Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-af...
Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-affiliated third party months in advance, embassies can hold passports for long periods, with applicants needing to satisfy vague criteria that can allow visa officials to arbitrarily deny applications. Furthermore, LMIC students often have to apply multiple times (paying new fees each time) to obtain a visa – which can be denied – thereby leaving students dejected having to delay or abandon their education abroad.
LMIC students have particular issues satisfying visa criteria around financial sufficiency, intent of return to home country (including family ties), and lack of job prospects in home country. [4] These criteria are often subjectively adjudicated by immigration officers with arbitrary results – e.g., anecdotal reports of LMIC students with full scholarships being rejected on the basis of financial insufficiency. Thus, merely offering LMIC students visa support/advice is not sufficient. Change is required in immigration policy and practice in HICs, particularly in Canada, UK, and the USA [5], to ensure LMIC students wanting to study global health can gain entry.
There are also important regional differences in how this is experienced across LMICs, with African students being more likely to be refused visas. [5, 6] Students from Asian LMICs (e.g., China, Japan, India) tend to have the easiest time at getting student visa to study in HICs – which results in HIC universities tending to concentrate their recruitment efforts in these countries, further entrenching educational inequities among LMICs.
Achieving equity in global health education will be ultimately secured as it will be in global health practice – by adequately addressing the underlying structural conditions/drivers. While everyone should support lower tuition fees and increased scholarship support for LMIC students, without a fundamental change to the current discriminatory approach to visa issuance, we will not be able to achieve equity in global health education.
References
1. Svadzian A, Vasquez NA, Abimbola S, et al. Global health degrees: at what cost? BMJ Glob Health 2020;5(8) doi: 10.1136/bmjgh-2020-003310 [published Online First: 2020/08/08]
5. The Lancet Global Health. Passports and privilege: access denied. Lancet Glob Health 2019;7(9):e1147. doi: 10.1016/S2214-109X(19)30337-7 [published Online First: 2019/08/14]
The COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Ea...
The COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Eastern Africa. As with any pandemic, emergency care acts as the receptacle for patients in extremis, with severe cases of illness, including those with imminent oxygen needs and breathing support with COVID-19 - two needs highlighted by Cabore et al. This has occurred with COVID-19 [4], as in other public health crises before it. The spotlight on emergency care as a priority for government agendas globally in the 2019 WHA 72.16 [5] resolution was a step in the right direction for the progress needed in countries where neglect of emergency care infrastructure has been appalling, and even fatal. Further research on best practices for emergency care in LMICs, including responsiveness in crises, understanding burden of NCDs in the emergency care setting, and the effect of the double burden in populations seeking care there cannot be overstated. To that end, our recent study in the largest public emergency department in East Africa [6] called Kenyatta National Hospital, shows equal or worse outcomes for all NCDs and leading risk factors outlined by the WHO’s 2013 action plan [7]. All the same, the capacity to handle emergency cases in Kenya, like most African nations, remains dismal at best due to lack of prioritization: lack of basic resources like oxygen, lack of adequately trained emergency professionals, and lack of health system infrastructure that facilitates timely access for patients.
For the first time, the global health community may have realized the crux of emergency care: as the front-lines to our healthcare systems. Communicable disease pandemics, and NCD co-afflictions alike. The WHO’s emergency care office is home to many initiatives that advance this agenda. I would hope that the remainder of the global health community follows suit.
1. Coronavirus Disease 2019 (COVID-19): Africa CDC Dashboard. 2020; Available from: https://africacdc.org/covid-19/.
2. World Health Organization. (2020). Laboratory testing strategy recommendations for COVID-19: interim guidance, 21 March 2020. World Health Organization. https://apps.who.int/iris/handle/10665/331509. License: CC BY-NC-SA 3.0 IGO.
3. Yang, J., et al., Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis, 2020. 94: p. 91-95.
4. Giving Oxygen to COVID-19 Patients in Kenya. 2020 August 8th, 2020]; Available from: https://www.emergencymedicinekenya.org/oxygenmanifold/.
5. World Health Assembly, Resolution 72.16. Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured. 2019.
6. Ngaruiya, M., MSc, DTMH, Christine, et al., The last frontier for global Non-Communicable Disease action: the Emergency Department - a cross-sectional study from East Africa. medRxiv, 2020: p. 2020.07.29.20164632.
7. World Health Organization. WHO global action plan: for the prevention and control of noncommunicable diseases 2013-2020. 2013; Available from: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf.
The effectiveness of masks in the household is a critically important topic for control of SARS-CoV-2 transmission. I am concerned the multivariate regression performed in this analysis incorrectly attributed all of the effect of post-symptomatic mask-wearing to the pre-symptomatic mask-wearing variable. It is highly likely that these 2 variables are highly co-linear, and looking at Table 2, it appears likely that those families that wore masks pre-symptoms (n=27 without transmission, n=4 with transmission) were largely the same families where all members of the household wore masks post-symptoms (n=31 without transmission, n=5 with transmission). It's likely there are not enough numbers to further disentangle whether pre-symptom or post-symptom mask-wearing truly was the benefit - most likely it's some of both.
The message that post-symptomatic mask-wearing has no effect appears to lack sufficient support, so I would caution anyone jumping to use that conclusion here.
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 as...
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 asymptomatic, 53 with mild symptoms, 7 severe cases and 1 critical case ). The median size of the families participating in this retrospective cohort study was 4 (ranging from 2 to 9 usually with children, parents and grandparents).
The conclusion and advices in the article based on data and design of the study presented needs more evidence. A retrospective cohort study based on questionnaires via telephone interviews is highly sensitive to bias and confounding. Several aspects that can influence viral infections and transmission in households have not been discussed, neither the negative aspects of implementing NPI in households and universal facemask wearing are discussed.
In this rapid response we briefly explain our interpretation of the data presented and the impact of universal face masking, social distancing and NPI as a preventive strategy in viral transmissions in households.
1. Unfortunately, the study does not explain why 39 households met exclusion criteria in the 128 households without secondary transmission compared to only 1 household in the 49 households with secondary transmission.
2. The authors do not discuss a higher percentage of people with co-morbidities in the households with secondary transmission (Table 1). Or whether severe and critical cases in the second transmission were people suffering from co-morbidities wearing masks prior to showing symptoms and/or the primary case was wearing a facemask all day or sometimes 2 days before the onset of symptoms. In many scientific publications and media articles a relation of developing severe COVID-19, Acute Respiratory Distress Syndrome (ARDS) for people with overweight, diabetes, cardiovascular disease and elderly, frail people has been described. As well as a disproportionate burden on black, Asian and minority ethnic individuals and communities.
