I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rathe...
I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rather to preserve common societal goods, such as population health and welfare? According to a Danish survey, citizens may be more worried about having their relatives or the society impaired, than about becoming themselves infected by the virus.5 Limiting the spreading of SARS-CoV-2 has a major role in maintaining population health; however, addressing citizens requires a discourse of compassion engaging with their concerns.
Second, the rhetoric of war may imply a form of heroic storytelling: a distinction between heroes (the army of health professionals, who are sent to the frontline to fight the pandemic) and non-heroes (citizens, who are asked to follow orders). Yet, if their position were reconsidered, these excluded followers could play a central role in solving the crisis, for groups of diverse individuals might outperform groups of experts alone on complex problems.6 Funding agencies offer support to scientific environments; citizens should also be encouraged to join their various skills and complement those of health professionals. As learnt from the Ebola crisis, artists could for instance help enhance the clarity of health messages via culturally relevant narratives to the community.7 Hence, the need for a cooperation discourse.
Third, while promoting diversity of perspectives is pivotal to solving complex problems,6 the rhetoric of war may instil the antithetical dogma in the population mind: discipline and obedience to a common thinking. Such war conditions might in fact hinder societal creativity,8 thereby posing a paradox: terming the current societal problem as “war” may repress its own resolution. Non-violent forms of storytelling and public-minded discourses (e.g. in Denmark, “samfundssind” [“community spirit”]) are therefore needed to emancipate and include citizens in building societal responsiveness to the COVID-19 pandemic.
References
1. Rajan D, Koch K, Rohrer K, et al. Governance of the Covid-19 response: a call for more inclusive and transparent decision-making. BMJ Global Health 2020; 5(5).
2. Bali S, Dhatt R, Lal A, Jama A, Van Daalen K, Sridhar D. Off the back burner: diverse and gender-inclusive decision-making for COVID-19 response and recovery. BMJ Global Health 2020; 5(5).
3. Organization WH. WHO Director General's remarks at the G20 Extraordinary Leaders’ Summit on COVID-19 - 26 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at....
4. Lakoff G, Johnson M. Metaphors we live by. Chicago & London: The University of Chicago Press; 1980.
5. Department of Public Health at the University of Copenhagen. What concerns the Danish population about the corona crisis? 2020. https://healthsciences.ku.dk/coronadata/results/resultat-1/.
6. Hong L, Page SE. Groups of diverse problem solvers can outperform groups of high-ability problem solvers. Proceedings of the National Academy of Sciences of the United States of America 2004; 101(46): 16385-9.
7. Sonke J, Pesata V. The arts and health messaging: Exploring the evidence and lessons from the 2014 Ebola outbreak. BMJ Outcomes, 2015. http://s15762.pcdn.co/wp-content/uploads/2016/08/BMJ-Outcomes-Article-Co...
8. Simonton DK. Political pathology and societal creativity. Creativity Research Journal 1990; 3(2): 85-99.
Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
It was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lomb...
Li et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
It was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lombardy health care system.[5]
In democratic regimes in the era of mass communications, an institutional line of communication based on misinformation is a fallacious attempt, presumably dictated by a desire to avoid alarm among the population while preparing health measures not taken in due time. For example, it was not until February 25th that the Italian Civil Defense purchased personal protective equipment for health care workers. Reasons of state cannot justify the sacrifice of the public’s right to information either: they exist to protect the integrity of the state in general and need to find legal formalization. Misinformation has had the effect of disorienting the population and has not prevented the country from spiraling into catastrophe.[5] Sadly, the traditional media has contributed to spreading misinformation, merely reporting government reassurances or, even worse, passing on fake news.[2]
By speeding up the process of publishing articles on Covid-19, scientific publishers have enabled timely dissemination of clinically relevant information to members of the scientific community. In addition, by making journal content free and easily accessible, verified information has become available to the public. The question is: how many individuals currently turn directly to these sources? Institutional voices are the only ones the public should be able to turn to with total trust. Governments must disseminate honest information in such a way to improve awareness among the general public regarding the true seriousness of the epidemic. Conversely, misinformation on the part of institutions betrays the public’s relationship of trust in institutions. Furthermore, it generates dangerous discrimination in knowledge of the phenomenon and access to treatment and exposure to epidemic risk, especially among weaker individuals who are more likely to be without access to scientific information and to glean unverified information from social networks.
