For a Radical Renewal of Democracy in Hospitals
Contributor: Patrick Martin
Editors’ note: Thank you to author Patrick Martin for contributing this further reflection on his article co-authored with Louise Bouchard, that appeared in ANS 43:4, October/December 2020, p. 306-321 (doi: 10.1097/ANS.00000000000003220)
The staff nurses, who gave us an interview in the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study,” recently published in Advances in Nursing Science, have felt left out of decision-making processes that prevail in hospital centers, even if decisions arising from them have a direct impact on the way in which they work. It should be noted that staff nurses who practice in hospital centers represent most of the nursing workforce. The same observation emerges from one of our research projects that is still ongoing, conducted with nurses working in different sectors of specialty care (clinical nurse specialists, pivot nurses, specialized nurse practitioners [SNP], etc.).
This situation, which is eerily similar to the one experienced by the subordinate citizen, systemically left out of places associated with the exercise of power, appears consistent with the broad trends our contemporary oligarchic societies are taking under the aegis of world governance and market globalization. Our results suggest overall that the hospital democracy is increasingly confined to hospital boards of directors and to instances in which usually nurses do not have access. In the words of some participating nurses, these instances would themselves be submitted to a strict hierarchy of command, itself dependent on guidelines, particularly ministerial directives, which would considerably affect overall positions taken by hospital centers. It should be noted that our research is taking place in Canada; our health care system is certainly a public one, which connects, however, to an entrepreneurial-style governance model that leaves more and more room for the private sector and is advocated in all care settings, a clear separation between decision makers and “implementers”.
Based on our research results, the nurses who stand out for their commitment are thereby mostly confined to instances that only have the powers of recommendations, such as the hospital councils of nurses (CN). Participation in instances where access is “open” to nurses was otherwise associated by some participants with strategies put in place by the hospital authority to ensure nurses deploy their energy with no success to make any changes whatsoever happen in constraints they live in their daily practice. Even the parity committees[1] within which union representatives have the opportunity to talk with the employer are perceived as being marginally effective for eliciting to improve conditions under which nurses work.
Although these instances may appear a priori as great opportunities to promote nurses’ interests to the employer for concrete changes can be made in work organization, the perceptions of those interviewed with access to these committees as union representatives are no way going in this sense. These testimonies rather suggest that, even within these instances, numerous techniques would be deployed by the employer in a way to paralyze the dialogue with the union and to push dispute settlements, which we think has the effect of accentuating the separation between decision makers and implementers, already very much present in hospital centers. The fact of constantly changing interlocutors with which the union must find common ground would be leveraged in many backgrounds; this context among these techniques sometimes has the effect of significantly pushing some grievance settlements, the delays may spread out more than one year. If, according to some participating nurses, this is the constant turnover of managers, which would be the source of these delays, the fact remains that the current situation benefits the employer, even if the phenomenon is not necessarily a planned strategy.
When acting for change, the Slovene philosopher Slavoj Žižek(2008a), who is very interested in political action, states that it is important to question ourselves about the possibility of efforts deployed to cause the reproduction of dominant discourse, as it would be the case when nurses are investing time and energy in committees bringing very little outcomes, the hospital governance by far prefers seeing them running around in circles in some frivolous proceedings rather than noting they organize themselves concretely to resist the hospital authority. Žižek will specify in these situations that it is sometimes better to do nothing rather than try to act the wrong way to transform the status quo. Not cooperating in the functioning of the hospital framework by refusing participation in these proceedings – of what, from the point of view for a lot of nurses who participated in our research, in no way enable to improve their situation – would thus become, in itself, an act of resistance.
Results from the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” revealed as well that decisions are usually made in accordance with decision-making processes in hospital centers, always consistent with interests of small influential groups. Participants on numerous occasions made reference to staff nurses in their discourse, but also to link nurses who, based on tacit knowledge, the one marginalized by the good governance doctrine, had warned institutions relative to decisions, many of which would achieve savings that have proven to be serious errors. Decisions even resulted in the death of many patients.
Our results suggest in addition that ideas from nurses are usually taken into account only when they are able to demonstrate they are in fact the partners “of those who play the game of the good governance” [free translation] (Deneault, 2013, p. 41). The nurse who sees herself complimented by a manager after having proposed, through a corporate website promoting innovation, that her colleagues bring their own toilet paper to workplaces for achieving savings, is a disconcerting example of this fact.
