Contribution of the COVID-19 Crisis to Teenage Pregnancy Upsurge: a Case of Mukuru Kayaba Slums, Nairobi Kenya

According to the 2014 Kenya Demographic and Health Survey (KDHS), 1 in 5 Kenyan teenage girls is a mother. Also, statistics by the United Nations Population Fund (UNFPA) indicated that between June 2016 and July 2017, 378,397 girls got pregnant before their twentieth birthday in Kenya. Similarly, 379,573 teenage girls were made pregnant by the end of last year as reported by the National Council on Population and development (NCPD). These huge numbers cause devastation bearing in mind that they were reported during normal times. What then are we to expect with the new normal where essential functions and healthcare services have been greatly compromised by the Covid-19 pandemic?

By Reagun Andera Odhiambo

M & E and Grants Officer at Toto Care Box Africa Trust

Contribution of the COVID-19 Crisis to Teenage Pregnancy Upsurge

A Case of Mukuru Kayaba Slums, Nairobi Kenya

 

Early estimates by a number of local and global health organizations point towards a potential increase in indirect mortalities caused by the Covid-19 pandemic. Among the areas that are expected to be greatly affected in this regard are Sexual and Reproductive Health (SRH) as well as maternal and newborn health. Disruption of essential health services and the subsequent inaccessibility by those in need is a direct effect of the Covid-19 pandemic which seemingly generates lethal outcomes.

To explore Covid-19 outcomes on the health of adolescents and young people, my attention has been drawn to teenage pregnancy. This is an endemic problem greatly rooted in our country just as in other middle and low income countries which is bound to escalate with the current crisis.

According to the 2014 Kenya Demographic and Health Survey (KDHS), 1 in 5 Kenyan teenage girls is a mother. Also, statistics by the United Nations Population Fund (UNFPA) indicated that between June 2016 and July 2017, 378,397 girls got pregnant before their twentieth birthday in Kenya. Similarly, 379,573 teenage girls were made pregnant by the end of last year as reported by the National Council on Population and development (NCPD). These huge numbers cause devastation bearing in mind that they were reported during normal times. What then are we to expect with the new normal where essential functions and healthcare services have been greatly compromised by the Covid-19 pandemic?

The Covid-19 pandemic brings with it massive consequences directly, indirectly and in multi-factored ways. The indirect consequences are mainly triggered by the breakdown of essential health services including SRH services such as family planning and maternal and newborn health. With the current lockdown, curfew and cessation of movement directives by the government, access to and provision of essential reproductive health services is interfered with and somehow compromised for both users and providers. Teenage girls and young women are part of those affected because they need these services.

According to Plan International, Covid-19 related school closures hit girls the hardest. This is because being out of school increases teenage girls’ vulnerabilities to not just early and unwanted pregnancies but also to early marriages or contraction of Sexually Transmitted Infections (STIs) including HIV/AIDS. Also, with schools closed, young girls are shut up at homes where they are faced with an increased risk of sexual exploitation and gender-based violence all of which may result in unwanted pregnancies.

With the current emphasis on “staying at home”, teenage girls and their male counterparts find themselves with plenty of uninterrupted time where they get to engage in experimental sexual activities in a curious exploration of their sexuality and the fulfilment of the demanding needs of their fast growing bodies. All these fun-filled explorations may go unnoticed only to be revealed a while later by “missing periods” or “a growing bump” otherwise said to be an unwanted pregnancy.

Teenage pregnancies have been proven to cause serious negative impacts on the lives and future of the affected girls especially with regards to their overall health as well as mental and social well-being. Teen mothers less likely continue with their pursuit of education and thus end up in poverty which comes with both depression and rejection. Some teens decide to terminate their pregnancies not looking at the numerous risks they present themselves to by choosing the risky procedure. Abortions are the second leading cause of death for girls 15-19 years of age and leave the victims who survive with lifelong complications including fistula. Worse even, some take their lives for fear of judgement and feelings of guilt.

Mukuru Kayaba, an informal settlement forming part of the larger Mukuru slums extending through Kwa Ruben and Kwa Njenga areas is one area that has been hard hit by the teenage pregnancy crisis over time.

The area just like other slum areas is faced with numerous problems relating to poverty and over congestion such as poor housing, high unemployment and dependency ratios, strain on available resources including essential healthcare, insecurity and high disease burden and prevalence.

Barely four months of the Covid-19 pandemic seems to produce an alarming upsurge in the number of teenage pregnancy cases being reported both to the local authorities in the area and to the health facilities offering maternity and other reproductive health services. Toto Care Box, an NGO working with women and newborns in the area reports an overwhelming demand for their services and products at this critical time and this is attributable to the rising number of cases of teenage pregnancy. At this point am tempted to imagine about the real iceberg lying in the unreported cases as well as those attempting to or already successful in termination of these unwanted and unplanned for pregnancies. Is there need for alarm?

Almost all the forty seven Counties in Kenya have been hard hit by the teenage pregnancy crisis. Latest statistics reveal that Nairobi County tops the list with 11,795 girls aged between 10-19 years reporting to be pregnant between the months of January and May this year. Here is the distribution for top ten counties as per the June Report on the state of teenage pregnancy in the country:

Direct causes of this sudden upsurge in the number of teenage pregnancy cases being reported can be explained using Covid-19 pandemic as the core trigger.

Depressing economic times such as the one presented by the Covid-19 pandemic are known to push teenage girls from poor families into sexual activities in exchange for food and other forms of necessities including protection from suffering. Most often, this type of vulnerability is hard to prevent because the victims are pushed to the limits and have no other options left. A number of studies point out to the fact that sexual exploitation in the context of sex in exchange for food and other essentials is widely reported as vulnerable girls and their families struggle to meet basic needs especially in times of crisis. This could be a perfect reality of what is being experienced by the suffering Kayaba residents.

Findings by the National Council for Population and Development (NCPD) support my hypothesis by confirming that approximately 26% of teen girls from poor households experience teenage pregnancy in comparison to 10% belonging to wealthier households. Poverty is actually a factor at play in Mukuru.

Also, as earlier mentioned in the article, the Covid-19 containment measures currently in place constrain teenage girls at home presenting them with enough free time to find innovative ways to experiment sex unnoticed. The “stay at home” directive therefore greatly helps flatten the Covid-19 curve while exponentially increasing the teenage pregnancy curve. Is the directive to be blamed in any way?

Teenage pregnancies have the cumulative effect of perpetuating the cycle of poverty which consequently lowers individual, social and economic development.

Toto Care Box is an organization working with poor women including girls in the Kenyan slums to better their reproductive health outcomes. The organization provides support to teenage girls undergoing the teenage pregnancy crisis by encouraging them to carry their pregnancies to term, to attend antenatal clinics, to deliver in health facilities and to care adequately for their teens despite the stigma, negative judgement and rejection.

This is done through a community-based approach involving education and incentivization. The organization does not however support the idea of young girls engaging in risky sexual behaviors that predispose them to early unwanted pregnancies. Visit www.totocarebox.org for details.

In conclusion, successful efforts to curb teenage pregnancy must address underlying drivers through programs such as behavior change, sex education, social and economic development, reproductive rights advocacy and health systems strengthening. With all that in mind I still remain with a number of unanswered questions; Who is to be blamed for the teenage pregnancy problem? Who are the male perpetrators and what consequences do they face for their actions? What role do parents play in solving the crisis? How many teens will be affected by the end of the Covid-19 pandemic?