Competing interests: none. The paper did not receive funding.
References
1. Li HO, Bailey A, Huynh D, et al. YouTube as a source of information on COVID-19: a pandemic of misinformation? BMJ Global Health2020;pii: e002604. DOI:10.1136/ bmjgh-2020-002604.
2. Zarocostas J. “How to fight an infodemic”, Lancet 2020;395,10225:676.
3. Wu TJ, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet2020;395,10225:689-697.
4. Consiglio dei Ministri. Dichiarazione dello stato di emergenza in conseguenza del rischio sanitario connesso all'insorgenza di patologie derivanti da agenti virali trasmissibili. Gazzetta Ufficiale della Repubblica Italiana. Serie Generale n. 26. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahU...
5) Lazzerini, Putoto G. “COVID-19 in Italy: momentous decisions and many uncertainties”. Lancet Global Health2020 8:e641-e642. DOI:10.1016/S2214-109X(20)30110-8.
This research would be more useful if we were given the raw data containing each misleading publication with precise references to why each misleads. Instead, we obtain a summary of the most inflammatory and outlying presentations, as if those represent the majority. Some of the videos are merely observations by professionals practicing in the field. One of the inflammatory examples about the Italian and Iranian strains stands out. Only last week Governor Cuomo said New York was afflicted by a European strain. Where were the critics calling him out?
To the Editor;
Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The t...
To the Editor;
Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The total amount of development aid dollars was obtained from the World Bank Database (Accessed on 9/26/2015), where information of foreign assistance to Afghanistan is open to the public. The total number of articles and the total number of ODA were plotted annually from 1980 to elucidate the correlation between aid amount and scientific publication on health related topics to Afghanistan.
As shown in the Figure, there was a substantial increase in the number of publications in relation to the increase in ODA dollars especially since 2001, the year US war in Afghanistan started.
We also examined whether the publication dealt with issues on the Afghan people (those who live in Afghanistan or Afghan refugees) or on deployed personnel (deployed soldiers and their families) based on titles. Persistently low percentage of healthcare articles were on Afghans (From 1980 to 2000, only 10.2% in period 1980-2000 and 17.5% between 2001-2015). The majority of the articles were on health issues related to deployed personnel either on active duty or veterans. There was a concern for publication bias given that the search was limited to articles published in English. But when filtered the same search by language, such as Afghan, Dari, Russian, German, Spanish, or French, and Chinese, not that many articles were identified; Russian 281, French 88, German 39, Japanese 14, Spanish 9 and Chinese 0. We agree with authors of the current three analyses in terms of difficulty to obtain best-practice evidence on victims of the humanitarian emergencies. As we showed in our analysis, the evidence might be affected by how much ODA funding distributed in individual emergency.
Reference:
1. Meteke, S., et al. (2020) Delivering infectious disease interventions to women and children in conflict settings: a systemic review. BMJ Glob Health 5, e001967 DOI: 10.1136/bmjgh-2019-001967
2. Shah, S., et al. Ibid.Delivering non-communicable disease intervention to women and children in conflict settings: a systemic review. e002047 DOI: 10.1136/bmjgh-2019-002047
3. Jain, R., et al. Ibid.Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review. e001980 DOI: 10.1136/bmjgh-2019-001980
4. Goodwin, T., et al. (2019). "From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings." J Trauma Acute Care Surg 87: S35-S39.
FIGURE: ODA and number of healthcare publications by year in Afghanistan
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
There are major inequalities with regards to disease distribution. The relationship between Gross Domestic Product (GDP) and health is a starting point for examination of inequalities in the global health context. High income countries tend to have greater GDPs, which often means nations have better health systems and social services.
The distribution of ZIKV infection is unevenly spread across the globe [2]. The weight of Zika Virus Disease falls on the poor for different reasons. In tropical urban areas, those from a low socioeconomic income group are not able to manage the cost of air-conditioning, window screens, or insect repellent [4]. With no piped water and poor sanitation, they are compelled to store water in containers, giving perfect conditions to the expansion of mosquitoes [5].