What Good is it?
A number of participating nurses encountered in studies and questioned relating to their commitment and the registry for political actions from nurses asked us if we really thought that it was possible to “change things”, with respect to the practice of the contemporary nursing profession in different backgrounds. The situations, described and criticized by them, have effectively come to our mind the most desperate throughout data collections, many participants indeed having openly admitted to us not believe in the possibility of making favorable changes happen to conditions for exercising the nursing profession, more particularly in the hospitals. As Žižek(2012) who, in a lecture given in Toronto, emphasized being regularly confronted with similar questions relating more specifically to pessimistic representations made of the state we find the world we are living in today, we responded to these participating nurses not being exactly sure it is possible to “change things”. And definitely we still have no certainty. Although many are likely to believe that things cannot change, paradoxically, however, we can only see the hectic pace at which, right now, they are changing radically, in both different care settings and our advanced capitalist society.
Not only in capitalist dynamics, but also in all spheres of life, things are in fact already changing automatically to a hectic pace. The very nature of sociability, of what constitutes a human being is as well shifting now and, if we let these changes be deployed passively – the same is true for the comparison to care –, it is expected that we will be heading towards an articulation of the society,[2] which is going to be characterized by a new form, permitted and perverse, of authoritarianism (Žižek, 2012). For Žižek, with whom we are in agreement on this, things are thus already changing to a hectic pace and that has to give us the motivation to act concretely to ensure these changes are getting a foothold in the sense of what we want, consistent with what nurses do. If Žižek postulates we are living the end of the world as we knew it, we also believe that we are witnessing here the end of care settings as we understood them, and sort of – to the end of the nursing professional practice as we knew it. Thereby drastic changes occurred, are happening and will continue to occur and it is expected that these are going to happen in a way even more authoritarian, arbitrary and perverse, because everything seems now okay in the name of the triumphant economy, and these ways of doing things in our societies necessarily affect care settings.
It is not a matter for staff nurses to foolishly accept these changes that will continue to occur quickly, but for them to reflect on what they can do to direct/influence these as well, certainly in a sense which would be salutary to them, but more particularly so we have some humanity. Nurses could also refuse categorically these changes – or some of them –, just as they can propose new ways of looking at the nursing professional practice – and they do so increasingly. And to those who believe that no change is possible because small groups disallow any transformation to the social order, Žižek(2012) unequivocally responded it is wrong to think there is only one social class governing and manipulating what is going on. According to Žižek(2012), reality is in fact more complex, certainly disconcerting, but with no way out – because those who are standing at the top of hierarchies are as well constantly destabilized by this ever-changing world and have enormous difficulties adapting to it. They are thus always improvising, definitely with a lot of means, to promote the maintenance of their hegemonies – hegemonies which, in all of this improvisation are necessarily much more fragile than we would like us to believe. As nurses, as a group, it is extremely important to become aware of this fact, which in regard to what we experienced as a society with the COVID-19 pandemic in the last year, looks absolutely undeniable.
In accordance with the writings of philosopher Rancière (1991, 1999), we refuse, however, to position ourselves in the expert role – a posture which remains anti-emancipatory – or in the Sartre’s trend of the intellectual, by dictating to nurses how they should act to cause the desired transformations to the nursing professional practice. But we feel strongly, consistent with what Gene Sharp (2012)[3] wrote, the power exercised in a hostile way, particularly by the governance of major hospital institutions, must be thwarted by an equal or greater nurses’ collective strength, without which the policies associated with it will continue to be imposed on them. To direct in the sense which is salutary to them, but also so we have some humanity, the societal changes affecting the nursing practice, we believe as well that there is no point for nurses to set off on a crusade against capitalism even if as a group, they and patients to whom they are giving care suffer enormously from collateral effects of this socio-political way of organizing we have. As Žižek (2008b) reminds it, this reflex obsessing the “old left” (p. 29) is not conducive, especially in the way in which the reality of today’s capitalism is structured, namely from a globalized manner where it becomes, for all practical purposes, impossible to have a grip on the ongoing transformations this ideology imposes to our existences.