PEAH News Flash 390

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Substantial Aspects of Health Equity During and After COVID-19 Pandemic

Health equity as a concept of minimizing health disparities among people, could be of utmost importance during the COVID-19 pandemic. Providing equity in health and participating in the acts of providing equitable healthcare have different aspects. Although this pandemic is not the first global-scale biological threat that humankind has faced, there is still some points to be further addressed. Deeming health as a public good, inevitably necessitates taking responsibilities for its fair provision. The aim of this study is to notify the public (policy makers, medical staff, and other individuals interested in the topic of health equity) about some strategies to consider the tenets of equity in health while managing the COVID-19 pandemic

By Erfan Shamsoddin

DDS, National Institute for Medical Research Development, Tehran, Iran

Substantial Aspects of Health Equity During and After COVID-19 Pandemic

A Critical Review 

 

 

Background

When emergencies occur, even principal ethos and tenets of any context might seem vulnerable to change under the imposed pressures. This has been the case for 2019 novel coronavirus disease (COVID-19) regarding different aspects of health equity till today. Humankind has already dealt with contagious outbreaks and plagues, which have caused significant changes in the trajectory of scientific, political, and social sentiments regarding the disasters alike (1,2). Spanish flu (1918-1920), Smallpox outbreak (1972), human immunodeficiency virus (HIV) pandemic (originated from 1980s), severe acute respiratory syndrome (SARS) (2002-2003), swine flu pandemic (2009-2010), and Ebola outbreak (2014-2016) are all some instances of such disasters (2). Appreciating all the efforts of healthcare systems around the world, there were also some major shortcomings and mistakes in response to these upsurges (1,3–5). Delayed provision of effective treatments, unclear and inefficient communication between the governments and their people, not providing enough education and awareness sources and even funds resources (previous to the occurrence of illnesses), are all among these wrongdoings (5,6). All these conditions seem to be partially or completely repeated for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) related disease. A highly contagious illness representing a basic reproduction number between 2 and 2.5, a crude mortality ratio between 3% to 4%, and an infectiousness phase starting at 2.3 days before the symptoms onset (7–9). Though substantial measures and means have been enhanced since the earlier crises (i.e. more technological advancements, swift communications, better healthcare resources and management, higher drug production figures, etc.), there still exists some discernible inconsistencies and differences within the management protocols among various countries and regions worldwide (6). Looked at from a health policy and management perspective, lowering the variations and increasing the commitment to certain cornerstones, which have been established and reinforced formerly, could ultimately lead to better results and more controllable political environments for populations and even governments (10). All in all, despite noticing the temporary nature of this issue, the provision of health in an equitable way seems to be rattling and reshaping over the period of COVID-19 outbreak. Such a claim could further be described in four separate domains: political position, development status, cultural tendencies, and baseline health status. Figure 1 depicts a schematic view of these components.

 

Figure 1

 

Political position

Political compass can greatly influence the initiation, implementation, and outcomes of the national and regional announced policies in response to plagues (11). Overall, this can be dissected into two major levels: national and international policies. Though the evidence could usually help in directing public policies, it is inevitably less effective when the event is unprecedented, at least in some aspects. Accordingly, although some official pandemic preparedness guidelines were available for Middle East respiratory syndrome-related coronavirus (MERS-CoV), the birth of imminent COVID-19 has shown some different characteristics (12). Management strategies obeyed by the initially-virus-acquainted governments show variations from the past as well. Hong Kong, as an instance, have gone through quite similar conditions at 1997, during the H5N1 influenza outbreak. Total judgements on the performance of Margaret Chan, minister of health in Hong Kong at that time, are usually regarded as positive, well-led, and justifiable (13). Decimating domestic poultry seemed and still seems the best choice to prevent a pandemic (13–15). On the other hand, during the initiation of COVID-19, despite all the effective efforts and interventions implemented by the Chinese government after the spread of COVID-19 (16), lack of transparency _since announcing an outbreak as soon as possible, greatly impacts on the extent of public engagement_ and not following the WHO protocols about conducting full surveillance and control of avian outbreaks, was undeniable during the beginning of the crisis (17–19). Several explanations could be given as the cause of these shortcomings, namely, avoiding evidence-based decisions in favor of political biases, experimenting new solutions in response to an unknown biothreat (hoping to control the threat locally), and lazy governance (18,20). Healthcare is not a private commodity and every government should seek its provision as a public good (21). Consistently, multilateral efforts to address an outbreak or disaster could usually be considered as a critical step toward the resolution of a healthcare crisis in the least time possible (22–24). This will be eventually in favor of public health promotion. Instructions introduced by WHO are mainly in accord with the same principle, mainly emphasizing on travelling regulations, high-capacity surveillance measures and rapid reporting of positive cases to the international health organizations (25).

Evidence-based/-oriented policy making is another component which is highly under the impression of political stances in each country. More developed countries have already established and paved the evidence-assisted policy making pathways to follow. Nevertheless, developing countries have been getting more and more involved in this discipline in the last few years (26,27). Practicing this type of policies, might probably require training more specialists, more interactive international relations, and as a result, more interim costs. To take or not to take this road is basically determined by the authorities in force in developing countries _who mostly have been under long-term effects of narrative and rhetoric evidence in their decision makings. More developed countries on the other hand, can scrutinize and introduce modern patterns of the process. These new governance patterns usually get distributed via different medias (e.g. publications, news, professional events, international organization reports, etc.) which could serve as “scientific advice” for developing countries (28,29). The resiliency, nature, and ethos of healthcare systems, are therefore greatly maneuvered by the political position of the leaderships (30).

It is worth mentioning degree of autonomy and emancipation for trade markets and originator companies for they are regarded as gamechangers, hugely depending on each country’s political perspectives (31). The lucrative market of non-pharmaceutical and pharmaceutical products (including personal protection equipment, therapeutic/palliative drugs, and therapeutic/preventive vaccines) can be a tempting target for brand industries seeking out for-profit policies in the region during and after the occurrence of a plague (32). The final pathway of local and international economic investments and interventions is mainly determined and assessed during and in response to mishaps like COVID-19 (33).

Overall, the extent to which every nation will follow these rules and reach the goal of better health status, significantly depends on the principles on which their political compass is built upon.

 

Development status

The more industrialized and affluent a country/region is, the more capable it gets to resolve the financial issues during counteracting infectious outbreaks (34). Healthcare systems get established by developing critical care-provision infrastructures, gaining experiences (healthcare stewardship), providing and implementing technological advancements, building reliable international collaborations and coalitions, and scientific progression. Lack of such infrastructures in less-developed regions, could additionally exacerbate the issues imposed by a pandemic like COVID-19 (35,36). Since health is an integrated, intertwined matter worldwide, such disasters will inevitably exert their afflictions globally.

History is always repeating itself. After occurring an imminent pandemic like COVID-19, it is most likely that the first therapeutic/preventive treatment will get produced in an industrialized country, which would then support the mass production and lead the huge pharmaceutical markets in the near future. This was the case for 1918 influenza pandemic, H1N1 Influenza pandemic, and H5N1 avian Influenza (37,38). The request for compulsory benefit sharing (for pharmaceutical interventions) from developed countries led to constant rejections. Standard Material Transfer Agreement in 2009 _when negotiating for equitable access to influenza vaccines_ went through the same pathway and reached an evident destination, failure (37). Conceiving equity in health as a “charity” or “help” flowing from industrialized regions toward the less well-off, would probably result in similar outcomes in the future. Therefore, there need to be more accurate and comprehensive covenants between international parties aiming for equity in health throughout the world (39).