The combination of ZIKV, DENV and CHIKV coinfections obfuscates the public health problem in various populations where complications due to poverty, poor basic sanitation and poor vector control persist. Further work is needed to elucidate the importance of the interactions between socio-environmental factors and transmission of ZIKV, DENV and CHIKV. The importance of SDH when understanding the risk factors that potentiate NTDs spread, is crucial for public health academics, health ministers and governments, as any interventions must consider ecological, biological and social factors.
References
1. Lobkowicz L, Ramond A, Sanchez Clemente N, et al. The frequency and clinical presentation of Zika virus coinfections: a systematic review. BMJ Global Health 2020;5:e002350.
2. Manderson L, Aagaard-Hansen J, Allotey P, Gyapong M, Sommerfeld J. Social Research on Neglected Diseases of Poverty: Continuing and Emerging Themes. PLoS Neglected Tropical Diseases. 2009;3(2):e332.
4. Lundgren K, Kjellstrom T. Sustainability Challenges from Climate Change and Air Conditioning Use in Urban Areas. Sustainability. 2013;5(7):3116-3128.
5. Dhimal M, Gautam I, Joshi H, O’Hara R, Ahrens B, Kuch U. Risk Factors for the Presence of Chikungunya and Dengue Vectors (Aedes aegypti and Aedes albopictus), Their Altitudinal Distribution and Climatic Determinants of Their Abundance in Central Nepal. PLOS Neglected Tropical Diseases. 2015;9(3):e0003545.
Responding to https://gh.bmj.com/content/5/4/e002094
‘The Commonwealth Pharmacists Association (CPA) https://commonwealthpharmacy.org/welcomes the publication of this systematic review which confirms the views held by the CPA that usable, point of prescribing decision information in low and middle income countries, is often not readily available where it is most needed. This of particular concern when we consider the prescribing and appropriate use of antimicrobials.
The UK DHSC Fleming Fund (https://www.flemingfund.org/) Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) Project has for the last 6 months been piloting an App for use in Ghana, Tanzania, Uganda and Zambia. This is part of the wider CwPAMS programme which is a collaboration between CPA and The Tropical Health and Education Trust (THET) https://www.thet.org/our-work/grants/cwpams/
The App guides prescribers as per national guidelines, and contains links to WHO resources and other training materials. It is explained clearly in this short u-tube video https://www.youtube.com/watch?v=MJ7fa_aLgCI It is free, to download to a smart phone or device anywhere in the world where there is access to the internet and then...
Responding to https://gh.bmj.com/content/5/4/e002094
‘The Commonwealth Pharmacists Association (CPA) https://commonwealthpharmacy.org/welcomes the publication of this systematic review which confirms the views held by the CPA that usable, point of prescribing decision information in low and middle income countries, is often not readily available where it is most needed. This of particular concern when we consider the prescribing and appropriate use of antimicrobials.
The UK DHSC Fleming Fund (https://www.flemingfund.org/) Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) Project has for the last 6 months been piloting an App for use in Ghana, Tanzania, Uganda and Zambia. This is part of the wider CwPAMS programme which is a collaboration between CPA and The Tropical Health and Education Trust (THET) https://www.thet.org/our-work/grants/cwpams/
The App guides prescribers as per national guidelines, and contains links to WHO resources and other training materials. It is explained clearly in this short u-tube video https://www.youtube.com/watch?v=MJ7fa_aLgCI It is free, to download to a smart phone or device anywhere in the world where there is access to the internet and then may be used off line. Whilst the analysis of the CwPAMS programme is ongoing, positive impacts are emerging. We believe that the CwPAMS App may have significant and far reaching benefits beyond this initial four country pilot https://viewer.microguide.global/CPA/CWPAMS’
Sarah Cavanagh CPA International Partnerships Lead and Victoria Rutter Executive Director CPA on behalf of the CPA App development team Chloe Tuck, Diane Ashiru-Oredope, Omotayo Olaoye, WeiPing Khor, Roisin McMenamin
Implementation research is crucial to determining effectiveness and appropriateness of interventions that are urgently needed in many contexts, constituting "global health". There is, however, an ongoing surprising relative lack of discussion on the need for appropriate understand of the ethical implications of Implementation research. Ethics committees and researchers are often not well versed in the ethics implications, and how these differ form traditional clinical research. the potential for unintended harm is great in the vulnerable circumstances wheer implementation research is often conducted. It is vital that if implementation research is conducted, ethical implications are considered throughout the process (i.e. continuing throughout the implementation itself and post-research). These issues have been laid out in an online teaching tool (by TDR/Global health Ethics Unit at WHO) and in the following publications: https://www.who.int/tdr/publications/year/2019/ethics-in-ir-course/en/ https://implementationscience.biomedcentral.com/articles/10.1186/s13012-... https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30310-9/fulltext
Paul et al [1] argue for a systemic approach to global health policy. This shift is long overdue, and as they pointed out systems thinking has long been suppressed by the all-powerful reductionist research industry.
