

As in La Peste, during erectile dysfunction treatment we have seen some public figures using words not always truthfully, carrying out a careful selection of words that serves to the goal of conveying certain interests in each moment. Dr Rieux refers in Part I to this language manipulation by the authorities:The measures that had been taken were insufficient, that was quite clear. As for the ‘ specially equipped wards’, he knew what they were.

Two outbuildings hastily cleared of other patients, their windows sealed up and the whole surrounded by a cordon sanitaire. (Camus 2002, Part I)He illustrates the need of frankness, the preference for clarity in language, which is often the clarity in thinking:No. I phoned Richard to say we needed comprehensive measures, not fine words, and that either we must set up a real barrier to the epidemic, or nothing at all.

(Camus 2002, Part I)At the end of this part, his fears about the inadequacy of not taking strict measures are confirmed. Oranian hospitals become overwhelmed, as they are now in many places worldwide due to erectile dysfunction treatment.Part IILeft behind the phases of ‘denial and disbelief’ and of ‘fear and panic’, it appears among the Oranians the ‘acceptance paired with resignation’ (Wigand, Becker, and Steger 2020, 443):Then we knew that our separation was going to last, and that we ought to try to come to terms with time. […] In particular, all of the people in our town very soon gave up, even in public, whatever habit they may have acquired of estimating the length of their separation.

(Camus 2002, Part II)In erectile dysfunction treatment as well, even if border closure has not been so immovable as in Oran, many people have seen themselves separated from their loved ones and some of them have not yet had the possibility of reunion. This is why, in the actual levitra, the idea of temporal horizons has emerged like it appeared in Camus’s epidemic. In Spain, the general lockdown in March and April 2020 made people establish the summer as their temporal horizon, a time in which they could resume their former habits and see their relatives again.

This became partially true, and people were allowed in summer to travel inside the country and to some other countries nearby. However, there existed some reluctance to visit ill or aged relatives, due to the fear of infecting them, and some families living in distant countries were not able to get together. Moreover, autumn brought an increase in the number of cases (‘the second wave’) and countries returned to limit their internal and external movements.Bringing all this together, many people nowadays have opted to discard temporal horizons.

As Oranians, they have noted that the epidemic follows its own rhythm and it is useless to fight against it. Nonetheless, it is in human nature not to resign, so abandoning temporal horizons does not mean to give up longing for the recovery of normal life. This vision, neither maintaining vain hopes nor resigning, is in line with Camus’s philosophy, an author who wrote that ‘hope, contrary to what it is usually thought, is the same to resignation.’ (Camus 1939, 83.

Cited by Haroutunian 1964, 312 (translation is ours)), and that ‘there is not love to human life but with despair about human life.’ (Camus 1958, 112–5. Cited by Haroutunian 1964, 312–3 (translation is ours)).People nowadays deal with resignation relying on daily life pleasures (being not allowed to make further plans or trips) and in company from the nearest ones (as they cannot gather with relatives living far away). Second, they observe the beginning of vaccination campaigns as a first step of the final stage, and summer 2021, reflecting what happened with summer 2020, has been fixed as a temporal horizon.

This preference for summers has an unavoidable metaphorical nuance, and their linking to joy, long trips and life in the streets may be the reason for which we choose them to be opposed to the lockdown and restrictions of the levitra.We alluded previously to the manipulation of language, and figures, as relevant as they are, they are not free from manipulation either. Tarrou, a close friend to Dr Rieux, points out in this part of the novel how this occurred:Once more, Tarrou was the person who gave the most accurate picture of our life as it was then. Naturally he was following the course of the plague in general, accurately observing that a turning point in the epidemic was marked by the radio no longer announcing some hundreds of deaths per week, but 92, 107 and 120 deaths a day.

€˜The newspapers and the authorities are engaged in a battle of wits with the plague. They think that they are scoring points against it, because 130 is a lower figure than 910.’ (Camus 2002, Part II)Tarrou collaborates with the health teams formed to tackle the plague. Regarding these volunteers and workers, Camus refuses to consider them as heroes, as many essential workers during erectile dysfunction treatment have rejected to be named as that.

The writer thinks their actions are the natural behaviour of good people, not heroism but ‘a logical consequence’:The whole question was to prevent the largest possible number of people from dying and suffering a definitive separation. There was only one way to do this, which was to fight the plague. There was nothing admirable about this truth, it simply followed as a logical consequence.

(Camus 2002, Part II)We consider suitable to talk here about two issues which represent, nowadays, a great part of erectile dysfunction treatment fears and hopes, respectively. New genetic variants and treatments. Medical achievements are another recurrent issue included in table 1, and we write about them here because it is in Part II where Camus writes for the first time about treatments, and where it insists on an idea aforementioned in Part I.

That the plague bacillus affecting Oran is different from previous variants:…the microbe differed very slightly from the bacillus of plague as traditionally defined. (Camus 2002, Part II)Related to erectile dysfunction treatment new variants, they represent a challenge because of two main reasons. Their higher transmissibility and/or severity and their higher propensity to skip the effect of natural or treatment-induced immunity.

Public health professionals are determining which is the actual threat of all the new variants discovered, such as those first characterised in the UK (Public Health England 2020), South Africa (Tegally et al. 2021) or Brazil (Fujino et al. 2021).

In La Peste, Dr Rieux is always suspecting that the current bacteria they are dealing with is different from the one in previous epidemics of plague. Since several genetic variations for the bacillus Yersinia pestis have been characterised (Cui et al. 2012), it could be possible that the epidemic in Oran originated from a new one.

However, we should not forget that we are analysing a literary work, and that scientific accuracy is not a necessary goal in it. In fact, Rieux’s reluctances have to do more with clinical aspects than with microbiological ones. He doubts since the beginning, relying exclusively on the symptoms observed, and continues doing it after the laboratory analysis:I was able to have an analysis made in which the laboratory thinks it can detect the plague bacillus.

However, to be precise, we must say that certain specific modifications of the microbe do not coincide with the classic description of plague. (Camus 2002, Part II)Camus is consistent with this idea and many times he mentions the bacillus to highlight its oddity. Insisting on the literary condition of the work, and among other possible explanations, he is maybe declaring that that in the novel is not a common (biological, natural) bacteria, but the Nazism bacteria.Turning to treatments, they constitute the principal resource that the global community has to defeat the erectile dysfunction treatment levitra.

Vaccination campaigns have started all over the world, and three types of erectile dysfunction treatments are being applied in the European Union, after their respective statements of efficacy and security (Baden et al. 2021. Polack et al.

2020. Voysey et al. 2021), while a fourth treatment has just recently been approved (EMA 2021a).

Although some concerns regarding the safety of two of these treatments have been raised recently (EMA 2021b. EMA 2021c), vaccination plans are going ahead, being adapted according to the state of knowledge at each moment. Some of these treatments are mRNA-based (Baden et al.

2021. Polack et al. 2020), while others use a viral vector (Bos et al.

They are mainly two-shot treatments, with one exception (Bos et al. 2020), and complete immunity is thought to be acquired 2 weeks after the last shot (CDC. N.d.b, Voysey et al.

2021). Other countries such as China or Russia, on the other hand, were extremely early in starting their vaccination campaigns, and are distributing among their citizens different treatments than the aforementioned (Logunov et al. 2021.

Zhang et al. 2021).Even if at least three types of plague treatments had been created by the time the novel takes place (Sun 2016), treatments do not play an important role in La Peste, in which therapeutic measures (the serum) are more important than prophylactic ones. Few times in the novel the narrator refers to prophylactic inoculations:There was still no possibility of vaccinating with preventive serum except in families already affected by the disease.

(Camus 2002, Part II)Deudon has pointed out that Camus mixes up therapeutic serum and treatment (Deudon 1988), and in fact there exists a certain amount of confusion. All along the novel, the narrator focuses on the prophylactic goals of the serum, which is applied to people already infected (Othon’s son, Tarrou, Grand…). However, both in the example above (which can be understood as vaccinating household contacts or already affected individuals) and in others, the differences between treating and vaccinating are not clear:After the morning admissions which he was in charge of himself, the patients were vaccinated and the swellings lanced.

(Camus 2002, Part II)In any case, this is another situation in which Camus stands aside from scientific matters, which are to him less relevant in his novel than philosophical or literary ones. The distance existing between the relevance of treatments in erectile dysfunction treatment and the superficial manner with which Camus treats the topic in La Peste exemplifies this.Part IIIIn part III, the plague’s ravages become tougher. The narrator turns his focus to burials and their disturbance, a frequent topic in epidemics’ narrative (table 1).

Camus knew how acutely increasing demands and hygienic requirements affect funeral habits during epidemics:Everything really happened with the greatest speed and the minimum of risk. (Camus 2002, Part III)Like many other processes during epidemics, the burial process becomes a protocol. When protocolised, everything seems to work well and rapidly.

But this perfect mechanism is the Prefecture’s goal, not Rieux’s. He reveals in this moment an aspect in his character barely shown before. Irony.The whole thing was well organized and the Prefect expressed his satisfaction.

He even told Rieux that, when all was said and done, this was preferable to hearses driven by black slaves which one read about in the chronicles of earlier plagues. €˜ Yes,’ Rieux said. €˜ The burial is the same, but we keep a card index.

No one can deny that we have made progress.’ (Camus 2002, Part III)Even if this characteristic may seem new in Dr Rieux, we must bear in mind that he is the story narrator, and the narration is ironic from time to time. For instance, speaking precisely about the burials:The relatives were invited to sign a register –which just showed the difference that there may be between men and, for example, dogs. You can keep check of human beings-.

(Camus 2002, Part III)In Camus’s philosophy, the absurd is a core issue. According to Lengers, Rieux is ironic because he is a kind of Sisyphus who has understood the absurdity of plague (Lengers 1994). The response to the absurd is to rebel (Camus 2013), and Rieux does it by helping his fellow humans without questioning anything.

He does not pursue any other goal than doing his duty, thus humour (as a response to dire situations) stands out from him when he observes others celebrating irrelevant achievements, such as the Prefect with his burial protocol. In the field of medical ethics, Lengers has highlighted the importance of Camus’s perspective when considering ‘the immediacy of life rather than abstract values’ (Lengers 1994, 250). Rieux himself is quite sure that his solid commitment is not ‘abstract’, and, even if he falls into abstraction, the importance relies on protecting human lives and not in the name given to that task:Was it truly an abstraction, spending his days in the hospital where the plague was working overtime, bringing the number of victims up to five hundred on average per week?.

Yes, there was an element of abstraction and unreality in misfortune. But when an abstraction starts to kill you, you have to get to work on it. (Camus 2002, Part II)Farewells during erectile dysfunction treatment may have not been particularly pleasant for some families.

Neither those dying at nursing homes nor in hospitals could be accompanied by their families as previously, due to corpses management protocols, restrictions of external visitors and hygienic measures in general. However, as weeks passed by, certain efforts were made to ease this issue, allowing people to visit their dying beloved sticking to strict preventive measures. On the other hand, the number of people attending funeral masses and cemeteries was also limited, which affected the conventional development of ceremonies as well.

Hospitals had to deal with daily tolls of deaths never seen before, and the overcrowding of mortuaries made us see rows of coffins placed in unusual spaces, such as ice rinks (transformation of facilities is another topic in table 1).We turn now to two other points which erectile dysfunction treatment has not evaded. s among essential workers and epidemics’ economic consequences. The author links burials with s among essential workers because gravediggers constitute one of the most affected professions, and connects this fact with the economic recession because unemployment is behind the large availability of workers to replace the dead gravediggers:Many of the male nurses and the gravediggers, who were at first official, then casual, died of the plague.

[…] The most surprising thing was that there was never a shortage of men to do the job, for as long as the epidemic lasted. […] When the plague really took hold of the town, its very immoderation had one quite convenient outcome, because it disrupted the whole of economic life and so created quite a large number of unemployed. […] Poverty always triumphed over fear, to the extent that work was always paid according to the risk involved.

(Camus 2002, Part III)The effects of the plague over the economic system are one of our recurrent topics (table 1). The plague in Oran, as it forces to close the city, impacts all trading exchanges. In addition, it forbids travellers from arriving to the city, with the economic influence that that entails:This plague was the ruination of tourism.

(Camus 2002, Part II)Oranians, who, as we saw, were very worried about making money, are especially affected by an event which jeopardises it. In erectile dysfunction treatment, for one reason or for another, most of the countries are suffering economic consequences, since the impact on normal life from the epidemic (another recurrent topic) means also an impact on the normal development of trading activities.Part IVIn Part IV we witness the first signals of a stabilisation of the epidemic:It seemed that the plague had settled comfortably into its peak and was carrying out its daily murders with the precision and regularity of a good civil servant. In theory, in the opinion of experts, this was a good sign.

The graph of the progress of the plague, starting with its constant rise, followed by this long plateau, seemed quite reassuring. (Camus 2002, Part IV)At this time, we consider interesting to expand the topic about the transformation of facilities. We mentioned the case of ice rinks during erectile dysfunction treatment, and we bring up now the use of a football pitch as a quarantine camp in Camus’s novel, a scene which has reminded some scholars of the metaphor of Nazism and concentration camps (Finel-Honigman 1978).

In Spain, among other measures, a fairground was enabled as a field hospital during the first wave, and it is plausible that many devices created with other purposes were used in tasks attached to healthcare provision during those weeks, as occurred in Oran’s pitch with the loudspeakers:Then the loudspeakers, which in better times had served to introduce the teams or to declare the results of games, announced in a tinny voice that the internees should go back to their tents so that the evening meal could be distributed. (Camus 2002, Part IV)Related to this episode, we can also highlight the opposition between science and humanism that Camus does. The author alerts us about the dangers of a dehumanised science, of choosing procedures perfectly efficient regardless of their lack in human dignity:The men held out their hands, two ladles were plunged into two of the pots and emerged to unload their contents onto two tin plates.

The car drove on and the process was repeated at the next tent.‘ It’s scientific,’ Tarrou told the administrator.‘ Yes,’ he replied with satisfaction, as they shook hands. €˜ It’s scientific.’ (Camus 2002, Part IV)Several cases with favourable outcomes mark Part IV final moments and prepare the reader for the end of the epidemic. To describe these signs of recovering, the narrator turns back to two elements with a main role in the novel.

Rats and figures. In this moment, the first ones reappear and the second ones seem to be declining:He had seen two live rats come into his house through the street door. Neighbours had informed him that the creatures were also reappearing in their houses.

Behind the walls of other houses there was a hustle and bustle that had not been heard for months. Rieux waited for the general statistics to be published, as they were at the start of each week. They showed a decline in the disease.

(Camus 2002, Part IV)Part VGiven that we continue facing erectile dysfunction treatment, and that forecasts about its end are not easy, we cannot compare ourselves with the Oranians once they have reached the end of the epidemic, what occurs in this part. However, we can analyse our current situation, characterised by a widespread, though cautious, confidence motivated by the beginning of vaccination campaigns, referring it to the events narrated in Part V.Even more than the Oranians, since we feel further than them from the end of the problem, we are cautious about not to anticipate celebrations. From time to time, however, we lend ourselves to dream relying on what the narrator calls ‘a great, unadmitted hope’.

erectile dysfunction treatment took us by surprise and everyone wants to ‘reorganise’ their life, as Oranians do, but patience is an indispensable component to succeed, as fictional and historical epidemics show us.Although this sudden decline in the disease was unexpected, the towns-people were in no hurry to celebrate. The preceding months, though they had increased the desire for liberation, had also taught them prudence and accustomed them to count less and less on a rapid end to the epidemic. However, this new development was the subject of every conversation and, in the depths of people’s hearts, there was a great, unadmitted hope.

[…] One of the signs that a return to a time of good health was secretly expected (though no one admitted the fact) was that from this moment on people readily spoke, with apparent indifference, about how life would be reorganized after the plague. (Camus 2002, Part V)We put our hope on vaccination. Social distancing and other hygienic measures have proved to be effective, but treatments would bring us a more durable solution without compromising so hardly many economic activities and social habits.

As we said, a more important role of scientific aspects is observed in erectile dysfunction treatment if compared with La Peste (an expected fact if considered that Camus’s story is an artistic work, that he skips sometimes the most complex scientific issues of the plague and that health sciences have evolved substantially during last decades). Oranians, in fact, achieve the end of the epidemic not through clearly identified scientific responses but with certain randomness:All one could do was to observe that the sickness seemed to be going as it had arrived. The strategy being used against it had not changed.

It had been ineffective yesterday, and now it was apparently successful. One merely had the feeling that the disease had exhausted itself, or perhaps that it was retiring after achieving all its objectives. In a sense, its role was completed.

(Camus 2002, Part V)They receive the announcement made by the Prefecture of reopening the town’s gates in 2 weeks time with enthusiasm. Dealing with concrete dates gives them certainty, helps them fix the temporal horizons we wrote about. This is also the case when they are told that preventive measures would be lifted in 1 month.

Camus shows us then how the main characters are touched as well by this positive atmosphere:That evening Tarrou and Rieux, Rambert and the rest, walked in the midst of the crowd, and they too felt they were treading on air. Long after leaving the boulevards Tarrou and Rieux could still hear the sounds of happiness following them… (Camus 2002, Part V)Then, Tarrou points out a sign of recovery coming from the animal world. In a direct zoological chain, infected fleas have vanished from rats, which have been able again to multiply across the city, making the cats abandon their hiding places and to go hunting after them again.

At the final step of this chain, Tarrou sees the human being. He remembers the old man who used to spit to the cats beneath his window:At a time when the noise grew louder and more joyful, Tarrou stopped. A shape was running lightly across the dark street.

