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...
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.
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
Since long, the debate on meritocracy has been in the academic circle which originated from academicians, researchers, professionals and students belonging to ‘lower and/or backward’ castes. However, not much attention was paid to such discussions by the privileged and elite majorly because of their vested interests associated with it or due to the fact that we considered this caste as an uneducated, uncivilized and voiceless community unless they are educated and speak for themselves their voice become a part of the politicization of caste system.
This uncomfortable point is time and again raised by many on several instances like suicide of Rohith Vemula (Leonard, 2019: 52), hurling abuses by Prof Seema Singh to the marginalized caste students in IIT Kg (Datta, 2021), etc. however, meritocracy becomes a topic of intense discussion when a globally recognized political philosopher Michael Sandel put them into words and problematizing the way the elites think.
Once again, the lateral entry in UPSC was criticised at various fronts ranging from students’ protests to policy researchers. The connection of meritocracy with public policy and public health is due to technocracies and the policy decisions which were not so fruitful in the recent past. However, this was the same danger which dissenters were warning the world. That reminds us of Avengers Endgame when Tony Stark said to Steve Rogers that we are Avengers and not “pre-vengers”.
Similarly, scientists believing in the perfect ‘built-in’ of science is objectifying the pillars of science which are in the language of Thomas Kuhn a scientist cannot rely on objectivism because science relies on subjective worldview, with the new scientific methods, inventions, discoveries for developing new paradigm it is important to redefine corresponding science wherein old problems could become relegated or considered unnecessary, hence thriving on endless subjective possibilities (Kuhn, 2012: 103). Through this, shifting from the linear path to a new paradigm may occur. Hence, believing in one ‘built-in’ and ‘structure’ are not scientific but fulfilling some interests of the ‘rock stars of science’.
The problematization of meritocracy can be viewed from various aspects in this country. The current social structure makes it challenging to develop an inclusive, long term and decentralizing policy whereas the present policy approach is short-sighted non-participatory in nature. The most intriguing instances of the current policy approach are: (1) India being one of the biggest exporter of wheat and millions of people are facing shortage of food; (2) Maharashtra is high performing state in NRHM and women in Palgarh region are suffering from Severe Acute Malnutrition.
The above mentioned problems may look grim but the author also portrays a dim light of hope in the form of collection of extraordinary stories by Dr R Balasubramaniam. These stories represent people who may not come to mainstream education system but with their wit and will they have made a path breaking journey.
Moreover, their remarkable leadership stories tell us about the state of the country. At one hand, unsuccessful implementation of public policies has made the condition of tribal population dreadful, leaving them with limited resources, and on the other hand, the tribals under specific circumstances build up pathways for a better life. These stories make the mainstream meritocrats think about their compassion to uplift others twice and demand introspection. In Dr Srinivas’ words, “authors’ lessons emerge from multiple grounded experiences, many of which were failures of his imagination, which he gladly accepts and learns from, all the while being open to learning more and bowing more”. Thus, the humility which Dawkins asked for. With this, author is challenging the top to bottom approach and demands meritocrats to learn from the grassroots social innovations.
1. Datta, Sayantan. (2021, May 22). Caste and Meritocracy Keep India’s Top Institutions Running. At What Cost? Science The Wire. https://science.thewire.in/education/seema-singh-iit-kharagpur-students-...
2. Kuhn, T. S. (2012). The structure of scientific revolutions: With an Introductory Essay by Ian Hacking. The Structure of Scientific Revolutions (pp. 1–128). The University of Chicago Press.
3. Leonard, D. (2019). Towards a caste-less community :Dalit experience and thought as “movement.” Economic and Political Weekly, 54(21), 47–54.
