The analysis categories were thefollowing: the creation and expansion of the Nightingalean Nursing TeachingSystem; the subsumption of the Nursing labor to capital; imperialism andinternational health; and the flexibilization of the Nursing labor.the expansion of the Nightingale Teaching System has trained nurses on aglobal scale. The capitalist system transformed the Nursing labor in thetwentieth century, culminating in the twenty-first century with precariousand intense turnover of nurses in their jobs.the Nursing labor, made professional by Nightingale, has assumed in the last200 years a dialectical relationship with capitalism in which it bothdetermines and is determined by it. New challenges, such as the Industry 4.0technologies, are constantly imposed on the profession. Inthe 1840s, Florence sparked her interest in public health, a time when a healthreform was being debated in the UK as a whole. The Nursing labor was part of herpublic health interests, including architecture and urban sanitation. Thus, the workers who left the countryside for the city in search ofwage labor found themselves in the need to subject themselves to taking on unhealthyjobs and forcing their children into equally degrading situations, such as in thecoal mines and in the workhouses.At that time, the incredible expansion of production promoted by the IndustrialRevolution increased the intensity of production and caused a relative reduction inthe amount invested in the purchase of labor power available on the market by freeworkers. Thus, rkhouses..Against her familys wishes, Florence Nightingale increased her interest in Nursing,hospital organization and architecture, and in epidemiological records. She workedin health services in England and, in 1849, visited Nursing services, among otherlocations, in Rome, Alexandria, Kaiserswerth and Paris. In 1851, she returned toKaiserswerth for observations and a three-month training in the KaiserswertherDiakonie and headed to Paris, where she completed her observations and training withthe Filles de la charit de Saint-Vincent-de-Paul. Returning to England in 1853, sheassumed the position of superintendent at the Establishment for Gentlewomen DuringTemporary Illness until October 1854, when she embarked for the Ottoman Empire toact alongside the British troops as superintendent of the Female NursingEstablishment of the English General Hospitals in Turkey in the CrimeanWar. After strong resistance from direct superiors to improve the sanitaryconditions at the Barrack Hospital, Florence Nightingale participated in thecreation of a health commission, headed by physician John Sutherland, who, afterarriving in March 1855, and with her support and that of her subordinates,transformed the health conditions of the hospital.In skdar, at the Barrack Hospital, Florence Nightingale found an environmentlacking instruments and supplies for personal and environmental hygiene, foradequate food and for the comfort of wounded and sick combatants. After hospital.. In 1859, with a collection close to 5.7 million in current values,the Nightingale Fund starts the construction of The Nightingale Home and TrainingSchool for Nurses at the newly built St Thomas Hospital in London, England.Inaugurated in July 1860, it received its first students and began a journey of deeptransformation in world Nursing towards the professionalization of the so-called artof caring.Upon returning to England in 1855, Florence was a national heroine for hercontributions to reducing mortality at the Barrack Hospital, having received severalobeisances. To honor her, her friends came up with the idea of creating a careinstitution that would be a kind of English Kaiserswerth through a fund, theNightingale Fund, established in 1857. The Nursing labor, considered regardless of any determined socialform, is characterized today by the labor act of caring for human beings that isperformed by human beings in the role of Nursing laborers. They apply esotericknowledge(-) and set up interactions with their service users in a givenenvironment.Today, there is more than one work process in Nursing administrative, teaching andresearch all of them acting in function of the Nursing labor. The Nunowledge-6 andWhen a work is subsumed to the capitalist mode of production, it ceases to be just aprocess of organic metabolism of the human being with nature in order to produceuseful effects to be also a conservative, creative and multiplying value activity.The Nursing labor was no different. and with nurses and midwives from Australia, New Zealand and the UnitedKingdom show that Nursing experiences similar situations in several countries,insufficient workdays, underwages and underemployments, showing the need forreflections on Nursing relationships in the world of labor.Studies carried out on Nursing in Brazil and witKingdom show thBearing in mind that in 2020 the 200th anniversary of the birth of the creator ofmodern Nursing is celebrated, many reflections have been made to discuss the currentstate of the discipline and profession and the necessary strategies to beimplemented in order to continue the advances and its expansion, with a betterposition in the world of labor; therefore, in this list of investments it isnecessary to analyze the development and outcomes of the profession within thedominant sociability system in most of the world, capitalism. Thus, this theoreticalessay starts from the following research question: What are the relationshipsbetween the development of the Nursing labor and capitalism over the 200 years ofFlorence Nightingale?That said, the purpose of this essay is to analyze the relationship between thedevelopment of the Nursing labor and capitalism over the 200 years of FlorenceNightingale., in which the economic categories function as ideal expressions ofhistorical relations of production and, therefore, correspond to a certain level ofdevelopment for the productive forces. The exposure method was developed aposteriori of the investigation process. The categories are the following: creationand expansion of the Nightingalean Nursing Teaching System; subsumption of theNursing labor to capital; imperialism and international health; and theflexibilization of the Nursing labor.This is an original, discursive, logical-reflective and theoretical production basedon interpretations of historical facts that represent turning points in capitalismand that determine the ways to perform the Nursing labor, as well as on Marxisttheories that assist in the interpretation of these historical facts. It isorganized into analytical categories, created from the method of scientificdialectics as described by Karl Marx, in whiKey ideas from the four analytical categories of this reflection are presented. Inthe creation and expansion of the Nightingalean Nursing Teaching System, TheNightingale Home and Training School for Nurses stands out, established in 1860 atSt Thomas Hospital. With a model that was based on pedagogically organizedscientific content and the mandatory residency of the students in the hospital, itcontributed to raising the quality of service provision and to reducing hospitalcare costs. Quality and prestige contributed to the international expansion of thisSystem.The subsumption of the Nursing labor to capital is observed when the work processtakes the form of a production process, which is constituted, at the same time, bythe work process and the valuation process. The 1929 Crisis, which hit centralcountries, such as the United States of America (USA), affected the Nursing laborthat, with the advent of private health insurance, also began to be directlyexploited by capital. The production of more value accompanied by an increase in theworkday is one of the main characteristics of the formal subsumption of labor tocapital. Concomitantly, the application of Taylorism and Fordism in Americanhospitals has intensified the productivity of the Nursing labor, characteristic ofthe real subsumption of labor to capital.The transition from the 19th century to the 20th century is marked by the developmentof Imperialism, which has had a major impact on international health. Thedevelopment of the international market has intensified the routes betweencountries, moving large intra- and international migratory flows. Such flows andpopulation growth in large urban and commercial centers have contributed to thespread of diseases, especially infectious and epidemic, generating the need forresponses from the health field to address the financial concerns of largeindustries. Within this framework, the Rockefeller Foundation stands out for itsperformance in the health field.Based on the influence of the Rockefeller Foundations scientific philanthropyactions, the Nursing labor starts to acquire new skills, such as the application ofknowledge about the social aspects of nosological events and health education aimedat the prevention of communicable diseases, and to deepen knowledge in dietetics,biology, pharmacology and other basic sciences. As a result of this influence, theNursing labor, based on specific and medicalizing public health actions, started toassume important functions in maintaining and recovering a sufficient level ofhealth for the working classes so that they could both offer their workforce and actas consumers in the market society, and was used to clean up the image of largecorporations in the oil industry and of the US imperialist interests.The many crises that marked the capitalist system have, throughout its history, ledto important changes in the world of labor. Productive restructuring, reduction ofsocial rights, precarious work, fragmentation of the working class, and weakening ofthe workers claiming forces are aspects to be considered in the debates on theflexibilization of the Nursing labor, which generates important impacts on healthcare..The creation of The Nightingale Home and Training School for Nurses on June 24th,1860, brought important new contributions, such as: the introduction of scientificknowledge discovered by physicians in the teaching of nurses; the soleresponsibility of the superintendent (matron) to control the Nursing service; theneed for apprentices to reside in the hospital; the payment of a reasonable amountto nurses after the first year of the course; carrying out manual work exclusivelyby servants; circulation of apprentices among different wards; and observation asthe main competence to be developed by the apprentices. Working class apprentices were considered to be ordinary apprenticesand the costs of