It was a cat, the first that had been seen since the spring. It stopped for a moment in the middle of the road, hesitated, licked its paw, quickly passed it across its right ear, then carried on its silent way and vanished into the night. Tarrou smiled.

The little old man, too, would be happy. (Camus 2002, Part V)Unpleasant things as a town with rats running across its streets, or a man spending his time spitting on a group of cats, constitute normality as much as the reopening of gates or the reboot of commerce. However, when Camus speaks directly about normality, he highlights more appealing habits.

He proposes common leisure activities (restaurants, theatres) as symbols of human life, since he opposes them to Cottard’s life, which has become that of a ‘wild animal’:At least in appearance he [ Cottard ] retired from the world and from one day to the next started to live like a wild animal. He no longer appeared in restaurants, at the theatre or in his favourite cafés. (Camus 2002, Part V)We do not disclose why Cottard’s reaction to the end of the epidemic is different from most of the Oranians’.

In any case, the narrator insists later on the assimilation between common pleasures and normality:‘ Perhaps,’ Cottard said, ‘ Perhaps so. But what do you call a return to normal life?. €™ ‘ New films in the cinema,’ said Tarrou with a smile.

(Camus 2002, Part V)Cinema, as well as theatre, live music and many other cultural events have been cancelled or obliged to modify their activities due to erectile dysfunction treatment. Several bars and restaurants have closed, and spending time in those who remain open has become an activity which many people tend to avoid, fearing contagion. Thus, normality in our understanding is linked as well to these simple and pleasant habits, and the complete achievement of them will probably signify for us the desired defeat of the levitra.In La Peste, love is also seen as a simple good to be fully recovered after the plague.

While Rieux goes through the ‘reborn’ Oran, it is lovers’ gatherings what he highlights. Unlike them, everyone who, during the epidemic, sought for goals different from love (such as faith or money, for instance) remain lost when the epidemic has ended:For all the people who, on the contrary, had looked beyond man to something that they could not even imagine, there had been no reply. (Camus 2002, Part V)And this is because lovers, as the narrator says:If they had found that they wanted, it was because they had asked for the only thing that depended on them.

(Camus 2002, Part V)We have spoken before about language manipulation, hypocrisy and public figures’ roles during epidemics. Camus, during Dr Rieux’s last visit to the old asthmatic man, makes this frank and humble character criticise, with a point of irony, the authorities’ attitude concerning tributes to the dead:‘ Tell me, doctor, is it true that they’re going to put up a monument to the victims of the plague?. €™â€˜ So the papers say.

A pillar or a plaque.’‘ I knew it!. And there’ll be speeches.’The old man gave a strangled laugh.‘ I can hear them already. €œ Our dead…” Then they’ll go and have dinner.’ (Camus 2002, Part V)The old man illustrates wisely the authorities’ propensity for making speeches.

He knows that most of them usually prefer grandiloquence rather than common words, and seizes perfectly their tone when he imitates them (‘Our dead…’). We have also got used, during erectile dysfunction treatment, to these types of messages. We have also heard about ‘our old people’, ‘our youth’, ‘our essential workers’ and even ‘our dead’.

Behind this tone, however, there could be an intention to hide errors, or to falsely convey carefulness. Honest rulers do not usually need nice words. They just want them to be accurate.We have seen as well some tributes to the victims during erectile dysfunction treatment, some of which we can doubt whether they serve to victims’ relief or to authorities’ promotion.

We want rulers to be less aware of their own image and to stress truthfulness as a goal, even if this is a hard requirement not only for them, but for every single person. Language is essential in this issue, we think, since it is prone to be twisted and to become untrue. The old asthmatic man illustrates it with his ‘There’ll be speeches’ and his ‘Our dead…’, but this is not the only time in the novel in which Camus brings out the topic.

For instance, he does so when he equates silence (nothing can be thought as further from wordiness) with truth:It is at the moment of misfortune that one becomes accustomed to truth, that is to say to silence. (Camus 2002, Part II)or when he makes a solid statement against false words:…I understood that all the misfortunes of mankind came from not stating things in clear terms. (Camus 2002, Part IV)The old asthmatic, in fact, while praising the deceased Tarrou, remarks that he used to admire him because ‘he didn’t talk just for the sake of it.’ (Camus 2002, Part V).Related to this topic, what the old asthmatic says about political authorities may be transposed in our case to other public figures, such as scholars and researchers, media leaders, businessmen and women, health professionals… and, if we extend the scope, to every single citizen.

Because hypocrisy, language manipulation and the fact of putting individual interests ahead of collective welfare fit badly with collective issues such as epidemics. Hopefully, also examples to the contrary have been observed during erectile dysfunction treatment.The story ends with the fireworks in Oran and the depiction of Dr Rieux’s last feelings. While he is satisfied because of his medical performance and his activity as a witness of the plague, he is concerned about future disasters to come.

When erectile dysfunction treatment will have passed, it will be time for us as well to review our life during these months. For now, we are just looking forward to achieving our particular ‘part V’..

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When we took the editorship of Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main objectives cheap levitra. To promote and embed an evidence-based medicine (EBM) approach into daily mental cheap levitra health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lot.EBM has been around for about cheap levitra 30 years now, shaping and changing the way we practice medicine.

When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, cheap levitra the clinical state and circumstances, and patient’s preferences and values. EBM and EBMH have since continuously evolved to deepen cheap levitra our understanding of these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health.

To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, cheap levitra can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the cheap levitra generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK.

While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in cheap levitra mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic cheap levitra health status scales simultaneously.

This study, therefore, attempts to link the depression-specific measure onto the generic measure of health in order to enable estimation of QALYs for depressive states cheap levitra and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing data in either of the two scales at baseline cheap levitra or at endpoint.

We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated cheap levitra on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from no problem at all in any dimension (11111) to severe problems cheap levitra on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population.

In TTO, respondents are asked to give the relative length of time in full health that they would be willing to sacrifice for the cheap levitra poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to minus values=worse than death bounded by cheap levitra −1. The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults.

Over the years, value sets for EQ-5D-3L have been produced for many cheap levitra countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each cheap levitra rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and cheap levitra severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a cheap levitra nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with cheap levitra the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only cheap levitra patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the cheap levitra studies administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after cheap levitra intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows the same between their cheap levitra change scores.

Table 1 cheap levitra summarises the correspondences between the two scales.PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline cheap levitra and endpoint.

EQ-5D,Euro-Qol Five Dimensions cheap levitra. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol cheap levitra Five Dimensions.

PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 cheap levitra change scores and EQ-5D change scores. EQ-5D,Euro-Qol Five cheap levitra Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores.

To summarise, subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, cheap levitra moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review cheap levitra of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed cheap levitra PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference cheap levitra of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.

It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is cheap levitra 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two cheap levitra points on PHQ-9. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is cheap levitra between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores.

If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year cheap levitra would be equal to 0.05 QALY. (See figure 3 for a cheap levitra schematic drawing to help understand the calculation of QALYs based on changing EQ-5D scores.

In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants cheap levitra costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and cheap levitra should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 of cheap levitra 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to cheap levitra 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the cheap levitra year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more cheap levitra smoothly curvilinear but the calculation will be similar.

EQ-5D, Euro-Qol Five Dimensions cheap levitra. PHQ-9, Patient cheap levitra Health Questionnaire-9. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start cheap levitra with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid cheap levitra line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to cheap levitra naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes cheap levitra. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.

EQ-5D,Euro-Qol Five cheap levitra Dimensions. PHQ-9, PatientHealth cheap levitra Questionnaire-9. QALY, quality-adjustedlife years.Several caveats should be considered when interpreting the results cheap levitra.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients with cheap levitra depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in cheap levitra PHQ-9 scores at baseline because some studies required minimum depression scores.

However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able to compare PHQ-9 to cheap levitra EQ-5D-3L only. The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive cheap levitra to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important strengths.

First, our sample included patients with subthreshold depression and major depression and from the community or workplace cheap levitra and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in cheap levitra our sample received iCBT or control interventions including care as usual.

Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform cheap levitra such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of cheap levitra impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request.

The overall database used for this IPD is restricted due to data sharing agreements with the research cheap levitra institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

When we levitra target pharmacy took the editorship of Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main levitra canada for sale objectives. To promote and embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an levitra target pharmacy impact factor (IF) for EBMH. Both aims have been big challenges and we levitra target pharmacy have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the levitra target pharmacy clinical state and circumstances, and patient’s preferences and values.

EBM and levitra target pharmacy EBMH have since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have levitra target pharmacy been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health levitra target pharmacy including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK. While the responsiveness of such levitra target pharmacy generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms.

Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of levitra target pharmacy impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously. This study, therefore, attempts to link the depression-specific measure onto the levitra target pharmacy generic measure of health in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing levitra target pharmacy data in either of the two scales at baseline or at endpoint.

We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive levitra target pharmacy symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from no problem at all in any dimension (11111) levitra target pharmacy to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full health that they would be willing to levitra target pharmacy sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death levitra target pharmacy to minus values=worse than death bounded by −1.

The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures levitra target pharmacy. The scale scores were converted into the levitra target pharmacy most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness. The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- levitra target pharmacy for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified.

Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile levitra target pharmacy linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion levitra target pharmacy of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only patients with major depressive disorder (MDD), one only patients levitra target pharmacy with subthreshold depression and the remaining three included both. All the levitra target pharmacy studies administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores levitra target pharmacy <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows the same levitra target pharmacy between their change scores. Table 1 summarises levitra target pharmacy the correspondences between the two scales.PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions.

PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 levitra target pharmacy PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions levitra target pharmacy. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol levitra target pharmacy Five Dimensions. PHQ-9, Patient Health Questionnaire-9." data-icon-position levitra target pharmacy data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.

EQ-5D,Euro-Qol Five levitra target pharmacy Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, levitra target pharmacy subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to levitra target pharmacy an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies levitra target pharmacy (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the levitra target pharmacy same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer. It is, therefore, reasonable to use the conversion table at baseline for relatively new cases levitra target pharmacy of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9 levitra target pharmacy.

The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 levitra target pharmacy and 0.13, producing an approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the levitra target pharmacy year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic drawing to help understand the calculation of QALYs based on levitra target pharmacy changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less.

If a levitra target pharmacy 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments for all levitra target pharmacy patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5 levitra target pharmacy. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 levitra target pharmacy months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the levitra target pharmacy difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more levitra target pharmacy smoothly curvilinear but the calculation will be similar. EQ-5D, Euro-Qol Five Dimensions levitra target pharmacy. PHQ-9, Patient levitra target pharmacy Health Questionnaire-9.

QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5 levitra target pharmacy. Then they may improve levitra target pharmacy after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out levitra target pharmacy over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY.

Please note that this is a schematic levitra target pharmacy drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar. EQ-5D,Euro-Qol Five levitra target pharmacy Dimensions. PHQ-9, PatientHealth Questionnaire-9 levitra target pharmacy. QALY, quality-adjustedlife years.Several caveats should be considered levitra target pharmacy when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients with depression undergoing other therapies or in other levitra target pharmacy settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some levitra target pharmacy studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able to compare PHQ-9 to EQ-5D-3L only levitra target pharmacy.

The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study levitra target pharmacy also has several important strengths. First, our sample included patients with subthreshold depression levitra target pharmacy and major depression and from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients levitra target pharmacy in our sample received iCBT or control interventions including care as usual. Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into levitra target pharmacy consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform such considerations.

Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts levitra target pharmacy of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this IPD is restricted due to data sharing levitra target pharmacy agreements with the research institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

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Crowding killsAs buy levitra usa journal Editors we keep a keen eye on Clicking Here Altmetric scores, the weighted count of online attention that the articles we publish gain across mainstream news, social networks and blogs. This month two articles have received unprecedented attention with Altmetric score above 1000, breaking records for the Emergency Medicine Journal. It is easy buy levitra usa to see why. The message is clear, Emergency Department crowding kills. In a retrospective analysis buy levitra usa of Hospital Episode Statistics and using logistic regression, Moulton and colleagues paint a stark statistical picture.

Delays to admission greater than 5 hours are associated with a significant increase in 30 day mortality. Delays to buy levitra usa admission between 8–12 hours have a number needed to harm of 72. How many patients in the last month have waited this long for a bed in your emergency departments?. It is a privilege to publish a lay perspective on these findings and thank Derek Prentice for his emotive commentary, this month’s Editor’s Choice.It seems pertinent to highlight the last (senior) author, buy levitra usa Cliff Mann, on Moulton’s work. Sadly, he did not live to see the impact of this work.

A truly exceptional and wise leader, this is just one important legacy for our specialty that he buy levitra usa leaves behind. Thank you Cliff, for your tireless dedication to delivering outstanding patient care.We continue the broader theme of ED admissions and the currently inevitable associated crowding in our next four articles covering varying methodology and conditions. The first buy levitra usa of these articles, by Wyatt and colleagues explores the association between admission and discharge decisions when ED and inpatient occupancy reaches extreme levels. Unsurprisingly perhaps, they find a modest association between higher admission thresholds and high bed occupancy, and conclude that riskier decisions are made when beds are full. However, to counter this, admission thresholds are also buy levitra usa high when occupancy is particularly low.

We need to think more carefully about avoidable hospital admissions.One of the traditional system-wide reflex responses to ED and hospital crowding has been to outlie patients with medical conditions to surgical wards. Patry et al, explore the impact of this strategy on our older, more vulnerable patients, within a matched case control study from France. Importantly, they use a primary outcome that goes beyond traditional metrics such as length of stay and explore function at 6 buy levitra usa months (living at home). They find that outlier status is associated with a lower probability of living at home. A simple reflex system response may have a huge impact at an individual patient level for our patients buy levitra usa living with frailty.Patient perceptions of crowding are underexplored.

It is therefore great to see a more formal evaluation of this important topic from Ian Kronish and his team from New York. This single centre analysis of patients with suspected acute coronary syndrome, cross correlates crowding metrics with patient perceptions buy levitra usa of interpersonal care. While only 11% of patients experienced crowding (you can bet that is higher now), there was a strong correlation between reduced patient satisfaction with care and crowding. And finally, a systematic review form Anniek Brink and colleagues in the buy levitra usa Netherlands, highlights the desperate need for implementation studies to evaluate tools to predict need for admission in an emergency setting.We have highlighted the problem of ED crowding, the obvious impacts on patients and our decision making, together with a lack of robust solutions. What better way to sum this issue up than the following excerpt from Derek Prentice in his commentary:“Yet…this trust and indeed the dedicated service of the clinicians is being undermined by a killer and one that for far too long the government, NHS leadership, Trust Boards and their Chief Executives have chosen to ignore or simply blame the patients for having the temerity to turn up.”Traumatic brain injuriesAway from politics, we include a number of papers exploring advances in brain injury care.

In an exploratory case-control analysis of some potential buy levitra usa brain injury biomarkers, Pia Koivikko et al may have put the kybosh on the potential clinical value of assessing clinical severity using a number of biomarkers. Carl Marcowitz and colleagues’ original research article does offer some promise that the Hull Salford Cambridge Clinical Decision Rule may facilitate early discharge of a small number of patients (3.5%) with traumatic brain injury who are at very low risk of deterioration. We also include a clinician survey that explores equipoise in the use buy levitra usa of platelet infusion in traumatic brain injury patients taking antiplatelets. One senses a grant application is in the offing for a trial in this area, although the applicants should be mindful of using routinely collected data to inform their power calculation, an issue highlighted by Ben Bloom et al in our In Perspective article.UasoundWith the continuing development of ED uasound practice it is great to see the next instalment of our Sono Case Series and also an original research article evaluating lung uasound in erectile dysfunction treatment that shows promising diagnostic accuracy.Quality improvementThe EMJ continues to offer publication of robust, well conducted Quality Improvement initiatives and it is great to see the work of Bodnar et al, which uses the Lean Six Sigma approach to test a number of discrete interventions to improve ED boarding time. Perhaps there is something emergency departments buy levitra usa can do about crowding after all?.

" data-icon-position data-hide-link-title="0">Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.A&E is a brand. It is among the best known brands in the UK and is trusted and loved buy levitra usa by the UK public. Why?. Because they know when all else fails, when other agencies just don’t or won’t respond, their local A&E department will be there for them 24/7, 365 days a year.Confirmation of this is available daily in every emergency department in the UK, with patient attendances at the highest since the inception of the National Health Service (NHS).Yet, as the paper by Moulton and colleagues reports,1 this trust and indeed the dedicated service of the clinicians is being undermined by a killer and one that for far too long the government, NHS leadership, trust boards and their chief executives have chosen to ignore or simply blame patients for having the temerity to turn up.For at least the last 12 years and more, we have seen cuts after cuts to the budget of the NHS, leading to reduced bed numbers and staffing. This is bad enough in itself but has been further compounded by repeated large reductions in central government financial support to local authorities, with a devastating impact buy levitra usa on social care.

The result has been fewer beds in hospitals and a grave lack of social care provision for those patients ready for discharge, or as it is called, exit block and delayed timely admission. Thanks to this report, we now have confirmation that such delay kills patients.UK patients and the population as a whole buy levitra usa love their NHS, they know only too well that it is not perfect, and they are prepared to be forgiving when things go wrong, perhaps too forgiving. Most people, for instance, wait patiently for hours to be seen in A&E. However, patients have buy levitra usa an absolute right to be informed when their trust in a service has serious consequences for their wellbeing and also, possibly, their life. As ever, it is the elderly/frail and those living in deprived communities who are most likely to be affected.From the perspective of the patient, and certainly from those of us who have the privilege to represent patient interest, one statement and one fact stand out.