Like Rancière (2014) and Žižek(2012), we think it is in the radical renewal of democracy in our societies and institutions as citizens, we must deploy our energies and concrete actions, actions that will do harm to the powers-that-be and destabilize oligarchs who have literally appropriated our democracies. It is in this sense, without telling nurses what to do, but we believe it is relevant to move towards a radically renewed hospital democracy[4] as the ultimate central purpose to which their collective actions must be structured, but also their individual ones, because it is always preferable to act on several fronts. Maybe that, starting from these concerted collective and individual actions in the thoroughness of everyday living, nurses will cause the establishment of a new balance of power and they finally have the opportunity to debate on the direction that must take the nursing practice – which, need we remind is essential to life.
Deneault, A. (2013). Gouvernance : le management totalitaire. Montréal : Lux Éditeur.
Rancière, J. (1991). The Ignorant Schoolmaster: Five Lessons in Intellectual Emancipation. Stanford : Standford University Press.
Rancière, J. (1999). Disagreement : Politics and philosophy. Minneapolis : University of Minnesota Press.
Rancière, J. (2014). Hatred of Democracy. Brooklyn : Verso.
Sharp, G. (2012). Sharp’s dictionary of power and struggle : language of civil resistance in conflicts. New York : Oxford University press.
Žižek, S. (2008a, January). Violence. Paper presented at: the London Review Bookshop, London, United Kingdom.
Žižek, S. (2008b). Violence : Six Sideways Reflections. New York : Picador.
Žižek, S. (2012, September). Until the end of the world. Paper presented at: Toronto’s Nuit Blanche Symposium, Toronto, Canada.
[1]Given our results, the grievances of nurses can be expressed and tolerated only when they – through their representatives – are invited expressly to do so by their superiors, particularly during these parity committees.
[2] By describing this new entity of new perverse permissively authoritarian society, which will be most rigid but, in a new way, Žižek(2012) prefers not to make reference to what some people are calling a new form of fascism, because he considers that those who use this term do it because they are too cowardly to think what is really new in these ways of doing things. The term “management totalitaire”, used by Deneault (2013), appears to us, however, as a key concept to describe this new articulation of our societies.
[3] Note that these writings of Sharp (2012) do not specifically refer to the nursing reality.
[4] We think at the same time nursing actions must also be directed so we have some radical renewal of democracy in our societies because it appears unlikely that a renewal so radical of the hospital democracy is done without much larger reflections, at the societal level, isn’t it put forward in this sense?
ANS: Advances in Nursing Science Blog 
Nov 1
Time to treat the climate and nature crisis as one indivisible global health emergency
The following editorial is apearing in more than 200 medical journals worldwide between October 25th, and the end of 2023. We are joining this international action to draw attention to the climate and nature crisis.
Over 200 health journals call on the United Nations, political leaders, and health professionals to recognise that climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe. This overall environmental crisis is now so severe as to be a global health emergency.
The world is currently responding to the climate crisis and the nature crisis as if they were separate challenges. This is a dangerous mistake. The 28th Conference of the Parties (COP) on climate change is about to be held in Dubai while the 16th COP on biodiversity is due to be held in Turkey in 2024. The research communities that provide the evidence for the two COPs are unfortunately largely separate, but they were brought together for a workshop in 2020 when they concluded that: “Only by considering climate and biodiversity as parts of the same complex problem…can solutions be developed that avoid maladaptation and maximize the beneficial outcomes.”[1]
As the health world has recognised with the development of the concept of planetary health, the natural world is made up of one overall interdependent system. Damage to one subsystem can create feedback that damages another—for example, drought, wildfires, floods and the other effects of rising global temperatures destroy plant life, and lead to soil erosion and so inhibit carbon storage, which means more global warming. [2] Climate change is set to overtake deforestation and other land-use change as the primary driver of nature loss. [3]
Nature has a remarkable power to restore. For example, deforested land can revert to forest through natural regeneration, and marine phytoplankton, which act as natural carbon stores, turn over one billion tonnes of photosynthesising biomass every eight days. [4] Indigenous land and sea management has a particularly important role to play in regeneration and continuing care. [5]
Restoring one subsystem can help another—for example, replenishing soil could help remove greenhouse gases from the atmosphere on a vast scale. [6] But actions that may benefit one subsystem can harm another—for example, planting forests with one type of tree can remove carbon dioxide from the air but can damage the biodiversity that is fundamental to healthy ecosystems. [7]
The impacts on health
Human health is damaged directly by both the climate crisis, as the journals have described in previous editorials, [8,9] and by the nature crisis. [10] This indivisible planetary crisis will have major effects on health as a result of the disruption of social and economic systems—shortages of land, shelter, food, and water, exacerbating poverty, which in turn will lead to mass migration and conflict. Rising temperatures, extreme weather events, air pollution, and the spread of infectious diseases are some of the major health threats exacerbated by climate change. [11] “Without nature, we have nothing,” was UN Secretary-General António Guterres’s blunt summary at the biodiversity COP in Montreal last year. [12] Even if we could keep global warming below an increase of 1.5◦C over pre-industrial levels, we could still cause catastrophic harm to health by destroying nature.
