With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.
The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Ita...
With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.
The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Italy) and the Research Center in Emergency and Disaster Medicine (CRIMEDIM, Università del Piemonte Orientale, Italy)3. According to the triage classifications, most “red” indications were maternal/perinatal emergencies, making this the most important focus of the service3.
We have seen the contribution of NEMS in our rural 80-bed hospital in Yele, Tonkolili district, with a catchment population of 150.000. The 2 ambulances stationed in our catchment area, together with ambulances sending referrals from elsewhere, presented an average of over 2 patients per 24 hours to our hospital for emergency services. We used NEMS ourselves for referrals to third-line indications upon indication. As a response to this well-functioning service, have scaled down our ambulance services with the number of drivers and vehicles reduced as they were no longer needed. In line with the NEMS-focus, the majority of presentations were maternal/perinatal admissions; we saw frequent advanced stage diseases due to first delays and in some cases second delays in light of the Three Delays framework. Still, despite the impressive pathology, there were many mothers that could receive proper care and return home in stable condition with a healthy newborn.
Fast forward not even 2 years after the connection of the last district, when the NEMS service was released to the MoHS on the first of January 2021. While ambulances frequented the hospital in December 2020, this came to a total stillstand one month later. As of that moment, the number of presentations by NEMS dropped from over 2 patients per day to one patient in the 9 months after. Due to financial troubles, the whole service collapsed. NEMS ambulances are currently gathering dust on the parking lots of governmental hospitals. Inquiry with hospitals in other districts showed a comparable drop in NEMS presentations after release of the service.
The case of NEMS may be a positive and negative example at the same time. The development of a nationwide ambulance service in a low-income country with high maternal and neonatal mortality is to be applauded. During the time NEMS was in service, the authors demonstrate that a respectable percentage of patients can be transferred to a hospital in time despite large distances and poor road conditions. Furthermore, as shorter prehospital times lead to improved outcome, the service was an important part of the health infrastructure of Sierra Leone.
The current situation with a powerless ambulance service is worse than when NEMS came into service. Before, hospitals had their own ambulance services and drivers, and were sometimes able to pick up patients from peripheral health units through intensified communication. Nowadays, hospitals have scaled down on their number of drivers and ambulances due to the presence of NEMS, and NEMS itself is unavailable for transportation of the needy. To us, it is unclear whether mismanagement, a premature program release, actual financial constraints or perhaps even corruption brought the NEMS-program to its current state. As such, the contrary of the research implications came true: due to the unavailability of the service, a lower percentage of mothers is able to reach hospitals, which will inevitably lead to an increase in maternal and neonatal mortality.
In conclusion, the authors demonstrate the NEMS-service has resulted in swift transport of patients to the proper health facilities, thereby reducing the maternal and perinatal mortality. The premature program release to the local government however has resulted in the unavailability of ambulance services, both by NEMS and local hospitals, thereby likely increasing the already worrisome maternal and perinatal mortality. The important lessons are that the development and deployment of an elaborate ambulance service is possible in sub-Saharan African countries, but premature release of such programs to local government that lack sustainable and durable resources to continue programs, may result in a situation that is worse than before the service started.
1 Caviglia M, Putoto G, Conti A, et al. Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study. BMJ Glob Heal 2021; 6: e007315.
2 Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. , 2015.
3 Caviglia M, Dell’aringa M, Putoto G, et al. Improving access to healthcare in sierra leone: The role of the newly developed national emergency medical service. Int J Environ Res Public Health 2021; 18: 1–12.
We agree with Sam-Agudu et al. on the importance of equity in public health (1), and for these reasons raise major concerns regarding the remainder of the Commentary’s focus, and similar view prevalent in this Journal (2) and the wider global health community. We respectfully outline these here, as they affect the current health focus being applied to over a billion people in sub-Saharan countries.
Sam-Agudu and co-authors state that ‘Global, equitable access to safe and effective vaccines for all age groups is critical to ending the COVID-19 pandemic’. This statement, reflecting those of the COVAX programme of the World Health Organization (WHO) and other agencies, is flawed. Equity in health means opportunity for good health, based on individual need, not measured by access to a particular pharmaceutical. A vaccine that does not significantly reduce transmission (3,4) will not end a pandemic, and where risk of severity is low from intrinsic or acquired immune status, will not significantly change outcomes. This flawed assertion also ignores costs of vaccination, both in potential adverse effects, and in resource diversion from other health programmes (public health programmes do not operate in isolation).