Within the Conclusions it states:‘The NHS 4-hour operational standard thus appears to have succeeded in preventing avoidable delay-related patient harm in hospitals where it has been achieved while also reducing additional morbidity and poor patient experiences.’1and in what is already known on this subject:‘Counterfactual modelling has shown reduced patient mortality as a result of the NHS 4-hour operational target.’1Little wonder therefore that some of us have such contempt for those in government and the NHS leadership who have done so much to try to undermine and remove buy levitra usa this key target.The authors defined the rise in mortality as starting at 5 hours and so a 4-hour threshold seems both justifiable and sensible. It is interesting to note that while the 4-hour target initially seemed to be an arbitrary figure, the paper’s graph plotting mortality rate against time in the emergency department clearly shows a steady rise after 4 hours.Let nobody be in doubt any longer, the NHS 4-hour operational target is, as many of us have always known, of key importance to patient safety. Patients are, and will continue to be, grateful for it and for the publication of this paper.However there are some difficult truths to be faced when discussing this target and some from sources that are uncomfortable to identify.The only practical concern with the target is when chief executives fail to see its achievement (or lack buy levitra usa thereof) as a hospital-wide issue and, it has to be said, too often there is a lack of support from other specialties. To this, can of course be added the lack of beds, lack of staff and chronic underfunding of the NHS and social care. Get these right and the target is achievable, as the majority of buy levitra usa NHS trusts proved during the decade between the introduction of the target in 2004 and the winter of 2014–2015.

This graph from the King’s Fund shows the change from 2010 (when the target was changed from 98% to 95%) and the current situation figure 12.Performance against the A&E waiting time standard has steadily declined." data-icon-position data-hide-link-title="0">Figure 1 Performance against the A&E waiting time standard has steadily declined.But, and here is the really uncomfortable issue, too many within the emergency medicine specialty have also sought to undermine this 4-hour target. Could there be buy levitra usa better measures?. Possibly, but until there are, and crucially, ones that have the support and trust of patients, the 4-hour target or one very close to this, must remain the gold standard. Those in doubt need look no further than the evidence provided by this excellent paper.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants..

Crowding killsAs journal Editors we keep a keen eye on Altmetric scores, the weighted count of online attention that the visit this website articles we publish gain across mainstream news, social networks levitra target pharmacy and blogs. This month two articles have received unprecedented attention with Altmetric score above 1000, breaking records for the Emergency Medicine Journal. It is easy to see levitra target pharmacy why. The message is clear, Emergency Department crowding kills. In a retrospective analysis of Hospital Episode Statistics and using logistic regression, Moulton and colleagues paint a stark levitra target pharmacy statistical picture.

Delays to admission greater than 5 hours are associated with a significant increase in 30 day mortality. Delays to admission between 8–12 hours have a number needed to harm of 72 levitra target pharmacy. How many patients in the last month have waited this long for a bed in your emergency departments?. It is a privilege to publish a lay perspective on these findings and thank Derek Prentice for his emotive commentary, this month’s Editor’s Choice.It seems pertinent to highlight the levitra target pharmacy last (senior) author, Cliff Mann, on Moulton’s work. Sadly, he did not live to see the impact of this work.

A truly exceptional and wise leader, this is levitra target pharmacy just one important legacy for our specialty that he leaves behind. Thank you Cliff, for your tireless dedication to delivering outstanding patient care.We continue the broader theme of ED admissions and the currently inevitable associated crowding in our next four articles covering varying methodology and conditions. The first of these articles, by Wyatt and colleagues explores the association between admission and discharge decisions when ED and inpatient levitra target pharmacy occupancy reaches extreme levels. Unsurprisingly perhaps, they find a modest association between higher admission thresholds and high bed occupancy, and conclude that riskier decisions are made when beds are full. However, to levitra target pharmacy counter this, admission thresholds are also high when occupancy is particularly low.

We need to think more carefully about avoidable hospital admissions.One of the traditional system-wide reflex responses to ED and hospital crowding has been to outlie patients with medical conditions to surgical wards. Patry et al, explore the impact of this strategy on our older, more vulnerable patients, within a matched case control study from France. Importantly, they use a primary outcome that goes levitra target pharmacy beyond traditional metrics such as length of stay and explore function at 6 months (living at home). They find that outlier status is associated with a lower probability of living at home. A simple levitra target pharmacy reflex system response may have a huge impact at an individual patient level for our patients living with frailty.Patient perceptions of crowding are underexplored.

It is therefore great to see a more formal evaluation of this important topic from Ian Kronish and his team from New York. This single centre analysis of patients with suspected levitra target pharmacy acute coronary syndrome, cross correlates crowding metrics with patient perceptions of interpersonal care. While only 11% of patients experienced crowding (you can bet that is higher now), there was a strong correlation between reduced patient satisfaction with care and crowding. And finally, a systematic review form Anniek Brink and colleagues in the Netherlands, highlights the desperate need for implementation studies to evaluate tools to predict need for admission in an emergency setting.We have highlighted the problem of ED crowding, the obvious impacts on patients and our decision making, together with a lack levitra target pharmacy of robust solutions. What better way to sum this issue up than the following excerpt from Derek Prentice in his commentary:“Yet…this trust and indeed the dedicated service of the clinicians is Source being undermined by a killer and one that for far too long the government, NHS leadership, Trust Boards and their Chief Executives have chosen to ignore or simply blame the patients for having the temerity to turn up.”Traumatic brain injuriesAway from politics, we include a number of papers exploring advances in brain injury care.

In an exploratory case-control analysis of some potential brain injury biomarkers, Pia Koivikko et al may have put the kybosh on the potential clinical value of assessing clinical severity using levitra target pharmacy a number of biomarkers. Carl Marcowitz and colleagues’ original research article does offer some promise that the Hull Salford Cambridge Clinical Decision Rule may facilitate early discharge of a small number of patients (3.5%) with traumatic brain injury who are at very low risk of deterioration. We also include levitra target pharmacy a clinician survey that explores equipoise in the use of platelet infusion in traumatic brain injury patients taking antiplatelets. One senses a grant application is in the offing for a trial in this area, although the applicants should be mindful of using routinely collected data to inform their power calculation, an issue highlighted by Ben Bloom et al in our In Perspective article.UasoundWith the continuing development of ED uasound practice it is great to see the next instalment of our Sono Case Series and also an original research article evaluating lung uasound in erectile dysfunction treatment that shows promising diagnostic accuracy.Quality improvementThe EMJ continues to offer publication of robust, well conducted Quality Improvement initiatives and it is great to see the work of Bodnar et al, which uses the Lean Six Sigma approach to test a number of discrete interventions to improve ED boarding time. Perhaps there is something levitra target pharmacy emergency departments can do about crowding after all?.

" data-icon-position data-hide-link-title="0">Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.A&E is a brand. It is among the best known brands in the UK and is trusted and loved by the UK public levitra target pharmacy. Why?. Because they know when all else fails, when other agencies just don’t or won’t respond, their local A&E department will be there for them 24/7, 365 days a year.Confirmation of this is available daily in every emergency department in the UK, with patient attendances at the highest since the inception of the National Health Service (NHS).Yet, as the paper by Moulton and colleagues reports,1 this trust and indeed the dedicated service of the clinicians is being undermined by a killer and one that for far too long the government, NHS leadership, trust boards and their chief executives have chosen to ignore or simply blame patients for having the temerity to turn up.For at least the last 12 years and more, we have seen cuts after cuts to the budget of the NHS, leading to reduced bed numbers and staffing. This is bad enough in itself but has been levitra target pharmacy further compounded by repeated large reductions in central government financial support to local authorities, with a devastating impact on social care.

The result has been fewer beds in hospitals and a grave lack of social care provision for those patients ready for discharge, or as it is called, exit block and delayed timely admission. Thanks to this report, we now have confirmation that such delay kills patients.UK levitra target pharmacy patients and the population as a whole love their NHS, they know only too well that it is not perfect, and they are prepared to be forgiving when things go wrong, perhaps too forgiving. Most people, for instance, wait patiently for hours to be seen in A&E. However, patients have an absolute right to be informed when their trust in a service has serious consequences for their wellbeing and also, possibly, their life levitra target pharmacy. As ever, it is the elderly/frail and those living in deprived communities who are most likely to be affected.From the perspective of the patient, and certainly from those of us who have the privilege to represent patient interest, one statement and one fact stand out.

Within the Conclusions it states:‘The NHS 4-hour operational standard thus levitra target pharmacy appears to have succeeded in preventing avoidable delay-related patient harm in hospitals where it has been achieved while also reducing additional morbidity and poor patient experiences.’1and in what is already known on this subject:‘Counterfactual modelling has shown reduced patient mortality as a result of the NHS 4-hour operational target.’1Little wonder therefore that some of us have such contempt for those in government and the NHS leadership who have done so much to try to undermine and remove this key target.The authors defined the rise in mortality as starting at 5 hours and so a 4-hour threshold seems both justifiable and sensible. It is interesting to note that while the 4-hour target initially seemed to be an arbitrary figure, the paper’s graph plotting mortality rate against time in the emergency department clearly shows a steady rise after 4 hours.Let nobody be in doubt any longer, the NHS 4-hour operational target is, as many of us have always known, of key importance to patient safety. Patients are, and will continue to be, grateful for it and for the publication of this paper.However there are some difficult truths to be faced when discussing this target and some from sources that are uncomfortable to identify.The only practical concern with the target is when chief executives fail to see its achievement (or lack thereof) as a hospital-wide issue and, it has to be said, too often there is a lack of support from other specialties levitra target pharmacy. To this, can of course be added the lack of beds, lack of staff and chronic underfunding of the NHS and social care. Get these right and the target is achievable, as the majority of NHS trusts proved during the decade between the introduction of the target in 2004 and levitra target pharmacy the winter of 2014–2015.

This graph from the King’s Fund shows the change from 2010 (when the target was changed from 98% to 95%) and the current situation figure 12.Performance against the A&E waiting time standard has steadily declined." data-icon-position data-hide-link-title="0">Figure 1 Performance against the A&E waiting time standard has steadily declined.But, and here is the really uncomfortable issue, too many within the emergency medicine specialty have also sought to undermine this 4-hour target. Could there be levitra target pharmacy better measures?. Possibly, but until there are, and crucially, ones that have the support and trust of patients, the 4-hour target or one very close to this, must remain the gold standard. Those in doubt need look no further than the evidence provided by this excellent paper.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants..

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Welcome to the first issue how to buy levitra online of 2022! http://monmouthrugbyclub.com/brand-name-levitra-online/. We have several exciting changes to announce in the new year. To begin with, we have been increasing our how to buy levitra online number of published submissions per issue, including some of our content exclusively online (the most common way that our readers access the journal).

In addition, we have put out additional calls for submissions and look forward to receiving new work.We have spent the last 4 years working towards social justice, accessibility, global …IntroductionThe subject of care is gaining importance within the medical humanities, but it also remains elusive. Hence, this paper aims to unpack theoretical notions of care in a way that integrates the elusiveness rather than trying to avoid it. It also responds to a recent article by Julia Kristeva et al, how to buy levitra online in which they claim that care holds humanity (Kristeva et al.

2018).When in need of theoretical elaboration or re-development, medical humanities scholars have sometimes evoked Greek or Roman myths, such as those of Narcissus, Hephaestus or Leto (Cilione, Marinozzi, and Gazzaniga 2019. Pannese 2011. Schott 2017) how to buy levitra online.

Similarly, this article evokes the Roman myth of Cura to unpack theoretical understandings of care. In this myth, known from the writings of the first century mythographer Hyginus, humanity is created from clay by a personification of care. It has proven useful to thinkers as diverse as Martin Heidegger, Arthur Kleinman (Kleinman and van der Geest 2009) how to buy levitra online and Julia Kristeva (Kristeva (2012), Kristeva et al.

2018). While utilisation by Heidegger 1927, 196–200 ‘challenges the myth of self-sufficiency and individual atomization that that has shaped much of how to buy levitra online modern Western philosophy’ (Froese 2005, 16), both Kleinman and Kristeva explore the tension between universalised knowledge and the singularity of individual patients and intimate care (Engebretsen, Fraas Henrichsen, and Ødemark 2020).While none of these scholars engage with Hyginus’ Fabulae directly, I use the text as an ‘engine’ in a four-step endeavour. This endeavour follows Brandy Schillace’s description of the medical humanities as ‘a field that at its core considers the human story behind and within medicine, its history, its cultural valence and its influence on practice’ Schillace (2017, 139).First, a ‘human story’ entails agency, the things that humans do in their lives.

While the ‘appeal’ from Kristeva et al uses a case from intercultural psychoanalysis, the authors have previously researched a variety of professional healthcare practices (Engebretsen 2016. Engebretsen, Sandset, and Ødemark how to buy levitra online 2017. Hetrick et al.

2017). However, it is crucial to note that Cura (in Hyginus’ text) will ‘hold’ how to buy levitra online humanity quamdiu vixerit (for as long as he shall live). Such a life-long temporality does not dovetail with the temporary, regulated and systematised relations of healthcare organisations.

Hyginus’ text has, I argue, a much stronger affinity to the temporality of parental care. Hence, I begin the how to buy levitra online endeavour by acknowledging that I am a scholar, and the father of a boy with little linguistic function.1 Although my parental care for my son entails a multitude of meanings and instances, I begin with two tales from my parental care in 2020:Sometimes, if he does not understand what is going on, or if his actions feel unintelligible to others who are present, I take him in my arms. In that way, we are at least together in a situation when both of us otherwise would have been on our own.

Suddenly, it feels as if how to buy levitra online I am not only holding or embracing him away from an abyss. I am also holding him—or, perhaps, shielding him—in the face of many, many abysses to come.In rough-and-tumble play, I often lift him up with my arms straight—holding him while he straightens his body, and ‘is an airplane’. Although this play is exhausting, particularly since I live with cerebral palsy, this is nevertheless an activity where we can be close to one another.

When I hold him up like this, or suddenly ‘crash’ him safely down next to me how to buy levitra online on the bed, we are skin to skin, but not exactly like I used to be with his older siblings, and I suddenly have the impression that it also differs from how most fathers do this with their children. I cannot know if our way is exclusively ours, but while I hold him, that is how it feels.Second, a human story ‘behind and within medicine’—or, for that matter, behind and within any social field—consists of underlying notions and involved cultural categories. Hence, this article aims to unpack theoretical notions of care with reference to the thinkers mentioned above.

Throughout, I try to unpack how different aspects of care ‘follow’ each other in an analytical ‘path’ how to buy levitra online or trajectory, as if in a story (Kristeva et al. 2018).Third, the investigation of the human story of care must become an investigation of ‘history’ and ‘cultural valence’. In order to think historically, the analytical ‘engine’ includes Hyginus’ text, and 18th and 19th century uses of Cura and related motifs.Fourth, I follow Schillace’s advice to examine ‘influence on practice’.

In addition to the practice of parental care, the exploration ends with how to buy levitra online a discussion of medical humanities as practice. When medical humanities scholars ’consider’ the human story of care, they bring together different perspectives and forms of knowledge. In this case, however both the how to buy levitra online intertextual analyses and the autotheoretical work indicate that those complexities might overpower our theoretical perspectives.

Hence, I conclude with a call for epistemological and analytical modesty.MethodAlthough the abovementioned scholars have used the myth of Cura for clearly theoretical purposes, several of them explore this also as carers in a personal sense. Julia Kristeva writes her work on care as the mother of a man with severe disabilities Kristeva (2013, 219–221), Arthur Kleinman and Geest (2009, 159–163) begin their rethinking with a rich narrative of his caring for his wife who lives with Alzheimer’s disease. In line with their work, this article combines textual interpretation with autotheoretical work.Often used in connection with genre-bending memoir The Argonauts by how to buy levitra online Maggie Nelson (2015), the term ‘autotheory’ designates a literary form involving ‘the combination of autobiography and critical theory’ (Pearl 2018, 200).

In this article, however, I rely on the work of the Canadian artist, curator, writer and interdisciplinary researcher Fournier (2019), who has unpacked autotheory with particular reference to illness and embodiment. Fournier describes autotheory as a specific form of academic practice:In autotheory as a conceptual and performative feminist practice, artists, writers, and critics use the first person, or related practices of self-imaging (Jones, Self/Image 134), to process, perform, enact, iterate, and wrestle with the hegemonic discourses of ‘theory’ and philosophy, extending the feminist practice of theorizing from one’s subject positioning as a way of engendering insights into questions related to aesthetics, politics, ethics, and social and cultural theory. In autotheory, one’s embodied experiences become the material through which one theorizes, and, in a similar way, theory becomes the discourse through which one’s lived experience is refracted (658).In Fournier’s definition, theory how to buy levitra online functions as ‘hegemonic discourses’, and as discourses through which one’s lived experience is refracted.

Contrary to this emphasis on language—as well as their emphasis on language elsewhere (Heidegger 1927Heidegger 1937. Kleinman 1995. Kristeva 2019)—neither Kristeva nor Kleinman or Heidegger focus on how to buy levitra online Hyginus’ text.

In contrast to this body of research, this article emphasizes the interpretative potential of the original text. In addition to grammatical analysis, I utilize the how to buy levitra online well-known concept of intertextuality, as introduced by Kristeva (1980). However, I use it in a less structuralist sense than in her early formulations in Desire in Language.