Dear Authors, very interesting and convincing study. It is known that smallpox and polio have no human reservoirs (only infecting Humans) making the vaccine strategy very efficient. However, what about the animal reservoirs of covid-19 ? If such animal reservoirs of covid-19 exists it (highly likely, and proposed as the initial step of the pandemy: infection of an human from an animal carrying covid-19 in Wuhan...) will make the eradication of the virus impossible, except if you vaccinate those animals also or kill them simply...Did you take into account animal reservoirs in your study (the big difference with smallpox and polio used as exemple). Regards. M Maresca
The authors report a reduction in transmission in households regularly disinfecting with chlorine or ethanol based agents, but what is being disinfected is quite vague. Does this include household that, for example, only use bleach in the bathroom? Was this limited to household disinfecting ALL non-porous contacted surfaces? Did this include the use of bleach on laundry? If the authors could clarify what cleaning practices this actually encompasses, that would be appreciated.
An additional factor of importance in the perception of a gender imbalance is the consequence of an age difference between partners (e.g. groom and bride) and the growth rate of the respective society. If, for example, there was a constant age difference of 5 years between (older) men and (younger) woman, and around 2% of annual population growth, leading to an increase of 10% in the number of births over each 5 years, that in its effect would just counterbalance a 10:9 sex imbalance (around 47.5% women to 52.5% men). In a shrinking society with a similar preference for younger women, the two effects would add and the imbalance in birth rates would feel even worse for men.
The imbalance would ultimately affect the “market power” of the respective genders in partnerships and/or the “marriage market”. If women actually prefer a partner of similar age, and woman of one cohort can start to pursue that preference due to the “oversupply” of men, this would further enhance the marriage squeeze for men, as even more of the older bachelors would be left out while the women turn to the younger competitors of the older men. Certainly, in the advent of such transition, some men will overlook that effect and thus be left out unmarried once the patterns have changed.
A gradual increase of the age of marriage may also trigger or enhance that effect: Young women (or their parents, to the extent they are participating in the choice of their daughters partner or life partner)...
A gradual increase of the age of marriage may also trigger or enhance that effect: Young women (or their parents, to the extent they are participating in the choice of their daughters partner or life partner) may prefer a somewhat older partner that has gained some experience in life and some economic wellbeing and thus can provide safety for a family. If women decide to marry later, partner of their own age will already be established in the workplace and thus deem adequate. The transitory effect, e.g. a cohort of women marrying around 20 combining with men around 25, to be followed by a cohort women that prefers to marry men of similar age when the marry at an age of around 25 or 30 will again contribute to a male shortfall.
Conversely, a surplus of male bachelor could also lead to them turning to increasingly young women or girls as wives, where local legislation allows, to offset the shortfall. That could, however, never be a permanent remedy and it should be investigated if such an effect is statistically visible at all among effects that provide for a lower age difference.
Effects to the other direction probably occurred when a significant proportion of men died in wars, as happened in Germany during the world wars, and led to a deficiency of men. As the age difference to their partner preferred by men gradually increase with age, and a male deficit makes it easier to pursue their preferences, a relative surplus of younger women can be absorbed rather easily: Even if every second man would disappear due to war, a relative balance could still be maintained if x% of all men of 20 to 29 combine with x% of women of 20 to 24, y% of the (remaining) men of 30 to 39 combine with y% of women of 25 to 29, and so on;
It can be assumed that a surplus or deficit in men or woman also affects the difference in age at marriage.
A statistical analysis should there look if the causing events “loss of young men in war” or “loss of female births due to prenatal sex selection” leads to a shift in the age difference between (first-time) grooms and brides. The evolution of dowries (payments by the bride’s parents) and of bride prices (payments to the bride’s parents) as a result of prenatal sex selection or other changes would also warrant attention.
A more elaborate investigation would also look at effects of male or female surplus in different social strata of society. Under conventional attitudes, it could be expected that in a male surplus situation, men marry “downwards” the social ladder and poorer men remain involuntary bachelors, while upward mobility through marriage becomes easier for women. In systems that allow some identification of the social status of persons by aspects like the Caste system in India and the Hukou system in China, these effects possibly can be identified more easily. Men belonging to one of the higher strata can be expected to fare better under male surplus conditions.
