Overview of the Healthcare Systems of the Maghreb Countries: Issues and Progress

Objectives: To provide an update overview on the current status of healthcare systems in the Maghreb region (Algeria, Morocco, and Tunisia) and to emphasize the progress made in the midst of the challenges facing these countries. Method(s): A descriptive comparative approach of healthcare systems in the three countries, based on data from sources with an established methodology, including descriptive healthcare data from the WHO database. Result(s): The population of the Maghreb will increase from 102 million to 132 million by 2050. The current population is mostly centered in Algeria and Morocco, accounting for 77%. Annual healthcare expenditure per capita is 447.9$, 776.8$ and 854.6$ in Morocco, Tunisia and Algeria, respectively. The average infant mortality rate per 1000 live improved to 10.9 in Tunisia, 16.8 in Morocco and 18.9 in Algeria. Maternal mortality rates have dropped to 43 and 48.5/100 000 births in Tunisia and Algeria, respectively while remaining relatively high in Morocco: 72.6. Number of hospital beds/1000 inhabitants is only 1.1 in Morocco, 1.9 and 2.9 in Algeria and Tunisia, respectively. The number of physicians/1000 people was 0.73 in Morocco, 1.3 in Tunisia and 1.72 in Algeria. This remains considerably low compared to the 3.9/1000 in Europe. The Maghreb countries are currently facing an exodus of physicians, mainly to France, which represents 7.1% and 10.7% of Tunisians and Moroccans, respectively, and more than 24% for Algerians. The Maghreb countries were very early mobilized (governments, ministries of health, civil society) to fight against COVID-19 and have successfully controlled the pandemic, according to pre-established control strategies and the strongly commitment of health professional. Conclusion(s): Despite the considerable progress made, the Maghreb countries still face major challenges. Physicians migration, rising cost of care and endemic infectious disease outbreaks constitute a huge hurdle on the already overburdened and resilient healthcare systems.Copyright © 2023

MORTALITY TRENDS IN CROATIA IN THE FIRST TWO DECADES OF THE 21st CENTURY

Negative demographic trends in Croatia (natural decrease, negative net migration and population aging) are increasingly influencing socio-economic development of the country. Already in early 21st century, the long term decrease of live births and the increase of deaths were recognized as destabilizing factors of population development in Croatia. After the Croatian accession to the EU, the concerns regarding future demographic development of the country raised even more due to intensive emigration to other EU countries, which coincided with the historically low birth rates and high death rates. The focus of this paper is on mortality trends in Croatia in the first two decades of the 21st century. In this period, mortality in Croatia was influenced by different socio-economic, demographic, and epidemiological factors. Given the lack of recent papers dealing with mortality in Croatia, the main aim of this paper is to provide an overview of the changes in selected mortality indicators and contribute to the discussion on recent mortality trends in Croatia. The results of this research indicate that Croatia experienced some positive changes regarding mortality (increase of life expectancy at birth and decrease of infant mortality rates in the first period, in particular), but, some of the trends are not favourable, particularly the changes in the causes of death. Although improvements were observed regarding the share of deaths caused by the diseases of the circulatory system, there was a notable increase in deaths caused by the endocrine, nutritional and metabolic diseases which can be attributed to the unhealthy lifestyle and various behavioural factors.

The role of digital transformation in the socio-economic recovery post COVID-19

Several measures have been taken to reduce the impact of COVID-19 pandemic. One of these measures is the broad digital transformation that has rapidly and unexpectedly forced the deployment of digital technologies into corporations' business models and organizational structures. This digital transformation has affected all the socio-economic aspects. In response to the COVID-19 global pandemic, this paper explores the impact of the implementation of digital transformation on the socio-economic recovery by employing cross-sectional regression analysis on 99 countries in year 2020. The paper analyzes the impact of digital transformation on each of economic growth, health care, and income inequality. The results reveal that the digital transformation has a positive and significant impact on the GDP per capita in which a 1% increase in digital transformation results in 1.52% increase in GDP per capita, a positive and significant impact on income equality in which a 1% increase in digital transformation leads to 0.05% increase in income equality, and a negative and significant impact on infant mortality rate, in which a 1% increase in digital transformation results in 0.85% decrease in infant mortality rate which reflects its positive impact on the health care. Hence, the digital transformation has a positive and significant effects on different socio-economic aspects.