Part of the problem is understanding of health and disease as distinctly dichotomous. However, the experience of health and dis-ease are dynamic as much in the presence as absence of identifiable disease [2]. In addition, health, illness dis-ease and disease occur on a continuum in the same person over time. It entails a continuous change in the physiological dynamics within the person that ultimately leads to changes that we recognise as one or the other disease. The process can lead to multiple expressions of disease, nevertheless, they are nothing more than the result of the overall physiological dysfunction within the same person [3].
As is well known health and disease disparities follow the socioeconomic gradient [4]. The question arises – how? There is increasing evidence from psychoneuroimmunology research that shows the longterm effects of psychosocial stress on the physiological stress response pathways resulting in chronic inflammatory dysregulation and its link to disease burden [5, 6].
Taken together, these findings provide a complex adaptive system explanation of the nature of health and disease arising through the network interaction between our environmental, socio-cultural and economic-political contexts and our biological...
Paul et al [1] argue for a systemic approach to global health policy. This shift is long overdue, and as they pointed out systems thinking has long been suppressed by the all-powerful reductionist research industry.
Part of the problem is understanding of health and disease as distinctly dichotomous. However, the experience of health and dis-ease are dynamic as much in the presence as absence of identifiable disease [2]. In addition, health, illness dis-ease and disease occur on a continuum in the same person over time. It entails a continuous change in the physiological dynamics within the person that ultimately leads to changes that we recognise as one or the other disease. The process can lead to multiple expressions of disease, nevertheless, they are nothing more than the result of the overall physiological dysfunction within the same person [3].
As is well known health and disease disparities follow the socioeconomic gradient [4]. The question arises – how? There is increasing evidence from psychoneuroimmunology research that shows the longterm effects of psychosocial stress on the physiological stress response pathways resulting in chronic inflammatory dysregulation and its link to disease burden [5, 6].
Taken together, these findings provide a complex adaptive system explanation of the nature of health and disease arising through the network interaction between our environmental, socio-cultural and economic-political contexts and our biological blueprint [3], and should be the basis for the redesign of effective, efficient and equitable health systems [7].
It is encouraging to see that systems thinking is slowly emerging in a wide range of health-related disciplines. Those involved ought to more closely collaborate to gain influence and impact [8].
References
1. Paul E, Brown GW, Ridde V. COVID-19: time for paradigm shift in the nexus between local, national and global health. BMJ Global Health. 2020;5(4):e002622. doi: https://dx.doi.org/10.1136/bmjgh-2020-002622
2. Sturmberg JP. The personal nature of health. J Eval Clin Pract 2009;15(4):766-69.doi: https://dx.doi.org/10.1111/j.1365-2753.2009.01225.x
3. Sturmberg JP, Picard M, Aron DC, Bennett JM, Bircher J, deHaven MJ, et al. Health and Disease—Emergent States Resulting From Adaptive Social and Biological Network Interactions. Frontiers in Medicine. 2019;6:59. doi: https://dx.doi.org/10.3389/fmed.2019.00059
4. Marmot M. The Influence Of Income On Health: Views Of An Epidemiologist. Health Aff. 2002;21(2):31-46. doi: https://dx.doi.org/10.1377/hlthaff.21.2.31
5. Slavich GM, Cole SW. The Emerging Field of Human Social Genomics. Clinical Psychological Science. 2013;1(3):331-48. doi: https://dx.doi.org/10.1177/2167702613478594
6. Seeman M, Stein Merkin S, Karlamangla A, Koretz B, Seeman T. Social status and biological dysregulation: the "status syndrome" and allostatic load. Social science & medicine (1982). 2014;118:143-51. doi: https://dx.doi.org/10.1016/j.socscimed.2014.08.002
7. Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.