If parents are made to learn earlier that the prospects of male and female descendants are changing, that should reduce their tendencies for prenatal sex selection.
McKinn et all state in their work published in the BMJ state that drivers of antibiotic misuse in Vietnam are socio-economic than biomedical in nature (1). However, does linguistics play a role as well?
What is an antibiotic? The generally accepted definition is that an antibiotic is a drug that is used for the treatment of bacterial infections (less commonly to prevent), these agents can either kill or inhibit the growth of bacteria.
However, the term antibiotic, as opposed to an antibacterial, may denote a drug with a wider activity, an agent that is active against any “biotic”. Reading on the origin of this term, it appears that this was the original meaning of this term (2).
In a couple of recent surveys that we conducted, we identified that many people have this misconception. This was more obvious in open ended questions. In an online survey conducted in Sri Lanka, 190 (93.1%) participants out of 204 stated they knew what an antibiotic is and defined it in their own terms. However, 51 (26.8%) of this190 defined antibiotics as agents that can kill any micro-organism (3).
In the same group of people, 12 mentioned substances other than antibiotics as examples of antibiotics, including antiseptics with antibacterial properties such as povidone iodine and triclosan, a vaccine (anti-rabies vaccine), paracetamol, chlorpheniramine and cetirizine, domperidone, aspirin, insulin, saline, and plants (cannabis and “weniwelgeta”).
In both the...
In both the above study and another survey done among a group of attendees to an out patient department in Sri lanka (4), many people believed that antibiotics can cure or speed up recovery from common cold. This was expressed by 391 out of 450 (86.9%) OPD attendees and 147 out of 204 (72.1%) in the online survey.
Has the use of the term “antibiotic” instead of “antibacterial” contributed to a confusion in understanding on the action of an antibiotic, leading to misuse of antibiotics?
1. McKinn S, Trinh DH, Drabarek D, Trieu TT, Nguyen PTL, Cao TH, Dang AD, Nguyen TA, Fox GJ, Bernays S. Drivers of antibiotic use in Vietnam: implications for designing community interventions. BMJ Glob Health. 2021 Jul;6(7):e005875. doi: 10.1136/bmjgh-2021-005875. PMID: 34257138.
2.Selman A. Waksman. What is an Antibiotic or an Antibiotic Substance?, Mycologia. 1947; 39:5, 565-569, DOI: 10.1080/00275514.1947.12017635
3.Priyasad I, Abeyrathna HMHGGSS, Abhayasinghe PRRMRD, Althaf KR, Amarajeea OR, Liyanapathirana LVC (2018). Knowledge, attitudes and practices related to antibiotic resistance among a cohort of internet users in Sri Lanka. The Bulletin of the Sri Lanka College of Microbiologists. Volume 16(1), 33-34. (Poster presentation)
4.Abhayasinghe PRRWMRD, Abeyrathna HMHGGSS, Amarajeewa OR, Althaf KR, Alahakoon AMAPK, Abewardhana IMAP, Alahakoon ARRP, Al-Hithaya UKF, Amarasinghe AKDAE, Dema C, Pelzom T, Liyanapathirana V. AWARENESS ON ANTIBIOTIC USE AND DRIVERS OF ANTIMICROBIAL RESISTANCE AMONG PATIENTS ATTENDING THE OUT PATIENT DEPARTMENT AT TEACHING HOSPITAL, PERADENIYA. Presented at the Annual Academic Sessions of the Kandy Society of Medicine 2020. Book of Abstracts pp 65.
Ranzani et al.  elegantly describe the research priority framework to address the deteriorating TB situation for the mainly LMIC countries of Latin America, which has relevance to other regions. Although the countries of WHO Europe have reduced the overall TB burden (by an average 5.1% annually from 2014-18), multidrug resistant TB rates (MDRTB) are persistently high with the proportion of Rifampicin-resistant and MDRTB among new (18%) and previously TB treated (54%) cases significantly exceeding the global average (3.4% and 18% respectively) . The HIV situation in this region is also dire; 1.4 million people were living with HIV in Eastern Europe and Central Asia in 2017, with the two highest proportions in Russia and Ukraine , creating a significant TB-HIV co-infection problem where 13.1% of TB patients tested were HIV infected .