One hundred years of health in a demographic, epidemiological and public policy context: the transition of childhood morbidity and its challenges

Chile is in an advanced stage of demographic and epidemiological transition. It is in this scenario that the political, economic and health crisis occurred, with the social outbreak in 2019 and then the COVID-19 pandemic. The mortality of children and adolescents dropped significantly, however, changes in lifestyles and demotivation, associated with long confinement and worsening health of parents and caregivers triggered an epidemic of mental health, developmental and nutritional pro-blems. Pediatricians were forced to reinvent themselves, exposing themselves to stress and burnout. The aim of the manuscript is to describe the demographic, epidemiological and public policy context of child health in Chile in the last century, as a backdrop to dimension the immediate impact of the COVID-19 pandemic. The new health challenges for this age group in the medium and long term are discussed. Some theories, conceptualizations, and relevant milestones of the public health system in Chile are presented. The emergence of "post-pandemic morbidity", such as sedentary lifestyle, food insecurity, screen addiction, identity conflicts, violence, mental health disorders and reemergence of morbidity and mortality due to infectious and contagious diseases is discussed. Professionals respon-sible for the care of children must redouble their efforts to provide comprehensive care, accompan-ying families in the new challenges, in order to rehabilitate a healthy childhood.

Fiscal Space Policies for Sustainable Development and Debt Relief: Empirical Analysis in West African Countries

The uncertainty that the COVID-19 pandemic has brought demonstrates that income redistribution and traditional debt relief mechanisms are insufficient to meet public spending needs, mitigate external debt, and comply with the UN's Sustainable Development Goals (SDGs), which aim to reduce multilateral debt to sustainable levels. Also, West African countries have focused their attention on the long-term fight against poverty and inequality and strengthening their social programs, especially in primary health care and macroeconomic stability. However, for more than a decade, the developing and least developed countries of West Africa have faced rapidly weakening macroeconomic conditions, combining several interrelated crises such as the sharp decline in oil prices, volatile financial markets and tourism disruptions, a global recession, the crisis of climate change, and shortages of food and energy, along with the economic contraction of COVID-19. Data from these countries show that health spending increases economic growth, minimizes infant mortality rates, and reduces debt. Furthermore, increasing government spending efficiency reduces the total debt and improves the health sector, in particular.

Can bigger health budgets cushion pandemics? An empirical test of COVID-19 deaths across the world

How has public healthcare spending prepared countries for tackling the COVID-19 pandemic? Arguably, spending is the primary policy tool of governments for providing effective health. We argue that the effectiveness of spending for reducing COVID deaths is conditional on the existence of healthcare equity and lower political corruption because the health sector is particularly susceptible to political spending. Our results, obtained using ordinary least squares and two-stage least squares estimations, suggest that higher spending targeted at reducing inequitable access to health has reduced COVID deaths. Consistent with the findings of others, our results indirectly suggest that health spending is necessary, but not sufficient unless accompanied by good governance and equitable access. Equitable health systems ease the effects of COVID presumably because they allow states to reach and treat people more effectively. Spending aimed at increasing health system capacity by increasing access thus seems a sound strategy for fighting the spread of disease, ultimately benefiting us all.