maintaining them in the first year of the program were financed bythe Nightingale Fund. Upon graduation, the so-called nurses were directed to assume regularobedience positions. The apprentices of the bourgeois classes, referred to as ladynurses, paid for their maintenance costs in the first year of the program and, upongraduation, were directed to assume leadership positions on an internationalscale.The model lasted three years, as in Kaiserswerth. The first year was devoted totheoretical classes and, in the following two years, hospital and home services wereperformed. Workinale Fund. Upon galscale..In addition to the prestige of adopting an education system associated with the imageof a UK heroine, the adoption of the relatively inexpensive labor of apprentices fortwo years made hospitals of the time interested in the system. The interest inraising the level of the nurses training and decreasing costs of providing hospitalservices through the adoption of this system crossed the Atlantic Ocean and reachedthe USA and Canada.. The Nightingalean System came to be known in the USA as the BellevueSystem, as it was introduced in the country by that institution. The education systems started disconnected from the hospitals but, dueto the lack of donations to finance them, they were integrated into hospitals. InCanada, in 1874, the St. Catharines General and Marine Hospital brought two trainednurses and five or six students from England to set up a teaching system that wouldlast three years. In 1875, the Montreal General hospital sought help from FlorenceNightingale to set up her education system and five nurses were sent from St.Thomas Hospital to establish the school in the institution.In 1873, three schools implemented Nursing education systems based on theNightingalean System in the USA: The Bellevue Training School in New York City onMay 1st; the Connecticut Training School in New Haven on October 1st; and the BostonTraining School on November 1st(-). With the arrival of the education system in these countries, the timein which students were trained, on average, tripled, keeping hospitals with moreemployees on low salaries (with a mean of $10 a month in 1874 in the USA) for longertime. The result of this equation was a rapid growth in the number of nursetraining schools. Between 1900 and 1929, the number of nursing schools in the USArose from 432 to 1,885. In Canada, the number of nurses between 1901 and 1921 rose from 280 to21,385, including the students.The hospitals in these two countries did not have good working conditions for thenurses. After completing their training in the hospitals, the nurses sought to selltheir workforce to families who hired them to provide their services within theirhomes-11. W. This process begins to affect the Nursing labor in the USA with thesale of health insurance, which started in the 1920s, gained popularity in the1930s, helped in the economic recovery of the hospitals, and boosted thecapitalization of these services. From 1934 to 1938, the Blue Cross, which was selling insurance forhospital care, went from 100,000 to 1.5 million insured clients, and to 22 millionin 1946. The Nursing labor already served the capital indirectly by improvingworkers productive capacity, keeping workers and bourgeois healthy or recoveringtheir health. However, from this process of capitalization of the health services,it is also directly exploited by capital.The process of formal subsumption of labor to the capitalist mode of production ischaracterized by the conversion of the work process into an instrument of theprocess of capital self-valorization, although this conversion does not necessarilyalter the work process itself. This pservices. From 1. It is characteristic of the real subsumption of labor to capital thatthe conscious application of sciences to the immediate production process in orderto produce more relative value. Formal subsumption is a precondition for real subsumption of labor inthe capitalist mode of production, since it is necessary to accumulate a minimum ofcapital in order to invest in the development of new methods of work and in theimprovement of its means.While in the process of formal subsumption, the work process only becomes a processof self-valorization of capital, in the process of real subsumption, capital acts inthe work process, intensifying it and making it more efficient to produceprofit. It is ve value. FormalIn the Nursing labor, the real subsumption of capital happened pari passu to formalsubsumption. As soon as the hospital services were being capitalized, the productionof absolute surplus value generated by the excessive increase in daily workinghours, the technical division of labor, the loss of ownership of the means ofproduction and the production of relative surplus value generated by application ofthe Taylorist and Fordist models of work management plagued this in a short periodof time.. The ANA proposed that hospitals could hire workers without formalqualifications to perform maintenance services, secretaries for administrative tasksand attendants for routine activities, in order to rationalize the work ofregistered nurses and reduce labor costs applied to simpler tasks. In this way, the ANA promoted an intensification of the separationbetween manual and intellectual work.In the 1930s, the American Nurses Association (ANA) defended the application ofTaylorism in hospital care and the consequent technical division of the Nursinglabor. The ANer tasks. In thi, as well as the hospital architecture. During this period, Functional Nursing emerged, which acted as anassembly line with an intense division of activities into small tasks, and time andmovement studies were applied to operations performed in the Nursing labor, whichled to a significant increase in the working pace on an industrial scale.Not only was Taylorism applied to Nursing care, Fordism also influenced thestructural changes in Nursing care in the 1930s in the USA, as welitecture. Duringal scale.. Although thousands of nurses left their countries to take part in thewar, they represented a small number of the available nurses and governments andprivate hospitals refused entry to male nurses, black-skinned nurses and people over40 years old to take up positions in hospitals.Under the pretext of an alleged shortage of nursing professionals caused by theSecond World War, American hospitals reversed many previously-achieved advances.They put an end to the eight-hour workload limit; reversed the restriction on thecreation of new Nursing schools; they exerted pressure on the War Nursing Council torelease the training of 50,000 nurses a year and on the National League for Nursingto loosen the requirements for admission to the Nursing courses, so as to reduce thetraining time for Nursing students, reintroduce Nursing students to conduct directassistance in wards and regulate the position of the Licensed Practical Nurse,trained from a one-year technical program. Althouospitals..Imperialism is a phase of the development of capitalism that started at the turn ofthe 19th to the 20th century. It is characterized by the acceleration of capitalconcentration and centralization processes; by the combination; financial capital;inherently capitalist exploitation in the dependence relationships between financialmonopolies located in metropolises and their colonies/areas of influence;transformation of the old sharing of the world into sharing between capitalistmonopolies over areas of exploitation of raw materials, trade routes and consumermarkets; and submission of the international division of labor to the monopolisticinterests of the metropolises, under penalty even for using the armedforces.. In this way, means of land and sea transportation, as well ascommercial routes, were developed to move goods and workers to meet the demands ofproduction and capital accumulation, generating large intra- and internationalmigratory flows and eventual contacts for the purchase and sale of goods. Inaddition, the First World War imposed the movement of large troops in foreign lands.Such elements, combined with the growing population concentration in urban centers,contributed to the population being exposed to microorganisms, for them new, and forthe rapid spread of communicable diseases.The technologies of the First Industrial Revolution and imperialist interests deeplyexpanded the production capacity and demanded a greater supply of raw materials,labor instruments, workers and consumer markets. In thidiseases.. Therefore, general health conditions, as well as basic levels ofeducation and the lifestyle/consumption pattern of people from all nations becamefinancial concerns for large industries and philanthropic organizations such as theCarnegie Corporation, created in 1911, the Rockefeller Foundation, created in 1913,and the Ford Foundation, created in 1936, which played an important role in creatingconditions favorable to US imperialist exploitation.In the meantime, potential or actual epidemics in one part of the globe came toaffect the profits of large international corporations headquartered in otherlocations. Therefoitation.. The Rockefeller Foundation in its creation had the InternationalHealth Commission (1913-1916), later named as the International Health Directorate(1916-1927) and, finally, as the International Health Division(1927-1951).The Rockefeller familys investment in health-related scientific philanthropy startedin 1909, with the Rockefeller Sanitary Commission for the Eradication of Hookworm inSouthern USA, followed in 1910 by the Sanitary Commission, until the creation of theRockefeller Foundation in 1913. The Ron 1913-19, later n, replacing or diminishing the influence of religious Nursing assistanceand existing traditional practices where the Foundation had advanced. In Brazil, the Rockefeller Foundation played a fundamental role inNursing and Public Health as a whole, creating schools for the training of nursesand health visitors throughout the national territory and, subsequently, the Special Public Health Service.Until 1950, the Rockefeller Foundation had invested or intended to invest in Nursingeducation programs in almost 30 countries around the world, in addition to promotingthe establishment of connections between Nursing schools and universities andproposing the curricular bases of dozens of Nursing education institutions aroundthe world based on the Anglo-American version of the Nightingalean Nursing TeachingSystem, replacadvanced. In Braerritory and, su. The so-called cyclical