The COVID-19 pandemic has impacted all countries, but acutely on TB diagnostics and treatment especially in high TB burden LMICs. Recently the StopTB partnership examined the diagnosis and treatment statistics for nine countries, including Ukraine, representing 60% of the global TB burden; TB diagnosis and treatment enrolment in 2020 declined by 1 million or an average 23% in individual countries compared to 2019 .
The WHO leads global efforts to prioritise research (and research is a key intervention as one of the pillars of the WHO End TB Strategy) with regional variations [5,6,7]. For Eastern Europe, the global i...
The WHO leads global efforts to prioritise research (and research is a key intervention as one of the pillars of the WHO End TB Strategy) with regional variations [5,6,7]. For Eastern Europe, the global importance of TB and HIV is clear but carefully planned priorities, pre the COVID epidemic, might not be as relevant to clinical investigators on the ground during the pandemic.
Drawing on current and planned research priority topics within the WHO European region , to frame our questionnaire, we surveyed respiratory and infectious disease specialists in the TB and HIV field in four cities in Ukraine, Russia and Moldova, to understand whether the view on these priorities was changing due to the ongoing COVID19 epidemic. Even if the main priorities for the programmes were to remain, would the delivery objectives remain similar? A questionnaire piloted in English, Ukrainian, Russian and Moldovan was cascaded via a senior infectious disease specialist and 42 respondents completed the survey: 17 Moldova (Chisinau), 13 Ukraine (Kharkiv, Vinnytsya) and 12 Russia (Arkhangelsk).
Priorities identified within each country;: 90 to 100% of all respondents prioritised: a whole genomic sequencing or targeted DNA generation sequencing approach for TB drug susceptibility testing from TB cultures or direct from patient sputa; improving HIV community testing and/or replacement of HIV diagnosis confirmation by Western blotting to address late presentation by HIV positive patients; implementation of integrated diagnostic testing strategies for TB, HIV and viral hepatitis (including a mobile laboratory solution).
Additionally, in Moldova between 90 and 100% of respondents prioritised research on a prospective non-sputum biomarker to establish TB diagnosis of TB and to establish cure of MDRTB patients.
In Ukraine, all respondents prioritised research on the effects of internal migration due to conflict – including the healthcare needs of displaced populations. In Russia, all respondents would also pursue research on a clinical trial of short course 12 months therapy of an all oral MDRTB drug regimen.
But reflecting the current pandemic, all Russian specialists, 89% Moldovan and 77% Ukrainian also prioritised understanding effects of COVID on TB and HIV healthcare issues.
In conclusion, we report a high level of interest in understanding COVID-19 impacts on TB and HIV, but overall, a clear determination to continue the core research priorities for TB and HIV which align with WHO European regional priorities [2,4,5,6,7].
 Ranzani, OT, Pescarini, JM, Martinez, L and Garcia-Basteiro, AL. Increasing TB burden in Latin America: an alarming trend for global control efforts. BMA Global Health 2021;6;e005639 doi10.1136/bmjgh-2021-005639.
 ECDC and WHO Regional Office for Europe. TB surveillance and monitoring in Europe: 2020-2018 data. ECDC Stockholm; 2020).
 Ending AIDS:UNAIDS, 2018
 StopTB partnership TB and COVID: One year on Media Brief FINAL 19 March 2021. http://www.stoptb.org/webadmin/cms/docs/20210316_TB%20and%20COVID_One%20...).
 Fifth European Laboratory Initiative (ELI) on TB, HIV and Viral Hepatitis Core Group Meeting Copenhagen, Denmark 14-15 November 2019 https://www.euro.who.int/__data/assets/pdf_file/0015/428001/5th-ELI-meet...