Instead, I approach Hyginus’ text in line with her approach in ‘Nos Deux’ or a short (hi)story of intertextuality (Kristeva 2002).For me, intertextuality is mostly a way of making history go down in us. We, two texts, two destinies, how to buy levitra online two psyches. It is a way if introducing history to structuralism and its orphan, lonely texts and readings.

[…] the etymological meaning of ‘semeion’ is a distinctive mark, a trace, an engraved or written sign, that makes us think of the Freudian ‘psychical’ marks, called drives, rhythmical articulations of embodied impulses and psychical movements. In this sense, the meaning of the how to buy levitra online socio-historical aspect of intertextuality, as already developed by Bakhtin and Barthes, acquires a new significance. Within each sociolect or ideology, (both well-established sign-systems) there will always be a breach of subjectivity carrying out a hidden matrix of pre-symbolic forces able to make history move on through all its short and singular stories.

(2002. 8-9)First, this means that I study Hyginus’ text not as a ‘lonely text’, but as part how to buy levitra online of a historical trajectory. The ‘singular stories’ are used to disturb the orderly (structural) notions of both textual and philosophical analysis.Second, I interpret Hyginus’ text—as well as other utilisations of the myth—with focus on traces.

Or, more specifically, how to buy levitra online to find ‘distinctive marks’ relevant to the same material as in authotheretical work. €˜embodied impulses and psychical movements’. This, however, does not mean that the texts are reduced to a canvas for an engraved sign.

In methodological term, the aim is to allow the two destinies—the textual trajectory of how to buy levitra online the Cura motif, and the personal trajectory that becomes so intimate when I hold my son in my arms—to shed light on one another.Third, the interaction between these two methodological approaches will hopefully allow history—what Schillace calls the ‘human story’—to move in two diachronic ways. I aim to emphasise the differences between the different utilisations of the myth. Finally, I also aim to locate breaches in the ‘well-established sign systems’ we call theories of care, to get a glimpse of something yet hidden.Humanity as creation, care as fundamental conditionIn a narrative sense, Hyginus tells three stories.

A story of the creation of how to buy levitra online humanity followed by a story of a quarrel between deities and finally, a verdict on the ontological role of care in human life. The first story in Hyginus’ fable begins thus:Cura cum quendam fluvium transiret, vidit cretosum lutum. Sustulit cogitabunda et coepit fingere hominem.When Cura was crossing a certain river, she saw some clayey mud.

She took it up thoughtfully and began to fashion a man.Before interpreting how to buy levitra online this first story, we must first acknowledge that the fable is an alteration or addition in a philological sense. While Fabulae is almost exclusively filled with Greek myths, the Cura fable’s position at the end of the collection suggests, ‘that this particularly Roman tale was simply added to the end of the existing narrative portion’ (Smith and Trzaskoma 2007, xlix). Moreover, philological research consistently argues that fable CCXX ‘hinges on Latin wordplay’ (Smith and Trzaskoma 2007, xlviii).More specifically, Hyginus, in the Cura fable, alters a prevailing myth in late antiquity, one that he has even told earlier in the pages of Fabulae how to buy levitra online.

That of how the titan Prometheus fashioned man from clay. In fable CXLII (‘Pandora’), Hyginus states explicitly that Prometheus lapeti filius primus homines ex luto finxit (Prometheus, son of Iapetus, first fashioned men from clay).Most Greek and Roman sources place the Prometheus plasticator motif within a three-stage narrative. First, Prometheus shapes the how to buy levitra online human from clay, and then Athena gives the creature inner life.

Finally, sometimes after Prometheus has given humankind fire against the orders of Jove, Jove intervenes and sentences Prometheus to eternal punishment in the Caucasus.To understand the human story—to which both this motif and Hyginus’ text belong—comparison is needed. First, we must note that the neutral or slightly idyllic depictions in Hyginus and Ovid (respectively) differ from earlier and less optimistic renderings in Republican times. The poet Propertius, for how to buy levitra online instance, in his Libri Elegiarum from the first-century BC, laments and elaborates on how Prometheus was careless in his creating.

Here, the adverbial clause ille parum caute casts Prometheus as a figure of titanic heedlessness:ille parum caute pectoris egit opus.corpora disponens mentem non vidit in arto:The making of man’s reason he performed with too little care.Arranging our bodies, he overlooked the mind in his handiwork (Goold 1990, 232).Carelessness, the counterpart to the notion of care, is involved in the Prometheus plasticator motif throughout antiquity. The adverbial clause ille parum caute does not derive from the same verb as Cura, but rather from the verb caveo (to take precautions, to be aware of something). Nevertheless, Prometheus’ lack of care underlines how how to buy levitra online Hyginus’ text is an inversion these earlier texts.

Instead of being created in a careless way, humanity is created by care.To be fair, a singular text never exhausts the potential of the history to which it belongs. Specific understandings—in how to buy levitra online this case. Theoretical notions of care—are only a part of a wide array of potentials.

The Prometheus Plasticator motif foreshadows 20th and 21st century theories of care, and 18th and 19th century depictions of Prometheus as a figure of romantic transgression. In Goethe’s poem Promethevs (written 1774, published 1789), Prometheus becomes a figure of independence and defiance—as expressed, for instance, in the final stanza:Hier sitz' ich, forme Menschen / Nach meinem Bilde, / Ein Geschlecht, das mir gleich sei, / Zu leiden, zu weinen, / Zu genießen und zu freuen how to buy levitra online sich, / Und dein nicht zu achten, / Wie ich!. (Goethe 1998, 44–46)Here sit I, forming mortals /In my image.

/ A race resembling me, / To suffer, to weep, / To enjoy, to be glad, / And thee to scorn, /As I!. (Bowring 2015, 182)Typical of Goethe’s Sturm und Drang period, his Prometheus Plasticator is a figure of creativity, and embodies ‘ideals of freedom and rebellion’ (Raggio 1958, how to buy levitra online 44). Goethe’s poem emphasised the ‘autonomous existence’ of mankind (Dougherty 2006, 95), thereby constituting an ‘emancipatory gesture’ (Edgar 2002, 161).

Hyginus’ text inverts both classical and romantic evokings of the myth by inserting dependency rather than autonomy and expansion. To shed further light how to buy levitra online on this inversion, we must first unpack the name of the personification that Hyginus instals in the Prometheus Plasticator motif. Cura.The name Cura is derived from the verb curo.

The Oxford Latin Dictionary defines the verb thus:To watch over, look after, care for.To tend to, to do what is necessary to.To administer remedies, to treat (a sick person, wound, disease, etc).To have charge of. (absol.) to be in command.To devote oneself to, to cultivate (a person).To undertake, to see to (a task or a responsibility).To regard with anxiety or interest, worry or care about, heed.As we can see, the first three senses of this verb invert the Prometheus motif we how to buy levitra online found in Propertius. To instal the personification of curo in the motif is to instal carefulness, attentiveness and responsibility in a motif usually filled with lack of care.

The third how to buy levitra online sense also injects an aspect that is totally absent in classical anthropogenies. That of human frailty. It also relates to aspects of human lives that are particularly relevant to understanding care, illness, disease and disability.The fifth and sixth senses of the word similarly invert the romantic depictions of Prometheus motif.

The anthropogenic act is no longer about how to buy levitra online rebellion and expansion, but devotion and responsibility. The seventh sense finally reverses the political impulse of the Sturm und Drang—the desire for increased individual freedom and self-expansion in every imaginable way—into worrying and heeding.In addition to these intertextual relations, it is also fruitful to note the verbs that connect humanity to the three deities. While Cura’s creating is described with the verb fingo (in Hyginus.

€˜fingere’), Jove’s and Tellus’ acts how to buy levitra online of giving are described by do (in Hyginus. €˜dedisti’). While the former verb is a very tactile verb, a matter of touch and contact, do signifies separation—to deliver or give something, to separate it from something in order to unite it with something else.

An initial understanding of care emerges from these how to buy levitra online textual relations. Care is fundamental (by belonging to the anthropogony), antithetical (by being the antithesis of carelessness and neglect) and intimate (by establishing relation through touch).Care imaginationsWhen modern scholars use Hyginus’ text, one word of the first sentence is often overlooked. Cogitabunda (thoughtful) how to buy levitra online.

Although an adjective in the purely grammatical sense, this is the only word with an adverbial function in Hyginus’ text. Hence, it is the lone term specifying how actions and interactions take place. While Greco-Roman deities often act from rage (as in the conflict how to buy levitra online between the titans and Olympian deities) or desire (as in the story of Zeus and Leda), Cura acts thoughtfully or with thought.As we can see, the adverb cogitabunda is attached to the picking up of the clay, not primarily to the act of creation.

Sustulit cogitabunda et coepit fingere hominem. Moreover, the temporal clause ‘and begun to’ (et coepit) also locates this thought as prior to the creation of humanity. To understand care as thoughtful, then, is about understanding thoughts and imaginaries ‘involved’ in care, and it includes thoughts how to buy levitra online and imaginaries that ‘pre-exist’, ‘frame’ or ‘underpin’ care and care work.It is useful to explore how the meaning of cogitabunda is preserved and unveiled in the work of the German philosopher, poet and literary critic Johann Gottfried Herder (1744–1803).

In his poem ‘Das Kind der Sorge’ (1787), Herder follows Hyginus very closely (Bernays 1869, 158-163). This poem was widely read, and it provided the basis for Goethe’s use of the Cura motif in Faust II (1832). Finally, Heidegger also comments on the poem and cites it in extenso when he develops his notion of Sorge as the fundamental human condition (Dye 2009, 207–218)., Kristeva (2001), too, refers several times how to buy levitra online to Herder, and even refers directly to this poem (25–26).

The first stanza describes the moment of creation thus:Einst saß am murmelnden StromeDie Sorge nieder und sann:Da bildet im Traum der GedankenIhr Finger ein leimernes Bild (von Herder 1889, 75).Once by a murmuring riverSorrow sat down, and there,In a vision, thought to form with the touchA wavering figure (Groth 2016, 31).von Herder positions the moment of creation as a radically imaginative act in at least three ways. First, the gaze is far more manifest in von Herder’s text than how to buy levitra online in Hyginus’. While Hyginus’ Cura shapes a human (hominen) directly, von Herder’s ‘Sorge’ shapes an image (Bild).

This dovetails well with important insights from care research. In relations of care, the cared-for becomes visible to the carer(s), thereby how to buy levitra online also becoming a valued imago. Conversely, the carer(s) become visible in the imagination of the cared-for—even in a Western culture that often obscures or silences interpersonal interdependence.Second, cogitabunda in Hyginus is also intertextually connected von Herder’s adverbial clause im Traum der Gedanken.

This phrase, roughly translatable as ‘in the dream of thoughts’, roots humanity in a singular image (or dream) that consist of or belong to several different thoughts or ways of thinking. This tension between how to buy levitra online individuality and multitude dovetails with research on the knowledge complexities involved in care.Third, the word ‘Traum’ (dream) in Traum der Gedanken does not denote unreality, fantasy or illusion. For von Herder, dreams are not the opposite of reality, but thoughts beyond or above manifest reality (Wirklichkeit überhöhenden Gedankens).

A dream of thoughts, then, is an experience or interpretation wherein the understanding of a phenomenon moves beyond how the phenomenon presently is, to what it should or could be. Just as Hyginus’ cogitabunda can, if we how to buy levitra online interpret in intertextual connection with von Herder’s Traum der Gedanken, also refract my experiences of holding my son in my arms. This is true of the experiences of performing actions that seem strange or unintelligible to those around us, but particularly true of the feeling of doing this in a way that is uniquely ours.

The combination of these feelings—where how to buy levitra online the socially estranged ways of caring is fundamentally ours and integral to my parenting—engenders or entails a striving ‘upwards’. This striving is not limited to the idealisation that so often takes place in parenting, but is also a utopian, imaginative glimpse of a world wherein the both of us truly belong.In other words, the Cura motif foreshadows the ‘horizontal’ complexities involved in care (multiple cultural imaginaries, multiple forms of knowledge). It also foreshadows ‘vertical’ complexities, through which care imaginations include both underlying categories and überhöhende dimensions.

These overarching or how to buy levitra online utopical dimensions, that both stem from and go beyond the localised, singular imaginations of care, is known by many names in and beyond the medical humanities. Examples include ’underlying values’, ‘ethical content of particular practices’, ‘transformative learning’ and many others (Ayala 2019, 269. Pettersen 2008, 188.

Winthrop 2003).Cogitabunda, can mean how to buy levitra online to be thoughtful and to be ‘full of thoughts’. The adverbial clause im Traum der Gedanken by von Herder (1888, 533), similarly, also signifies something unclear or disorganised. In his poetotological treatise Über Bild, Dictung und Fabel (1888, 533), von Herder juxtaposes this state with being in Leidenschaft (in passion), in Verrückung (in madness) or nicht auf seiner Hut (off guard).

There is complexity and openness—perhaps even fantasy or at least exploration—in this how to buy levitra online. When I hold my son in my arms connecting different realms of thought. As in ruff-and-tumble-play, these how to buy levitra online realms are also at play as I think.The quarrel of the deities.

Culture, nature and careAfter the first narrative, the second deals with a quarrel between the deities Cura, Jove and Tellus. Once humanity has been given inner life, the focus in Hyginus’ texts shifts from creating to name-giving:Cum vellet Cura nomen suum imponere, Iovis prohibuit suumque nomen ei dandum esse dixit. Dum de nomine Cura how to buy levitra online et lovis disceptarent, surrexit et Tellus suumque nomen ei imponi debere dicebat, quandoquidem corpus suum praebuisset.When Cura wanted to give it her name, Jove forbade, and said that his name should be given it.

But while they were disputing about the name, Tellus arose and said that it should have her name, since she had given her own body.To name something after something else (and, perhaps particularly, after someone else) places the object within a certain taxonomy. Major deities such as Jove and Tellus are both rulers and personifications of different ontological realms or ‘elements’. Hyginus’ Cura is how to buy levitra online not known from other Roman sources.

Instead, Cura is a ‘deification of abstract ideas’, a common feature of Roman culture (Axtell 1907). Hence, it becomes clear that the quarrel deals with ontological ideas, more specifically with the ontology of humanity. Each deity proposes a how to buy levitra online ‘location’ in classical ontology.The philosopher John T.

Hamilton has used the myth of Cura to explore how any understanding of security presupposes both care and carefulness. He underlines how this ‘locating’ somehow names humanity after something that is neither identical nor particularly resembling humanity:The controversy over the creature’s name strives to resolve the issue of the how to buy levitra online figure’s proper being, without the aid of physical resemblance, without the talent for self-reflection. In my view, the debate over the name revolves on whether humanity is essentially atemporal (Telluric matter or Iovian spirit) or instead fundamentally temporal and constituted by time and history (Hamilton 2013, 71).It is worth noting that the deities are not offering or suggesting certain framings of human life.

Hyginus’ text—in particular, the fact that Jove forbade any name other than his own—indicates conflicts between perspectives and disciplines. The imaginative richness involved in care, indicated by Hyginus cogitabunda or by the plural in von Herder’s Traum der Gedanken, is a how to buy levitra online plurality where incommensurabilities remain. In my view, the myth of Cura points towards three possible but incommensurable ways of studying, describing and interpreting care (corresponding to Jove, Tellus and Cura, respectively):As a cultural or semantic phenomenon, elucidated in terms of meaning or more or less idealised notions.As a biological phenomenon, elucidated in medical, psychological or other health-related terms.As a relational phenomenon, elucidated in terms of care work (professional or not).Although it is necessary to understand care in all these ways, it is nevertheless impossible to fully merge them or produce those understandings simultaneously.

Hence, it is necessary to add a more epistemologically oriented aspect of care. Care is fundamentally imaginative and how to buy levitra online context-dependent, and stands in-between otherwise incommensurable interpretative domains.Saturn’s verdict. The continuous presence of careIn the third narrative in Hyginus, the quarrel is somehow resolved when the deities choose Saturn as their judge.

Sadly, this part of the text is fragmented. There is agreement, however, that Saturn’s verdict clarifies that Jove will receive human souls, while how to buy levitra online Tellus will receive the body post mortem:Tu Iovis quoniam spiritum dedisti, <…>. Corpus recipito.

Cura quoniam prima eum finxit, quamdiu vixerit, cura eum possideat how to buy levitra online. Sed quoniam de nomine eius controversia est, homo vocetur quoniam ex humo videtur esse factusJove, since you gave him spirit, let [Tellus] receive his body. Since Cura fashioned him from the start, let Cura possess him for as long as he lives.

But since there is controversy about his name, let him be called homo, how to buy levitra online since he seems to be made from humus.Let us begin by pointing out that Saturn’s verdict exposes yet another way in which Hyginus’ text alters the Prometheus plasticator motif. In most classical renderings, Prometheus is a trickster, and a transgressor from whom humanity is eventually separated. After discovering his transgressions, the Olympian deities chain Prometheus to a mountain in the Caucasus, and humanity lives on without him.

The relation how to buy levitra online between humanity and its creator is therefore temporary. Hyginus, in contrast, makes it clear that humanity will remain under the guardianship of Cura quamdiu vixerit ‘for as long as he shall live’.The significance of this difference becomes clearer if we compare Hyginus’ text to Ovid’s use of the Prometheus plasticator motif in Metamorphoses. After describing the original moment when Prometheus created Humanity, Ovid goes on to describe the human condition:quam satus Iapeto mixtam pluvialibus undis / finxit in effigiem moderantum cuncta deorum, / pronaque cum spectent animalia cetera terram, / os homini sublime dedit caelumque videre(Ovid 1997, 47)so that his new creation, upright man, / was made in image of commanding gods?.