crises, which took place every 7 or 10 years,occurred within longer periods, around 50 years, which are called longwaves.Crises are the natural mode for the existence of capitalism and, therefore, since itsinitial stage of development at the international level, the capitalist mode ofproduction has faced several crises. The songwaves.. Each was initiated from a technological or industrial revolution andall were composed of two phases: an initial expansion, marked by accelerated capitalaccumulation, and a final one with a tendency to stagnation, marked by graduallydecelerated accumulation.Until the 1950s, there were four long waves in the history of capitalism: (i) betweenthe end of the 18th century and the 1847 crisis; (ii) between 1847 and the beginningof the 1890s; (iii) between the 1890s and the Second World War; and (iv) the lastone that started in the mid-1940s. Each wmulation.. This phase was also marked by the end of the Bretton Woods Agreementin 1971, the oil crisis caused by the Arab-Israeli conflict in 1973, the neoliberallaboratory installed in the military coup in Chile in 1973 and the crash of theStock Exchange in 1973/74. This period of crisis and recession on a global scale led to the deepdeterioration of the Social Welfare State in countries that assumed a centralposition in the international labor division. In Brazil, contradictorily and due toits quality as a country with a dependent economy, the Unified Health System isbuilt as an element of a universal social security system in the midst of thisinternational setting and, consequently, suffers from pro-market reforms,underfunding and deepening competition between public and private institutions sinceits inception. The 1970s were crucial for capitalism, marking the end of the SocialWelfare State guided by Keynesianism, starting the implementation of neoliberalrationality, and marked the beginning of a crisis of another nature: the structuralcrisis of capitalism.The stagnation phase of this last long wave, called the Golden Age of Capitalism, wasmarked by recessions in imperialist economies in western Europe  andJapan between the 1960s and 1970s that culminated in the 1974/75 worldrecession. This p 1973/74. This pnception. The 19pitalism..Capital has three fundamental dimensions: production,distribution/circulation/materialization, and consumption. These dimensions,although they have relative autonomy from each other, are fundamentallyinterdependent and tended to be strengthened, expanded and made increasingly complexthrough their interactions. When one of these dimensions met a limit, anothercompensated and gave the feeling that this contradiction had been overcome. With thestructural crisis, this triad that leads to the self-expansion of capitals suffersmore and more disturbances to the point of presenting flaws in its mechanisms fordisplacing contradictions from one dimension to another.. A productive restructuring was necessary to generate a more flexiblepattern of accumulation and to be better able to overcome the contradictions withinthis crisis. This restructuring, which is still under development until the presentday, had the Toyota Production System as its main reference.Unlike the long waves that happened until the 1970s, with the structural crisis thereis a situation of cumulative, endemic and chronic crisis on a globalscale. A prods crisis. This reference.. Upon returning and discussing what he had found in Detroit withTaiichi Ohno, they understood that Fordism would not serve Japan and developed analternative that would be called the Toyota Production System and, later on, LeanProduction.In 1950, Eiji Toyoda visited Fords Rouge plant in Detroit to study the plant and itsmodes of production and management. Upon roduction.. In Lean Production, wastes are results of operations that do not addvalue to the product developed. To eliminate wastes in the Lean Production, therefore, it is necessaryto define what is and what is not value according to the view of its consumer beit the final consumer or some intermediary in the production chain , trace thevalue chain, that is, define the set of absolutely necessary actions for theproduction of a certain product or service, and ensure that the entire productionprocess of the product or service reaches the necessary fluidity to meet the needsand desires of the consumers in less time, with fewer errors and with the lowestcompetitive price(-).One of the main features of Lean Production is the search for eliminating wastesthrough processes that promote continuous improvement of the capital accumulationprocess. In Leaeveloped. To elive price-25.. Thus, unproductive work performed by assistants, such as maintenance,monitoring and quality control, are now performed by productive workers. Such modifications in the production process generated negativerepercussions for social rights, precarious working conditions, greaterfragmentation of the working class, and weakening of confrontational unionism to thedetriment of negotiating unionism.With the transformations generated by Lean Production, the intellect of the workers,previously rejected, started to function as an intellect of capital, based on thevalorization of value and on the devaluation of work. Thus,  workers. Such munionism.; the Virginia Mason Medical Center in Seattle, Washington,USA, an institution associated to the Virginia Mason Institute, thatcreated the Virginia Mason Production System inspired in Lean Production and makesconsultations with diverse health institutions, among them the NHS itself; ThedaCarein Wisconsin, USA, that created the ThedaCare Improvement System based on LeanProduction; the Institute for Healthcare Improvement in Cambridge, Massachusetts,USA; in addition to organizations in Brazil, Canada, Taiwan, New Zealand,Germany, Sweden, Italy and Holland.Lean Production has been applied not only in the automotive industry, but also inother branches of the manufacturing industry and in branches of the serviceindustry, including health care, where it takes the shape of Lean Health Care.Currently, Lean Health Care is not the sole management model that aims torestructure the health industry towards greater flexibilization of work andemployment contracts, but many health organizations and systems apply Lean HealthCare principles around the world. Some examples with higher prominence are theBritish National Health System (NHS); the Viton,USA, an insoduction; the Intts,USA; in addlland and a mentality of continuous improvement(which presupposes the understanding that the philosophy is for the long-term andtherefore is not limited to a single intervention), and that it is expressed bycarrying out Lean evaluation activities  and Lean improvement activities (such as 5S or the 6S variation whichincludes safety(33), level production, visual management and standardizedoperations).A very comprehensive and promising operational definition was developed for LeanHealth Care. The aurations)..A key concept for applying the Lean Production principles in the health field iswaste. The NHS currently recognizes eight health wastes: (i) Defects: rework causedby failed processes or lack of access to correct information in the first attempt;(ii) Waiting: when the individuals cannot perform their work due to the absence ofpeople, equipment and information at the appropriate time; (iii) Transport:unnecessary movement of materials; (iv) Over processing: performing unnecessarystages that do not add value; (v) Inventory: characterized by excess stockedmaterials and patients waiting to be discharged or waiting for procedures; (vi)Motion: when people move unnecessarily and for things that are difficult to access;(vii) Over production: the act of producing more than necessary or when it is notnecessary; and (viii) Skills: not making the best use of peoplesabilities.(-), intensive care units and coronary units, outpatient clinics, surgery centers, laboratories, diagnosis services, pharmaceutical services, gynecology and obstetrics, primary health care and ophthalmology. It is common for the Lean Health Care model to be associated with workmanagement instruments from other models, such as Six Sigma.The Lean Health Care model has been applied in several types of health services andunits, such as: emergency-36, i units,-38 anry units, outpat clinics, surgerters,-, laboraratories,37, drvices,-40, pstetrics, primaralmology. It is igma,,-42.. In this contemporary model of hiring, the employer does not settle aminimum number of hours worked, and can serve both to fill the void left by jobabandonment or by medical leave, and for hiring professionals to work from theirhomes in a situation of flexible demand for health care.Nursing laborers, mainly in England, have suffered from the so-called zero-hourcontracts. In thilth care,43.. This same report points out that the turnover of these workers ishigher in all the scenarios. In Brazil, there is currently a trend to intensify the precariousnessof the health work, either due to the deterioration of the working conditions or ofthe contractual employment ties.From 2016 to 2017, the British National Health System recorded a total ofapproximately 325,000 workers employed in the zero-hour contracts for adult care,representing almost a quarter (24%) of the entire workforce employed in this sector,with the most affected workers being registered nurses, with 55% of the workforcesubjected to this precarious hiring regime, and caregivers, with 56% of theworkforce. This scenarios. In Braent ties.. In this sense, for the Nursing labor to produce health care for thepopulation, in the light of the Nightingalean ideas, Nursing laborers need decentconditions to safely exercise their professional practices.The area still needs to invest more in studies on the increasing precariousness ofthe Nursing labor but, from what it has produced, wear out and work overload areverified as consequences, with negative impacts on the physical and mental health ofthe workers. In thiThe Nursing labor, which becomes professional under Florence Nightingales influence,has assumed a dialectical relationship with capitalism in the last 200 years, inwhich it both determines it and is determined by it. New transformations are yet tocome. The technologies of the Fourth Industrial Revolution, also known as Industry4.0, have demonstrated their ability to radically transform the international labordivision, including Nursing. Recovering the visionary impetus of the Lady of theLamp to lay the foundations of the Nursing transformation is a challenge of theagenda.


