What would it really take to solve the overdose epidemic in the United States?

The high overdose mortality rates in the United States poses several questions: Why have they been increasing exponentially since 1979? Why are they so high? And how can they be greatly reduced? Building on past research, the causes of the increase seem to be deeply rooted in US social and economic structures and processes, rather than due only to opioid prescription patterns or the advent of synthetic opioids. Given this, we consider what changes might be needed to reverse the exponentially-increasing overdose mortality. We use a path dependency argument to argue that the United States political, economic, and public health systems have helped create this crisis and, unfortunately, continue to heighten it. These same systems suggest that proposals to expand harm reduction and drug treatment capacity, to decriminalize or legalize drugs, or to re-industrialize the country sufficiently to reduce "communities of despair" will not be enacted at a scale sufficient to end the overdose crisis. We thus suggest that in the United States serious improvements in overdose rates and related policies and structures require massive social movements with a broad social change agenda.

How reforms hamper priority-setting in health care: an interview study with local decision-makers in London.

The fair allocation of scarce resources for health remains a salient topic in health care systems. Approaches for setting priorities in an equitable manner include technical ones based on health economic analyses, and ethical ones based on procedural justice. Knowledge on real-world factors that influence prioritisation at a local level, however, remains sparse. This article contributes to the empirical literature on priority-setting at the meso level by exploring how health care planners make decisions on which services to fund and to prioritise, and to what extent they consider principles of fair priority-setting. It presents the findings of an interview study with commissioners and stakeholders in South London between 2017 and 2018. Interviewees considered principles of fair prioritisation such as transparency and accountability important for offering guidance. However, the data show that in practice the adherence to principles is hampered by the difficulty of conceptualising and operationalising principles on the one hand, and the political realities in relation to reform processes on the other. To address this challenge, we apply insights from the policy and political sciences and propose a set of considerations by which current frameworks of priority-setting might be adapted to better incorporate issues of context and politics.

The Role of the Policy Process on Health Service Reconfigurations: Evidence, Path Dependency and Framing Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

Historically healthcare services have largely developed on an incremental basis, with various piecemeal changes and some notable policy leaps that illustrate a punctuated equilibrium health policy process. More recently policy-makers have attempted, successfully and unsuccessfully, to reconfigure healthcare services to address perceived problems in the delivery of important services such as stroke, cancer, and trauma. Perry et al provide a welcome addition to research in this area by focusing on the importance of history in a reconfiguration of cancer services in Greater Manchester (GM). Perry et al analyse how and why this configuration was successful after several failed attempts in the past and in this commentary, I want to reflect on the explanatory role health policy analysis can contribute to studying the reconfiguration of healthcare services.

Making sense of breaks in landscape change.

Context: The paper studies the possibilities of how the cultural explosion theory and path dependence approach could be used for exploring landscape (change). The former is an approach (not theory) used in humanities and social sciences to study the processes that happen when culture changes rapidly-how new cultural processes are created and how the past ones are integrated or forgotten. The latter is an approach developed also in social sciences, mostly economy, to study how the current decisions are dependent on the past decisions. Objectives: To demonstrate the possibilities the two theoretical approaches might offer. Methods: We discuss the ways landscape change could be analysed using, first, cultural explosion theory and, second path dependence approach, and demonstrate this on the example of the post-Soviet military areas. Results: Both approaches are indeed useful in understanding landscape change. The demo case on military landscapes allows for distinguishing three different development paths for the future of the areas: set-aside, active use, and neglect. Similarly three different ways of relating with the past are found: ignorance and oblivion; acknowledging the past; and making use of the past. Conclusions: Landscapes have time boundaries and these two analytical tools in fact help us to navigate through these boundaries, understand better the trajectories of change and the importance (or the lack of it) of the past.

[Overwhelming Differences at the Expense of Many Small Details]. / Eindeutige Unterschiede auf Kosten vieler kleiner Details.