Regarding the evidence base used to support their argumentation, and related expected benefits of vaccination, much of Sam-Agudu et al.’s arguments are based on the African Forum for Research and Education in Health (AFREhealth) study r...
We agree with Sam-Agudu et al. on the importance of equity in public health (1), and for these reasons raise major concerns regarding the remainder of the Commentary’s focus, and similar view prevalent in this Journal (2) and the wider global health community. We respectfully outline these here, as they affect the current health focus being applied to over a billion people in sub-Saharan countries.
Sam-Agudu and co-authors state that ‘Global, equitable access to safe and effective vaccines for all age groups is critical to ending the COVID-19 pandemic’. This statement, reflecting those of the COVAX programme of the World Health Organization (WHO) and other agencies, is flawed. Equity in health means opportunity for good health, based on individual need, not measured by access to a particular pharmaceutical. A vaccine that does not significantly reduce transmission (3,4) will not end a pandemic, and where risk of severity is low from intrinsic or acquired immune status, will not significantly change outcomes. This flawed assertion also ignores costs of vaccination, both in potential adverse effects, and in resource diversion from other health programmes (public health programmes do not operate in isolation).
Regarding the evidence base used to support their argumentation, and related expected benefits of vaccination, much of Sam-Agudu et al.’s arguments are based on the African Forum for Research and Education in Health (AFREhealth) study recording 39 child deaths among 25 African hospitals across an 8-month period (5). At less than two deaths per hospital over nine months, we contend that this confirms data elsewhere that Covid-19 is in fact a relatively low-burden disease in Africa (6) and of low impact in children (7). We suggest that the authors claim that 8.3% mortality in African children compared to 0.02% in Western countries is thus flawed by a misunderstanding of the denominators involved. It should include all infection in the paediatric catchment of the five hospitals, not those admitted for Covid-19. This appears to undermine their main argument for child-vaccination.
Regarding the translation of the study’s results into policymaking, Sam-Agudu et al. do not take account of vaccination costs and indirect effects, except for the fact that they argue that vaccination will reduce school closures. This is false dilemma. School closures result from a policy decision aimed at reducing community transmission. Irrespective of their impact on health outcomes, use of vaccination that allow continued transmission will not change this dynamic.
At no point in the article do the authors mention adverse events associated with Covid-19 vaccination. Myocarditis rates alone in teenage boys are widely shown to greatly outnumber expected Covid-19 admissions (8–10), and the capacity of African health systems for dealing with these will be limited. Similarly, the article makes no reference to the existence of post-infection immunity. Evidence from several countries indicates high levels of post-infection immunity (11,12), which is demonstrated to reduce additional vaccine benefit against Covid-19 to close to zero (13). Finally, the recent arrival of Omicron is reducing disease severity and accelerating acquisition of immunity, thereby further reducing the burden of Covid-19 on health systems and populations (14).
These latter factors mean that a mass population-wide vaccination campaign, as advocated by the authors, will very likely provide minimal benefit against Covid-19 whilst coming at considerable risk. Even if vaccinating African children and adolescents was cost-effective – which it doesn’t appear to be – this would not necessarily mean it is affordable, or good value-for-money when weighed against other priorities (15). The Africa CDC estimated the direct costs of Covid-19 vaccines necessary to vaccinate the continent amounted to $10 billion (16). This consists in a diversion of resources and local capacity away from the growing burden of malaria, tuberculosis and malnutrition in these countries (17,18), to a vaccination the efficacy of which is demonstrated to wane within several months (19).
We suggest that public health interventions must be based on a comprehensive cost/risk-benefit analysis with a strong evidence-base, not restricted to one narrow aspect of a proposed intervention. Further, that equity be considered as prioritising local health needs, not simply transferring interventions considered desirable in populations elsewhere. Without this, the above analysis indicates a mass population-wide vaccination of children in sub-Saharan Africa can be expected to produce net harm.
Sincerely.
References
1. Sam-Agudu NA, Quakyi NK, Masekela R, Zumla A, Nachega JB. Children and adolescents in African countries should also be vaccinated for COVID-19. BMJ Glob Health. 2022 Feb 1;7(2):e008315.