The National Library of Medicine (NLM) Michael E. DeBakey Fellowship in the History of Medicine is a unique program in a unique institution: the world’s largest biomedical library, which is part of the National Institutes of Health (NIH). The fellowship is rooted in strong connections between its namesake and the NLM and is an expression of Dr. Michael E. DeBakey’s longstanding appreciation of the library and the role of the humanities in medical education and practice. This article explains Dr. DeBakey’s connections to the NLM and describes the origins, development, and structure of the NLM Michael E. DeBakey Fellowship in the History of Medicine. It also highlights research achievements of selected NLM Michael E. DeBakey Fellows, demonstrating that the fellowship is successfully carrying forward Dr. DeBakey’s principles and practices of weaving science, technology, and the humanities to form holistic understanding of the human condition, inspiring well-rounded careers built on both scientific and humanistic knowledge. During his 75-year career, Dr. Michael E. DeBakey (1908-2008) transformed cardiovascular surgery, raised medical education standards, and shaped national healthcare policy. He pioneered dozens of operative procedures such as aneurysm repair, coronary bypass, and endarterectomy, which routinely save thousands of lives each year, and performed some of the first heart transplants. Dr. DeBakey’s inventions included the roller pump (a key component of heart-lung machines) as well as artificial hearts and ventricular assist pumps. He was a driving force in building Houston’s Baylor University College of Medicine into a premier medical center, where he trained several generations of top surgeons from all over the world.Dr. DeBakey played a central role in the establishment of the National Library of Medicine (NLM). He was a visionary supporter of the institution, serving two terms as chairman of its Board of Regents and actively participating in many of its programs, from the establishment of the National Network of Libraries of Medicine in the 1960s to launching NLM outreach initiatives in the 1990s, and promoting the digitization of its indexes to pre-1960s journal articles.Figure 1).Dr. DeBakey valued a well-rounded approach to medicine. During World War II, when he was serving as a surgical consultant to the Army Surgeon General’s Office in Washington, DC, he spent countless hours in the Army Medical Library (AML), gaining an appreciation for its collections as well as its tenuous and fraught circumstances as an underfunded, often neglected part of the Army Medical Department. After the war, Dr. DeBakey was appointed as an honorary consultant to the AML, and, in this capacity, he presented a detailed analysis of the library’s status  and John F. Kennedy (Democrat from Massachusetts) to draft legislation for a National Library of Medicine as part of the US Public Health Service. The senators introduced the bill in March 1956; with a push from Dr. DeBakey, it made it to the senate floor for a vote, and the National Library of Medicine Act was signed into law by President Eisenhower on August 3, 1956.Figure 2). One of the first orders of business was establishing a home for the new library, a challenge Dr. DeBakey took on with enthusiasm. The pros and cons of about 10 locations were discussed, and as part of the following meeting one month later on April 29, most of the regents went on a bus tour of several of the locations.The first NLM Board of Regents met in March 1957, with Dr. DeBakey as an appointed member .After much debate, the Board agreed with Dr. DeBakey’s proposal and selected the NIH campus as the home of the new NLM. In 1959, the Board of Regents Chairman appointed Dr. DeBakey to serve on a working group to consult about the design of the new building, and less than 3 years later, in January 1962, the NLM opened to the public. Dr. DeBakey continued to serve on the board for many years, in two separate tenures. A few years later, expressing this appreciation of the NLM and other medical libraries, Dr. DeBakey stated: “Our libraries are our most valuable and precise link between generations and between people working in many areas. We must protect them at any cost.”3 Five years on, these programs have successfully carried forward, preserved, and made widely known the dynamic legacy of Michael E. DeBakey.In February 2016, the NLM received a generous gift from The DeBakey Medical Foundation to support development, expansion, and enhanced public access to the library’s collection of Michael E. DeBakey papers and to develop related programs in the history of medicine, specifically the NLM Michael E. DeBakey Fellowship in the History of Medicine. The gift also supported free videocasting and permanent archiving of NLM History Talks so they could be widely appreciated.4 The collections include papers of Michael E. DeBakey himself, reflecting the expanse of his life, achievements, and interests as a world-renowned medical statesman, innovator, and champion of humanitarianism and life-long learning.Launched in April 2016, the NLM Michael E. DeBakey Fellowship in the History of Medicine provides selected individuals with up to $10,000 to support onsite research in the collections of the NLM, which span ten centuries, encompass a variety of digital and physical formats, and originate from nearly every part of the globe.Circulating Now. Understandably, the COVID-19 pandemic has impacted the fellowship, and the NLM expects flexibility in scheduling future visits of fellows when it reopens to support onsite research. In the interim, library staff are available to provide reference support and planning for onsite research.The fellowship is administered on behalf of the NLM by the Foundation for Advanced Education in the Sciences (FAES). Through this partnership, the NLM and FAES operate the fellowship on an annual cycle with calls for applications each spring, application deadlines each fall, and announcements of fellows each winter. FAES receives applications to the fellowship program through a dedicated online portal. Staff of the NLM History of Medicine Division and the Office of NIH History review submitted applications based primarily on the viability of the research plan, including its scholarly rigor and extent to which it engages NLM’s collections, as well as the feasibility of the plan given the proposed budget. Fellowships are awarded to individual applicants, not to institutions, to help offset the costs associated with visiting and using the NLM historical collections. Anyone over the age of 18, of any academic discipline and status, who has not previously received the Fellowship, is eligible. Non-US citizens may apply. On average, the NLM has named four fellows annually. Fellows are expected to make at least one in-person visit to the NLM to undertake their historical research projects during the calendar year following their selection. Fellows are also required to author at least one guest blog post, based on their research, for the popular blog of the NLM History of Medicine Division, Figure 4). This international and multidisciplinary cohort of women and men at various stages of their careers has produced an impressive and measurable body of research work encompassing five scholarly books, four articles, and 16 essays on Circulating Now, which have been collectively viewed over 25,000 times.5Since the launch of the NLM Michael E. DeBakey Fellowship in 2016, nearly two dozen individuals have been named to the fellowship (NLM DeBakey Fellows have published on a diversity of subjects ranging from the evolution of modern surgery to the development of medical libraries and medical librarianship to the interplay between health care and urban economies. They also have produced a global history of civilian internment during wartime, the first biography of Dr. DeBakey himself along with various detailed studies of his surgical techniques and innovations, a history of the internationalization of medical education, and a study of how doctors’ wives transformed American medicine and the evolution of wartime bacteriology and wound care.https://videocast.nih.gov/PastEvents?c=221. Notably, beginning in 2021, all NLM History Talks incorporate American Sign Language interpretation. Support for this expanded access to NLM History Talks is made possible in part through a gift to the NLM from the DeBakey Medical Foundation.The library presents an annual NLM Michael E. DeBakey Lecture in the History of Medicine, which complements the NLM Michael E. DeBakey Fellowship in the History of Medicine and further expands public awareness of Dr. DeBakey and his appreciation of well-rounded careers built on both scientific and humanistic understanding. Delivered by a selected fellow, the NLM DeBakey Lecture is a cornerstone of the NLM History Talks program, which promotes awareness and use of NLM and other historical collections for research, education, and public service in biomedicine, the social sciences, and the humanities. All NLM History Talks are livestreamed globally by NIH Videocasting, closed-captioned, permanently archived, and freely available at Circulating Now have been read more than 6,500 times. This data, along with that associated with the posts authored by NLM DeBakey Fellows themselves, offers a quantitative measure by which these initiatives overall have raised public awareness of the name and legacy of Dr. DeBakey.Together, the first five annual NLM Michael E. DeBakey Lectures, from 2017 through 2021, have been viewed more than 1,500 times, and their associated posts on The NLM Michael E. DeBakey Fellowship in the History of Medicine and its related initiatives are carrying forward Dr. DeBakey’s principles and practices of weaving science, technology, and the humanities to form a holistic understanding of the human condition, inspiring an ever-growing cohort of scholars to embrace his perspective by pursing well-rounded careers built on both scientific and humanistic knowledge. In stewarding this program and the legacy it represents, and no less the papers of Michael E. DeBakey himself, which document his life and career, the NLM is advancing the study of history with heart—and impact.


Recent years have brought multiple crises and global challenges to light: financial hardships, economic crises, climate change, the COVID-19 pandemic and, most recently, the war in Ukraine (to name a few). These crises are connected to biopsychosocial and societal burden, and their management requires resilient, collaborative and positive governance in a global community. The crisis management cycle identifies preparedness, response, recovery and mitigation as important stages of dealing with crises.As prevention scientists, practitioners and policy-makers, we ask ourselves how we can contribute to this process. Naturally, prevention and health promotion are connected to the preparedness of populations as they strengthen resources and build resilience. Prevention also plays a role in response, recovery and mitigation, for example by supporting adaptive coping skills, providing psychoeducation and promoting health behaviors.Moreover, these crises are an opportunity for learning and development in our discipline. As prevention professionals, we are aware of the enormous human suffering and the potential for additional environmental harm, but we also aim to create opportunities for positive and sustainable change. Reducing physical and often also social contacts during the COVID-19 pandemic, for instance, led to innovative digital solutions and digitalized behavior change interventions to support communication, health, and healthy relationships across physical distances. The field of prevention science was forced to think about new ways to interact, conduct research and implement and evaluate interventions.As another example, the shared concern about climate change fosters new opportunities for multi-sectoral cooperation and interdisciplinary and global action, for instance, in international working groups on prevention, public and mental health, cross-continental research projects and calls to action. The most recent crisis, the war on Ukraine, reveals the potential of global digital communities and their impact on social support and the prevention of violence, crime and hate. Taken together, these challenging times tell us a lot about the human condition, from extraordinary strain to exceptional bravery and endurance.What have we, as prevention professionals, learned from these crises for our personal and professional lives, and what implications do we see for the field of prevention science?How has prevention science helped us to foresee, respond, recover, and mitigate, and how can we improve the contribution of prevention science not only on an individual but also a social, societal and even global level in the critically decisive years to come?How can research on the effective ingredients of interventions and policies be applied to rapidly emerging challenges and problems, i.e. how can we contribute to the resilience of our cultures, societies and families under immediate stress or even threat?Which directions is prevention science going in, and how are more traditional approaches and topics like individual health behavior change, and substance use, connected to global issues , policies and communities?Best practices and lessons learned from these events are also among key questions of the European Society for Prevention Research (EUSPR) in its journey with the Journal of Prevention. As a society for prevention scientists, practitioners and policy-makers across Europe, we want to explore, innovate, and improve the reach and impact of prevention from a cross-sectoral, cross-cultural and interdisciplinary perspective, for instance by preserving mental health, fostering positive and healthy youth development, and creating nurturing, sustainable and safe environments. With regards to current crises, the EUSPR asks:These are some of the questions that we would like to invite you to investigate, reflect on and discuss with us in the Journal of Prevention. Apart from these topical discussions, the Journal of Prevention also covers focused research on risk and protective factors, health and risk behaviors, determinants and etiology of positive and negative individual and social health outcomes as well as the development, implementation and evaluation of preventive interventions or local policies, the synthesis of evidence , and debates on current and future directions in the field. Together, we want to examine the current state of the art of prevention science and practice, develop and discuss ways forward into an increasingly cyberphysical future, and create sustainable networks of scientists, practitioners and the public for the future or prevention science – in Europe and beyond.COVID-19 has taught us how many lives can be lost due to misinformation, pseudoscience and inefficient narratives and false claims about science. This is why the Journal of Prevention will keep high standards on what we shall call “effective” or “promising” interventions but also give space to debates on upcoming topics, and a forum for those who work in applied prevention so that the practical relevance and the concrete usefulness of prevention sciences can be explained and communicated as well.One of the first messages we received from our Ukrainian colleagues in the first days of the attack on Ukraine was an appeal to help them get their children out of the country into safety. The same happened when the Spanish democracy was attacked in 1936. It is an intrinsic and innate feature of human nature to first worry and think about the safety and wellbeing of children. And this is our mission and driver: the prevention sciences can provide the ideas for action, tools and necessary innovation for everybody to be able to offer a livable future to their children, with and without the help of technology. If the Journal of Prevention succeeds in communicating this clearly and understandably, we can make a positive and optimistic contribution to our societies’ resilience in this gloomy period.Finally, the researchers, practitioners and policymakers gathered in EUSPR have a need for meeting each other to exchange experiences and challenge each other’s studies in forum and debate, following the pandemic. The Journal of Prevention is for this society an opportunity to document, sustain and further disseminate these debates, implying a robust upgrade of the academic discourse on prevention in and beyond Europe. We invite you to share and contribute.The Board of Directors,European Society for Prevention Research (EUSPR).https://euspr.org/.