McCoy's comparative study focuses on the different styles and reasonings by which the United States and Great Britain responded and continue to respond to epidemics. While disease control in Britain focused on the environment, comparatively later efforts in the United States concentrated on quarantine and control of the infected. Drawing on the concept of path dependence, McCoy argues for the continuing importance of the historical factors surrounding the emergence of the first disease control structures. In doing so, he considers the centralisation of the state, a coherent theory of disease, pressures of civil society, and the idea of the population as a social body to be crucial. However, his pleasantly lucid study inevitably omits some important research areas and questions.

Land-use trajectories for sustainable land system transformations: Identifying leverage points in a global biodiversity hotspot.

Sustainable land-system transformations are necessary to avert biodiversity and climate collapse. However, it remains unclear where entry points for transformations exist in complex land systems. Here, we conceptualize land systems along land-use trajectories, which allows us to identify and evaluate leverage points, i.e., entry points on the trajectory where targeted interventions have particular leverage to influence land-use decisions. We apply this framework in the biodiversity hotspot Madagascar. In the northeast, smallholder agriculture results in a land-use trajectory originating in old-growth forests and spanning from forest fragments to shifting hill rice cultivation and vanilla agroforests. Integrating interdisciplinary empirical data on seven taxa, five ecosystem services, and three measures of agricultural productivity, we assess trade-offs and cobenefits of land-use decisions at three leverage points along the trajectory. These trade-offs and cobenefits differ between leverage points: Two leverage points are situated at the conversion of old-growth forests and forest fragments to shifting cultivation and agroforestry, resulting in considerable trade-offs, especially between endemic biodiversity and agricultural productivity. Here, interventions enabling smallholders to conserve forests are necessary. This is urgent since ongoing forest loss threatens to eliminate these leverage points due to path dependency. The third leverage point allows for the restoration of land under shifting cultivation through vanilla agroforests and offers cobenefits between restoration goals and agricultural productivity. The co-occurring leverage points highlight that conservation and restoration are simultaneously necessary to avert collapse of multifunctional mosaic landscapes. Methodologically, the framework highlights the importance of considering path dependency along trajectories to achieve sustainable land-system transformations.

Managing pandemics as super wicked problems: lessons from, and for, COVID-19 and the climate crisis.

COVID-19 has caused 100s of millions of infections and millions of deaths worldwide, overwhelming health and economic capacities in many countries and at multiple scales. The immediacy and magnitude of this crisis has resulted in government officials, practitioners and applied scholars turning to reflexive learning exercises to generate insights for managing the reverberating effects of this disease as well as the next inevitable pandemic. We contribute to both tasks by assessing COVID-19 as a "super wicked" problem denoted by four features we originally formulated to describe the climate crisis: time is running out, no central authority, those causing the problem also want to solve it, and policies irrationally discount the future (Levin et al. in Playing it forward: path dependency, progressive incrementalism, and the "super wicked" problem of global climate change, 2007; Levin et al. in Playing it forward: Path dependency, progressive incrementalism, and the "super wicked" problem of global climate change, 2009; Levin et al. in Policy Sci 45(2):123-152, 2012). Doing so leads us to identify three overarching imperatives critical for pandemic management. First, similar to requirements to address the climate crisis, policy makers must establish and maintain durable policy objectives. Second, in contrast to climate, management responses must always allow for swift changes in policy settings and calibrations given rapid and evolving knowledge about a particular disease's epidemiology. Third, analogous to, but with swifter effects than climate, wide-ranging global efforts, if well designed, will dramatically reduce domestic costs and resource requirements by curbing the spread of the disease and/or fostering relevant knowledge for managing containment and eradication. Accomplishing these tasks requires building the analytic capacity for engaging in reflexive anticipatory policy design exercises aimed at maintaining, or building, life-saving thermostatic institutions at the global and domestic levels.

The costs and benefits of environmental sustainability.