 WHO Regional Workshop on Advancing Implementation Science on HIV and Viral Hepatitis in Eastern Europe and Central Asia. 10–11 February 2020 Berlin, Germany. WHO Europe 2020.
 World Health Organization. (2019). WHO recommends countries move away from the use of western blotting and line immunoassays in HIV testing strategies and algorithms: policy brief. World Health Organization. https://apps.who.int/iris/handle/10665/329915.
Tamrakar and colleagues have undertaken a welcome, and coherent, evaluation of the completeness and representativeness of prevalence inputs for low back pain used in the Global Burden of Disease (GBD) 2017 study . These types of assessments are particularly important so that users are aware of the uncertainties at each stage of the process for estimating disability-adjusted life years – and even more so for low back pain, which is consistently found to be one of the leading causes of health losses worldwide. They can assist users in appraising modelled estimates in a way that can more readily be triangulated with country-level evidence.
Issues of uncertainty and generalizability of modelled estimates mainly arise due to a paucity of data. From the perspective of burden of disease assessment this is common across many health conditions which are data sparse, and thus have to rely on modelled estimates on the occurrence and distribution of severity of cases . In the case of low back pain this mainly arises because a large proportion of people do not routinely access care services to manage their symptoms, which is also common for other musculoskeletal disorders and headaches. In both the GBD and national burden of disease assessments, the reliance of secondary use of administrative data (e.g. hospital, prescriptions or GP consultation records) is not an ideal proxy.
The public health monitoring of individual health conditions has reached a watershed mome...
The public health monitoring of individual health conditions has reached a watershed moment with the COVID-19 pandemic. The wider harms of the pandemic have meant there have been delays, cancellations and restrictions to accessing health, and other care, services. It is expected, and has been since reported, that this will lead to increases in both the severity and occurrence of disease [3,4]. From the perspective of low back pain and other musculoskeletal disorders, there is a potential for increased, and exacerbated, short- and long-term harm in relation to occurrence and severity. The main influencing factors are related to the mass move to individuals working from home in environments that may not allow them to work ergonomically, and changes to level of physical activity, both of which are likely to have differential exposure depending on socioeconomic status.
A harmonized and generalizable approach for monitoring both the prevalence and severity of low back pain and other common, and debilitating, health conditions that are not suitably captured by routine administrative records are required to ensure we can monitor, and respond to, changing population health needs.
 Tamrakar M, Kharel P, Traeger A, et al. Completeness and quality of low back pain prevalence data in the Global Burden of Disease Study 2017. BMJ Global Health. 2021;6:e005847.
 Wyper GMA, Assuncao R, Fletcher E, et al. The increasing significance of disease severity in in a burden of disease framework. Scandinavian Journal of Public Health 2021;in press.
 Douglas M, Katikireddi SV, Taulbut M, et al. Mitigating the wider health effects of covid-19 pandemic response. BMJ 2020;369:m1557.
 Niedzwiedz CL, Green MJ, Benzeval M, et al. Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study. Journal of Epidemiology and Community Health 2021;75:224-231.
None of the authors of this decolonising roadmap listed an association with an academic institution in a low-and middle-income country (LMIC). They represented two London schools, two NGO organizations based in Geneva, and one from a former colony—Australia. No doubt these authors share a wealth of experience in low- and middle-income countries but the platforms they chose to speak from exemplify some of the best of high-income country Western (Northern?) educational and humanitarian outreach.
The critical inequities they cite include:
• Limiting participation of LMIC experts and community representatives
• Arbitrarily choosing interventions or research topics with little coordination or engagement
• Typically placing European or North American ‘experts’ in leadership positions with minimal experience working in the project setting,
• Basing staff, offices and other resources in high-income countries
• Funding application evaluation panels without or with limited representation from affected communities or stakeholders in which work will be done; grants awarded without due consideration for partnership ethics.