Background: The outbreak of novel coronavirus disease 2019 (COVID-19) has led to tremendous individuals visit medical institutions for healthcare services. Public gatherings and close contact in clinics and emergency departments may increase the exposure and cross-infection of COVID-19.Objectives: The purpose of this study was to develop and deploy an intelligent response system for COVID-19 voice consultation, to provide suggestions of response measures based on actual information of users, and screen COVID-19 suspected cases.Methods: Based on the requirements analysis of business, user, and function, the physical architecture, system architecture, and core algorithms are designed and implemented. The system operation process is designed according to guidance documents of the National Health Commission and the actual experience of prevention, diagnosis and treatment of COVID-19. Both qualitative (system construction) and quantitative (system application) data from the real-world healthcare service of the system were retrospectively collected and analyzed.Results: The system realizes the functions, such as remote deployment and operations, fast operation procedure adjustment, and multi-dimensional statistical report capability. The performance of the machine-learning model used to develop the system is better than others, with the lowest Character Error Rate (CER) 8.13%. As of September 24, 2020, the system has received 12,264 times incoming calls and provided a total of 11,788 COVID-19-related consultation services for the public. Approximately 85.2% of the users are from Henan Province and followed by Beijing (2.5%). Of all the incoming calls, China Mobile contributes the largest proportion (66%), while China Unicom and China Telecom are accounted for 23% and 11%. For the time that users access the system, there is a peak period in the morning (08:00–10:00) and afternoon (14:00–16:00), respectively.Conclusions: The intelligent response system has achieved appreciable practical implementation effects. Our findings reveal that the provision of inquiry services through an intelligent voice consultation system may play a role in optimizing the allocation of healthcare resources, improving the efficiency of medical services, saving medical expenses, and protecting vulnerable groups. In late December 2019, a cluster of pneumonia cases caused by a new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were firstly reported in Wuhan, Hubei Province, China , 4. As oGiven the situation of the COVID-19 pandemic, avoiding tremendous population visits to medical institutions and realizing remote healthcare consultation and triage of patients have become the important means to allocate healthcare resources optimally, which can contribute to the control of the pandemic indirectly. To date, one of the imperative tools that have not yet been fully explored is to employ information and communications technologies (ICTs) to support social distancing and quarantine, optimal healthcare delivery, and reduction of exposure and cross-infection for healthcare professionals and COVID-19 patients , 15. IntAccording to the analysis of voice messages of users, an artificial intelligence-based voice consultation system for COVID-19 can automatically identify health consultation questions of users from different distances and then provide specific answers and response opinions –20. As tAccordingly, to reduce the number of non-essential in-person visits at hospitals, lessening face-to-face contact among the healthy public, COVID-19 patients, and healthcare professionals, preserving already strained medical resources, increasing service capacity of medical institutions to screen suspected cases and deliver healthcare information, and eventually help reduce the spread of COVID-19, this study has developed and deployed an intelligent response system for COVID-19 voice consultation. The system would support the functions of collecting and analyzing information of users through intelligent inquiry and interaction with users, propose suggestions of corresponding mitigation measures based on the actual situations of the users, and screen suspected COVID-19 cases. According to our knowledge, this intelligent response system is one of the first tools developed and applied on a large scale for COVID-19 in China. The findings of the present study may play a helpful role in avoiding the frequent visits of healthy people to fever clinics, improving the utilization efficiency of medical resources, and preventing and controlling the COVID-19 infection among healthy people and medical practitioners.This study intends to design an intelligent response system for COVID-19 voice consultation, which can complete user self-assessment. When users access the system, the system will ask questions about the basic information of users. Through natural language processing (NLP) technology, it dynamically adjusts the follow-up questions that need to be confirmed according to the different options selected by the user and then give corresponding response opinions depending on actual situations, which can quickly screen out COVID-19 suspected cases and offer specific suggestions for further actions. Due to the incompleteness of online consultation, the system is not connected to any healthcare systems, once a COVID-19 case is suspected, she/he will be recommended to go to the nearest COVID-19 designated hospital for further confirmation and treatment immediately. To achieve the above functions, according to the requirements analysis of software engineering, the intelligent response system needs to meet the following items.Business requirements: Build an intelligent voice consultation system for COVID-19, users can complete self-assessment by accessing the system. For related workers, the chances of contact with other people should be minimized during the development, deployment, and application stages of the system.User requirements: Users only need to make a phone call to access the system. They can complete a self-assessment about COVID-19 without going to the hospital. Through real-time voice communication, individualized assessment results and suggested response measures are ultimately obtained.a) Remote deployment and maintenance: Given the high infectiousness of COVID-19, non-contact should be the first requirement of this system, and remote operation should be achievable at all stages from deployment to application of the system.b) Accurate speech understanding: Accurate and real-time speech understanding is a key to the successful application of this system. Minor mistakes in speech recognition and understanding may lead to severe errors.c) The intelligence of the system: Each epidemiological history and personal symptoms of user are different. Using a fixed process in all consultations is not appropriate, the system should be able to dynamically and intelligently adjust its contents based on the subsequent answers of user.d) Data statistics and analysis: Statistical analysis of data from system logs and routine operation can quickly identify characteristics of users and provide suggestions for improving the consultation framework, and it is also helpful for medical staff to conduct scientific research.Functional requirements:To meet the abovementioned requirements, the physical architecture of the system is designed as shown in System administrators can access the system backstage remotely through web and then design and adjust the consultation process and configure the relevant parameters of the system. To realize subdivided medical services, the web server is open with various application programming interfaces (APIs) and can also contact with a hospital information system according to actual business needs.It contains three parts: intelligent voice engine server, load balancing, and storage server. The speech engine completes interactive services, such as speech recognition, synthesis, and understanding. The system dynamically balances services through load balancing, and the recording storage server is used to store recordings of the users.Users can directly dial the phone number to access the soft-switching system. The soft-switching system interacts with the core module through the Session Initiation Protocol and transmits the data of the conversation process to the recording storage server simultaneously.The architecture of the system is shown in This layer adopts a soft-switching system to handle different types of incoming calls. It supports multiple pathways of access, such as telephone, email, short messaging service (SMS), and Web call.This layer is the core layer of the system. Key technologies, such as automatic speech recognition (ASR), prosody recognition, pragmatic analysis, and syntax analysis are employed, which can work together to achieve multiple rounds of dialogue with the system.The background business layer does not provide services directly to users, but it is open to system administrators to support related business.This layer is in charge of functions, such as user terminal management, outgoing and incoming call tasks management, call center control, API management, and security module, which provides services directly to users and engineers of system operation.Two samples were used in the present study. Firstly, sampling the voice signal, before training the model, it is necessary to sample the sound wave to convert the analog audio signal into a digital signal, which is convenient for the computer to process. This work was completed by using the following arguments: sample rate 8 kHz, bit depth 16 bit, and bit rate 128 kbps. After sampling the voice signal, Mel-scale frequency cepstral coefficients were employed to sample features of digital signals, which was able to achieve efficient modeling of the principles of the human voice, while reducing feature dimensions. Secondly, sampling the data set of speech recognition training. Before putting the speech recognition system into practical application, one of the biggest challenges is the accent problem. Actually, there are many accents in China, and the accents from different dialect regions are quite different . To dealThe core algorithm of this system is based on multiple rounds of speech recognition. The implementation process of the algorithm is shown in Complete the conversion of speech to text by constructing a speech recognition acoustic model based on long short-term memory (LSTM). Since voice is a typical timing signal, a recurrent neural network (RNN) has strong timing modeling capabilities and therefore is suitable for voice recognition. The LSTM model is a variant of RNN, which has three more gates: forget gate, input gate, and output gate. Compared to traditional RNN, LSTM can process a longer sequence of voice data through the combination of three kinds of controllers and achieve better voice recognition. LSTM has shown state-of-the-art performance on many tasks of speech recognition –25. To iht from the lower maxout LSTM layer is the input xt of the upper maxout LSTM layer. These Stacked maxout LSTMs networks have the power to combine the multiple levels or representations with flexible use of long-range context. The equations of the