Another necessary fundament in healthcare systems, is the delivery. Provision of treatments in an effective and efficient way is of critical importance during infectious spreads, mostly affecting more susceptible patients (40). Individuals with special needs, systemic conditions, life-threatening and/or incurable diseases, women during the pregnancy period, older adults, and people under conditional restrictions (e.g. individuals restricted in jails) are all considered as susceptible people whom need to be specially treated by the governments during pandemics (41).  Other than the pharmaceutical pools, constructive care delivery needs sufficient assets of human resources and healthcare facilities (36). Care providing centers with limited hospital beds, have already been facing an overflow of COVID-19 patients in several countries and districts (e.g. China, EU, USA, Middle East) (42–45).  It can be said that the pandemic has damaged less-developed countries more severely in terms of value of fiscal crisis management costs as a share of country’s gross domestic product (GDP) (46). For example, defining fiscal stimulus packages and supportive funds to provide people with financial aids during the COVID-19 pandemic, has been of very different amounts among various countries (47).

All in all, the economic status and available resources of any country count as critical determinants of the COVID-19 management protocol.

 

Cultural norms

When enforcing local and domestic policies, the trail which the interventions will follow, and accordingly the empirical outcomes, are substantially affected by public opinion (48,49). The responsiveness of healthcare policies is perpetually being amended and directed by citizens’ predilections. Many current healthcare plans shift control and decision-making to the governments, whilst the final beneficiaries from these would be the citizens. The vast majority of people always care about the quality of care as the first aspect of healthcare provision in their regions. Increasing access, lowering the costs, and improving the choices are other considered variables for the quality of care (49). Nevertheless, the circumstances substantially differ in the case of a pandemic like COVID-19.

Public acceptance rate of the local and global policies concerning the health status is crucially affected by people’s personal beliefs (religion, etc.), ethnic prejudice, and culture (50). Inhabitants and citizens are actually the “performers” of the announced policies in each area, making them the most critical elements in directing the implementation of each intervention. For example, insisting on not obeying the curfews and not following the social distancing program (SDP) have been seen in various locations during the COVID-19 outbreak (51–54). Other countries, have redefined and reshaped some of the SDPs in order to be able to adjust the measures in accord with general people’s beliefs (55,56). These contextual policies have not shown promising results so far, as they fundamentally differ from the basic non-pharmaceutical interventions defined to cut the transmission routes of the virus (57). Epidemiologic advices relating to SDPs usually consider the following as critical tips: possibility of aerosol transmission, contact time necessary for contracting the COVID-19 during exposures, the minimum infectious dose, the degree of infectivity prior to onset of symptoms and its duration after recovery, seasonality effect, and immune responses in human beings (58). Looking at these factors, it seems challenging to gain people’s compliance after announcing new policies in a region to be obeyed, especially if the number of cases had been low (insignificant for the public) before the announcement date (59).

Two other important aspects of cultural beliefs during this pandemic, are the stigma about people who contracted the virus and have been cured (and the ones in contact with them, either directly or indirectly), and the origins of COVID-19 (60–62). Educating the citizens of any country is an utmost imperative to be addressed by their government. Accusing the Chinese residents of “unhealthy” eating habits or simply blaming the Wuhan virology lab as the causes and origins of SARS-CoV-2, would be superficial and not backed up by robust evidence till today.

 

Public health status

When a pandemic happens, regardless of what infrastructures are available, previous state of public health plays a critical role in the management phase (64). This refers to the therapeutic service-provision phase. In the case of COVID-19 pandemic, no definitive treatment is obtained yet (July 7th, 2020). This has led to a widespread human infection status (phase 5-6 of pandemic according to WHO’s classification of Influenza pandemic) and it is currently proceeding as the medical scientific teams seek highly effective treatment lines and possible candidates as preventive/therapeutic vaccines (65,66). This makes it indispensable for the medical staff to provide their patients with the best possible supportive and palliative treatments.

Generally, the presence of comorbidities can impose higher risks of exacerbation for the secondary illnesses or conditions. Results of a nationwide cross-sectional study conducted on 1590 Chinese patients, shows the same trend. Patients with any type of comorbidity have shown poorer clinical prognoses and resulted in less-favorable clinical outcomes. A greater number of comorbidities also correlated with poorer clinical outcomes and the most prevalent comorbidities were hypertension (16.9%) and diabetes (8.2%) (67). Taking these two systemic conditions as the cornerstones for further inferences, data shows that the prevalence, and consequently the burden imposed by them differs throughout the world. Data from the year 2010 shows that 28.5% (95% confidence interval (CI), 27.3-29.7%) of the world’s adults had hypertension in high-income countries. This figure was 31.5% (95% CI, 30.2-32.9%) in low- and middle-income countries (68). Another study evaluating the burden of type 2 diabetes in 2011, stated that Asia accounted for 60% of the world’s diabetic population with India placing as the second epicenter of diabetes pandemic (69). More studies concerning COVID-19 have represented the following results:  Portion of population at increased risk of contraction with SARS-CoV-2 virus was the highest in countries with older populations, African countries with high HIV/AIDS prevalence, and small island nations with high diabetes prevalence. Table 1 shows the results of regional names ordered by the number of individuals at increased risk of severe COVID-19 illness (units are measured in million(s) of people).

Table 1

 

These numbers can implicitly show the disparities among countries facing a global challenge like COVID-19. Although a lower share of population was displayed to be at risk for COVID-19 in African countries (3.1%) (compared to Europe with 6.5%), this simply implies the existence of much younger populations in African region. It was also mentioned that age-specific risks in African countries tend to be similar or higher than age-specific risks in European countries (70). Given that the opportunities and necessary basics to manage the disease are not similar worldwide, reporting the mortality occurrences could not simply be considered as the best choice to assess countries’ performances regarding the pandemic. Correspondingly, countries have been using some other measures to report their performance and productivity loss. Excess mortality (the number of deaths above and beyond what we would have expected to see under ‘normal’ conditions) or disability-adjusted life years (DALY) _which is usually adjusted by age, sex, and region (burden of COVID-19) are two examples of such measures (71,72).

Overall, when assessing the performance of each country against COVID-19 pandemic, everybody should first notice the baseline health status, initially available infrastructures, and the imperative costs of management for each country.

 

Discussion

Health equity is defined by the international society for equity in health (ISEqH) as: “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically”. This definition implies the existence of systematic (rather than random or haphazard) differences pertaining to health equity. This allows for comparisons regarding health status alterations due to a specific disease/condition/illness, between the residents of geographically distinct (but socially alike) areas (73). However, as stated by P. Braveman and S. Gruskin in 2006, “a health disparity/inequality is a particular type of potentially avoidable difference in health or in important influences on health that can be shaped by policies; it is a difference in which a disadvantaged social group or groups … systematically experience worse health or greater health risks than the most advantaged social groups” (73). In consequence of accepting both these interpretations, we should continuously and perpetually seek for a reduction in health disparities/inequalities in the context of public health assessments. Health policies can actively change the values of health-related indices within populations, making them as the first-line actors responsible for creating/deteriorating health disparities. In a time of economic downturn due to the COVID-19 pandemic, which is forecasted to lower the global economic growth by 0.5% in 2020 (from 2.9% in 2019 to 2.4% in 2020) (74), one might consider the issue of health equity as “unnecessary” or “unsuitable”. However, health equity is a universal term, highly intertwined with basic human rights and political justice. This would additionally stress the exigency of health equity during the COVID-19 outbreak, when underserved people around the world would probably need it the most. Some suggestions for not ignoring health equity amidst and after the pandemic are going to be introduced in this section.