Access to clean water is fundamental to human health, and yet pollution has damaged water quality, causing a rise in water-borne diseases. [13] Contamination of water on land can also have far-reaching effects on distant ecosystems when that water runs off into the ocean. [14] Good nutrition is underpinned by diversity in the variety of foods, but there has been a striking loss of genetic diversity in the food system. Globally, about a fifth of people rely on wild species for food and their livelihoods. [15] Declines in wildlife are a major challenge for these populations, particularly in low- and middle-income countries. Fish provide more than half of dietary protein in many African, South Asian and small island nations, but ocean acidification has reduced the quality and quantity of seafood.[16]
Changes in land use have forced tens of thousands of species into closer contact, increasing the exchange of pathogens and the emergence of new diseases and pandemics. [17] People losing contact with the natural environment and the declining loss in biodiversity have both been linked to increases in noncommunicable, autoimmune, and inflammatory diseases and metabolic, allergic and neuropsychiatric disorders. [10,18] For Indigenous people, caring for and connecting with nature is especially important for their health. [19] Nature has also been an important source of medicines, and thus reduced diversity also constrains the discovery of new medicines.
Communities are healthier if they have access to high-quality green spaces that help filter air pollution, reduce air and ground temperatures, and provide opportunities for physical activity. [20] Connection with nature reduces stress, loneliness and depression while promoting social interaction. [21] These benefits are threatened by the continuing rise in urbanisation. [22]
Finally, the health impacts of climate change and biodiversity loss will be experienced unequally between and within countries, with the most vulnerable communities often bearing the highest burden. [10] Linked to this, inequality is also arguably fuelling these environmental crises. Environmental challenges and social/health inequities are challenges that share drivers and there are potential co-benefits of addressing them. [10]
A global health emergency
In December 2022 the biodiversity COP agreed on the effective conservation and management of at least 30% percent of the world’s land, coastal areas, and oceans by 2030.[23] Industrialised countries agreed to mobilise $30 billion per year to support developing nations to do so.[23] These agreements echo promises made at climate COPs.
Yet many commitments made at COPs have not been met. This has allowed ecosystems to be pushed further to the brink, greatly increasing the risk of arriving at ‘tipping points’, abrupt breakdowns in the functioning of nature.[2,24] If these events were to occur, the impacts on health would be globally catastrophic.
This risk, combined with the severe impacts on health already occurring, means that the World Health Organization should declare the indivisible climate and nature crisis as a global health emergency. The three pre-conditions for WHO to declare a situation to be a Public Health Emergency of International Concern [25] are that it: 1) is serious, sudden, unusual or unexpected; 2) carries implications for public health beyond the affected State’s national border; and 3) may require immediate international action. Climate change would appear to fulfil all of those conditions. While the accelerating climate change and loss of biodiversity are not sudden or unexpected, they are certainly serious and unusual. Hence we call for WHO to make this declaration before or at the Seventy-seventh World Health Assembly in May 2024.
Tackling this emergency requires the COP processes to be harmonised. As a first step, the respective conventions must push for better integration of national climate plans with biodiversity equivalents. [3] As the 2020 workshop that brought climate and nature scientists together concluded, “Critical leverage points include exploring alternative visions of good quality of life, rethinking consumption and waste, shifting values related to the human-nature relationship, reducing inequalities, and promoting education and learning.” [1] All of these would benefit health.