maxout LSTM layers are as follows:Maxout units can summarize a group of spatially neighboring neurons in a lower layer that is capable of achieving the property of local translation invariance. Specifically, output i, f, o, a, and c are the input gate, forget gate, output gate, cell input activation, and cell state vectors, respectively, all of which are the same size as the hidden vector h. Wci, Wcf, and Wco are diagonal weight matrices for peephole connections, G is the group size in the maxout unit.For the equations, σ is the logistic sigmoid function, and Dividing prosodic structure based on speech and text information, such as accent classification of prosodic words, pitch analysis of phrases at the boundary of prosodic phrases, and classification of tones at the boundary of intonation phrases.Based on text recognition, text phrase structure classification, short sentence type classification, and sentence category classification are performed.The information structure of phrases, the semantic inheritance relationship among dialogue rounds, and the topic of dialogue segments are analyzed.Classifying the speech act verbs firstly, and then categorizing the response type of this round of dialogue and confirming whether it is the trigger or response. In the wake of the classification, the adjacent pair category to which this round of dialogue belongs is investigated, and according to the source of the utterance, sentence category, or information structure, the corresponding answer type is determined.Based on the results of the pragmatics analysis and combined with the current logical nodes, the next logical node can be determined, and through speech synthesis technology, a new round of dialogue can be pushed to users.According to the actual experience of prevention, diagnosis, and treatment of COVID-19, and considering the guidance documents of the National Health Commission , this stIn this system, the epidemiological history includes four types. (1) People who have traveled or contacted history of the outbreak epicenters; (2) people who have been in contact with emerging epidemic areas announced by the government; (3) people who had close contact with suspected or confirmed COVID-19 patient(s); and (4) many people around occurred symptoms, such as fever, fatigue, cough, and sore throat. After completing the consultation, the system will automatically select an appropriate opinion from the four predefined guidelines to recommend to the user. The details of the guidance opinions are summarized in The system has been developed and put into operation since March 31, 2020. People in China can access the intelligent response system by dialing the telephone number 0371-96299.With the support of necessary hardware and software environment conditions, this system can be deployed remotely, docking with local telephone lines, and then provides voice consultation services. During the operation of the system, the status of the system can be monitored remotely, and the consultation process mentioned above can also be adjusted remotely, which can avoid on-site operation and maintenance, reduce human contact, and decrease potential exposure of COVID-19.The operation procedure of this system can be adjusted quickly and efficiently according to the actual needs, and nodes can be set up based on the original process. Functional modules, such as manual transfer and SMS distribution, can be added in if required, and the remote deployment of each procedure can be completed smoothly.The system can realize the statistical analysis of disconnection reasons, the dialogue data, consultation time, and geographical distribution of users. Based on the analysis, administrators can promptly identify and adjust the current existing or newly emerging problems of the system, which can help medical staff understand and count data in relation to COVID-19 well and then take more effective countermeasures.The security module is located in the basic service layer of the system, which includes the following functions: (1) metadata management: viewing and modifying the information, such as the type, description, security level, and operation authority of each field in the data table; (2) account management: through unified management of user accounts, to make the granularity of permission control as small as possible, meanwhile, set a validity period for the permissions, and automatically recover the permissions when they expire; and (3) log management: recording and auditing the logs of account management operation, permission approval, and data access operation. Based on these functions, the security module can help the system achieves effective protection of user privacy and information security.To assess the performance of the proposed intelligent response system, 100 h of telephone voice conversation from the 12,000 h corpus were extracted as the test dataset, and the comparisons of speech recognition performances of different models were conducted. The Gaussian Mixture Models and Hidden Markov Models (GMM-HMM) model was selected as the baseline model, while the KALDI toolkit was used to train the GMM-HMM model. The Stacked LSTMs model was chosen as the state-of-the-art model, in which three conventional LSTMs were stacked, and each layer had 750 LSTM cells. In the Stacked maxout LSTMs, three maxout LSTMs were stacked, each layer had the same configurations as Stacked LSTMs. These three models were evaluated based on the same dataset.Character Error Rate (CER) was employed to evaluate the different models. CER is a typical metric of the performance of the Chinese Speech Recognition System. Through comparing the output character sequence predicted by ASR with the correct reference character sequence, CER can be computed as:Where S, D, and I are the number of substitutions, deletions, and insertions, respectively, and N is the number of words in the reference.In terms of the test results listed in Since the intelligent response system was launched, the average number of user visits per day was 69 . As of SThe geographical distribution of the incoming calls users was analyzed . Total 8The proportion of different mobile operators among users was also investigated. There are three major mobile operators in China: China Mobile, China Unicom, and China Telecom. Of all the incoming calls of the system, China Mobile with the largest proportion, and its users were responsible for 66% , while China Unicom and China Telecom were accounted for 23%  and 11% , respectively .The time distribution that when users access the system for COVID-19-related voice consultation is shown in Based on ASR, text to speech, and NLP technologies, the present study developed and initiated an intelligent response system for COVID-19 voice consultation. The functions, performance, and application effect of the system were then investigated. To the best of our knowledge, this is the first time, from the provincial level real-world practice in China, that the comprehensive account of an intelligent response system for COVID-19 voice consultation was explored. The findings of the current study may provide a helpful reference for further regional, national, and even international actions against the COVID-19 pandemic.Coronavirus Diesease-2019 is a highly infectious disease, since the officially reported emergence of COVID-19 in Wuhan, China, the epidemic scale has spread rapidly, with cases arising across China and many other countries. As of February 14, 2021, in mainland China, 89,772 confirmed COVID-19 cases were reported across 31 provinces and municipalities, with 4,636 fatalities. The COVID-19 pandemic has sharply increased the demand for medical services and inevitably exceeded the maximum supply of healthcare facilities. In China, the socio-economic development gap between different regions is huge, and the distribution of medical resources is extremely uneven. For example, although 42.65% population of China lives in rural areas, ~80% of medical resources of China are concentrated in urban areas, two-thirds of which are in megacities . This geThe high levels of human-to-human transmission, asymptomatic infection, and long incubation period are the main reasons for the large-scale epidemic of COVID-19 , 35. If The intelligent response system proposed in the present study can analyze the information about consultation content of users and the response of the system. Then according to the specific situation of the users, the system dynamically provides targeted treatment opinions and action suggestions . This maRecurrent neural networks are networks with loops in them, allowing information to persist. LSTM is a special kind of RNNs, which can learn long-term dependencies. LSTM was firstly introduced by Hochreiter and Schmidhuber in 1997 and then was further developed and popularized by many researchers , 41. LSTIn the current study, the application of the intelligent response system can achieve effective triage of outpatients, reduce public gatherings, and help control the spread of the COVID-19 epidemic. Moreover, with the help of the system, users are able to visit the nearest hospital or fever clinic according to their specific symptoms and receive appropriate diagnosis and treatment in time. These findings are consistent with other similar studies , 46, 47.Our findings showed that 85.2% of the users are from Henan Province and followed by Beijing (2.5%), while for the time users visited the system, there was a peak period in the morning and afternoon, respectively. By analyzing the time and geographical distribution information of the calls of users, the system can summarize and conclude the characteristics and habits of users, which can help to optimize the allocation of medical resources and improve both the quality of healthcare services and user satisfaction. For instance, 8:00–10:00 am and 2:00–4:00 pm are the peak periods for user visits , during As one of the latest applications of artificial intelligence and ICTs in the battle with the COVID-19 epidemic, the intelligent response system for COVID-19 voice consultation proposed in the current study has both social and economic advantages. First, the system can triage and divert relevant healthcare needs of the public, thereby, alleviating the already shortage of medical resources. Second, the voice consultation services of the system can reduce the number of fearful people visiting the hospital, avoid frequent public gatherings in medical institutions, and decrease the exposure and infection risk of healthy individuals and medical staff. Third, based on the system, healthcare facilities can save and optimize the allocation of medical resources, and improve the efficiency, capacity, and quality of their services. Fourth, the system provides COVID-19-related consultation services through telephone and voice, which is appropriate and helpful for those who cannot read or use smartphones, and of course increases the coverage, acceptability, and adherence of the intelligent voice services. In addition, through advising healthy people to stay at home for isolation and observation, in addition to reducing unnecessary consumption of medical resources and the cost of healthcare services, the