2. Govender K, Nyamaruze P, McKerrow N, Meyer-Weitz A, Cowden RG. COVID-19 vaccines for children and adolescents in Africa: aligning our priorities to situational realities. BMJ Glob Health. 2022 Feb 1;7(2):e007839.
3. Franco-Paredes C. Transmissibility of SARS-CoV-2 among fully vaccinated individuals. Lancet Infect Dis. 2022 Jan 1;22(1):16.
4. Eyre DW, Taylor D, Purver M, Chapman D, Fowler T, Pouwels KB, et al. Effect of Covid-19 Vaccination on Transmission of Alpha and Delta Variants. N Engl J Med [Internet]. 2022 Jan 5 [cited 2022 Feb 15]; Available from: https://doi.org/10.1056/NEJMoa2116597
5. Nachega JB, Sam-Agudu NA, Machekano RN, Rabie H, van der Zalm MM, Redfern A, et al. Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries. JAMA Pediatr [Internet]. 2022 Jan 19 [cited 2022 Feb 14]; Available from: https://doi.org/10.1001/jamapediatrics.2021.6436
6. Bell D, Schultz Hansen K. Relative Burdens of the COVID-19, Malaria, Tuberculosis, and HIV/AIDS Epidemics in Sub-Saharan Africa. Am J Trop Med Hyg. 2021 Dec 1;105(6):1510–5.
7. Funk AL, Florin TA, Kuppermann N, Tancredi DJ, Xie J, Kim K, et al. Outcomes of SARS-CoV-2–Positive Youths Tested in Emergency Departments: The Global PERN–COVID-19 Study. JAMA Netw Open. 2022 Jan 11;5(1):e2142322–e2142322.
8. Lai FTT, Li X, Peng K, Huang L, Ip P, Tong X, et al. Carditis After COVID-19 Vaccination With a Messenger RNA Vaccine and an Inactivated Virus Vaccine. Ann Intern Med [Internet]. 2022 Jan 25 [cited 2022 Feb 15]; Available from: https://doi.org/10.7326/M21-3700
9. Patone M, Mei XW, Handunnetthi L, Dixon S, Zaccardi F, Shankar-Hari M, et al. Risks of myocarditis, pericarditis, and cardiac arrhythmias associated with COVID-19 vaccination or SARS-CoV-2 infection. Nat Med [Internet]. 2021 Dec 14; Available from: https://doi.org/10.1038/s41591-021-01630-0
10. Chua GT, Kwan MYW, Chui CSL, Smith RD, Cheung EC-L, Ma T, et al. Epidemiology of Acute Myocarditis/Pericarditis in Hong Kong Adolescents Following Comirnaty Vaccination. Clin Infect Dis. 2021 Nov 28;ciab989.
11. Müller SA, Wood RR, Hanefeld J, El-Bcheraoui C. Seroprevalence and risk factors of COVID-19 in healthcare workers from 11 African countries: a scoping review and appraisal of existing evidence. Health Policy Plan. 2021 Nov 2;czab133.
12. Institute for Health Metrics and Evaluation (IHME). COVID-19 Results Briefing - The African Region [Internet]. 2022 Feb. Available from: https://www.healthdata.org/sites/default/files/files/Projects/COVID/2022...
13. León T, Dorabawila V, Nelson L, et al. COVID-19 Cases and Hospitalizations by COVID-19 Vaccination Status and Previous COVID-19 Diagnosis — California and New York, May–November 2021 [Internet]. Centers for Disease Control and Prevention; 2022 Jan. Report No.: 71: 125-131. Available from: https://www.cdc.gov/mmwr/volumes/71/wr/mm7104e1.htm?s_cid=mm7104e1_w
14. Maslo C, Friedland R, Toubkin M, Laubscher A, Akaloo T, Kama B. Characteristics and Outcomes of Hospitalized Patients in South Africa During the COVID-19 Omicron Wave Compared With Previous Waves. JAMA. 2022 Feb 8;327(6):583–4.
15. Charlton V, Littlejohns P, Kieslich K, Mitchell P, Rumbold B, Weale A, et al. Cost effective but unaffordable: an emerging challenge for health systems. BMJ. 2017 Mar 22;356:j1402.
16. Meldrum A. African Union buys 270 million vaccine doses for continent. AP News [Internet]. 2021 Jan 13; Available from: https://apnews.com/article/pandemics-africa-cyril-ramaphosa-south-africa...