Health professionals must be powerful advocates for both restoring biodiversity and tackling climate change for the good of health. Political leaders must recognise both the severe threats to health from the planetary crisis as well as the benefits that can flow to health from tackling the crisis. [26] But first, we must recognise this crisis for what it is: a global health emergency.
Kamran Abbasi, Editor-in-Chief, BMJ; Parveen Ali, Editor-in-Chief, International Nursing Review; Virginia Barbour, Editor-in-Chief, Medical Journal of Australia; Thomas Benfield, Editor-in-Chief, Danish Medical Journal; Kirsten Bibbins-Domingo, Editor-in-Chief, JAMA; Stephen Hancocks, Editor-in-Chief, British Dental Journal; Richard Horton, Editor-in-Chief, The Lancet; Laurie Laybourn-Langton, University of Exeter; Robert Mash, Editor-in-Chief, African Journal of Primary Health Care & Family Medicine; Peush Sahni, Editor-in-Chief, National Medical Journal of India; Wadeia Mohammad Sharief, Editor-in-Chief, Dubai Medical Journal; Paul Yonga, Editor-in-Chief, East African Medical Journal; Chris Zielinski, University of Winchester.
Correspondence: chris.zielinski@ukhealthalliance.org
This Comment is being published simultaneously in multiple journals. For the full list of journals see: https://www.bmj.com/content/full-list-authors-and-signatories-climate-nature-emergency-editorial-october-2023
References
1. Otto-Portner H, Scholes B, Agard J, Archer E, Arneth A, Bai X, et al. Scientific outcome of the IPBES-IPCC co-sponsored workshop on biodiversity and climate change. 2021 Jun. doi:10.5281/zenodo.4659159
2. Ripple WJ, Wolf C, Lenton TM, Gregg JW, Natali SM, Duffy PB, et al. Many risky feedback loops amplify the need for climate action. One Earth. 2023;6: 86–91. doi:10.1016/j.oneear.2023.01.004
3. European Academies Science Advisory Council. Key Messages from European Science Academies for UNFCCC COP26 and CBD COP15. 2021 Aug. Available: https://easac.eu/publications/details/key-messages-from-european-science-academies-for-unfccc-cop26-and-cbd-cop15 (accessed 1/10/2023)
4. Falkowski P. Ocean Science: The power of plankton. In: Nature Publishing Group UK [Internet]. 29 Feb 2012 [cited 27 Jun 2023]. doi:10.1038/483S17a
5. Dawson N, Coolsaet B, Sterling E, Loveridge R, Gross-Camp N, Wongbusarakum S, et al. The role of Indigenous peoples and local communities in effective and equitable conservation. Ecol Soc. 2021;26. doi:10.5751/ES-12625-260319
6. Bossio DA, Cook-Patton SC, Ellis PW, Fargione J, Sanderman J, Smith P, et al. The role of soil carbon in natural climate solutions. Nature Sustainability. 2020;3: 391–398. doi:10.1038/s41893-020-0491-z
7. Levia DF, Creed IF, Hannah DM, Nanko K, Boyer EW, Carlyle-Moses DE, et al. Homogenization of the terrestrial water cycle. Nat Geosci. 2020;13: 656–658. doi:10.1038/s41561-020-0641-y
8. Atwoli L, Baqui AH, Benfield T, Bosurgi R, Godlee F, Hancocks S, et al. Call for emergency action to limit global temperature increases, restore biodiversity, and protect health. BMJ. 2021;374: n1734. doi:10.1136/bmj.n1734
9. Atwoli L, Erhabor GE, Gbakima AA, Haileamlak A, Ntumba J-MK, Kigera J, et al. COP27 climate change conference: urgent action needed for Africa and the world. BMJ. 2022;379: o2459. doi:10.1136/bmj.o2459
10. WHO, UNEP, Convention on Biological D. Connecting Global Priorities: Biodiversity and Human Health: A State of Knowledge Review. 2015. Available: https://www.cbd.int/health/SOK-biodiversity-en.pdf (accessed 1/10/2023)
11. Magnano San Lio R, Favara G, Maugeri A, Barchitta M, Agodi A. How Antimicrobial Resistance Is Linked to Climate Change: An Overview of Two Intertwined Global Challenges. Int J Environ Res Public Health. 2023;20. doi:10.3390/ijerph20031681