/ how to buy levitra online On earth the brute creation bends its gaze, / but man was given a lofty countenance / and was commanded to behold the skies. / and with an upright face may view the stars (Melville and Kenney 2009, 76).As we can see, Ovid’s Prometheus creates a strong and vital human being. Humanity seems not dependent on care or assistance, but ‘made in image of commanding gods’.

In Ovid, human life is essentially an independent life which resembles the lives of gods (in effigiem moderantum how to buy levitra online cuncta deorum). It is common—and tempting—to imagine care relations as exceptions in human lives. In care research, for instance, one often how to buy levitra online reserves care needs for vulnerable groups, thereby contrasting them with some kind of original, non-vulnerable state.

In life-course research, similarly, care leaves life as people move into adolescence and adulthood, only to re-enter it in the special cases of disability, serious illness or old age. Hyginus’ text, in contrast, opens up for a rethinking of care as a fundamental, continuous part of human lives.This is essentially an ontological argument. Although we often reserve the term for human beings who have unusual needs—for instance, how to buy levitra online children or people with disabilities—care is, in fact, much more pervasive.Noting the etymology of the verb curo—denoting what we call caring and worrying—Hyginus’ text also points towards an understanding of care as protection.

The notion of care becomes meaningful in and of itself, and in relation to its counterparts, such as conflict, violence and neglect. If the so-called ‘normal’ human life—in Ovid’s words. Lives lived ‘in the image of commanding gods’—is met by a radical lack of care, it would have little freedom and in fact be over in a matter of days.Hyginus’ text points towards an understanding wherein care reigns, organises or facilitates human lives how to buy levitra online.

Cura somehow ‘holds’ humanity in this life, indicating that Jove’s and Tellus’ receiving somehow lies outside that life (after death). For the medical humanities, this understanding of care suggests ways to think about both medical and cultural knowledge as forms of afterlife. Biological knowledge, for how to buy levitra online instance, is a form of knowledge that has been aggregated outside and beyond individual lives.

Through clinical generalisations, anatomical knowledge, systematic literature reviews and more. Cultural knowledge, conversely, is deeply historical and contextual—thereby inevitably also a testament to how both how to buy levitra online historical and contextual relations stretch far beyond individual lives.These ambiguities lead to a further understanding of care. Care is not only a fundamental precondition—whose impact depends on context and interpretation—care is indeed a fundamental and omnipresent condition, that continuously engenders and relies on interpretative processes.Care as holding-togetherWhen I hold my son I ruff-and-tumble play, I am also holding together forms of knowledge.

I connect many different forms of knowledge—my intimate experiences with him, my research experience from disability studies, the bits of knowledge I have received from medical and educational professionals and many others—with one another. Moreover, the how to buy levitra online knowledge I produce—from the actual holding, from being skin to skin and from sensing if he cannot understand others—is used in knowledge translation. I use it to stretch the understandings of medical professionals beyond uncertain prognoses.

I also use it to connect the knowledge of the preschool teachers—a knowledge which mainly deals with so-called ordinary children—with the lives of extraordinary children such as my son.In Hyginus’ text, too, Cura holds together what otherwise would have been separate. Had it not been for Cura’s holding, and Saturn’s verdict, humanity how to buy levitra online would have belonged to either Jove or Tellus. A recent ‘appeal to the medical humanities’ uses the potential of this narrative.

In it, Kristeva et al. (2018) use the myth of Cura to explore how humanity ‘belongs to different ontological domains’ held together by care:Saturn, the God of time, settles the matter through an act of naming and by how to buy levitra online dividing and temporalising the possession of the various parts that comprise man. Jove is offered man’s soul and Tellus his body, after man’s death, while Cura will possess the creation in its lifetime since she made it.

[…] Thus, human life as a composite assembly of spiritual (Jove) and material how to buy levitra online elements (Tellus) is held together by Cura’s temporal care (55).In their unpacking, Cura’s holding of humanity becomes a holding-together of two forms of knowledge. Biomedical knowledge of bios and sociocultural knowledge of zoe. Faced with situations of care—situations that neither biomedical science nor cultural studies of health can understand sufficiently—the understanding of care becomes a point of intersection between otherwise separate landscapes.This holding-together is visible in a variety of care practices.

In the case of evidence-based care, for instance, temporal doing at a certain point in time how to buy levitra online and history (professional work) holds together atemporal knowledge of effects (evidence) and atemporal norms (professional ethics). The temporal care work may seem like a mere ‘application’ of these atemporal knowledges. However, recent studies argue that both evidence and norms exist as such if and only if they are interwoven with embodied practices.

While ‘evidence in clinical decision making is how to buy levitra online relentlessly situated and contextual’ (Wieringa et al. 2017, 964), so can the normative aspects only be sufficiently understood as ‘embodied process’, located at ‘the action level’ (Doane and Varcoe 2008).Jove, Tellus and Cura personify ontological orders (ways of being), and epistemological orders (ways of knowing). If we then revisit the epistemological aspect of care, a further understanding emerges.

Care is a relational matter—in the lived lives of care receivers, as well as in the work of care professionals—and it is crucial in holding together different social agents and different knowledge domains.Care as withholdingWhen I ‘play airplane’ with my son—or hold him close to me in situations where others do not understand him or vice versa—one might say that I know what I am doing how to buy levitra online. On the other hand, this holding challenges several parts of my knowledge of this world. It challenges my images of what it is to be a father, since the play differs from how how to buy levitra online most fathers do this with their children.

More importantly, perhaps, the knowledge produced when I hold my son in my arms in the face of many, many abysses to come differs from much of my academic and medical knowledge, including that which is inherent in his diagnoses and prognoses.This withholding might seem, contrary to the straightforward clarity of Hyginus’ text. However, a more detailed examination can refract these interpretations. It is particularly worth noting that the relation between Cura and the human how to buy levitra online being—that is, the fundamental ontological condition in this life—is described with a specific verbal clause with the verb possideo.

Cura eum possideat (Cura shall hold him).The Oxford Latin Dictionary defines possideo thusly:To have (land) in one’s control, occupy (as a tenant, etc). (absol.) to hold land.(in general) to hold as property, b. To take (property) into one’s keeping, appropriate.(of a sovereign, army, etc) to have control of (a country, position, etc) […] to how to buy levitra online assume or exercise control over (persons).To take or have in its power, dominate, overwhelm, possess.To fill or take up (a space) with one’s bulk.To take up wholly (a person’s time).

To absorb the thoughts and energies of someone.Possideo denotes not a general sense of holding, or a more general sense of contact or connection, but an exclusive holding—similar to the English verb to possess. Cura, then, is not only holding a humanity that belongs to both Jove and Tellus, but she is also withholding this humanity from them. This becomes even clearer if we emphasise that possideo is a how to buy levitra online transitive verb.

At least to some extent, the clauses quamdiu vixerit, Cura eum possideat entail a micro-narrative. Although ‘created from,’ or consisting of biological matter, and being characterised by the presence of ‘soul’ or some measure of cognition, humanity is fundamentally ‘controlled’ by how to buy levitra online care in this life. The separating into meaning (spirit) and biology (bodily remains) takes place outside this life.

Cura’s holding, then, allows us to understand the holding-together of medicine and culture, and a withholding from both these domains.The ‘hermeneutic story’ (Kristeva 2002, 10) of Hyginus’ possideat—wherein care holds humanity at the expense of both culture and biomedicine—contradicts epistemological optimism. Hyginus text allows us to glimpse intimate care knowledge that connects cultural and how to buy levitra online biomedical knowledge, and that holds human life away from generalised knowledge. When Cura withholds humanity from generalised cultural knowledge (Jove) and generalised biochemical knowledge (Tellus) and care produces knowing—often described as insight, sharing and holding-together—and un-knowing.These difficulties indicate the need for an additional understanding of care.

Care must be understood as a practice that holds together multiple parties and multiple forms of knowledge. However, it how to buy levitra online must also be understood as a practice—or if you will. A form of human relation—that withholds something from knowledge.I shall hold him for as long as I shall liveThe ‘human story’ of care relations (eum possideat) will necessarily entail a human story of singular actions that to some extent can only be described in first-person singular.

Eum possideam (I shall hold him). To explore this individual how to buy levitra online eum possideam, I try to ‘theorise from my subject position’ (Fournier 2019, 658). When activating my own intimate experiences, it became clear that interpretations of my eum possideam quamdiu vixerit can refract—or even fracture—theoretical notions of care.To connect intimate experiences of holding—be it in bodily care, in adverse social situations or in rough-and-tumble play—with cultural and political theory is clearly a daunting task.

Although this still seems unclear to me, I can at least how to buy levitra online outline four aspects of the refraction. First, I do hold together cultural and biomedical knowledge. When my son is in my arms, multiple cultural imaginaries are involved.

My understanding of his life (and of mine) is dependent on my language and my cultural frames, and how to buy levitra online I am consistently aware of a clinical gaze. My son’s life—and, thereby, also my own life and my care work—are viewed or observed by medical professionals, psychologists, special needs educators and preschool teachers.Second, the holding is troublesome. In a narrower sense, I note that his needs lead me to hold and even carry him in ways that most parents only do with substantially younger children.

Combined with my own embodied condition, there emerges a bodily trouble, an element of exhaustion, uncertain walking and how to buy levitra online muscular pain. Regarding my cultural knowledge, it becomes clear that my own imaginaries entail expectations and understandings that somehow seem incompatible with his life. In this social context—parenting in Norway, located in middle-class families—childhood is simultaneously about ‘findings one’s own voice’ (autonomy) and about ‘following the path’ (social reproduction).

To claim that autonomy outside language is possible, or that a person in his situation may reproduce his parents, seems how to buy levitra online equally futile.Regarding biomedical knowledge, I take care of my 4-year-old (as I do all three of my children) within a biomedical framework. Most Norwegian children are screened regularly for somatic problems, and to measure linguistic, cognitive and psychosocial development. While this how to buy levitra online knowledge has thus far granted me a certain comfort in parenting my two oldest children—confirming, as it were, that all is well—that has, obviously, not been the case with my youngest son.

Hence, his life is also framed by medical knowledge in a more direct way. He receives a range of health-related services, a provision that also positions my parental care within the same frame.Third, there is an uncertain future involved in this. This is of course always true of how to buy levitra online any intersubjective relation in general and of care relations in particular.

The future is open, and it can entail painful events. However, his situation exposes uncertainty in a more radical way. Culturally, it exposes how I see my other children—as having how to buy levitra online quite stable chances for social reproduction—partly thanks to how I see him.

Through a fatherly lens of rather unclear hopes and worries. Medically, the tests of my youngest son continuously yield inconclusive results. This has replaced my former sense how to buy levitra online of parental comfort with gnawing anxiety over his future.

Moreover, the complexities of his living leaves me, as a caregiver, with the unpredictability of his diagnostic results, rather than with stable prognoses.Fourth, these intimate situations entail a particular life-course temporality, which differs from the temporality of professional care, as well from the temporality in Hyginus’ text. In the case of professional careers, their work is regulated to certain hours (of paid work), and to certain phases of life. Most professional carers will retire, and many will pursue other forms how to buy levitra online of work at some point in time.

In Cura’s case, her care work is also time limited. The temporality of the deity’s existence is how to buy levitra online sufficient to encompass the temporality of humanity. In both cases, the life course temporality of the carer is sufficient for the imagined care work.In my parental care work, however, the temporality is insufficient rather than sufficient.

In all likelihood, I will somehow care for my son for as long as I am alive. Moreover, this lifelong work will how to buy levitra online likely be insufficient in at least two ways related to the temporality of my life. My own ageing will likely reduce my ability to perform the care work, and I will likely die before my son, leaving him without parental care.

Hence, the temporality of my care cannot be formulated as eum possideam quamdiu vixerit (I shall hold him for as long as he shall live), but as eum possideam quamdiu vixero (I shall hold him for as long as I shall live).This rudimentary autotheoretical investigation brings to light three forms of withholding. First, the nature of the holding (eum possideam) withholds care from the epistemological domains that the medical how to buy levitra online humanities traditionally investigate. Second, the temporality involved in parental care (quamdiu vixero) withholds something from the temporality of professional care.

Third, something is also withheld from the ‘parental temporality.’. The need care depends on his life (quamidiu vixerit), not how to buy levitra online on mine. Several forms of knowledge, and several forms of embodied holding, are involved without being fully commensurable.

Since I cannot resolve these enigmatic forms how to buy levitra online of withholding, the theoretical understandings remain breached, implicitly pointing towards not-yet-explicable or not-yet-nameable understandings.Withholding and ambiguityMy holding of my son in my arms come with several temptations. One of them—in particular, as I am holding him, or, perhaps, shielding him—is to think that I hold some kind of vast, privileged knowledge. While this is of course true to some extent, there are more powerful movements at play.

On the one hand, the complexities in the situation forces me out of the internal comfort that characterises the centre of any ontological or epistemological how to buy levitra online ‘domain’. On the other hand, I am also forced to admit another thing. That I can hold him, but it remains unclear—to some extent—if I can know him.

I cannot know if our way how to buy levitra online is exclusively ours.Similarly, intertextual analysis locates breaches in specific ‘sign-systems’, and in larger ‘social and historical material’ (Kristeva 2002, 9–10). Hence, the specific inquiries presented in this article relate to more general ways of inquiry. When we use those notions, we connect different academic investigations, and different academic disciplines, theoretical traditions and research methodologies.

In Julia Kristeva’s words, these relations are ‘temporal connections’ and how to buy levitra online ‘points of contact‘ (2002:8) and points of ‘distortion, ambiguity and contradiction’ (2002:11).The understanding of care as holding-together connects very well with the rise in interdisciplinarity within the medical humanities. The three deities Jove, Tellus and Cura are brought together in dispute, and Saturn’s verdict foreshadows how different ontological domains are held together in human life.Studying an interaction between form of knowledge—in their case. The interaction between medical imagining and patient creativity—Stahl and Stahl use the insufficiencies of medical knowledge in an argument for multiple perspectives:Although in contemporary Western society, many how to buy levitra online tend to believe the hard science provide the truest or most accurate interpretation of the natural world, it cannot exhaust the meaning of the body.

If we believe we are more than the sum of our parts, then we ought to allow for multiple and even varied interpretations of our bodies (Stahl and Stahl 2016, 159).Interpreting care as connectedness and holding-together, medical humanities scholars aim to hold together medical and cultural knowledge in new, explorative and enriching ways, and they often succeed.Such interpretations also speak to an even more radical ambition, that of academic convergence, sometimes referred to as transdisciplinary research. Such appeals are often embedded in a considerable epistemological ambition. Pointing out the insufficiencies of ‘illustrative’ or ‘additive’ work in the medical humanities, Kristeva et how to buy levitra online al.

(2018) express a particularly radical version of this ambition:[W]e do not consider the humanities as a critical and potentially liberating perspective that can be applied to medicine as an object in need of repairment. Medical humanities should not be construed as a humanistic perspective on medicine. They should rather be seen as a cross-disciplinary and cross-cultural space for a bidirectional critical interrogation of both biomedicine (simplistic reductions of life how to buy levitra online to biology) and the humanities (simplistic reductions of suffering and health injustice to cultural relativism).

On the one hand, this implies breaking with the culture–nature dichotomy and considering both the humanities and medicine as biocultural practices. On the other hand, it also implies understanding that boundary work requires boundaries, and that incommensurability between various partial disciplinary perspectives can—and will—emerge (56).The ambition at stake here listens to the holding-together outlined above. Whereas more ‘additive’ ways of connecting knowledge are valuable—for instance, when humanities-based research ‘fill the gaps’ of ‘pure’ medical research in order to facilitate evidence-based care—this is not what Hyginus’ text indicates how to buy levitra online.

Just as the relation between Jove and Tellus is symmetric and mutual (they are equally necessary for the creation of humanity and will ‘hold’ remain with equal sovereignty after this life), so is the relation between Cura and the two other deities. Jove and Tellus are separated from humanity in how to buy levitra online this life, and Cura is equally separated from humanity after this life. This fable cannot be intertextually connected with asymmetrical or additive relations between knowledge fields, but it is connected with a ‘space for bidirectional critical interrogation’.It is perhaps less clear how care as un-knowing speaks to larger trends in the medical humanities.

It is therefore necessary to ask. How can understandings of care that emphasise withholding and un-knowing, including autotheoretical investigations that how to buy levitra online increase uncertainty, ambiguity and painful affects, inform knowledge production?. To outline a provisional response to this question, it is useful to return to Hyginus’ text once again.

The description of Cura’s relation to humanity—Cura quoniam prima eum finxit, quamdiu vixerit, cura eum possideat (Since Cura fashioned him from the start, let Cura hold him for as long as he shall live)—should also be read with attention to grammar. While the conjunction quoniam (since) introduces a causal clause in the indicative mood (finxit), followed by an adverbial clause in the indicative how to buy levitra online (vixerit), the resulting clause is in the subjunctive (possideat). Interestingly, this subjunctive inflection is the only use of the subjunctive mood in Hyginus’ text.This use of the subjunctive mood—sometimes called ‘independent’ usage—can have a variety of purposes.

Although the usage in fable CCXX is iussive—in the sense that makes a permanent judgement—it is worth noting that the subjunctive mood is often associated with potentiality in classical Latin. Other common areas of usage include ‘questions in which the speaker or writer expresses doubt or disbelief by “thinking aloud” (deliberative), wishes that cannot or may not be fulfilled (optative), and the potentiality that something may how to buy levitra online happen or might have happened (potential)’ (Palma 2012, 377). Moreover, it is worth noting that possideat is in present tense.

