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Animal care continues during COVID-19, writes Ranald Leask

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While human medicine takes centre stage, vets, vet nurses and researchers dedicated to caring for our pets and livestock, continue their work.

The University’s Easter Bush campus is home to some of the world’s foremost animal health experts. As with their counterparts in human medicine, they’re responding to the current crisis with innovation and dedication.

A number of researchers at the Roslin Institute are currently investigating various aspects of Covid-19 in an effort to find ways to combat the infection.

Continuity of care

At the Royal (Dick) School for Veterinary Studies Hospital for Small Animals, familiar to many members of the public for the care given to beloved family pets, work continues to provide diagnosis and treatment, albeit with adjustments. Keeping staff, students, clients and their animals safe is the first priority, with new methods of team working now in place, to minimise possible exposure to the virus.

Dr Sue Murphy is Director of the Small Animal Hospital: “By working within the Royal College of Veterinary Surgeons guidelines of seeing only urgent or emergency cases we are protecting the public and our staff, as well as ensuring the welfare of the animals under our care isn’t compromised.”

The Vet School has made available essential medical kit to NHS Lothian, with the provision of four ventilator machines and the donation of 450 surgical masks, and a quantity of surgical scrubs.

Looking after livestock

Large animal care responsibilities also continue for staff and students at Easter Bush. For many in the agricultural industry, Covid-19 could not have come at a worst time, as spring lambs and calves are born. The University’s Farm Animal Hospital and Practice provides essential advice to farmers and vets around the UK.

Keeping the nation fed requires healthy, productive livestock, meaning the role of vets and vet nurses is crucial. These professionals have adopted new working practices that enable them to continue to attend sick animals, while minimising contact with others.

Online support

With campus teaching suspended, keeping in touch online has become evermore vital. One example the Vet School has employed is the ‘Bit of Fresh Air’ Facebook sessions. Hosted every Monday afternoon for vet students, the interactive sessions are led by Lecturer in Veterinary Clinical Skills, Caroline Mosley.

Caroline says: “There is a very strong feeling of cohesiveness at Easter Bush, so losing this at a critical time of the year – in the run up to graduation – we wanted to give our students some way of staying in touch with staff. We have had some lovely feedback from students, saying they are missing Scotland and the University and that it was lovely to be on the live video and just see a bit of the outdoors, plus the animals that feature in them have been popular too.”

Making a difference

Staff and students are also volunteering at local charities, such as the Cyrenians and Trussell Trust, which support people who are disadvantaged and living in poverty.

Julian Mashingaidze, in his first year of a BSc in Global Agriculture and Food Security, says that while tiring, his voluntary work in a distribution warehouse has been very rewarding: “The Covid-19 situation had led me to start feeling useless and demotivated, but through helping out I have found a purpose. It has helped immensely with my mental health, which I’d been struggling with recently. Now I’m doing something that uplifts the local Edinburgh community while keeping me busy.”

Practical assistance has also been the aim of Amanda Warr, a post-doctoral researcher at the Roslin Institute. She has used her own 3-D printer to produce plastic components for face shields. These are used by front line NHS and care staff to protect themselves.

Amanda has already produced parts for more than 500 shields: “We get sent photos of workers wearing the shields, which is lovely and really reminds you that every shield is helping to protect a real person who is in a dangerous situation. It is heart warming to see them, and of course we are very grateful for everything they are doing.”

Donations to help Amanda’s efforts can be made at her GoFundMe page, here.

For Professor David Argyle, Dean of Veterinary Medicine, the key to overcoming this crisis is by calling upon the sense of unity traditionally enjoyed by staff and students at Easter Bush: “We have always had a really strong sense of community. These efforts to support the greatest public health crisis in decades shows our students and staff working together at their best through hugely challenging circumstances.”

This article was originally published on the University of Edinburgh Covid-19 Responses website: https://www.ed.ac.uk/covid-19-response/our-community/animal-care-remains-priority-during-covid-crisis

Ranald Leask is Corporate Communications  Manager for the University of Edinburgh 



Authorities turned a blind eye to Nepali migrant workers, writes Radha Adhikari

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In recent months, people’s mobility has been synonymous with the transmission of Coronavirus, and the Covid-19 pandemic has had a devastating impact. Global economies are in peril and the very future of humanity has been seriously threatened. Currently, there is almost no country in the world which has not been affected. Countries have adopted various measures to tackle this threat. Complete or partial lockdowns in mobility, in tandem with social distancing, have been seen as the most important primary measures to minimise infection rates.

Global lockdown and its impact on low-skilled and unskilled migrants

Considering how contagious Coronavirus is, most countries are following lockdown guidelines, which have created nightmare situations for many migrant workers. For example, India’s swiftly imposed lockdown has created havoc in the lives of migrant workers, causing suffering and uncertainty, as these workers have had no time to plan and prepare. They were forced to pack up their belongings and head home, and all within four hours. Within a short time, hundreds and thousands of migrants were out on the street, starting their journeys home.

Regional and global news channels showed images of migrants stranded in railway stations and walking along India’s long dusty roads. The sight of these men and women, some with babies on their backs, and carrying their possessions, was reminiscent of similar historical journeys made in 1947, at the time of Partition, when the Indian Independence Act came into force.

Following government-imposed lockdowns in several countries, the Nepal Embassy in New Delhi (and also in the Gulf states) issued a notice that all Nepali migrants should stay where they were, and not to break the government’s advice. They were not to travel, they were to maintain a social distancing policy, and to follow Government advice. However, as Nepali migrants in India revealed, many had nowhere to stay. They lost their jobs when factories, shops, and businesses were closed and construction sites halted, and landlords then asked them to vacate their accommodation.

Similarly, reports from journalists from the Gulf States have begun to emerge about the situation of Nepali migrants and of other migrants in Qatar, UAE, and in other countries, who were also left stranded following the lockdown. Despite the Covid-19 outbreak and social-distancing advice, some migrant workers have had to continue to work on the construction sites for the Qatar Olympics, and their lives remain as usual. A large number of migrant workers – Nepalis and other nationals – live in small over-crowded dormitories and have little choice for social distancing and self-isolating. A notable rise in Covid-19 cases in the Gulf States has been reported, with the majority of positive cases being migrant workers. The health and wellbeing of migrant labourers has always entailed a higher degree of occupational risk, even before the Covid-19 outbreak, as employers rarely put the needs of migrant labourers before profit. The crowded accommodation and the lack of choice about social distancing for low-income migrants means that the Covid-19 crisis will continue until migrants’ accommodation and other issues are addressed. Countries in Asia are already experiencing a second wave of Covid-19 transmission and migrants are hit the hardest by this.

Time for better welfare and justice for all migrants

It is clear that the concept of ‘social-distancing’ is achievable only by the most privileged groups in societies, not to those living in slums in Mumbai, Dhaka, and on construction sites in Qatar. When migrant workers lose their jobs and are evicted from their accommodation, social distancing becomes impossible. Most governments seem to have given little thought to the plight of migrant workers, and have failed to adopt any measures to support these underprivileged groups. The safety of vulnerable migrants has been an issue of low priority for employers and the governments of destination or home countries. Nepali and Indian authorities have turned a blind eye to the hundreds and thousands of workers stranded in India, and those at the India-Nepal border. Now is the time for us to learn a historical lessons from this pandemic: that all migrants should have access to basic social security and living wages; that governments should treat migrants with compassion, dignity, and respect. In global efforts to manage and control a pandemic effectively, the rights and welfare of migrant workers should not be sacrificed.

This article was originally published on the Justice in Global Health Emergencies & Humanitarian Crisis website: https://www.ghe.law.ed.ac.uk/nepali-migrant-workers-during-the-covid-19-crisis-by-radha-adhikari/

Radha Adhikari is a Research Fellow in SSPS, and currently working on a project examining the ‘Documentation of Nepali migrants’ death, injury and ill-treatment in transit and destinations’. Currently, the research fieldwork has been on hold due to Covid-19 outbreak.



Eastern Europe got the lockdown responses to COVID-19 right, writes Igor Rudan

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Why did Croatia, Slovenia, Montenegro, Bosnia and Herzegovina, North Macedonia, Bulgaria, Hungary, Serbia and Ukraine respond much better than other countries of the European Union?

Nearly a month ago, I stressed that Croatia was the country with the lowest percentage of newly COVID-19 infected persons in Europe during the two weeks from the 2nd to the 17th of March, 2020. This means that our “first line of defense” did an excellent job. Then we went into quarantine at the right time, at a much earlier stage of the spread of the epidemic than pretty much anyone else in the European Union did. We have all become “Quarantine Croatia”, so I joined forces with our famous mathematician Toni Milun to explain together just how we came to be in this situation at all.

In mid-January 2020, a number of friends from Croatia suggested that I should start a new popular science series on Facebook in order to follow the COVID-19 epidemic in Wuhan. I called my Chinese colleagues at the time, asking them to briefly describe what was happening there. They conveyed a few simple but very helpful messages. What surprised me the most was the thought of putting 56 million people in quarantine for an extended period. That, then, on the 17th of January — so, just three months ago — sounded like a completely radical idea. But when I found out more, and then one week later — on the 23rd and 24th of January — I noticed that they’d indeed closed off Wuhan and fifteen other cities, I realized that it was an almost surreal event. One that was certainly worth following and writing about. Thus, on the 29th of January, “The ‘Quarantine of Wuhan’’ series began and in Croatian, it attracted more than 30,000 followers on Facebook, than 500,000 in Croatia’s media space when I started writing it for “Vecernji list” newspaper. The online version gets picked by other news portals, so it is now reaching more than 1 million people across the 6 countries from the former Yugoslavia.

My Chinese colleagues told me that more and more people with some sort of unusual pneumonia began to show up at Wuhan’s huge hospitals on a daily basis. That would usually drag on about ten days without responding to any sort of antibiotic therapy. Some people soon required additional oxygen or mechanical support to help them to breathe. When the doctors themselves became infected, the fear would grab them. How could it not? It was an unknown cause of pneumonia, and about one in ten patients would die even with hospital treatment. But what would surprise them was that the infected doctors had generally mild symptoms. They didn’t understand how it was possible that these infected patients were in such a poor condition but the infected doctors seemed much better if the cause of their respiratory infection was the same.

The answer to that enigma, however, could be found by looking through hospital windows to the streets of Wuhan, with its eleven million residents. To epidemiologists, such a rift of symptoms was a clear signal that an epidemic had to have been spreading rapidly among the population of that city for some time. It would be causing a broad spectrum of symptoms in different people. In the vast majority of those infected, the symptoms would be rather mild or moderate, so they would never report to the hospital. Symptoms would be worse in about fifteen percent of people and they would struggle to breathe, report to Wuhan’s hospitals and require extra oxygen. Only the remaining five percent of those affected with symptoms would end up in critical condition, in need of ventilators and intensive care. They further noticed that when doctors transmitted this unknown virus to other patients in the hospital, it would also kill about one in ten people who were infected. Those were mostly people who already had other serious illnesses. Men, smokers and older people were the most high-risk groups.

The doctors in the hospitals saw only that extreme part of the spectrum of the sick — serious and critical cases. Other infected residents, those with mild and moderate symptoms, walked around Wuhan spreading the infection at a rapid speed. Epidemiologists in Wuhan realized that the new illness would therefore not kill every tenth person it infects, but maybe every 100th person, maybe even every thousandth, depending on how many infected were there in the streets already.

The number of deaths in the hospitals could be used as a numerator, but all infected residents of Wuhan outside the hospital should have been placed in the denominator, i.e., the numerous people with milder symptoms. At the beginning of the epidemic in this city of eleven million people, no one knew if there were already a thousand, ten thousand, a hundred thousand, a million, or perhaps even ten million infected people. Therefore, quarantine had to be declared immediately. It was urgent to stop the ongoing exponential spread and only then explore what was going on.

***

It then became clear that COVID-19 was not an illness that primarily kills owing to the sheer severity of its symptoms. This was an illness that kills with an incredibly high rate of spread among the community. This spread leads to a tremendously rapid increase in the total number of infected people. With five percent of them falling critically ill, this would generate vast numbers of critically ill people, all of whom could no longer receive adequate care. That is why, for every deceased person who couldn’t be saved, there were several others who probably could be, but they all came in for treatment at the same time.

This overloaded the hospital’s intensive care facilities. My colleagues in China have told me that, after all the bad news from Wuhan that we’ve heard in the mainstream media, it would probably surprise us how relatively mild it is for most infected people once it reaches our part of the world through tourists or seafarers. They told me that the illness itself is not to be feared, but its rapid spread should be. Therefore, three things are crucial to its control:

(1) The spread from China to other countries should simply be stopped by the “first line of defense” — the constant isolation of the infected people and their contacts. This approach had proved successful and stopped two previous coronaviruses, SARS and MERS — although both of them had managed to spread to more than twenty countries from China and Saudi Arabia, respectively. Therefore, it seemed likely that this would work for COVID-19, too.

(2) We must be extremely careful if a virus manages to break through the “first line of defense”. That is when all those infected people with milder symptoms will start spreading it to the population very quickly, aided by the “super spreaders” that infect many individuals. Then the rate of increase in the number of cases can make anyone unpleasantly surprised and catch them entirely unprepared.

This is because the infections we’re confirming today reflect the spread of the infection days earlier and not the current situation. Between the infection and the diagnosis of the symptoms, there is a period of “incubation”, which lasts about a week. Therefore, if we diagnose 100 infected people on Saturday, we gain information about the spread of the infection since last Saturday. But during those seven days, the virus has spread rapidly, so today it has, in fact, infected more than 1,000 new people — who will only become visible to us next Saturday. This is the problem of “silent”, invisible, exponential growth, which isn’t intuitive to the human brain.

In short, the actual current state of the spread of the COVID-19 infection is always significantly worse for us, as the current number of confirmed cases indicates — about ten times worse. Therefore, if the virus breaks through the first line of defense, the key decision becomes to declare quarantine as soon as possible. In this way, the virus can’t escape our control and start infecting healthy individuals exponentially. The effects of quarantine will not be visible immediately, but only in a week’s time or later. Until then, terrible losses will be suffered if a state of quarantine is declared too late, as it happened in Italy and some other EU countries.

(3) Surely, we must take great care to prevent the virus from entering our hospitals or nursing homes, as it can create a huge amount of fatalities among patients who are already old, ailing and impaired. These three points are the standard epidemiological measures of protection, so it was quite clear what to do when COVID-19 knocked at our door. I began to closely monitor the results of the quarantine effect in Wuhan, but also a comparative increase in the number of cases in Europe.

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One of the most important days of COVID-19 pandemic, at least so far, was probably the 8th of February, 2020. Thanks to several consecutive days of declining infections in Wuhan, it became clear that the epidemic in China was beginning to wane and would virtually be extinguished over the coming weeks. It was great news for all of us. It meant that the COVID-19 epidemic can, in fact, be suppressed even if the virus breaks through the first line of defense.

From the 8th of February to the 21st of February things were constantly getting better globally. The number of newly infected individuals in China had been steadily declining. China’s surrounding countries that already learned their lesson from the experience with SARS — Singapore, Vietnam, Taiwan, and Japan — “caught” the virus that spread from China using their first line of defense. They controlled it with a stricter regime along borders, with frequent testing and the isolation of the infected and their contacts. They didn’t even need a quarantine, as the first line of defense produced good results.

Furthermore, with the exception of three cases in Australia and one case in Argentina, there were no recorded deaths from COVID-19 in the entire Southern Hemisphere. It gave us all hope that COVID-19 would actually prove to be a seasonal virus and disappear from the Northern Hemisphere with the arrival of late spring and summer. And in Europe and the US, very rare cases of the disease were being easily ‘’captured’’ by their first lines of defense, which identified those who were affected and isolated them and all their contacts.

Since the 21st of February, however, South Korea and Iran unexpectedly came into focus. The former of the two countries had a really awkward incident, which I’ll describe in one of the future sequels as an example of another successful way to fight this virus. They were able to extend their first line of defense quite broadly and deeply and avoided quarantine. On the other hand, very little was known about the developments in Iran. I was worried that this country could eventually become the biggest problem with COVID-19 because it was the first less developed country in which the virus began to spread freely. On the positive side, however, Iranian epidemiologists are very adept at combating infectious diseases.

I also noticed that Italy jumped from 3 to 20 cases on the 21st of February. I assumed that this may be due to a group of infected tourists traveling together or perhaps a small epidemic within a retirement home. But on a day-to-day basis, on the 24th of February, Italy reported a total of 229 infected people, while other European Union (EU) countries had only a few cases and still controlled the epidemic relying on their first lines of defense.

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When I landed in Zagreb four days later, on the 25th of February, Croatia diagnosed its first citizen infected with the novel coronavirus. Italy, our neighbor at the other side of the Adriatic Sea, already counted 322 infected by then. The virus had already penetrated their first line of defense by then, so I expected that they would declare a quarantine for at least the Lombardy area the very next morning.

If they’d already registered 322 infected people, it meant that there must have been many more infected in the population. However, the situation in all other EU countries was still calm. Their first lines of defense were expected to successfully control the entry of the virus. Any country within the European Union that got into trouble trying to contain the virus could always be isolated from the others in case of need. Italy was a pretty well-isolated country in terms of its geography anyway. I was assuming, in fact, that Italian authorities in charge of pandemic response would have had some additional reports from China, based on which they would have calculated their hospital capacity. It was plausible to conclude, at that point, that they were eager to preserve Italian tourism and the economy for as long as possible and prepare people for quarantine, which they’d obviously have to declare as the first such country in Europe.