Special considerations in the premature and ex-premature infant

Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.Copyright © 2022

Income inequality and population health: A panel data analysis

The dissertation examines the link between income inequality and population health indicators, including life expectancy, infant mortality, and COVID-19 mortality. It aims to determine if an unequal income distribution poses a hazard to the health status of individuals in society. Using a large international panel dataset from the newest version of the Standardized World Income Inequality Database, the study re-examines the relative income hypothesis and solves such methodological challenges as countries' stratification and heterogeneity bias. Pooled time-series cross-section and country fixed-effects models estimates, based on a sample of developed and developing countries, indicate that income inequality is negatively associated with life expectancy at birth and does not play a significant role in determining infant mortality. Furthermore, the results indicate different effects of income inequality depending on a country's economic standing. Once countries were divided into income groups, the association between income inequality and life expectancy was found only relevant for the group of low-income countries. On the contrary, in the case of infant mortality, a significant association was observed for high-income countries only, thus supporting the relative income hypothesis for the most developed countries. Finally, examining the role of income inequality as a possible driver of health inequities during the COVID-19 pandemic indicates a positive and statistically significant association between the country's Gini coefficient and the number of excess deaths during the first year of the COVID-19 pandemic. The findings emphasize the need to develop strategies to address income inequality as a critical socio-economic factor and target interventions beneficial for the population in the lowest part of the income distribution. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Neonatal mortality in Ukraine against COVID-19 pandemic: do not lose vigilance

Purpose - to highlight the peculiarities of mortality of children in the first year of life (absolute number and level by individual causes and gender) in Ukraine in 2019-2020;to find out whether there have been changes during the year of the COVID-19 pandemic in the country that could hinder the achievement of the SDGs in the area of reducing child mortality. Materials and methods. The information base of the study was the official data from the State Statistics Service of Ukraine regarding the distribution of deceased children by sex, age groups, place of residence and causes of death in 2019-2020. For comparative analysis were used a data from the Statistics Poland and World Population Review (USA) databases. In the course of the analysis were used the following methods: systematic approach, bibliosemantic, epidemiological, statistical, graphical representation. Results. It has been shown that approximately 80% in the structure of mortality under the age of 1 year in Ukraine are accounted for by two main causes: certain conditions that occur in the perinatal period - 58.5% (in 2019 - 54%) and congenital malformations - 22.3% (in 2019 - 25%). The focus is on preventable causes (first of all, external causes and infectious diseases). In 2020 were reported six deaths under the age of 1 year due to COVID-19 firstly. Despite the decline in infant mortality in 2019-2020 from 7.0 to 6.7 per 1000 live births, indicates the likelihood of a negative impact of the COVID-19 pandemic on infant mortality in Ukraine, primarily as a result of the influence of indirect factors, and the need for actions to eliminate or minimize such influence. Conclusions. An analysis of the spectrum and weight of the contribution of the causes of death is a tool for determining the lines and scope of intervention to prevent them on the way to Ukraine achieving by 2030 the declared indicator of infant mortality in children aged 0-4 years old of 6.7 per 1000 live births. © 2022 Group of Companies Med Expert, LLC. All rights reserved.

One hundred years of health in a demographic, epidemiological and public policy context: the transition of childhood morbidity and its challenges

Chile is in an advanced stage of demographic and epidemiological transition. It is in this scenario that the political, economic and health crisis occurred, with the social outbreak in 2019 and then the COVID-19 pandemic. The mortality of children and adolescents dropped significantly, however, changes in lifestyles and demotivation, associated with long confinement and worsening health of parents and caregivers triggered an epidemic of mental health, developmental and nutritional pro-blems. Pediatricians were forced to reinvent themselves, exposing themselves to stress and burnout. The aim of the manuscript is to describe the demographic, epidemiological and public policy context of child health in Chile in the last century, as a backdrop to dimension the immediate impact of the COVID-19 pandemic. The new health challenges for this age group in the medium and long term are discussed. Some theories, conceptualizations, and relevant milestones of the public health system in Chile are presented. The emergence of "post-pandemic morbidity", such as sedentary lifestyle, food insecurity, screen addiction, identity conflicts, violence, mental health disorders and reemergence of morbidity and mortality due to infectious and contagious diseases is discussed. Professionals respon-sible for the care of children must redouble their efforts to provide comprehensive care, accompan-ying families in the new challenges, in order to rehabilitate a healthy childhood. Copyright © 2022, Sociedad Chilena de Pediatria. All rights reserved.