Since the subjunctive mood lacks a future tense in Latin, the active present tense can also denote future actions how to buy levitra online. Hyginus’ text, then, points towards knowing and un-knowing, and towards openness to potentiality and some degree of uncertainty.When held together, withholding and uncertainty give a clear implication for the medical humanities as a form of academic practice. The epistemological ambitiousness in medical humanities should be supplemented with what one might call epistemological modesty.

Such modesty is rooted in the specifics of care, how to buy levitra online and in the relation between complexity and synthesis. What is at stake in care research—if we take the abovementioned complexities into account—is a ‘bidirectional space’, and an ever-expanding and exponentially multidimensional space. When medical humanities emerged, it was only a question of time before the field began to involve other humanities and social sciences disciplines than those involved in the initial phase.

Similarly, the growth of critical medical humanities steadily increases the engagements with all kinds of critical research frontiers, in how to buy levitra online the social sciences as well as in the humanities. At least in an area such as studies of care—where the intimacy is so acutely palpable—it will become increasingly clear that the medical humanities will remain ‘outnumbered’ or ‘overpowered’ by the analytical complexities the field itself brings forth.Some scholars in the critical humanities have argued that scholars should ‘embrace’ this kind of overpowering (Viney, Callard, and Woods 2015, 2–7). However, Hyginus’ text complicates the relation between care practices (Cura), culture (Jove) and biomedicine (Tellus) regardless of such embraces.

Although care holds humanity at the expense of the other forms of knowing, how to buy levitra online his holding neither implies any disregard for humanities-based nor medical knowledge. Rather, the unpacking presented in this article demonstrates how care brings forth an epistemological modesty. Only an epistemologically modest way of doing medical humanities can address how to buy levitra online the intimate and enigmatic qualities of care.Discussion.

Scholarly and analytical contributionWhile the textual and autotheoretical analyses presented in this paper followed the suggestion from Kristeva et al—to we question ‘the cultural distinction between the objectivity of (medical) science and the subjectivity of culture’ (2018:55)—it nevertheless ended in an emphasis on intimate withholding. This withholding—be it epistemological, theoretical or inherent in the intimate experience of holding or embracing my son away from an abyss—is relevant to the medical humanities in general. However, it is also a contribution to four more specific tendencies in the available literature.First, the unpacking contributes to how to buy levitra online feminist care research.

Beginning with the canonical work on ‘a different voice’ by Gilligan (1982), feminist care research has increasingly emphasised the knowledge multitude involved in care. More recent research also shows a multitude of empirical delineations. While some scholars reserve how to buy levitra online the term for face-to-face interaction, or for situations characterised by asymmetrical dependency, others do not.

The investigation in this article brings forth additional multitude by combining academic disciplines that rarely interact—care research, linguistic analysis of Latin texts, romanticism studies and autotheoretical analysis work—and implies many possibilities for further research.Second, the autotheoretical interpretations can contribute to the research field sometimes known as ethics of care. Following such works as the book Learning from my Daughter by Kittay Kittay (2019, xx), where she proposes that the relation of parental care provides ‘the only universal and morally significant property that all humans possess’, I aim to shed light on how care work engenders ethical thinking. My holding of my son in my arms—as well as the withholding how to buy levitra online that both this holding and Hyginus’ text entail—is as political and ethical as it is personal and embodied.Third, this paper also relates to a more critical strain of ethics of care.

Pettersen (2008) work, for instance, demonstrates how the ethics of care ’subverts the public/private dimension altogether’, thereby allowing for a broader range of criticism (45). Moreover, Fletcher and Piemonte (2017) shed light on how healthcare practices constitute a how to buy levitra online ’quiet subversion’ of neoliberal cultural structures. Arguably, both intimate withholding and epistemological overwhelming shows the power involved in such subversions.Fourth, I hope to contribute to the strand of research—in care research as well as in disability studies—that relate to the work of Julia Kristeva.

On the one hand, the rethinking presented in this paper dovetails with her perspectives on how intimate aspects of care destabilise the larger frameworks, cultural structures that are nevertheless sustained by those actions of care. The autotheoretical exploration towards the emblematic formulation eum possideam quamdiu vixero (I shall hold him for as long as I shall live) might also respond fruitfully to Kristeva’s account of how her “living with […] the neurological how to buy levitra online difficulties of my son David” (2013, 220) lead her to explore maternity as I want that you be (2013, 229). On the other hand, I also try to challenge what I see as an epistemological and political optimism in Kristeva’s work.Data availability statementNo data are available.

Since this is an autoethnographic investigation, primary data will not be available.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe ethical aspects have been reviewed by the research management at the Work Research Institute. See also footnote 1.AcknowledgmentsI would like to thank how to buy levitra online Eivind Engebretsen and John Ødemark for their encouragements, and the anonymous reviewers for their helpful suggestions.Notes1. Patient and public involvement statement.

Although there is no public involvement in the writing of this paper, the autotheoretical approach does of course involve my son. This approach how to buy levitra online hinders full anonymisation, just like his way of living in this world hinders informed consent in the traditional sense. The approach also excludes the potential for full anonymisation.

The consent is therefore, in consultation with his mother, given by me as his legal guardian..

Welcome to discover here the levitra target pharmacy first issue of 2022!. We have several exciting changes to announce in the new year. To begin with, we have been increasing our number of published submissions per issue, including some of our content exclusively online levitra target pharmacy (the most common way that our readers access the journal). In addition, we have put out additional calls for submissions and look forward to receiving new work.We have spent the last 4 years working towards social justice, accessibility, global …IntroductionThe subject of care is gaining importance within the medical humanities, but it also remains elusive.

Hence, this paper aims to unpack theoretical notions of care in a way that integrates the elusiveness rather than trying to avoid it. It also responds to a recent article by levitra target pharmacy Julia Kristeva et al, in which they claim that care holds humanity (Kristeva et al. 2018).When in need of theoretical elaboration or re-development, medical humanities scholars have sometimes evoked Greek or Roman myths, such as those of Narcissus, Hephaestus or Leto (Cilione, Marinozzi, and Gazzaniga 2019. Pannese 2011.

Schott 2017) levitra target pharmacy. Similarly, this article evokes the Roman myth of Cura to unpack theoretical understandings of care. In this myth, known from the writings of the first century mythographer Hyginus, humanity is created from clay by a personification of care. It has proven useful to levitra target pharmacy thinkers as diverse as Martin Heidegger, Arthur Kleinman (Kleinman and van der Geest 2009) and Julia Kristeva (Kristeva (2012), Kristeva et al.

2018). While utilisation by Heidegger 1927, 196–200 ‘challenges the myth of self-sufficiency and individual atomization that that has shaped much of modern Western philosophy’ levitra target pharmacy (Froese 2005, 16), both Kleinman and Kristeva explore the tension between universalised knowledge and the singularity of individual patients and intimate care (Engebretsen, Fraas Henrichsen, and Ødemark 2020).While none of these scholars engage with Hyginus’ Fabulae directly, I use the text as an ‘engine’ in a four-step endeavour. This endeavour follows Brandy Schillace’s description of the medical humanities as ‘a field that at its core considers the human story behind and within medicine, its history, its cultural valence and its influence on practice’ Schillace (2017, 139).First, a ‘human story’ entails agency, the things that humans do in their lives. While the ‘appeal’ from Kristeva et al uses a case from intercultural psychoanalysis, the authors have previously researched a variety of professional healthcare practices (Engebretsen 2016.

Engebretsen, Sandset, levitra target pharmacy and Ødemark 2017. Hetrick et al. 2017). However, it is crucial to levitra target pharmacy note that Cura (in Hyginus’ text) will ‘hold’ humanity quamdiu vixerit (for as long as he shall live).

Such a life-long temporality does not dovetail with the temporary, regulated and systematised relations of healthcare organisations. Hyginus’ text has, I argue, a much stronger affinity to the temporality of parental care. Hence, I begin the endeavour by acknowledging that I am a scholar, and the father of a boy with little linguistic function.1 Although my levitra target pharmacy parental care for my son entails a multitude of meanings and instances, I begin with two tales from my parental care in 2020:Sometimes, if he does not understand what is going on, or if his actions feel unintelligible to others who are present, I take him in my arms. In that way, we are at least together in a situation when both of us otherwise would have been on our own.

Suddenly, it feels as if I am not only levitra target pharmacy holding or embracing him away from an abyss. I am also holding him—or, perhaps, shielding him—in the face of many, many abysses to come.In rough-and-tumble play, I often lift him up with my arms straight—holding him while he straightens his body, and ‘is an airplane’. Although this play is exhausting, particularly since I live with cerebral palsy, this is nevertheless an activity where we can be close to one another. When I hold him up like this, or suddenly ‘crash’ him safely down next to me on the bed, we are skin to skin, but not exactly like I used levitra target pharmacy to be with his older siblings, and I suddenly have the impression that it also differs from how most fathers do this with their children.

I cannot know if our way is exclusively ours, but while I hold him, that is how it feels.Second, a human story ‘behind and within medicine’—or, for that matter, behind and within any social field—consists of underlying notions and involved cultural categories. Hence, this article aims to unpack theoretical notions of care with reference to the thinkers mentioned above. Throughout, I try to levitra target pharmacy unpack how different aspects of care ‘follow’ each other in an analytical ‘path’ or trajectory, as if in a story (Kristeva et al. 2018).Third, the investigation of the human story of care must become an investigation of ‘history’ and ‘cultural valence’.

In order to think historically, the analytical ‘engine’ includes Hyginus’ text, and 18th and 19th century uses of Cura and related motifs.Fourth, I follow Schillace’s advice to examine ‘influence on practice’. In addition to levitra target pharmacy the practice of parental care, the exploration ends with a discussion of medical humanities as practice. When medical humanities scholars ’consider’ the human story of care, they bring together different perspectives and forms of knowledge. In this case, however both the intertextual analyses and the autotheoretical work indicate that levitra target pharmacy those complexities might overpower our theoretical perspectives.

Hence, I conclude with a call for epistemological and analytical modesty.MethodAlthough the abovementioned scholars have used the myth of Cura for clearly theoretical purposes, several of them explore this also as carers in a personal sense. Julia Kristeva writes her work on care as the mother of a man with severe disabilities Kristeva (2013, 219–221), Arthur Kleinman and Geest (2009, 159–163) begin their rethinking with a rich narrative of his caring for his wife who lives with Alzheimer’s disease. In line with their levitra target pharmacy work, this article combines textual interpretation with autotheoretical work.Often used in connection with genre-bending memoir The Argonauts by Maggie Nelson (2015), the term ‘autotheory’ designates a literary form involving ‘the combination of autobiography and critical theory’ (Pearl 2018, 200). In this article, however, I rely on the work of the Canadian artist, curator, writer and interdisciplinary researcher Fournier (2019), who has unpacked autotheory with particular reference to illness and embodiment.

Fournier describes autotheory as a specific form of academic practice:In autotheory as a conceptual and performative feminist practice, artists, writers, and critics use the first person, or related practices of self-imaging (Jones, Self/Image 134), to process, perform, enact, iterate, and wrestle with the hegemonic discourses of ‘theory’ and philosophy, extending the feminist practice of theorizing from one’s subject positioning as a way of engendering insights into questions related to aesthetics, politics, ethics, and social and cultural theory. In autotheory, one’s embodied experiences become the material through which one levitra target pharmacy theorizes, and, in a similar way, theory becomes the discourse through which one’s lived experience is refracted (658).In Fournier’s definition, theory functions as ‘hegemonic discourses’, and as discourses through which one’s lived experience is refracted. Contrary to this emphasis on language—as well as their emphasis on language elsewhere (Heidegger 1927Heidegger 1937. Kleinman 1995.

Kristeva 2019)—neither levitra target pharmacy Kristeva nor Kleinman or Heidegger focus on Hyginus’ text. In contrast to this body of research, this article emphasizes the interpretative potential of the original text. In addition to grammatical analysis, I utilize the well-known concept of levitra target pharmacy intertextuality, as introduced by Kristeva (1980). However, I use it in a less structuralist sense than in her early formulations in Desire in Language.

Instead, I approach Hyginus’ text in line with her approach in ‘Nos Deux’ or a short (hi)story of intertextuality (Kristeva 2002).For me, intertextuality is mostly a way of making history go down in us. We, two texts, two destinies, two levitra target pharmacy psyches. It is a way if introducing history to structuralism and its orphan, lonely texts and readings. […] the etymological meaning of ‘semeion’ is a distinctive mark, a trace, an engraved or written sign, that makes us think of the Freudian ‘psychical’ marks, called drives, rhythmical articulations of embodied impulses and psychical movements.

In this sense, the meaning of the levitra target pharmacy socio-historical aspect of intertextuality, as already developed by Bakhtin and Barthes, acquires a new significance. Within each sociolect or ideology, (both well-established sign-systems) there will always be a breach of subjectivity carrying out a hidden matrix of pre-symbolic forces able to make history move on through all its short and singular stories. (2002. 8-9)First, this means that I study Hyginus’ text not as a ‘lonely text’, but as levitra target pharmacy part of a historical trajectory.

The ‘singular stories’ are used to disturb the orderly (structural) notions of both textual and philosophical analysis.Second, I interpret Hyginus’ text—as well as other utilisations of the myth—with focus on traces. Or, more levitra target pharmacy specifically, to find ‘distinctive marks’ relevant to the same material as in authotheretical work. €˜embodied impulses and psychical movements’. This, however, does not mean that the texts are reduced to a canvas for an engraved sign.

In methodological term, the aim is to allow the two destinies—the textual trajectory of the Cura motif, and the personal trajectory that becomes so intimate when I hold my son in my arms—to shed light on one another.Third, the interaction between these two methodological approaches will hopefully allow history—what Schillace levitra target pharmacy calls the ‘human story’—to move in two diachronic ways. I aim to emphasise the differences between the different utilisations of the myth. Finally, I also aim to locate breaches in the ‘well-established sign systems’ we call theories of care, to get a glimpse of something yet hidden.Humanity as creation, care as fundamental conditionIn a narrative sense, Hyginus tells three stories. A story of the creation of humanity followed by a story of a quarrel between deities levitra target pharmacy and finally, a verdict on the ontological role of care in human life.

The first story in Hyginus’ fable begins thus:Cura cum quendam fluvium transiret, vidit cretosum lutum. Sustulit cogitabunda et coepit fingere hominem.When Cura was crossing a certain river, she saw some clayey mud. She took it up thoughtfully and began to fashion a man.Before levitra target pharmacy interpreting this first story, we must first acknowledge that the fable is an alteration or addition in a philological sense. While Fabulae is almost exclusively filled with Greek myths, the Cura fable’s position at the end of the collection suggests, ‘that this particularly Roman tale was simply added to the end of the existing narrative portion’ (Smith and Trzaskoma 2007, xlix).

Moreover, philological research consistently argues that fable CCXX ‘hinges on Latin wordplay’ (Smith and Trzaskoma 2007, xlviii).More specifically, Hyginus, in the Cura fable, alters a prevailing myth in late antiquity, one that he has even told earlier in levitra target pharmacy the pages of Fabulae. That of how the titan Prometheus fashioned man from clay. In fable CXLII (‘Pandora’), Hyginus states explicitly that Prometheus lapeti filius primus homines ex luto finxit (Prometheus, son of Iapetus, first fashioned men from clay).Most Greek and Roman sources place the Prometheus plasticator motif within a three-stage narrative. First, Prometheus shapes the levitra target pharmacy human from clay, and then Athena gives the creature inner life.

Finally, sometimes after Prometheus has given humankind fire against the orders of Jove, Jove intervenes and sentences Prometheus to eternal punishment in the Caucasus.To understand the human story—to which both this motif and Hyginus’ text belong—comparison is needed. First, we must note that the neutral or slightly idyllic depictions in Hyginus and Ovid (respectively) differ from earlier and less optimistic renderings in Republican times. The poet Propertius, for instance, in his Libri Elegiarum from the first-century BC, laments and elaborates on how Prometheus was careless in levitra target pharmacy his creating. Here, the adverbial clause ille parum caute casts Prometheus as a figure of titanic heedlessness:ille parum caute pectoris egit opus.corpora disponens mentem non vidit in arto:The making of man’s reason he performed with too little care.Arranging our bodies, he overlooked the mind in his handiwork (Goold 1990, 232).Carelessness, the counterpart to the notion of care, is involved in the Prometheus plasticator motif throughout antiquity.

The adverbial clause ille parum caute does not derive from the same verb as Cura, but rather from the verb caveo (to take precautions, to be aware of something). Nevertheless, Prometheus’ lack of care underlines how Hyginus’ text is an inversion levitra target pharmacy these earlier texts. Instead of being created in a careless way, humanity is created by care.To be fair, a singular text never exhausts the potential of the history to which it belongs. Specific understandings—in levitra target pharmacy this case.

Theoretical notions of care—are only a part of a wide array of potentials. The Prometheus Plasticator motif foreshadows 20th and 21st century theories of care, and 18th and 19th century depictions of Prometheus as a figure of romantic transgression. In Goethe’s poem Promethevs (written 1774, published 1789), Prometheus becomes a figure of independence and defiance—as expressed, for instance, in the final stanza:Hier sitz' ich, forme Menschen / Nach meinem Bilde, / Ein Geschlecht, das mir gleich sei, / levitra target pharmacy Zu leiden, zu weinen, / Zu genießen und zu freuen sich, / Und dein nicht zu achten, / Wie ich!. (Goethe 1998, 44–46)Here sit I, forming mortals /In my image.