A 15 April 2021 Nature Medicine letter reported, “Not one African institution was named in the press release” when a USD30 million grant for assisting African nations in “improved use of data for decision-making in malaria control and elimination” was announced. 1
Perhaps this BMJ GH editorial is a roadmap for s...
Perhaps this BMJ GH editorial is a roadmap for starting a revised and improved dialogue. When viewed through the lens of the LMIC academic community who often are involved directly or indirectly in projects and especially research, there are additional areas of decolonising that require addressing:
• Trusting and supporting local LMIC stakeholders to initiate projects of value to their communities and to head or co-head those projects including shared authority over funds
• Agreeing to share benefits of projects including (but not limited to)
o equipment, travel support for presentations
o authorship equity, i.e., criteria that is not Western dominated 2, 3
• Ensuring bidirectional visits between HIC and LMIC researchers rather than LMIC stakeholders serving only as hosts
• Encouraging international conferences to be “hybrid” with options for virtual presentations and posters to avoid the financial burdens of air travel, visas, and accommodation while allowing for professional advancement and CV entries (the
Covid-19 pandemic demonstrated the feasibility of the virtual and hybrid meetings)
• Promoting recognition for the vital research and programs initiated and performed by LMIC-based organizations such as African Academy of Science, African Union, and institutions including universities in Nigeria, Ghana, Botswana, South Africa, Uganda, Kenya, Ethiopia, Rwanda, etc.
• Discouraging the push to submit articles to “high-impact” (spell that Western, often proprietary that may charge exorbitant fees for open access) journals rather than encouraging publication in the national or continent-wide journals within the LMICs
• Seeking solutions to attenuate the dominance of English proficiency for communication as well as publications
The road to decolonising global health is long with numerous curves and potholes but the authors of the editorial are clearly thoughtful and intentional in addressing the issues. We appreciate the opportunity to expand the dialogue.
1 Erondu, N.A., Aniebo, I., Kyobutungi, C. , Midega J, Okoro E, Okumu F. Open letter to international funders of science and development in Africa. Nat Med. 2021. https://doi.org/10.1038/s41591-021-01307-8
2 International Committee of Medical Journal Editors. Defining the Role of Authors and Contributors. Available at: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/d.... Accessed 15 April 2021.
3 Tarpley M. Letter to the editor: Honorary authorships in surgical literature. World J Surg. 2020; 44(2):644-645. DOI 10.1007/s00268-019-05261-y.
Ghaffar, Rashid, Wanyenze, and Hyder invite to the dialogue and debate on the revision for public health education (PHE) as a topic of global importance. They do it from a diverse perspective including the developed and developing economies, and the challenges of practice.
I want to contribute based on the lessons learned from my experience during a previous pandemic, and my concern on the lack of full realization of the potential of public health methods and knowledge to manage this current crisis.
Since the Influenza A(H1N1) 2009 pandemic, we realized that its management called for work with the economic, educational, agriculture and nutrition, labor, housing, transportation, tourism, and it can be achieved only with established platforms for this collaboration (1). The epidemic demanded for a differentiated care of the poor and those with cultural barriers, the pregnant, of those living with obesity or chronic co-morbidities. That it required massive behavioral change – only possible though effective health promotion functions -, and the assurance of safe settings, medical care (2), and products. That the local action had global implications. It was clear since then the central role of well-organized local public health service delivery, the place for effectively containing the spread. And we saw the importance to constrain the politicizing of the epidemic, by having rigorous, rapid, and fearless exercise of the public health authority....
Since the Influenza A(H1N1) 2009 pandemic, we realized that its management called for work with the economic, educational, agriculture and nutrition, labor, housing, transportation, tourism, and it can be achieved only with established platforms for this collaboration (1). The epidemic demanded for a differentiated care of the poor and those with cultural barriers, the pregnant, of those living with obesity or chronic co-morbidities. That it required massive behavioral change – only possible though effective health promotion functions -, and the assurance of safe settings, medical care (2), and products. That the local action had global implications. It was clear since then the central role of well-organized local public health service delivery, the place for effectively containing the spread. And we saw the importance to constrain the politicizing of the epidemic, by having rigorous, rapid, and fearless exercise of the public health authority.