Having landed in Zagreb, Croatia, I was really amazed by the panic that gripped people when they heard that our first case had been confirmed. I knew that our first line of defense could easily deal with sporadic infections. Meanwhile, the global situation was getting better day by day. For epidemiologists, the most important of all indicators during an epidemic is the transition of the number of newly infected cases from exponential growth to a linear growth, which indicates that the epidemic spread has greatly slowed down. The growth was exponential until about the 17th of February and then linear from the 17th of February to the 1st of March. After this “linear” period of growth, the epidemic is largely expected to enter into a final stage. This includes a steady decrease in the daily number of new cases and flattening of the curve that visualizes their growth. The epidemic ends when the curve becomes parallel with X-axis, which measures the time since the first confirmed case.

While I was in Zagreb, from the 25th of February to early March, all of the available data at the time fuelled the real hope that the first lines of defense of all developed countries would successfully stop it. There even seemed to be a good chance that the virus was indeed seasonal. We already knew that all Chinese provinces to which the virus had expanded from the Hubei province had already stopped and suppressed it — some thirty of them. Japan, Singapore, Taiwan, and South Korea had also succeeded. So why wouldn’t it be stopped by the EU and the US?

Owing to all that reassuring burden of evidence, panic in Zagreb didn’t really seem appropriate to me. As my return coincided with the first recorded case, the cameras of many televisions ‘’stumbled’’ upon me unexpectedly during a guest appearance at Edward Bernays University College, where I gave an invited lecture. At that time, I tried to allay concerns among the journalists and the general public, knowing that all epidemiological measures were delivering results globally. The virus was already under control in China and it was held back by the first lines of defense elsewhere.

When asked what kind of ailment was approaching our borders, I compared it to “more severe flu, but for which we don’t have a vaccine.” As an epidemiologist, I knew that severe flu season could lead to about 500,000 to 650,000 deaths a year, and without a vaccine, it would cause well over a million fatalities in the world.

It didn’t seem to me that COVID-19 could reach those numbers of deaths, given that it had been effectively halted in China at less than 5,000 deaths, and elsewhere the situation was quite calm. But what I wasn’t aware of was how little of a danger people in Croatia associate the flu with today. Unfortunately, this misunderstanding still follows me around in many conversations. Then, on the 1st of March, I explained on a very popular Croatian TV-show “Sunday at 2.00 pm”, that was watched by close to a quarter of the country’s population, that Croatians had no reason to panic. Unless the virus mutates, it could hardly endanger more than 0.5 to 1 percent of all infected people.

I also stressed that it would not endanger the younger age groups, but mostly those over fifty years of age. Also, I explained that it can’t even infect us all, because infecting the entire population would also become self-limiting at some point when the herd immunity threshold would be reached. To this day I didn’t need to change any of these predictions. However, after my appearance on that show, incredible things began to happen — as if it all suddenly became a nightmare designed for an epidemiologist.

First, on the 3rd of March, WHO Director Tedros Adhanom announced that the COVID-19 case-fatality rate so far had been 3.4%. This was not entirely inaccurate, because he explained that this was the death rate among all those who were positively tested, but not among all of those who were infected. Therefore, it wasn’t really a useful piece of information to communicate to the public as it magnified the real risk. Specifically, this figure of 3.4% was a combination of the case-fatality rate of hospital infections among the elderly and sick from Wuhan and Italy, which was as high as 5–10%, and the death rate when the virus has spread in the community, which is typically about 0.5–1%. Therefore, it wasn’t actually representative of either situation.

But how could I explain to anyone that the director of the World Health Organisation in Geneva doesn’t understand how confusing it was for the concerned public to hear such a high figure, which was perhaps five times larger than the one that was really more applicable? To make matters worse, though, he was first opposed by United States’ President, Mr. Donald Trump, who called that number “wrong”. I could understand that he was largely correct in doing so. Suddenly, I found myself in a situation where I had to explain to many of my fellow Croats that I wasn’t deliberately downplaying the danger of COVID-19 when I estimated the case-fatality rate, applicable to the whole population, to be 0.5–1%. And next to me, united in this view and opposing the director of the World Health Organisation in Geneva, stood Donald Trump. No wonder that many people who were trusting my assessment of the pandemic were about to lose their minds at that point. Fortunately, many other experts came forward over the next few days, confirming the estimates of 0.5–1% to be far more realistic at the population level.

Thus, I spent the days between the 5th to 7th of March trying to explain the applicable case-fatality rate in three consecutive long posts on Facebook, which attracted a flurry of comments. All of this at least contributed to my first notable newspaper column in Index.hr, which was a “long read” providing answers to 20 confusing initial questions about COVID-19. This column opened a series of columns that provided a health education campaign on COVID-19 which I then continued writing for the “Vecernji list” (Evening Herald) newspaper. As I mentioned, the series of columns attracted a large audience across six countries from former Yugoslavia — in addition to Croatia, it also gained influence in Slovenia, Bosnia and Herzegovina, Serbia, Montenegro, and North Macedonia. I hope that my series helped many to understand quite a bit more about the threat we were all facing. It also helped to reduce the noise and “infodemia”, working to oppose a deluge of unsubstantiated claims that were circulating in the media. However, as I was writing my columns, I also kept looking at the numbers of newly infected people around the world through the corner of my eye.

Suddenly, the situation in Italy was no longer clear to me. However, it got worse — the situation in the whole of Europe became a blur. What was everyone waiting for, why didn’t they declare quarantines? On Saturday evening, the 7th of March, Austria already had 79 cases, Sweden 161 cases, Belgium 169 cases, Switzerland 268 cases, Spain 500 cases, Germany 799 cases, France 949 cases… and Italy had 5883 confirmed infected people?!

Looking at all these figures, I was growing deeply concerned — and I just couldn’t believe the Italian situation. Their numbers indicated that they already had at least 60,000 infected people who were spreading the infection and that number would grow exponentially for at least another several days, even if they were to have declared quarantine the very next day. Whatever happens, from that point it was entirely clear that everyone in Europe would have to be quarantined, regardless of the fact that we in Croatia were still holding up with our first line of defense.

The next day, on the 8th of March, Lombardy was quarantined, but the news leaked to the media too soon. Numerous students fled to the south of the country, spreading the contagion. The whole of Italy was then quarantined. On the same day, on the 8th of March, I wrote a column “The Justification of the Huge Quarantines” where I explained the problem of a remarkably fast exponential growth in numbers of infected persons as a key problem of the COVID-19 pandemic.

It was clear to me at that point that we’ll have to be quarantined in Croatia in a few days. I started counting when it would be best to declare this. I figured that the first major jump from 10 to 20 infected people would be a good time. The number of infected people who would develop a severe form of disease would then, with a little luck, only rise to a very manageable level. Our health system should have a good chance of helping everyone, with a truly minimal number of serious cases of infection and hardly any fatalities, if we manage to avoid epidemics in hospitals, rehabilitation centers, and retirement homes.

That jump, from 14 to 19 infected people, happened on the 11th of March. At 3:00 am on the 12th of March I immediately posted a Facebook status with a new column that was spread through the Croatian online media space the very next day. It was entitled “Contrast is the mother of clarity”. It explained that we had the option to either quarantine very strictly within the next 30 hours and then cure the severely ill as they emerge. However, we could also choose to gamble and let the virus spread, hoping to save the economy and preserve normal life, but also prepare for a fairly large number of deaths. I knew that our epidemiologists in Croatia were looking at these figures and thinking about them, too. Therefore, I wanted to give them the support and confirm that the science was sound and fully behind them and that they weren’t wrong. It was, however, a rather unbelievable decision — to ask the whole nation to temporarily self-isolate.

In the Croatian case, that decision was further complicated. Namely, Croatia was holding the rotating Presidency of the European Union. On the 12th of March, it only had 19 persons who were confirmed to be infected and we were thinking about closing our borders. Other countries of the European Union, however, had already reported hundreds, if not thousands of infected people. Their numbers were growing exponentially, but they were not even suggesting such a move yet. I was pleased to see that as early as Friday, on the 13th of March, a decision was made to close the schools, sending a message to the population that Croatia was withdrawing into self-isolation.

We locked our country up exactly when we needed to, so we didn’t have to worry about too many infected cases. Before that, during the two weeks of March the 2nd to the 17th, Croatia was the country with the lowest percentage increase in newly infected cases in the European Union. That meant that our “first line of defense” did a great job and endured for the longest period of time. Then we went into quarantine at the right time, at a much earlier stage of the spread of the epidemic than most other European Union countries did. This has prevented a very large number of infections so that we don’t have to treat them.

A similar sequence of events also unraveled in other countries in Eastern Europe. The whole region of former Yugoslavia watched each other closely and moved into quarantine at the similar time, between the 13th and the 18th of March. Slovakia, Bulgaria, Hungary, Romania, and Ukraine all followed. It was favorable for all these countries, in a sense, that they do not have so much traffic and international transit as do some other countries in Central Europe, because Czechia and Poland fared quite a bit worse. In the countries of former Yugoslavia, we were certainly helped and influenced in all steps by the legacy of the great Andrija Stampar, a pioneer in public health globally. We also had a relatively recent war experience which forced us to re-read the books on the epidemiology of infectious diseases. Wealthy countries of the European Union did not have a reason to do this. But now that we are in lockdown, if anyone thinks this is the end of these dramatic events now, I’m afraid that they would be deluding themselves. This is just the end of the beginning.

This article was originally published on:  https://medium.com/@irudan/initial-response-to-covid-19-how-did-eastern-europe-get-it-right-cd20d53124dd

Professor Igor Ruden is Professor of International Health and Molecular Medicine at the Usher Institute; Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK,  and Editor-in-Chief, Journal of Global Health



Edinburgh based anthropologist and artist auctions her painting to raise funds for the NHS, writes Aphaluck Bhatiasevi

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Inês-Hermione Mulford is a resident artist at the Royal College of Surgeons.  She graduated form the University of Edinburgh in Social Anthropology in 2018.  She combines the disciplines of the arts and sciences through anthropological research and uses the medium of paint to present her findings.   She wanted to do something to help raise funds for National Health Services (NHS).  Her mother is a midwife based in Oxford, while she lives in Edinburgh.

“We are in a health crisis and are told to stay home to help prevent the spread of COVID-19, and to protect our NHS. My sister Felicity and I wanted to do something, but during these times, we can’t go on long distance runs or organize a social activity to raise funds. We’ve been discussing over Facetime as she’s in Oxford,” said Ms Mulford. They decided to develop a website where they could auction one of her oil paintings to help raise funds.

She has relocated her studio to her flat and developed her website during the lockdown.  The oil painting she chose to put out for auction was recently created as part of her surgical art series from her flat during the COVID-19 pandemic.   It displays the white gowns and hands of a surgeon and a nurse performing a surgery. She has named this painting “PPE” (personal protective equipment). The auction will be closed at 5pm on Friday the 8th of May 2020. The funds from the auction will be managed by the NHS Trust, with the contributions going to  NHS Edinburgh and NHS Oxford.

To create the paintings, in normal times, she captures images of surgery in real time, while performing the surgery, through sketches and photographs. She then follows-up with discussions with surgeons and nurses. When she gets back to her studio, she reviews these materials, and then begins to work on her painting.  “I try to reflect on the complexity of the surgical artform, both in the theatre and on canvas,” said Mulford.

Ms Mulford is currently working on a set of paintings on robotic surgery where she explores relationships between the surgeon, the robot and the painting. This piece of work is part of ‘The Body Voyager’ exhibition which will feature work on the future of surgery. It was scheduled to be on display at the Surgeon’s Hall Museum in October 2020, but due to the pandemic, the exhibition has been postponed to March 2021.

Aphaluck Bhatiasevi is a PhD candidate in Social Anthropology at the University of Edinburgh

 

 



The UK COVID-19 response ignores impact of social inequalities, by Nasar Meer, Kaveri Qureshi, Ben Kasstan and Sarah Hill

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In April 2020, National Health Service (NHS) England and Public Health England launched an inquiry into the disproportionate impact of COVID-19 on Black Asian and Minority Ethnic (BAME) communities. As we wait for the terms of reference to be announced, and with mounting disquiet over the lack of transparency and appropriateness of its membership, it is imperative that policy-makers, public agencies and researchers maintain a broad focus on the underlying determinants of susceptibility to the virus and not allow the physiological risks to be separated from their social exposures.

In our recent submission of evidence on COVID-19 and the disproportionate infection and mortality rates for BAME groups, we set out why the UK government response, including its emergency legislation in the Coronavirus Act 2020, overlooks the inequalities broadly experienced by ethnic minorities.

As of 24 April, data from the Intensive Care National Audit and Research Centre indicate that people from Mixed, Asian, Black and Other ethnic groups make up a third of patients critically ill with confirmed COVID-19, whilst only constituting 14% of the general population in England and Wales. Meanwhile, the Racial Equality Foundation calculated – from data up to 21 April – that the risk of dying in hospital from COVID-19 was twice as high for people of Mixed ethnicity, nearly three times as high for British Asians, and four times as high for Black and Other ethnic groups compared with White British people.

This disproportionate burden of COVID-19 among ethnic minorities mirrors the picture emerging elsewhere, including the United States, Sweden and Spain.

Despite long-standing evidence that increased health risk in UK ethnic minorities reflects underlying inequalities in housing, employment and income, medical ‘experts’ continue to propose various biological (and even genetic) ‘explanations’ for this pattern. A recent piece in the British Medical Journal opined that “BAME individuals… lack knowledge on the importance of a balanced and healthy diet containing all essential micronutrients that are required to boost immunity and prevent infectious diseases”.

This ignores the overwhelming weight of evidence that ethnic inequalities in health are driven by social, economic and political divisions, and reinforces harmful (and flawed) conceptions of cultural essentialism which deflect responsibility onto the victims of structural discrimination (Williams and Mohammed, 2013).

It is true that the disproportionate burden of COVID-19 among BAME undoubtedly reflects greater levels of pre-existing chronic health conditions in these groups. Yet these higher levels of chronic illness are themselves the product of socioeconomic disadvantage and other manifestations of racial discrimination (Phelan and Link 2015).

From the post-war to the present, both institutional and personally-mediated racism have channelled new migrantsinto the lowest rungs of the UK’s segmented labour market (Meer, 2020). As in most countries, institutional racism in the UK ‘unwittingly’ allows White people to gain more from the education system, the labour market, and the health system (Hill 2015), while also affording marginal attention to the racial dimensions of policy responses in health and other sectors (Salway, 2020).

It is for these reasons that COVID-19 and the UK Government response have the potential to amplify existing socio-economic disparities and racial discrimination that undergird ethnic health inequalities. The same factors that predispose people from ethnic minorities to live and work in circumstances that engender chronic ill health are those that will make it harder for these same people to protect themselves from COVID-19 by social distancing.

Ethnic minority households are more likely to be overcrowded and multi-generational, minority groups are grossly overrepresented in institutional settings where social distancing is ineffective and impracticable, and they are more likely to be in keyworker occupations where they are compelled to continue at work.

Worryingly, we anticipate extremely disproportionate economic impacts from the lockdown that will compound these social inequalities even further. As noted above, ethnic minorities have been incorporated into the UK’s segmented labour market in ways that direct them predominantly towards sectors offering few job protections, including a lack of provision for sick leave and sick pay (Qureshi et al., 2014).

It is deplorable – but sadly unsurprising – that The Independent’s BMG poll found people from BAME households are almost twice as likely as White British people to have lost income and jobs.

As such, the terms of reference for the inquiry must not be narrowly focused, but reach beyond these peak months into the long-term and disproportionate impact of COVID-19 on BAME groups. We urge NHS England and Public Health England to focus on the social determinants of health, and demand action on long-standing inequalities. In order to secure sustained public health preparedness, the UK needs a long-term commitment to improving social protection and social equity for all our communities.

This post is reproduced from Discovery Society

References
Hill, S. (2015) ‘Axes of health inequalities and intersectionality’, in: K. Smith, C. Bambra and S. Hill (eds) Health inequalities: critical perspectives. Oxford: Oxford University Press.
Meer, N. (2020) ‘Race and Social Policy: challenges and contestations’, Social Policy Review, 32, 5-23.
Phelan J. and B. (2015) ‘Is racism a fundamental cause of inequalities in health?’, Annual Review of Sociology, 41: 311-330
Qureshi, K., et al. (2014) ‘Long‐term ill health and the social embeddedness of work: a study in a post‐industrial, multi‐ethnic locality in the UK’, Sociology of Health & Illness, 36(7), 955-969.
Salway, S. et al. (2020) ‘Transforming the health system for the UK’s multiethnic population’, British Medical Journal, 368.
Williams D. and Mohammed S. (2013) ‘Racism and health I: Pathways and scientific evidence’, American Behavioral Scientist, 57(8): 1152–1173.

Nasar Meer is Professor of Race, Identity and Citizenship at the University of Edinburgh and a Commissioner on the Post-COVID-19 Futures Commission convened by the Royal Society of Edinburgh (RSE). @NasarMeer Kaveri Qureshi is a Lecturer in Global Health Equity in the School of Social and Political Science at the University of Edinburgh. @KaveriQureshi Ben Kasstan is a medical anthropologist based at the Department of Sociology & Anthropology at the Hebrew University of Jerusalem, and affiliated with the University of Sussex. Twitter: @kasstanb Sarah Hill is a Senior Lecturer in the Global Health Policy Unit at the University of Edinburgh. @sarahhilltop

 



Edinburgh based sociologists document their social transformation by the COVID-19 pandemic to create new sociological knowledge, writes Aphaluck Bhatiasevi

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As sociologists voice out on how the COVID-19 lockdown is impacting societies across the world by transforming the social relations and interactions, a group of sociologists at the University of Edinburgh have come together to curate a blog to document and share personal experiences on how the pandemic has transformed them socially.  The objective of this virtual diary in the form of a blog, is to share experiences as a collective, and to generate new knowledge on social transformation.