Data gathering transparency is a key determinant in obtaining the best health-related outcomes. Reporting the true figures obtained from diagnostic tests gives the policy makers a correct insight about the situation in their sectors. This can later direct their decisions in shortcut ways to manage the outbreak promptly. Government-level transparency is also of utmost importance when it comes to reaching the best outcomes in the least possible time. Presenting the risks and hazards existing in the environment (without prioritizing politically-oriented aims over the health status of the nation) will attract public attention. This is going to be followed by more public engagement regarding the SPDs and participating to curb the viral transmission.

Another matter being suggested here is to provide open access to COVID-19 related topics for medical research teams around the world. There have already been some valuable efforts to gather and publish medical results free of fees worldwide. This is more necessitated when a plague threats the lives of humankind globally. Also, it is mutually accepted for all the physicians that providing their patients with the best possible treatment options, is a moral obligation. Following the same trend in other disciplines (technological advancement, political strategies, etc.) would definitely assist in resolving the troubles.

Two years after the Ebola outbreak (in 2014), the world bank announced the creation of the pandemic emergency funding facility (PEF) which is described as “a health insurance scheme for the world’s poorest countries and for qualified international responding agencies” (21). Although the coverage may seem low ($500m fund compared to the estimated 8.8 trillion dollars cost of COVID-19), the act itself lays a reliable pattern to scale up the response to such outbreaks in the world. Another example of introducing such acts is designing patent pools for pharmaceutical products. When settled as effective treatments against COVID-19, the demand for some limited types of drugs (antimalarial, anti-inflammatory, or anti-viral) will be soaring in the medical market. Suggesting effective ways to reach sustainable agreements between the brand industry and the generic competitors will increase the accessibility and affordability of the therapeutic/preventive agents in the near future. Patent pooling was suggested as one strategy to address the same issue for antiretroviral drugs (potential treatments for acquired immunodeficiency syndrome (AIDS) (75). Designing similar interventions and not-for-profit-policies could immensely affect the fair availability of vaccines and drugs in the near future.

Lastly, educating residents about possible risks in nutrition patterns could be critical to halt the occurrence of other imminent outbreaks. A meeting report published by WHO in 2008 clearly claims the possibility of viral transmission via non-typical routes. Foodborne infection is introduced as a “frequent” viral transmission route. SARS-CoV and highly pathogenic avian influenza (HPAI) are described as resistant to (mild) food production processes routinely used to inactivate or control bacterial pathogens in contaminated foods (76). Regardless of literacy rate in a country, specific education in certain fields seems to be necessary to promote and reinforce the public engagement for some policies. Whenever there would be sufficient and robust evidence to claim a scientific critique about the origins of SARS-CoV-2, modifying Chinese residents’ nutrition patterns, which are engraved in them during several generations, might only be possible by extensive and persistent long-term education to achieve significant results. This claim is not limited to the Chinese nation and would be applicable to all kinds of risky dietary patterns around the globe.

 

Conclusion

Perceiving health as a public good obliges all governments to participate in the act of providing equity in health globally. Given that the favors will eventually return to their own nations, these acts should be done by any means available to the healthcare systems. Governments should refrain from political biases and cultural prejudices and reinforce the healthcare infrastructures as they are all necessary steps for achieving health equity.

 

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PEAH News Flash 389

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 389

 

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The Future Path of U.S. Clinical Research: Bridging Geographic Diversity

In this era of the COVID-19 pandemic, norms have been upended in every aspect of society. A lesser known complication in the healthcare environment is the impact on clinical trials. There is an opportunity to rethink how trials are conducted and also implement much-needed changes for greater inclusion of diverse trial participants by building on the momentum of developments started prior to the Coronavirus pandemic. The scope of this review will focus on rural study subjects and their barriers to participation

By Nicole Jarosinski, MA

AllBe Health, Amsterdam, The Netherlands

Info@AllBeHealth.NL

https://allbehealth.nl/

 The Future Path of U.S. Clinical Research: Bridging Geographic Diversity

 

In this era of the COVID-19 pandemic, norms have been upended in every aspect of society. The media has paid particular attention to the challenges and demands on healthcare around the world as hospitals navigate a surge in patient census, pause elective procedures, and otherwise cope with new realities. A lesser known complication in the healthcare environment is the impact on clinical trials. Trials determine the treatments and best practices of the future. With the ongoing changes in healthcare and society at large, there is an opportunity to rethink how trials are conducted and also implement much-needed improvements for greater inclusion of diverse trial participants by building on the momentum of developments started prior to the Coronavirus pandemic.

In 2019, the US Food and Drug Administration (FDA) issued guidance[1] calling for greater diversity of clinical trial populations with the purpose of developing a full picture of the risk or benefit of an investigational medical product. Further, “experience has shown that there can be important differences in how people of diverse groups respond to medical products. Information on those differences can then be included in the product labeling to help doctors and patients make treatment decisions.”[2] Given that the majority of clinical trial participants in the United States tend to be affluent white males in urban and suburban locations, diversity in this context means more than racial factors. A diverse clinical trial would also include different ages, ethnic groups, genders, and geographic settings. Participants with diverse characteristics have vital information to contribute to a more complete scientific understanding of medicine. The scope of this review will focus on rural study subjects and their barriers to clinical trial participation. Rural populations are historically underrepresented in United States trials and face the possibility of being even less represented in this time of COVID.

 

Challenges of rural populations

Rural populations in the United States share a number of common challenges. According to the Pew Research Center, residents of rural areas have lower income and rates of employment.[3] They have problems accessing fast, reliable internet service, with 22% saying they never go online.[4] Rural Americans are also older, sicker, and less likely to be insured than their suburban and urban counterparts.[5] Twenty percent of Americans live in rural areas, but the proportion participating in clinical trials is far less. Fewer than five percent of studies funded through the National Institutes of Health National Cancer Institute (NIH NCI) demonstrate recruitment in rural populations.[6] Given these challenges, there are a number of reasons that rural populations are often overlooked as potential sources of research participants.

The Devil You Know

Sponsors tend to choose academic medical centers located in major metropolitan areas as study sites due to their dedicated investigative resources and research-based mission. Academic centers have reputations for cutting-edge medicine that also make them destination hospitals, drawing patients from across the country. It is expensive for a clinical trial sponsor to prepare sites to conduct clinical trials due to multiple on-site visits, inspections, and training. It’s not uncommon for a sponsor to invest $30,000 in each site at startup, but this investment does not guarantee that a site will ever enroll any subjects. Therefore, sponsors often return to sites that have delivered high enrollment and complete data in past studies. Sponsors are also reluctant to contract with new sites that may not have as large of a patient pool.

Transportation Roadblocks

Reliable transportation is a barrier for rural populations to participate in trials that have a heavy number of in-person follow-up visits. These types of visits have their advantages, including more complete data capture. In-person visits also allow an unbroken chain of custody for investigational drugs that are literally handed from the research team to the patient, thus eliminating the possibility of restricted medications being lost in the mail. Despite these advantages, on-site visits can place a heavy travel demand on study subjects. Demands are exacerbated for those who must traverse long distances, those who need assistance, such as the elderly or children, and those who have to miss work or other obligations in order to participate.

Technical Difficulties

Telehealth technologies that could potentially reach rural populations have been slow to develop in the United States. One barrier to telehealth is the lack of highspeed internet in rural communities, but arguably the biggest factor for slow telehealth development has been non-involvement from the Centers for Medicare & Medicaid Services (CMS). CMS is the largest payor of medical claims in the US and greatly influences the direction of healthcare. Even though telehealth technology was developed in the early 2000s, CMS strictly limited telehealth reimbursement until 2018. Without financial support from CMS, healthcare providers had little incentive to make investments in telehealth.