Still, these elements did not remain embedded in the health systems (3): for the COVID-19 pandemic, we had to go through the process again. That was not reflected in the International Health Regulations (4) and their very limited biomedical scope, the exercise of health authority (5), nor from the accreditation of essential public health services. The PHE graduate programs did not incorporate it either. And we can count the cost of that in the millions of lives lost from COVID-19, avoidable non-COVID mortality, long-term COVID-19 disease burden, and trillions of dollars in human capital lost, besides the Gross World Product lost.
We must frame investment in PHE within a virtuous cycle in the institutional capacity building, integrated with the research enterprise in schools of public health, that assemble practitioners to systematize the lessons learnt from public health practice and make curriculum pertinent. And with the trained workforce, to make structural durable changes in the health system.
With these elements I would like not only to support the “four areas for consideration by schools of public health for the development”, but to propose other four. The first one is Health Regulation for Health Protection (6) at the local, subnational, national, and global levels; the approval and registration of vaccines and medical treatments is the most visible, but also relates to safe disinfectants, meeting paces, workplaces, etc. a function that has failed globally. The second area is Public Health in Social Structures, its integration outside the health system, tackling the social and commercial determinants of health, getting public and private actors the capacity to be agents for health, advancing towards the redefinition of the scope of action of health authorities, and defining the roles of public health practice in other sectors. The third area is Crisis Management. Public health professionals should be readied to address difficult times urgent delivery of services, decision making under pressure, as medical professionals are to care for patients at emergency rooms. They should be able to talk to its audience and to listen to them, be capable communicators, and able to gather the societal resources to deal with the common problem, to plan and advocate for it. And the fourth is Public Health Law, as the way to structure the organized social response, protect human rights, and support a rigorous exercise of the health authority.
The strategy should be a transformation on the perspective of the role of public health in society, and how we see the future role of our graduates in leading a response realizing the potential of public health. The opportunity is there for LMICs countries, but the whole world claims for it.
1. PAHO/Ministry of Health of Mexico. Influenza A(H1N1): Health Promotion Actions, sharing our experience. Publication. México, 2009 https://www.paho.org/mex/index.php?option=com_docman&view=download&alias...
2. Rubinson, L., Mutter, R., Viboud, C., Hupert, N., Uyeki, T., Creanga, A., Finelli, L., Iwashyna, T. J., Carr, B., Merchant, R., Katikineni, D., Vaughn, F., Clancy, C., & Lurie, N. (2013). Impact of the fall 2009 influenza A(H1N1)pdm09 pandemic on US hospitals. Medical care, 51(3), 259–265. https://doi.org/10.1097/MLR.0b013e31827da8ea
3. Cascini F, Hoxhaj I, Zaçe D, Ferranti M, Di Pietro ML, Boccia S, Ricciardi W. How health systems approached respiratory viral pandemics over time: a systematic review. BMJ Glob Health. 2020 Dec;5(12):e003677. doi: 10.1136/bmjgh-2020-003677.
4. Cameron EE, Nuzzo JB, Bell JA. Global Health Security Index. Building Collective Action and Accountability October 2019. Johns Hopkins Health Security Center/Nuclear Threat Initiative. https://www.ghsindex.org/wp-content/uploads/2020/04/2019-Global-Health-S...
5. KPMG. Government and institution measures in response to COVID-19Update 49. Downloaded April 1, 2021. https://home.kpmg/xx/en/home/insights/2020/04/government-response-global...
6. National Academies of Sciences, Engineering, and Medicine 2020. Stronger Food and Drug Regulatory Systems Abroad. Washington, DC: The National Academies Press. https://doi.org/10.17226/25651