The natural science in GEO-6 makes clear that a range and variety of unwelcome outcomes for humanity, with potentially very significant impacts for human health, become increasingly likely if societies maintain their current development paths. This paper assesses what is known about the likely economic implications of either current trends or the transformation to a low-carbon and resource-efficient economy in the years to 2050 for which GEO-6 calls. A key conclusion is that no conventional cost-benefit analysis for either scenario is possible. This is because the final cost of meeting various decarbonisation and resource-management pathways depends on decisions made today in changing behaviour and generating innovation. The inadequacies of conventional modelling approaches generally lead to understating the risks from unmitigated climate change and overstating the costs of a low-carbon transition, by missing out the cumulative gains from path-dependent innovation. This leads to a flawed conclusion as to how to respond to the climate emergency, namely that significant reductions in emissions are prohibitively expensive and, therefore, to be avoided until new, cost-effective technologies are developed. We argue that this is inconsistent with the evidence and counterproductive in serving to delay decarbonisation efforts, thereby increasing its costs. Understanding the processes which drive innovation, change social norms and avoid locking in to carbon- and resource-intensive technologies, infrastructure and behaviours, will help decision makers as they ponder how to respond to the increasingly stark warnings of natural scientists about the deteriorating condition of the natural environment.

Participation in training at older ages: A European perspective on path dependency in life course trajectories.

Investments in lifelong learning may create unsatisfactory results, and this could potentially contribute to the reproduction of inequalities. We argue that the process is related to the accumulation of opportunities and barriers for participation in training, which can lock individuals in disadvantageous path-dependent trajectories. We take a longitudinal approach to analyse whether participation in training in older age is path-dependent, and whether this path dependency is related to institutional contexts. Using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE), we trace individual training trajectories in the population aged 50+ in twelve European countries between 2010 and 2015 (27 370 respondents). Hierarchical Bayesian logit models serve to assess the probability of training during the sixth wave, with a lagged dependent variable as a predictor. Results suggest that training participation is path-dependent and participation in training is limited for people who have not trained previously. It is also related to macrostructural context: path dependency is lower in countries with stronger knowledge economies, stronger emphasis on education, and a proactive ageing climate. Recognising path dependency can help to improve access to training and design policies that address problems of cohesion, active ageing and adult learning.

[Path dependency, bifurcation points and the role of sociology. A sociological attempt at interpreting the corona crisisDépendance au sentier, points de bifurcation et le rôle de la sociologie. Une tentative d'interprétation sociologique de la crise du coronavirus]. / Pfadabhängigkeit, Bifurkationspunkte und die Rolle der Soziologie. Ein soziologischer Deutungsversuch der Corona-Krise.

The contribution begins by attempting to specify the corona crisis' essence and form by means of acceleration theory. In so doing, the diagnosis of a politically induced, objectively measurable deceleration is pivotal. In a second step, the social theoretical conclusions from this diagnosis are drawn in contrast to system theory on the one hand, and neomarxist approaches on the other. The focus is on the argument that the political reaction to SARS-CoV­2 can neither be explained by reference to the principles of functional differentiation nor through the logic of securing political power or through capital accumulation. Following this line of thought, the article maps out the possibilities created by the crisis for societal path and system change, and outlines the role that sociology as a scientific discipline can and should play in this historical situation.

Cet article tente tout d'abord de déterminer plus précisément la nature et les manifestations de la crise du coronavirus à l'aide de la théorie de l'accélération. Dans ce cadre, le constat d'une décélération sociale provoquée par la politique et mesurable objectivement occupe une place centrale. De là, on tire dans un second temps les conséquences de la crise en termes de théorie sociale en la confrontant d'une part à la théorie des systèmes, d'autre part aux approches néo-marxistes. Ce faisant, l'accent est mis sur l'argument selon lequel la réaction politique au virus SARS-CoV­2 ne s'explique ni par les principes de la différenciation fonctionnelle ni par la logique du maintien de la domination ou de l'accumulation du capital. Ensuite, cet article met en évidence les possibilités de changement de sentier ou de système social que recèle cette situation de crise et le rôle que la sociologie peut et devrait jouer en tant que discipline scientifique dans cette situation historique.

How Society Changes: Sociological Enlightenment and a Theory of Social Evolution for Freedom.