17. UNICEF. COVID-19 and children [Internet]. Available from: https://data.unicef.org/covid-19-and-children/
18. World Health Organization. World malaria report 2021 [Internet]. World Health Organization; 2021. Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/978924004049-e...
19. Nordström P, Ballin M, Nordström A. Risk of infection, hospitalisation, and death up to 9 months after a second dose of COVID-19 vaccine: a retrospective, total population cohort study in Sweden. The Lancet [Internet]. 2022 Feb 4; Available from: https://www.sciencedirect.com/science/article/pii/S0140673622000897
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now...
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now begun to see the ill effects of pandemic on nutrition as collateral damage.We report two important observations on occurrence of Neural tube defects and severe acute malnutrition in children during the years from 1st January to 31st December of 2020 and 2021. The study has been done in Maharashtra, India, where a team of doctors under the national health program of RBSK(Rashtriya Bal Swasthya Karyakram), examined children below 18 years for '4Ds' i.e. Defects at birth, Diseases in children, Deficiency conditions and Developmental delays including disabilities. The same districts and anganwadis were screened in 2020 and 2021. The year 2020 was a reflection of health and nutrition status of adolescent girls, who were married in the pre-Covid years and delivered babies in the year 2020 and children in precovid time. The year 2021 reflected the health and nutrition status of women in the Covid year of 2020 who had to bear the brunt of the pandemic. It also reflected the status of nutrition in children in 2020 i.e. precovid times and 2021 reflecting nutritional insult in 2020.
A total number of 2121564 children were examined in 2020. Out of them 112(0.005%) were detected to have neural tube defects ( NTDs-meningocoele, meningomyelocoele, spina bifida), though anencephaly with resultant still births do not get reported in this data. In 2021, a total of 516655 babies were examined and 101(0.02%) had neural tube defects which are four times that of 2020 as per records from RBSK .The difference is statistically highly significant.(p<0.001). The number of babies born with NTDs were probably affected by Covid induced collateral nutrition insult i.e. folic acid deficiency in women during periconceptional period. Severe acute malnutrition was detected by measuring weight for height below -3SD on WHO growth charts. 7482 children had SAM (0.353%) in 2020 and 7148 (1.38%) children had SAM in 2021.The difference is statistically highly significant (p<0.001).
Occurrence of SAM is a measure of nutritional status of children of the community. It also is indicative of acuteness of nutritional insult. Unimaginably, it stands to reason that inadequate nutrition in 2020 manifested in more children developing SAM and the number is four times more than previous year.
High incidence of NTDs is even more alarming. Covid 19 resulted in women consuming less folate rich green vegetables, and they could probably not receive iron folic acid tablets during lockdowns. This resulted in birth of more children with neural tube defects.
NTDs are a surrogate marker of micronutrient deficiency in mothers during periconceptional period ; highlighting the importance of adolescent pre pregnancy and antenatal health. This is probably the first report of micronutrient impact of Covid 19 in periconceptional women.
Both these results depict nutritional impact of Covid 19 on women and children from Maharashtra, India.
We declare no conflict of interest.
1. Sr. Adv, and former Vice Chancellor, MUHS, Mumbai, India
2. Nutrition Specialist, UNICEF, Mumbai, India,
3. Assoc. Prof, Ped and Med Edu, DYP. Med college, Pune,India
4. Sr. Consultant, Pub.health, RJNM,Mumbai, India
5. Addl Chief Sec. Govt of Mah,Mumbai, India.
References
1.Zeus Aranda, Thierry Binda, Katherine Tashman,Ananya Tadikon Daniel Maweu,Emma Jean Boley6,Isaac Mphande, Isata Dumbuya, Mariana Montaño, Mary Clisbee, Mc Geofrey Mvula,
Melino Ndayizigiye Meredith Casella Jean-Baptiste, Prince F Varney,Sarah Anyango Karen Ann GrépiJean Bethany Hedt-Gauthier, Isabel R Fulcher on behalf of the Cross-site COVID-19 Syndromic Surveillance Working Group. Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries BMJ Global Health 2021 Vol7 issue1http://dx.doi.org/10.1136/bmjgh-2021-007247)
Dear authors,
Since I have worked in remotest of PHCs in Himachal Pradesh, India and now am supervising them, the most unfavorable atmosphere for embedded research at grass roots is non availability of ethical committees and due to that either doctor fail to do research in field conditions or their research is hijacked by the medical colleges as PIs . Most of the medical colleges don't allow outside field doctors to get ethical clearance and have condition that medical college faculty would be PI for any research proposal/project, only then anyone can get research proposal listed in IEC.