I recently interviewed Prof Liz Stanley and Dr Angus Bancroft, curators of the blog Edinburgh Decameron: Lockdown Sociology at Work. They told me about how the blog emerged from conversations they had with other members of the Sociology Department through Skype, Zoom and Teams meetings under the lockdown.  Dr Bancroft is interested in maintaining the sociological community and documenting the social change which may influence the creation of new knowledge, while Prof Stanley is interested in ideas of storytelling, from the “Decameron” perspective where different people who may be in similar situations, tell different stories because of their different experiences. Both the experts wanted their blog to get away from the usual scientific discussions they have in the academia, to reflect on the COVID-19 times as sociologists and as human beings, which includes being able to express anger and upsetness with the situation.

Concerning some of the contradictory things happening, Prof Stanley spoke about one of these being the tussle between rationality and emotionality that many people, herself included, are presently experiencing. Although not a sentimental person, she commented on finding that things like the Thursday clap for care staff and reports of hundred-year birthdays touched an emotional nerve because linked to the shared sorrow or trauma of so many deaths occurring.

Dr Bancroft says the lockdown has changed their lives as academics. “How we do scholarship and teaching will be very different.  Whether our students will be based in Edinburgh or not in the coming year, we don’t know.” Inspired by renowned British sociologist Sir Patrick Geddes’ observational techniques to discover and work with relationships among place, work and folk, Dr Bancroft says this form of documentation of experiences may lead to new knowledge and theories in sociology.  For instance, Edinburgh as a place which houses the University is important to the discovery of how education may be transformed by COVID-19.  The notion of how time is perceived and during the lockdown is very different for different people, says Prof Stanely. While some people say they have a lot of free time at hand, others may feel their time has passed by quickly without being able to do what they had planned to.

As a collective, they want to document the different stories told by sociologists living in a real pandemic, a transformation from the imagination, only a month ago. These stories, told in forms of structured narratives through written texts, poems, images and voice or video recordings, carry momentum that moves forward accounts. Interpretations of these viewpoints in future dates will provide evidence and arguments, analysis and conclusions to inform development of social theory.

The blog is open to the university’s staff, students and alumni, to share their experiences from different parts of the world.

 

Prof Liz Stanley is a professor of Sociology in the School of Social and Political Science at the University of Edinburgh.

Dr Angus Bancroft is a senior lecturer of Sociology in the School of Social and Political Science at the University of Edinburgh.

 

 



Edinburgh Infectious Diseases members make COVID-19 information accessible in over twenty languages, writes Hilary Snaith

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COVID-19 is affecting the great majority of people on the planet in one way or another and information (fact and fiction) relating to the pandemic is circulating via social media streams at an astonishing rate.

Providing factual, accessible, and unbiased interpretations of insights emerging from COVID-19 research is critical.  To help contribute to this Edinburgh Infectious Diseases  published summaries of the talks at the Edinburgh Coronavirus Workshop at the end of March.

However, as with so much of the information that is available about COVID-19, these summaries are in English.

Engaging locally and globally

To make this information much more accessible for people whose first language is not English, the Edinburgh Infectious Diseases community came together to translate these summaries into twenty one different languages from around the world.

Over 50 students, postdocs and group leaders have generously contributed their scientific and linguistic knowledge to the project, which has now published translations in Arabic, Bosnian, Chinese, Croatian, Czech, Dutch, Esperanto, French, German, Hindi, Italian, Malay, Nepali, Polish, Portuguese, Romanian, Russian and Spanish, Telugu, Thai and Turkish.

“I’m delighted that so many members of our international community in Edinburgh have contributed to this initiative allowing access for non-English speakers from around the world to learn about the cutting edge COVID-19 science being carried out in Edinburgh that is being used to inform clinical treatment and public health measures,” said Professor Ross Fitzgerald, Director of Edinburgh Infectious Diseases.

Particular thanks are due to Nat Ring at the Roslin Institute and Julie Fyffe in the School of Biological Studies, who collated and compiled the translated texts, he added.

It has been wonderful to see how many people from across Edinburgh Infectious Diseases and beyond have come together to make this project possible, and highlights the truly global diversity of our staff and students.

For the translated summaries of the talk from SARS-CoV2/COVID-19 workshop please visit Edinburgh Infectious Diseases website.

Hilary Snaith is the Manager of Edinburgh Infectious Diseases, Univeristy of Edinburgh.



Edinburgh symposium shows anthropology can help us understand the social dynamics of COVID-19, writes Ritti Soncco

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On 27 April 2020, the Students of Medical Anthropology (SoMA), a student-body subgroup of the Edinburgh Centre for Medical Anthropology (EdCMA), held their annual Symposium virtually. This year’s symposium was entitled ‘Uncertain Futures, Uncanny Present(s)” and was divided into two sections: what the covid-19 pandemic reveals and what the covid-19 obfuscates. The call for papers was open to postgraduate students and early career researchers regardless of university and discipline, and encouraged think pieces, works-in-progress, or completed articles discussing the impact of covid-19 on their research. Students from various British universities attended as speakers and audience members.

The Symposium highlighted how covid-19 is transforming PhD research in wide-ranging fields, regardless of academic focus or geographic locality. More importantly, however, the Symposium revealed the creativity, adaptability, and re-imagining made possible by the PhD researchers. In the concluding remarks, the participants brainstormed together that the overarching themes of the presentations demonstrated:

  • Even disruption and absence can be data. Paying attention to these moments of interruption is important.
  • The importance of resisting the naturalising of responses to the pandemic. These are not automatic responses; they are political. Anthropology is well-placed to highlight and explore this resistance.
  • Covid-19 has dismantled the division of a researcher’s ‘home’ from a researcher’s ‘field’. Research at the moment is beyond anthropology at home.

The Symposium further served to provide some normalcy during the lockdown, offering students the opportunity to network, receive feedback on their work, and re-experience a conference setting at a time when academic life is disrupted.

Overview of papers
‘Reveal’
  • The wisdom of Lyme disease patients – Ritti Soncco
  • Healthcare in Bangladesh – Janet Perkins
  • Social distancing in India – Jordan Mullard
  • Healthcare in Taiwan – Yi-Cheng Wu
  • Abortion pills access in the UK – Leah Eades
‘obfuscate’
  • Military metaphors in Covid-19 – Iona Walker 
  • Houses as public health technology – Imogen Bevan  
  • Re-imagining death – Tara Pollak
  • A world without touch – Andrea Lambell  
  • Hospitals as environments in suspension – Cristina Moreno  Lozano
Summary of the Presentations

Ritti Soncco (University of Edinburgh) conceptualised that in this new world created by covid-19, those holding a torch and a map are people who have lived with chronic illnesses for years. Her interlocutors, people living with Lyme disease in Scotland, reacted with familiarity and preparedness to the lockdown, stockpiling and social distancing, enabled by years of experience due to their chronic illness. She explored her theory that these new and frightening ‘states of pandemic’ are, to the chronically ill, continued ‘states of normality’. In this world, nothing has really changed. This highlighted that the panic and fear many people felt at the start of the pandemic is a panic and fear Lyme disease patients have lived with for years. Her paper then elaborated on the lessons and advice her interlocutors gave to prepare the public for lockdown, concluding that now is an important time to remake visible those made invisible by their illnesses. Her paper is available here.

Janet Perkins (University of Edinburgh) described how covid-19 has highlighted the fragmentation and weakness in both the private and public health sectors in Bangladesh. Social distancing is a hard product to ‘sell’, where the ‘self’ begins with ‘the family’ and a crowd is more cosy than suffocating. Rather than a social good, healthcare is conceived akin to ‘charity’. The private sector, unregulated by the state, has the luxury of deciding if and when it would engage in the battle with covid-19. Some closed their doors; others rented out their beds to the elite in case these become sick. Until then, the beds remain empty. Perkins’ research concluded to explore how covid-19 revealed who could access healthcare and who couldn’t, as well as who was on the frontline – and who could opt out.

Jordan Mullard (University of Durham) questioned what it means to be ‘socially distant’ in India, describing two forms: vertical and horizontal. Vertical social distancing has been present for a long time in the form of caste and class. Horizontal social distancing, the harder one to enforce, takes place among people within the same group. The attempts to enforce social distancing as a duty have revealed that social distancing is a luxury because to be near is a necessity. She further questioned what duty means in a setting where solidarity, resistance and resilience are created through nearness. What are the associated moralities with this? Mullard argued that for this, it is important to engage simultaneously with moral anthropology and the anthropology of moralities, in order to explore duty, kinship, mutuality and responsibility. She concluded with the question: “Is duty to shame what guilt might be responsibility?” This paper is a work-in-progress with an upcoming publication. 

Yi-Cheng Wu (University of Durham) is currently witnessing covid-19 as a doctor in Taiwan and deconstructed what has been called Taiwan’s ‘advanced deployment’ strategy. His paper argued that war politics are never easy to measure, depicting how patriotic symbolism prevail and government officials are celebrated as ‘national heroes’. Expanding upon Taiwan’s medical strategy, Wu described medical staff as aggressive resisters of strategies, highlighting their demands for upgrades. Such upgrades, Wu exemplified, are thermal cameras at hospital entrances, and insurance cards which record a patient’s travel history data and can be read in card readers. Wu argued that the logic of ‘advanced deployment’ reveals Taiwan’s struggle for international recognition.

Leah Eades (University of Edinburgh)  opened with an international overview of abortion in the era of Covid-19, from Argentina to Poland. She described how some countries had attempted to implement stronger anti-abortion measures, using the lockdown as a means to bypass public protests, or by proclaiming abortions ‘non-essential’ elective procedures. Focusing then on England, Scotland and Wales (where the 1967 Abortion Act applies), she described the recent introduction of telemedicine abortion. In Northern Ireland, however, the government argued it did not have the resources to begin providing abortion services during the pandemic, stating women would need to travel to England for abortions in spite of the lockdown; following a 10-day standoff, the government now offers abortions in clinics, although not remotely as in the rest of the UK. Eades argued that Covid-19 has revealed a major reconfiguration of abortion access, with infrastructures affecting who can and who cannot access abortions of various kinds during this time. Equally, while medication abortion provides many opportunities, it is not available or appropriate to all. Eades concluded that the crisis reveals both the possibilities and shortcomings of abortion pills and a need to address the broader structural issues in which they are used.

Iona Walker (University of Edinburgh) asked in a more-than-human-world, what are the consequences of military language in response to threats of contagion and how do these differ for slow and quick crises? Walker explored covid-19 as a ‘fast’ crisis with military language transforming the social, political and material world of hospitals as warzones, masks as protective armour and political offices as war rooms – contrasting this with AMR as a ‘slow burn’ with consequences for shaping the movement of resources for an ‘arms race again bacteria’ and imagining bodily landscapes of fortress against superbugs. Her upcoming research seeks to understand the limits, possibilities and consequences of military language for human and microbial relationships and how these might be imagined differently.

Imogen Bevan (University of Edinburgh) deconstructed the NHS campaign ‘Stay Home, Stay Safe’ in her presentation. In Britain, home confinement seems to provoke little controversy, understood as a sacrifice willingly made in times of pandemic. Bio-surveillance technologies on the other hand provoke profound moral discomfort. Why is this? Isn’t the house also a technology of sorts? What is being expected of the house? And what might houses in times of covid-19 reveal about social relationships and values in contemporary Britain? Reflecting on past public health interventions on  and through  the house, Bevan’s talk explored the implications of rethinking houses as a public health technology of preparedness.

Tara Pollak (University of Edinburgh), whose PhD research is about pregnancy loss, used her paper to explore death during covid-19. She considered the narrative of ‘heroic death’ in relation to NHS workers, in contrast to ‘neglected narratives’ of deaths not reported, e.g., due to cancelled surgeries, reduced services, accidents or age. She explored the new productions around managing death, from the disruption of social and emotional networks to altered emotional labour of bereavement, asking how these deaths will be remembered and understood after the pandemic is over. “Death itself has become viral”, Pollak argued, concluding to ask: Will the current situation result in a memorialisation of essential workers? What are the socio-political implications of such memorialisation? Are we going to re-think how we report deaths in public health statistics and make sense of such numbers in emotionally intelligent ways? Are we going to talk about funeral poverty and the ways in which people relate to the dead socially, spiritually, materially?

Andrea Lambell (University of Durham) had planned her fieldwork around massage ethnography in palliative care – but in the world created by covid-19, ‘touch has become the thing we all crave and the thing we all fear at the same time’. As she cannot currently conduct fieldwork, Lambell has shifted her focus to explore what is hidden when touch is taken out of the communication repertoire of palliative care. ‘Covid has taken away my toolkit, it has taken away from all massage and touch therapists,’ she states. How will this gap be bridged? How do we reach out to people who are hidden, dying on their own? ‘If we are afraid of touch or becoming close physically to people, we as friends, family, neighbours, will struggle further to give end-of-life care,’ Lambell argued. Her new project will thereby explore non-verbal, non-tactile communication and how the loss of touch obscures communication. 

Cristina Moreno Lozano (University of Edinburgh) discussed how antibiotic stewardship programmes in hospitals and the problem of antimicrobial resistance (AMR) have been interrupted. Healthcare workers can think of nothing other than covid-19, they are exhausted and have worked heavy shifts for over 50 days by now. She argued for a perception of hospitals as more than buildings: they are enclosed environments, habitats, containing infrastructures, relationships, and technologies all at once, where microbial-human relationships are experienced and governed. Her paper was dedicated to the La Paz Hospital in Madrid, one of the most heavily transformed hospitals in Madrid to treat covid-19 patients in the past weeks. As an iconic feature, it represents a familiar skyline, reflections of privatisation and austerity, and unkept promises. The photographs she shared highlighted the hospital as a space/place which produces social value and mobilised affects, much as Alice Street, Janina Kehr or Fanny Chabrol have shown in their hospital ethnographies. Hospitals during the covid-19 pandemic are an enclosed environment where – resistant or non-resistant microbes, affected technology, care, experience and control relate to each other. All these things, argued Moreno, were already there before covid-19. What has changed is that covid-19 has put her project, antimicrobial stewardship programmes, and the La Paz Hospital into suspension, and now we can somewhat see what these hospitals ‘contain’ in greater detail.



The many masks of a lockdown, by Krithika Srinivasan

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The ways in which a ‘non-discriminatory’ virus can very quickly evolve into a disease of the poor

Communicable diseases, we know, affect socio-economically disadvantaged communities disproportionately. But how do these inequalities emerge? We now have a live example in COVID-19.

Until recently, the virus has been non-selective in whom it affects: it could be people in the global North, the non-poor everywhere, people who are not used to being vulnerable to contagious diseases. These are also the people who influence state responses — scientists, policy-makers, commentators. And so lockdown and social distancing were rapidly established as the one-size-fits-all response to COVID-19 globally — despite the variations in the impact of the disease and the serious social consequences of such measures.

While these measures protect people by reducing and slowing down transmission, what has also become quickly apparent everywhere is that they benefit only a minority of the population — those who have salaried jobs, savings, fridges large enough to stock groceries, and homes spacious enough to stay indoors without confinement causing health problems.

Whom they cannot protect are those who face bigger everyday health threats — hunger, homelessness, the risks of more dangerous diseases. If anything, a lockdown adversely affects the vast majority of people for whom this novel coronavirus is a smaller risk when compared to more serious and immediate issues such as hunger, domestic violence or eviction. And when ‘home’ is a room in a slum with community toilets, or when lockdown refugees are transported in buses or housed in makeshift camps, there is clearly greater crowding than if they were outdoors: it might well be that lockdown then exacerbates the spread of the virus among them.

Even in the U.K., where social security systems are stronger, more than 2 million people are estimated to fall through the cracks: sex workers, gig economy workers, the newly self-employed, lone parents in small flats with little savings and no childcare support, women and children subject to domestic violence, and those with other physical or mental ailments.

In the dominant response to COVID-19, there is clearly a deeply uneven distribution of risks and benefits. And this includes inequalities in the impact of the disease. Indeed, there is already evidence from major cities in the U.S. and the U.K. that minority ethnic groups are disproportionately impacted by, and die of, COVID-19 — because they are more likely to be employed in essential services, or live in conditions that don’t allow for social distancing, and are less likely to have access to healthcare.

Political pathogen

And so what was initially a ‘non-discriminatory’ virus is very quickly evolving into a disease of the poor because of the response of lockdown and social distancing. Lockdown flattens the curve, but in the process skews the curve in terms of who is affected. It helps prevent situations where hospitals have to make ethically-charged decisions about whom to prioritise for beds and ventilators — but it does so by displacing ethical questions onto ‘inadequate social security systems’ and amorphous government and private sector processes.

Some argue that social distancing and lockdown have to be in place until there is a vaccine or until healthcare systems are strengthened. But both vaccine and systemic improvements will again be more readily accessible to the middle and upper classes, as is already the case with testing and hospital-based care for COVID-19. So, when the lockdown is finally lifted, COVID-19 will become firmly established as a disease of the poor, like so many other infectious diseases already are.