This article clarifies the relationship between individual freedom and social order by relying on Niklas Luhmann's social systems theory and thereby defines sociology's contribution to social evolution as sociological enlightenment, which seeks otherwiseness in living experience and action. For this purpose, Luhmann's theory will specifically be compared with Emile Durkheim's and Alfred Schutz's sociological theories. Durkheim, a "child of the Enlightenment," considered freedom a collective ideal of moral individualism and conceived that the rational state realizes freedom by spreading the civil-religious human ideal for modern social order. In contrast, Schutz, following Henri Bergson, who criticized rationality for spatially fixing inner time, regarded freedom as a given in the individual's underlying duration, not as a shared ideal. Yet, unlike Bergson, he continued relying on rationalism, and he thought that the sociological observer observes how something appears to people with the epoché of natural attitude, not what it objectively is. Inheriting this phenomenological subjectivism, Luhmann showed that the self-referentiality of consciousness also applies to society: A social system, which path-dependently emerges itself from a double contingency, observes the world in its own way based on its self-referentially constituted eigen-time. On account of this system closure, and contrary to Durkheim's illuminist belief, there is no controlling entity in a highly evolved society, where freedom results from the enlarged, diversified possibilities of living experience and action (contingency). Thus, sociological enlightenment doubts self-evidence so that society brackets the taken-for-granted social order or social reality and amplifies individuals' deviations to evolve toward freedom.

Turkish Health Policies: Past, Present, and Future.

In this article, health policies in Turkey from the 1900s to the present are reviewed in light of the available data on the number of health institutions, life expectancy, infant mortality, and state budget allocation. While a significant quantitative development is observed in the provision of health services, the state by far maintained a leading role in the provision of health services until the 1980s, when an initially weak but steady deviation began, significantly increasing its pace from 2002 and creating a new path where the private sector raised its share with the extensive implementation of neoliberal economic policies. The emergence of public-private partnership projects as a financing tool in the health sector, with various models from the 1990s around the world, found its place in the Turkish health system in the form of city hospitals from 2013, creating a new deviation in the provision of health services by the state.

Sticky Policies, Dysfunctional Systems: Path Dependency and the Problems of Government Funding for Science in the United States.

Leaders of the scientific community have declared that American science is in a crisis due to inadequate federal funding. They misconstrue the problem; its roots lie instead in the institutional interactions between federal funding agencies and higher education. After World War II, science policy elites advocated for a system of funding that addressed what they perceived at the time as their most pressing problems of science-government relations: the need for greater federal funding for science, especially to universities, while maintaining scientific autonomy in the distribution and use of those funds. The agencies that fund university research developed institutional rules, norms, and procedures that created unintended consequences when they interacted with those of American higher education. The project system for funding, justified by peer-review and coupled with rapidly increasing R&D budgets, created incentives for universities to expand their research programs massively, which led to unsustainable growth in the demand for federal research money. That system produced spectacular successes but also created the unintended longer-term problem that demand for science funding has grown more quickly than government funding ever could. Most analysts neglect potentially painful reforms that might address these problems. This case demonstrates that successful political coalitions can create intractable long-term problems for themselves.

Fuelling regional development or exporting value? The role of the gas industry on the Limestone Coast, South Australia.

The degree to which host regions benefit from resource extraction is a major issue for research and policy. In Australia and Canada, the dominant narrative of resource extraction is that most of the benefits flow away from host regions. This paper draws on evolutionary economic geography, presenting a case study of the Limestone Coast in South Australia, which previously extracted and distributed gas locally to food and fibre manufacturing industries. New policies seeking to renew the gas industry in the region, provide subsidies for exploration. Scenarios were developed to help inform decisions about the role of gas within this region. Qualitative analysis of the scenarios emphasised that gas needs to be affordable and locally accessible. Quantitative modelling showed that using the gas locally by manufacturing industries as part of broader industrial expansion would lead to greater benefits compared with exporting all gas outside the region. We conclude that policy settings have gone some way towards realising increased benefits for the region. Regional stakeholders clearly favoured the local use scenario but saw it as unlikely in the context of current infrastructure limitations. Stakeholders sought policy support for infrastructure to enable the preferred scenario to be realised.