8. International Society for Systems and Complexity Sciences for Health. [Internet] www.isscsh.org
Richardson (1) argues three substantive points:
1. Models are merely fables dressed in formal language.
2. Fables are unscientific.
3. Models serve as epistemic confines to our understanding.
We argue that 2., a premise he makes implicitly, is wrong. Formal language in fables cannot produce an ‘illusion’ of scientific-ness, because there is no division between ‘fables’ and ‘science’. We suggest that scientific models are stories (2) in some real sense, and therefore it does not make sense to say that models are unscientific because they are fables. Science is composed of a complex web of interacting models (stories) whose aims are to explain and understand the world. This would be consistent with Sugden’s (3) view of economic models as credible worlds.
Richardson cites Rubinstein (4) to buttress his argument that models are merely fictions. This misuses Rubinstein, who argues ‘The models presented… are nothing but fables. Neither of them describes reality, but both of them still describe something from reality… studying both of them together helps to some extent in understanding economic mechanisms.’ (p.182). It does not seem fair to brand models as ‘merely’ fables on this reading, and nor does this give us licence to dismiss fables as unscientific.
Epidemiologists often make significant assumptions in order to model disease progression. Many parameters are unknown, and there are often practical constraints to modelling significant hete...
Richardson (1) argues three substantive points:
1. Models are merely fables dressed in formal language.
2. Fables are unscientific.
3. Models serve as epistemic confines to our understanding.
We argue that 2., a premise he makes implicitly, is wrong. Formal language in fables cannot produce an ‘illusion’ of scientific-ness, because there is no division between ‘fables’ and ‘science’. We suggest that scientific models are stories (2) in some real sense, and therefore it does not make sense to say that models are unscientific because they are fables. Science is composed of a complex web of interacting models (stories) whose aims are to explain and understand the world. This would be consistent with Sugden’s (3) view of economic models as credible worlds.
Richardson cites Rubinstein (4) to buttress his argument that models are merely fictions. This misuses Rubinstein, who argues ‘The models presented… are nothing but fables. Neither of them describes reality, but both of them still describe something from reality… studying both of them together helps to some extent in understanding economic mechanisms.’ (p.182). It does not seem fair to brand models as ‘merely’ fables on this reading, and nor does this give us licence to dismiss fables as unscientific.
Epidemiologists often make significant assumptions in order to model disease progression. Many parameters are unknown, and there are often practical constraints to modelling significant heterogeneity in the population, for example computing power. When an epidemiologist assumes ‘symptomatic individuals are 50% more infectious than asymptomatic individuals,’ [https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020... they are explaining how the world might be under this assumption. This is just one example, but we are not the first to suggest that models in science describe the world as it might be rather than necessarily as it is (5–7).
Therefore, science is composed of a network of interconnected stories (models), and it does not make sense to think that because models are stories, they are unscientific.
Richardson’s description of models appears to grant them agency (8). This means it is the models themselves that warp our understanding of the spread of SARS-CoV-2. He thinks this happens in a similar fashion to philanthropists obscuring economic exploitation. We argue, however, that this is an unhelpful inflation of models’ agency: if models restrict COVID-19 discourse and impose epistemic confines, it is humans, political actors, who make them do so. Thus, just as billionaire philanthropists (humans) marginalise discussions over more equitable taxation regimes, it is human political actors who instrumentalise models to suppress contemplation of potential worlds. Concern over one or another model’s agency seems to lead only to more discussion over models - if the model has too much or too little agency, this is a problem for the model, and the question of how humans use models is vanished.
Even if we accept that models are indeed agentic, we argue his remedy of ‘liberation by model’ is misplaced. More modelling with ‘radical wealth redistribution as its moral’ feels unlikely to move discussion away from the modelling and towards the other causes of poor health. Instead, we suggest looking to other materials to aid our understanding of COVID-19. Models must sit alongside (e.g.) history and politics as tools to usefully describe what is happening (and what could) - but models cannot tell us what ought to.