Income inequality and population health: A panel data analysis

The dissertation examines the link between income inequality and population health indicators, including life expectancy, infant mortality, and COVID-19 mortality. It aims to determine if an unequal income distribution poses a hazard to the health status of individuals in society. Using a large international panel dataset from the newest version of the Standardized World Income Inequality Database, the study re-examines the relative income hypothesis and solves such methodological challenges as countries' stratification and heterogeneity bias. Pooled time-series cross-section and country fixed-effects models estimates, based on a sample of developed and developing countries, indicate that income inequality is negatively associated with life expectancy at birth and does not play a significant role in determining infant mortality. Furthermore, the results indicate different effects of income inequality depending on a country's economic standing. Once countries were divided into income groups, the association between income inequality and life expectancy was found only relevant for the group of low-income countries. On the contrary, in the case of infant mortality, a significant association was observed for high-income countries only, thus supporting the relative income hypothesis for the most developed countries. Finally, examining the role of income inequality as a possible driver of health inequities during the COVID-19 pandemic indicates a positive and statistically significant association between the country's Gini coefficient and the number of excess deaths during the first year of the COVID-19 pandemic. The findings emphasize the need to develop strategies to address income inequality as a critical socio-economic factor and target interventions beneficial for the population in the lowest part of the income distribution. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

From Evidence to Action: Uniting Around Nutrition in the 1000-Day Window

If you had 1000 days to change the world, how would you do it? For us, it starts with an urgent opportunity to safeguard a child's potential to learn, grow, and thrive.Studies show that countries that fail to invest in the well-being of women and children in the first 1000 days, the time between a pregnancy and the baby's second birthday, lose billions of dollars to lower economic productivity and higher health costs.1 Roger Thurow, author of The First 1000 Days, said, "If we want to shape the future, to truly improve the world, we have 1000 days to do it, mother by mother, child by child."2While the international global health community has been guided by the United Nations Millennial Development Goals-and now, the Sustainable Development Goals-since 2000, the United States has failed to take meaningful action to protect its mothers and young children. The United States has one of the highest infant mortality rates and maternal mortality rates of any wealthy country, with notable disparities along racial and ethnic lines. Our nation also ranks among the worst of our peers on key child health metrics: one in 10 babies is born prematurely,3 one in six babies is never breastfed,4 and one in eight toddlers is overweight.5 Workers are not guaranteed comprehensive, job-protected paid leave, jeopardizing the ability of many parents to care for themselves and their children. And too many families struggle to put nutritious foods on the table. Even before the COVID-19 pandemic and related economic recession hit, nearly one in seven households with children were food insecure.6Nutrition plays a foundational role in a child's development and her country's ability to prosper. Poor nutrition in the first 1000 days can cause irreversible damage to a child's growing brain, affecting her ability to do well in school and earn a good living-and making it harder for a child and her family to rise out of poverty.7In 2008 (https://bit.ly/3BIgxlG), and again in 2013 (https://bit.ly/3oYUtLY) and 2021 (https://bit.ly/3Q7g5Sy), a landmark series of papers was published that identified the first 1000 days as a powerful window of opportunity for tackling undernutrition and improving maternal and child health in low- and middle-income countries. For nearly two decades, the first 1000 days has been an organizing agenda for nutrition advocacy and programming in international settings.While the medical, public health, and social support communities in the United States know which interventions are most critical to support the health and well-being of vulnerable families, a clear, unifying plan for policy, systems, and environmental change to improve nutrition security has been elusive. Now more than ever-in the face of persistent racial health disparities, an ongoing pandemic, and its economic fallout, we see four sectors where immediate actions can be taken, and where long-term investment can make a significant impact on maternal and child health.

PRE-COVID MORTALITY IN NORTH OSSETIA-ALANIA

North Ossetia-Alania (NOA) regional mortality over thirty years of transition is described in detail for the first time. Though NOA and other Caucasus regions are perceived to have higher life expectancy than Russia overall, we find that, like the rest of Russia, men live much shorter lives in both rural and urban areas. Urban mortality is lower for most causes of death than rural mortality with women in particular showing improvements in lowering mortality and higher life expectancy at birth. Male mortality across all ages is better in the 21st century than the 1990s but has not improved recently relative to the early 2000s. Sigma and beta mortality divergence reveal little improvement in male mortality relative to female mortality with the gender gap unchanged since the Soviet era which is unusual at the regional level. Nostalgia for Soviet era health systems is misplaced as health has improved since then especially like other regions in the area of infant mortality and deaths before the age of 5. Policy recommendations include moving some health care out of the capital of Vladikavkaz to take advantage of relatively lower rural mortality as well as promoting more rural economic development.