3. In Table 2 a delay in laboratory confirmation in the group of people with secondary transmission as compared to the group of families without secondary transmission is observed. Previously, it has been reported that there have been difficulties with RT PCR tests at some stages of the epidemic in China (2). It is not clear if people have been repeatedly tested for the presence of SARS-COV-2 virus to confirm infection with the virus. The article states that the virus in respiratory or blood specimen was ‘highly homologous’ with known SARS-COV-2 through gene sequencing. It is not clear if this could be SARS-COV-1 or one of the other beta coronavirus frequently causing respiratory infections during winter times.
4. Table 3 shows a major difference in the ventilation duration per day which was less in frequency and total hours per day and residential area per capita in the group of families with secondary transmission. The review of prof Moriyama et al. “Seasonality of respiratory viral infections” indicate that the winter environment promotes the spread of a variety of respiratory virus infections. In the industrialized world most people interact and spend 90 % of their lifetime in enclosed spaces and share a limited amount of breathing air. The implication is that indoor climate and air change rates, modulated by outdoor seasonal conditions are the key drivers of seasonal patterns in epidemiology. In addition, exposure to outdoor conditions (albeit 10 % of lifetime) contributes to alteration of respiratory defence of the existing virome (3). The possibility that dry and unventilated air can increase opportunity to spread influenza virus infection in winter times has been demonstrated in mice studies. The inhalation of dry air causes immediate effects by epithelial cilia loss, impaired epithelial cell repair in lungs and inflammation of the trachea in a study with guinea pigs. Ventilation to refresh the air in crowded homes to remove aerosols with virions and support an effective immune system is important. Furthermore, recent studies reveal that season dependent environmental factors, such as temperature and humidity can affect the host antiviral innate immunity against respiratory infections (3). Therefore, it cannot be excluded that a simple ventilation of the home could have been of influence in the second transmission in the group of families with second transmissions.
5. Table 1 describes that various facemasks (cloth masks, medical masks or N95 masks) were used. How frequently masks were refreshed or washed, taken of, re-used and disposed in an appropriate way is not documented. The quality of facemasks can differ in pore size and materials used. Depending on the materials used toxic material or fibres may impair the innate immune system. A study of Chughtai et al demonstrated the existence of respiratory pathogens on the outer surface of used medical masks which may result in self-contamination. The risk was higher with longer duration of mask use (> 6h) and with higher rates of clinical contact (4). Furthermore, heart rate, microclimate temperature humidity and subjective ratings were significantly influenced by wearing of different kinds of facemasks. The local thermal stimulus also affected heat exchange from the respiratory tract. Microclimate temperature, humidity and skin temperature inside the facemask increased with the start of step exercise, which led to different perceptions of humidity, heat and high breathing resistance among subjects wearing facemasks. High breathing resistance makes it difficult for the subject to breathe and take in sufficient oxygen. Shortage of oxygen stimulates the sympathetic nervous system and increase heart rate and may results in stress and anxiety experience (5). It is probable that people feel unfit, fatigued and overall discomfort due to this reason. For people and children with hearing loss face masks can be devastating (6).
If facemasks determine a humid habitat where the SARS-COV-2 virus can remain active due to the water vapour continuously provided by breathing and captured by the mask fabric , they determine an increase in viral load and therefore they can defeat of the innate immunity and increase in infections. Whereas the main purpose of the innate immune system is to prevent the spread and movement of pathogens through the body. Other important potential side effects of wearing face masks that we should bear in mind have been clearly described by dr AL Lazzarino on 20 April 2020 in a rapid response to the article of Greenlagh et al; Face masks for the public during covid-19 crisis(7)
In the Advice on the use of masks in the context of COVID-19, interim guidance 5 June 2020 the WHO writes that potential harms and risks should be carefully taken into account when adopting the approach of targeted continuous medical mask use including self-contamination, dermatitis, false security, uncomfortable to wear, risk for droplet transmission, difficulty wearing in hot and humid environments and by vulnerable populations with mental health disorders, developmental disabilities, the deaf and hard of hearing community and children (8).
6. The negative influence of stress and anxiety on the immune system increasing the risk of upper respiratory tract infections has been well documented (9). In the period February – March China was in lockdown and families with people infected with COVID-19 virus were in quarantine. Symptoms of Post-Traumatic Stress Disorder (PTSD) and depression were observed in 28,9 % and 31,2 % of respondents in the study, respectively. has been described in Toronto after a period of quarantine during the SARS epidemic in 2002 (10). Longer durations of quarantine was associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.
7. Another major impact on the effectiveness of the immune system is nutrition and lifestyle. It is not clear if persons included in the study started to eat differently due to stress, more sitting hours in a crowded home and if families had less possibilities to buy fresh food i.e. unprocessed vegetables, fruit and meat. There could have been a difference between the group of families without transmission and families with a secondary transmission. The role of nutrition and lifestyle (sleep, social interaction and being active outdoors) in view of the preparedness for a second peak of COVID-19 for all people especially for those at higher risk preventing severe viral infections by reversing weight loss, diabetes type 2 and other chronic diseases was published by Fiona Godlee : editor in chief of the BMJ (11).
8. In the perspective on Universal Masking in Hospitals in the Covid-19 era American doctors wrote in the New England Journal of Medicine “We know that wearing a mask outside healthcare facilities, offers little, if any protection from infection. Public health authorities define a significant exposure to Covid-19 as face to face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflective reaction to anxiety over the pandemic. Focusing on universal masking alone may paradoxically lead to more transmission of Covid-19 if it diverts attention from more fundamental infection-control measures”
Results from cluster randomized controlled trials on the use of masks among young adults living in university residences in the United States of America indicate that face masks may reduce the rate of influenza-like illness but showed no impact on risk of laboratory confirmed influenza. At present there is no direct evidence (from studies on COVID-19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including COVID-19 (12)
Advice on universal face mask use and other NPI in households for people at risk or during epidemics for persons of a family of whom one or more are working in healthcare needs more advanced studies. Not only is the evidential basis insufficient, also potential risks argue against the implementation of mask wearing by billions of people and healthcare workers in family circumstances. A review of available scientific publications evaluating on the efficacy in limiting viral transmission and the impact on the physiology, immunity, mental, social, ecological (environmental) and economic level will be highly valuable for defining strategies to prevent future viral infections and transmissions. Especially in the presence of young children, people with mental disorders and disabilities and elderly people in households the negative impact on physiology, immunity as well as psychology with limitations in verbal and nonverbal expression and a risk of developing a Post-Traumatic Stress Syndrome due to quarantine needs more attention. Simple ventilation and sufficient air humidity % instructions in households, offices, transport, public areas and healthcare settings might be more effective in limiting viral transmission and entail less negative effects on physiology, immunological, social and mental level. At the mental-psychological level, face masks interfere with the exchange of facial expressions, which is quintessential for mental health. Research on mirror neurons (13) showed that humans constantly mirror each other’s facial expressions and that this exchange is the neural basis of empathy, in this respect that it allows to gauge the affective and emotional state of the other. In particular within the mother-child relationship, the quality of the affective exchange is directly related to overall mental and physical health, to this extent that when quality is poor, mortality rates in children raise dramatically (14). This has been confirmed in the most straightforward way in the field of psycho-neuro-immunology, remarkably enough specifically in viral lung disease. In 2008, Nielsen and his colleagues (15) found in a naturalistic study that mental stress leads to significantly higher mortality rates in humans suffering from viral lung disease; in 2020, Wieduwild et al.(16) reported that mice are 40% more likely to die from viral infections due to experimentally generated stress.