 

Overcoming the Challenges

Increasing participation of rural populations in clinical trials requires a three-pronged approach: 1) expanding the network of potential trial sites; 2) improving participants’ access to healthcare; and 3) providing flexibility for the method and frequency of trial follow-up visits.

Broader Site Networks

Reputation is important, so it is understandable that sponsors would return to high-enrollment research sites that they contracted with in the past. However, to meet FDA expectations of diverse enrollments, it is imperative for sponsors to extend their reach into new territories. To facilitate expanded connections in rural areas, sponsors can partner with organizations who have existing networks, such as the NCI Community Oncology Research Program (NCORP). With a mission to bring “cancer clinical trials and care delivery studies to people in their own communities,” NCORP is already conducting trials in rural and underserved areas.[7] By collaborating with NCORP or similar entities, sponsors may find new long-lasting partners while also bringing cutting edge treatments to areas of the country that otherwise wouldn’t have access.

Clearing the Road

Social infrastructure improvements in recent years have increased the mobility of rural populations. Clinical trial sponsors and sites can take advantage of these enhancements for patients that struggle with travel. For short distances, ridesharing services such as Uber and Lyft can bring patients to research sites. Lesser known services that specifically serve rural populations are shuttles offered by local counties. Community-based councils on aging or volunteers from elder care and/or disabled advocacy groups also offer rides to medical appointments for study participants who would otherwise be homebound. These agencies may offer multi-county transport options at low to no cost.

Travel reimbursement can ease the burden of trial participation for all subjects regardless of distance from the study site, and it is a small cost to promote study enrollment. The FDA has clarified that it “does not consider reimbursement for travel expenses to and from the clinical trial site and associated costs such as airfare, parking, and lodging to raise issues of undue influence.”[8] Such reimbursements are generally considered acceptable practice.

Another unique solution is to bring studies to rural subjects through collaboration with healthcare services that already interact with patients in remote settings. As an example, university researchers in Arkansas found great success in recruiting rural and minority participants by joining forces with traveling care teams, such as mobile mammography units. They also recruited by participating in community events, such as the Susan G. Komen Race for the Cure, church functions, and health fairs.[9]

Streamlined Follow-ups

There are many common sense and innovative ways sponsor can rethink the strategy for a follow-up visit schedule. First, reduce the frequency of visits to only those necessary for appropriate safety and efficacy monitoring. Not only would this reduce the burden of study participation for research subjects, it would also decrease costs for sponsors.

Another factor is to build flexibility for the method of follow-up visits so that they could be conducted at the research site, the patient’s home, or virtually. There are an increasing number of remote and mobile communication platforms that can accommodate clinical trials. Providing multiple options makes study participation more convenient to patients.

Finally, research sites can take advantage of incentive programs for the expansion of telehealth. The Federal Communications Commission (FCC) recently announced that it is offering telehealth startup funding through the COVID-19 Telehealth Program and Connected Care Pilot Program.[10] These programs will lower the initial investment needed from study sites to build telehealth infrastructure.

 

The Path Forward

Historically, the pharmaceutical industry has been extremely conservative, changing very slowly due to its risk-averse nature. However, clinical research is in tumultuous times as sponsors and sites hurry to figure out the path forward through complications brought on by COVID-19. It has been said that necessity is the mother of invention. In the midst of such great change there is also vast opportunity.

Sponsors can easily build on the momentum of recent innovations to both adapt ongoing clinical trials to the new 6-foot (1.5 meter) society and be more inclusive of rural participants. In fact, the above recommendations could be easily translated to increase diversity of all kinds, since concerns about transportation and low income span across all races, genders, ages, and geographic locations.

There will inevitably be speed bumps for a while as new best practices are established, technology is refined, and new bridges are crossed. But for the clinical trial industry, the COVID-19 pandemic is an inflection point. There is no going back to the way it has always been done. Patience, ingenuity, and a willingness to embrace change are what is needed in this time.

 

References

[1] U.S. Department of Health and Human Services, Food and Drug Administration. (2019). Enhancing the diversity of clinical trial populations: Eligibility criteria, enrollment practices, and trial designs. Draft Guidance. Retrieved from https://www.fda.gov/media/127712/download.

[2] U.S. Department of Health and Human Services, Food and Drug Administration. (2018). FDA encourages more participation, diversity in clinical trials. Retrieved from https://www.fda.gov/consumers/consumer-updates/fda-encourages-more-participation-diversity-clinical-trials.

[3] Parker, K., Horowitz, J.M., Brown, A., Fry, R., Cohn, D., & Igielnik, R. (2018). What unites and divides urban, suburban and rural communities: Amid widening gaps in politics and demographics, Americans in urban, suburban and rural areas share many aspects of community life. Pew Research Center. Retrieved from https://www.pewsocialtrends.org/2018/05/22/what-unites-and-divides-urban-suburban-and-rural-communities/.

[4] Anderson, M. (2018). About a quarter of rural Americans say access to high-speed internet is a major problem. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2018/09/10/about-a-quarter-of-rural-americans-say-access-to-high-speed-internet-is-a-major-problem/.

[5] U.S. Centers for Disease Control and Prevention (2017). About Rural Health. Retrieved from https://www.cdc.gov/ruralhealth/about.html#:~:text=A%20series%20of%20studies%20from,stroke%20than%20their%20urban%20counterparts.

[6] Blake, K.D., Moss, J.L., Gaysynsky, A., Srinivasan, S., & Croyle, R.T. (2017). Making the case for investment in rural cancer control: An analysis of rural cancer incidence, mortality, and funding trends. Cancer Epidemiol Biomarkers Prev. 26, 992-997.

[7] National Cancer Institute Community Oncology Research Program. (n.d.). About NCORP. Retrieved from https://ncorp.cancer.gov/about/.

[8] U.S. Department of Health and Human Services, Food and Drug Administration. (2018). Payment and reimbursement to research subjects: Guidance for institutional review boards and clinical investigators. Final Information Sheet. Retrieved from https://www.fda.gov/RegulatoryInformation/Guidances/ucm126429.htm.

[9] McElfish, P.A, Su, L.J., Lee, J.Y., Runnells, G., Henry-Tillman, R., & Kadlubar, S.A. (2019). Mobile Mammography Screening as an Opportunity to Increase Access of Rural Women to Breast Cancer Research Studies. Breast Cancer: Basic and Clinical Research, 13, 1-6. DOI: 10.1177/1178223419876296.

[10] U.S. Federal Communications Commission. (2020). FCC Approves Emergency COVID-19 Telehealth and Connected Care Pilot Programs. Retrieved from https://www.fcc.gov/fcc-approves-emergency-covid-19-telehealth-and-connected-care-pilot-programs.