Policy design and state capacity in the COVID-19 emergency in Italy: if you are not prepared for the (un)expected, you can be only what you already are.

Italy was the first large epicentre of the COVID-19 pandemic in the Western world. Since the country has not had any serious experience with this kind of disease in recent decades, its response has been indicative of a first reaction to an (un)known and (un)expected event. At the same time, the Italian experience is an emblematic case of how a lack of specific preparedness measures drives a country to deal with this kind of crisis through a process in which the existing characteristics of the policy and political system, with all their pros and cons, prevail. This means that the existing country characteristics that affects policy design, state capacity, institutional arrangements and political games forge the process and content of the response. Based on this observation, this paper analyses the policy dynamics of the first four months of management of the COVID-19 outbreak in Italy, focusing on how the health and economic responses were designed and implemented.

The future of bioenergy.

Energy from biomass plays a large and growing role in the global energy system. Energy from biomass can make significant contributions to reducing carbon emissions, especially from difficult-to-decarbonize sectors like aviation, heavy transport, and manufacturing. But land-intensive bioenergy often entails substantial carbon emissions from land-use change as well as production, harvesting, and transportation. In addition, land-intensive bioenergy scales only with the utilization of vast amounts of land, a resource that is fundamentally limited in supply. Because of the land constraint, the intrinsically low yields of energy per unit of land area, and rapid technological progress in competing technologies, land intensive bioenergy makes the most sense as a transitional element of the global energy mix, playing an important role over the next few decades and then fading, probably after mid-century. Managing an effective trajectory for land-intensive bioenergy will require an unusual mix of policies and incentives that encourage appropriate utilization in the short term but minimize lock-in in the longer term.

Adapting Coercion: How Three Industrialized Nations Manufacture Vaccination Compliance.

CONTEXT: This research examines the development of vaccination policy in Britain, the United States, and Australia to begin to understand the different forms of coercion that industrialized states utilize to achieve vaccination compliance from the majority of their citizens. METHODS: This research applies a comparative-historical analysis of the three countries listed, using a combination of primary and secondary documents. FINDINGS: The different degrees of compulsion in the vaccination policies of Britain, the United States, and Australia is explained through an analysis of the path-dependent ways that each nation adapted coercion in response to civil society resistance. Each nation has moved up and down a continuum of coercion searching for a policy that balances overcoming passive noncompliance without engendering active resistance. Arriving at different balancing points between these two objectives, the three nations have now institutionalized policies with different degrees of coercion. CONCLUSIONS: This research shows that vaccination policy is not just created top-down by the state, but through an ongoing interactive process with citizens and civil society. Furthermore, as vaccination is a "wicked problem" that faces ongoing civil society resistance, states will need to perpetually adapt the coerciveness of their policies into the foreseeable future.

The anatomy of antagonistic coregulation: Emergent coordination, path dependency, and the interplay of biomechanic parameters in Aikido.

Using a video-supported cognitive ethnographic and phenomenological approach, we address the interactively generated dynamic of bouts in Aikido. This "soft" martial art enables a defender to blend with and then redirect an attacker's aggressive energy so as to break his balance, while preserving an ethos of non-violence, mutuality, and respect. Our analysis explores the skills used to minutely adapt to the opponent, the causal-temporal structure of Aikido, notably the cumulative effect build-up and main decision points in a bout, as well as the perceptual cues from inter-body geometry, timing, and force dynamics that inform decisions. We then contrast different interaction scenarios by focusing on micro-events that shape defensive preferences. For a successful defense, technical modulations or even the preferred technique itself can be selected as the interaction unfolds ("decision-making-in-action"). For a closer look, we analyze the interplay of multiple parameters: flexibility of intention (i.e. early deciding vs. keeping options openlonger), technique (i.e. type of lever or throw), initial body symmetry, step combinations, spacing and timing relative to the attacker, degree of force, as well as possible skill differentials. We describe complex interdependencies between these parameters, which can be balanced in various ways as agents respond to the interaction dynamic.

Imaginaries of Invention Management: Comparing Path Dependencies in East and West Germany.