References
1. Richardson ET. Pandemicity, COVID-19 and the limits of public health ‘science.’ BMJ Glob Heal [Internet]. 2020 Apr 1;5(4):e002571. Available from: http://gh.bmj.com/content/5/4/e002571.abstract
2. Frigg R. Models and Fiction. Synthese [Internet]. 2010 Apr 18;172(2):251–68. Available from: http://www.jstor.org/stable/40496038
3. Sugden R. Credible worlds: the status of theoretical models in economics. J Econ Methodol [Internet]. 2000 Jan 1;7(1):1–31. Available from: https://doi.org/10.1080/135017800362220
4. Rubinstein A. Economic fables. Open book publishers; 2012.
5. Frigg R, Nguyen J. The turn of the valve: representing with material models. Eur J Philos Sci [Internet]. 2018;8(2):205–24. Available from: https://doi.org/10.1007/s13194-017-0182-4
6. Frigg R, Hartmann S. Models in Science. In: The Stanford Encyclopedia of Philosophy [Internet]. Spring 202. Metaphysics Research Lab, Stanford University; 2020. Available from: https://plato.stanford.edu/archives/spr2020/entries/models-science/
7. Rhodes T, Lancaster K, Rosengarten M. A model society: maths, models and expertise in viral outbreaks. Crit Public Health [Internet]. 2020 Mar 31;1–4. Available from: https://doi.org/10.1080/09581596.2020.1748310
8. Latour B. On actor-network theory: A few clarifications. Soz Welt [Internet]. 1996 Apr 18;47(4):369–81. Available from: http://www.jstor.org/stable/40878163
As highlighted by Bowe and colleagues, air pollution is closely linked to burden of Chronic Kidney Disease (CKD). (1) A recent article on cardio-pulmonary mortality also highlighted similar issue, with a focus on provision of ventilation. (2)
India faces similar issues due to air pollution attributable to wide spread traditional habit of cooking with biomass. The contribution of CKD to Disability Adjusted Life Years (DALY) in the country has increased from 0.8% in 1990 to 1.6% in 2016 and it is the 9th common cause of mortality. (3)
With focus on prevention, CKD has been included under National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, the flagship program for Non-Communicable Diseases (NCD). Through NCD Clinics, diabetes and hypertension, two common risk factors for CKD, are being addressed. Population based screening is also underway for prevention, awareness and early diagnosis of these two morbidities. (4) Pradhan Mantri National Dialysis Program has been put in place to meet the need of dialysis services by the poor people at free of cost. (5) Ujjwala scheme has recently been introduced, under which more than 80 million families have been provided clean fuel. The scheme specifically targets rural areas where biomass is considered as one of the major mean for cooking. (6)
With so many initiatives, researches are warranted from India to estimate their effects in mitigating CKD burden and to tailor hea...
As highlighted by Bowe and colleagues, air pollution is closely linked to burden of Chronic Kidney Disease (CKD). (1) A recent article on cardio-pulmonary mortality also highlighted similar issue, with a focus on provision of ventilation. (2)
India faces similar issues due to air pollution attributable to wide spread traditional habit of cooking with biomass. The contribution of CKD to Disability Adjusted Life Years (DALY) in the country has increased from 0.8% in 1990 to 1.6% in 2016 and it is the 9th common cause of mortality. (3)
With focus on prevention, CKD has been included under National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, the flagship program for Non-Communicable Diseases (NCD). Through NCD Clinics, diabetes and hypertension, two common risk factors for CKD, are being addressed. Population based screening is also underway for prevention, awareness and early diagnosis of these two morbidities. (4) Pradhan Mantri National Dialysis Program has been put in place to meet the need of dialysis services by the poor people at free of cost. (5) Ujjwala scheme has recently been introduced, under which more than 80 million families have been provided clean fuel. The scheme specifically targets rural areas where biomass is considered as one of the major mean for cooking. (6)
With so many initiatives, researches are warranted from India to estimate their effects in mitigating CKD burden and to tailor health policies according to the need.
References
1. Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. The global and national burden of chronic kidney disease attributable to ambient fine particulate matter air pollution: a modelling study. BMJ Glob Health 2020;5:e002063.
2. Yu K, Lv J, Qiu G, et al. Cooking fuels and risk of all-cause and cardiopulmonary mortality in urban China: a prospective cohort study. Lancet Glob Health 2020; 8(3):e430-e439.
3. Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation. India: Health of the Nation's States - The India State-level Disease Burden Initiative. New Delhi, India: ICMR, PHFI, and IHME. 2017.
4. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. (Available at http://dghs.gov.in/content/1363_3_ NationalProgrammePreventionControl.aspx, last accessed on 1st April, 2020).