I am trying to have an ethical committee notified at the level of Directorate of health so that PHC doctors can also get ethical clearance for their research this paper is talking about.
Thanks for raising this issue at global level.
Regards,
Dr. Omesh Kumar Bharti, Field Epidemiologist bhartiomesh@yahoo.com
Hi,
Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationally accepted methodologies and standards to conduct independent investigations that lasted several months and concluded the conflict could not be labeled as ethnic cleansing or genocide; and that acts of sexual violence were committed by individual soldiers and militia from all warring factions including those operating under the TPLF umbrella (3).
In describing humanitarian efforts in the region, the analysis fails to mention that food aid was systematically diverted to combatants rather than civilians and has been used by TPLF leadership in what could be fairly labeled “food as weapons for military recruitment”. Further, the analysis focuses on the assistance of multilateral organizations but fails to describe the extensive assistance provided by the Federal Ministry of Health of Ethiopia in the form of healthcare equipment (worth billions of Ethiopian Birr), medicines, salaries and other benefit packages for over 20,000 healthcare workers in the region, and to analyze the impact of the deployment of over 400 Ethiopian healthcare professionals to the Tigray region to support the Health Care Restoration Plan between November 2020 and June 2021.
This protracted war has indeed ravaged health infrastructure – not only in Tigray, but also in vast regions of Amhara and Afar. It has cost too many lives, devastated the economy, broken families, torn friendships apart, and set back global health and economic initiatives aiming to improve the health and well-being of all Ethiopians. The main victims of this war are ordinary Ethiopians: farmers, drivers, clerks, storekeepers, healthcare workers, mothers and children. We owe it to them to respect the basic tenets of academic integrity, and base our analyses on an even-handed look at the evidence and clearly reasoned arguments, rather than faulty premises and distorted narratives.
Dear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Dear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Thus, a new implementation strategy could be significantly more costly than the previous one.
Yours Sincerely
Thomas Walsh
References
1. Ross I, Esteves Mills J, Slaymaker T, et al. Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries. BMJ Global Health 2021;6:e007361.
Vaccines are our only promising key to minimizing the spread of the virus and returning to a normal life. Lockdowns and quarantines have a negative impact on people’s mental health and social lives. Vaccine passports can allow us to participate in certain activities such as traveling without having to go through extreme channels such as quarantining for weeks when you travel into or outside of a country. This can helps us transition back to life before COVID-19 while minimizing the fears of spreading the virus globally.
A very informative and well-round study that gives a somewhat comprehensive explantation (as a pioneer study) on how scientists from different fields interact with policymakers during the COVID19-pandemic. It gives a good explanation of how difficult the “sandwich position” seems to be when you have to work in a field requiring interdisciplinary competencies.
Some critique points might include the fact that one of the interviewed scientists mentioned, that wearing a mask was not effective (P4, the Netherlands on page 5). Given the view from a very European perspective, a view over to the Asian neighbours would have or could have clarified this point. (1)
The European point is another thing that needs to be taken into consideration. Although the authors mentioned that the result might not apply to other parts of the world, it is crucial to mention that this issue needs to be addressed if we talk about a better interdisciplinary workforce globally during a pandemic.
Moreover, could a quantitative approach would have led to different results? Maybe the purview or range among scientists would have been more applicable with a fitting survey so that more scientists in related fields and positions could have been reached.
Fears and reservations about anonymity could be eradicated by this study design over a potentially large(r) study population.
However, I would like to thank you for this paper and hope that broader research on the field could bring...
A very informative and well-round study that gives a somewhat comprehensive explantation (as a pioneer study) on how scientists from different fields interact with policymakers during the COVID19-pandemic. It gives a good explanation of how difficult the “sandwich position” seems to be when you have to work in a field requiring interdisciplinary competencies.