Moreover, with higher temperatures, sunlight and high humidity in countries in the Northern hemisphere the number of people dying from Covid-19 have been drastically reduced in the past two months. We need to use the summertime effectively to repair and boost the immune system and develop a humoral and cellular immunity to the SARS-COV-2 virus developing herd immunity among the population by being outdoors, social interactions and exposure to sunlight. At the same time improve the ventilation and absolute humidity in healthcare settings and support the immune system by improving the vitamin status of elderly people and people with co-morbidities at risk for viral infections.
References
1. Wang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W et al. Reduction of secondary transmission of SARS-COV-2 in households by face mask use, disinfection and social distancing: a short study in Beijing China. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
2. Li Y, Yar L, Li J, Chen L, Sang Y, Cai Z, Yang C. Stability issues on RT-PCR Testing of SARS-COV-2 for hospitalized patients clinically diagnosed with COVID19. J. Med. Virol. 2020; 92:903-908. Doi: 10.1002/jmv/25768.
3. Moriyama M, Hugentobler WJ, Iwasaki I. Seasonality of respiratory viral infections. Annual reviews of virology. 2020 7: 2.1-2.19 doi: 10.1146/annurev-virology-012420-02445
4. Chughtai AA, Stelzer-braid S, Rawlinson W, Potivivio G, Wang Q, Pan Y et al. Contamination by respiratory viruses on the outer surface of medical masks used by hospital healthcare workers. BMC Infect. Dis. 2019: 19:491. Doi:1186/s12879-019-4109-x
5. Liu Y, Tokura H, Guo YP, Wong ASW, Wong T, Chung J and Newton E. Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int Arch Occup Environ Health 2005; 78(5): 501-509. Doi 10.1007/s00420-004-0584-4
6. Chodosh J, Freedman ML, Weinstein BE, Blustein J. Face masks can be devastating for people with hearing loss BMJ 2020: 370 doi: /10.1136/bmj.m2683
7. Greenlagh T, Schmid MB. Czypionka T, Bassler D, Gruer L. Face masks for the public during the covid-19 crisis. BMJ 2020:369:m1435 doi:10.1136bmj.m1435. Rapid response Covid-19: important potential side effects of wearing face masks that we should bear in mind. Lazzarino AL. 20 April 2020.
8. Advice on the use of masks in the context of COVID-19. Interim guidance. 5 June 2020. https//www.who.int/publications-detail/global-surveillance-for-covid-19 caused-by-human-infection-with-covid19-virus-interim-guidance
9. Drummond PD, Hewson-Brower B. Increased psychosocial stress and decreased mucosal immunity in children with recurrent upper respiratory tract infections. J. Psych. Res. 1997.43(3):271-278. Doi:10.1016/S0022-3999(97)00002-0
10. Hawryluck L, Gold WL, Robinson S, Pogorski S, Gales S Styra R. SARS Control and Psychological effects of quarantine. Emerg. Infect. Dis. 2004. 10(7): 1206-1212. Doi: 10.3201/eid1007.030703
11. Godlee F. Covid-19: What we eat matters all the more now. BMJ 2020;370:n2840. Doi.org/10136/bmjm2840
12. Klompas M, Morris CA, Sinclair J, Pearson M, Shenoy ES et al. Universal masking in Hospitals in the Covid-19 era. New England Journal of Medicine. 2020; 382:e63 doi: 10.1056/NEJMp2006372
13. Rizolatti G, Craighero L. The mirror neuron system. Annu Rev Neurosci 2004; 27:169-192. Doi: 10.1146/annurev.neuro.27.070203.144230
14. Spitz, R. A. (1965). The first year of life: a psychoanalytic study of normal and deviant development of object relations. New York: International Universities Press.
15. Nielsen N, Kristensen T, Schnohr P, Gronbaek M. Perceived stress and cause-specific mortality among men and women: results from a prospective cohort study. Am J Epid 2008; 168(5); 481-491. https://doi.org/10.1093/aje/kwn154
16. Wieduwild E., Girard-Madoux JM, Quatrini , Laprie C, Chasson L, Rossignol R, Bernat C, Guia S, Ugolini S. 2-adrenergic signas downregulate the innate immune response and reduce host resistance to viral infection. J Exp Med 2020; 217(4). e20190554. Doi.org/10.1084/jem.20190554
Competing interests: none
Dr Carla Peeters
CEO COBALA Good Care Feels Better®
Immunology, nutrition and health transformation expert
Utrecht, The Netherlands
Professor Dr Mattias Desmet
Faculty of Psychology and Educational Sciences
University Ghent
Ghent, Belgium
We read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favou...
We read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favourable young demographic profile. However, in the highly dense urban metropolitan areas like Mumbai, Chennai and Delhi, maintenance of social distancing in overcrowded clusters is a challenge. The otherwise neglected public health care system is struggling to play the pivotal role in undertaking control measures in these areas. Lack of properly manufactured PPEs, isolation beds for mild and moderate symptomatic patients and adequate negative air pressure isolation wards for serious patients with high viral load are being highlighted at different forums [3, 4, 5]. Yet India is fighting the virus with optimism for the future.
Effective mitigation strategies will be critical to establish positive impact in control of future emerging airborne pandemics either in a mutated form or as a bioweapon. Host preferences of social distancing, restrictions on spitting, practicing hand hygiene, using disposal tissue or napkins while coughing and sneezing in public and practicing the Indian tradition of Namaste will be important in breaking the chain of transmission in other airborne diseases as well, like tuberculosis. Creation of many quarantine facilities in metropolitan cities and construction of negative air pressure isolation wards in the hospitals will be needed for successful control. Research conducted in unknown areas like aerosol transmissibility of the virus and its surface stability in the Indian circumstances will be forthcoming for undertaking disinfection [6].
References
1. Paul E, Brown GW, Ridde V COVID-19: time for paradigm shift in the nexus between local, national and global health BMJ Global Health 2020;5:e002622.
2. Brauer F. A simple model for behaviour change in epidemics. BMC Public Health. 2011;11:S3.
3. Narain JP. Public Health Challenges in India: Seizing the Opportunities. Indian J Community Med. 2016;41(2):85–88
4. R Srinivasan. Health Care in India: Issues and Prospects. Available at . Accessed on 15 Apr 2020.
5. T Jacob John. Tuberculosis Control in India: Why are we Failing? Indian Pediatrics 2014;51:523-527
6. Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020; 382:1564-1567.
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
However, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coron...
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
However, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coronavirus that is not align with or is against the recommendations of WHO and local health authorities, is now not allowed on YouTube (3) This raises the question of whether the results of this study would still be applicable now, given that it was initially conducted relatively early on in the pandemic when limited information was available from scientific bodies.
There is a lack of evidence supporting whether this new policy actually helps to reduce the number of non-factual videos gaining views on YouTube as a source of information, likely due to the fact the policy was only implemented in May 2020. It is however a positive step in a direction to combating medical misinformation.
As mentioned by the authors, the numerous ways YouTube presents content ensures that important healthcare information has the potential to reach over 2 billion users (4) of all demographic backgrounds. Although this study provides insight into the use of YouTube to disseminate reliable information during the current pandemic, as an advancement it would be useful to determine the impact of these videos on public health efforts. The YouTube videos are seen by viewers that use keywords to search for information on the virus but may not reach the wider audience needed to successfully manage the crisis. To address this concern, further studies are needed to evaluate the impact healthcare information available on YouTube is having and explore how to improve outreach of the videos containing the accurate information. This research has shown that 27.5% of the YouTube videos included spread non-factual information about COVID-19 to 24.1% of viewers (2) thus highlighting the need for social media platforms, such as YouTube, to use algorithms to prevent upload and viewing of misleading information. These changes would further the effort of public health agencies to present more of the population with accurate information to help successfully manage future public health crises.
Finally, YouTube, and social media platforms in general, may be criticised for acting as a vector in allowing misinformation to be released into the public without proper factual checks. However, there are plenty of useful roles for YouTube to play in a situation such as a pandemic. Hand washing has been proven to be one of the most effective methods of fighting the virus. (5) A study into the educational usefulness of YouTube videos about proper hand washing found 55.7% of 70 videos analysed were described as educationally useful. (6) This was a similar sample size to the original article, and demonstrates a positive role YouTube has played in providing education on a simple yet highly effective method of infection control. Social media platforms have a large influence in society and continue to grow, this creates a need for government and professionals to ensure they are effectively utilising platforms used by their populations to provide factual content to a wide audience; this is critical in a situation such as a pandemic to prevent non-factual information becoming more dominant and potentially hindering the public health initiative.
Again, we send our appreciation to the authors for bringing this very topical piece of research to light and hope the insight gained from such work can be acted upon by local, national and international governments and professional bodies in the future.
REFERENCE LIST:
Limaye RJ, Sauer M, Ali J, et al. Building trust while influencing online COVID-19 content in the social media world. The Lancet Digital Health. 2020;2;e277-e278
Li HO, Bailey A, Huynh D, et al. YouTube as a source of information on COVID-19: a pandemic of misinformation?. BMJ Global Health 2020;5:e002604.
Youtube. YouTube Policy Update 2020: Help Centre. Available at: https://support.google.com/youtube/answer/9891785 [Accessed: 10 June 2020]
Google. Press, 2020. Available at: https://www.youtube.com/about/press/ [Accessed: 11 Jun 2020]
Lotfinejad N, Peters A, Pittet D. Hand hygiene and the novel coronavirus pandemic: The role of healthcare workers. Journal of hospital infection. 2020
Lim K, Kilpatrick C, Storr J, et al. Exploring the use of entertainment-education Youtube videos focused on infection prevention and control. AM J Infect Control. 2018;46(11):1218-1223
We fully agree with the authors in terms of need for a paradigm shift. We have called it a 'pandemic' but response has been largely country centric and not at all global.
We would also like to highlight a typical reactionary response globally leading to exclusion of fathers from maternity and neonatal units.
The Covid-19 pandemic is dividing families all over the world, especially at a time when togetherness is particularly important, such as at the time of birth, death and illness. Many families are experiencing situations that are prone to leave life-long scars.
While the protection of the health of staff and mothers is of paramount importance, social distancing, curbs to travel and additional restrictions to presence of parents instituted by maternity and neonatal units across the world have created obvious difficulties for families. Having a sick baby in a neonatal unit during this pandemic is a particularly intense hardship for families. We are well aware of negative impacts of separation on children and families and the pandemic related restrictions have made this worse for the whole family, perhaps more so for parents of preterm and sick newborns.
We have previously highlighted, along with many others, the importance of optimising fathers’ experiences in the neonatal unit (Ref 1-8) and suggested a focus on a co-parenting paradigm with a clear set of recommendations for neonatal and maternity services (Ref 1).
Even though we...
We fully agree with the authors in terms of need for a paradigm shift. We have called it a 'pandemic' but response has been largely country centric and not at all global.
We would also like to highlight a typical reactionary response globally leading to exclusion of fathers from maternity and neonatal units.
The Covid-19 pandemic is dividing families all over the world, especially at a time when togetherness is particularly important, such as at the time of birth, death and illness. Many families are experiencing situations that are prone to leave life-long scars.
While the protection of the health of staff and mothers is of paramount importance, social distancing, curbs to travel and additional restrictions to presence of parents instituted by maternity and neonatal units across the world have created obvious difficulties for families. Having a sick baby in a neonatal unit during this pandemic is a particularly intense hardship for families. We are well aware of negative impacts of separation on children and families and the pandemic related restrictions have made this worse for the whole family, perhaps more so for parents of preterm and sick newborns.
We have previously highlighted, along with many others, the importance of optimising fathers’ experiences in the neonatal unit (Ref 1-8) and suggested a focus on a co-parenting paradigm with a clear set of recommendations for neonatal and maternity services (Ref 1).