5. Ministry of Health and Family Welfare. Pradhan Mantri National Dialysis Program. (Available at https://mohfw.gov.in/basicpage/pradhan-mantri-national-dialysis-programm..., last accessed on 1st April, 2020).
6. Pradhan Mantri Ujjwala Yojana. (available from www.pmuy.gov.in, last accessed on 1st April, 2020)
I thank both Rajan et al. and Bali et al. for highlighting a lack of inclusivity in the governance of the coronavirus disease 2019 (COVID-19) response.1,2 While the pandemic raises societal concerns, decision-making bodies remain unrepresentative of civil society and suffer from a dearth of diversity – with, for instance, an underrepresentation of women’s perspectives.1,2 I would add that inclusivity may have been thus far derogated by the popular discourse of some traditional, paternalistic leadership – namely, that which is conveyed through wordings worthy of warlords.
“We are at war”, as declared the Director-General of the World Health Organization, before exhorting G20 leaders to “fight like hell” and calling for “aggressive action” to combat the COVID-19 pandemic.3 This rhetoric of war echoes that of some men country leaders and scientists, pressing authorities for immediate action. Yet, as metaphors frame the way people act,4 triggering civil and societal responsiveness should instead begin with wordings of compassion, cooperation and emancipation.
First, the rhetoric of war may monopolize the public attention to a unique, imminent goal: mustering all forces to defeat and annihilate an enemy (here, the severe acute respiratory syndrome coronavirus, SARS-CoV-2) – any other objectives being put aside as under war economy. This imposed monopoly may contrast with population concerns: Do we – civil society – strive merely to exterminate SARS-CoV-2, or rathe...
Show MoreLi et al.[1] analyzed misinformation about the Covid-19 pandemic generated by social media, as well as that from traditional means of communication.[2] We focus here on a further, more insidious form of misinformation: that generated by institutions, by paradigmatically analyzing the case of Italy.
Show MoreIt was well known on January 31, 2020 that Covid-19 had the potential to become pandemic and detailed measures for adoption by health authorities to combat the disease had already been indicated.[3] On the same day, the Italian government declared a state of emergency.[4] However, while neglecting scientific data [3] and in contrast to the seriousness of the decision,[4] institutional figures (government officials and health authorities), reassured the population through statements in the media that the situation was under control even when the virus had demonstrated its contagiousness and lethality. For weeks prior to the outbreak in Lombardy, the population was told that COVID-19 was little more than a flu. Authorities reassured the population that the measures being adopted to prevent/limit the epidemic were the most stringent in Europe. On February 26th, with 330 infected individuals and 11 dead, the Italian Prime Minister declared that the number of infections should not cause alarm. In the coming days, citizens became aware of the magnitude of the outbreak and found themselves psychologically/materially unprepared, in a stupor in the face of the collapse of the Lomb...
This research would be more useful if we were given the raw data containing each misleading publication with precise references to why each misleads. Instead, we obtain a summary of the most inflammatory and outlying presentations, as if those represent the majority. Some of the videos are merely observations by professionals practicing in the field. One of the inflammatory examples about the Italian and Iranian strains stands out. Only last week Governor Cuomo said New York was afflicted by a European strain. Where were the critics calling him out?
To the Editor;
Show MoreThree articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
The t...
Dear Editor,
It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).
Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.
There are major ineq...
Show MoreResponding to https://gh.bmj.com/content/5/4/e002094
Show More‘The Commonwealth Pharmacists Association (CPA) https://commonwealthpharmacy.org/welcomes the publication of this systematic review which confirms the views held by the CPA that usable, point of prescribing decision information in low and middle income countries, is often not readily available where it is most needed. This of particular concern when we consider the prescribing and appropriate use of antimicrobials.
The UK DHSC Fleming Fund (https://www.flemingfund.org/) Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) Project has for the last 6 months been piloting an App for use in Ghana, Tanzania, Uganda and Zambia. This is part of the wider CwPAMS programme which is a collaboration between CPA and The Tropical Health and Education Trust (THET) https://www.thet.org/our-work/grants/cwpams/
The App guides prescribers as per national guidelines, and contains links to WHO resources and other training materials. It is explained clearly in this short u-tube video https://www.youtube.com/watch?v=MJ7fa_aLgCI It is free, to download to a smart phone or device anywhere in the world where there is access to the internet and then...