 

 

PEAH News Flash 388

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 388

 

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COVID-19 puts a spotlight on the Medicines Patent Pool 

New UNESCO report shows COVID-19 leaving vulnerable children behind 

Over 1,000 clinical trials involving children are missing results across Europe 

Health system’s response to the COVID-19 pandemic in conflict settings: Policy reflections from Palestine 

Webinar Registration: Sustainable Health Equity Movement Global Launch Event: “The Ethical Principle of Equity in the Response to the Pandemic and Beyond” Jul 2, 2020 08:00 AM 

An update on the fight against antimicrobial resistance 

‘Alarming’ use of critical human antibiotics on crops 

MSF: Analysis and Critique of the Advance Market Commitment (AMC) for Pneumococcal Conjugate Vaccines 

Ebola in the Democratic Republic of the Congo 2020 

It is time to abandon “development” goals and demand a post-2030 Utopia 

Senegalese Women’s Participation in Energy Sector equals Empowerment 

CDI 2020: China’s Commitment to Development 

Tencent’s ‘smart city’ seen as model for post-coronavirus China 

Coastal fishing communities ‘facing disaster’ 

Lifting Livelihoods by Lifting Water 

UN says seeking to verify Arctic heat record 

Joint CSO Letter on the EIB Climate Bank Roadmap 

 

 

 

 

 

 

 

 

COVID Death: Direct Death or Excess Mortality Worth to Report in Low- and Middle-Income Countries?

Low -and middle-income countries should assess the overall (direct and indirect) effects of COVID-19 on excess mortality. This is very important for monitoring both the direct and indirect impact of the pandemic to set policy directions and develop context-based mitigation strategies for both direct and indirect (excess) mortalities related to COVID-19

By Lemi Belay Tolu (MD)1, Alex Ezeh (Ph.D.)2, Garumma Tolu Feyissa (Ph.D.)2

  1. Saint Paul’s Hospital Millennium Medical College, Department of Obstetrics and Gynaecology, Addis Ababa, Ethiopia
  2.  Dornsife School of Public Health, Drexel University, Philadelphia, USA

Corresponding author: lemi.belay@gmail.com

COVID Death: Direct Death or Excess Mortality Worth to Report in Low- and Middle-Income Countries?

 

Covid-19 has caused severe economic, social, and health impacts around the world. Thousands have died of the virus since its identification in the Wuhan province of China. Deaths from the coronavirus disease 2019 (COVID-19) pandemic might arise both in those infected (direct effects), as well as those affected (indirectly, not infected) by altered access to health services; the physical, psychological, and social effects of distancing; and economic changes. Yet there is no consistency on what to consider as COVID-19 death. In some countries, COVID-19 mortality did not consider counting of the deaths attributed to underlying conditions even though the cases had tested positive for COVID-19. In some counties, on the other hand, such cases were counted. In other countries, suspected cases were also included in the reports of COVID-19 mortalities. These factors make it difficult to compare case fatality rates across countries especially in low- and middle-income countries where registration and data recording system is poor.

Direct COVID-19 death

Different countries use different definitions of COVID-19 death.  There are two main ways in which COVID-19 deaths are defined. The first, based on the WHO definition (see below), uses clinically confirmed or probable COVID-19 case. The second, on the other hand, is reliant primarily on a positive laboratory test.  WHO defined COVID-19 death as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). Additionally, WHO stated that there should be no period of complete recovery from COVID-19 between illness and death to consider as COVID-19 death.  This is a direct death due to COVID-19, not attributed to another disease (e.g. cancer), and should be counted independently of preexisting conditions that might have exacerbated a severe course of COVID-19.  In the absence of a clear alternative cause of death, both confirmed and suspected cases could be considered as COVID-19 death (Figure 1 below).  Where the WHO definition is used, it is more likely that a greater share of COVID-19-associated deaths will be captured in low-and middle-income countries  because of the following factors: variations in testing policies across countries (population groups eligible for tests in some countries were restricted to people with severe symptoms); limited testing capacity, and PCR test sensitivity can be as low as 54% missing false negative cases. Therefore, this might result in limiting reporting to mainly hospital deaths and testing severe cases that present in hospital, resulting in high case-fatality rates as a result of the smaller volume of tests if the COVID-19 death is defined primarily based on a positive laboratory test only. Additionally, reporting all positive laboratory tests as COVID-19 death might complicate some medicolegal issues. For example, a person who died of road traffic accident at the scene might be asymptomatic positive for COVID-19 up on forensic investigation.

 

Figure 1: Medical certification of suspected and confirmed COVID-19 cases as COVID-19 death. Taken from WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death

Persons with COVID-19 may die of other diseases or accidents, such cases are not deaths due to COVID-19 and should not be certified as such (Figure 2 below). This includes postmortem COVID-19 positive cases during the forensic investigation if there is a clear alternative cause of death.   However, COVID-19 should be recorded on the medical certificate of cause of death for all decedents where the disease caused (COVID-19 death) or is assumed to have caused (COVID-19 death) or contributed to death (Non-COVID-19 death).

Figure 2: Medical certification of COVID-19 cases that die of accidents or other diseases as non-COVID death. Taken from WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death

 

Excess of COVID-19 mortality

These include indirect deaths among those affected (indirectly, not infected) by altered access to health services; the physical, psychological, and social effects of distancing; and economic changes. This type of death specifically might increase dramatically in low- and middle-income country because of the weak health care system, lack of well-established virtual or other alternative health care methods during the lockdown, and the dwellers suffer from underlying health conditions, such as malnutrition, chronic diseases and several other factors related to poverty. For example, evidence from the Ebola virus outbreak in 2013–2016 in Western Africa shows the negative, indirect effects that such crises can have. According to an analysis of data from Sierra Leone’s Health Management Information System (HMIS), decreases in maternal and newborn care due to disrupted services and fear of seeking treatment during the outbreak contributed to an estimated 3,600 maternal deaths, neonatal deaths, and stillbirth, a quantity that approaches the number of deaths directly caused by the Ebola virus in the country.

According to early estimates by Roberton et al. 2020, if the routine healthcare services are interrupted and access to food is limited because of limited production related to Covid-19 lockdown in low- and middle-income countries, it is expected to rise under-five mortality (from 9.8% to 44.7% increase per month) and maternal mortality (8.3–38.6% per month).  According to Guttmacher Institute, early projection of the indirect impact of the pandemics, a 10% service reduction in low- and middle-income countries will result in 28,000 and 1,000 additional maternal deaths from obstetric complications and unsafe abortion respectively. Similarly, it will result in 168,000 additional newborn deaths.

Reporting excess mortality has an important advantage considering variations in the definitions of COVID-19 death between countries. It includes deaths among those who probably had COVID-19 providing a more comprehensive picture of the scale of mortality during the crisis and facilitates comparisons across countries. Excess mortality not only makes a better understanding of the overall impact of the pandemic on population health, but it also facilitates tracking of the impact of the pandemic in real-time.

Conclusions

There is variation in definitions of COVID-19 death and broadly categorized into two: diagnosis-based (confirmed and probable, in line with the WHO definition) and test-based. WHO definition is more likely to capture COVID-19-associated deaths. Therefore, we recommend low- and middle-income countries to use WHO international guidelines for certification and classification (coding) of COVID-19 as the cause of death for appropriate identification of COVID-19 death and non-COVID-19 death. However, WHO’s definition accuracy may vary depending on the implementation of the WHO guidelines in practice within countries, and death certificate registration might take time challenging prompt report. These might be further complicated in low- and middle-income countries with limited testing capacity and data tracking capacity. Estimating excess death could be used as a solution for such problems and express the true scale of the COVID-19 pandemic. Therefore, low -and middle-income countries should assess the overall (direct and indirect) effects of the pandemic on excess mortality. This is very important for monitoring both the direct and indirect impact of the pandemic to set policy directions and develop context-based mitigation strategies for both direct and indirect (excess) mortalities related to the pandemic.