Even though we have seen some progress internationally on this front, concerns related to the spread of Covid-19 have led to restrictions, which many would argue, are significant backward steps in our journey to improve fathers’ engagement, experience and enjoyment of their newborn. Beyond the father, these restrictions may also adversely impact the infant and the family. While we understand the rationale for considering the restrictions, the restrictions per se are concerning on many levels and raise many questions.
The restrictions on father’s presence seem more like an ‘easy’ knee jerk reaction rather than based on evidence. If they were based on evidence, how can we explain the wide variation in restrictions across the world? There is no suggestion that the variation is based on rates of community transmission and risk. This begs the question whether there is a lack of understanding of the negative impacts of the restriction.
In areas of low risk of community transmission it would have been useful to explore alternatives to blanket restrictions, for example, more vigorous surveillance in terms of history, temperature check and use of PPE (personal protective equipment).
In situations where restrictions were considered the most appropriate strategy, it would have been useful to put in place systems to try to mitigate some of the risks especially in very vulnerable families with very preterm and sick newborns where neonatal stay may last for months. In some places technology including apps have been used to minimise isolation and improve family bonding.
We urge healthcare providers to closely monitor how restrictions have disrupted the support that parents of a sick baby provide each other or how early father-baby attachment and development of co-parenting is being disrupted. They need to explore what measures need to be put in place for fathers and families to minimise any on-going risks and optimise outcomes.
We hope that these insights and the pandemic experience will help us to understand how better practices can be implemented in the future, when confronted with similar circumstances.
The overall economic and societal cost of the Covid-19 pandemic should not overshadow the psychological burden of parents with a preterm/sick newborn during the pandemic. Policy makers will need to consider inclusion of psychological reparation tools and actions within the recovery programmes as well as a more consistent evidence based strategy for any future pandemics.
Minesh Khashu*, MBBS MD FRCPCH FRSA; Consultant Neonatologist, Poole Hospital NHS Foundation Trust, United Kingdom
Esther Adama, RN, PhD: School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
Livio Provenzi, PhD; Psychologist, Child Neurology and Psychiatry Unit, IRCCS
Mondino Foundation, Pavia, Italy
Craig F. Garfield, MD, MAPP; Professor, Northwestern University Feinberg School of Medicine and Attending Pediatrician, Lurie Children’s Hospital, Chicago, Illinois, USA
Flora Koliouli, PhD; Psychologist, Université de Toulouse II-Jean Jaurès, Toulouse, France
Duncan Fisher OBE; FamilyIncluded.com, U.K.
Betty Nørgaard, ; Department of Paediatrics, Lillebaelt Hospital, Sygehusvej 24, 6000, Kolding, Denmark
Frances Thomson-Salo, Royal Women's Hospital, Carlton, 3053, Australia
Edwin van Teijlingen, Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH, UK
Jilly Ireland, RM, MSc, Professional Midwifery Advocate, Poole Hospital NHS Foundation Trust, Dorset, UK and Visiting Associate, Bournemouth University, UK
Nancy Feeley, RN PhD, Associate Professor, Ingram School of Nursing, McGill University, and Centre for Nursing Research & Lady Davis Institute - Jewish General Hospital, Montréal, Quebec, Canada
*Corresponding Author: minesh.khashu@nhs.net on behalf of the
FINESSE group ( Fathers In Neonatal Environment-Supporting Salubrious Experiences)
References:
1. Fisher D, Khashu M, Adama EA, Feeley N, Garfield CF, Ireland J, Koliouli F, Lindberg B, Nørgaard B, Provezi L, Thomson-Salo F, & van Teijlingen E. Fathers in neonatal units: Improving infant health by supporting the baby-father bond and mother-father coparenting. J Neon Nurs. 2018; 24(6): 306-312.
2. Stefana A, Padovani EM, Biban P, Lavelli M. Fathers' experiences with their preterm babies admitted to neonatal intensive care unit: A multi-method study. J Adv Nurs. 2018;74(5):1090-1098.
3. Arockiasamy V, Holsti L, Albersheim S. Fathers' experiences in the neonatal intensive care unit: a search for control. Pediatrics. 2008; 121(2):e215-22.
4. Sisson H, Jones C, Williams R, Lachanudis L. Metaethnographic Synthesis of Fathers' Experiences of the Neonatal Intensive Care Unit Environment During Hospitalization of Their Premature Infants. J Obstet Gynecol Neonatal Nurs. 2015; 44(4):471-80.
5. Valizadeh S, Mirlashari J, Navab E, Higman W, Ghorbani F. Fathers: The Lost Ring in the Chain of Family-Centered Care: A Phenomenological Study in Neonatal Intensive Care Units of Iran. Adv Neonatal Care. 2018; 18(1):E3-E11.
6. Noergaard B, Ammentorp J, Garne E, Fenger-Gron J, Kofoed PE. Fathers' Stress in a Neonatal Intensive Care Unit. Adv Neonatal Care. 2018; 18(5):413-422.
7. Chen YL, Lee TY, Gau ML, Lin KC. The Effectiveness of an Intervention Program for Fathers of Hospitalized Preterm Infants on Paternal Support and Attachment 1 Month After Discharge. J Perinat Neonatal Nurs. 2019; 33(2):160-169.
8. Ireland, J., Khashu, M., Cescutti-Butler, L., van Teijlingen, E., Hewitt-Taylor, J. Experiences of fathers with babies admitted to neonatal care units: A review of the literature. Journal of Neonatal Nursing. 2016; 22 (4):171–176.
We were pleased to read the review by Eisenhut K, Sauerborn E, García-Moreno C, et al. and appreciated their insights on the landscape of mobile apps addressing violence against women.
We read with great interest the authors’ observation that “collaborations between mHealth and ‘traditional’ approaches should be actively sought, subordinating the technology to the overall aims of preventing violence against women and mitigating its impacts.” In that spirit, we would like to highlight Physicians for Human Rights’ (PHR) experience implementing a “tech” solution within a larger “low-tech” programmatic ecosystem to address violence against women (VAW).
The Program on Sexual Violence in Conflict Zones at Physicians for Human Rights works with medical, legal, and law enforcement partners in Central and East Africa to address impunity for sexual violence in conflict. Since 2011, we and our partners have trained more than 2,000 professionals in the collection, documentation, and use of court-admissible forensic evidence of sexual violence. As part of this initiative, PHR developed MediCapt, an award-winning mobile application, which standardizes and digitizes the collection of forensic documentation of medical evidence of sexual violence and combines it with a mobile camera to capture and securely store forensic photographic evidence of injuries. MediCapt was “co-designed” with clinician-partners in Kenya and the Democratic Republic of the Congo a...