Implementation research is crucial to determining effectiveness and appropriateness of interventions that are urgently needed in many contexts, constituting "global health". There is, however, an ongoing surprising relative lack of discussion on the need for appropriate understand of the ethical implications of Implementation research. Ethics committees and researchers are often not well versed in the ethics implications, and how these differ form traditional clinical research. the potential for unintended harm is great in the vulnerable circumstances wheer implementation research is often conducted. It is vital that if implementation research is conducted, ethical implications are considered throughout the process (i.e. continuing throughout the implementation itself and post-research). These issues have been laid out in an online teaching tool (by TDR/Global health Ethics Unit at WHO) and in the following publications:
https://www.who.int/tdr/publications/year/2019/ethics-in-ir-course/en/
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-...
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30310-9/fulltext
Paul et al [1] argue for a systemic approach to global health policy. This shift is long overdue, and as they pointed out systems thinking has long been suppressed by the all-powerful reductionist research industry.
Part of the problem is understanding of health and disease as distinctly dichotomous. However, the experience of health and dis-ease are dynamic as much in the presence as absence of identifiable disease [2]. In addition, health, illness dis-ease and disease occur on a continuum in the same person over time. It entails a continuous change in the physiological dynamics within the person that ultimately leads to changes that we recognise as one or the other disease. The process can lead to multiple expressions of disease, nevertheless, they are nothing more than the result of the overall physiological dysfunction within the same person [3].
As is well known health and disease disparities follow the socioeconomic gradient [4]. The question arises – how? There is increasing evidence from psychoneuroimmunology research that shows the longterm effects of psychosocial stress on the physiological stress response pathways resulting in chronic inflammatory dysregulation and its link to disease burden [5, 6].
Taken together, these findings provide a complex adaptive system explanation of the nature of health and disease arising through the network interaction between our environmental, socio-cultural and economic-political contexts and our biological...
Show MoreRichardson (1) argues three substantive points:
1. Models are merely fables dressed in formal language.
2. Fables are unscientific.
3. Models serve as epistemic confines to our understanding.
We argue that 2., a premise he makes implicitly, is wrong. Formal language in fables cannot produce an ‘illusion’ of scientific-ness, because there is no division between ‘fables’ and ‘science’. We suggest that scientific models are stories (2) in some real sense, and therefore it does not make sense to say that models are unscientific because they are fables. Science is composed of a complex web of interacting models (stories) whose aims are to explain and understand the world. This would be consistent with Sugden’s (3) view of economic models as credible worlds.
Show MoreRichardson cites Rubinstein (4) to buttress his argument that models are merely fictions. This misuses Rubinstein, who argues ‘The models presented… are nothing but fables. Neither of them describes reality, but both of them still describe something from reality… studying both of them together helps to some extent in understanding economic mechanisms.’ (p.182). It does not seem fair to brand models as ‘merely’ fables on this reading, and nor does this give us licence to dismiss fables as unscientific.
Epidemiologists often make significant assumptions in order to model disease progression. Many parameters are unknown, and there are often practical constraints to modelling significant hete...
As highlighted by Bowe and colleagues, air pollution is closely linked to burden of Chronic Kidney Disease (CKD). (1) A recent article on cardio-pulmonary mortality also highlighted similar issue, with a focus on provision of ventilation. (2)
Show MoreIndia faces similar issues due to air pollution attributable to wide spread traditional habit of cooking with biomass. The contribution of CKD to Disability Adjusted Life Years (DALY) in the country has increased from 0.8% in 1990 to 1.6% in 2016 and it is the 9th common cause of mortality. (3)
With focus on prevention, CKD has been included under National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, the flagship program for Non-Communicable Diseases (NCD). Through NCD Clinics, diabetes and hypertension, two common risk factors for CKD, are being addressed. Population based screening is also underway for prevention, awareness and early diagnosis of these two morbidities. (4) Pradhan Mantri National Dialysis Program has been put in place to meet the need of dialysis services by the poor people at free of cost. (5) Ujjwala scheme has recently been introduced, under which more than 80 million families have been provided clean fuel. The scheme specifically targets rural areas where biomass is considered as one of the major mean for cooking. (6)
With so many initiatives, researches are warranted from India to estimate their effects in mitigating CKD burden and to tailor hea...
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