12. Jelskov U. “Without nature, we have nothing”: UN chief sounds alarm at key UN biodiversity event. In: UN News [Internet]. 6 Dec 2022 [cited 20 Jun 2023]. Available: https://news.un.org/en/story/2022/12/1131422 (accessed 1/10/2023)
13. World Health Organization. State of the world’s drinking water: An urgent call to action to accelerate progress on ensuring safe drinking water for all. World Health Organization; 2022 Oct. Available: https://www.who.int/publications/i/item/9789240060807 (accessed 1/10/2023)
14. Comeros-Raynal MT, Brodie J, Bainbridge Z, Choat JH, Curtis M, Lewis S, et al. Catchment to sea connection: Impacts of terrestrial run-off on benthic ecosystems in American Samoa. Mar Pollut Bull. 2021;169: 112530. doi:10.1016/j.marpolbul.2021.112530
15. IPBES. Assessment report on the sustainable use of wild species. 2022 Aug. Available: https://www.ipbes.net/sustainable-use-assessment
16. Falkenberg LJ, Bellerby RGJ, Connell SD, Fleming LE, Maycock B, Russell BD, et al. Ocean Acidification and Human Health. Int J Environ Res Public Health. 2020;17. doi:10.3390/ijerph17124563
17. Dunne D. Climate change “already” raising risk of virus spread between mammals. 28 Apr 2022 [cited 24 Mar 2023]. Available: https://www.carbonbrief.org/climate-change-already-raising-risk-of-virus-spread-between-mammals/ (accessed 1/10/2023)
18. Altveş S, Yildiz HK, Vural HC. Interaction of the microbiota with the human body in health and diseases. Biosci Microbiota Food Health. 2020;39: 23–32. doi:10.12938/bmfh.19-023
19. Schultz R, Cairney S. Caring for country and the health of Aboriginal and Torres Strait Islander Australians. Med J Aust. 2017;207: 8–10. doi:10.5694/mja16.00687
20. Macguire F, Mulcahy E, Rossington B. The Lancet Countdown on Health and Climate Change – Policy brief for the UK. 2022. Available: https://s41874.pcdn.co/wp-content/uploads/Lancet-Countdown-2022-UK-Policy-Brief_EN.pdf (accessed 1/10/2023)
21. Wong FY, Yang L, Yuen JWM, Chang KKP, Wong FKY. Assessing quality of life using WHOQOL-BREF: a cross-sectional study on the association between quality of life and neighborhood environmental satisfaction, and the mediating effect of health-related behaviors. BMC Public Health. 2018;18: 1113. doi:10.1186/s12889-018-5942-3
22. Simkin RD, Seto KC, McDonald RI, Jetz W. Biodiversity impacts and conservation implications of urban land expansion projected to 2050. Proc Natl Acad Sci U S A. 2022;119: e2117297119. doi:10.1073/pnas.2117297119
23. Secretariat of the Convention on Biological Diversity. COP15: Nations Adopt Four Goals, 23 Targets for 2030 In Landmark UN Biodiversity Agreement. In: Convention on Biological Diversity [Internet]. 12 Dec 2022 [cited 21 Apr 2023]. Available: https://www.cbd.int/article/cop15-cbd-press-release-final-19dec2022 (accessed 1/10/2023)
24. Armstrong McKay DI, Staal A, Abrams JF, Winkelmann R, Sakschewski B, Loriani S, et al. Exceeding 1.5°C global warming could trigger multiple climate tipping points. Science. 2022;377: eabn7950. doi:10.1126/science.abn7950
25. WHO guidance for the use of Annex 2 of the International Health Regulations (2005). In: World Health Organization [Internet]. [cited 5 Oct 2023]. Available: https://www.who.int/publications/m/item/who-guidance-for-the-use-of-annex-2-of-the-international-health-regulations-(2005) (accessed 1/10/2023)
26. Australian Government Department of Health, Care A. Consultation on Australia’s first National Health and Climate Strategy. In: Australian Government Department of Health and Aged Care [Internet]. 26 Jul 2023 [cited 26 Jul 2023]. Available: https://www.health.gov.au/news/consultation-on-australias-first-national-health-and-climate-strategy (accessed 1/10/2023)
Share this: