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.
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.
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]
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
There are major inequalities with regards to disease distribution. The relationship between Gross Domestic Product (GDP) and health is a starting point for examination of inequalities in the global health context. High income countries tend to have greater GDPs, which often means nations have better health systems and social services.
The distribution of ZIKV infection is unevenly spread across the globe [2]. The weight of Zika Virus Disease falls on the poor for different reasons. In tropical urban areas, those from a low socioeconomic income group are not able to manage the cost of air-conditioning, window screens, or insect repellent [4]. With no piped water and poor sanitation, they are compelled to store water in containers, giving perfect conditions to the expansion of mosquitoes [5].
The combination of ZIKV, DENV and CHIKV coinfections obfuscates the public health problem in various populations where complications due to poverty, poor basic sanitation and poor vector control persist. Further work is needed to elucidate the importance of the interactions between socio-environmental factors and transmission of ZIKV, DENV and CHIKV. The importance of SDH when understanding the risk factors that potentiate NTDs spread, is crucial for public health academics, health ministers and governments, as any interventions must consider ecological, biological and social factors.
References
1. Lobkowicz L, Ramond A, Sanchez Clemente N, et al. The frequency and clinical presentation of Zika virus coinfections: a systematic review. BMJ Global Health 2020;5:e002350.
2. Manderson L, Aagaard-Hansen J, Allotey P, Gyapong M, Sommerfeld J. Social Research on Neglected Diseases of Poverty: Continuing and Emerging Themes. PLoS Neglected Tropical Diseases. 2009;3(2):e332.
4. Lundgren K, Kjellstrom T. Sustainability Challenges from Climate Change and Air Conditioning Use in Urban Areas. Sustainability. 2013;5(7):3116-3128.
5. Dhimal M, Gautam I, Joshi H, O’Hara R, Ahrens B, Kuch U. Risk Factors for the Presence of Chikungunya and Dengue Vectors (Aedes aegypti and Aedes albopictus), Their Altitudinal Distribution and Climatic Determinants of Their Abundance in Central Nepal. PLOS Neglected Tropical Diseases. 2015;9(3):e0003545.
To the Editor;
Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The t...
To the Editor;
Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The total amount of development aid dollars was obtained from the World Bank Database (Accessed on 9/26/2015), where information of foreign assistance to Afghanistan is open to the public. The total number of articles and the total number of ODA were plotted annually from 1980 to elucidate the correlation between aid amount and scientific publication on health related topics to Afghanistan.
As shown in the Figure, there was a substantial increase in the number of publications in relation to the increase in ODA dollars especially since 2001, the year US war in Afghanistan started.
We also examined whether the publication dealt with issues on the Afghan people (those who live in Afghanistan or Afghan refugees) or on deployed personnel (deployed soldiers and their families) based on titles. Persistently low percentage of healthcare articles were on Afghans (From 1980 to 2000, only 10.2% in period 1980-2000 and 17.5% between 2001-2015). The majority of the articles were on health issues related to deployed personnel either on active duty or veterans. There was a concern for publication bias given that the search was limited to articles published in English. But when filtered the same search by language, such as Afghan, Dari, Russian, German, Spanish, or French, and Chinese, not that many articles were identified; Russian 281, French 88, German 39, Japanese 14, Spanish 9 and Chinese 0. We agree with authors of the current three analyses in terms of difficulty to obtain best-practice evidence on victims of the humanitarian emergencies. As we showed in our analysis, the evidence might be affected by how much ODA funding distributed in individual emergency.
Reference:
1. Meteke, S., et al. (2020) Delivering infectious disease interventions to women and children in conflict settings: a systemic review. BMJ Glob Health 5, e001967 DOI: 10.1136/bmjgh-2019-001967
2. Shah, S., et al. Ibid.Delivering non-communicable disease intervention to women and children in conflict settings: a systemic review. e002047 DOI: 10.1136/bmjgh-2019-002047
3. Jain, R., et al. Ibid.Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review. e001980 DOI: 10.1136/bmjgh-2019-001980
4. Goodwin, T., et al. (2019). "From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings." J Trauma Acute Care Surg 87: S35-S39.
FIGURE: ODA and number of healthcare publications by year in Afghanistan
This research would be more useful if we were given the raw data containing each misleading publication with precise references to why each misleads. Instead, we obtain a summary of the most inflammatory and outlying presentations, as if those represent the majority. Some of the videos are merely observations by professionals practicing in the field. One of the inflammatory examples about the Italian and Iranian strains stands out. Only last week Governor Cuomo said New York was afflicted by a European strain. Where were the critics calling him out?
Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
It was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lomb...
Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
It was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lombardy health care system.[5]
In democratic regimes in the era of mass communications, an institutional line of communication based on misinformation is a fallacious attempt, presumably dictated by a desire to avoid alarm among the population while preparing health measures not taken in due time. For example, it was not until February 25th that the Italian Civil Defense purchased personal protective equipment for health care workers. Reasons of state cannot justify the sacrifice of the public’s right to information either: they exist to protect the integrity of the state in general and need to find legal formalization. Misinformation has had the effect of disorienting the population and has not prevented the country from spiraling into catastrophe.[5] Sadly, the traditional media has contributed to spreading misinformation, merely reporting government reassurances or, even worse, passing on fake news.[2]
By speeding up the process of publishing articles on Covid-19, scientific publishers have enabled timely dissemination of clinically relevant information to members of the scientific community. In addition, by making journal content free and easily accessible, verified information has become available to the public. The question is: how many individuals currently turn directly to these sources? Institutional voices are the only ones the public should be able to turn to with total trust. Governments must disseminate honest information in such a way to improve awareness among the general public regarding the true seriousness of the epidemic. Conversely, misinformation on the part of institutions betrays the public’s relationship of trust in institutions. Furthermore, it generates dangerous discrimination in knowledge of the phenomenon and access to treatment and exposure to epidemic risk, especially among weaker individuals who are more likely to be without access to scientific information and to glean unverified information from social networks.
Competing interests: none. The paper did not receive funding.
References
1. Li HO, Bailey A, Huynh D, et al. YouTube as a source of information on COVID-19: a pandemic of misinformation? BMJ Global Health2020;pii: e002604. DOI:10.1136/ bmjgh-2020-002604.
2. Zarocostas J. “How to fight an infodemic”, Lancet 2020;395,10225:676.
3. Wu TJ, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet2020;395,10225:689-697.
4. Consiglio dei Ministri. Dichiarazione dello stato di emergenza in conseguenza del rischio sanitario connesso all'insorgenza di patologie derivanti da agenti virali trasmissibili. Gazzetta Ufficiale della Repubblica Italiana. Serie Generale n. 26. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahU...
5) Lazzerini, Putoto G. “COVID-19 in Italy: momentous decisions and many uncertainties”. Lancet Global Health2020 8:e641-e642. DOI:10.1016/S2214-109X(20)30110-8.
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.
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.
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 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.
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...
Show MoreSvadzian 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 MoreDear Editor,
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
There are major ineq...
Show MoreTo the Editor;
Show MoreThree articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The t...
This research would be more useful if we were given the raw data containing each misleading publication with precise references to why each misleads. Instead, we obtain a summary of the most inflammatory and outlying presentations, as if those represent the majority. Some of the videos are merely observations by professionals practicing in the field. One of the inflammatory examples about the Italian and Iranian strains stands out. Only last week Governor Cuomo said New York was afflicted by a European strain. Where were the critics calling him out?
Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
Show MoreIt was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lomb...
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...
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...
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 MorePages