system can also help users avoid expenses due to hospital visits and related transportation and accommodation. The prevention and control of the COVID-19 pandemic are multifaceted, and the intelligent response system for COVID-19 voice consultation developed and applied in this study can undoubtedly play a helpful role in reducing public gatherings, preserving medical resources, increasing the service capacity of healthcare facilities, and eventually curbing the spread of COVID-19.Some limitations of the intelligent response system in practical applications also need to be acknowledged. Firstly, the intelligent voice service functions of the system are relatively simple. It can only provide suggestions in relation to the prevention and control measures of COVID-19 based on the consultation and feedback information of users, such as personal precautionary practices, self-monitoring of body temperature at home, fever clinic visits, early detection and quarantine, and COVID-19-designated hospitals treatment, which may hardly meet the additional healthcare needs of the users. Secondly, the system is designed and constructed mainly according to or adapt to the COVID-19 epidemic situations of Henan Province. Thus, the functions and contents of the intelligent voice service may not be perfectly suitable for the prevention and control of COVID-19 in other regions in China. This can be seen from the fact that the healthcare inquiries of the system were mainly concentrated in Henan Province. The plausible phenomenon suggests that to increase the coverage and capacity of the intelligent response system, there is a need to further enrich and improve its services in the future, or do some adaption and adjustment works whenever necessary, according to the actual situations and policies where it is used. Lastly, based on the epidemiological characteristics and personal symptoms, this intelligent response system can complete the preliminary screening of users and then make relevant suggestions and guidance. However, the system only provides information for the reference of users, the COVID-19 prevention and control recommendations are neither belonging to the medical category nor can they replace the hospital doctor's diagnosis and treatment. Further research and practice works are urgently needed to address these limitations.Given the general susceptibility, high prevalence, and wide distribution of COVID-19 across the world, substantial and various public health intervention and control measures involving social, economic, and healthcare sectors, especially the vital response arrangements based on the application and analysis of real-world data are continuously warranted. Based on NLP and modern ICTs, the present study designed and deployed an intelligent response system for COVID-19 prevention and control. Through identifying and analyzing the voice information of users, the intelligent response system realized functions, such as user-oriented intelligent inquiry, screening of suspected COVID-19 cases, and targeted recommendations of response measures, which achieved appreciable practical application effects. To further improve the efficiency and quality of prevention, diagnosis, and treatment of COVID-19, in the future, the improvement and application of the system should take the actual medical service activities of clinicians into consideration. For instance, through integrating different function models into the system to promote its versatility and then to increase the capacity of the system in the battle with COVID-19. Generally, in terms of the unprecedented the COVID-19 pandemic, the provision of inquiry services through an intelligent response system in this study plays a valuable role in optimizing the allocation of healthcare resources, improving the efficiency of medical services, saving medical expenses, containing the new pandemic, and protecting vulnerable groups.The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.JS, JG, JZ, and YZ conceptualized, designed, initiated the study, reviewed, and revised the manuscript. JS, JG, and YZ drafted the initial manuscript. MY, YL, XH, FC, and QM were involved in the development of methodology and discussion of the article structure. All authors have read and approved the final manuscript as submitted.This work was supported by the National Key R&D Program of China (Grant No. 2017YFC0909901), the Natural Science Foundation of Henan Province of China (202300410409), and the Joint Construction Project of the Henan Province Medical Science and Technology Research Plan (2018) (Grant No. 2018020120). The funders played no role in the design, development, or interpretation of the present work.The views expressed in the article are those of the authors and do not necessarily reflect the position of the funding bodies.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BACKGROUND: As endpoint of cohort studies on cancer, the incidence, rather than the mortality is preferable. Of 45 areas in the Japan Collaborative Cohort Study (JACC Study), surveys for incidence of cancer were conducted in 24.METHODS: The proportion of the study subjects aged 40 to 79 years in areas of survey for the incidence of cancer  was 58.2% of the total subjects of the JACC Study . Among the 24 areas of survey for the incidence of cancer (ASI), 10 areas were combined because of similarity. Then, we present the incidence rate of cancer among 15 ASI unified from the 24 ASI by gender according to area. We also report the completeness of the survey for cancer incidence presenting the mortality-incidence ratio (MI ratio) among the ASI.RESULTS: Where a population-based cancer registry was utilized, the MI ratio deviated from 0.31 to 0.61 in the male subjects and from 0.15 to 0.53 in the female subjects. However, where a population-based cancer registry was not used, the MI ratio deviated from 0.25 to 0.72 in the male subjects and from 0.13 to 0.79 in the female subjects, and there was an area where the MI ratio exceeded 0.70 in both of the male and female subjects.CONCLUSION: Establishment of population-based cancer registries is strongly desired throughout Japan to assess risk factors of cancer development for primary prevention of cancer. Because the established population-based cancer registries did not cover all of Japan,3 some of the ASI did not utilize these registries for identifying subjects with cancer. Where established population-based cancer registries were not available, hospital-based cancer registries or inpatient records of the hospitals treating cancer patients were used for identifying the subjects with cancer.As endpoint of cohort studies on cancer, the incidence, rather than the mortality is preferable, if risk factors have been assessed with regard to cancer development. Many cohort studies make use of existing routine surveillance systems of the incidence of cancer, such as population-based cancer registries, to ascertain the outcome of interest.4 presenting the mortality-incidence ratio by gender according to area among the ASI. We not only show the crude rates and the age-adjusted rates of cancer incidence, but those of cancer mortality by gender according to area among the ASI.We report here the number of the subjects with cancer as well as the completeness of the survey for cancer incidenceOur entire study design, which comprised singular and collective use of epidemiologic data and biological materials (serum only), was approved in 2000 by the Ethical Board at Nagoya University School of Medicine, where the central secretariat of the JACC study is located.Of 45 areas in the JACC Study, surveys for incidence of cancer were conducted in 24. Among them, 10 areas were located in the same prefecture in Kyushu, and were surveyed by the same institution, utilizing a population-based cancer registry. Consequently, we combined these 10 areas, and present the data of 15 ASI unified from the 24 ASI by gender according to area in As tools to survey for cancer incidence, population-based cancer registries were utilized in 11 out of the 15 ASI, and hospital-based cancer registries or inpatients’ records of hospitals treating cancer patients were used in the remaining 4 ASI. Although the tentative end of observation was in 1997 in 14 of the 15 ASI for this article, it was in 1994 in an area because of incidental interruption in the survey for cancer incidence, as shown in Excluding the subjects who had cancer before the baseline survey, we present the numbers of the study subjects, the dead subjects, the subjects dead who died from cancer, and the subjects with incident cancer during the periods of observation by sex according to area in 4,5 Ideally, completeness should be close to 100%, so that comparison of rates among areas will reflects true differences in the risk of cancer and not artifacts of the survey process. Generally, however, most ASI would have the possibility of incompleteness due to failure to identify and include incident cancers. Completeness is assessed by measuring the percentage of the subjects with cancer identified from the death certificate only (DCO%), the percentage of the subjects with cancer first notified via death certificate (DCN%), and the mortality/incidence ratio (MI ratio). Although the DCO% and the DCN% could not be estimated because of lack in relevant information, the MI ratio was evaluated as shown in Completeness of survey for incidence of cancer is defined as the extent to which all the incident cancers occurring in a target population are included for the study subjects.5 of incident cancers. As shown in If the MI ratio exceeds 0.70, it is usually a signal of under-registration67 standardized to the 1985-model Japanese population.8 The age-adjusted rates of cancer incidence varied from 344.14 to 1187.97 in the male subjects and from 216.83 to 597.00 in the female subjects. Likewise, the age-adjusted rates of cancer mortality varied from 95.66 to 607.64 in the male subjects and from 33.89 to 265.55 in the female subjects.Cancer incidence varies strongly with age. Hence, standardization of age increases the ability to compare rates of cancer among different areas by distribution of age.9 standardized to the 1985-model Japanese population,8 as well. As a result, the age-adjusted rates of cancer incidence were 751.21 and 429.77 per 100,000 in Japanese males and females, respectively. Consequently, the medians of the age-adjusted rate of cancer incidence in the males  and the females  of the 15 ASI were very much close to the above figure.For comparison to the whole Japanese population, we calculated the age-adjusted rate of cancer incidence with reference to the data for age-specific rates of cancer incidence for those aged 40 to 79 years in 1993 in Japan,10 standardized to the 1985-model Japanese population,6 as well. As a result, the age-adjusted rates of cancer mortality were 436.08 and 204.42 per 100,000 in Japanese males and females, respectively. Accordingly, the medians of the age-adjusted rate of cancer mortality in the males  and the females  of the 15 ASI were slightly lower than the above figure. Because the study subjects were not only selected from the participants of health check-up program in some areas, but also