This is how a pathogen becomes political. This is how health inequalities are created. But this isn’t new; there’s ample research on health inequalities. Yet, as social distancing and lockdown started being replicated across the world as the only appropriate response to COVID-19, there was almost no resistance in the U.K. and the U.S.

On the contrary, there was near-total compliance and those who raised uncomfortable questions were dismissed and shamed. In India, some sections of the media, academia and the Left have actively challenged the lockdown approach from the start, but in the U.K., critical questioning began only after the third week.

The strength of science lies in its openness about uncertainty, and the ability to challenge assumptions and hypotheses. However, with COVID-19, modelling predictions that support lockdown have been presented and accepted as the singular truth. Other equally plausible interpretations querying the lockdown rationale have been condemned or ignored. Countries like South Korea, Taiwan, Sweden and Germany, which have adopted different approaches to COVID-19, have been set aside as anomalies or, in some cases, even had their data on mortality rates questioned.

In India, where transmission and mortality rates have so far been very low relative to population size and density, the dominant narrative is that this is an indicator of inadequate monitoring and reporting, or because the country is yet to experience a peak. There is a reluctance to engage with other explanations.

Some lives only

Why has the lockdown solution become so entrenched? Is it because the debate became inaccurately framed as a conflict between the economy and human lives, when in fact, as one writer pointed out, it is actually a conflict between some lives and other lives? Or does it have to do with the pathogen and disease itself? Is it because those of us in the middle and upper classes are not accustomed to the risk of catching and dying of communicable diseases?

Epidemiological transitions have meant that communicable diseases have become strongly associated with poverty. To be then suddenly faced with a contagious disease that can kill and that cannot be avoided with better nutrition and living conditions must be deeply unsettling. Money and social privilege have temporarily lost their protective function — the list of high-profile people affected by COVID-19 includes Idris Elba, Prince Charles and Boris Johnson.

This situation is further complicated because it appears that many infected people are asymptomatic but can nevertheless transmit the virus. So, suddenly, everyone is at risk and everyone poses a risk — even if being infected does not always lead to disease, and even if having the disease is unlikely to cause death. It is not really possible to develop a public health strategy that selectively protects only those who are vulnerable — because we don’t know who is likely to be vulnerable.

Perhaps this explains why COVID-19 has generated so much fear among the wealthy and the middle classes even though its impacts and death toll pale in comparison to diseases of the poor such as diarrhoeal disease and tuberculosis, each of which kills around 1.3 million people every year. Perhaps this explains the lack of resistance to the ‘There Is No Alternative’ to lockdown narrative.

Some of its strongest advocates, such as hedge fund billionaires, are from sections of society that have always spoken against state investment in public health. Lockdown has made visceral sense to those of us who by virtue of belonging to the middle or upper classes have not really known — until now — what it means to have one’s health vulnerable to factors outside one’s perceived control.

With COVID-19, we have become acutely aware that our health is tied to others, and to what the state does or does not do. We want the state to take ‘strong’ measures that protect us from the rest of society, the rest of humanity. The poor have always known this — that their health is not within their control; that the choice is between drinking no water at all and drinking contaminated water. But their lives have not mattered enough to generate the kind of state-led action that COVID-19 has.

Personal stakes

Perhaps this is why, barring some exceptions, those who have spent their lives investigating health inequalities now seem oblivious to how only one data interpretation has been favoured in the media and by thought-leaders, and others rejected as anti-science. Perhaps we have suddenly lost our capacity for critical reflection because this is an issue in which we have personal stakes. After all, lockdown benefits ‘people like us’, a minority of humankind, even as it actively harms the rest.

The irony is that those who benefit from lockdown do so only because there are others who aren’t going into lockdown and who continue to face the risk of infection. In our deeply interconnected societies, every minute aspect of our everyday lives — from food and water to electricity, phone and internet connections, sewage systems and waste management services, and medical supply chains — depends on the work of other people who, more often than not, are those in low-income occupations. We may cheer them from the safety of our homes on Thursdays or Sundays, but we lose no time in also shaming them for their ‘irresponsible behaviour’ for being out on the roads or in public spaces.

So, what is the alternative? How can we address COVID-19 in ways that don’t further marginalise and harm already vulnerable people?

The first step is to overcome the ‘There Is No Alternative’ loop. Looking beyond lockdown will enable more careful engagement with the evolving science on the disease, the experiences of countries that have considered alternative approaches, and the regional variations in the prevalence and impact of the disease.

Crucially, we must foreground fundamental ethical issues. At this juncture, it is simply not enough to call for better social security measures — all that does is to displace blame and responsibility in time and space. We must instead ask hard and immediate questions about whether it is right to expect the poor to shoulder the burden of measures that don’t really protect them, and worse, can actively harm them.

More specifically, we could examine a strategy that is based on voluntary measures: trust people to decide whether the risks of contracting COVID-19 are higher than the risks of starvation or being beaten to death or dying of some other disease; back it up with the necessary social security interventions so that they have real choices. This is crucial, because no matter how serious a threat the novel coronavirus might pose, there are people everywhere who face and have always faced far greater threats to their lives, health and well-being. We need to think beyond pathogen and infection and act for health.

Last week, I was at a grocery store in Edinburgh when a woman came in to do her shopping wearing a mask, visor and gloves. The elderly shop assistant of South Asian origin smiled kindly at her and said in broken English: “You are very afraid? We are all going to ‘go up’ one day, you know?” This to me captures the essence of the huge social divide that characterises the dominant response to COVID-19.

Krithika Srinivasan is a lecturer in Human Geography at the University of Edinburgh. This post was originally published: https://www.thehindu.com/todays-paper/tp-features/tp-sundaymagazine/many-masks-of-a-lockdown/article31379402.ece

 



Lockdowns save, lockdowns kill: valuing life after coronashock, writes Stefan Ecks

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The scale and severity of the coronavirus pandemic is a shock to health systems. It is a shock to economies and governments. It is also a shock to the life sciences, which were meant to anticipate a pandemic of this magnitude, but failed to do so. The “life sciences” in question are virology, epidemiology, biomedicine and pharmacology. But the social, political, and economic life sciences were also unprepared for COVID-19. It will take an in-depth autopsy to see why anyone in the social sciences believed the people in medical sciences when they told us it would only be “the pandemic perhaps” (Caduff 2015) rather than the pandemic for sure—and probably soon. COVID-19 is not only a viral pandemic, it is also a pandemic of epistemic unpreparedness.

How life is valued has become an urgent question (if it hasn’t been an urgent question long before). As the social life sciences are reeling from coronashock, how can we theorize the value of life to make sense of the current moment? At its most basic, life is value, and enhancing life means to enhance value. Living means valuing, and what makes people’s lives better is valuable. But what, exactly, “improves life”? To say that life values living “still doesn’t answer the question of what it means to ‘improve people’s lives,’ and on that, of course, rests everything” (Graeber 2019: 208). What does it mean to “make life better” in coronatimes? Lockdowns have been enacted in many countries, with profound consequences. What is the value of “lockdowns,” are they worth it?

The “lockdown” has emerged as the signature biopolitical response to coronashock. The rationale of the lockdown is to delay the spread of coronavirus infections. The value of lockdowns is that they “buy time.” Without lockdowns, hospitals might be overrun by patients and too many lives might be lost before a biomedical treatment can perhaps be found. To date, no vaccine or any other pharmaceutical therapy is available. COVID-19 reduces the scope of biomedicine to acute intensive care: keeping people alive on respirators if the infection takes a bad turn. The only interventions available are about population control. Some of these techniques include contact tracing and testing for acute infections. Other measures control individual movement and behaviors. These include border checks, travel bans (both internal and cross-border), quarantine (at home or in public facilities), physical distancing, closing of workplaces and educational institutions, canceling public events, closing public transport, and wearing face masks (Hale et al. 2020). Any of these measures can be advisory or mandatory. A “lockdown” is a maximal combination of these measures, with a focus on prohibiting citizens’ physical movement outside their homes. Lockdowns are investments in population health that come at a huge cost in other areas of life. But what are these “costs,” and what are these “other areas of life”?

SARS-CoV-2 was first detected in the city of Wuhan in China’s Hubei province in December 2019. For several weeks, the Chinese authorities suppressed news reporting about the spread of the new disease. Li Wenliang, a Wuhan doctor who used social media to alert medical colleagues of the disease was forced by the police to retract everything he had said; he died on 7 February with COVID-19 (Buckley & Myers 2020). China officially notified the World Health Organization of the outbreak on 31 December 2019. In early January, WHO issued its first guidance on how to deal with the virus “based on experience with SARS and MERS and known modes of transmission of respiratory viruses” (WHO 2020). The first case outside China was confirmed in Thailand on 13 January 2020. The first WHO committee meeting on whether COVID-19 should be classified as “public health emergency of international concern” (PHEIC) took place on 22-23 January. A consensus was not formed at the time, but one week later, WHO decided that the outbreak is a PHEIC. On 23 January, the Chinese government imposed a fēng chéng (“blockade line”), first on Wuhan and soon on other Chinese cities. On 11 March, WHO classified the outbreak as a “pandemic.” On 13 March, the Chinese government partially lifted the lockdown, and ended it officially on 8 April 2020.

Most governments were initially skeptical of lockdowns. Governments asking citizens to stay indoors and avoid meeting others has been used in epidemics many centuries before. But the Wuhan lockdown was unprecedented in its scale, its length, and its administrative rigor. On 23 January, Gauden Galea, the WHO representative in China, said that the Wuhan lockdown is an extreme intervention that needs to be carefully evaluated: “The lockdown of 11 million people is unprecedented in public health history, so it is certainly not a recommendation the WHO has made” (Reuters 2020a). Nevertheless, beginning from January, many governments started to issue travel warnings and some moved to close air traffic with China. Italy, for example, suspended flights to and from China as early as 31 January (thousands of Chinese tourists then travelled to Italy via Frankfurt). The same day, the US government declared COVID-19 a “public health emergency” and mandated a 14-day quarantine for passengers who had been to Hubei. From February, country-wide lockdowns that included closure of businesses, schools, and restrictions on all but essential travel came into effect in the US on 15 March. In the UK, similar measures started on 23 March. In India, a country-wide lockdown was imposed on 24 March, stopping the movement of its entire population of 1.3 billion people. The measures in India are the strictest in the world (e.g., not even outside physical exercise is allowed). Most governments hesitated to impose lockdowns but felt pressured to act by the exponential spread of the virus. On 6 March, there were over 100,000 confirmed cases worldwide. Cases numbers doubled by 17 March, doubled again by 23 March, and doubled again by 30 March. By 15 April, more than 2 million people had confirmed infections and 140,000 people had died with the virus (Center for Systems Science & Engineering 2020). By March 2020, the Wuhan lockdown had become the “Great Lockdown” of the world (International Monetary Fund 2020).

Governments in both the US and the UK were reluctant to disrupt their national economies by imposing Wuhan-style lockdowns, but by mid-March the spread of the infection threatened to make hospitals collapse under a “tsunami” of people needing intensive care. Until early March, the US and UK declared their countries would “stay open for business,” both denied that COVID-19 was much to worry about, and both failed in preparing their health services for the massive rise of infections. Boris Johnson, referring to the Wuhan lockdown in a speech on 3 February, said that Brexit Britain values freedom: “humanity needs some government somewhere that is willing at least to make the case powerfully for freedom of exchange, some country ready to take off its Clark Kent spectacles and leap into the phone booth and emerge with its cloak flowing as the supercharged champion of the right of the populations of the Earth to buy and sell freely among each other” (cited in Helm, Graham-Harrison & McKie 2020). Dominic Cummings, the UK prime minister’s chief adviser, summarized the initial strategy: “protect the economy, and if that means some pensioners die, too bad” (cited in Walker 2020). Similar arguments were made in the US (e.g., Katz 2020). Letting the virus “run its course” while protecting the economy is a typically neoliberal policy response. Free movement and free markets are more important than saving as many lives as possible. Governments are not meant to disrupt the free market for the sake of population health. And yet even the US and the UK governments eventually followed other countries into lockdown, “deliberately inducing one of the most severe recessions ever seen” (Tooze 2020). Governmental attempts at stalling the health disaster accepted that lockdowns would do unfathomable harm to the economy. The world is staring at the worst recession in a century. Businesses are going bankrupt and people are losing their jobs at catastrophic rates. Even countries that did not impose lockdown measures are experiencing an unprecedented economic shock due to the disruption of supply chains, bans on travel, and trillions of dollars of capital flight.

In India, the socioeconomic fallout of the lockdown is even more severe than in the US and the UK. The lockdown hit India’s large population daily wage laborers particularly hard. 380 million people in India work in the informal economy. Millions of them are rural-urban migrants. After the lockdown was imposed, hundreds of thousands of migrant laborers started to walk by foot to rural areas, some of them for hundreds of miles. The government’s response strongly discriminates along entrenched social divisions, such as that the majority of casual laborers are from lower castes and ethnic minorities. The strict measures imposed in India caused extreme economic hardship, with hunger and much collateral damage to people’s health and wealth. In turn, it remains unclear if the Indian lockdown will protect many people from dying with SARS-CoV-2 in the long run. Public health experts argue fear the Indian lockdown might cost more lives than save them: “The national lockdown will delay things, but will not reduce the overall numbers greatly in the long-term … this will cause serious economic damage, increase hunger and reduce the population resilience for handling the infection peak” (Center for Disease Dynamics, Economics & Policy 2020). Another prediction is that the combined effects of the coronavirus pandemic will throw poverty levels back by 30 years. The global number of people living in poverty could increase by 580 million worldwide (Sumner, Hoy & Ortiz-Juarez 2020). The Indian governments’ emergency food relief is stymied by bureaucratic hurdles: to access food relief, people must be registered with food welfare schemes or have official documents to show that they are entitled, but the majority of people do not have the required documentation (Reuters 2020b). Put bluntly, COVID-19 kills, but poverty kills as well. Whether lockdowns will save more lives than they destroy is not clear.

In Living Worth: Value and Values in Global Pharmaceutical Markets (Duke UP, in press), I argue that the value of life is negotiated between social actants within contexts of good practice. Building on Espeland & Stevens (1998), I call these valuing processes biocommensurations. In biocommensurations, lively matters are valued toward pragmatic goals. Biocommensurations are processes that draw vitality, health, disease, and healing into comparisons and exchanges with living and non-living entities. These commensurations are done by human actants and involve different transactions, either with other humans (as individuals or groups) or with nonhuman entities. Biocommensurations put two or more entities into value comparisons toward a pragmatic decision: “Two roads diverged in a wood and I—/I took the one less traveled by/And that made all the difference” (Frost, The Road not Taken).

Biocommensurations rest on agreements about what “good practice” looks like. What is valuable and what is not depends on the criteria for value, and these criteria are based on context. In turn, what counts as good practice depends on different degrees of recognition from actants (A and B). What A sees as good practice may differ from what B recognizes as good practice. Recognition can be nuanced by direct mutual recognition between A and B, and wider social recognition of the relation between A and B and of the entities transacted. Trust is a form of recognition that the other will behave in a manner consistent with past behavior. Further, there are different degrees of transparency about what is being valued and who is doing the valuing. Each dimension differs by how routinized commensurations are. This includes different degrees of institutionalization. Each differs by levels of expertise required to perform a convincing valuation. Levels of expertise, routinization and institutionalization are tied to levels of technological elaboration. When life is biocommensurated, the work of experts in institutions, and of the accounting technologies used, varies considerably. Questioning the power of institutional experts doing health metrics is a difficult task, which requires substantial counter-expertise (Adams 2016).

Coronavirus lockdowns reveal extremely conflicted biocommensurations. To begin with, it is not obvious which interventions are being compared to each other. Countries have adopted a host of interventions in various constellations, to various degrees, for different lengths of times and at different points in time. This makes it difficult to compare their relative value. The easiest value comparison would be between comprehensive lockdowns and doing nothing, but all governments have done something, even if it was just asking people to wash their hands. Some countries were able to avoid full lockdowns by a combination of interventions. Hong Kong, for example, managed to avoid a lockdown by using border restrictions, mandatory quarantine, and physical distancing (Cowling et al. 2020). The coronavirus pandemic is a real-time experiment in biopolitical responses. The research design is extremely messy and there is no placebo control group. Nevertheless, value comparisons must be made because so many lives are at stake.

Biocommensurating coronavirus lockdowns shows vastly different levels of certainty and routinization. Value comparisons address the following questions: (1) what makes two possibilities similar? (2) What is the degree of similarity between them? (3) How are these similarities relevant? (4) Why are possibilities similar? (5) To whom are these similarities relevant? (6) What is the pragmatic operation that the value comparison makes possible? In the case of lockdowns, (1) “similarity” between different policy responses might be established by “number of human lives saved.” However, it is not clear whose lives are saved, and if these are lives saved in the short term or in the long term. (2) The degree of similarity is determined by “number of people saved from dying with SARS-CoV-2 infection.” How this number should be assessed, and whether there are not hundreds of other criteria for comparison, is uncertain. (3) The “relevance” of valuing different interventions is clear: human life and well-being is at stake at a global scale. (4) Why different policy responses might be “similiar” is not as clear as it may seem. For example, it is certain that close proximity influences how fast the virus spreads, but it is not clear by how much. Further, physical proximity is not the only factor. How infectious SARS-CoV-2 is and which routes of infection are more likely than others is still to be determined. (5) To whom the similarities are relevant is clear: anyone who lives on this planet now, or in the near future, or maybe even the distant future (we don’t know). One reason why this pandemic is so extraordinary is that no one alive today can self-isolate from either the virus or the responses to the virus. (6) The pragmatic operation that the comparison should make possible is starting or ending lockdowns and deciding on what forms of movement should be prohibited.