Examples of Outcome Reporting Bias in Vaccine Studies: Illustrating How Perpetuating Medical Consensus Can Impede Progress in Public Health.

INTRODUCTION: Outcome reporting bias in vaccine studies is a widespread problem among all researchers who have a tendency to report selective results and conclusions that support their beliefs and values or those of sponsoring agencies. Especially during the COVID-19 pandemic, this bias surfaced through the unprecedented proliferation of conflicting vaccine studies. Many researchers strongly recommend and report on the safety and effectiveness of the COVID-19 vaccine. Those researchers who embrace the COVID-19 vaccine and vaccines, in general, are often dismissive of other researchers who present views that differ from medical orthodoxy and oppose medical consensus. METHODS: The aim of this analysis is to critically evaluate seven vaccine studies using qualitative and/or quantitative approaches to identify outcome reporting bias and assess its potential impact on the stated conclusions that align with medical consensus. Four studies claim to have found no association between autism and (a) blood levels of mercury, (b) measles, mumps, and rubella (MMR) vaccine, and (c) thimerosal-containing vaccines. Three other studies claim no association exists between infant mortality rate and the number of vaccine doses, universal varicella vaccination and herpes zoster, and pandemic influenza vaccines and fetal losses. RESULTS: The presence of outcome reporting bias and independent reanalysis demonstrated an impact on both the direction and magnitude of the observed effect - raising questions concerning the robustness of the original study design and conclusions and challenging the current medical consensus. Medical consensus has exonerated vaccines as having any causal relationship to autism spectrum disorders (ASDs), yet no other reasonable cause has been proposed. Medical consensus attributes significant ASD increases to better case ascertainment and broadened clinical diagnosis. According to 2018 data, an estimated 1 in 44 eight-year-olds has been identified with ASD. From 1990 to 2019, there have been an estimated two million new cases of ASD in the US, with lifetime social costs exceeding $7 trillion (in 2019 dollars). Can perpetuating medical consensus impede the advancement of public health? Or has it already done so? CONCLUSIONS:  Conflicts of interest (e.g., financial) that abound between health regulatory agencies and the pharmaceutical industry impact what is ultimately reckoned as medical consensus. Outcome reporting bias that is inherent to all researchers to some degree, obscures medical and scientific truth. Advancement of public health requires that researchers have integrity and an openness and willingness to collaborate to resolve contradictory findings. In fact, it is usually through meticulous, rigorous, scientific investigation of contradictory findings that medical science has advanced and contributed to improvements in public health - since medical consensus and orthodoxy can be incorrect.

An Overlooked Strategic Powerhouse: How Nurses Can Rise to the Challenge of Integrating Public Health and Primary Care

Although the United States is one of the wealthiest countries in the world and a leader in biomedical innovation, its health care system is consistently ranked among the worst in terms of cost and health outcomes. Americans have short life expectancies, high infant mortality and obesity rates, and soaring chronic disease rates compared with other wealthy nations. In 2021, the National Academy of Medicine (NAM) was charged with examining what it would take to improve US primary care. The NAM report described the practice of siloing public health from primary care or treating these areas as separate fields of scientific inquiry, practice, and billable service.1 NAM identified this separation as a key driver of poor health outcomes and health inequities in the United States. The Institute of Medicine (IOM) examined similar phenomena in a 2012 report, noting how the two fields tend to operate independently, despite complementary functions and common goals.2Where these silos persist, we see communication and process breakdowns at the point of care. For instance, when large swaths of Americans turned to trusted primary care providers for COVID-19 vaccine insights, their primary care providers did not always have the most up-todate information, in part because of a lack of interprofessional cohesion (including fragmented public health messaging and data systems). If we are to remedy such issues, a substantive paradigm shift must take place: We must move toward what DeSalvo et al.3 termed "Public Health 3.0." In this model, multiple sectors, specialties, and stakeholders form coalitions to mobilize data, people power, and resources in a strategic manner to advance health for all. To be truly strategic, we must think carefully about how to leverage nurses-who care for patients across the lifespan and in nearly all public health nursing (PHN) and primary care settings-within these coalitions.The 2021 NAM report urges health care teams to undertake the mission of integrating systems. However, NAM stops short of describing exactly how teams ought to accomplish this aim and the proposed makeup ofsaid teams. Like any group project, success will depend on the ability of teams to identify leaders and clearly delineate responsibilities. The purpose of this editorial is to explore the potential of PHN and primary care nurses and to describe the roles they might assume in the collaborative integration of their respective silos.