Some critique points might include the fact that one of the interviewed scientists mentioned, that wearing a mask was not effective (P4, the Netherlands on page 5). Given the view from a very European perspective, a view over to the Asian neighbours would have or could have clarified this point. (1)
The European point is another thing that needs to be taken into consideration. Although the authors mentioned that the result might not apply to other parts of the world, it is crucial to mention that this issue needs to be addressed if we talk about a better interdisciplinary workforce globally during a pandemic.
Moreover, could a quantitative approach would have led to different results? Maybe the purview or range among scientists would have been more applicable with a fitting survey so that more scientists in related fields and positions could have been reached.
Fears and reservations about anonymity could be eradicated by this study design over a potentially large(r) study population.
However, I would like to thank you for this paper and hope that broader research on the field could bring also global perspectives and answers into account.
(1) Galvin CJ, Li YJ, Malwade S, Syed-Abdul S. COVID-19 preventive measures showing an unintended decline in infectious diseases in Taiwan. Int J Infect Dis. 2020 Sep;98:18-20. DOI: 10.1016/j.ijid.2020.06.062. Epub 2020 Jun 23. PMID: 32585283; PMCID: PMC7308751.
In the BMJ Global Health article, “Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19“, Meyerowitz-Katz et al. (1) seek to assess the impact of lockdowns on population health. However, any comprehensive evaluation of the impacts of lockdown may benefit from including the broader effects that such restrictions may have on health due to environmental changes - particularly in regard to air pollution and greenhouse gas (GHG) emissions and the flow-on effects these have on human health due to climate change.
As described by the authors, lockdowns are associated with broad detriments to human health and are generally undesirable. However, there is now considerable evidence that lockdowns result in noticeable decreases in air pollution. The 6th IPCC Assessment Report deems with high confidence that air quality improved as a result of COVID-19 lockdowns (2). When global lockdowns reached their most widespread point in April 2020, global CO2 emissions decreased by 17% (3), while global NOx emissions decreased by 30% (4), representing reductions in both long-lived and short-lived climate forcers.
Unfortunately, though these variations are measurable, the effect of such fluctuations on climate change are likely to be negligible (4) and transitory in nature (5, 6). Despite the popular perception that “nature is healing” as a result of lockdowns, the effects are unlikely to mitigate climate change on their own.
In the BMJ Global Health article, “Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19“, Meyerowitz-Katz et al. (1) seek to assess the impact of lockdowns on population health. However, any comprehensive evaluation of the impacts of lockdown may benefit from including the broader effects that such restrictions may have on health due to environmental changes - particularly in regard to air pollution and greenhouse gas (GHG) emissions and the flow-on effects these have on human health due to climate change.
As described by the authors, lockdowns are associated with broad detriments to human health and are generally undesirable. However, there is now considerable evidence that lockdowns result in noticeable decreases in air pollution. The 6th IPCC Assessment Report deems with high confidence that air quality improved as a result of COVID-19 lockdowns (2). When global lockdowns reached their most widespread point in April 2020, global CO2 emissions decreased by 17% (3), while global NOx emissions decreased by 30% (4), representing reductions in both long-lived and short-lived climate forcers.
Unfortunately, though these variations are measurable, the effect of such fluctuations on climate change are likely to be negligible (4) and transitory in nature (5, 6). Despite the popular perception that “nature is healing” as a result of lockdowns, the effects are unlikely to mitigate climate change on their own.
Yet even so, they have demonstrated that behavioural change is possible, and that it is within human behaviour to reduce greenhouse gas emissions (2, 5). Behavioural pattern shifts from the pandemic – away from motor vehicle use and with decreased output from emissions-intensive industries – will cause a short-term decrease in CO2 emissions of 5% over 5 years - a change we should strive to build upon (7, 8). Lockdowns demonstrate that reducing emissions can indeed produce tangible effects on the environment.
Therefore, more than any numerical reduction in emissions, lockdowns may have given the global effort against climate change something altogether more powerful: strong evidence that widespread behavioural changes in favour of emissions reductions are possible. In short, it has given us hope. Hope that governments can – when determined – take rapid, drastic action to meet oncoming global crises. Hope that we can make a difference, and it is not beyond our collective, concerted efforts to improve our environment.
The pandemic itself, meanwhile, has been a timely wake-up call to societies that we are not invulnerable to the forces of nature – and the devastating consequences of inaction.