We were pleased to read the review by Eisenhut K, Sauerborn E, García-Moreno C, et al. and appreciated their insights on the landscape of mobile apps addressing violence against women.
We read with great interest the authors’ observation that “collaborations between mHealth and ‘traditional’ approaches should be actively sought, subordinating the technology to the overall aims of preventing violence against women and mitigating its impacts.” In that spirit, we would like to highlight Physicians for Human Rights’ (PHR) experience implementing a “tech” solution within a larger “low-tech” programmatic ecosystem to address violence against women (VAW).
The Program on Sexual Violence in Conflict Zones at Physicians for Human Rights works with medical, legal, and law enforcement partners in Central and East Africa to address impunity for sexual violence in conflict. Since 2011, we and our partners have trained more than 2,000 professionals in the collection, documentation, and use of court-admissible forensic evidence of sexual violence. As part of this initiative, PHR developed MediCapt, an award-winning mobile application, which standardizes and digitizes the collection of forensic documentation of medical evidence of sexual violence and combines it with a mobile camera to capture and securely store forensic photographic evidence of injuries. MediCapt was “co-designed” with clinician-partners in Kenya and the Democratic Republic of the Congo and is currently in use with patients in Naivasha, Kenya (Mishori et al., 2017; Naimer et al., 2017).
While MediCapt was not included in the study as it did not meet the inclusion criteria for number of downloads, it provides a clear example of an app that is deeply integrated into non-tech programmatic approaches to combat the social and institutional challenges that survivors face in accessing justice and health services. MediCapt serves as one element of a progressive series of interventions that partners engage in with PHR, helping to reinforce the overall goal of the program. In Kenya, the team at the Naivasha County Referral Hospital first engaged with PHR in 2013 through a multisectoral training with legal and law enforcement colleagues focused on forensic evidence of sexual violence and survivor-centered care.
Following more than five years of collaborating with and training clinicians at Naivasha Hospital on forensic documentation with the tools available in resource-constrained settings, we introduced MediCapt in 2018 and worked closely with the hospital team to ensure the app was integrated effectively into the clinician workflow and patient pathway. As the end users in Naivasha noted in a recent report, the MediCapt pilot was successful in part because of the multiple trainings and how the initiative fit into our joint long-term capacity development and mentoring model with the health facility (PHR, 2019).
It is critical for organizations and companies developing apps focused on sexual violence to recognize that these apps do not exist in a vacuum. Our experience with MediCapt has consistently illustrated that integration with “low-tech” approaches is critical for the success of these projects.
“mJustice: Preliminary Development of a Mobile App for Medical-Forensic Documentation of Sexual Violence in Low-Resource Environments and Conflict Zones.” Ranit Mishori, Michael Anastario, Karen Naimer, Sucharita Varanasi, Hope Ferdowsian, Dori Abel, Kevin Chugh. Global Health: Science and Practice Mar 2017, 5 (1) 138-151; DOI: 10.9745/GHSP-D-16-00233.
"MediCapt in the Democratic Republic of the Congo: The Design, Development, and Deployment of Mobile Technology to Document Forensic Evidence of Sexual Violence." Karen Naimer, Widney Brown, and Ranit Mishori. Genocide Studies and Prevention: An International Journal 2017, 11 (1) 25-35, DOI: http://doi.org/10.5038/1911-9933.11.1.1455.
The report on "Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review" is intetresting [1]. Yaacoub et al. concluded that "there is a need for contextual evidence in relation to these proposed management strategies (ie, acceptability, feasibility, impact on equity, resources considerations) [1]". Indeed, the safety issue on practicing with death body during COVID-19 pandemic is interesting but little mentioned. The evidences on possibility of disease transmission from corpse to a living person is not available. Although there is a report on infection in a medical worker who has an occupational job relating to corpse, there is still no scientific confirmation by molecular diagnostic test to confirm that there is a spreading of disease from dead body [2 - 3]. It is apparently that there are attempts for control of possible disease spreading by any settings but the important question is ont he efficacy of rpreventive methods. A simple question is whether we require a routine screening for COVID-19 pathogen in all dead bodies in the present COVID-19. crisis.
Conflict of inteterest
none
References
1. Yaacoub S, Schünemann HJ, Khabsa J, El-Harakeh A, Khamis AM, Chamseddine F, El Khoury R, Saad Z, Hneiny L, Cuello Garcia C, Muti-Schünemann GEU, Bognanni A, Chen C, Chen G, Zhang Y, Zhao H, Abi Hanna P, Loeb M, Piggott T, Reinap M, Rizk N, Stalteri R, Duda S, Solo K, Chu DK, Akl E...
The report on "Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review" is intetresting [1]. Yaacoub et al. concluded that "there is a need for contextual evidence in relation to these proposed management strategies (ie, acceptability, feasibility, impact on equity, resources considerations) [1]". Indeed, the safety issue on practicing with death body during COVID-19 pandemic is interesting but little mentioned. The evidences on possibility of disease transmission from corpse to a living person is not available. Although there is a report on infection in a medical worker who has an occupational job relating to corpse, there is still no scientific confirmation by molecular diagnostic test to confirm that there is a spreading of disease from dead body [2 - 3]. It is apparently that there are attempts for control of possible disease spreading by any settings but the important question is ont he efficacy of rpreventive methods. A simple question is whether we require a routine screening for COVID-19 pathogen in all dead bodies in the present COVID-19. crisis.
Conflict of inteterest
none
References
1. Yaacoub S, Schünemann HJ, Khabsa J, El-Harakeh A, Khamis AM, Chamseddine F, El Khoury R, Saad Z, Hneiny L, Cuello Garcia C, Muti-Schünemann GEU, Bognanni A, Chen C, Chen G, Zhang Y, Zhao H, Abi Hanna P, Loeb M, Piggott T, Reinap M, Rizk N, Stalteri R, Duda S, Solo K, Chu DK, Akl EA; COVID-19 Systematic Urgent Reviews Group Effort (SURGE) group. Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review. BMJ Glob Health. 2020 May;5(5):e002650.
2. Sriwijitalai W, Wiwanitkit V. COVID-19 in forensic medicine unit personnel: Observation from Thailand. J Forensic Leg Med. 2020 May;72:101964.
3. Sriwijitalai W, Wiwanitkit V. Corrigendum to "COVID-19 in forensic medicine unit personnel: Observation from Thailand" [J Forensic Legal Med 72 May 2020, 101964]. J Forensic Leg Med. 2020 May;72:101967.
I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rathe...