Stuck between Mother Earth and a mother’s womb? On women, population policy and ecological sustainable development

This article considers how the metaphor of Mother Earth, for women, concerns a dual stance of both belonging and distance. The link between women, nature and Mother Earth is problematised by considering the possible, or contested, link between population growth and climate change, and the South African population policy specifically is considered as an example. Ecofeminism’s challenge to the perceived connection between women, motherhood and Earth, that is the ‘distance’ stance, is considered and a response to that is offered by reflecting on Mercy Oduyoye’s notion of mothering, which represents the ‘belonging’ stance. In this regard, an intercultural approach to the definition of motherhood is implied. It is ultimately indicated that for women to reclaim their own agency regarding a perceived responsibility towards nature, it is necessary to deconstruct and reconstruct ‘motherhood’ to free themselves from being stuck between Mother Earth and a mother’s womb. Contribution: This article makes a contribution to feminist studies at the intersection of gender roles and the climate crisis, as it relates to population growth and an intercultural definition of motherhood. It contributes to UN’s sustainable development agenda as it relates to both SDG 5 (gender equality) and SDG 13 (climate action).

Representation and reconciliation—Indigenous leadership for health in Canada

1 Indigenous peoples in Canada and worldwide continue to experience worse health outcomes than non-Indigenous people, resulting from the ongoing legacy of colonialism that includes higher rates of poverty, inadequate housing, infant mortality, non-communicable diseases, mental health problems, and nutritional disorders related to food insecurity.2 Physicians and medical organisations play an important role in tackling these inequities through advocacy for Indigenous people’s health and rights, policy implementation to support culturally appropriate and accessible healthcare, and medical education and curriculum development that considers the unique needs of Indigenous patients as well as Indigenous perspectives. In our roles as physicians of Anishinaabe ancestry (LR) and Métis ancestry (JS), we co-chair a national working group focused on the recruitment and retention of Indigenous physicians in healthcare and academic institutions, working to outline pathways to support their careers and leadership development.5 Observations from this initiative and our personal experiences show that representation of Indigenous leaders in medical schools and other organisations is a key factor in recruitment and retention of future students and practitioners. In the face of unprecedented levels of burnout among health providers, a holistic understanding of health and its physical, mental, emotional, and spiritual dimensions, which is foundational in many Indigenous approaches to wellness, urges us to think broadly about our needs and those of our colleagues, learners, and patients.9 As organisations strive to be fairer and more inclusive, learning from leadership and governance practices of local Indigenous nations can inform leaders and organisations on how to build networks of collaboration, working in non-hierarchical ways and valuing the contributions of everyone equally;build consensus and enact meaningful action;learn from others whose expertise often is not recognised within institutions;and consider the impact of current initiatives on the next seven generations and on the land.10 As medicine comes to rely more and more on large datasets and algorithms, Indigenous data sovereignty frameworks can guide responsible use of data for all families and patients by upholding guidelines and codes of conduct to ensure that Indigenous peoples and communities retain control of their data’s use in formal partnership agreements.11 As the health effects of climate change become more prominent, the teachings of diverse elders about the interconnectedness of all living beings with the land and the water can influence current and future generations of physicians in how to care for our communities and our planet.12 By electing Alika Lafontaine as CMA president, Canadian physicians have made the decision to uphold and amplify Indigenous voices.