Together they have delivered us both a stern warning and the confidence that we can address such crises. Lockdowns are detrimental to human health, yes. But as the biggest disruption to “business as usual” in decades, they also offer all of humanity an inflection point for action, that with appropriate behavioural changes we can reduce our GHG emissions and curtail climate change’s effects in order to protect global health (9).
I do not contend that lockdowns should be employed as a solution to the climate crisis. But governmental responses to COVID-19 should serve as a blueprint for climate action, with similar resources and impetus mustered to address a comparable global threat. In the same way that economic incentives and stimulus measures such as Australia’s JobKeeper were leveraged to protect vulnerable segments of society and ease economic disruption (10, 11), so too should similar fiscal levers be utilised to incentivise clean energy transitions, retraining programs for fossil fuel-dependent communities, and the adoption of sustainable technologies and systems.
To conclude, though lockdowns exact a toll, any comprehensive evaluation of their effects on health should consider their associated reductions in air pollution and greenhouse gas emissions, and the potential ramifications they may have for the climate crisis. The drastic alteration of human behaviour – appropriately supported and facilitated by government intervention - offers humanity an inflection point to prevent climate change and a timely call to action that we must not squander.
References:
1. Meyerowitz-Katz G, Bhatt S, Ratmann O et al. Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19. BMJ Global Health 2021;6:e006653. doi:10.1136/bmjgh-2021-006653
2. Intergovernmental Panel on Climate Change (IPCC), 2021. Climate Change 2021: The Physical Science Basis. Contribution of Working Group I to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge University Press. In Press. Available from: https://www.ipcc.ch/report/ar6/wg1/downloads/report/IPCC_AR6_WGI_Full_Re...
3. Le Quéré C, Jackson R, Jones M et al. Temporary reduction in daily global CO2 emissions during the COVID-19 forced confinement. Nature Climate Change 2020;10:647-653. doi:10.1038/s41558-020-0797-x
4. Forster P, Forster H, Evans M et al. Current and future global climate impacts resulting from COVID-19. Nature Climate Change 2020;10:913-919. doi:10.1038/s41558-020-0883-0
5. Li L, Li Q, Huang L et al. Air quality changes during the COVID-19 lockdown over the Yangtze River Delta Region: An insight into the impact of human activity pattern changes on air pollution variation. Science of The Total Environment 2020;732:139282. doi:10.1016/j.scitotenv.2020.139282
6. Shi Z, Song C, Liu B et al. Abrupt but smaller than expected changes in surface air quality attributable to COVID-19 lockdowns. Science Advances 2021;7. doi:10.1126/sciadv.abd6696
7. Shan Y, Ou J, Wang D et al. Impacts of COVID-19 and fiscal stimuli on global emissions and the Paris Agreement. Nature Climate Change 2020;11:200-206. doi:10.1038/s41558-020-00977-5
8. Le Quéré C, Peters G, Friedlingstein P et al. Fossil CO2 emissions in the post-COVID-19 era. Nature Climate Change 2021;11:197-199. doi:10.1038/s41558-021-01001-0
9. Venter Z, Aunan K, Chowdhury S et al. COVID-19 lockdowns cause global air pollution declines. Proceedings of the National Academy of Sciences 2020;117:18984-18990. doi:10.1073/pnas.2006853117
10. Kent K, Murray S, Penrose B et al. Prevalence and Socio-Demographic Predictors of Food Insecurity in Australia during the COVID-19 Pandemic. Nutrients 2020;12:2682. doi:10.3390/nu12092682
11. Bryson H, Mensah F, Price A et al. Clinical, financial and social impacts of COVID-19 and their associations with mental health for mothers and children experiencing adversity in Australia. PLOS ONE 2021;16:e0257357. doi:10.1371/journal.pone.0257357
To the editor,
With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.
The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Ita...
Show MoreDear Editor,
We agree with Sam-Agudu et al. on the importance of equity in public health (1), and for these reasons raise major concerns regarding the remainder of the Commentary’s focus, and similar view prevalent in this Journal (2) and the wider global health community. We respectfully outline these here, as they affect the current health focus being applied to over a billion people in sub-Saharan countries.