I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rather to preserve common societal goods, such as population health and welfare? According to a Danish survey, citizens may be more worried about having their relatives or the society impaired, than about becoming themselves infected by the virus.5 Limiting the spreading of SARS-CoV-2 has a major role in maintaining population health; however, addressing citizens requires a discourse of compassion engaging with their concerns.
Second, the rhetoric of war may imply a form of heroic storytelling: a distinction between heroes (the army of health professionals, who are sent to the frontline to fight the pandemic) and non-heroes (citizens, who are asked to follow orders). Yet, if their position were reconsidered, these excluded followers could play a central role in solving the crisis, for groups of diverse individuals might outperform groups of experts alone on complex problems.6 Funding agencies offer support to scientific environments; citizens should also be encouraged to join their various skills and complement those of health professionals. As learnt from the Ebola crisis, artists could for instance help enhance the clarity of health messages via culturally relevant narratives to the community.7 Hence, the need for a cooperation discourse.
Third, while promoting diversity of perspectives is pivotal to solving complex problems,6 the rhetoric of war may instil the antithetical dogma in the population mind: discipline and obedience to a common thinking. Such war conditions might in fact hinder societal creativity,8 thereby posing a paradox: terming the current societal problem as “war” may repress its own resolution. Non-violent forms of storytelling and public-minded discourses (e.g. in Denmark, “samfundssind” [“community spirit”]) are therefore needed to emancipate and include citizens in building societal responsiveness to the COVID-19 pandemic.
References
1. Rajan D, Koch K, Rohrer K, et al. Governance of the Covid-19 response: a call for more inclusive and transparent decision-making. BMJ Global Health 2020; 5(5).
2. Bali S, Dhatt R, Lal A, Jama A, Van Daalen K, Sridhar D. Off the back burner: diverse and gender-inclusive decision-making for COVID-19 response and recovery. BMJ Global Health 2020; 5(5).
3. Organization WH. WHO Director General's remarks at the G20 Extraordinary Leaders’ Summit on COVID-19 - 26 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at....
4. Lakoff G, Johnson M. Metaphors we live by. Chicago & London: The University of Chicago Press; 1980.
5. Department of Public Health at the University of Copenhagen. What concerns the Danish population about the corona crisis? 2020. https://healthsciences.ku.dk/coronadata/results/resultat-1/.
6. Hong L, Page SE. Groups of diverse problem solvers can outperform groups of high-ability problem solvers. Proceedings of the National Academy of Sciences of the United States of America 2004; 101(46): 16385-9.
7. Sonke J, Pesata V. The arts and health messaging: Exploring the evidence and lessons from the 2014 Ebola outbreak. BMJ Outcomes, 2015. http://s15762.pcdn.co/wp-content/uploads/2016/08/BMJ-Outcomes-Article-Co...
8. Simonton DK. Political pathology and societal creativity. Creativity Research Journal 1990; 3(2): 85-99.
Svadzian et al. [1] noted that most universities in high-income countries (HICs) demand higher tuition fees from low- and middle-income country (LMIC) students for masters-level global health degrees – a problem potentially further exacerbated by COVID-19, with many HIC universities increasing international tuition fees to make up a resultant funding deficit. [2] While the paper only focuses on masters-level global health degrees, it should be noted that some HIC universities, such as York University in Toronto, have long-standing undergraduate-level global health degree programs. Taking significantly longer to complete than masters degrees, these problems are felt to a greater extent for LMIC students who want to study global health as their first degree.
The fundamental premise in their paper is that if HIC universities were serious about equity then they would be offering lower tuition fees (and scholarships to support living/travel costs) to students from LMICs. This presumes that merely lowering tuition or offering more scholarships would eliminate the primary access barrier for LMIC students, especially those from less privileged backgrounds. Unfortunately, this is sadly not the case. Even students with tuition waivers/scholarships can have difficulty obtaining visas to study at HIC universities.
Student visas are a regressive tax on LMIC [3] – the requirements to obtain numerous documents that require certification, additional fee payments to an HIC-af...
Show MoreThe COVID-19 pandemic has taken the world by storm, Low- and Middle- Income Countries (LMICs) not withstanding. Cabore et al modelled best estimates for peak prevalence of the virus on the African continent to be projected at more than 37 million symptomatic cases, requiring 4.6 million hospitaliations. Current estimates by Africa CDC show over 1 million cases as of August 6th, 2020, and more than 22,000 deaths [1]. South Africa has the highest prevalence with more than half a million reported cases, followed by Egypt and Nigeria, respectively. While the actual incidence and mortality rates may be evasive given limited access to testing globally [2], it is clear that the disease has not been forgiving on African soil either.
Non-Communicable Diseases (NCDs) constitute the backdrop for worse outcomes among those infected with COVID-19 [3], and those with poorer access to care fare worse. While NCDs have gained increasing attention in the last decade, the current pandemic illuminates the alarming gap in data on the double burden of disease that is threatened by a continued lag in focus on NCDs – an improved understanding of which would have been critical in effectively addressing our current plight.
A prime example of this is in the case of research addressing NCDs in the emergency care setting, an area of research in global health that is virtually non-existent in many resource-variable settings like Kenya, which has the highest number of COVID-19 cases in Ea...
Show MoreThe effectiveness of masks in the household is a critically important topic for control of SARS-CoV-2 transmission. I am concerned the multivariate regression performed in this analysis incorrectly attributed all of the effect of post-symptomatic mask-wearing to the pre-symptomatic mask-wearing variable. It is highly likely that these 2 variables are highly co-linear, and looking at Table 2, it appears likely that those families that wore masks pre-symptoms (n=27 without transmission, n=4 with transmission) were largely the same families where all members of the household wore masks post-symptoms (n=31 without transmission, n=5 with transmission). It's likely there are not enough numbers to further disentangle whether pre-symptom or post-symptom mask-wearing truly was the benefit - most likely it's some of both.
The message that post-symptomatic mask-wearing has no effect appears to lack sufficient support, so I would caution anyone jumping to use that conclusion here.
Rapid response
Preventing viral transmissions in communities and households: strategies from a multidisciplinary view highly needed
Re: Reduction of secondary transmission of SARS-COV-2 in households by facemask use, disinfection and social distancing: a cohort study in Beijing, China. Yu Wang. BMJ Global Health 2020; 5: e002794, doi: 10.1136/bmjgh-2020-002794
Dear Editor,
In their original research in BMJ Global Health Wang et al. (1) claim that their study provides the first evidence for the effectiveness of face mask use and social distancing in preventing COVID-19 transmission, not just in public spaces but inside the household with members at risk of getting infected. They argue that these non-pharmaceutical interventions (NPI) reduce risk for families living with someone in quarantine or isolation and families of healthcare workers who may face ongoing risk and that NPI are effective at preventing transmission even in homes that are crowded and small.