Biocommensurations are context-based negotiations between different actants. Governments’ lockdowns received a relatively high level of recognition from citizens. Some governments introduced lockdowns almost by popular demand. Countries with high levels of citizens’ trust in governments appear to be more successful in stemming the spread of the infection (New Zealand, South Korea, and Taiwan are cited as positive examples). Governments show various levels of transparency about how the lockdowns would be enforced and what they are meant to achieve. The US government stands out globally for its lack of transparency: government advice was muddled and President Trump often contradicts his own policies (e.g. when he urged US citizens to “liberate” themselves from his own administration’s lockdown policies). But no government can be fully transparent about the advantages and disadvantages of the lockdowns because no one knows what these measures do. No one knows how to biocommensurate lockdown effects. One of the deepest shocks of the coronacrisis is the absence of expertise, technological elaboration, and routinization among the agencies in charge of pandemic preparedness.

In hindsight, it is also stunning how unprepared the social life sciences were for this pandemic. Before coronashock, versions of Foucauldian biopolitics provided a comfortable frame to describe the work of experts (Caduff 2014; Lakoff 2017). Foucault never doubts that “power” is grounded in “knowledge.” The experts are portrayed as competent, methodical, and bureaucratically routinized. Social scientists believed that there were experts anticipating an outbreak such as this, and they believed that these experts had developed a solid grasp of “prevention, precaution, preparedness” (Keck 2020). If anything, social scientists believed that pandemic experts went too far in their quest for biosecurity. But when the COVID-19 pandemic unfolded and governments scrambled for a response, it became clear that the expertise does not exist. Epidemiologists knew nothing of economic impacts, and macroeconomists knew nothing about viruses. Guidance from the World Health Organization was entirely focused on epidemiological interventions such as contact tracing and testing but had nothing to say about lockdowns and their effects. Institutions such as the World Bank or the International Monetary Fund were also caught out cold by the economic shock of the lockdowns. No one knew how to make informed value comparisons between locking down and not locking down. The criteria do not exist, the institutions do not exist, and the technological infrastructures do not exist. The International Monetary Fund opens its 2020 Report on World Economic Outlook by admitting that “none of us had a meaningful sense of what [a pandemic] would look like on the ground and what it would mean for the economy” (2020: v). Biocommensurations are most successful when they are routinized and when everyone concerned agrees what should be done. Coronashock revealed that no one knows what a “good practice” of comparing different possible interventions even looks like. Perhaps “lockdowns” cannot even be called “measures” as long as no one knows how to measure what they do.

We still do not know the full scale and severity of COVID-19. The unintended consequences of the lockdown interventions are even less clear (Ecks 2020). The task of anthropologists is to listen to the people we work with and hear how they perceive the consequences of lockdowns. We need to discover with them what the relevant criteria for good comparisons are. The experts failed to describe the criteria for valuing different interventions. It’s now time to hear from the people most affected what these criteria should be.

 

References

Adams, Vincanne, ed. 2016. Metrics: what counts in global health. Durham: Duke University Press.

Buckley, Chris & Steven Lee Myers. 2020. As new coronavirus spread, China’s old habits delayed fight. The New York Times, February 7, 2020.

Caduff, C. 2014. On the verge of death: visions of biological vulnerability. Annual Review of Anthropology, 43: 105-121.

Caduff, C. 2015. The pandemic perhaps: dramatic events in a public culture of danger. Oakland: University of California Press.

Center for Disease Dynamics, Economics & Policy. 2020. IndiaSIM Model. https://cddep.org/covid-19/india/

Center for Systems Science & Engineering at Johns Hopkins University. 2020. COVID-19 Dashboard. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

Cowling, B. J., et al. 2020. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: An observational study. The Lancet Public Health, April 17, 2020, S2468-2667(20)30090-6. https://doi.org/10.1016/

Ecks, S. 2020. Coronashock capitalism: The unintended consequences of radical biopolitics. Medical Anthropology Quarterly blog, April 6, 2020. http://medanthroquarterly.org/2020/04/06/coronashock-capitalism-the-unintended-consequences-of-radical-biopolitics/

Espeland, W. N. And M. L. Stevens. 1998. Commensuration as a social process. Annual Review of Sociology 241: 313-343.

Graeber, D. 2019. Bullshit jobs: A theory. New York: Simon & Schuster.

Hale, Thomas, et al. 2020. Variation in government responses to COVID-19. Version 4.0. Blavatnik School of Government Working Paper. April 7, 2020. www.bsg.ox.ac.uk/covidtracker

Helm, T., Graham-Harrison, E. & McKie, R. 2020. How did Britain get its coronavirus response so wrong? The Guardian 19 April 2020.

International Monetary Fund. 2020. World economic outlook. Chapter 1, The Great Lockdown. Washington, DC: International Monetary Fund.

Katz, D. 2020. “Opinion: Is our fight against coronavirus worse than the disease?” The New York Times, March 20, 2020.

Keck, F. 2020. Avian reservoirs: virus hunters and birdwatchers in chinese sentinel posts. Durham: Duke University Press.

Lakoff, A. 2017. Unprepared: global health in a time of emergency. Oakland: University of California Press.

Reuters. 2020a. Wuhan lockdown ‘unprecedented’, shows commitment to contain virus: WHO representative in China. https://www.reuters.com/article/us-china-health-who-idUSKBN1ZM1G9.

Reuters. 2020b. India’s coronavirus relief plan could leave millions without food aid, activists say. https://www.reuters.com/article/us-health-coronavirus-india-poverty-idUSKCN21S122

Sumner, A., Hoy, C., Ortiz-Juarez, E. 2020. Estimates of the impact of COVID-19 on global poverty. WIDER Working Paper 2020/43. Helsinki: United Nations University World Institute for Development Economics Research.

Tooze, A. 2020. Coronavirus has shattered the myth that the economy must come first. The Guardian, 20 March 2020.

Walker, P. 2020. No 10 denies claim Dominic Cummings argued to ‘let old people die’. The Guardian, 22 March 2020.

World Health Organization. 2020. WHO timeline COVID-19. https://www.who.int/news-room/detail/08-04-2020-who-timeline—covid-19.

 

 

Stefan Ecks co-founded Edinburgh University’s Medical Anthropology programme. He teaches social anthropology and directs PG teaching in the School of Social & Political Sciences. He conducted ethnographic fieldwork in India, Nepal, Myanmar, and the UK. Recent work explores value in global pharmaceutical markets, changing ideas of mental health in South Asia, multimorbidity, poverty, and access to health. Publications includeEating Drugs: Psychopharmaceutical Pluralism in India(New York University Press, 2013) andLiving Worth: Value and Values in Global Pharmaceutical Markets(Duke University Press,forthcoming), as well as many journal articles on the intersections between health and economics.



Recognising childrens’ rights in responses to COVID-19, by Aphaluck Bhatiasevi

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We are all trying our best to deal with the COVID-19 pandemic crisis, be it from governments seeking to protect public health and livelihoods, to key workers trying to ensure essential services are maintained, to many of us trying to maintain social distancing and self-isolating as individuals and for our families. But in the immediacy of responding to the crisis, adults can focus on protection and overlook the part children can and do play in the fightback to the crisis.

Why does it matter?

In emergency contexts, it is easy to concentrate solely on children’s physical protection, and overlook the importance of emotional and social protection, which is critical both during times of emergencies and in post-emergency situations. It is also easy to ignore children’s participation rights – rights to have information, to provide information, to have their views considered and enacted in decisions that affect them. The University of Edinburgh’s Childhood and Youth Studies Research Group works on a project in parthership with the International and Canadian Children’s Rights Partnership (ICCRP).  This project often works in sites of immediate and ongoing fragility. The project demonstrates that not involving children leads to poorer decision-making and thus poorer outcomes for both children and their communities.

The partnership  of the Childhood and Youth Studies Research Group and ICCRP  works with children and young people, civic society and government stakeholders and academic institutions in Brazil, Canada, China, South Africa and the UK on children’s human rights in situations of international child protection.

For further informationon the project, please visit: https://blogs.ed.ac.uk/cysrg/2020/04/09/recognise-children-rights-covid-19/



Children and young people aged 5-18 years should stay active. Here’s why, write Samantha Fawkner, Ailsa Niven, Steven Hanson, Chloë Williams & Coral L Hanson

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Researchers from the Physical Activity for Health Research Centre (PAHRC) in Moray House School of Education and Sport have been contributing to a series of blogs in the British Journal of Sports Medicine that aim to promote physical activity during Covid-19.  These blogs have focused on adults, ‘at risk’ populations, and in this blog that follows on children and young people aged 5-18.  Each blog is accompanied by an infographic to summarise the blog, and present the information in a public-facing format.  In this blog, led by Dr Sam Fawkner and Dr Ailsa Niven, we draw on current evidence to focus on why children should be active, provide examples of activity, and importantly outline how to encourage this activity. 

Covid-19 presents many challenges and anxieties. For parents and carers of school-aged children (young people), daily lives are barely recognisable.  We are attempting to juggle work, life and schooling from home, while trying to keep everyone happy.  The benefits of physical activity for young people are widely recognised, and during COVID-19, moving more and sitting less is very important to help families maintain physical and mental health.  Being confined to home means that young people, who are used to school P.E., after school activities, active travel, organised sport and outdoor play, have to find a ‘new normal’. Screen use, which is mainly sedentary, has likely increased because of the switch to online education, entertainment and ‘babysitting’ services for overstretched parents.

In this blog, we focus on why encouraging our children to move more and sit less (if they can) is a priority at this trying time. We deliberately focus on being inside; although if guidelines allow, getting outside is also beneficial.

WHY?

Young people ideally should accumulate 60 minutes of at least moderate intensity activity a day; this can involve lots of short bouts of physical activity and a range of intensities. Over the week, activities should include some that stress muscles and bones (like yoga and jumping) and some to help promote movement skill (involving balance, coordination and body awareness).  These guidelines are based on evidence that more active young people have better health outcomes, including cardiovascular and bone health, muscle fitness and weight status.[1]  There is also evidence that increased physical activity is associated with enhanced mental health, improved cognitive (mental) function, aspects of self-esteem, and reduced depressive symptoms in young people.[2, 3]  As with adults, immediate benefits of each bout of activity may include reduced anxiety and a ‘feel good’ effect.[1]

what?

Activity ideas: games and yoga

Although there is limited evidence about the benefits of specific home-based activities for young people, any activity that gets your child moving is beneficial.  Activity ideas include playing traditional playground games indoors (e.g. hide and seek, tag, skipping), dancing to music, and getting creative (e.g. building an obstacle course, playing balloon volleyball, making an action movie or learning to juggle).  Check for age appropriate web-based activity programmes, such as The Body Coach.  Yoga has a range of positive benefits for young people and everyone can do it at home.  Try Cosmic Kids or The Yoga Crow.  A range of organisations offer ideas for home-based activities (e.g. Active Schools, Change for Life and SportEngland).  Try a few different activities and alternate them to keep young people interested. While 60 minutes a day is ideal, it may not always be achievable. Just remember that any opportunity to move more and sit less is good.

Moving more to help home-schooling, or combining them!

Physical activity (performed regularly as well as just a single bout) can help young people’s cognitive function and their attention.[4, 5]  So, a short bout of activity is a great way to break up periods of school work or screen use, and also help them focus on their work.  As well as the suggestions above, GoNoodle provides a series of short fun activity breaks for primary school children.

Combining physical activity with learning has cognitive benefits [6] and is fun, especially with younger children.  Turn ‘Simon says’ into a maths game, ‘Simon says jump 4+5 times’.  Do an activity (jump, burpee etc.) the number of times shown on a pair of dice or a playing card.  Count how many times you can hit a balloon between you.  Ask your child to spell out a word, and find objects in the house that begin with each of the letters as fast as they can. The opportunities are endless.

Moving more to break up sitting time

Sitting for long periods (especially when using screens) is associated with poor physical and mental health outcomes in young people.[7, 8]  If able, interrupting sitting time regularly with brief periods of movement will help, as will swapping sedentary gaming for active gaming.[9]  In school-based settings, young people are happy to work for short periods while standing, rather than sitting.[10] Try creating a makeshift standing desk, which the whole family could use.

HOW?

Motivating young people to move more

Despite our best intentions to encourage physical activity, every parent or carer has been faced with ‘but I don’t want to….go on a walk….dance…etc’.  Recent research provides guidance on how to create the best motivational environment to enhance physical activity and well-being.[11-13]  It isn’t rocket science to realise young people will be more motivated to engage in fun and enjoyable activities. Focus on the 3Cs of Competence, Control and Connectedness.

Competence; we are motivated to engage in and enjoy doing activities that we feel we can do.  1) Try to select activities for young people that are achievable but also challenging (if too easy, ask them ‘how could we make this harder – I think you could do more’).  2) Provide feedback to build feelings of competence; focus your feedback on self-improvement and effort ‘you worked really hard at that, and got better’, and try to avoid comparisons with others ‘but your sister can do that really well’.  3) Encourage your child to set achievable goals and keep a record to monitor progress.  We don’t know a great deal about the value of young people using wearables and apps to track physical activity, but if you have them, they could be a way for your child to set and monitor goals. Remember to be realistic given the current circumstances; unrealistic goals are unachievable and demotivating.

Control; relates to engaging your children in decision making, and providing opportunities for choice.  Let your children choose what activity to do (give them up to four options), when, and who with. Be creative and include variety (the links above will help).  Try ‘kids in charge’ sessions!  Feelings of control can be enhanced if we provide a reason for why we are being active (focus on immediate positive outcomes – ‘it will be fun and will help us all feel better’), and try to minimize controlling language (‘must’, ‘should’, ‘have to’).

Connectedness; relates to feeling supported and connected with others.  For some young people this could be achieved by parents/carers being active with them in a way that helps them feel competent and in control (see above). Getting involved and having fun models positive behaviour, and provides a focus for family time.  For some young people, connecting with their peer group through activity will help (e.g., online or by phone).

The 3Cs provides guidance, but no parent or carer will be able to adhere to them 100% of the time, and that is O.K. (https://selfdeterminationtheory.org/parenting/).  At this time, it is especially important to be kind to ourselves. Many of us are anxious and emotional (as are our children). Sometimes the time isn’t right – so don’t force it. Try again another time.

We hope that you find this useful to help keep our children active at this challenging time.  We’ve drawn from the latest scientific evidence, and our experiences as parents. Stay safe and be active when you can.

Samantha Fawkner 1 (corresponding author) @s_fawkner, Ailsa Niven 1 @AilsaNiven, Steven Hanson 2 @SteveFloatBoat, Chloë Williamson 1 @Chlobobs_, and Coral L Hanson 3 @HansonCoral

1 Physical Activity for Health Research Centre, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, Edinburgh, UK Email: s.fawkner@ed.ac.uk

2 Floating Boat Design Solutions, Stocksfield, UK

3 School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Edinburgh, EH11 4DN, UK 

Competing interests

Website and YouTube links are provided for illustrative purposes. Dr Fawkner has an on-going professional relationship with The Yoga Crow. The authors have otherwise no affiliation to any of the organisations or companies referred to, and cannot comment directly on the activities promoted.

References
  1. Department of Health and Human Services. 2018 Physical Activity Guidelines Advisory Committee Scientific Report [date accessed April 2020] https://health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf; 2018
  2. Biddle SJH, Ciaccioni S, Thomas G, et al. Physical activity and mental health in children and adolescents: An updated review of reviews and an analysis of causality. Psychol Sport Exerc 2019;42:146-55. doi: 10.1016/j.psychsport.2018.08.011
  3. Dale LP, Vanderloo L, Moore S, et al. Physical activity and depression, anxiety, and self-esteem in children and youth: An umbrella systematic review. Ment Health Phys Act 2019;16:66-79. doi: 10.1016/j.mhpa.2018.12.001
  4. de Greeff JW, Bosker RJ, Oosterlaan J, et al. Effects of physical activity on executive functions, attention and academic performance in preadolescent children: a meta-analysis. J Sci Med Sport 2018;21(5):501-07. doi: 10.1016/j.jsams.2017.09.595
  5. Donnelly JE, Hillman CH, Castelli D, et al. Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children: A Systematic Review. Med Sci Sports Exerc 2016;48(6):1197-222. doi: 10.1249/mss.0000000000000901
  6. Daly-Smith AJ, Zwolinsky S, McKenna J, et al. Systematic review of acute physically active learning and classroom movement breaks on children’s physical activity, cognition, academic performance and classroom behaviour: understanding critical design features. BMJ Open Sport Exerc Med 2018;4(1):e000341. doi: 10.1136/bmjsem-2018-000341
  7. Rodriguez-Ayllon M, Cadenas-Sánchez C, Estévez-López F, et al. Role of Physical Activity and Sedentary Behavior in the Mental Health of Preschoolers, Children and Adolescents: A Systematic Review and Meta-Analysis. Sports Med 2019;49(9):1383-410. doi: 10.1007/s40279-019-01099-5
  8. Tremblay MS, LeBlanc AG, Kho ME, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 2011;8:98. doi: 10.1186/1479-5868-8-98
  9. Sween J, Wallington SF, Sheppard V, et al. The role of exergaming in improving physical activity: a review. J Phys Act Health 2014;11(4):864-70. doi: 10.1123/jpah.2011-0425
  10. Verloigne M, Ridgers ND, De Bourdeaudhuij I, et al. Effect and process evaluation of implementing standing desks in primary and secondary schools in Belgium: a cluster-randomised controlled trial. Int J Behav Nutr Phys Act 2018;15(1):94. doi: 10.1186/s12966-018-0726-9
  11. Ha AS, Ng JYY, Lonsdale C, et al. Promoting physical activity in children through family-based intervention: protocol of the “Active 1 + FUN” randomized controlled trial.(Report). BMC Public Health 2019;19(1) doi: 10.1186/s12889-019-6537-3
  12. Lubans DR, Lonsdale C, Cohen K, et al. Framework for the design and delivery of organized physical activity sessions for children and adolescents: rationale and description of the ‘SAAFE’ teaching principles. Int J Behav Nutr Phys Act 2017;14(1):24. doi: 10.1186/s12966-017-0479-x
  13. Morgan PJ, Young MD, Barnes AT, et al. Engaging Fathers to Increase Physical Activity in Girls: The “Dads And Daughters Exercising and Empowered” (DADEE) Randomized Controlled Trial. Ann Behav Med 2019;53(1):39-52. doi: 10.1093/abm/kay015

Reproduced from Fawkner S, Niven A, Hanson S, Williamson C, Hanson C.L. (2020). Physical activity for children and young people aged 5-18 years during COVID-19. Stay safe; be active. British Journal of Sports Medicine Blog Published Online First: (13/04/2020).https://blogs.bmj.com/bjsm/2020/04/13/physical-activity-for-children-and-young-people-aged-5-18-years-during-covid-19-stay-safe-be-active/ with permission from BMJ Publishing Group Ltd.