Sam-Agudu and co-authors state that ‘Global, equitable access to safe and effective vaccines for all age groups is critical to ending the COVID-19 pandemic’. This statement, reflecting those of the COVAX programme of the World Health Organization (WHO) and other agencies, is flawed. Equity in health means opportunity for good health, based on individual need, not measured by access to a particular pharmaceutical. A vaccine that does not significantly reduce transmission (3,4) will not end a pandemic, and where risk of severity is low from intrinsic or acquired immune status, will not significantly change outcomes. This flawed assertion also ignores costs of vaccination, both in potential adverse effects, and in resource diversion from other health programmes (public health programmes do not operate in isolation).
Show MoreRegarding the evidence base used to support their argumentation, and related expected benefits of vaccination, much of Sam-Agudu et al.’s arguments are based on the African Forum for Research and Education in Health (AFREhealth) study r...
Covid 19- women’s health, occurrence of neural tube defects and severe acute malnutrition in children
Phadke M1,Nair R2,Menon P3,Jotkar R4, Saunik S5
Dear sir,
We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
Show MoreIndia has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now...
Dear authors,
Since I have worked in remotest of PHCs in Himachal Pradesh, India and now am supervising them, the most unfavorable atmosphere for embedded research at grass roots is non availability of ethical committees and due to that either doctor fail to do research in field conditions or their research is hijacked by the medical colleges as PIs . Most of the medical colleges don't allow outside field doctors to get ethical clearance and have condition that medical college faculty would be PI for any research proposal/project, only then anyone can get research proposal listed in IEC.
I am trying to have an ethical committee notified at the level of Directorate of health so that PHC doctors can also get ethical clearance for their research this paper is talking about.
Thanks for raising this issue at global level.
Regards,
Dr. Omesh Kumar Bharti, Field Epidemiologist
bhartiomesh@yahoo.com
Hi,
Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.
Dear Editor
The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.
In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...
Show MoreDear Editor
Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)
The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.
However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.
When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.
Thus, a new implementation strategy...
Show MoreVaccines are our only promising key to minimizing the spread of the virus and returning to a normal life. Lockdowns and quarantines have a negative impact on people’s mental health and social lives. Vaccine passports can allow us to participate in certain activities such as traveling without having to go through extreme channels such as quarantining for weeks when you travel into or outside of a country. This can helps us transition back to life before COVID-19 while minimizing the fears of spreading the virus globally.
A very informative and well-round study that gives a somewhat comprehensive explantation (as a pioneer study) on how scientists from different fields interact with policymakers during the COVID19-pandemic. It gives a good explanation of how difficult the “sandwich position” seems to be when you have to work in a field requiring interdisciplinary competencies.
Show MoreSome critique points might include the fact that one of the interviewed scientists mentioned, that wearing a mask was not effective (P4, the Netherlands on page 5). Given the view from a very European perspective, a view over to the Asian neighbours would have or could have clarified this point. (1)
The European point is another thing that needs to be taken into consideration. Although the authors mentioned that the result might not apply to other parts of the world, it is crucial to mention that this issue needs to be addressed if we talk about a better interdisciplinary workforce globally during a pandemic.
Moreover, could a quantitative approach would have led to different results? Maybe the purview or range among scientists would have been more applicable with a fitting survey so that more scientists in related fields and positions could have been reached.
Fears and reservations about anonymity could be eradicated by this study design over a potentially large(r) study population.
However, I would like to thank you for this paper and hope that broader research on the field could bring...
In the BMJ Global Health article, “Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19“, Meyerowitz-Katz et al. (1) seek to assess the impact of lockdowns on population health. However, any comprehensive evaluation of the impacts of lockdown may benefit from including the broader effects that such restrictions may have on health due to environmental changes - particularly in regard to air pollution and greenhouse gas (GHG) emissions and the flow-on effects these have on human health due to climate change.
As described by the authors, lockdowns are associated with broad detriments to human health and are generally undesirable. However, there is now considerable evidence that lockdowns result in noticeable decreases in air pollution. The 6th IPCC Assessment Report deems with high confidence that air quality improved as a result of COVID-19 lockdowns (2). When global lockdowns reached their most widespread point in April 2020, global CO2 emissions decreased by 17% (3), while global NOx emissions decreased by 30% (4), representing reductions in both long-lived and short-lived climate forcers.
Unfortunately, though these variations are measurable, the effect of such fluctuations on climate change are likely to be negligible (4) and transitory in nature (5, 6). Despite the popular perception that “nature is healing” as a result of lockdowns, the effects are unlikely to mitigate climate change on their own.
Yet even so...
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