More specific, Wang et al. (1) conclude that face mask use 2 days prior to symptom onset could be preventing secondary transmission while starting to wear facemasks after the onset of symptoms did not have any effect on a secondary transmission. Almost a quarter of family members became infected in the families with a second transmission ( total of 77 persons with 13 children with a mean age of 3 years with mild symptoms and one child with asymptomatic symptoms, 64 adult cases; 3 as...
Show MoreWe read with interest the commentary on COVID-19: time for paradigm shift in the nexus between local, national and global health by Elisabeth Paul et al [1] and agree with them. We would like to bring out the Indian perspective in our article and how it might change the host behaviour and health system.
Every time a pandemic has occurred, it has changed the course of history and paved the way for economic development. People have changed their health behaviour out of fear of contracting the disease and the change has become a new norm.
The novel COVID 19 pandemic is known to the world for around six months now. With a long incubation period, asymptomatic transmission and high infectiousness, it has spread rapidly, and has caused thousands of deaths in a short period. Right from the mode of transmission, control measures like ‘lockdown’, testing strategies and variable treatment modalities, the natural history of COVID 19 has been unusually rapid and lot has remained unexplained. Despite several predictive mathematical modeling exercises, the disease progression has been on its own will, infecting individuals at random and regulating itself as it has spread to countries of its choice. The clinical phenotype of the disease has been varying with time, place and person, defying the fundamental order of epidemiology. [2]
The India curve has been delayed but community transmission in clusters is evident. India is a densely populated country but with a favou...
Show MoreDear Editor,
After reading the article, we would like to sincerely congratulate the authors Heidi Oi-Yee Li, Adrian Bailey, David Huynh and James Chan on their successful piece titled ‘YouTube as a source of information on COVID-19: a pandemic of misinformation?’ published in the British Medical Journal. This is a very relevant piece of work and we would like to offer some contributions.
As the Covid-19 pandemic progresses daily, social media platforms such as YouTube, unfortunately can become victims to showcasing anecdotal and premature evidence that can lead to fatal consequences and further spread of the so called ‘infodemic’(1). The article we are responding to worryingly demonstrates the large viewership, 62,042,609, of the non-factual videos on YouTube (2). Despite this representing only a quarter of the videos used in the study this shows these videos are perhaps more popular to watch which risks miseducating a large number of viewers.
Show MoreHowever, it appears that since the publication of this article in March 2020 this issue has come to light and been addressed. YouTube has now updated its policies and created a ‘COVID-19 medical misinformation policy’ (3) . Assumingly, this policy has been created to protect its audiences from misinformation, going against viewing algorithms that would normally display videos higher up on the suggestions based on viewing number levels. The policy enforces that the spread of medical misinformation regarding coron...
We fully agree with the authors in terms of need for a paradigm shift. We have called it a 'pandemic' but response has been largely country centric and not at all global.
We would also like to highlight a typical reactionary response globally leading to exclusion of fathers from maternity and neonatal units.
The Covid-19 pandemic is dividing families all over the world, especially at a time when togetherness is particularly important, such as at the time of birth, death and illness. Many families are experiencing situations that are prone to leave life-long scars.
Show MoreWhile the protection of the health of staff and mothers is of paramount importance, social distancing, curbs to travel and additional restrictions to presence of parents instituted by maternity and neonatal units across the world have created obvious difficulties for families. Having a sick baby in a neonatal unit during this pandemic is a particularly intense hardship for families. We are well aware of negative impacts of separation on children and families and the pandemic related restrictions have made this worse for the whole family, perhaps more so for parents of preterm and sick newborns.
We have previously highlighted, along with many others, the importance of optimising fathers’ experiences in the neonatal unit (Ref 1-8) and suggested a focus on a co-parenting paradigm with a clear set of recommendations for neonatal and maternity services (Ref 1).
Even though we...
Dear Editor,
We were pleased to read the review by Eisenhut K, Sauerborn E, García-Moreno C, et al. and appreciated their insights on the landscape of mobile apps addressing violence against women.
We read with great interest the authors’ observation that “collaborations between mHealth and ‘traditional’ approaches should be actively sought, subordinating the technology to the overall aims of preventing violence against women and mitigating its impacts.” In that spirit, we would like to highlight Physicians for Human Rights’ (PHR) experience implementing a “tech” solution within a larger “low-tech” programmatic ecosystem to address violence against women (VAW).
The Program on Sexual Violence in Conflict Zones at Physicians for Human Rights works with medical, legal, and law enforcement partners in Central and East Africa to address impunity for sexual violence in conflict. Since 2011, we and our partners have trained more than 2,000 professionals in the collection, documentation, and use of court-admissible forensic evidence of sexual violence. As part of this initiative, PHR developed MediCapt, an award-winning mobile application, which standardizes and digitizes the collection of forensic documentation of medical evidence of sexual violence and combines it with a mobile camera to capture and securely store forensic photographic evidence of injuries. MediCapt was “co-designed” with clinician-partners in Kenya and the Democratic Republic of the Congo a...
Show MoreThe report on "Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review" is intetresting [1]. Yaacoub et al. concluded that "there is a need for contextual evidence in relation to these proposed management strategies (ie, acceptability, feasibility, impact on equity, resources considerations) [1]". Indeed, the safety issue on practicing with death body during COVID-19 pandemic is interesting but little mentioned. The evidences on possibility of disease transmission from corpse to a living person is not available. Although there is a report on infection in a medical worker who has an occupational job relating to corpse, there is still no scientific confirmation by molecular diagnostic test to confirm that there is a spreading of disease from dead body [2 - 3]. It is apparently that there are attempts for control of possible disease spreading by any settings but the important question is ont he efficacy of rpreventive methods. A simple question is whether we require a routine screening for COVID-19 pathogen in all dead bodies in the present COVID-19. crisis.
Conflict of inteterest
none
References
Show More1. Yaacoub S, Schünemann HJ, Khabsa J, El-Harakeh A, Khamis AM, Chamseddine F, El Khoury R, Saad Z, Hneiny L, Cuello Garcia C, Muti-Schünemann GEU, Bognanni A, Chen C, Chen G, Zhang Y, Zhao H, Abi Hanna P, Loeb M, Piggott T, Reinap M, Rizk N, Stalteri R, Duda S, Solo K, Chu DK, Akl E...
I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rathe...
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