The needs of public health and the economy need to be finely balanced during the pandemic, write Farah Huzair and Joyce Tait

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Our work on previous emerging infectious diseases has built up a wealth of knowledge that we are bringing to bear on Covid-19.  This paper brings together some of this research: (i) demonstrating the importance of understanding human behavioural dynamics, (ii) supporting the role of innovation in diagnostics, drugs and vaccines for emerging infectious diseases, and (iii) justifying more rapid, adaptive regulatory systems, as part of an enabling innovation ecosystem.

In the run-up to the declaration of a Covid-19 pandemic, there have been major reactions in financial markets, with global recession and longer term structural adjustment on the cards. However, previous emerging infectious diseases have built up a wealth of knowledge that we are bringing to bear on Covid-19. Pandemic preparedness was initiated during the SARS outbreak in 2002. SARS was not declared a pandemic, but health care advisors became quickly attuned to the threat of emerging zoonotic diseases. SARS was followed by the H5N1 event in 2005, the H1N1 pandemic in 2009 (resulting in an estimated 84,000 deaths worldwide (1), MERS in 2012, H7N9 in 2013 and Ebola in 2019, all of which were thought to have pandemic potential at the time of outbreak. Throughout these previous challenges, as with Covid-19, governments have been faced with the mutually incompatible challenges of encouraging social distancing to minimise the spread of the disease and encouraging healthy people to go to work as usual to minimise the impact on the economy.

Each event has added to the body of knowledge that might be used by governments, regulators and health agencies on how to manage pandemic events and improve the chances of a quick recovery. 

Understanding human behaviour

The H5N1 epidemic did not, as had been feared, evolve to enable human-to-human transmission and the infection from birds to humans was restricted largely to East Asian countries. However, the case fatality rate (CFR) was ~60% leading to alarm and serious contingency planning for a pandemic outbreak. In the UK at the time, pandemic preparation included the prospect of simultaneously giving contradictory public messages – “business as usual” and “social distancing”, potentially leading to serious disruption of the economy (2) (Figure 1). The research underlying tis figure analysed the views of emergency responders on the UK’s preparedness plans, probably the best informed group to make such comments. It also looked at the economic value of a vaccine, given the expected tendency towards “prophylactic absenteeism” (top left-hand side of Figure 1), where healthy people would avoid going to work in case of contracting infection (3). Modelling the impact of the disease on UK GDP showed that, although prophylactic absenteeism would reduce the infection rate by ~1%, its impact on the economy would be in the billions of pounds. We proposed that the benefits of an effective vaccine or drug should be calculated, not just on the basis of its health impacts, but also on its economic value in giving people the confidence to continue to go to work. This study highlighted the importance of the expected CFR in determining the extent to which prophylactic absenteeism would occur. In the H1N1 event, the ‘problem-related’ behaviours described in Figure 1 began to appear in several countries, including the UK, but rapidly evaporated when it became clear that the CFR was similar to normal winter flu. This eliminated the need for the vaccines and drugs that had been made rapidly available in response to a higher expected CFR.

The role of innovation in diagnostics, drugs and vaccines

At the time of the H1N1 outbreak, vaccine manufacturing was dominated by a handful of multi-national corporations, with hope and trust mainly invested in standard inactivated or attenuated virus vaccines. The innovation ecosystem is now much more vibrant and varied, occupied by small, medium and large biotechnology firms, working in partnerships, consortia, and other collaborative arrangements. New scientific discoveries in synthetic biology, gene editing, and other biotechnologies are enabling small, agile and dynamic firms to develop radically new approaches to diagnosis and, potentially, treatment for Covid-19 (4). For example, Geovax (US) and BravoVax (Wuhan, China) are developing a vaccine using a ‘plug-and-display’ technology platform that uses virus-like particles and genetic material specific to Covid-19. This approach has been used to produce vaccines for Zika, Lassa fever and Ebola. iBio (US) and CC-Pharming (China) are developing a vaccine in plants that combines automated hydroponics, vertical farming systems and plant bioreactor technology to rapidly scale-up production. This has already been used to produce antibody candidates for Ebola, Dengue fever, HPV, seasonal and avian influenza. LineaRx (US) and Takis Biotech (Italy) have produced a synthetic gene to be delivered to muscles for the temporary generation of an antigen which could trigger an immune response against Covid-19 (5). APEIRON Biologics AG in Austria has a recombinant human enzyme product (APN01) which is already approved for other indications (e.g. acute lung injury) and is being trialled in Covid-19 patients in China in partnership with Angalpharma Co., Ltd (China) and dMed Pharmaceutical Co. (China) (6). Impressively this work is being undertaken without the coordination activities of the WHO which, during H1N1, developed and circulated both the seed strain and reagent and facilitated data sharing between vaccine producers (7).

More rapid, adaptive regulatory systems

During the H1N1 pandemic, the European Medicines Agency undertook significant regulatory adaptation, with new expedited review and licensing procedures (8). In April 2009, the new strain was identified and characterised. On June 11th, the WHO declared a pandemic, allowing fast track assessment of mock-up vaccines and rolling review of vaccine quality. Non-clinical and clinical pharmacovigilance (RMP) data and labelling information were submitted to the regulator by the Marketing Authorisation Holders. The timeframe for evaluation of the vaccines was reduced from 210 days to 70 days (9).

The H5N1 and H1N1 events also stimulated new approaches to health communication between public health agencies, healthcare organizations and frontline clinicians (11) and review and updating of risk assessment and management procedures (12).

Lessons for Covid-19

Covid-19 is again demonstrating the difficulty of adopting the necessary social distancing to protect the health of the population without also creating severe economic repercussions. Most governments have prioritised ‘social distancing’ over protecting the economy (‘business as usual’), even though the CFR for the majority of people seems to be low enough to avoid public panic. At the time of writing it is not clear how necessary this action is or how effective it will be. However, Covid-19 has re-emphasised the over-riding importance of setting up a new globally coordinated research programme to find more rapid ways: (i) to develop targeted diagnostics, drugs and vaccines, (ii) to scale up their production to meet the needs of global populations, and (iii) to develop routine, smarter and faster approaches to their regulation. The cost to the global economy of Covid-19 justifies whatever cost will be involved to deliver this outcome so that when the next pandemic comes along we are better prepared to deal with it.

This paper was originally published in the INNOGEN Policy Briefs: https://www.innogen.ac.uk/reports-and-commentaries

Dr Farah Huzair is the current programme director for the MSc in Management of Bioeconomy, Innovation and Governance in the department of Science, Technology and Innovation Studies, University of Edinburgh. Professor Joyce Tait is the director of INNOGEN in the department of Science, Technology and Innovation Studies, University of Edinburgh. 

References
  1. CIDRAP (2020) “CDC estimate of global H1N1 pandemic deaths: 284,000” Available at: http://www.cidrap.umn.edu/news-perspective/2012/06/cdc-estimate-global-h1n1-pandemic-deaths-284000 Last accessed 16th March 2020.
  2. Tait, J. (2011) “Innovation, Policy, and Public Interactions in the Management of Infectious Diseases” Available at: http://scienceforglobalpolicy.org/wp-content/uploads/5522b96206a09-Tait.pdf. Last accessed 16th March 2020.
  3. Smith et al. (2009) “The economy-wide impact of pandemic influenza on the UK: A computable general equilibrium modelling experiment” BMJ;339: b4571 doi:10.1136/bmj.b4571
  4. Clinical Trials Arena (17th February 2020) “Covid-19: Pharmaceutical companies and agencies that partnered for coronavirus vaccine development”. Available at: https://www.clinicaltrialsarena.com/analysis/covid-19-pharmaceutical-company-partnerships-for-coronavirus-vaccines-development/. Last accessed 16th March 2020.
  5. Pharmaceutical technology (10th February 2020) “Applied DNA and Takis Biotech partner on coronavirus vaccine”. Available at: https://www.pharmaceutical-technology.com/news/applied-dna-coronavirus-vaccine/ . Last accessed 16th March 2020.
  6. Pipeline Review.com (26th February, 2020) “APEIRON’s respiratory drug product to start pilot clinical trial to treat coronavirus disease COVID-19 in China”. Available at: https://pipelinereview.com/index.php/2020022673884/Proteins-and-Peptides/APEIRONs-respiratory-drug-product-to-start-pilot-clinical-trial-to-treat-coronavirus-disease-COVID-19-in-China.html . Last accessed 16th March 2020.
  7. Huzair, F (2012). The influenza vaccine innovation system and lessons for PDPs. Human Vaccines & Immunotherapeutics. Vol 8, Issue 3. Available at: https://doi.org/10.4161/hv.18701. Last accessed 10 March 2020.
  8. Shivji, R and Purves, J. (2009) “European Medicines Agency: Influenza Pandemic Preparedness”. In Risk Wise: Epidemics. J.Griffiths and R.Lambert eds. Available at: http://digital.tudor-rose.co.uk/risk-wise-epidemics/files/assets/common/downloads/publication.pdf. Last accessed 16th March 2020.
  9. EMA (24th September 2009) “Pandemic influenza A(H1N1)v vaccines authorised via the core dossier procedure: Explanatory note on scientific considerations regarding the licensing of pandemic A(H1N1)v-vaccines” Available at: https://www.ema.europa.eu/en/documents/medicine-qa/explanatory-note-scientific-considerations-regarding-licensing-pandemic-ah1n1v-vaccines_en.pdf. Last accessed 16th March 2020
  10. EMA ‘Vaccines for Pandemic Influenza’. Available at: https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/pandemic-influenza/vaccines-pandemic-influenza. Last accessed 19th March.
  11. Abraham, T. (2011) “Lessons from the pandemic: the need for new tools for risk and outbreak communication” Emerging Health Threats Journal, Vol 4, Issue 1. Available at: https://www.tandfonline.com/doi/full/10.3402/ehtj.v4i0.7160. Last accessed 2020.
  12. WHO (May, 2017) “Pandemic Influenza Risk Management”. Available at: https://www.who.int/influenza/preparedness/pandemic/PIRM_update_052017.pdf. Last accessed 16th March 2020.


COVID-19 reveals the politics of xenophobia in real-time, writes Janet E Perkins

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Pseudonyms have been used for all people and places in order to protect the identity and anonymity of individuals

“Khulna’s Very Own Foreigner”

Four days turned my field site, and my place in it, upside down. It was early March 2020 and I had spent the previous four months establishing myself in Khulna, Bangladesh, to carry out ethnographic data collection for my PhD: untangling how human rights ideas intersect with women’s experiences of pregnancy and childbearing. I was lucky enough to have the support of friends and colleagues from icddr,b, an international public health research institution based in the capital of Dhaka, who had agreed to host me for my research in Khulna. I had a vibrant social work life: I shared an apartment with my roommate, Rosa, a young medical assistant who quickly became my ‘younger sister’, diligently correcting my Bangla and assisting me to navigate this unfamiliar location. I was taken in as family by the icddr,b field team, who invited me over regularly for dinners and painstakingly attempted to teach me to play cricket. I had built friendly relationships with the managers of the health facilities in the different sub-districts where I spent most of my days, who referred to me affectionately as ‘Khulna’s very own foreigner’. I did not hold any pretense that I was actually blending in by any stretch of the imagination. While bideshis, or foreigners, literally meaning from a place that is not part of the desh, or the homeland of Bangladesh, were certainly not unheard of around here, neither were we a common appearance. Unlike in Dhaka, people did not typically refrain from showing their intrigue with my presence. In some cases, women would ask politely to touch my pale arm or stroke my chestnut hair, which I typically accepted, or young men would ask to take a selfie with me, which I typically declined. 

Like in most parts of the world, COVID 19 was on people’s minds in Bangladesh by the end of February. You could not travel far without overhearing a conversation including the word ‘coronavirus’. However, no cases had been reported in the country up until that point, so there was still a sense of security. Indeed, the government had a particular interest in keeping COVID 19 from surfacing in the country: They were preparing for Mujib Borsho, or the Year of Mujib, to commemorate the centenary of the birth of the iconic figure Sheikh Mujibir Rahman, the leader of the liberation movement and first president of Bangladesh. Sheikh Mujib, known as the Father of the Nation, and the literal father of the current Prime Minister, Sheikh Hasina, had taken power of a newly liberated Bangladesh in 1972, but was assassinated in a coup d’état in 1975. The countdown to the inaugural event of Mujib Borsho, set for his birthday on March 17th, had been launched on January 10th, marking the day that Sheikh Mujib had returned to an independent Bangladesh after being held in captivity in Pakistan during the liberation war. Now you could hardly turn your head without some reminder: countdown clocks erected at government buildings counting down the days, hours, minutes and seconds; stickers with the Mujib Borsho logo on government hospital doors; banners and signs with images of him and his family; a daily news segment dedicated to his legacy. The grand inauguration was to be held in Dhaka, attended by hundreds of thousands of participants, including a number of heads of state and special guests, notably Prime Minister Justin Trudeau of Canada and Prime Minister Narendra Modi of India. 

“COVID WAS A DISEASE of the Bidesh“

Each morning, I watched on the news as the Director of the Institute of Epidemiology, Disease Control and Research (IEDCR) gave her perfunctory press briefing, each day wrapped in a different and elegant sari, assuring the country that there were no cases of COVID in Bangladesh. The main refrain was that COVID was a disease of the bidesh, foreign land, and that the country was taking efforts to ensure that people entering from abroad were screened, and if coming from certain places, quarantined for 14 days upon arrival. In tandem, I was hearing reports of a number of suspected cases and rumours that IECDR was refusing to test people. Each time the word bidesh was uttered in relationship to COVID, I could not help but take it just a little bit personally. One evening I found myself walking down the road with Azam, the field manager of icddr,b and one of my most trusted friends in Khulna. As we walked from the icddr,b office to my home, he informed me that icddr,b had instructed him to not shake hands with bideshis, indicating that he should keep his distance from me. I was taken a bit aback by his comment;  I had been maintaining close communication with the Dhaka icddr,b team and there had certainly been no such official instruction. 

This narrative of COVID’s association with the bidesh became simultaneously more pronounced as all the neighbouring countries of Bangladesh began reporting cases. As the discourse of social distancing became increasingly more entrenched throughout early March, the foreign dignitaries who had initially accepted the invitation to attend the Mujib Borsho inaugural event started to decline one by one. I began hearing more reports in Dhaka and in Khulna of suspected cases, but people seemed resigned to accept the open secret that nothing would, or could, be revealed officially until after the 17th of March.  I travelled back to Dhaka to attend a national dissemination event scheduled for March 8, hosted by icddr,b. It was an emotional lead up to the event, hosting around 200 people, including national public health leaders. Even as attendees were arriving there was still heated debates of whether it should be maintained or cancelled. Without clear guidance from the government in a country that was supposedly free from COVID, this was a particularly difficult and politically fraught decision to take. In the end, the show went on. 

After this event, I sat with the ten members of the icddr,b Dhaka team I was working most closely with at Gloria Jeans, a coffee shop located in one of the upscale areas of Dhaka. The mood was still light-hearted enough as we replayed the circus of events leading up to what finally turned out to be a successful event. And then the notification came. I am not sure who saw it first, but IECDR had announced that three people had tested positive for COVID in Bangladesh. Consistent with the narrative, two were men who had recently returned from Italy and the third was one of their family members. This news came as a jolt and immediately transformed our moods to something more sombre.

“Khulna no longer felt like home”

I returned to a transformed Khulna four days after I had left, admittedly unprepared for what I was to find. The announcement of the COVID cases had transformed Khulna into a place I no longer recognized. People on the streets were wearing masks now. I could feel people’s eyes fix on me and then readjust their masks over their mouth and nose while moving away to avoid me. The drivers of the CNGs, the small green three-wheeled vehicles that we took to move from village to village, were wearing masks. But it was not until I reached my destination, a small village about 45 minutes from the city of Khulna, that I realized just how deeply this ran. I had travelled there to visit a satellite clinic being run by a private hospital. In this temporary clinic, a paramedic was providing basic health consultations to women and children in an empty room. 