 


By the same authors recently on PEAH

How Prepared is Africa for the COVID-19 Pandemic Response? The Case of Ethiopia by Garumma Tolu Feyissa, Lemi Belay Tolu, Alex Ezeh 

How to Survive COVID-19: Now and the Future

Having crossed the initial hurdle of accepting the present COVID-19 pandemic context and uncertainties that the future entails, we are now faced with answering how this ‘new normal’ should pan out across different sectors. As some human activities will become redundant, others will have to rapidly adapt. In essence, we are fast approaching the age where not just the ‘fittest’ will survive, but also those who are ‘quickest’ to adapt to this new way of life

Credit: Centers for Disease Control and Prevention (CDC)

By

Dr. Subhash HiraProfessor of Global Health, University of Washington-Seattle

Sudhanshu MalhotraSambodhi Research and Communications, New Delhi, India

Santosh Gupta, Indian Social Responsibility Network, New Delhi, India

Kaamila Patherya, Sambodhi Research and Communications, New Delhi, India

Addresses for correspondence: hiras2@uw.edu; kaamila.patherya@sambodhi.co.in

 How to Survive COVID-19: Now and the Future

 

It is now globally acknowledged that the COVID-19 pandemic has changed our world for good. People across the globe are navigating on a daily basis what the ‘new normal’ will look like. The initial denial, confusion and resentment has given way to gradual acceptance that the coronavirus is here to stay and it is up to communities to find ways of living with it by minimizing risk to the greatest extent, both in terms of health as well as social and economic life.

Having crossed the initial hurdle of accepting the present context and uncertainties that the future entails, we are now faced with answering how this ‘new normal’ should pan out across different sectors. As some human activities will become redundant, others will have to rapidly adapt. In essence, we are fast approaching the age where not just the ‘fittest’ will survive, but also those who are ‘quickest’ to adapt to this new way of life.

Social and Economic Restructuring

Epidemiologic Status of COVID-19 as of June 18, 2020

 

     

Figure 1: Slides 1-4 show global cases, deaths, sex and age distribution of deaths. Slides 5-6 depict Indian figures by mid-June 2020

Source: Worldometer, JHU https://www.worldometers.info/coronavirus/?utm_campaign=homeAdvegas1?%22%20%5Cl%20%22countri#countries

 

Wuhan, China being the epicenter, COVID-19 has developed into a pandemic with small chains of transmission in many countries and large chains resulting in extensive spread in a several countries, such as Italy, Iran, South Korea, USA, and Japan. While the number of cases in India is on the increase, we know that as epidemics progress the effective reproduction number (R0) declines until it falls below unity in value when the epidemic peaks and then decays, either due to the exhaustion of people susceptible to infection and/or the impact of control measures. With the governments gradually lifting lockdown measures, reducing transmission will primarily be an individual-level effort involving social distancing, mask-wearing, hand hygiene, and self-isolation. [1,2]

 Social and Mental Health Impacts of COVID-19

Countries across the globe are facing major social transformations that dictate their behaviors and interactions. These impacts are particularly staggering for Global South countries where marginalized populations are facing serious setbacks along vital SDG parameters such as gender equality, education, employment, refugees, and environmental protection. Historically, there has been a strong correlation between epidemics and increase in human trafficking. COVID-19 could offset gross human rights violations on women, refugees, and children, and could also disadvantage the elderly. Scaling in counseling services for lonely patients and families with COVID and accelerating community participation must be made a priority.

Equally important is the need to focus on mental health. Healthcare workers, those already dealing with mental health pre-COVID, and people with disabilities as those who are at greatest mental health risk during this period. It is important to destigmatize groups such as elderly people and healthcare workers, and to stress on the importance of basic care such as eating and sleeping. Helplines and deploying mental health professionals will be paramount in helping people deal with anxiety, resentment, depression, and trauma induced by lockdowns. Setting routines, meditation, expression of gratitude, and adaptability are useful practices in helping individuals cope with the volatile period.

Economic Impact

 

Figure 2: Mapping select countries based on comparative lockdown restrictions and socio-economic outcomes. Source: Boston Consulting Group (with modifications)

 

Figure 2 above shows various levels of lockdown restrictions in different countries represented by blue, pink, or red halos. Quadrant 1 where Vietnam and other countries show blue halo, meaning low restrictions. In Quadrant 2, India is seen with blue halo i.e. low restrictions, South Africa with pink halo i.e. moderate restrictions, and Argentina with red halo i.e. severe lockdown restrictions.

The quadrants are made up by vertical axis representing economic outcomes using GDP and industrial/agricultural production indicators, and horizontal axis shows Public Health (PH) outcomes using number of COVID cases detected, fatality rate, and social outcomes.

Quadrant 1 is characterized by high economic and high Public Health outcomes. The countries include China, Vietnam, Bangladesh, Indonesia, where low to moderate lockdown restrictions were used. Quadrant 2 shows low economic but high PH outcomes, including India, South Africa, Germany, Australia, South Korea, Taiwan, Japan. Low to high lockdown restrictions were used. Quadrant 3 displays low economic and low PH outcomes, including economies such as the USA, UK, Brazil, Saudi Arabia, Iran.. Moderate to high lockdown restrictions were instituted in these countries. Quadrant 4 has high economic but worse PH outcomes, including majorly of EU countries. Here, there were moderate restrictions, pictured with the pink halo.

It can be inferred that Quadrant 1 countries got the best socio-economic outcomes, and Quadrant 3 countries got the worst socio-economic outcomes.

Figure 3: IMF World Economic Outlook

 

Figure 3 above provided by the IMF in April 2020 shows real GDP of major countries and how this has comparatively changed over 2019 and 2020 due to the impacts of COVID-19.The real GDP of the United States will fall to 1/4th of what it was the last year.EU countries will collectively lose their GDP to 1/7th of what it was. Japan GDP will drop to 1/8th of what it was the last year. The Indian GDP will drop from 4.2 to 1.9, which is almost like one half. On a comparative scale, Indian GDP still survives with significantly lesser drop than countries such as South Africa or Brazil or even China to that extent.

Based on these trends across countries that are at various stages of lockdown, it seems that the economic slump will be varied and different from recessions in the past. Unlike past recessions, the economy should recover more swiftly, and the scenario should start inching towards business-as-normal within the next 6-8 months. Adopting a protectionist stance will have to be viewed with some caution, as developed economies imposing high tariffs could negatively impact some of the emerging economies. Economic reforms accompanying the rollout of stimulus packages, similar to the approach adopted by India, might be a useful mechanism to put countries back on the path of speedy economic recovery.

With the above major changes happening in the world, the following five concepts define the ‘new normal’ areas for our survival:
 
Acceptance that the world has changed forever with onset of COVID-19 pandemic.
 
Adaptation is required in all spheres of human life.

It will be survival of the “quickest”; not survival of the ‘fittest’.

Accept “forced entrepreneurship” as the way to survive in the industry of your choice.

In order to avoid making mistakes, drop your ‘ego’ and accept changes as they come.
Sectoral Changes

Personal Protection

While governments are actively taking steps for prevention and containment, protection is primarily the individual’s responsibility. Mask wearing, frequent hand washing, and maintaining 6 feet physical distance are becoming ingrained in our social behaviors. [3] Mask wearing, in fact, has long been a tradition in many countries such as Japan as a precautionary step against respiratory diseases. Other countries would do well to similarly adopt these measures as a way of life. According to research studies, the cotton mask is as effective as a medical mask for protection. [3,4] In developing countries including India, owing to socio-economic disparity, homemade masks or cloth coverings that protect the nose and mouth are sufficient and practical solutions. Figure 5 shows findings of a mathematical modeling study, wherein there is an average of 30-50 contacts/day for individuals <18 years of age, and an average of 100 contacts/day for individuals >=18 years of age. [4]

Figure 4: Probability of contagion at various levels of protection

Figure 5: Effectiveness of various protection measures in reducing transmission [4] 

Travel, Hospitality Industry, and Vacations

The delayed closing of international flights and borders was not only the primary cause for global transmission of the virus that deemed it a pandemic, but it is also the most alarming aspect that sets it apart from other epidemics of the past. In the case of SARS in Hong Kong or Ebola in Africa, shutting down flights and closing borders was the first governmental response measure to contain the spread of infections. Needless to say, the lack of these measures for COVID-19 is what has transpired into the current state of affairs.