/ A race resembling me, / To suffer, to weep, / To enjoy, to be glad, / And thee to scorn, /As I!. (Bowring 2015, 182)Typical of Goethe’s Sturm und Drang period, his Prometheus Plasticator is a figure of creativity, and embodies ‘ideals of levitra target pharmacy freedom and rebellion’ (Raggio 1958, 44). Goethe’s poem emphasised the ‘autonomous existence’ of mankind (Dougherty 2006, 95), thereby constituting an ‘emancipatory gesture’ (Edgar 2002, 161). Hyginus’ text inverts both classical and romantic evokings of the myth by inserting dependency rather than autonomy and expansion.

To shed further light on this inversion, we must first unpack the name of the levitra target pharmacy personification that Hyginus instals in the Prometheus Plasticator motif. Cura.The name Cura is derived from the verb curo. The Oxford Latin Dictionary defines the verb thus:To watch over, look after, care for.To tend to, to do what is necessary to.To administer remedies, to treat (a sick person, wound, disease, etc).To have charge of. (absol.) to be in command.To devote oneself to, to cultivate (a person).To undertake, to see to (a task or a levitra target pharmacy responsibility).To regard with anxiety or interest, worry or care about, heed.As we can see, the first three senses of this verb invert the Prometheus motif we found in Propertius.

To instal the personification of curo in the motif is to instal carefulness, attentiveness and responsibility in a motif usually filled with lack of care. The third sense also injects an levitra target pharmacy aspect that is totally absent in classical anthropogenies. That of human frailty. It also relates to aspects of human lives that are particularly relevant to understanding care, illness, disease and disability.The fifth and sixth senses of the word similarly invert the romantic depictions of Prometheus motif.

The anthropogenic levitra target pharmacy act is no longer about rebellion and expansion, but devotion and responsibility. The seventh sense finally reverses the political impulse of the Sturm und Drang—the desire for increased individual freedom and self-expansion in every imaginable way—into worrying and heeding.In addition to these intertextual relations, it is also fruitful to note the verbs that connect humanity to the three deities. While Cura’s creating is described with the verb fingo (in Hyginus. €˜fingere’), Jove’s levitra target pharmacy and Tellus’ acts of giving are described by do (in Hyginus.

€˜dedisti’). While the former verb is a very tactile verb, a matter of touch and contact, do signifies separation—to deliver or give something, to separate it from something in order to unite it with something else. An initial understanding of care emerges from levitra target pharmacy these textual relations. Care is fundamental (by belonging to the anthropogony), antithetical (by being the antithesis of carelessness and neglect) and intimate (by establishing relation through touch).Care imaginationsWhen modern scholars use Hyginus’ text, one word of the first sentence is often overlooked.

Cogitabunda (thoughtful) levitra target pharmacy. Although an adjective in the purely grammatical sense, this is the only word with an adverbial function in Hyginus’ text. Hence, it is the lone term specifying how actions and interactions take place. While Greco-Roman deities often levitra target pharmacy act from rage (as in the conflict between the titans and Olympian deities) or desire (as in the story of Zeus and Leda), Cura acts thoughtfully or with thought.As we can see, the adverb cogitabunda is attached to the picking up of the clay, not primarily to the act of creation.

Sustulit cogitabunda et coepit fingere hominem. Moreover, the temporal clause ‘and begun to’ (et coepit) also locates this thought as prior to the creation of humanity. To understand care as thoughtful, then, is about understanding thoughts and imaginaries levitra target pharmacy ‘involved’ in care, and it includes thoughts and imaginaries that ‘pre-exist’, ‘frame’ or ‘underpin’ care and care work.It is useful to explore how the meaning of cogitabunda is preserved and unveiled in the work of the German philosopher, poet and literary critic Johann Gottfried Herder (1744–1803). In his poem ‘Das Kind der Sorge’ (1787), Herder follows Hyginus very closely (Bernays 1869, 158-163).

This poem was widely read, and it provided the basis for Goethe’s use of the Cura motif in Faust II (1832). Finally, Heidegger also comments on the poem and cites it in extenso when he develops his notion of Sorge as the fundamental human condition (Dye 2009, 207–218)., Kristeva (2001), too, refers several times to Herder, and even refers directly to this poem levitra target pharmacy (25–26). The first stanza describes the moment of creation thus:Einst saß am murmelnden StromeDie Sorge nieder und sann:Da bildet im Traum der GedankenIhr Finger ein leimernes Bild (von Herder 1889, 75).Once by a murmuring riverSorrow sat down, and there,In a vision, thought to form with the touchA wavering figure (Groth 2016, 31).von Herder positions the moment of creation as a radically imaginative act in at least three ways. First, the levitra target pharmacy gaze is far more manifest in von Herder’s text than in Hyginus’.

While Hyginus’ Cura shapes a human (hominen) directly, von Herder’s ‘Sorge’ shapes an image (Bild). This dovetails well with important insights from care research. In relations levitra target pharmacy of care, the cared-for becomes visible to the carer(s), thereby also becoming a valued imago. Conversely, the carer(s) become visible in the imagination of the cared-for—even in a Western culture that often obscures or silences interpersonal interdependence.Second, cogitabunda in Hyginus is also intertextually connected von Herder’s adverbial clause im Traum der Gedanken.

This phrase, roughly translatable as ‘in the dream of thoughts’, roots humanity in a singular image (or dream) that consist of or belong to several different thoughts or ways of thinking. This tension between individuality and multitude dovetails with research on the knowledge complexities involved in care.Third, the word ‘Traum’ (dream) in Traum der Gedanken does not levitra target pharmacy denote unreality, fantasy or illusion. For von Herder, dreams are not the opposite of reality, but thoughts beyond or above manifest reality (Wirklichkeit überhöhenden Gedankens). A dream of thoughts, then, is an experience or interpretation wherein the understanding of a phenomenon moves beyond how the phenomenon presently is, to what it should or could be.

Just as Hyginus’ cogitabunda can, if we interpret in intertextual connection with von Herder’s Traum der Gedanken, also refract my experiences of holding my son levitra target pharmacy in my arms. This is true of the experiences of performing actions that seem strange or unintelligible to those around us, but particularly true of the feeling of doing this in a way that is uniquely ours. The combination of these feelings—where the socially estranged ways of caring is fundamentally ours and integral to my parenting—engenders levitra target pharmacy or entails a striving ‘upwards’. This striving is not limited to the idealisation that so often takes place in parenting, but is also a utopian, imaginative glimpse of a world wherein the both of us truly belong.In other words, the Cura motif foreshadows the ‘horizontal’ complexities involved in care (multiple cultural imaginaries, multiple forms of knowledge).

It also foreshadows ‘vertical’ complexities, through which care imaginations include both underlying categories and überhöhende dimensions. These overarching or utopical dimensions, that both levitra target pharmacy stem from and go beyond the localised, singular imaginations of care, is known by many names in and beyond the medical humanities. Examples include ’underlying values’, ‘ethical content of particular practices’, ‘transformative learning’ and many others (Ayala 2019, 269. Pettersen 2008, 188.

Winthrop 2003).Cogitabunda, can mean to be thoughtful levitra target pharmacy and to be ‘full of thoughts’. The adverbial clause im Traum der Gedanken by von Herder (1888, 533), similarly, also signifies something unclear or disorganised. In his poetotological treatise Über Bild, Dictung und Fabel (1888, 533), von Herder juxtaposes this state with being in Leidenschaft (in passion), in Verrückung (in madness) or nicht auf seiner Hut (off guard). There is complexity and openness—perhaps levitra target pharmacy even fantasy or at least exploration—in this.

When I hold my son in my arms connecting different realms of thought. As in ruff-and-tumble-play, these realms are levitra target pharmacy also at play as I think.The quarrel of the deities. Culture, nature and careAfter the first narrative, the second deals with a quarrel between the deities Cura, Jove and Tellus. Once humanity has been given inner life, the focus in Hyginus’ texts shifts from creating to name-giving:Cum vellet Cura nomen suum imponere, Iovis prohibuit suumque nomen ei dandum esse dixit.

Dum de nomine Cura et lovis disceptarent, surrexit levitra target pharmacy et Tellus suumque nomen ei imponi debere dicebat, quandoquidem corpus suum praebuisset.When Cura wanted to give it her name, Jove forbade, and said that his name should be given it. But while they were disputing about the name, Tellus arose and said that it should have her name, since she had given her own body.To name something after something else (and, perhaps particularly, after someone else) places the object within a certain taxonomy. Major deities such as Jove and Tellus are both rulers and personifications of different ontological realms or ‘elements’. Hyginus’ Cura is not levitra target pharmacy known from other Roman sources.

Instead, Cura is a ‘deification of abstract ideas’, a common feature of Roman culture (Axtell 1907). Hence, it becomes clear that the quarrel deals with ontological ideas, more specifically with the ontology of humanity. Each deity proposes a ‘location’ in levitra target pharmacy classical ontology.The philosopher John T. Hamilton has used the myth of Cura to explore how any understanding of security presupposes both care and carefulness.

He underlines how this ‘locating’ somehow names humanity after something that is neither identical nor particularly resembling humanity:The controversy over the creature’s name strives to resolve the issue of the figure’s proper being, without levitra target pharmacy the aid of physical resemblance, without the talent for self-reflection. In my view, the debate over the name revolves on whether humanity is essentially atemporal (Telluric matter or Iovian spirit) or instead fundamentally temporal and constituted by time and history (Hamilton 2013, 71).It is worth noting that the deities are not offering or suggesting certain framings of human life. Hyginus’ text—in particular, the fact that Jove forbade any name other than his own—indicates conflicts between perspectives and disciplines. The imaginative richness involved in care, indicated by Hyginus cogitabunda or by the plural in von Herder’s Traum der Gedanken, is levitra target pharmacy a plurality where incommensurabilities remain.

In my view, the myth of Cura points towards three possible but incommensurable ways of studying, describing and interpreting care (corresponding to Jove, Tellus and Cura, respectively):As a cultural or semantic phenomenon, elucidated in terms of meaning or more or less idealised notions.As a biological phenomenon, elucidated in medical, psychological or other health-related terms.As a relational phenomenon, elucidated in terms of care work (professional or not).Although it is necessary to understand care in all these ways, it is nevertheless impossible to fully merge them or produce those understandings simultaneously. Hence, it is necessary to add a more epistemologically oriented aspect of care. Care is levitra target pharmacy fundamentally imaginative and context-dependent, and stands in-between otherwise incommensurable interpretative domains.Saturn’s verdict. The continuous presence of careIn the third narrative in Hyginus, the quarrel is somehow resolved when the deities choose Saturn as their judge.

Sadly, this part of the text is fragmented. There is agreement, however, that Saturn’s verdict clarifies that Jove will receive human souls, while Tellus will receive the body post mortem:Tu Iovis levitra target pharmacy quoniam spiritum dedisti, <…>. Corpus recipito. Cura quoniam prima eum finxit, quamdiu levitra target pharmacy vixerit, cura eum possideat.

Sed quoniam de nomine eius controversia est, homo vocetur quoniam ex humo videtur esse factusJove, since you gave him spirit, let [Tellus] receive his body. Since Cura fashioned him from the start, let Cura possess him for as long as he lives. But since there is controversy about his name, let him be called homo, since he seems to be made from humus.Let us begin by pointing out that Saturn’s verdict exposes yet another way in which levitra target pharmacy Hyginus’ text alters the Prometheus plasticator motif. In most classical renderings, Prometheus is a trickster, and a transgressor from whom humanity is eventually separated.

After discovering his transgressions, the Olympian deities chain Prometheus to a mountain in the Caucasus, and humanity lives on without him. The relation between humanity and its creator is therefore temporary levitra target pharmacy. Hyginus, in contrast, makes it clear that humanity will remain under the guardianship of Cura quamdiu vixerit ‘for as long as he shall live’.The significance of this difference becomes clearer if we compare Hyginus’ text to Ovid’s use of the Prometheus plasticator motif in Metamorphoses. After describing the original moment when Prometheus created Humanity, Ovid goes on to describe the human condition:quam satus Iapeto mixtam pluvialibus undis / finxit in effigiem moderantum cuncta deorum, / pronaque cum spectent animalia cetera terram, / os homini sublime dedit caelumque videre(Ovid 1997, 47)so that his new creation, upright man, / was made in image of commanding gods?.

/ On earth the brute levitra target pharmacy creation bends its gaze, / but man was given a lofty countenance / and was commanded to behold the skies. / and with an upright face may view the stars (Melville and Kenney 2009, 76).As we can see, Ovid’s Prometheus creates a strong and vital human being. Humanity seems not dependent on care or assistance, but ‘made in image of commanding gods’. In Ovid, human life is essentially an independent life which resembles the lives of gods levitra target pharmacy (in effigiem moderantum cuncta deorum).

It is common—and tempting—to imagine care relations as exceptions in human lives. In care research, levitra target pharmacy for instance, one often reserves care needs for vulnerable groups, thereby contrasting them with some kind of original, non-vulnerable state. In life-course research, similarly, care leaves life as people move into adolescence and adulthood, only to re-enter it in the special cases of disability, serious illness or old age. Hyginus’ text, in contrast, opens up for a rethinking of care as a fundamental, continuous part of human lives.This is essentially an ontological argument.

Although we often reserve the term for human beings who levitra target pharmacy have unusual needs—for instance, children or people with disabilities—care is, in fact, much more pervasive.Noting the etymology of the verb curo—denoting what we call caring and worrying—Hyginus’ text also points towards an understanding of care as protection. The notion of care becomes meaningful in and of itself, and in relation to its counterparts, such as conflict, violence and neglect. If the so-called ‘normal’ human life—in Ovid’s words. Lives lived ‘in the image of commanding gods’—is met by a radical lack of care, it would have little freedom and in fact be levitra target pharmacy over in a matter of days.Hyginus’ text points towards an understanding wherein care reigns, organises or facilitates human lives.

Cura somehow ‘holds’ humanity in this life, indicating that Jove’s and Tellus’ receiving somehow lies outside that life (after death). For the medical humanities, this understanding of care suggests ways to think about both medical and cultural knowledge as forms of afterlife. Biological knowledge, levitra target pharmacy for instance, is a form of knowledge that has been aggregated outside and beyond individual lives. Through clinical generalisations, anatomical knowledge, systematic literature reviews and more.

Cultural knowledge, conversely, is deeply historical and contextual—thereby inevitably also a testament to how both historical and contextual relations stretch levitra target pharmacy far beyond individual lives.These ambiguities lead to a further understanding of care. Care is not only a fundamental precondition—whose impact depends on context and interpretation—care is indeed a fundamental and omnipresent condition, that continuously engenders and relies on interpretative processes.Care as holding-togetherWhen I hold my son I ruff-and-tumble play, I am also holding together forms of knowledge. I connect many different forms of knowledge—my intimate experiences with him, my research experience from disability studies, the bits of knowledge I have received from medical and educational professionals and many others—with one another. Moreover, the knowledge I produce—from the actual holding, levitra target pharmacy from being skin to skin and from sensing if he cannot understand others—is used in knowledge translation.

I use it to stretch the understandings of medical professionals beyond uncertain prognoses. I also use it to connect the knowledge of the preschool teachers—a knowledge which mainly deals with so-called ordinary children—with the lives of extraordinary children such as my son.In Hyginus’ text, too, Cura holds together what otherwise would have been separate. Had it levitra target pharmacy not been for Cura’s holding, and Saturn’s verdict, humanity would have belonged to either Jove or Tellus. A recent ‘appeal to the medical humanities’ uses the potential of this narrative.

In it, Kristeva et al. (2018) use the myth of Cura to explore how humanity ‘belongs to different ontological domains’ held together by care:Saturn, the God of time, settles the matter through an act of naming levitra target pharmacy and by dividing and temporalising the possession of the various parts that comprise man. Jove is offered man’s soul and Tellus his body, after man’s death, while Cura will possess the creation in its lifetime since she made it. […] Thus, human levitra target pharmacy life as a composite assembly of spiritual (Jove) and material elements (Tellus) is held together by Cura’s temporal care (55).In their unpacking, Cura’s holding of humanity becomes a holding-together of two forms of knowledge.

Biomedical knowledge of bios and sociocultural knowledge of zoe. Faced with situations of care—situations that neither biomedical science nor cultural studies of health can understand sufficiently—the understanding of care becomes a point of intersection between otherwise separate landscapes.This holding-together is visible in a variety of care practices. In the case of evidence-based care, for instance, temporal doing at a certain point in time and history (professional work) holds together atemporal knowledge of effects levitra target pharmacy (evidence) and atemporal norms (professional ethics). The temporal care work may seem like a mere ‘application’ of these atemporal knowledges.

However, recent studies argue that both evidence and norms exist as such if and only if they are interwoven with embodied practices. While ‘evidence in clinical decision making is levitra target pharmacy relentlessly situated and contextual’ (Wieringa et al. 2017, 964), so can the normative aspects only be sufficiently understood as ‘embodied process’, located at ‘the action level’ (Doane and Varcoe 2008).Jove, Tellus and Cura personify ontological orders (ways of being), and epistemological orders (ways of knowing). If we then revisit the epistemological aspect of care, a further understanding emerges.