Like usual, there was an interest in my presence and the women gathered around me to ask the typical questions: Where was I from? Was I married? Did I have children? But it was only moments before the topics turned from the banal to deeper concerns: Did I have coronavirus? They had heard that the government was not letting bideshis in anymore. How did I get into the country? It was then that it sunk in. Even these women here, in such a remote place, had gotten the message: there was an infection ‘coronavirus’ which was a risk to them, and this was a risk from the bidesh, embodied by bideshis. And now I, quite possibly the only bideshi that they had interacted with, embodied this infection and I was seen as a risk of contamination. 

It was impossible not to notice the reactions that my presence provoked in the days that followed. Some responses felt more vicious than others. People who wanted to catch a glimpse of a bideshi would still approach me, but now women would cover their mouths and noses with a headscarf before getting close and would quickly retreat when I approached. In the market, men would shout out comments in my direction about coronavirus. 11-year-old boys wearing face masks would pretend to chase after me. Other responses felt more legitimately concerned, and some seemed intended to be supportive. For example, the deputy manager of the district hospital had assured Azam that I would be exempt from going before the board that they had established to examine any person coming from abroad to determine whether they were a risk to the district. “Don’t worry, Azam,” he had assured him. “Janet is your family. She will not have to face the board.” However, what struck me was that creating this board specifically for people coming from abroad, of which there were notably few here, had become the priority of this crisis in Khulna, amidst the many which could have been chosen, with health facilities underprepared for providing basic services.

I found myself ruminating over my security in ways I had not before. Was it even safe for me to visit the more remote areas? And if I chose to go, should I (God forbid) take a man with me to be more secure? Was it even ethical for me to go to health facilities where the patients would most likely associate me with COVID? Somehow, the fact that I was spending time with pregnant women made these ethical questions feel more weighted. Khulna no longer felt like home.

When I woke up to the news that the World Health Organization had declared COVID 19 a pandemic, I did not know that it would be my last morning waking up in Khulna.  I visited a sub-district hospital close to home that day. When I arrived, the health manager was standing out in the front of the building. He invited me into his office, and like usual I took the seat in front of his desk. The concern was visible in his face. A few patients passed in and out to consult him. In between, we chatted and sipped on the sugary black tea with fresh ginger he had asked his staff to serve us. He sighed heavily as he told me of his worries of what he now felt to be the inescapable approach of coronavirus. His hospital was already at capacity; what were they going to do when COVID patients started to come as well? He asked me whether I had brought hand sanitizer. I proudly held up my small bottle of the clear Purell liquid, which was finally going to use after six months in the country. The substance had already become scarce here, as it had elsewhere. He showed me his bottle of blue sanitizer in turn. “I had to bring this from home,” he told me, explaining that he did not have sanitizer or masks to protect himself or his health service providers. His anxiety was palpable. Inevitably, people passing through the office would make comments in my direction about coronavirus and the manager would assure them that I had been in Bangladesh for a long time and was not infectious. 

“COVID has allowed us to watch xenophobia produced in real time”

After that day, as flight routes started shutting down one by one, I knew that I had to return to my family in Europe before I no longer could. My last evening in Bangladesh was spent, once again, with the icddr,b team in the same Gloria Jeans where we had learned of the first COVID cases in Bangladesh. Sitting with some of my closest friends, we laughed and joked over coffee and greasy potato wedges. They teased me when I insisted that they accept my dab of hand sanitizer between touching their phones and grabbing a potato wedge. For some of them, my decision to go back to Switzerland did not make much sense. Of course they understood that I should be with my family during this turbulent period, but why go back to the epicentre of the pandemic when I could ride it out in the comparatively better off Bangladesh? 

I landed in Europe two days before what little of the Mujib Borsho inauguration ceremony was able to go on. There were still fireworks, but no crowds to admire them. As expected, things changed immediately after March 17th. Testing increased (though not sufficiently), cases started being confirmed on a daily basis, and people were officially dying as a result of COVID 19. Although schools were closed in the country as of March 18th, the government declared a national ‘holiday’ as of March 26th that keeps getting extended. A holiday sounds nicer than an emergency or a lockdown but is supposed to communicate the same idea. Everyone is scrambling to make sense of this situation, not only in terms of health, but in terms of the economic situation in a context in which a social safety net is something of a pipe dream. Watching from afar, I wish that we could go back to the frivolity of my last evening in Gloria Jeans, when someone could still throw out a far-fetched theory of the climate of Bangladesh being protective against COVID, or that Bangladeshis’ natural immunity will serve to fend it off—Europeans obviously have the weaker immune systems as they get annual flu shots and are not exposed to as many pathogens. These theories felt more hopeful than naïve, as none of us wanted to imagine the alternative. Now I can only watch from afar and hope that the worst-case scenarios do not materialize.

COVID 19 has not created xenophobia and it is unfortunately too much a part of what many people have to navigate in their everyday even under (more) normal circumstances. However, what COVID has allowed is for us to watch the insidious and swift ways in which xenophobia and racism are produced in real time. It is often heard that COVID 19 is an ‘invisible enemy’. While it may be true that the material virus is too small for the human eye to perceive, through politicizing it and associating it with particular bodies, we render the virus visible. Though manifesting differently, these xenophobic responses have been ubiquitous. At their most innocuous, they lead to a waste of valuable energy and resources that could be better directed towards working toward solutions that address this crisis shared by humanity. At their worst they have led to many people feeling less safe in this already destabilized world and to violence. It is my hope that when the dust has settled, we are able to use this experience to better understand how xenophobia is produced both politically and otherwise in order to work towards a world where there is less of it. 

Janet Perkins is a PhD candidate in Social Anthropology at the University of Edinburgh School of Social and Political Science. Her research focuses on human rights, women’s health and international development, building on extensive professional experience in global health and international development. 



For the ‘at-risk’ or vulnerable COVID-19 group: staying or becoming active during social distancing , by Lis Neubeck, Sheona McHale, Chloe Williamson, Paul Kelly, Alice Pearsons, Steven Hanson & Carol Hanson

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During COVID-19, the World Health Organisation has defined vulnerable groups as those aged over 60 years (regardless of health condition), and those with underlying health conditions, such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer. Additionally, the UK Government has identified pregnant women as an ‘at risk’ group. The benefits of physical activity for these groups are well known and emphasised in the 2019 UK physical activity guidelines.[1] As well as physical benefits, being active promotes emotional well-being.[2] With anxiety levels escalating, this matters more than ever. Normally, we tailor our physical activity advice around community provision, such as swimming, fitness classes and even walking with friends. These options may no longer be available and home-based activity could be your best option. Although some providers have tested home-based activity programmes for people with underlying health conditions, we need to adapt resources for those who need to stay indoors for long periods and practice social distancing. Many people might feel lonely and may not have a plan to maintain their health. More than ever, physical activity can help to reduce the effects of social isolation and prevent deconditioning caused by extended sitting. In this blog, we share some of the evidence about home-based physical activity, and provide practical advice to begin a home-based activity programme.

No equipment? No problem

If you are now having to spend more time at home than you are used to, increasing moving time and reducing sitting time are the key components to physical and emotional well-being.[3] Typically, we talk about four key components to maintaining physical wellbeing. These are endurance, strength, balance and flexibility. Here are some ideas to promote all of these:

Being active does not need to rely on fancy equipment. Recently, one man completed a marathon on his 7 metre balcony.[4] We would not suggest that you try this, but it shows that anything is possible even with very little space! We recommend making a daily commitment to do some form of activity, even walking around the room will give you some health benefits. If you have stairs, walk up and down them a few times. As we age, we tend to have less strength in our muscles. Studies recommend repeated movements of between 8- 10 repetitions to help reduce the effort of daily living activities such as stair climbing and carrying groceries. Doing muscular strengthening activities on at least two days per week has physical benefits.  You can use kitchen items, such as tins of beans or filled water bottles, instead of hand weights. We suggest counting to three during each part of the activity (e.g. in a bicep curl, to three as you raise your arms and to three as you lower them again).

Practical activities to frequently break up sitting time can really improve your mood.[4]  Try to stand up every 30 minutes if you are able, and move for two minutes. To improve general wellbeing, mood and energy levels, activities that increase breathing rate as well as muscle strength activities are important factors.[3] Dancing to music is fun, and if done regularly, is effective in improving quality of life and fitness for people with underlying conditions.[5] Other beneficial activities include walking inside and outside the home, Tai Chi and yoga.[6, 7] If you have to walk outside, remember to strictly observe the guidelines to stay at least two metres from anyone outside your household. A simple activity to improve your balance is walking heel-to-toe across the room. At first, you might find it helpful to hold on to the back of the sofa for stability. Although there is no definitive threshold to achieve benefits, for some people, small changes (e.g. increasing the number of times you stand from sitting throughout the day) can improve physical function within a few weeks.[8] Overall, the key message is it does not really matter what you do, as long as you do something!

How can I use technology to be more active?

If you have a mobile phone, computer or television with internet access, there are many online opportunities to help you be active. Mobile apps, text messaging and web-based solutions help people be physically  active and improve wellbeing.[9]  One study that brought together all the evidence for remote interventions for older adults found that booklets with goal setting, videos and telephone calls were effective in helping people to be more active.[10] Phone a friend and encourage each other to be active.

If you have a condition such as heart disease, the Heart Manual is a self-management book for people recovering from a heart attack, heart surgery, stroke and cancer.  A digital format is now available and research shows that this is as effective as face-to-face cardiac rehabilitation for people with heart disease.[11] If you have a heart problem, telephone your cardiac rehabilitation team and ask what is available.

Physical activity is safe if you are pregnant.[12] Choices should reflect activity levels pre-pregnancy and include strength activities. If you were not active before, do not suddenly take up strenuous activity. You should be able to hold a conversation as you exercise when pregnant. If you become breathless as you talk, reduce your intensity.

Overall, the good news is that many activity providers are working very hard to make sure that there is access to online resources to help you. Check what your local leisure provider is offering. We recommend this online booklet for ideas on home-based activities http://www.laterlifetraining.co.uk/wp-content/uploads/2015/08/OEP-Home-Ex-Booklet-FullS_A4.pdf

We have constructed the above infographic using evidence-based principles on how to construct and deliver messages to promote physical activity among the ‘at risk’ or vulnerable group during this global pandemic.[14]

Who is this infographic for?

The infographic is for all adults aged 70+ years, pregnant women, or those with underlying conditions, who are staying at home. This population may be facing unprecedented restrictions to travel, social, and family life.

What is the aim of the infographic?

The aim of the infographic is to give people classed as ‘at risk’ or vulnerable ideas about how to remain safely active during COVID-19 and to motivate them to do so. We hope to achieve this through increasing awareness and knowledge of physical activity benefits, and by improving confidence to be active during this pandemic.

What is the content of the infographic?

Evidence supports the use of gain-framed messages (information on the benefits of physical activity) with particular focus on the short-term social and mental health benefits.[15] We have positively framed messages on links between physical activity and mood, stress, energy levels/fatigue, depressive symptoms, and anxiety. We have given practical examples about “how to” remain active during COVID19.

How should the infographic be used?

We encourage the sharing of the infographic to friends and family through online channels (Twitter, Facebook, WhatsApp etc.). You could print out the infographic to remind you to remain active.

***

Lis Neubeck 1,2 (corresponding author), Sheona McHale 1 Chloë Williamson 3, Paul Kelly 3Alice Pearsons 1, Steven Hanson 4, Coral L Hanson 1

1 School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Edinburgh, EH11 4DN, UK. Email: c.hanson@napier.ac.uk Tel: +44 7908861666
2 Sydney Nursing School, Charles Perkins Centre, University of Sydney, Australia
3 Physical Activity for Health Research Centre, Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, Edinburgh, UK
 4 Floating Boat Design Solutions, Stocksfield, UK

References

  1. UK chief medical officers, UK Chief Medical Officers’ Physical Activity Guidelines. [Date accessed 25/03/2020] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf. 2019
  2. World Health Organisation, Global action plan on physical activity 2018-2030: more active people for a healthier world.
  3. Gibson‐Moore, H., UK Chief Medical Officers’ physical activity guidelines 2019: What’s new and how can we get people more active? Nutr Bull, 2019. 44(4): p. 320-328. doi:10.1111/nbu.12409
  4. The Guardian, Man runs marathon on 7-metre balcony during French lockdown avaliable at https://www.theguardian.com/world/2020/mar/21/man-runs-marathon-on-7-metre-balcony-during-french-lockdown  [Accessed 23/03/2020].
  5. Gomes Neto, M., M.A. Menezes, and V.O. Carvalho, Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis. Clin Rehabil, 2014. 28(12): p. 1172-1179. doi:10.1177/0269215514534089
  6. Chen, Y.-W., et al., The effect of Tai Chi on four chronic conditions—cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses. Br J Sports Med, 2016. 50(7): p. 397-407. doi:10.1136/bjsports-2014-094388
  7. Thayabaranathan, T., et al., Determining the potential benefits of yoga in chronic stroke care: a systematic review and meta-analysis. Top Stroke Rehabil, 2017. 24(4): p. 279-287.
  8. Rosenberg, D.E., et al., The feasibility of reducing sitting time in overweight and obese older adults. Health Educ Behav, 2015. 42(5): p. 669-676. doi:10.1177/1090198115577378
  9. Jin, K., et al., Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis. Eur J Cardiovasc Nurs, 2019. 18(4): p. 260-271. doi:10.1177/1474515119826510
  10. Zubala, A., et al., Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews, PLoS One. 2017. doi: 1371/journal.pone.0180902
  11. Clark, M., T. Kelly, and C. Deighan, A Systematic Review of the Heart Manual Literature. Eur J Cardiovasc Nurs, 10(1): p. 3-13. doi:10.1016/j.ejcnurse.2010.03.003
  12. National Health Service. Exercise in pregnancy Your pregnancy and baby guide https://www.nhs.uk/conditions/pregnancy-and-baby/pregnancy-exercise/ [Accessed 26/03/2020] 2020.
  13. Latimer, A.E., L.R. Brawley, and R.L. Bassett, A systematic review of three approaches for constructing physical activity messages: what messages work and what improvements are needed? Int J Behav Nutr Phys Act, 2010. 7(1): p. 36. doi:10.1016/ 1186/1479-5868-7-36
  14. Williamson, C., et al., A conceptual framework for physical activity messaging. Int J Behav Nutr Phys Act, 2020 (in press)
  15. C., et al., A conceptual framework for physical activity messaging. ResearchGate, 2019 (pre-print)

Reproduced from Neubeck L, McHale S, Williamson C,  Kelly P, Pearsons A, Hanson S, Hanson C.L. (2020). For the ‘at-risk’ or vulnerable COVID-19 group: staying or becoming active during social distancing.British Journal of Sports Medicine Blog Published Online First: (08/04/2020)https://blogs.bmj.com/bjsm/2020/04/08/for-the-at-risk-or-vulnerable-covid-19-group-staying-or-becoming-active-during-social-distancing/ with permission from BMJ Publishing Group Ltd.



The science of quarantine and the social life of COVID-19, writes Aphaluck Bhatiasevi

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So much has been happening in the last months. Since the WHO declared the coronavirus a global pandemic on 11th March, the situation has been rapidly evolving on a daily basis, in different parts of the world.

Speaking about the social life of COVID-19, we began to hear about the virus in January, on how it was spreading rapidly in Wuhan, China. Within a few weeks, the virus traveled to different parts of the world and has since been moving around on airplanes and on cruise ships. It is now reported in all countries and territories.  COVID-19 has no nationality. It did not require a boarding pass or a passport, and was able to slip through border controls without difficulty. It has been very active in the mainstream and social media and is now part of our daily lives.

This pandemic is real

The situation we are in is serious. COVID-19 is taking many lives and making more and more people sick every day. And the numbers of people infected will continue to multiply.  Governments of many countries are being demanded to take action quickly to stop the spread of the virus. The measures taken by communist China – the lockdown which began in Wuhan, a city of 11 million people, and soon extended to other parts of Hubei province, impacting more than 60 million lives – was observed with skepticism from the outside. These measures are now adopted by the most liberal and republican countries of the global north.

Since the beginning of this event, the narratives around COVID-19 has been evolving and the social media is playing a key role in shaping and reshaping these narratives. The power and influence of the social media is undeniable. This is evident from the WHO DG made the announcement of COVID-19 as the global pandemic at a press briefing streamed live on several social media platforms. This changed the public perception on WHO which is often criticized for being slow and conservative, to becoming one of the most influential information sources for COVID-19.

Narratives of COVID-19

We will all experience the lockdown and the quarantine differently in different parts of the world. Our experiences will be shaped on the basis of our social status at the macro and the micro level. At the macro level, it would depend on our experiences and the relationship we have with state authorities, our access to basic needs (such as food, water, shelter, toilets), and our access to health care. At the micro level, it depends on our relationship with our family, friends or the people we live with during this lockdown period and the personal space we have.  Relationships will foster in some households, while they could break down in others. The fear of the unknown and the uncertainty of the situation will influence our day-to-day lives.

There are so many evolving narratives around COVID-19.  How did we move so fast from hand washing to social/physical distancing to quarantine and now lockdown in many parts of the world as a protective measure against the virus?  The narrative shifted quickly from China being the epicenter of the outbreak to Europe and the United States being the epicenter of the pandemic.  There has also been a quick shift from a public health response to the political and economic response.