they were probably liable to examine their symptom at medical institution, earlier detection and treatment might cause relatively higher rate of cancer incidence and lower rate of cancer mortality among them.Similarly, for further comparison to the whole Japanese population, we calculated the age-adjusted rate of cancer mortality with reference to the data on age-specific rates of cancer mortality in persons aged 40 to 79 years in 1995 in Japan,6 That is, mortality rates do not meaningfully reflect incidence rates, especially, in cancers with a favorable prognosis like skin, thyroid, breast, and prostate cancer.Because death registries are available in the whole areas of the JACC Study, most of the previous reports of the JACC Study made use of the cancer mortality for the outcome. However, it is well known that mortality rates depend on prognosis or survival.6 However, only 58.2% of the study subjects were involved in the ASI of the JACC Study, and considerable variations were observed in the MI ratio of the survey for incidence. Therefore, the findings from the results of analysis of the subjects with incident cancer should be reported with the MI ratio of Incidence rates provide the clearest measure of the burden of carcinogenic exposures at the population level.The present investigators involved, with the co-authorship of this paper, in the JACC Study and their affiliations are as follows: Dr. Akiko Tamakoshi (present chairman of the study group), Nagoya University Graduate School of Medicine; Dr. Mitsuru Mori, Sapporo Medical University School of Medicine; Dr. Yutaka Motohashi, Akita University School of Medicine; Dr. Ichiro Tsuji, Tohoku University Graduate School of Medicine; Dr. Yosikazu Nakamura, Jichi Medical School; Dr. Hiroyasu Iso, Institute of Community Medicine, University of Tsukuba; Dr. Haruo Mikami, Chiba Cancer Center; Dr. Yutaka Inaba, Juntendo University School of Medicine; Dr. Yoshiharu Hoshiyama, Showa University School of Medicine; Dr. Hiroshi Suzuki, Niigata University School of Medicine; Dr. Hiroyuki Shimizu, Gifu University School of Medicine; Dr. Hideaki Toyoshima, Nagoya University Graduate School of Medicine; Dr. Shinkan Tokudome, Nagoya City University Graduate School of Medical Science; Dr. Yoshinori Ito, Fujita Health University School of Health Sciences; Dr. Shuji Hashimoto, Fujita Health University School of Medicine; Dr. Shogo Kikuchi, Aichi Medical University School of Medicine; Dr. Akio Koizumi, Graduate School of Medicine and Faculty of Medicine, Kyoto University; Dr. Takashi Kawamura, Kyoto University Center for Student Health; Dr. Yoshiyuki Watanabe, Kyoto Prefectural University of Medicine Graduate School of Medical Science; Dr. Tsuneharu Miki, Kyoto Prefectural University of Medicine Graduate School of Medical Science; Dr. Chigusa Date, Faculty of Human Environmental Sciences, Mukogawa Women’s University ; Dr. Kiyomi Sakata, Wakayama Medical University; Dr. Takayuki Nose, Tottori University Faculty of Medicine; Dr. Norihiko Hayakawa, Research Institute for Radiation Biology and Medicine, Hiroshima University; Dr. Takesumi Yoshimura, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan; Dr. Akira Shibata, Kurume University School of Medicine; Dr. Naoyuki Okamoto, Kanagawa Cancer Center; Dr. Hideo Shio, Moriyama Municipal Hospital; Dr. Yoshiyuki Ohno, Asahi Rosai Hospital; Dr. Tomoyuki Kitagawa, Cancer Institute of the Japanese Foundation for Cancer Research; Dr. Toshio Kuroki, Gifu University; and Dr. Kazuo Tajima, Aichi Cancer Center Research Institute.


According to the World Health Organization (WHO), in June 3, 2021, there were 171,292,827 confirmed coronavirus disease (COVID-19) cases and 3,687,589 deaths. In addition, by June 2, 2021, a total of 1,581,509,628 vaccine doses had been administered worldwide , creates a predictable interval of three to four months that allows the resumption of the various activities as well as the economy of these locations, enabling companies and governments to plan within this new productive context.However, some nations and regions insist on another type of social isolation, the partial lockdown, which, unfortunately, has a greater permissiveness that produces a slight effect on the incidence, as part of the population adheres to the process, although the majority, mainly the denialists, do not comply with restrictive and protective measures such as the use of masks, prohibition of mass gatherings (parties), and others .The problem with this process is the impossibility of planning the economic recovery by the authorities  and companies because of the incidence of cases and deaths remaining in continuous flow, as in Brazil, with no quantitative reduction that allows the return of general activities in adequate safety conditions, for example, the resumption of schools for face-to-face classes.This type of measure may please companies and politicians, as it allows the economy to be in apparent operation. However, there is no way for certain segments to continue, especially if involving mass gathering, as they can generate unprecedented growth in the incidence, as has occurred in Brazil in the current context, after the various holidays at the end of the year and reduction of preventive measures adopted by some localities.p-value<0.0001, corroborating the hypothesis that non-pharmacological measures, including social distance, are fundamental for the protection of people and for the resumption of the economy.The United States  adopted In this sense, we realize the inexistence of the paradigm that national economies can fail because of the lockdown , althougUnfortunately, we need to reinforce the issue that preventive measures are important and that they do not lead to the collapse the economy if properly coordinated by the authorities.Economic collapse can occur because of the uncontrolled growth of the disease without producing herd immunity. However, the development of more contagious and lethal variants, in addition to the expenses that could be avoided, such as the treatment of patients and deaths, purchasing equipment and supplies, and days of not going to work, might not exist if there was an effective national public health policy to combat this disease.All authors affirmed that they contributed to the development of the manuscript. Fujita DM designed the study, collected data, and wrote and edited the manuscript. Nali LHS designed the study, collected data and discussed the results. Salvador FS contributed to the investigation, methodology and manuscript review. Luna EJA performed the analysis and reviewed the manuscript.


The last and corresponding author Saeed Amini is affiliated with institutions 4 and 5, as shown in author list of this Correction, and not with institutions 3 and 5, as initially shown in the original article.Furthermore, institution 4 is the Department of Health, Khomein University of Medical Sciences, Khomein, Iran, as shown in the “Author details” section of this Correction, and not the Department of Health Services Management, Khomein University of Medical Sciences, Khomein, Iran, as initially shown in the original article.Following the publication of the original article , it was The original article has already been corrected as above.


We share with great sadness that our long-time friend and colleague Prof. Dr. Hans-Dieter Klenk passed away on 1 June 2021, at the age of 82. With the passing of Hans-Dieter Klenk, the worldwide virology and infectious disease community is losing one of its most eminent representatives who has shaped the scientific landscape of these disciplines for decades.Hans-Dieter Klenk studied medicine and biochemistry in Tübingen, Vienna and Cologne. From 1967 to 1970 he started his outstanding scientific career as a visiting scientist in the laboratory of Purnell W. Choppin at the Rockefeller University in New York. In 1973, back in Germany, he was appointed as a Full Professor in Virology at the Justus Liebig University of Gießen, and in 1985 he became the Chair of the Department of Virology at the Philipps University of Marburg. He held this position until his retirement in 2007. It did not come as a surprise to any of his colleagues, friends and family, he continued to serve science in many ways until his death.Prof. Dr. Klenk has decisively shaped Germany’s virology with a strong international orientation and visibility. Under his leadership, numerous scientists not only had the opportunity to develop their own scientific careers, but were also appointed in leading positions at national and international institutions in academia, industry and government. He used the power of new molecular, genetic, biochemical, and cellular methods to study viruses and identify the functions of their specific genes and proteins. Directly associated with the name Hans-Dieter Klenk is the very successful research work on influenza viruses, in particular the role of the surface protein hemagglutinin in the pathogenesis of influenza infections. In addition, other zoonotic viruses that threaten public health as emerging viruses, such as Ebola, Marburg and Lassa viruses, were of great interest to him. He founded the BSL4 laboratory in Marburg and gave the Department of Virology a completely new infectious disease research direction, which has been highly successful and competitive and is still very actively pursued today.Prof. Dr. Klenk served as the president of the German Society for Virology from 1999 to 2005. He has been the vice-president of the von Behring-Röntgen-Stiftung, Gießen-Marburg, since its foundation. He coordinated numerous scientific consortia, including the highly successful Collaborative Research Center SFB 286 of the German Research Foundation (DFG), and was active on editorial boards of multiple scientific journals with specific involvement in the establishment of the journal Emerging Microbes & Infections (EMI). He served as an advisory board member for many scientific institutions including but not limited to the Georg-Speyer-Haus, the Feldberg Foundation for Anglo-German Scientific Exchange, the Institute Pasteur of Shanghai, and the Institute of Medical Microbiology, Fudan University. After his retirement, he specifically invested time supporting Chinese virologists in collaboration with leading scientists in China.Hans-Dieter Klenk was an intellectual leader in his field, in the pantheon of virologists, for many decades. He has received numerous highly respected scientific prizes for his work, among those the Robert Koch Medal, the Ernst Jung Medal for Medicine and the Emil von Behring Prize. In addition, he was awarded the Grand Cross 1st class of the Order of Merit of the Federal Republic of Germany in 2018.His death weighs heavy on our hearts and minds as we all will miss this outstanding and visionary scientist, this strong and commanding leader, this supportive and respectful mentor and advisor, and this straightforward, humorous, and generous person that he was until the very end.Our deepest and sincere sympathy goes out to his wife Ulrike, their three sons Christoph, Philipp, Alexander, and the entire extended Klenk family.Our sincere gratitude to Hans-Dieter Klenk whose science and personality has shaped our careers and lives.