Care is a relational matter—in the lived lives of care receivers, as well as in the work of care professionals—and it is crucial in holding together different social agents levitra target pharmacy and different knowledge domains.Care as withholdingWhen I ‘play airplane’ with my son—or hold him close to me in situations where others do not understand him or vice versa—one might say that I know what I am doing. On the other hand, this holding challenges several parts of my knowledge of this world. It challenges my images of what it is to be a father, since the play differs levitra target pharmacy from how most fathers do this with their children. More importantly, perhaps, the knowledge produced when I hold my son in my arms in the face of many, many abysses to come differs from much of my academic and medical knowledge, including that which is inherent in his diagnoses and prognoses.This withholding might seem, contrary to the straightforward clarity of Hyginus’ text.

However, a more detailed examination can refract these interpretations. It is particularly worth noting that the relation between Cura and the levitra target pharmacy human being—that is, the fundamental ontological condition in this life—is described with a specific verbal clause with the verb possideo. Cura eum possideat (Cura shall hold him).The Oxford Latin Dictionary defines possideo thusly:To have (land) in one’s control, occupy (as a tenant, etc). (absol.) to hold land.(in general) to hold as property, b.

To take (property) into one’s keeping, appropriate.(of a sovereign, army, etc) levitra target pharmacy to have control of (a country, position, etc) […] to assume or exercise control over (persons).To take or have in its power, dominate, overwhelm, possess.To fill or take up (a space) with one’s bulk.To take up wholly (a person’s time). To absorb the thoughts and energies of someone.Possideo denotes not a general sense of holding, or a more general sense of contact or connection, but an exclusive holding—similar to the English verb to possess. Cura, then, is not only holding a humanity that belongs to both Jove and Tellus, but she is also withholding this humanity from them. This becomes even clearer if we emphasise that possideo is a levitra target pharmacy transitive verb.

At least to some extent, the clauses quamdiu vixerit, Cura eum possideat entail a micro-narrative. Although ‘created from,’ or consisting of biological matter, and being characterised by the presence of ‘soul’ or some measure of cognition, humanity is fundamentally ‘controlled’ by levitra target pharmacy care in this life. The separating into meaning (spirit) and biology (bodily remains) takes place outside this life. Cura’s holding, then, allows us to understand the holding-together of medicine and culture, and a withholding from both these domains.The ‘hermeneutic story’ (Kristeva 2002, 10) of Hyginus’ possideat—wherein care holds humanity at the expense of both culture and biomedicine—contradicts epistemological optimism.

Hyginus text allows us to glimpse intimate care knowledge that connects cultural and biomedical levitra target pharmacy knowledge, and that holds human life away from generalised knowledge. When Cura withholds humanity from generalised cultural knowledge (Jove) and generalised biochemical knowledge (Tellus) and care produces knowing—often described as insight, sharing and holding-together—and un-knowing.These difficulties indicate the need for an additional understanding of care. Care must be understood as a practice that holds together multiple parties and multiple forms of knowledge. However, it levitra target pharmacy must also be understood as a practice—or if you will.

A form of human relation—that withholds something from knowledge.I shall hold him for as long as I shall liveThe ‘human story’ of care relations (eum possideat) will necessarily entail a human story of singular actions that to some extent can only be described in first-person singular. Eum possideam (I shall hold him). To explore levitra target pharmacy this individual eum possideam, I try to ‘theorise from my subject position’ (Fournier 2019, 658). When activating my own intimate experiences, it became clear that interpretations of my eum possideam quamdiu vixerit can refract—or even fracture—theoretical notions of care.To connect intimate experiences of holding—be it in bodily care, in adverse social situations or in rough-and-tumble play—with cultural and political theory is clearly a daunting task.

Although this still seems unclear to me, I can at least outline four aspects of the levitra target pharmacy refraction. First, I do hold together cultural and biomedical knowledge. When my son is in my arms, multiple cultural imaginaries are involved. My understanding of his life (and of mine) is dependent on my language and my cultural levitra target pharmacy frames, and I am consistently aware of a clinical gaze.

My son’s life—and, thereby, also my own life and my care work—are viewed or observed by medical professionals, psychologists, special needs educators and preschool teachers.Second, the holding is troublesome. In a narrower sense, I note that his needs lead me to hold and even carry him in ways that most parents only do with substantially younger children. Combined with my own embodied condition, there emerges a bodily trouble, an element of exhaustion, uncertain walking levitra target pharmacy and muscular pain. Regarding my cultural knowledge, it becomes clear that my own imaginaries entail expectations and understandings that somehow seem incompatible with his life.

In this social context—parenting in Norway, located in middle-class families—childhood is simultaneously about ‘findings one’s own voice’ (autonomy) and about ‘following the path’ (social reproduction). To claim that autonomy outside language is possible, or that a person in his situation may reproduce his parents, seems equally futile.Regarding biomedical knowledge, I take care of my 4-year-old levitra target pharmacy (as I do all three of my children) within a biomedical framework. Most Norwegian children are screened regularly for somatic problems, and to measure linguistic, cognitive and psychosocial development. While this knowledge has thus far granted me a certain comfort in parenting my two oldest children—confirming, as it were, that all is well—that levitra target pharmacy has, obviously, not been the case with my youngest son.

Hence, his life is also framed by medical knowledge in a more direct way. He receives a range of health-related services, a provision that also positions my parental care within the same frame.Third, there is an uncertain future involved in this. This is of course always true of any intersubjective relation in general levitra target pharmacy and of care relations in particular. The future is open, and it can entail painful events.

However, his situation exposes uncertainty in a more radical way. Culturally, it exposes how I see levitra target pharmacy my other children—as having quite stable chances for social reproduction—partly thanks to how I see him. Through a fatherly lens of rather unclear hopes and worries. Medically, the tests of my youngest son continuously yield inconclusive results.

This has replaced my former sense of parental levitra target pharmacy comfort with gnawing anxiety over his future. Moreover, the complexities of his living leaves me, as a caregiver, with the unpredictability of his diagnostic results, rather than with stable prognoses.Fourth, these intimate situations entail a particular life-course temporality, which differs from the temporality of professional care, as well from the temporality in Hyginus’ text. In the case of professional careers, their work is regulated to certain hours (of paid work), and to certain phases of life. Most professional carers will retire, and many will pursue other forms levitra target pharmacy of work at some point in time.

In Cura’s case, her care work is also time limited. The temporality of the deity’s existence is levitra target pharmacy sufficient to encompass the temporality of humanity. In both cases, the life course temporality of the carer is sufficient for the imagined care work.In my parental care work, however, the temporality is insufficient rather than sufficient. In all likelihood, I will somehow care for my son for as long as I am alive.

Moreover, this lifelong work will likely levitra target pharmacy be insufficient in at least two ways related to the temporality of my life. My own ageing will likely reduce my ability to perform the care work, and I will likely die before my son, leaving him without parental care. Hence, the temporality of my care cannot be formulated as eum possideam quamdiu vixerit (I shall hold him for as long as he shall live), but as eum possideam quamdiu vixero (I shall hold him for as long as I shall live).This rudimentary autotheoretical investigation brings to light three forms of withholding. First, the nature of the holding (eum possideam) withholds care from the epistemological domains levitra target pharmacy that the medical humanities traditionally investigate.

Second, the temporality involved in parental care (quamdiu vixero) withholds something from the temporality of professional care. Third, something is also withheld from the ‘parental temporality.’. The need care depends on his life (quamidiu levitra target pharmacy vixerit), not on mine. Several forms of knowledge, and several forms of embodied holding, are involved without being fully commensurable.

Since I cannot resolve these enigmatic forms of withholding, the theoretical understandings remain breached, implicitly pointing towards not-yet-explicable or not-yet-nameable understandings.Withholding and ambiguityMy holding of my son in levitra target pharmacy my arms come with several temptations. One of them—in particular, as I am holding him, or, perhaps, shielding him—is to think that I hold some kind of vast, privileged knowledge. While this is of course true to some extent, there are more powerful movements at play. On the one hand, the complexities in the situation forces me out of the internal comfort that characterises the levitra target pharmacy centre of any ontological or epistemological ‘domain’.

On the other hand, I am also forced to admit another thing. That I can hold him, but it remains unclear—to some extent—if I can know him. I cannot know if our way is levitra target pharmacy exclusively ours.Similarly, intertextual analysis locates breaches in specific ‘sign-systems’, and in larger ‘social and historical material’ (Kristeva 2002, 9–10). Hence, the specific inquiries presented in this article relate to more general ways of inquiry.

When we use those notions, we connect different academic investigations, and different academic disciplines, theoretical traditions and research methodologies. In Julia Kristeva’s words, these levitra target pharmacy relations are ‘temporal connections’ and ‘points of contact‘ (2002:8) and points of ‘distortion, ambiguity and contradiction’ (2002:11).The understanding of care as holding-together connects very well with the rise in interdisciplinarity within the medical humanities. The three deities Jove, Tellus and Cura are brought together in dispute, and Saturn’s verdict foreshadows how different ontological domains are held together in human life.Studying an interaction between form of knowledge—in their case. The interaction between medical imagining and patient creativity—Stahl and Stahl use the insufficiencies of medical knowledge in an argument for multiple perspectives:Although in contemporary Western society, many tend to believe the hard science provide the truest or most accurate interpretation of the natural levitra target pharmacy world, it cannot exhaust the meaning of the body.

If we believe we are more than the sum of our parts, then we ought to allow for multiple and even varied interpretations of our bodies (Stahl and Stahl 2016, 159).Interpreting care as connectedness and holding-together, medical humanities scholars aim to hold together medical and cultural knowledge in new, explorative and enriching ways, and they often succeed.Such interpretations also speak to an even more radical ambition, that of academic convergence, sometimes referred to as transdisciplinary research. Such appeals are often embedded in a considerable epistemological ambition. Pointing out the insufficiencies of ‘illustrative’ or ‘additive’ work in the medical humanities, Kristeva et levitra target pharmacy al. (2018) express a particularly radical version of this ambition:[W]e do not consider the humanities as a critical and potentially liberating perspective that can be applied to medicine as an object in need of repairment.

Medical humanities should not be construed as a humanistic perspective on medicine. They should rather be seen as a levitra target pharmacy cross-disciplinary and cross-cultural space for a bidirectional critical interrogation of both biomedicine (simplistic reductions of life to biology) and the humanities (simplistic reductions of suffering and health injustice to cultural relativism). On the one hand, this implies breaking with the culture–nature dichotomy and considering both the humanities and medicine as biocultural practices. On the other hand, it also implies understanding that boundary work requires boundaries, and that incommensurability between various partial disciplinary perspectives can—and will—emerge (56).The ambition at stake here listens to the holding-together outlined above.

Whereas more ‘additive’ ways of connecting knowledge are valuable—for instance, when humanities-based research ‘fill the gaps’ of ‘pure’ medical research levitra target pharmacy in order to facilitate evidence-based care—this is not what Hyginus’ text indicates. Just as the relation between Jove and Tellus is symmetric and mutual (they are equally necessary for the creation of humanity and will ‘hold’ remain with equal sovereignty after this life), so is the relation between Cura and the two other deities. Jove and Tellus are separated from humanity in this levitra target pharmacy life, and Cura is equally separated from humanity after this life. This fable cannot be intertextually connected with asymmetrical or additive relations between knowledge fields, but it is connected with a ‘space for bidirectional critical interrogation’.It is perhaps less clear how care as un-knowing speaks to larger trends in the medical humanities.

It is therefore necessary to ask. How can understandings of care that emphasise withholding and un-knowing, including autotheoretical investigations that increase levitra target pharmacy uncertainty, ambiguity and painful affects, inform knowledge production?. To outline a provisional response to this question, it is useful to return to Hyginus’ text once again. The description of Cura’s relation to humanity—Cura quoniam prima eum finxit, quamdiu vixerit, cura eum possideat (Since Cura fashioned him from the start, let Cura hold him for as long as he shall live)—should also be read with attention to grammar.

While the conjunction quoniam (since) introduces a levitra target pharmacy causal clause in the indicative mood (finxit), followed by an adverbial clause in the indicative (vixerit), the resulting clause is in the subjunctive (possideat). Interestingly, this subjunctive inflection is the only use of the subjunctive mood in Hyginus’ text.This use of the subjunctive mood—sometimes called ‘independent’ usage—can have a variety of purposes. Although the usage in fable CCXX is iussive—in the sense that makes a permanent judgement—it is worth noting that the subjunctive mood is often associated with potentiality in classical Latin. Other common areas of usage include ‘questions in which the speaker or writer expresses doubt or disbelief by “thinking aloud” (deliberative), wishes that cannot or may not be fulfilled (optative), and the potentiality that something levitra target pharmacy may happen or might have happened (potential)’ (Palma 2012, 377).

Moreover, it is worth noting that possideat is in present tense. Since the subjunctive mood lacks a future tense in Latin, the active present tense can also levitra target pharmacy denote future actions. Hyginus’ text, then, points towards knowing and un-knowing, and towards openness to potentiality and some degree of uncertainty.When held together, withholding and uncertainty give a clear implication for the medical humanities as a form of academic practice. The epistemological ambitiousness in medical humanities should be supplemented with what one might call epistemological modesty.

Such modesty levitra target pharmacy is rooted in the specifics of care, and in the relation between complexity and synthesis. What is at stake in care research—if we take the abovementioned complexities into account—is a ‘bidirectional space’, and an ever-expanding and exponentially multidimensional space. When medical humanities emerged, it was only a question of time before the field began to involve other humanities and social sciences disciplines than those involved in the initial phase. Similarly, the growth of critical medical humanities steadily increases the engagements with all kinds of critical research frontiers, levitra target pharmacy in the social sciences as well as in the humanities.

At least in an area such as studies of care—where the intimacy is so acutely palpable—it will become increasingly clear that the medical humanities will remain ‘outnumbered’ or ‘overpowered’ by the analytical complexities the field itself brings forth.Some scholars in the critical humanities have argued that scholars should ‘embrace’ this kind of overpowering (Viney, Callard, and Woods 2015, 2–7). However, Hyginus’ text complicates the relation between care practices (Cura), culture (Jove) and biomedicine (Tellus) regardless of such embraces. Although care holds humanity at the expense of the other levitra target pharmacy forms of knowing, his holding neither implies any disregard for humanities-based nor medical knowledge. Rather, the unpacking presented in this article demonstrates how care brings forth an epistemological modesty.

Only an epistemologically modest levitra target pharmacy way of doing medical humanities can address the intimate and enigmatic qualities of care.Discussion. Scholarly and analytical contributionWhile the textual and autotheoretical analyses presented in this paper followed the suggestion from Kristeva et al—to we question ‘the cultural distinction between the objectivity of (medical) science and the subjectivity of culture’ (2018:55)—it nevertheless ended in an emphasis on intimate withholding. This withholding—be it epistemological, theoretical or inherent in the intimate experience of holding or embracing my son away from an abyss—is relevant to the medical humanities in general. However, it is also a contribution to four more specific tendencies in the available literature.First, levitra target pharmacy the unpacking contributes to feminist care research.

Beginning with the canonical work on ‘a different voice’ by Gilligan (1982), feminist care research has increasingly emphasised the knowledge multitude involved in care. More recent research also shows a multitude of empirical delineations. While some scholars reserve the term levitra target pharmacy for face-to-face interaction, or for situations characterised by asymmetrical dependency, others do not. The investigation in this article brings forth additional multitude by combining academic disciplines that rarely interact—care research, linguistic analysis of Latin texts, romanticism studies and autotheoretical analysis work—and implies many possibilities for further research.Second, the autotheoretical interpretations can contribute to the research field sometimes known as ethics of care.

Following such works as the book Learning from my Daughter by Kittay Kittay (2019, xx), where she proposes that the relation of parental care provides ‘the only universal and morally significant property that all humans possess’, I aim to shed light on how care work engenders ethical thinking. My holding of my son in my arms—as well as the withholding that both this holding and Hyginus’ text entail—is as political and ethical as it is personal and embodied.Third, this paper also levitra target pharmacy relates to a more critical strain of ethics of care. Pettersen (2008) work, for instance, demonstrates how the ethics of care ’subverts the public/private dimension altogether’, thereby allowing for a broader range of criticism (45). Moreover, Fletcher and Piemonte (2017) shed light on how healthcare levitra target pharmacy practices constitute a ’quiet subversion’ of neoliberal cultural structures.

Arguably, both intimate withholding and epistemological overwhelming shows the power involved in such subversions.Fourth, I hope to contribute to the strand of research—in care research as well as in disability studies—that relate to the work of Julia Kristeva. On the one hand, the rethinking presented in this paper dovetails with her perspectives on how intimate aspects of care destabilise the larger frameworks, cultural structures that are nevertheless sustained by those actions of care. The autotheoretical exploration towards the emblematic formulation eum possideam quamdiu vixero (I shall hold him for as long as I shall live) might also respond fruitfully to Kristeva’s account of how her “living with […] the neurological difficulties of my son David” (2013, 220) lead her to explore maternity as I want that you be (2013, levitra target pharmacy 229). On the other hand, I also try to challenge what I see as an epistemological and political optimism in Kristeva’s work.Data availability statementNo data are available.

Since this is an autoethnographic investigation, primary data will not be available.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe ethical aspects have been reviewed by the research management at the Work Research Institute. See also footnote 1.AcknowledgmentsI would like to thank Eivind Engebretsen and John levitra target pharmacy Ødemark for their encouragements, and the anonymous reviewers for their helpful suggestions.Notes1. Patient and public involvement statement. Although there is no public involvement in the writing of this paper, the autotheoretical approach does of course involve my son.

This approach hinders full levitra target pharmacy anonymisation, just like his way of living in this world hinders informed consent in the traditional sense. The approach also excludes the potential for full anonymisation. The consent is therefore, in consultation with his mother, given by me as his legal guardian..