Since the beginning of the outbreak of COVID-19, WHO has been advocating handwashing as the most effective protection against the virus, at the individual level. While recommendations for state authorities to implement measures such as social/physical distancing, which involves closure of schools and universities, and cancellation of events with public gatherings like concerts and sports was delayed.  WHO also advised against countries imposing travel or trade restrictions. However, soon after the pandemic was declared, countries in Europe began shutting down their individual national borders. Travel restrictions were imposed against Europeans by the United States, and multiple flights were cancelled across the world.   How did this happen so quickly?

When the epicenter of the pandemic moved from China to Europe, multiple countries took immediate actions to safeguard their own territories and populations.  Unfortunately, Italy and Spain being are hit hardest, with high numbers of infections and deaths among the elderly people and health care workers.  The UK and the US governments which have been criticized for their slow actions, are being warned that they could face a similar fate as Italy and Spain.

What can we learn from the past?

Looking back at the responses to Ebola outbreaks in West Africa in 2014 and more recently in the Democratic Republic of the Congo, what they have taught us  is that the most important tool to control an infectious disease outbreak is to gain community trust build trust and to communicate frequently with the people.  “Care builds trust” says Vinh-Kim Nguyen of The Graduate Institute of Geneva. If governments want to build trust, they have to look after the people who are sick and protect them. They need to do something that is tangible and visible, to show that they care and that something is being done.

In this case, most governments are choosing to highlight quarantine, which is an ancient infectious disease control measure, dating back to the 12th Century. It was first introduced in what is today  Croatia, on a ship, in relation to a plague outbreak. It has since been used in limited geographical areas as an international health measure to control the spread of infectious diseases like cholera, smallpox, yellow fever, tuberculosis, leprosy, influenza, AIDS, SARS and more recently for Ebola.

When quarantine was imposed on the British licensed cruise ship ‘Diamond Princess’ which docked in Japan in February, experts blamed the Japanese authorities mismanaging the outbreak through the quarantine. The numbers of COVID-19 infection increased from 10 to more than 700 persons, out of  a total of 3700 passengers on board, by the end of the 14 days quarantine.  Conversely, the lockdown in Hubei province was praised by the international team of experts led by WHO to assess China’s response to COVID-19 in late February. They said the lockdown was effective in slowing down the spread of the virus. Government policies in Europe and the US on quarantines and lockdown are being influenced by projections of numbers of infections and deaths.   Neil Ferguson of Imperial College, whose mathematical modeling is informing the UK government’s policy decisions says these measures need to be in place until a vaccine is available. This means for at least 12-18 months.

The question is whether quarantine or lockdown is the best option and whether it should be the main focus of the pandemic response?  Is it diverting the attention and resources away from where the needs are most, that is in the health care sector? Are health care workers being equipped to carry out their work confidently? Do they have adequate PPE? Are the people suspected of COVID-19 who are at risk of developing severe outcomes of illness being tested and cared for?

Why don’t governments also consider projections of the consequences a lockdown would have on other health problems and on social issues?

WHO’s Mike Ryan said on 22 March that countries can’t simply lock down their societies to defeat coronavirus. What is really needed is to focus on finding the people who are infected, their contacts and to isolate them so that the virus does not further transmit to others.

Devi Sridhar of the University of Edinburgh‘s Usher Institute says lockdown is not the solution. It just buys time to do mass testing, contact tracing and isolation of virus carriers. It is something that allows health services to be prepared to deal with rising number of patients.

Carlos Caduff of King’s College questions whether quarantine or lockdown is an effective tool. He asks if countries with less restrictions on movement are witnessing faster and wider transmission of the virus.

Based on the history of quarantine, in many instances, groups that are already socially marginalized and stigmatized tend to be inappropriately quarantined.  A web-based roundtable discussion on COVID-19 carried out by Somatosphere on 28 February says evidence from the early days of the AIDS epidemic in Haiti and in the United States show that gay men suffered from worsened health conditions and access to health needs during the quarantine period.

Wendy Parmet of Northeast University says quarantine can be a useful tool when done well – when it separates the persons who are not sick from the sick, when it does not enforce laws or authority of the state in policing people.

Mark Rothstein a health policy legal expert says 4 key issues need to carefully be considered before imposing quarantine (1) necessity, effectiveness, scientific rationale (2) proportionality and least infringement (3) humane supportive services (4) public justification.

A study conducted Hawryluck et al from University of Toronto, on 15,000 persons who were quarantined during SARS in Canada in 2003 showed that 29% of those who were quarantined for an average of 10 days had symptoms of PTSD, and 31% had depression.

A rapid literature review of the psychological impact of quarantine carried out by Samantha Brooks and team from King’s College shows that most studies reported negative psychological effects which include post-traumatic stress symptoms, confusion and anger. The main stressors were associated with longer quarantine duration, the fear of infection, frustration, boredom, inadequate supplies, inadequate information, financial loss and stigma.  Some research suggest that the effects could be long lasting.

To mitigate the consequences of quarantine, Brooks et al suggests that the quarantine period be kept short, based on the duration of the incubation period of the disease, and that authorities stick to the timeframe announced. “For people already in quarantine, an extension, no matter how small, is likely to exacerbate any sense of frustration or demoralization. Imposing a cordon indefinitely on whole cities with no clear time limit might be more detrimental than strictly applied quarantine procedures limited to the period of incubation.”

This pandemic is socially exhibiting both positive and negative effects. It has definitely increased awareness on the infectious disease and the importance of handwashing. It has drawn attention to epidemiology of disease spread (e.g. many people are talking about flattening the curve). It has connected people across the world through social media and through lockdown.  It has displayed expressions of care, compassion, solidarity and creativity.

While at the same time, it has demonstrated xenophobia, fear, anxiety, paranoia, blame, limits of capacities of both rich and poor countries in dealing with a major health crisis.  I have mainly focused on the big picture issues related to the global North. I cannot imagine how the prolonged lockdown will play out in countries like India and South Africa.

This is just the beginning. We need to look into the health and social consequences of the lockdown, just as we are on the economic aspects.

Aphaluck Bhatiasevi is a PhD Candidate in Social Anthropology at the University of Edinburgh.



Interview of Agomoni Ganguli Mitra on pandemic related social inequalities by University of Oxford’s Practical Ethics channel

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Is the Coronavirus Pandemic Worse for Women?

Dr Agomoni Ganguli Mitra of the University of Edinburgh’s Law School talks about how pandemics increase existing inequalities in societies, and how this may result in even more victims than those from the disease itself. She urges governments and others to take social justice considerations much more into account when preparing for, and tackling, pandemics.

This is an interview with Katrien Devolder as part of the Thinking Out Loud video series from Oxford University’s Practical Ethics channel

 



How the social and behavioural sciences can help us beat the pandemic, writes Gowri Iyer and Nanda Kishore Kannuri

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The social and behavioural sciences (SBS) in public health have had an essential but relatively unacknowledged role since the beginning of the field in the early 19th century. Over the last few decades, there has been a slow and gradual paradigm shift in the field globally with growing acknowledgement of the need for SBS research to drive interventions for successful public health outcomes.

However, in India, experts argue that public health continues to be dominated by a biomedical approach to health. In public health, infectious disease management is a high-priority area due to the large number of existing and emerging infectious diseases, such as malaria, measles, diarrhoeal diseases, tuberculosis, Ebola, Zika, Nipah, etc. All of these pose numerous and complex challenges in detecting and managing them. While SBS approaches in disease outbreak investigation and management have been used in the past, the systematic inclusion of social science-based interventions (SSIs) as an integral part of operational response remains a challenge.

In India, SSIs have also been used but only in a relatively episodic manner, relegated to targeted interventions focused towards dealing with conditions like HIV/AIDS and tuberculosis. However, SBS methods, to be effective, must be developed in an integrated manner with affected populations to bring a disease outbreak or health emergency to an end. In addition, there needs to be a systematic use of methods and analyses to understand the cultural and social contexts of communities affected by health emergencies, as well as the need to detect behaviours and practices that increase the risk of death, disease or social and economic loss.

In the current COVID-19 crisis, epidemiologists and other health experts are working tirelessly to understand the scale of the problem and to help develop strategies to mitigate risks associated with it. In addition, scientists in both the public sector and private enterprises are racing to develop tests and vaccines. However, social and behavioural scientists can also play an important role in the current pandemic, especially given the current absence of any vaccines and medicines.

SBS interventions such as effective communication (improving awareness of the virus and risks) and behaviour change (physical distancing, frequent hand washing, avoiding mass gatherings, etc.) are critical at this juncture to contain the transmission of the virus and flatten the curve. In addition, established social interventions, including social mobilisation, health promotion through education enable community level adaptations to comply with the new social norms. These measures give the government a critical window to strengthen the health system and evolve strategies for testing, isolation and contact tracing of new cases.

For effective communication, we need to understand the intended audience, level of public trust in the people conveying the message, and the level of public awareness of the pandemic. The aim of good messaging should increase public awareness, reduce the anxiety and distress that arises, and also facilitate the behaviour change that might be required by the people in such situations.

So how can we use SBS to inform effective communication over COVID-19? Successful communication campaigns have incorporated accuracy, consistency, clarity and empathy as key components. In contrast, ill-informed communication strategies carry the risk of precipitating behaviours that run counter to stated public health goals. This risk is exacerbated in a people whose cultural familiarity and risk perception is low in behaviours such as physical distancing, making adherence to them difficult. Studies report that ambiguous and inconsistent messaging increases chaos, confusion and distrust, leading to non-compliance to the behaviour change that may be essential during the pandemic, ultimately making the situation worse.

We see some evidence of the public’s difficulty in grasping these concepts across the situations that have emerged since the lockdown, for example panic buying, increasing stigma, anxiety and frustration, the exodus of labourers from cities after the lockdown, and people crowding streets to bang plates, etc.

To enable behavioural change in the public, we need to understand individual (beliefs, motivations, biases, etc.) and group level factors (group dynamics, peer influence, cultural beliefs, public trust, etc.) that can influence our judgment and decision making. Understanding of these factors is achieved through systematically studying how different individuals perceive risk and what prompts them to act upon it. Some of the seminal work in this field by Daniel Kahneman, Amos Tversky and other researchers present substantial evidence of the heuristics and biases people use to make judgements and decisions. This body of research has consistently shown that people’s decisions are swayed by factors such as their beliefs and emotions, and which often ignore logic and facts, even during peaceful times. Such tendencies will be further enhanced during a pandemic.

Beyond effective communication and immediate behaviour change (such as physical distancing), there are other critical SBS aspects that need to be studied and understood for their impact on people during this unprecedented crisis. These include growing stigma associated with healthcare professionals, people exposed to the virus, the adverse mental health issues due to social and economic costs, role of communities, etc.

These adverse events are a consequence of the restrictive policies (such as quarantine, lockdown), misinformation, ineffective communication and poor health literacy, and using SBS research and evidence to inform policy and interventions can mitigate some of these effects. A review article recently published by The Lancet reports that the psychological impact of quarantine includes post-traumatic stress, anxiety, depression and public anger.

While there is evidence of successful strategies from previous public health campaigns using SSIs, such as using graphic imagery in the anti-tobacco campaign, and reducing stigma associated with HIV/AIDS patients by awareness campaigns involving celebrities. Such approaches when broad-based and integrated into public health will be most impactful. These approaches work best in tandem with social protections and policy measures that help alleviate some of the inevitable social and economic distress.

As the COVID-19 pandemic evolves and worsens without any visible respite, sustaining these social interventions is critical. It is important to engage with the community to ground our pandemic response in the social, cultural and ecological contexts to reinforce their long-term participation. We need creative ways to build community resilience, evolve models of care, social support and solidarity.

While there has been a considerable and understandable push for biomedical research to help us deal with COVID-19, it is important to invest in public health research with a particular emphasis on social and behavioural approaches and methods for a holistic response. It is critical to focus on a collaboration and real-time integration of interdisciplinary approaches involving epidemiologists, social and behavioural scientists and other disciplines in designing innovative, rapid, culturally sensitive and precise public health interventions to respond to crises and also enable us to be better prepared for such public health emergencies in future.

Gowri Iyer is a cognitive and behavioural scientist and Nanda Kishore Kannuri is a medical anthropologist, both at the Indian Institute of Public Health, Hyderabad. The views expressed here are the authors’ own.

This piece was originally published in https://science.thewire.in/health/how-the-social-and-behavioural-sciences-can-help-us-beat-the-pandemic/



Edinburgh Infectious Diseases held a workshop to highlight research carried out in the University of Edinburgh and NHS Lothian in response to the COVID-19 pandemic

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The aim of the workshop held on 25th March 2020, was to highlight research being carried out in the University of Edinburgh and NHS Lothian in response to the COVID-19 pandemic.  The presentations were delivered by some of the top scientists and clinicians working in this field in Edinburgh.

The Director of Edinburgh Infectious Diseases, Professor Ross Fitzgerald, said that the workshop provided “an excellent forum for discussion of early data emerging from a number of projects at the University of Edinburgh, which are in receipt of substantial funding to enhance our understanding of both the virus and the patient response to the virus.”

The workshop was attended by more than 250 people, who heard from local scientists and clinicians on a range of topics, including basics of coronavirus virology, epidemiological modelling of the outbreak, how we can use rapid sequencing to track the course of the epidemic, and the sociological effects of quarantine.

The workshop, which was hosted on Blackboard Collaborate virtually, stimulated a variety of useful discussions and ideas for future research. As research progresses, it is likely a similar workshop will be held later in the year.

Videos and summaries of each talk are available at:

https://www.ed.ac.uk/edinburgh-infectious-diseases/covid-19/covid-19-events-and-activities/edinburgh-coronavirus-workshop/workshop-summaries

 



The return of the expert, by Christina Boswell

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One of the striking aspects of the Covid-19 crisis in the UK has been the apparent rehabilitation of the expert. Experts – whether economists, lawyers, civil servants or academics – were famously maligned during the Brexit debate. But the likes of Chris Whitty, Neil Ferguson and Catherine Calderwood have become household names over the past few weeks. The return of the expert is most vivid in the daily UK Government press conferences, where political leaders are flanked by scientific and medical advisors; and it’s constantly repeated in the Government’s reassurance that its policies are being guided by ‘the scientific advice’.

So why this damascene conversion to expertise? In my book The Political Uses of Expert Knowledge I distinguished three possible functions of expertise in politics: to inform policy; to substantiate particular claims or decisions; and to signal the competence of actors to take well-founded decisions. In fact, all three seem to be at play here.

First, it’s clear that the UK Government is keen to draw on expertise to fix the problem. Unlike in many other areas of policy where the effects of policy are diffuse and long-term, the government’s legitimacy in handling the pandemic is very closely dependent on actions it takes now. Whether it sustains the lockdown, rolls out testing, or expands ICU capacity, will have a very tangible effect on health outcomes. In this situation, it can’t get away with compelling rhetoric and symbolic gestures – or at least not for long. Which is, of course, why populist administrations may find themselves foundering in this situation.

Adding to the potential for exposure, these outcomes are being measured and compared across countries. The daily graphs showing trajectories in death-rates across countries can be a harsh indictment of the performance of governments. So it is crucial for political leaders to get this right, and mobilise the best evidence possible to guide actions. Contrast this to Brexit, where the effects of government actions were always going to be diffuse and difficult to attribute, partly explaining why government didn’t need to be so careful about heeding the evidence.

Of course, it’s never that clear what the ‘best’ evidence is, especially where different disciplinary perspectives produce conflicting conclusions, and where public health considerations need to be balanced against a wide range of social and economic factors. Officials are keenly aware of the uncertainty of science – which is partly why they tend to prefer trial-and-error, incremental approaches to testing new policies, rather than introducing new and untested interventions based on abstract modelling.

But this isn’t just about getting decisions right – politics never is. There is also a strong symbolic dimension to the use of expertise. The government wants to make it clear to the public that its decisions are based on scientific evidence. And different protagonists are keen to use scientific claims as ammunition to support their positions – the substantiating function of expert knowledge. To complicate matters, the government isn’t using expertise simply to validate claims, it also appears to be using it as an insurance policy. If things go wrong – and the curve gets too steep – it will be the scientific advice that is to blame.

And herein lies the risk, to both science and government. If science is held responsible for poor political decisions, its authority becomes eroded. Science does not, and cannot, offer definitive answers to new and complex social problems – just propositions and hypotheses that are more or less robust. So pinning policy on such uncertain claims is disingenuous, and will only serve to undermine trust in science.

The related risk for politics is that any attempt to blame the scientists will risk rebounding on them – playing the blame game will be seen as a sign of weakness and poor judgement.

So while it’s good to see the return of experts, let’s not burden them with unrealistic expectations, or conflate their role with that of political leaders. Science is a vital resource for modelling scenarios and developing medical and technical responses; but for many aspects of decision-making it is contested and uncertain. If we set our scientific advisors up to find policy solutions, we risk generating disillusionment with science, and, in the long term, further erosion of its authority.

Christina Boswell is Professor of Politics at the University of Edinburgh. Her books include: Manufacturing Political Trust: Targets and Performance Measurement in Public Policy (Cambridge, 2018); and The Political Uses of Expert Knowledge: Immigration Policy and Social Research (Cambridge, 2009).  Professor Boswell’s article featured in The Guardian: https://www.theguardian.com/world/2020/apr/23/scientists-criticise-uk-government-over-following-the-science