The ways in which societies and institutions institutionalize and practice invention management reflects not only how new ideas are valued, but also imaginaries about the role of science and technology for societal development. Often taking the US Bayh-Dole-Act as a model, many European states have recently implemented changes in how inventions at academic institutions are to be handled to optimize their societal impact. We analyze how these changes have been taken up-and made sense of-in regions with different pre-existing infrastructures, practices and semantics of invention management. For doing so, we build on a comparative analysis of continuities and changes in infrastructures, practices and semantics of invention management in North-Rhine Westphalia (NRW, a former Western state) and Saxony (a former GDR state) to reflect on how academic institutions have been handling inventions along transforming socio-political contexts. Building on document analysis and qualitative interviews with research managers, we discuss ongoing differences in practices of invention management and the semantic framing of the societal value of inventions in NRW and Saxony, and discuss how this can be understood before the background of their ideological, political and economic separation until reunification in 1990. Joining the conceptual perspectives of path dependencies and sociotechnical imaginaries, we argue that two critical incidents in the history of these states (the reunification in 1990 and a legal change in 2002) allowed for wide-ranging institutional alignments, but also allowed path dependencies in practices and semantics of invention management to prevail.

Natural Hazard Management from a Coevolutionary Perspective: Exposure and Policy Response in the European Alps.

A coevolutionary perspective is adopted to understand the dynamics of exposure to mountain hazards in the European Alps. A spatially explicit, object-based temporal assessment of elements at risk to mountain hazards (river floods, torrential floods, and debris flows) in Austria and Switzerland is presented for the period from 1919 to 2012. The assessment is based on two different data sets: (1) hazard information adhering to legally binding land use planning restrictions and (2) information on building types combined from different national-level spatial data. We discuss these transdisciplinary dynamics and focus on economic, social, and institutional interdependencies and interactions between human and physical systems. Exposure changes in response to multiple drivers, including population growth and land use conflicts. The results show that whereas some regional assets are associated with a strong increase in exposure to hazards, others are characterized by a below-average level of exposure. The spatiotemporal results indicate relatively stable hot spots in the European Alps. These results coincide with the topography of the countries and with the respective range of economic activities and political settings. Furthermore, the differences between management approaches as a result of multiple institutional settings are discussed. A coevolutionary framework widens the explanatory power of multiple drivers to changes in exposure and risk and supports a shift from structural, security-based policies toward an integrated, risk-based natural hazard management system.

Se adopta una perspectiva co-evolucionista para entender la dinámica de la exposición a los riesgos de montaña en los Alpes europeos. Se presenta una evaluación temporal espacialmente explícita y basada en objeto de los elementos de riesgo en catástrofes de montaña (inundaciones fluviales, inundaciones torrenciales y flujos de detritos) en Austria y Suiza, para el período de 1919 a 2012. La evaluación descansa en dos conjuntos de datos diferentes: (1) información de riesgos que adhiere a las restricciones de planificación de uso del suelo legalmente obligatorias, y (2) información combinada sobre tipos de construcciones desde diferentes fuentes de datos espaciales a nivel nacional. Discutimos estas dinámicas transdisciplinarias y nos enfocamos en interdependencias e interacciones económicas, sociales e institucionales entre sistemas humanos y físicos. La exposición cambia en respuesta a múltiples controles, incluyendo crecimiento de la población y conflictos por usos del suelo. Los resultados muestran que mientras algunas ventajas regionales están asociadas con un fuerte incremento en exposición a los riesgos, otras están caracterizadas por un nivel de exposición por debajo del promedio. Los resultados espaciotemporales indican puntos calientes relativamente estables en los Alpes europeos. Estos resultados coinciden con la topografía de los países y con el respectivo ámbito de actividades económicas y el contexto político. Adicionalmente, se discuten las diferencias entre los enfoques de administración como resultado de múltiples escenarios institucionales. Un marco co-evolucionario amplía el poder explicativo de múltiples controles a los cambios en exposición y riesgo, y soporta un cambio de políticas estructurales, basadas en seguridad, hacia un sistema integrado de manejo de catástrofes naturales basado en riesgo.