As borders gradually open and certain flight routes resume, we will have to continue to approach travel with some caution till some time to come. Tourism and non-essential travel must be stalled. While airlines are enforcing strong protection measures, air travel should only be resorted to when absolutely essential.

The Future of Work from Home

We are transitioning not just in terms of how we work, but also in the very nature of work itself. Occupations which demand close contact, such as in restaurants, hospitality, malls, salons etc., are the most impacted. However, the economy is fast adapting to a new way of doing business. The ‘digital economy’ has been infused with new vigor, and one can foresee emerging demand for a host of new services. Online teaching, for example, is emerging. The work from home model is now largely accepted as the way of the future. [2]

Apart from digital businesses, the health sector and alternative medicine will both see a surge. Investments in this space will also increase. Startups focusing on how technology and Data Science can optimize public health are also appearing on the horizon.

Entertainment and Leisure

The old ways for entertainment and leisure will probably not resume for some time to come. Cinema halls, malls, and restaurants, though gradually opening up, continue to pose some risk. However, this need not necessarily result in the stalling of entertainment activities. Home-based streaming services are providing access to films and media at nominal costs, and video conferencing software are ensuring that people are connected for meetings and consultations. Adapting to new mode of enjoyment, as opposed to its altogether disbandment, is how we need to reorient our thinking.

Education

While the economy may have momentarily halted in the last few months, learning and education across the globe has remained largely unaffected at least in private and university settings. The mode of instruction has moved to the virtual space, and it will be so for some time to come. The challenge will now be to navigate how public schools and establishments in remote areas and villages that lack access to technology can be resumed. Testing at end-of-course is another concern that institutions across the world are currently finding solutions to. Virtual teaching, which had been gathering momentum, is now going to be indispensable. The benefits offered in terms of access, reach, and innovative methods are fast convincing education professionals as well as students of the efficacy of this medium of instruction.

Treatments, Vaccines and Herd Immunity

A variety of approved treatments are being used by the Government of India to treat COVID-19 patients. Hydroxychloroquine (HCQ), Azithromycin, Oseltamivir, Vitamin C tablets, among other drugs, are being administered depending on specific patient conditions. Convalescent plasma therapy, which has successfully treated other infectious diseases in the past, is being used for severe COVID-19 cases and the initial results have been favorable. [5,6,7]

There has been some debate on the usage of Hydroxychloroquine (HCQ) in the treatment of COVID-19. Despite claims, there is no conclusive evidence against is usage as yet and in-vitro studies have shown that HCQ reduces viral shedding and also hampers replication. The only concern is that of cardiotoxicity and ECG baselines have to be done to determine usage. [8]

While we continue to remain hopeful for a vaccine for COVID, we must learn and be cognizant of realities and of our experiences with vaccines throughout the course of history. The Smallpox vaccine took almost 200 years to develop and the Polio vaccine took almost 60 years. Several rounds of animal and human level testing are involved in developing vaccines and taking shortcuts in this regard can be dangerous. We need to wait at least 18 months before we reach any conclusions regarding a potential COVID vaccine. Even after discovery, administering it to a global population will not be an easy task. Instead of pinning hopes on the vaccine, it is important to reorient our thinking to how we can adapt and live with coronavirus. Wishful thinking of vaccine as a magic bullet could be misleading at this stage.

The theme of herd immunity is also being deliberated. Sweden, after a couple of weeks of lockdown, has adopted a stance of minimal restrictions and eventual herd immunity as a means of responding to the pandemic. However, this is still widely contested with inconclusive evidence, particularly since the parameter to judge the herd immunity raises challenges. [7] Normally, it is known that once the body fights a disease, antibodies are produced in the bloodstream which protect against future infections. However, antibodies can be created in the body for various reasons, rendering it not the best parameter to judge herd immunity. In some animal models, it may take 6-8 months for herd immunity to develop. Neutralizing antibodies take very long to develop, and more research is needed in this space. [9]

Alternative Medicine

While we continue to protect ourselves from COVID through safety measures, strengthening our innate mechanisms to fight infections is an equally important aspect that deserves attention. Alternative medicine, in particular Ayurveda and homeopathy, hold some potential in this regard. As a prophylactic measure, homeopathic treatments have been known to boost immunity and the body’s natural defenses against infections. In fact, homeopathic treatments have been widely used during past epidemics such as cholera, Spanish flu etc. While they may not be able to scientifically prevent infection, they do not pose any harm or side-effects. [10]

Conclusion

The COVID-19 pandemic has transformed the social and economic fabric of our lives. While on the one hand the effects have been catastrophic in terms of lives and livelihoods lost, the speed and optimism with which communities and businesses have responded holds testament to the innate adaptability of human beings as a species. Adapting, the very quality that ensures our survival on earth, will prove most instrumental in how we meet the challenges and demands of ‘new normal’ in the future.

 

References
  1. Roy M Anderson, Hans Heesterbeek, Don Klinkenberg, Déirdre Hollingsworth. How will country-based mitigation measures influence the course of the COVID-19 epidemic? https://doi.org/10.1016/S0140-6736(20)30567-5
  2. Mark Barnes, Paul E. Sax. Challenges of “Return to Work” in an Ongoing Pandemic. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMsr2019953
  3. Derek K Chu, Elie A Akl, Stephanie Duda, Karla Solo, Sally Yaacoub, Holger J Schünemann, on behalf of the COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext
  4. Stadnytskyi V, Bax CE, Bax A, Anfinrud P. The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission. Proc Natl Acad Sci U S A. 2020;117(22):11875‐11877. doi:10.1073/pnas.2006874117
  5. Government of India, Ministry of Health and Family Welfare, Directorate General of Health Services (EMR Division). Clinical Management Protocol: COVID-19. https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19.pdf
  6. World Health Organization. Clinical management of COVID-19: Interim guidance, May 2020.
  7. World Health Organization. Key criteria for the ethical acceptability of COVID-19 human challenge studies. Reference number: WHO/2019-nCoV/Ethicscriteria/2020.1
  8. Anwar M. Hashem,Badrah S. Alghamdi,Abdullah A. AlgaissiFahad S. Alshehri, Abdullah BukhariMohamed A. Alfaleh, and Ziad A. Memish. Therapeutic use of chloroquine and hydroxychloroquine in COVID-19 and other viral infections: A narrative review. https://doi.org/10.1016/j.tmaid.2020.101735
  9. Haley E. Randolph, Luis B. Barreiro. Herd Immunity: Understanding COVID:19. https://doi.org/10.1016/j.immuni.2020.04.012
  10. Government of India, Ministry of AYUSH. GUIDELINES for HOMOEOPATHIC PRACTITIONERS for COVID 19. https://www.ayush.gov.in/docs/homeopathy-guidelines.pdf

 

PEAH News Flash 387

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PEAH News Flash 386

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 386

 

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